item 4: minutes of the last meeting - West London …...TRUST BOARD MEETING IN PUBLIC (PART 1) To be held in the White Room Trust Headquarters, 1 Armstrong Way, Southall UB2 4SA o

TRUST BOARD MEETING IN PUBLIC (PART 1) To be held in the White Room

Trust Headquarters, 1 Armstrong Way, Southall UB2 4SA on Wednesday 24th September 2014 - from 1330 to 1630 hrs

AGENDA

Approx. Timing

Agenda No.

Title Objective Lead Enclosed or Verbal

Item

1330 1 Opening & Welcome To note Chairman Verbal

2 Apologies for Absence To note Chairman Verbal

3 Declaration of Interests If any member of the Board has an interest in any item on the agenda, they must declare it at the meeting, and if necessary withdraw from the meeting.

To note Chairman Verbal

MINUTES & ACTIONS

4 Minutes of the Last Meeting To approve Chairman Enclosed

5 Board Action Schedule & Matters Arising

To note Chairman Enclosed

PERFORMANCE & ACTIVITY 1350 6 Chairman’s Report To note Chairman Verbal

7 Chief Executive’s Report To note Chief Executive Enclosed

1405 8 8.1 8.2

8.3

Executive Directors’ Reports Director of Local Services’ Report Director of High Secure & Forensic Services’ Report Medical Director’s Report

To note Executive Directors

Enclosed

9 Integrated Performance Report To note Director of Finance / DCEO

Enclosed

QUALITY & SAFETY

1455 10 Board Members’ Visits Meridian Ward – 23/07/2014

To note Various Directors Enclosed

11 Nurse and Health Care Assistant Staffing Levels – Exception Report for June 2014

To note Interim Director of Nursing & Patient Experience

Enclosed

STRATEGY & PLANNING 1525 12 Development Support Plan To note Director of

Business & Strategy

Enclosed

1535 – 5 minute break

1540 13 Communications Strategy Update To note Director of Communications & Involvement

Enclosed

GOVERNANCE & LEGAL 14 Register of Members’ Interests To note Trust Secretary Enclosed

REPORTING COMMITTEES & GROUPS 1600 15

15.1

15.2

Audit Committee Chair’s Report of meeting on 03/09/2014 inc. Proposed Amendments to Trust Standing Orders & Standing Financial Instructions Approved Minutes of meeting of 02/07/2014

To approve

Committee Chair Enclosed

16

Finance & Investment Committee Approved Minutes of meeting of 04/06/2014

To note Committee Chair Enclosed

17 17.1 17.2

Strategic Projects Programme Board Chair’s Report of meeting on 26/08/2014 Approved Minutes of meeting of 29/07/2014


18 18.1 18.2

Staff Engagement Committee Chair’s report of the meeting on 31/07/2014 Approved Minutes of meeting of 16/04/2014


19

Service User Forum Chair’s report of the meeting on 02/09/2014


RISKS & INFORMATION FLOW EMERGING FROM MEETING

20 Consider if any new risks were identified during the meeting or changes to risks proposed

To discuss Chairman Verbal

21 Actions for Committees identified during the meeting


AOB 22 Any Other Business

Previously notified to the Chairman Verbal

INVITATION FOR QUESTIONS FROM THE PUBLIC

23 Questions from Members of the Public Verbal

FOR DIARY

Date of Next Trust Board Meeting in Public: Wednesday 29

th October 2014

White Room, THQ 1 Armstrong Way, Southall UB2 4SA

REVEW OF BOARD MEETING

Following completion of formal business, the Board will reflect, in confidence on the operation and content of the day’s meeting

DRAFT MINUTES OF THE TRUST BOARD MEETING

Held on Wednesday 30th July 2014 In the White Room

Trust Headquarters, Armstrong Way, Southall UB2 4SA Present: Mr Nigel McCorkell Chairman

Mr Steve Shrubb Chief Executive Mrs Barbara Byrne Director of Finance / Deputy Chief Executive Dr Anne Aiyegbusi Interim Director of Nursing & Patient Experience Ms Christine Higgins Non-Executive Director Mr Neville Manuel Vice Chairman / Non-Executive Director Miss Leeanne McGee Director of High Secure & Forensic Services Mrs Rachael Moench Director of Organisation Development & Workforce Ms Elizabeth Rantzen Non-Executive Director Mr Geoff Rose Non-Executive Director Ms Sarah Rushton Interim Director of Local Services

Attending: Dr Michael Phelan Deputy Medical Director

Ms Helene Feger Director of Communications & Involvement (to item 7) Mr David Stacey Director of Business & Strategy (item 11) Mrs Barbara Wörts Trust Secretary (minutes)

Items were discussed in the sequence they are recorded in the minutes Ref:

Discussion: Action:

296/14 Item 1

OPENING & WELCOME The Chairman welcomed everyone to the meeting.

297/14 Item 2

APOLOGIES FOR ABSENCE Apologies for absence were received from Mrs Barbara Kerin Non-Executive Director Professor Sally Glen Non-Executive Director Dr Nicholas Broughton Medical Director Ms Jean George Director of Local Services It was noted that Dr Phelan was attending the meeting as Dr Broughton’s representative.

298/14 Item 3

DECLARATION OF INTERESTS There were no interests declared in any of the items of business to be transacted.

299/14 Item 4

a)

MINUTES OF THE LAST MEETING The minutes of the Board meeting held on Wednesday 25th June 2014 were agreed to be a correct record, subject to some

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Ref:

Discussion: Action:

b)

typographical amendments, and the following addition: 244/14 (f) – item 8.3: Change: “Therefore, Mr Malcolm Rae OBE had been commissioned by the Trust to conduct an independent review of safeguarding and governance arrangements.” To: “Therefore, Mr Malcolm Rae OBE had been commissioned by the Trust to conduct an independent review of safeguarding and governance arrangements, Trust-wide.”

301/14 Item 5

a)

b)

c)

d)

e)

f)

g)

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Board considered the action schedule, noting the completed actions and receiving the following updates: 25th June 2014: 249/14 (c.): item 12.2: Corsellis collection: referring to Dr Richie’s comments regarding the potential for the Corsellis collection to become cost neutral, Mrs Byrne said she was not confident that this would be achievable and it was noted that the R&D Committee would continue to monitor the financial implications. 25th June 2014: 249/14 (d): item 12.2: R&D strategy update: noting that Dr Ritchie would be attending the Board Development Session in September, Ms Higgins stressed the need for his presentation to include a clear financial report. 15th June 2014: 246/14 (d): item 10.3: bank staff DNAs: Mrs Moench advised the Board that, all instances of a bank staff member failing to attend for a shift were followed-up personally by the Head of Temporary Staffing. Also, a policy was currently under development to ensure practice was standardised and a facility on the e-rostering system allowed the inclusion of a any comments regarding an individual’s failure to attend for their shift. 21st May 2014: 206/14 (b): item 12: Board Development Plan: It was noted that the plan had been updated as required and that the new format ‘patient stories’ would become a regular feature of the Board’s agenda from September 2014. 25th June 2014: 249/14 (f): item 12.3: fitness to practice: It was noted that Miss McGee had provided Mrs Moench with the required information. Matters Arising 25th June 2014: 247/14 (a): item 17.1: non executive director appointment: The Chairman advised the Board that he had, today, received a letter from Imperial College with a nominated non executive director, to fill the vacancy left by the departure of Professor Lefkos Middleton.

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Discussion: Action:

302/14 Item 6

CHAIRMAN’S REPORT The Board received the Chairman’s report, the content of which was noted.

303/14 Item 7

a)

b)

c)

d)

e)

f)

g)

h)

i)

CHIEF EXECUTIVE’S REPORT Mr Shrubb presented his report to the Board. Two Year Operating Plans Members noted the Trust’s response to the TDA’s letter regarding the 2 year operating plan 2014/15 -2015/16. Ms Higgins asked for additional information regarding the Trust’s non-recurrent income. Mrs Byrne said there was a relatively small amount with in Local Services, but none in High Secure or Forensic Services. She said, in terms of materiality, which was deemed to be circa £0.5m, there was nothing. Mrs Byrne undertook to bring the detail of recurrent and non-recurrent funding to the F&I Committee in October and she reminded members that the Trust did not release any non-recurrent income into the system recurrently. The Board considered Mr Shrubb’s response to the letter to be accurate and straightforward and endorsed its content. Mental Health & Wellbeing Strategy The plans for the 8 north west London CCGs to develop a strategy, co-ordinated by the existing Mental Health Programme Board were noted. Kings Fund Report on Staff Engagement The Board was interested to note the proposal that the NHS should explore an organisational model based on mutual social enterprises. There was no suggestion that this model would be an alternative to becoming an FT and such organisations would still be subject to CQC scrutiny. The Board agreed to set aside some time to consider this further. Filming Board Meetings The Board had previously discussed filming its meetings to make their content available to a wide range of stakeholders. In response to this, Ms Feger had prepared a briefing paper with a range of options for members to consider. Following discussion, it was agreed that ‘option D’, a monthly information film, produced by the communications department, which would focus on key strategic highlights from the Board meeting along with other key messages, would probably be the most accessible and cost effective.

Mrs Byrne Mr Shrubb

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Ref:

Discussion: Action:

j)

k)

The Board asked Ms Feger to develop this proposal; to provide detailed costings and identify the resources required to deliver it, which Mrs Moench said should be considered in the wider context of improving staff engagement. Mrs Byrne said that whilst she fully supported the proposal and recognised the value and importance of staff engagement, given current financial constraints, the Board may need to consider stopping something else in order to fund this development. The Chairman noted this concern and said further consideration would be given to it when Ms Feger’s follow-up report was received.

Ms Feger ALL

304/14 Item 8.1 Item 8.2 Item 8.3

a)

b)

c)

d)

e)

EXECUTIVE DIRECTORS’ REPORTS Interim Director of Local Services’ Report Ms Rushton presented her report, drawing members’ attention to the current bed pressures which had necessitated the temporary opening of Starlight ward. In response to Ms Higgins’ question, Dr Phelan said that peaks of demand were not uncommon in mental health services and it was the CSU’s effective bed management that reduced the need for the contingency plans to be implemented more frequently. Director of High Secure & Forensic Services’ Report The Board received and noted Miss McGee’s report. She drew members’ attention to Broadmoor Hospital’s cancellation of activities on 13 occasions during May, advising that a number of staff had been recruited to existing vacancies, but had not yet started in post. The Chairman, noting that Broadmoor had met its CQUIN targets for 2013/14, formally recorded his thanks to the staff for their efforts. Medical Director’s Report In Dr Broughton’s absence, Dr Phelan presented his report to the Board. Members were disappointed to note that Imperial College’s planned review of psychiatric research had yet to commence owing to an inability to identify an independent, review panel chair. Mr Shrubb described this as very frustrating. Ms Higgins suggested that the Trust should feed proposals for PhD study topics to the university, in order to potentially increase benefits to the Trust from this academic link. Mr Shrubb agreed this would be helpful and gave examples of the type of studies, some currently ongoing, that would contribute to future service development.

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Ref:

Discussion: Action:

Item 8.4

f)

g)

h)

Director of OD & Workforce’s Report Mrs Moench presented her report to the Board which detailed the actions the Trust had undertaken to improve the content and uptake of mandatory training. The Chairman suggested that services be charged for staff who did not attend courses for which they were registered. Mrs Moench agreed this was feasible but the cost of administration made it an unattractive proposition. Instead, the Trust used the Exchange system to send alerts to the managers and they were expected to follow up with their staff and take appropriate action to address non-compliance. Mrs Moench tabled up to date figures which showed significant improvement in the completion of PDR reviews 2013/14 and the setting of objectives 2014/15. There was some discussion regarding the breakdown of the data, in that not all staff had been allocated to the correct department. The recommendations contained in the report were approved, with the Board noting that the organisation was committed to improving the quality of PDRs and work was currently underway to achieve this. Members agreed that the threshold for compliance should be set at 90%.

305/14 Item 9

a)

b)

c)

d)

e)

INTEGRATED PERFORMANCE REPORT The Board discussed the IPR in some detail. KPI 013 – in-patient readmission rate: Ms Rushton said she had examined the detail underpinning this indicator and was satisfied that any spikes in the data were random. There was no correlation with bed pressures. A small number of service users with complex needs were known to engage in high risk behaviours in order to be readmitted and their clinical management was discussed at the complex case meetings. KPI 057 – DNA rate CAMHS (all HCPs): the Board noted the rise to 22% (296 non attendances out of 1351 appointments) of the DNA rate in June 2014 and agreed to keep this indicator under active review. KPI 035 – CQUIN linked to income loss: Ms Higgins asked why there was no data for the past 3 months and Ms Rushton explained the reconciliation process to be undertaken with commissioners before the Trust was able to confirm whether the target had been met. Finance – cost improvement plans: The Chairman expressed concern regarding the achievement of CIPs this year. Mrs Byrne said that the organisation was still on track to deliver the Trust’s financial plan. She agreed the CIP variation from plan was an

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Ref:

Discussion: Action:

f)

g)

h)

issue and the subject of weekly review. Without radical change in service delivery, however, the situation was unlikely to improve. Mr Shrubb said discussions were ongoing with commissioners regarding the need to fund adequately current service provision and he confirmed it had been made clear that unfunded activity was not sustainable. Mr Rushton said she expected Local Services’ budgetary position to be back on track by year-end, referring to skill mix changes in in-patient services, and stressing again that the main issues were commissioning related rather than due to poor internal management. Dr Phelan emphasised the need for senior management to support clinicians struggling to meet client need with limited resources. The Chairman suggested that the Board be provided with a projected year end outturn figures. Mrs Byrne confirmed that this would be submitted to the F&I Committee’s September meeting for a detailed discussion and, thereafter come to the Board. There was some discussion regarding the approach to be adopted in negotiations. Mr Shrubb emphasised the need to provide commissioners with informative data and independently verified figures. He said clinicians needed to be involved in the decision making processes regarding future service design and assured the Board that the Trust’s overall financial viability was seen favourably. Finance – capital (non-redevelopment): Mrs Byrne reminded the Board that for the reasons discussed in confidential session, the Trust’s capital programme was under particular pressure.

Mrs Byrne

306/14 Item 10.1 Item 10.2

a)

b)

c)

BOARD MEMBERS’ VISITS Brunel Ward – 18th June 2014 Ms Higgins said there appeared to be a disconnect between the work being undertaken in relation to staff engagement and the feedback received during this visit. Miss McGee emphasised that these issues were understood by the CSU’s senior management team, referring to the recent presentation to the Board by Dr Romero, Mr Carthy and Ms Harwood. Tom Main Ward – 18th June 2014 Noting the reference to staff supporting smoking breaks for patients, Mr Rose asked what progress was being made with the review of the Trust’s smoking policy. Miss McGee said Mr Jimmy Noak was leading on this and would be reporting to the Board in November. Mr John Killeen will be addressing the issues raised with respect to the ligature audit.

Mr Noak

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Ref:

Discussion: Action:

Item 10.3 Item 10.4

d)

e)

f)

The Limes - 18th June 2014 Ms Rushton fed back on the visit she and Mr Rose had made to the Limes, referring to the good standard of patient care that had been in evidence. However, some issues of concern relating to site security had been identified and these were being discussed with Mr Killeen. Rollo May Ward – 9th July 2014 Ms Rushton advised the Board that she had reported immediately the lack of functioning radios on the ward and, as a result Mr Killeen subsequently confirmed that a new system would be in place from 22nd July 2014. The Board discussed the process for bringing issues identified during these visits to the CSUs’ attention in a timely way and the necessity for senior management teams to ensure required action is undertaken.

307/14 Item 11

a)

b)

NURSE & HEALTHCARE ASSISTANT STAFFING LEVELS: EXCEPTION REPORT – JUNE 2014 The Board noted Dr Aiyegbusi’s report, which detailed all the occasions during June 2014 where ward staffing levels failed to meet planned requirements. 58 (1.3%) of shifts were RAG rated red as a result of staffing shortfalls being escalated to unit co-ordinators or site managers. It was agreed that future reports would contain trend data and, in due course, comparisons with other similar organisations would be possible.

Dr Aiyegbusi

308/14 Item 12

a)

b)

BUSINESS PLANNING: QUARTER 1 MONITORING REPORT Mr Stacey joined the meeting to present an update of progress against the Trust’s annual business plan and corporate objectives. Discussion focussed on ensuring that RAG ratings realistically reflected achievements. Members thought it incongruous that, given earlier discussions regarding the Trust’s performance against its CIP targets, its only ‘amber’ rated milestone related to the ‘Bright Ideas’ portal. The Chairman urged Mr Stacey to bring this project to a conclusion as it was identified as a priority through the staff reporters’ feedback. Another apparent inconsistency was a ‘green’ rating for the Shifting Settings of Care work. Ms Rushton explained it was ‘green’ because all the actions scheduled for completion by the Trust, to date, had been achieved. However with only 72 people having been discharged back to secondary care so far, she felt the rating did not accurately reflect the position of the overall objective.

Mr Stacey

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Ref:

Discussion: Action:

c)

It was agreed that, in future, once directors had RAG rated their progress against milestones, this would be subject to peer review, challenge and sense checking at the Executive Directors’ forum, to ensure consistency, before onward reporting to the Board.

Mr Stacey / Executive Directors

309/14 Item 13

a)

b)

c)

d)

e)

f)

REPORT ON PROGRESS WITH ORGANISATION DEVELOPMENT & WORKFORCE STRATEGY The Board was pleased to receive Mrs Moench’s update on progress with implementing the Trust’s OD & Workforce Strategy. She outlined the structure and governance arrangements for the underpinning workstreams and fed back on the work of the Staff Engagement Committee. A recent review of staff engagement, conducted by the Trust’s internal auditors, which provided ‘reasonable assurance’ would be received by the Audit Committee in September, she said. Board members expressed disappointment that the recent staff survey and temperature check had shown there was still much work to be done to embed culture change and improve staff satisfaction levels. Mrs Moench said emerging themes were broadly in line with those from the initial ‘fishbowl’ exercise. The importance of line managers in enabling cultural change was emphasised and the Board was pleased to note the initiatives that had been brought in to support and develop this group. Mrs Moench anticipated that next year’s staff survey results would begin to reflect results of the work undertaken thus far. Dr Phelan felt that clinical leadership at team level remained a key issue and, as staff survey results showed that doctors were one of the least engaged staff groups, Mrs Moench agreed that more needed to be done to address this. Another ‘fishbowl’ exercise had been planned for February / March 2015 but, in light of the forthcoming CQC inspection, the timing of the staff survey and the implementation of revised clinically led structures, Mrs Moench sought the Board’s view on whether this should be reconsidered. Members were strongly in favour of repeating the exercise but agreed that it should be re-scheduled.

Mrs Moench

310/14 Item 14

QUARTERLY REPORT OF DOCUMENTS SEALED The Board received and noted the report of documents signed and sealed during quarter 1 (April to June) 2014/15.

311/14 Item 15

a)

AUDIT COMMITTEE The Board received the chair’s report of the Audit Committee

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Ref:

Discussion: Action:

b)

c)

d)

e)

f)

g)

meeting held on 2nd July 2014 and its ratified minutes of 27th May 2014. Ms Higgins drew members’ attention to the poor outcome of the I.T. disaster recovery audit and explained how the report’s recommendations were being addressed to improve practice. The Committee had also discussed how safe the Trust was from cyber-attacks and, having ascertained that an annual report on penetration testing was produced, requested that this be taken to the Informatics Sub Committee in future. The Board revisited the issue of committees being required to produce annual reports and the suggestion, at the last Board meeting, that this practice might cease. Following discussion it was agreed that, going forward, the F&I and QA Committees would still be required to produce such a report for the Audit Committee and the Audit Committee was required to produce one for the Board. For other committees and forums production would cease. Broadmoor Hospital Redevelopment Invoice Approval Limits Ms Higgins advised the Board that this issue had been brought to the Audit Committee as the Redevelopment Team was seeking approval of a process that would require amendment of the Trust’s Standing Orders/Standing Financial Instructions (SO/SFIs). Invoices from Kier for the work being undertaken at Broadmoor would routinely be in excess of £1m. Under SO/SFIs approval for this magnitude of expenditure was reserved to the Board but it would not be possible to seek Trust Board approval for each invoice and still meet contractual deadlines. Therefore, for this project only, the proposal was for revised approval limits, to be delegated to senior members of the Redevelopment Team and to the Chief Executive. There was some debate regarding the reference to ‘cashflow’ and Mrs Byrne explained that this referred to the main works cashflow, which was agreed with Kier at the beginning of each year. She said it would not be possible for Kier to get ahead of the agreed cashflow, but if work was delayed (e.g. because of bad weather) it may be possible as they caught up, for the cost of work undertaken during the period to exceed £5m in value. Mrs Higgins sought confirmation that any proposed changes to the main works cashflow would be brought to the Board’s attention and Mrs Byrne said that it would, via the Broadmoor Hospital Redevelopment Programme Board The Board considered the proposal and agreed to accept it, subject to

an absolute maximum delegated approval limit of £10m.,

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Ref:

Discussion: Action:

anything above that amount being reserved to the Board

there being no further delegation down and, in the absence of any named signatory, invoices being passed to the next level up for authorisation

the addendum to the SO/SFIs providing clear information on the cashflow or detailing where this can be found (document & page)

the provision of quarterly reports via the Programme Board, to the Trust Board on expenditure

312/14 Item 16

a)

b)

c)

QUALITY ASSURANCE COMMITTEE The Board received and noted the Chair’s report of the Quality Assurance Committee (QAC) meeting held on 9th July 2014 and its approved minutes of 7th May 2014. Mr Rose drew the Board’s attention to the recent Clinical Effectiveness & Compliance sub-committee meetings being inquorate. He also recommended that more Board Member Visits should be made to community rather than in-patient settings and highlighted the Committee’s request to Mr Joseph and Dr Broughton that they review the BAF risk relating to the management of clinical risk (risk ref 6754: failure to manage clinical risk effectively, resulting in serious self-harm or suicide) and advise the Committee on actions to be taken to reduce the risk rating. Mr Rose reported that QAC had discussed the need to ensure the organisation’s culture was one of supervision and support, expressed concern regarding possible under-reporting of incidents and suggested that this might be the subject of a future Board Development Session. Mr Shrubb and Dr Broughton will meet to discuss these issues.

Mr Shrubb / Dr Broughton

313/14 Item 17

STRATEGIC PROJECTS PROGRAMME BOARD The Board received the chair’s report of the Strategic Projects Programme Board meeting held on 24th June 2014 and its ratified minutes of 27th May 2014.

314/14 Item 18

a)

b)

TRUST MANAGEMENT TEAM The chair’s report of the Trust Management Team meeting held on 16th July 2014 and the approved minutes of the meeting held on 11th June 2014 were received and noted by the Board. The Chairman noted with concern that the R&D Department were currently predicting a year-end overspend of £32k. Mr Shrubb explained that the delay in signing the TOMMORROW contract had impacted on this position and he assured the Board that the Trust Management Team would continue to monitor closely the ongoing financial position.

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Ref:

Discussion: Action:

315/14 Item 19

a)

b)

c)

d)

SERVICE USERS’ & CARERS’ FORUM The chair’s report of the Service Users’ & Carers’ Forum of 8th July 2014 and the approved minutes of the meeting held on 6th May 2014 were received and noted by the Board. Mr Shrubb provided an update on progress being made to establish the West London Collaborative and fed back on a recent meeting he had held with Dr Aiyegbusi, Ms Flippa Watkeys and Ms Jane McGrath at which a number of actions had been agreed. Issues around capacity had been explored as had the apparent disconnect between the expectations of the Collaborative and Accession. Mr Shrubb advised the Board that it had been made clear that no funds could be released until the West London Collaborative existed as an entity with a steering group and a constituency and to this end he had encouraged Ms McGrath and Ms Watkeys to greater collaboration with other service users and carers.

316/14 Item 20

BROADMOOR REDEVELOPMENT PROGRAMME BOARD The Board received the chair’s report of the Broadmoor Hospital Redevelopment Programme Board meeting held on 7th July 2014, its ratified minutes of 13th January 2014 and the project timeline.

317/14 Item 21

ANY NEW RISKS IDENTIFIED OR CHANGES TO RISKS PROPOSED No new risks had been identified or changes to other risks proposed.

318/14 Item 22

ACTIONS REMITTED TO OTHER COMMITTEES To F&I Committee

receive a report outlining recurrent and non-recurrent service funding (minute 303/14 (c.) refers) – to October meeting

to receive and consider in some detail the projected year end outturn figures (minute 305/14 (g) refers) – to September meeting

319/14 Item 23

ANY OTHER BUSINESS There were no other items of business to be transacted.

320/14 Item 24

QUESTIONS FROM MEMBERS OF THE PUBLIC There were no members of the public in attendance.

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Ref:

Discussion: Action:

DATE OF NEXT MEETING

Wednesday 24th September 2014 White Room Trust Headquarters 1 Armstrong Way Southall UB2 4SA

REFLECTION Following completion of formal business, Board members reflected in confidence on the operation and content of the day’s meeting.

Signed: ________________________________ Date: ________________________

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TRUST BOARD MEETING

ACTION SCHEDULE

WEST LONDON MENTAL HEALTH NHS TRUST

Work in progress, not yet due WIP

Completed on time Green

Completed late Amber

Incomplete and overdue Red

MEETING

DATE

MINUTE

NUMBER

AGENDA

ITEM

AGREED ACTION ACTION LEAD BY WHEN

(end of)

REVISED

DATE

UPDATE ON PROGRESS STATUS

25-Jun-14 245/14 (t) Item 9 cost improvement plans - provide a quarterly

review of financial performance, including a

review of CIPS

Mrs Byrne Sep-14 Completed: on (confidential) agenda Green

25-Jun-14 250/14 (c.) Item 13 BAF: ensure most up to date information re risk

reviews is captured in reports

Mr Joseph Aug-14 Completed: Green

30-Jul-14 308/14 (b) Item 12 Bright Ideas' - to be implemented Mr Stacey Sep-14 Completed: successfully launched to

staff on 18Aug14. 5 submissions from

staff were received in the first 24hrs

Green

30-Jul-14 309/14 (f) Item 13 Fishbowl' exercise - report back on proposed

new timing of next exercise

Mrs Moench Sep-14 Completed: The timing of the fishbowl

exercise was discussed at the July Staff

Engagement Committee and it was

agreed that the exercise will be

conducted in the 3rd quarter of 2015/16

Green

30-Jul-14 312/14 (c.) Item 16 Quality Governance Issues - meet and discuss

how the concerns raised by QAC might be

addressed

Mr Shrubb / Dr

Broughton

Aug-12 Completed: meeting took place on

11Aug14 when these issues were

explored

Green

30-Jul-14 305/14 (f) Item 9 Projected year-end financial outturn - provide

report to F&I in September

Mrs Byrne Sep-14 Completed: Report was submitted &

discussed.

Green

KEY

COMPLETED - on time

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TRUST BOARD MEETING

ACTION SCHEDULE


MEETING

DATE

MINUTE

NUMBER

AGENDA

ITEM


(end of)

REVISED

DATE


NONE THIS MONTH

NONE THIS MONTH

26-Mar-14 111/14 (g) Item 9 IPR - provide a list of targets & definitions for the

KPIs

Dr Broughton Sep-14 Update 16Sep14: work is ongoing to

complete this before month end

WIP

30-Apr-14 165/14 (c.) Item 15 Objectives & Strategic Aims etc - produce single

page document that captures objectives, aims,

quality priorities, values & vision

Mr Stacey Jul-14 Oct-14 Update 11Sep14: Board to receive

update on work to refresh vision etc. at

Board Development Seminar on

17Sep14

WIP

30-Jul-14 303/14 (b) Item 7 Recurrent & non-recurrent income - take paper

to F&I in October

Mrs Byrne Oct-14 WIP

30-Jul-14 308/14 (c.) Item 12 Business Plan RAG rating - RAG rated

objectives to be peer reviewed by E.Ds prior to

reporting to Board

Mr Stacey /

Executive

Directors

Oct-14 WIP

30-Jul-14 306/14 (b) Item 10.2 Trust smoking policy review - report to the Board Mr Noak Nov-14 WIP

21-May-14 201/14 (e) Item 7 access/waiting times for mental health services:

revisit these issues (Board Development

Session?)

Mr Shrubb Nov-14 WIP

30-Jul-14 303/14 (f) Item 7 Kings Fund report on staff engagement - identify

time for Board to discuss mutual social

enterprise model

Mr Shrubb early

2015/16

WIP

30-Apr-14 160/14 (f) Item 10.3 Cherrington House - feedback on plans and

progress with service changes

Ms Rushton Oct-14 Jan-15 Update 11Sep14: The urgent care

business case is with the

commissioners who have requested

further information prior to decision

making. Revised date for paper to TMT

is Nov14

WIP

WORK IN PROGRESS (not yet due)

INCOMPLETE & OVERDUE

COMPLETED - late item

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TRUST BOARD MEETING

ACTION SCHEDULE


MEETING

DATE

MINUTE

NUMBER

AGENDA

ITEM


(end of)

REVISED

DATE


30-Jul-14 303/14 (j) Item 7 Filming Board meetings - provide costed

proposal for a monthly information film, including

any additional resources required in context of

wider staff engagment work

Ms Feger Jan-15 WIP

30-Jul-14 307/14 (b) Item 11 Nurse & HCA staffing levels report - include

trend analysis in future reports and comparisons

with other organisations

Dr Aiyegbusi Jan-15 Update 15Sep14: trend analysis

included this month. Report will evolve

over time as more information becomes

available

WIP

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SUMMARY REPORT - TRUST BOARD MEETING (PART 1):

24 September 2014

Report Title: Chief Executive’s Report to the Board

Executive Lead: Chief Executive

Report Author(s): Chief Executive

Report discussed previously at: N/A

Purpose of the Report and Action Required

To provide an update to the Board on issues of note. Approval

Discussion

Information

Summary of Key Issues

Relationship to Trust Strategic Aims

SA1: To provide a safe and effective service.

SA2: To deliver excellent personalised care, treatment and support.

SA3: To become a provider of choice.

SA4: To continuously improve the quality and productivity of our services.

SA5: To build an engaged workforce that is focussed on recovery and the needs of service users and carers.

Relationship to the Board Assurance Framework

Are any existing risks in the Board Assurance Framework affected?

If yes, insert relevant risk reference:

Do you recommend a new entry to the Board Assurance Framework (i.e. Trust-wide level 1 risk) is made?

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Corporate Impact Assessment OR Board Statements: Assurance(s) against:

Legal and regulatory implications

Financial Implications

Equality and Diversity

Public, Service User and Carer

Performance Management

Communication

Relevance of Report to Monitor’s Quality Governance Framework

Strategy Yes

Capabilities and Culture Yes

Processes and Structure Yes

Measurement

Acronyms / Terms used in the report

Supporting Documents &/or Further Reading

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TRUST BOARD MEETING (PART 1) – 24 SEPTEMBER 2014

CHIEF EXECUTIVE’S REPORT

1 RECRUITMENT

1.1 Board colleagues will be aware of the context in which the decision was taken to

bring recruitment back into the trust. Significant progress has been made in transferring recruitment back from Capita. A new recruitment team has been appointed and two staff members started early. The focus has been to identify where individuals are in the recruitment process so that priority can be given to getting clinical staff (mainly nurses) in post. The data received from Capita has underlined the delays that have built up. I remained concerned that the delays are impacting on the Trust’s ability to maintain appropriate staffing levels. The situation is being monitored closely and executive directors are discussing what further actions should be taken to maintain safe care.

2 ANNUAL AWARDS 2.1 I had the pleasure on the 8th of September of presenting awards to 60 staff who

had completed training programmes (either provided or supported by the Trust). The majority of the staff were Bands 1-4 and had undertaken training programs which included health and safety, administration, security, care of diabetes and care of dementia.

3 CHIEF MEDICAL OFFICER’S REPORT 3.1 I have sent Board members copies of the CMO’s report which clearly describes the

need to give a greater priority to mental health. This is the first time I can recall a CMO's report has contained such a clear message regarding mental health

4 MRS VICKIE HOLCROFT, REDEVELOPMENT PROGRAMME DIRECTOR

4.1 Mrs Vickie Holcroft has decided that now is the right time for her to retire. I would

like to place on record the Trust's thanks for the work she has done since joining the organisation in January 2010 without which the full business cases and subsequent funds would not have been achieved to develop a new Broadmoor Hospital and a new medium secure service. Vickie's hard work, tenacity and commitment has made a significant contribution to the development programme. Vickie will continue in post until the end of November.

Steve Shrubb Chief Executive

24 September 2014

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24th September 2014

Report Title:

Executive Director Report, Local Services

Executive Lead:

Sarah Rushton, Executive Director

Report Author(s):

Sarah Rushton

Report discussed previously at: n/a


To inform the Board of key issues not covered in other Board specific reports

Approval

Discussion

Information


The report updates the Board on events and issues related to Local Services.







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no



no







Communication


Strategy

Capabilities and Culture

Processes and Structure

Measurement


GIC Gender Identity Clinic

SMT Senior Management Team

CNWL Central & North West London Foundation Trust


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TRUST BOARD MEETING (PART 1) – 24th SEPTEMBER 2014

EXECUTIVE DIRECTOR REPORT – LOCAL SERVICES

1 PURPOSE

1.1 The purpose of this report is to inform the Board of key issues not covered in other

specific reports. 2 RECOMMENDATION(S) 2.1 The Board is asked to note the report 3 ISSUES RELATING TO LOCAL SERVICES 3.1 The interviews for the Urgent Care and Planned Care Clinical Director posts will

take place on 11th and 19th September. 3.2 The time-limited project management for managing all the component parts of the

change to service line delivery, including budgets, governance, performance reporting and the transfer of specialist services has recruited and will start during October.

3.3 The transfer of the operational management of the Rehabilitation Service (Mott

and Glyn) took place on 1st September following a number of consultation meetings with staff.

3.4 Work continues with the Forensic Service to disaggregate the performance

and finance of the specialist services which will transfer to Local Services namely the GIC, the Cassel and the Rehabilitation Service. The transfer date is set for 1st November.

3.5 The Local Services’ SMT has noted a gap in the leadership and capacity to

deliver on nursing developments such as the Safewards initiative and some elements of the Francis action plan. It is proposed that a new post is created of Head of Nursing. To create the funding for this post a limited restructure and consultation will be required.

3.6 Local Ealing Southall MP Virendra Sharma visited the Wolsey Wing on 4th

September and expressed support for mental health services. He expressed an interest in further work with the Trust.

4 NORTH WEST LONDON MENTAL HEALTH STRATEGY 4.1 Shaping Healthier Lives is the current 8-borough strategic plan for mental health

services in North West London, developed with support from McKinsey in 2012. This was a three year plan, due to conclude in 2015. As such, commissioners and providers in North West London have agreed the need to refresh this and develop a more rounded mental health and wellbeing strategy.

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4.2 Much has changed over the course of Shaping Healthier Lives. Significant strategic projects such as Shaping a Healthier Future and Whole Systems Integration have made progress; in combination with the financial challenge facing the NHS, an ambitious new plan needs to be developed. It is acknowledged that the new strategy needs to be broader than before - taking in all age groups, populations and partners, particularly social care and public health / prevention, both of which sit within Local Government.

4.3 NHS North West London has identified six key stages in developing this plan:

establishing the needs and wants of the population developing the evidence base for good quality care establishing the ambitions and the case for continuity and change developing the proposed care models establishing the required infrastructure to deliver, and identifying options for

change implementation plan.

4.4 This is an ambitious project, which will require significant clinical input and support.

An initial phase was initiated in August 2014, supported by external consultants Carnall Farrar. This focuses on the Trust's finances, activity, performance and transformation readiness. We are working closely with neighbouring CNWL as the project continues, and expect initial findings in early October, to inform the wider project described above.

Sarah Rushton Executive Director Local Services

September 2014

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24th September 2014

Report Title:

Monthly update from High Secure Services CSU and Specialist & Forensic Services CSU

Executive Lead:

Leeanne McGee Executive Director, High Secure Services and Forensic Services

Report Author:

Leeanne McGee

Report discussed previously at: Senior Management Team and Heads of Service meetings


To provide the Board with salient information Approval

Discussion

Information










N/A



N/A

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N/A


N/A


N/A


User involvement and participation evident


N/A

Communication

N/A


Strategy



Measurement


MHA Mental Health Act

ECT Electro Convulsive Therapy


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TRUST BOARD MEETING (PART 1) – 24TH SEPTEMBER 2014

MONTHLY UPDATE FROM HIGH SECURE SERVICES AND SPECIALIST & FORENSIC SERVICES

1. PURPOSE 1.1. The purpose of this report is to provide an update on activity in High Secure and

Forensic Services. 2. RECOMMENDATION(S) 2.1 The Board is asked to note the contents of this paper. 3. ISSUES FROM HIGH SECURE AND FORENSIC SERVICES 3.1. Following the publication of The Savile Investigation Report on 26 June 2014 a

review of governance arrangements Trust-wide has commenced, led by Malcolm Rae.

3.2. Thirty two ward activities and twenty seven sessions provided by Sports and

Leisure, the Caffe, Main Workshops and Kitchen Gardens within Broadmoor Hospital were cancelled in the month of August when staff were redirected from off ward activities or there were insufficient staff to provide the planned activity on the ward.

3.3. Forensic Services and Broadmoor have developed a secure services version of a

national suicide prevention audit tool. The Trust worked in collaboration with NHS England and the instrument was launched on the NHS Confederation website on 10th September (World Suicide Prevention Day).

3.4. ImROC published a new briefing entitled ‘Recovery in Secure Settings’ on 11th

September 2014. A number of senior clinicians within the Trust have contributed to the development of the recently published guidance.

3.5. Andrew Herd, Policy Lead for High Secure Services at the Department of Health

visited Broadmoor Hospital on 3rd September to meet with patients as part of the consultation process around the MHA Code of Practice. The Trust submitted its response to the consultation on 11th September 2014.

3.6. The ECT Clinic at Broadmoor has been accredited with continuing excellence for

year one of the three year cycle. 3.7 The Rt Hon Norman Lamb (Minister of State for Care & Support) visited the hospital

on 10th September 2014 to formally open the Violence Reduction Centre. He received an update on the Trust’s implementation of ‘positive and safe’ practices and met the staff who provide the training at Broadmoor.

3.8. Dr Callum Ross, Interim Clinical Lead for PD at Broadmoor, has recently published

a paper on ‘Clozapine and the Treatment of Men with Psychopathic Disorders’,

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which has attracted one of the largest number of downloads and will also be published in several journals.

3.9. Senior Managers at Broadmoor have met with Staff Side representatives regarding

the proposal that the Hospital Leads will not be included in the CIPs for the next 12 – 18 months. Staff side were happy with this proposal.

4. RECOMMENDATION 4.1. The Board is asked to note the content of this report

Leeanne McGee Executive Director High Secure Services

& Forensic Services September 2014

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24th September 2014

Report Title:

Medical Director’s Report

Executive Sponsor:

Nick Broughton, Medical Director

Report Authors:

Medical Director



To inform the Board regarding key issues relating to the Medical Directors portfolio of responsibilities

Approval

Discussion

Information



SA2: To provide excellent personalised care, treatment and support.



SA5: To build an engaged workforce which is focussed on recovery and the needs of service users and carers.



No

If yes, risk reference n/a


No

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Corporate Impact Assessment


None

Financial Implications None

Equality and Diversity None

Public, Service User and Carer None

Performance Management None

Communication None


Strategy



Measurement


GMC General Medical Council

Attachments / Appendices

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MEDICAL DIRECTOR’S REPORT

1 PURPOSE 1.1 To inform the board regarding particular developments related to the Medical

Director’s portfolio of responsibilities.

2 RECOMMENDATION 2.2 The Board is asked to note the report.

3 KEY ISSUES 3.1 National Training Survey 2014 3.1.1 The survey undertaken by the GMC of trainees working across the Trust this year

showed significant improvement in terms of satisfaction and quality of training compared to the last two years. As you will see from the summary document at Appendix 1, the survey demonstrated marked improvement in general psychiatry where previously the Trust had performed poorly as demonstrated by the number of areas where we were a strong negative outlier. This year there were only two areas where the Trust was found to be such an outlier namely workload in Child & Adolescent Psychiatry and clinical supervision in medical psychotherapy. The medical education team is currently working closely with the relevant clinical leads and education supervisors in order to address these areas and to ensure the continued improvement in the Trust’s performance.

3.2 Information Governance

3.2.1 The Trust’s Information governance manager Edwina Withe, retired earlier this

month and has been replaced on an interim basis by Keith James. Keith brings with him considerable information governance experience having worked in a variety of healthcare organisations in this field for more than a decade.

3.3 External Governance Review

3.3.1 The external governance review commissioned in response to the findings of the Jimmy Savile investigation began earlier this month. The review is being led by Mr Malcolm Rae. Malcolm will be assisted in this undertaking by Sue Hooton and Stephen Colgan. Attached at Appendix 2 are the amended terms of reference for the review.

3.4 New Electronic Patient Record

3.4.1 The Trust’s new electronic patient record system, RiO Version 7, went live as

planned on the 11th August across the Trust’s London Services. In the immediate aftermath of the rollout there were a number of technical difficulties including an outage caused by incompatible hardware in the Servelec Data Centre. Such

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problems were resolved quickly and the IM&T Department has been impressed by the responsiveness to date of Servelec. A number of benefits from the new system have already become apparent including the ability to modify forms.

3.4.2 It is planned that the new system will now go live in Broadmoor Hospital towards the end of October and in line with this training for Broadmoor staff has begun.

3.5 Research & Development

3.5.1 Dr Kevin Murray has been appointed to become the Trust’s new R&D Director and

as such will succeed Dr Craig Ritchie who has been appointed to a professorial position at the University of Edinburgh beginning 1st October.

3.6 Medical Engagement

3.6.1 A survey of the Trust’s medical workforce completed during the course of August demonstrated relatively high levels of medical engagement across the Trust when compared to a data base comprising of survey results from 80 comparable organisations.

3.6.2 The survey’s findings and recommendations will now be discussed and addressed at the Staff Engagement Committee and inform work going forward.

Dr Nick Broughton Medical Director September 2014

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West London Mental Health NHS Trust

Programme Group Indicator 2012 2013 2014 2012 2013 2014

Overall Satisfaction WHITE WHITE WHITE 80.33 81.73 79.9

Clinical Supervision WHITE WHITE WHITE 90.87 88.45 90.21

Handover WHITE WHITE WHITE 71.67 60.47 65.2

Induction WHITE WHITE WHITE 83.23 76.7 79.62

Adequate Experience WHITE WHITE WHITE 81.25 82.27 80.77

Work Load WHITE WHITE WHITE 55.82 50.99 46.21

Educational Supervision WHITE WHITE WHITE 78.65 79.55 82.05

Access to Educational Resources WHITE WHITE WHITE 67.3 65.46 63.48

Feedback PINK PINK PINK 78.49 79.56 80.56

Local Teaching WHITE WHITE WHITE 74.52 71.73 73.82

Regional Teaching WHITE RED WHITE 69.56 64.09 70.92

Study Leave WHITE WHITE WHITE 80 69.57 69.59

Overall Satisfaction WHITE PINK PINK 89.33 76.57 78.4

Clinical Supervision WHITE PINK PINK 96.58 88.39 90.1

Handover WHITE WHITE WHITE 40.63 45 41.67

Induction GREEN WHITE PINK 95.83 91.43 79

Adequate Experience WHITE WHITE WHITE 90 81.43 80

Work Load PINK RED RED 45.83 47.32 30.83

Educational Supervision WHITE WHITE WHITE 95.83 85.71 75


Feedback PINK PINK WHITE 81.94 76.78 86.67


Regional Teaching GREEN GREEN GREEN 86.92 88 86.33

Study Leave WHITE WHITE WHITE 84.17 74.05 73

Overall Satisfaction WHITE WHITE WHITE 83.64 85.71 84.4

Clinical Supervision WHITE WHITE WHITE 91.32 94.75 95.28

Handover PINK WHITE WHITE 12.5 41.07 50

Induction WHITE WHITE PINK 85 92.14 73

Adequate Experience WHITE WHITE WHITE 85.45 88.57 85

Work Load WHITE WHITE WHITE 61.55 51.79 65

Educational Supervision WHITE WHITE PINK 81.82 78.57 67.5


Feedback PINK WHITE PINK 82.58 87.5 76.39


Regional Teaching PINK WHITE WHITE 63.28 70.06 69.4

Study Leave WHITE WHITE WHITE 91.06 84.76 76.33

Overall Satisfaction RED RED WHITE 76.21 76.75 83.43

Clinical Supervision WHITE RED WHITE 91.67 84.81 91.32

Handover WHITE RED WHITE 25 20 40

Induction RED RED PINK 53.95 56.25 77.14

Adequate Experience RED RED WHITE 75.79 78.13 87.14

Work Load RED PINK WHITE 48.79 49.74 50.74

Educational Supervision RED RED WHITE 65.35 71.88 75

Access to Educational ResourcesRED RED WHITE 57.67 57.77 67.77

Feedback PINK PINK WHITE 76.82 80.28 85.42


Regional Teaching RED RED WHITE 62.5 53.64 68.82

Study Leave WHITE WHITE WHITE 78.11 78.22 90.38

Forensic psychiatry

General psychiatry

Outcome Mean

Core Psychiatry

Child and adolescent psychiatry

NATIONAL TRAINING SURVEY 2014Programme group by trust/board outlier summary

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West London Mental Health NHS Trust

Programme Group Indicator 2012 2013 2014 2012 2013 2014

Overall Satisfaction WHITE WHITE WHITE 81.33 81.33 87

Clinical Supervision PINK PINK RED 88.33 88.75 88.44

Handover GREY GREY PINK 18.75

Induction PINK PINK PINK 65 66.67 72.5

Adequate Experience WHITE WHITE WHITE 80 86.67 92.5

Work Load WHITE WHITE WHITE 50 62.5 64.06

Educational Supervision WHITE WHITE WHITE 75 75 75

Access to Educational Resources WHITE WHITE PINK 63.61 65.56 64.36

Feedback WHITE PINK PINK 84.72 61.11 80.56


Regional Teaching GREY GREY GREY

Study Leave PINK RED WHITE 64.44 66.67 73.33

Overall Satisfaction WHITE WHITE WHITE 86 92 90.67

Clinical Supervision WHITE WHITE PINK 90.75 91.75 90.33

Handover WHITE WHITE WHITE 34.38 28.13 37.5

Induction WHITE WHITE GREEN 70 82.5 98.33

Adequate Experience WHITE WHITE WHITE 87.5 92.5 86.67

Work Load WHITE WHITE WHITE 56.25 53.65 50

Educational Supervision WHITE PINK WHITE 91.67 56.25 75


Feedback PINK WHITE PINK 69.79 83.34 81.95

Local Teaching WHITE WHITE WHITE 64.75 71.75 71

Regional Teaching GREY GREY GREY

Study Leave WHITE WHITE GREEN 94.17 75 98.33

RedPink

GreenLight Green

WhiteGrey

Yellow

Positive in comparison to the average but not quite a positive outlier

Within the range of the average

Less than three Trainees

No Trainees responded to questions relating to this indicator

Strong negative outlier

Negative in comparison to the average but not quite a negative outlier

Strong positive outlier

Medical psychotherapy

Mean

Old age psychiatry

NATIONAL TRAINING SURVEY 2014Programme group by trust/board outlier summary

Outcome

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Revised Terms of Reference 9th September, 2014

External Review of West London Mental Health NHS Trust’s Clinical Governance

Arrangements

The external review will report on:

Terms of Reference 1

A review of the Trust Board’s approach to quality. We will focus on the following

recommendations from the Savile report which indicate the need to address culture :

Recommendation 5 – closed & introspective institutional culture discouraged

physical & sexual abuse reporting & discouraged staff from taking action

Recommendation 9 – Multiple sexual relationships between senior and junior staff &

tolerance of relationships between staff & patients

We will do this at Trust Board level by:

Interviewing Trust Board members around cultural issues

Interviewing non Executive Directors

Reviewing board reports

Reviewing recent progress made

Reviewing internal & external assurance reports

Using CQC ‘well led’ prompts and questions


A review of Trust wide safeguarding arrangements for both children and adults at risk

including a review of current assurance processes regarding the effectiveness of such

arrangements. We will focus on the following safeguarding recommendations in the Savile

report:

Recommendation 1 – Review safeguarding processes within the organisation

Recommendation 4 – Review procedures for safeguarding vulnerable people and

how safeguarding theory is put into practice.

We will do this at Trust Board/ senior Local Authority level by:

Meeting Executive Leads for safeguarding

Reviewing progress made regarding the separate LA responsibilities & the provision

of social workers which might lead to divided responsibilities

Reviewing risk assessment in relation to safeguarding structures & processes

Assessing the effectiveness of safeguarding partnerships

Examining learning as a result of safeguarding investigations

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A comprehensive review of quality governance systems and processes paying particular

attention to:

Reporting arrangements both within selected clinical service units and to the Trust Board.

We will review the effectiveness of the systems and processes currently in place to ensure

the dissemination and embedding of learning (across selected units within the Trust).

The effectiveness of the systems and processes in place to ensure early identification of

areas where patient safety could be compromised.

We will review what we hear at Trust Board and Senor Management level about quality

governance systems and processes by ‘testing’ our findings in 3 clinical services:

Broadmoor Hospital (2 day review)

Low secure services – Solaris unit (1 day review)

Older People’s Services - Jubilee Ward (including Community service links) (1 day

review)

We will do this by:

Visiting local services & interviewing staff on site (MDT focus)

Meeting with service users, family members and advocates

Meeting with commissioners

Reviewing reporting from ‘board to ward’

Reviewing the extent to which local quality data informs decision making

Testing the CQC ‘well led’ prompts with frontline staff

We will prepare a narrative based report to be presented to the senior management team at

the end of November 2014 and to be presented to the Trust Board in December 2014.

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24th Sep 2014

Report Title:

Integrated Performance Report – Aug 2014 (Proposed content and layout)

Executive Sponsor:

Director of Finance & Deputy Chief Executive

Report Authors:

All Executive Directors

Report discussed previously at: A more detailed performance report is discussed at TMT each month


This is a standard monthly report that aims to distil for the Board key areas within the performance framework. The report provides assurance to the Board that expected performance is being delivered and where performance falls below expected levels that action is being taken.

Approval

Discussion

Information


Key Quality and Performance Summary (Medical Director):

Quality: Clinical effectiveness

KPI001- Admission via CRT: Compliance dropped below the 95% target for the second time this year. 91 admissions out of 100 were gate kept by CRT in August

(91 %●). CSU breakdown is as follows; Ealing 95%● (1 breach), H&F 94%● (3

breaches) and Hounslow 84%● (5 breaches). No apparent themes for these

breaches except that three admissions were under Section-2, two admissions under S-136 and one admission under Section-3.

KPI002- Delayed Transfer of Care: Performance improved slightly trust wide (3.6

%●) Hounslow based wards showed an improvement of 2.5% compared to last

month. Registered clients also improved compared to last month but Ealing and Hounslow CCG still exceeded the 7.5% target @ ●12.2% and ●13.3% respectively.

Quality Patient Experience

KPI010- Out of the 34 complaints closed this month, 9 %( 3) were closed over the agreed timeframe - these were within HSS due to final response amendments & further investigation required. The cumulative response rate at the end of this month is 88% which is a slight increase in comparison to 87% last month. Out of the 34 complaints closed: 24 %( 8) were upheld (emerging themes were communication around appointments), 38 %( 13) were partially upheld (themes

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were 'all aspects of care & treatment' - general issues relating to clinical care and 'staff attitude') 38 %( 13) were not upheld (emerging theme 'staff attitude').

KPI011- % Overall Trust Community DNA rate (All HCPs) - DNAs increased slightly in August compared to July but are still within target trust wide. Breakdown by

service is as follows: Local Services 13%●, CAMHS 22%● and Gender 20%●.

DNAs in CAMHS service have increased by 7% in last three months. Spike in CAMHS DNAs is a national trend for children and young people’s services associated with the school holidays.

Quality: Patient safety

KPI015 –Number of Grade 1 Incidents commissioned- 8 Grade 1 Reviews were commissioned in August 2014. HSS (assault physical to staff), LS Ealing In-Patient – (abuse by staff to patient), LS Hounslow Community – (death to patient -suspected suicide), LS H&F Community – (unexpected death of community patient), LS H&F Community (Assault physical to others), LS H&F Inpatient – (self-injury to patient), S&F Male Medium Secure – (Abuse by staff to patient) and S&F Low Secure – (personal accident to patient).

KPI019- CPA 7 day follow ups. Trust wide performance is (93.7 %●) against a

target of 95%. Breakdown by CSU is as follows: Ealing (96 %●), Forensic (56 %●),

H&F (100 %●), Hounslow (94 %●). There were 5 compliant follow ups in Forensic

out of 9 discharges. Out of 4 non-compliant, 2 were discharges to prison, one to care home and one breach where no reason was given by service.

KPI024 - % Staff appraisal – Performance improvement trend continues in August.

Last 3 months’ performance is as follows: (June 63 %●), (July 73 %●) and (August

81 %●). There are variations across CSU's in PDR compliance ratings

External assessment

KPI065 - TDA Financial Risk Rating: The overall TDA risk rating has changed to GREEN, having been AMBER in previous months, as a result of the current CIP performance and forecast CIP position. However further work is currently underway to review the forecast position, which may result in an AMBER rating in future months.

CSU High level KPIs (Director CSUs)

As per CSU High Level KPIs Performance – Summary on IPR Note inclusion of The LS CSU safety thermometer performance

Finance (Director of Finance & Information):

As per Finance - Executive Summary on IPR

Workforce (Director of OD & Workforce):

As per OD & Workforce - Executive Summary on IPR

Risk Rating

As per Risk rating - IPR

Relationship to Strategic Aims

SA1: To provide a safe and effective service. √

SA2: To deliver excellent personalised care, treatment and support. √

SA3: To become a provider of choice. √

SA4: To continuously improve the quality and productivity of our services. √

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√



The IPR is derived from the Trust wide balance scorecard. This is segmented by CSU and there are protocols to determine when red rated items should be added to the risk register









This report provides overall assurance that the Trust Board receives information on key areas of performance

Communication

Key points are summarised in the monthly Team brief. External bodies such as CQC will take note of this report


Strategy



Measurement


The final page of IPR has an explanation of acronyms and specialist terms used


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Contents:

1. Key Quality and Performance Summary

KPI Performance Executive Summary

WLMHT Balanced Dashboard

2. CSU High Level KPIs Performance

CSU High Level KPIs Performance Summary

LS CSU - Safety Thermometer

3. Finance

Finance KPIs

Finance Executive Summary

Finance Activity

4. Organisation Development and Workforce

OD Executive Summary

OD Activity

5. Risk Rating

Risk rating update

6. Glossary

Integrated Performance ReportAugust 2014

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KPI Number

KPI001

Admission via CRT: Compliance dropped below the 95% target for the second time this year. 91 admissions out of 100 were gate kept by CRT in

August (91%●). CSU breakdown is as follows; Ealing 95%● (1 breach), H&F 94%● (3 breaches) and Hounslow 84%● (5 breaches). No apparent

theme for these breaches except that three admissions were under Section-2, two admissions under S-136 and one admission under Section-3.

KPI002

% Delayed Transfer of Care (Sitrep) - All reasons: Trust wide performance improved slighlty in August (3.6%●) compared to July (4.3%●) . All

boroughs except Hounslow (16.7%●) achieved the 7.5% target. Hounslow DToC rate has improved after a peak last month (19.1%●). Ealing and

H&F also decreased the DToC by 2% in August compared to July .

Breakdown by CCG is as follows: Ealing CCG (12.2%●), Hounslow CCG (13.3%●). There was no H&F CCG patient delayed for discharge in August.

KPI Number Comments

KPI008

Complaints have increased this month by 28% (7) when compared with last month from 25 to 32 this month. The 32 complaints are distributed

trust wide as: HSS (16), SFS (9), LS (7) - in comparison to last month complaints have increased in the forensic services by 100% (8) within HSS,

29% (3) in SFS and decreased within LS by 30% (3). There is 100% compliance again this month with the statutory requirement of acknowledging

all complaints within 3 working days. Top 3 themes trust wide have been: 38% (12) all aspects of care & treatment (admission, detention,

unhappy with seclusion, medication concerns, discharge into community, detention), 13% (4) staff attitude (unhappy with consultant, unfairly

treated by staff & alleged bullying), 13% (4) communication/information to patients (lack of communication regarding appointments & incorrect

information being provided).

KPI010

Out of the 34 complaints closed this month, 9%(3) were closed over the agreed timeframe - these were within HSS due to final response

amendments & further investigation required. The cumulative response rate at the end of this month is 88% which is a slight increase in

comparison to 87% last month. Out of the 34 complaints closed: 24%(8) were upheld (emerging themes were communication around

appointments), 38%(13) were partially upheld (themes were 'all aspects of care & treatment' - general issues relating to clinical care and 'staff

attitude') 38%(13) were not upheld (emerging theme 'staff attitude') .

KPI011

% Overall Trust Community DNA rate (All HCPs)- DNAs increased slightly in August compared to July but are still within target trust wide.

Breakdown by service is as follows: Local Services 13%●, CAMHS 22%● and Gender 20%●. DNAs in CAMHS service have increased by 7% in last

three months.

There is always a spike in CAMHS DNAs during August, this is a national trend for children and young people’s services associated with the school

holidays. In previous years the August spike has been more pronounced, it is actually reduced this year as a result of improved admin processes to

ensure confirmation of appointments in advance. There were some sickness absence issues in the admin team which meant that these processes

could not be fully implemented and so we were not able to reach the 15% target.

KPI Number Comments

KPI015

8 Grade 1 Reviews were commissioned in August 2014 being: HSS - MI Directorate being assault physical to staff, LS Ealing In-Patient - being abuse

by staff to patient (SGA), LS Hounslow Community - being death to patient (suspected suicide), LS H&F Community - being unexpected death of

community patient, LS H&F Community - being assault physical to others, LS H&F Inpatient - being self-injury to patient, S&F Male Medium Secure

- being abuse by staff to patient, S&F Low Secure - being personal accident to patient

KPI018There was one community suicide recorded in Local Services Hounslow Community during August. An incident review has been commissioned as

per KPI015 above.

KPI019

CPA 7 day follow up: Trust wide performance is (93.7%●) against a target of 95%. Breakdown by CSU is as follows: Ealing (96%●), Forensic

(56%●), H&F (100%●), Hounslow (94%●). There were 5 compliant follow ups in Forensic out of 9 discharges. Out of 4 non-compliant, 2 were

discharges to prison, one to care home and one breach where no reason was given by service.

KPI026Sickness stands at 4.6% this month. It is expected that this rate will fall once any outstanding open ended sickness is closed and the sickness

module re-ran.

KPI030Cumulative turnover rate (Cumulative) - annual forecast rate: It should be noted there were a higher than normal rate of employees leaving

through Retirement this month which has had an impact on the monthly rate.

KPI Number Comments

KPI038FT Monitor - Governance Risk Rating: Performance is amber in August because we didn't achieve target for CPA 7 Day follow ups and Admissions

via CRT.

KPI065

The overall TDA risk rating has changed to GREEN, having been AMBER in previous months, as a result of the current CIP performance and

forecast CIP position. However further work is currently underway to review the forecast position, which may result in an AMBER rating in future

months.

External Assessment indicators

Key Quality and Performance Executive Summary Data Month 5 (Aug 2014)

Quality - Clinical Effectiveness indicators

Quality - Patient Experience indicators

Quality - Patient Safety indicators

Integrated Performance Report 2014-15 Page 2 of 14

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KPI Quality - Clinical Effectiveness indicators Strategic

AimsFramework Qtr 1

13/14

Qtr 2

13/14

Qtr 3

13/14

Qtr 4

13/14

Qtr 1

14/15Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

KPI001 CRHT Gatekeeping SA1 >95% lE 99% 99% 99% 98% 96% 99% 98% 93.2% 97% 97% 91.0%

KPI002 % Delayed Transfer of Care (Sitrep) - All reasons1 SA1 <=7.5% lE 5% 5% 7% 6% 3.8% 5.2% 4.0% 3.6% 3.9% 4.3% 3.6%

KPI003 % Delayed Transfer of Care (Sitrep) - Health Reasons only1 SA2 <=7.5% lE 3% 4% 5% 5% 3.0% 4.3% 3.3% 2.7% 3.1% 3.4% 2.8%

KPI004Early Intervention Services - New Cases (Cumulative by year

end)SA1 >147 (YTD) lE 43 93 144 190 40 190 15 26 40 54 62

KPI005 Data completeness: identifies MHMDS (Exc CAMHS)2 SA3 >97% lE 99% 99.6% 99.5% 99.5% 99%* 99.5% 99.4% 99.4% 99.4% 99%* 99%*

KPI006 Data completeness MHMDS: Outcomes for Pts on CPA2 SA4 >50% lE 58% 59% 58% 57% 57%* 57.2% 57.4% 57.5% 57%* 57%* 57%*

KPI Quality - Patient Experience indicators Strategic

AimsFramework Target Qtr 1

13/14

Qtr 2

13/14

Qtr 3

13/14

Qtr 4

13/14

Qtr 1


KPI007 Access to health care for people with LD SA2 lE

P P P P P P

KPI008 Number of new Complaints received in period (Trust) SA2 120 100 117 110 102 27 44 29 29 25 32

KPI009 Number of complaints still open outside agreed timeframe 4 SA2 0 lI 0 0 0 2 0 0 0 0 0 0 0

KPI010 Number of complaints closed outside agreed timeframe SA2 0 lI 8 20 15 12 15 5 1 5 9 2 3

KPI011 % Overall Trust Community DNA rate (All HCPs) SA4 <15% 13.6% 13.4% 13.1% 11.9% 12.8% 11.7% 12.8% 12.5% 13.1% 13.5% 13.8%

KPI012 % Overall Trust Cancellation rate (All HCPs) SA4 <5% 2.6% 2.3% 2.3% 2.7% 3.3% 2.5% 3.4% 3.3% 3.2% 2.6% 2.9%

KPI013% Inpatient Readmission Rate for Acute Local CSU (All ages

and wards) (30 Days)SA4 CCGs

<8.1 end

Qtr 4l

E 9.6% 8.4% 9.1% 5.3% 9.2% 4.3% 9.6% 5.7% 12.3% 5.8% 8.0%

KPI Quality - Patient Safety indicators Strategic


13/14

Qtr 2

13/14

Qtr 3

13/14

Qtr 4

13/14

Qtr 1


KPI014 Number of Grade 2 Incidents commissioned SA1 0 lI 2 4 2 1 1 0 1 0 0 0 0

KPI015 Number of Grade 1 Incidents commissioned SA1 0 lI 12 17 11 16 11 5 2 6 3 11 8

KPI016 Number of Grade 2 incidents reports overdue3 SA1 0 lI 2 2 0 1 0 1 0 0 0 0 0

KPI017 Number of Grade 1 incidents reports overdue3 SA1 0 lI 5 7 4 0 0 0 0 0 0 0 0

KPI018 Number of Community Suicides SA1 0 lI 2 4 2 2 3 0 2 1 0 4 1

KPI019 CPA 7 day follow up SA1 95% lE 95.0% 96.5% 96.4% 97.8% 96.7% 94.6% 98.6% 98.2% 93.9% 97.6% 93.7%

KPI020 Service user CPA review 12 months2 SA1 >95% lE 96% 95% 95% 95% 95%* 95.1% 95.5% 96.0% 95%* 95%* 95%*

KPI021 % of Inpatient Risk Assessment within 72 hrs admission SA1 >95% lI 98% 99% 98% 97% 100% 96% 100% 99% 100% 99% 100%

KPI022% of Inpatients Physical health check within 72hrs

admissionSA1 >95% lI 98% 99% 99% 97% 99% 97% 99% 99% 99% 99% 99%

KPI023 Number Safeguarding Referrals made to Local authorities SA1 lI 23 28 33 35 50 9 20 17 13 19 16

KPI024 % staff appraisal SA5 100% lI 47% 71% 75% 76% 63% 76% 76% 43% 63% 73% 81%

KPI025 % Vacancy rate SA1 <=10% lI 9.0% 10.2% 10.8% 11.8% 11.2% 12.3% 11.1% 11.1% 11.4% 10.4% 12.7%

KPI026 % Sickness rate SA12014/15

<=4.1%lI 4.5% 4.7% 4.5% 4.4% 5.0% 4.4% 4.8% 5.7% 4.5% 4.6% n/a

KPI027 % Spend Agency SA4 <=5% lI 6% 6% 7% 6% 8% 6% 8% 8% 8% 9% 8%

KPI028 Compliance Overall Mandatory Training SA5 17/17

>85%lI 12/17 11/17 12/17 10/17 14/22 10/17 10/17 14/22 15/22 16/22 17/22

WLMHT Balanced Dashboard 2014-15

Target1

Data Month 5 (Aug 2014)

Partially compliant


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WLMHT Balanced Dashboard 2014-15 Data Month 5 (Aug 2014)

KPI Workforce Indicators Strategic


13/14

Qtr 2

13/14

Qtr 3

13/14

Qtr 4

13/14

Qtr 1


KPI029 Dignity at Work reported (new cases) SA5 0 lI 0 3 5 7 1 2 1 0 0 0 0

KPI030Cumulative turnover rate (Cumulative) - annual forecast

rateSA5 12% lI 2.5% 5.8% 9.1% 12.8% 3.3% 12.8% 16.2% 12.9% 13.1% 13.7% 12.9%

KPI031 Average Number of Weeks to fill a vacancy SA5 14 wks lI 15.8 19.3 20.4 19.6 19.3 19.0 19.7 19.3 23 16.9 14.1

KPI External Assessment indicators Strategic


13/14

Qtr 2

13/14

Qtr 3

13/14

Qtr 4

13/14

Qtr 1


KPI036 CQC Registration Requirements SA3 Met lE

P x x P P P P P P P P

KPI037 FT Monitor - Financial Risk Rating 5 SA3 >4 lE 3 3 3 4 4 4 4 4 4 4 4

KPI038 FT Monitor - Governance Risk Rating SA3 <1 lE * * * *

KPI039 FT Delivery of FT membership SA3 >=10000 lE Met Met Met Met Met Met Met Met Met Met Met

KPI040 CQC Red rated Overall QRP Outcomes (Published) SA3 0 Reds lE 0 0 0 0 0 0 0 0 0 0 0

KPI041 Compliance with IGT SA3 Lvl-2 lE Met Met Met Met Met Met Met Met Met Met Met

KPI065 TDA Financial Risk Rating Green lE Amber Amber Red Amber Amber Amber Amber Amber Amber Amber Green

Notes:

1 lE External Target lI Internal Target

2 Data is updated when the published figures are released by the DOH HSCIC. Where possible a forecasted position is provided marked with *

3 Incidents overdue is based on a Qtr end snapshot, rather than cumulative totals per month end

4 Qtr end snapshot position

5 Note that Monitor have changed the calculation of the Financial Risk Rating from October 2013 onwards. The new rating is on a 1-4 scale, with 4 being the lowest risk and 1 being the highest.

* Forecasted position (Based on internal projections until confirmed performance is published by DOH IC (This applies to MHMDS and SUS submissions and other statutory returns)

KPI004 MHMDS data completeness based on NHS Number, DOB, postcode, Gender GP practice, Commissioner code completeness

KPI005 MHMDS Outcomes for patients on CPA based on data completeness for accommodation and employment status and HONOS assessment in last 12 months


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CSU High Level KPIs Performance

KPI Specialist and Forensic CSU KPI indicatorsStrategic

AimsMar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

KPI042 Number of patient on staff assaults (S&FS) SA4 lI 15 26 12 23 19 12

KPI043 Number of patient on patient assaults (S&FS) SA4 lI 13 12 9 19 15 10

KPI044 Number of new Complaints received in period (S&FS) SA3 lI 4 11 6 8 7 9

KPI045 % Occupancy (Cassel Services Specialist PD) SA4 >=87% lI 98% 95% 94% 96% 94% 100%

KPI046 % of delayed discharges out of Forensic Services (S&FS) SA3 7.5% lE 5% 4% 3% 3% 2% 2%

KPI046

A% of internal delayed discharges (S&FS) SA3 7.5% lI 5% 4% 6% 4% 4% 2%

KPI047 Avg Waiting times Referral to Assessment - Gender SA3 3 mths lI 12mth 12mth 12mth 12mth 12mth 12mth

KPI High Secure CSU KPI indicatorsStrategic

AimsMar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

KPI048-

ASecurity incidents cat A (Broadmoor) 0 lI 0 0 0 0 0 0

KPI048-

BSecurity incidents cat B (Broadmoor) 0 lI 2 2 2 2 3 4

KPI049 Length of stay based on discharges (years) (Broadmoor) 5.7yrs lI 4.8 5.7 6 4.9 4.7 4.6

KPI050 Referral to admission interval (weeks) (Broadmoor) <12wks lE 7 2 11 0 8 10

Target

Target


Commentary: Category A&B incidents: There have been no category A Incidents. There were 4 category D-W , 3 in MI and 1 in PD. Average length of stay for discharged patients - this was 4.6 years - this continues to meet the target level of 5.75 years The longest number of weeks that a patient was waiting for admission since the referral date: this was 10 weeks for August.

Commentary: Patient on Staff assaults: 12 patient on staff assaults, x3 in Male Medium Secure; x1 in Low Secure; x2 in Adolescent and x6 in Women's service. (Majority of assaults in Garnet ward) Patient on Patient assaults: 10 patient on patient assaults, x3 in Male Medium Secure; x2 in Low Secure; x4 in Women's service and x1 in the Adolescent service. Number of complaints' in month: 9 complaints received in August. Breakdown as follows: x3 GIC relating to appointments, delay/ cancellations; clinical treatment and communication/ information to patients. x2 Male Medium secure service relating to attitude of staff and communication/ information to patients. x3 in Low Secure relating to clinical treatment and patients privacy and dignity and x1 in Forensic Outreach service (community) relating to clinical treatment. Number of delayed/planned discharges/transfers: There were 11 total delayed discharges in the month of August. Number of delayed/planned discharges out of Forensic Services: 5 delayed discharges are reportable nationally, these include: In Male Medium secure: x1 awaiting external completion of assessment. In Low secure x1 awaiting residential home placement or availability and x1 awaiting public funding. In the Women's service x1 awaiting residential home placement/ availability and x1 awaiting completion of assessment Number of internal delayed/planned discharges 6 delayed discharges are internal. This includes Male medium secure- x3 on internal waiting list .In Low secure and rehab x2 awaiting internal vacancy. In the Women's service x1 on trial leave.


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KPI Local CSU KPI indicatorsStrategic

AimsTarget Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

Community Productivity

KPI051FTF contacts % variance (Cum) (LS Community) -Year to Date

Variance compared to previous yearSA4 -2% -14% -14% -13% -12% -13%

KPI052 % DNA rate Adult (All HCPs) (LS Community) SA4 <15% lI 12% 12% 12% 12% 13% 13%

KPI054 - Number of Referrals - All teams (LS Community) - lI 1605 1612 1541 1612 1672 1435

KPI055-

A

IAPT Referral to Assessment Average Waiting time (LS

Community) - EalingSA3 90 days l

E 14 7 7 7 7 TBC

KPI055-

B


Community) - H&FSA3 90 Days l

E 1 2 5 5 5 TBC

KPI055-

C


Community) - HounslowSA3 90 Days l

E 41 33 28 23 25 TBC

CAMHs Productivity

KPI056 FTF contacts % variance (Cum) (CAMHS) SA4 15% -17% -19% -4% 2% 1%

KPI057 % DNA rate CAMHs (All HCPs) (CAMHS) SA4 <15% lI 14% 19% 16% 16% 17% 22%

KPI058 % Cancellation Rate CAMHs (All HCPs) (CAMHS) SA4 <5% lI 2.0% 1.6% 3.7% 2.0% 1.0% 2.0%

KPI059 Number of Referrals - All teams (CAMHS) SA4 lI 322 258 284 299 286 184

Inpatient Productivity

KPI060 % Occupancy (Local Services) 93% 91% 89% 97% 98% 92%

KPI061% Inpatients Acute LOS > 50 days (Aged < 65 years) (Excluding

Limes) (Local Services)SA4 <30% lI 47% 45% 43% 40% 46% 44%

KPI062Median LOS for Discharged Clients (Cumulative) (Local

Services)SA4 lI 31 26 29 37 29 33

KPI063% Delayed Transfer of Care (Sitrep) - Health Reasons only

(Local Services)SA4 <=7.5% l

E 6.9% 4.7% 4.6% 7.0% 10.0% 7.0%

KPI064% Inpatient Readmission Rate for Acute Local CSU (All ages

and wards) (30 Days) (Local Services)SA4

CCG

<=8.1% l

E 2.1% 9.6% 5.7% 12.3% 5.8% 8.0%

Commentary: Community Substantially less FTF contacts have been undertaken during the first five months of 2014/15 compared to the same period in 2013/14 (72176 contacts in M1-M5 2014/15 compared to 82620 in 2013/14). This is due to the cessation of walk-in services and the reduction in staff numbers. DNA rates for all HCPs remain static and within target at 13% due to the issue being continuously raised with Team Managers following CCG feedback on the high rate. The August figures relate to 1794 DNA's out of 14278 appointments. Cancellation rates for all HCPs remain well within target at 2% and relate to 321 cancellations out of 14599 appointments. The cancellation rates are being proactively managed; a report is circulated to all of the community teams on a weekly basis. Referrals to all teams in the community have decreased in August which was expected due to the summer holidays and is consistent with the trend seen in 2013/14. We are currently awaiting the figures for the IAPT average waiting times for 1st assessment for August, but up to July the service was well within the 90 day target in each of the three boroughs. CAMHS More FTF contacts have been undertaken during the first four months of 2014/15 compared to the same period in 2013/14 (7042 contacts in M1-M5 2014/15 compared to 6982 in 2013/14). This is due in part to having someone in post to enter current Ealing Tier 2 data and also the increase in number of cases needing to be seen across the three teams. The % DNA Rate (All HCPs) has increased to 22% and relates to 248 DNA's out of 1332 appointments. The figures are distorted by a cohort of difficult to engage patients that have more than one DNA in month. Other issues, such as incorrect coding, have also been identified as an issue in the recent DNA audit. Repeat DNA audits will be undertaken each quarter. Cancellation Rates continue to show excellent compliance with the 5% target and relate to 20 cancellations out of 1152 appointments. The number of referrals reduced in August but this was expected due to the school holidays and is consistent with the trend seen in 2013/14. Inpatient % Inpatients Acute LOS > 50 days reduced in month and is reflective of the fact that although 4 more patients had a LOS of 50 days or more in August compared to July there were 18 more patients overall in august (93/210 in M5 compared to 89/192 in M4). The 93 patients with a LOS > 50 days were located as follows: Ealing = 20, H&F = 39 & Hounslow 34. The Median LOS for Discharged Clients in August increased to 33 days due to the discharges in month having longer stays than the July discharges. The M5 figure relates to 47/135 discharges in month having a LOS of 50 days or more compared to 45/139 in M4. The Head of Inpatients is undertaking a piece of work to understand why patients are still in hospital beyond 50 days. Delayed transfers of care are back within target due to Hounslow managing to discharge a number of cases into placements and others they took to the Homeless Person's Unit. The Associate Director is reviewing the process for delayed transfers of care and will put a proposal together. The % Occupancy has reduced to 92% and is reflective of the fact their was an abnormal drop in bed usage for two weeks in August, which could not be predicted. The occupancy rate per borough was Ealing 95%, H&F 92% and Hounslow 90%. The % Readmission Rate remains within target in August and relates to 11/138 discharges being readmitted within 30 days.


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LS CSU - Safety Thermometer

KPI LS CSU - Safety Thermometer Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14

KPI066 Harm Free 92.1% 94.6% 91.4% 89.2% 89.2% 89.2% 83.8% 78.8% 97.2% 94.3% 100.0% 100.0%

KPI067 Pressure Ulcers - All 5.3% 5.4% 8.6% 5.4% 5.4% 8.1% 8.1% 9.1% 2.8% 5.7% 0.0% 0.0%

KPI068 Pressure Ulcers - New 0.0% 0.0% 2.9% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

KPI069 Falls with Harm 2.6% 0.0% 0.0% 5.4% 5.4% 2.7% 8.1% 9.1% 0.0% 0.0% 0.0% 0.0%

KPI070 Catheters & UTIs 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0%

KPI071 Catheters & New UTIs 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0% 0.0% 0.0% 0.0% 0.0%

KPI072 New VTEs 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

KPI073 All Harms 7.9% 5.4% 8.6% 10.8% 10.8% 10.8% 16.2% 21.2% 2.8% 5.7% 0.0% 0.0%

KPI074 New Harms 26.3% 0.0% 2.9% 5.4% 5.4% 2.7% 8.1% 12.1% 0.0% 0.0% 0.0% 0.0%

KPI075 Sample (total number of patients) 38 37 35 37 37 37 37 33 36 35 35 35

KPI076 Surveys (Limes DS & Jubilee Ward) 2 2 2 2 2 2 2 2 2 2 2 2


Commentary: In M5 there were a total of 35 inpatients surveyed, 17 on Jubilee Ward and 18 in Limes Dementia Service. Overall 100% of the patients surveyed were harm free. All harm related incidents are routinely reported on the IR1 system. Tissue viability related issues are reported via the Infection Control Lead and the TVN. Work that the Unit Manager, Ward Manager and the Ward Physiotherapist have undertaken around falls has paid off because no falls were reported for the second consecutive month.


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KPIFinancial - income and Expenditure

Related

Strategic

AimsFramework Target

Qtr 1

13/14

Qtr 2

13/14

Qtr 3

13/14

Qtr 4

13/14

Qtr 1


KPI032 Financial Efficiency - I&E Surplus Margin (%) SA3 1.50% 0.9% 1.0% 1.4% 2.7% 1.3% 2.7% 1.2% 1.2% 1.3% 1.4% 1.4%

KPI033 Cash position versus plan SA3 +/- 10% +8% -49% -56% 5% 7% 5% -13% 4% 7% 0% -1%

KPI034 Capital spend v plan ratings SA3 +/- 10% -51% -31% -27.0% -8% -14% -8% -29% -45% -14% -5% 1%

KPI035 CQUIN- Linked to Income Loss SA4 CCGs <=5 % inc. loss Met Met Met Met tbc Met tbc tbc tbc tbc tbc

Finance KPIs 2014-15 Data Month 5 (Aug 2014)

Commentary: - Commentary on Finance Executive Summary page


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Finance Executive Summary

FINANCIAL OVERVIEW

DIRECTORATE POSITION

The Trust wide agency spend year-to-date has reduced to 8% in August compared to the previous month (9%).

BALANCE SHEET AND CASHFLOW POSITION

BALANCE SHEET MOVEMENTS

PSPP

AGED DEBT POSITION

CASH FLOW POSITION

CAPITAL

Since M4, NHS debt over 90 days has increased by £25k and non NHS debt over 90 days has increased by £115k. Outstanding SLA CQUIN balances relating to

2013/14 NWL CCG's constitute the majority of over 90 days NHS debt. However further to high level communications between Local Services management and the

relevant CCG's a resolution to this is now in place with payment for the majority of this balance expected in September

Cash balance is £31.3k at the end of August which is line with plan. The Trust will draw upon PDC and loan funding in the financial year to help fund the two major

capital redevelopments, this will result in a spike in the cash position in January 2015 which will then be utilised in Q4 of the financial year. The year end cash balance is

forecast to be in line with expectations.

Capital spend is £13m at the end of August against the planned year to date expenditure of £12.9m. The two major redevelopments are progressing marginally behind

plan year to date whereas operational capital is overspent. Capital expenditure is forecast to be in line with planned spending within the next few months. The CAPMG is

maintaining a robust oversight of the operational capital commitments.


High Secure Services underspent by £62k in August due primarily to vacancies across a range of disciplines.

Specialist and Forensic services overspent by £95k in the month and £400k year to date. The main reason for the adverse variance relates to under occupancy on Glyn

ward, a £70k adverse variance in the month (£332k YTD). In addition to this there has been high level of sickness absence, unplanned leave and high levels of EE&O

across some of the wards.

Estates and Facilities overspent by £89k which is in line with the planned position (£491k YTD against a planned position of £500k overspent).

Fixed assets have increased in August by £2.6m because of the increased spend on the redevelopment projects. Current liabilities have increased to reflect the PDC

accrual for M5, which will be paid in September.

The Trust's YTD PSPP results are at or above target in all four areas. Average number and value of NHS invoices paid was 96% each; for Non NHS the average

number and value was 95% and 96% respectively. The PSPP target is 95%.

The planned position for the year is a surplus of £3.4m. To the end of month 5 the position was £1,275k surplus which is in line with the planned position.

EBITDA 11.2% achieved, compared to plan of 10.7%

Financial Risk Rating of '4' (no evident concerns)

The overall TDA risk rating has changed to GREEN, having been AMBER in previous months, as a result of the current CIP performance and forecast CIP position.

However further work is currently underway to review the forecast position, which may result in an AMBER rating in future months.

CIPs have under-delivered by £1,152k year-to-date with slippage across all areas. Broadmoor gap of £253k mainly includes slippage on the following schemes; review

of consultants payment and numbers (£103k), redesign of therapeutic activities includes Education functions (£61k) and review of the administration function (£47k).

Broadmoor are considering further schemes and are confident that the full year target will be achieved. Local Services slippage of £553k includes mainly includes

underachievement in management cost savings (£122k) and reductions in bank & agency spend (£289k). Specialist & Forensic gap of £145k relates to the need to

identify new schemes to meet the current gap (£116k) and slippage on review of Education provision scheme (£21k). The Procurement savings scheme within Estates &

Facilities has not yet delivered (£208k slippage). In addition to this IM&T have not delivered against a number of their partnership schemes plan to date (£127k).

Local services overspent by £392k in-month and £1,570k YTD (against £708k planned overspend YTD). The main reason for the overspend in the community service

relates to the under achievement against the QIPP cost reduction scheme and high bank and agency usage (although a significant improvement from the previous

month). The Inpatient directorate overspend relates to PICU outliers, shortfall in funding relating to the Limes unit, which is being discussed with commissioners (The

CSU anticipates that this will be resolved in M6), there are also a number of vacancies which are being covered by bank staff (recruitment campaign underway). There

are continued risks around CIP and QIPP achievement across other areas within local services including the Medical directorate.


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Finance Balance Sheet and Cash

Summary Income & Expenditure as at 31s August 2014 Table 1

( £ '000 ) Current month Year to dateForecast

outturn

Budget Actual Variance Budget Actual Variance Budget Actual Variance

Operating income (18,592) (18,503) 88 (92,736) (92,739) (3) (222,889) (222,889) 0

Operating Expenditure

Pay 13,259 13,545 286 67,286 69,455 2,169 158,766 158,766 0

Non-pay 3,510 2,871 (639) 16,335 12,902 (3,433) 38,562 38,562 0

Total Operating Expenditure 16,769 16,415 (354) 83,621 82,358 (1,263) 197,328 197,328 0

EBITDA (1,823) (2,088) (265) (9,115) (10,382) (1,267) (25,561) (25,561) 0

Non-Operating Income/Expenditure

Interest Receivable (6) (8) (1) (30) (37) (7) (73) (73) 0

Interest Payable 0 0 0 0 0 (0) 460 460 0

Impairment 0 0 0 0 0 0 0 0 0

Discount unwound 0 0 (0) 1 0 (1) 2 2 0

Restructuring 0 0 0 0 0 0 0 0 0

Profit/loss on disposal of assets 0 0 0 0 0 0 0 0 0

Depreciation 747 747 0 3,735 3,735 (0) 8,798 8,798 0

PDC dividend 1,082 1,082 0 5,410 5,410 0 12,983 12,983 0

Net surplus/ deficit 0 (267) (267) 0 (1,274) (1,274) (3,391) (3,391) 0

Balance Sheet as at 31st August 2014 Table 2

( £ '000 ) 31/07/2014 31/08/2014 Mvmt in monthForecast

Outturn( £ '000 ) 31/07/2014 31/08/2014

Mvmt in

month

Forecast

Outturn

Fixed Assets 365,885 368,511 2,626 373,454 Financed by

Current Assets 41,219 40,401 (818) 35,824 Public Dividend Capital 292,241 292,241 292,241

Current Liabilities (29,966) (31,942) (1,976) (23,329) Revaluation Reserve 134,149 134,149 152,024

Total Assets Less Current Liabilities 377,138 376,971 (168) 385,949 I&E Reserve (52,785) (52,518) 267 (61,265)

Long term creditors (110) (110) (114)

Provisions for Liabilities & Charges (3,423) (2,989) 434 (2,835)

Total Assets Employed 373,605 373,872 267 383,000 Total Capital & Reserves 373,605 373,872 267 383,000

Cash flow Table 3

Table - 4 Table - 5

Annual CIPs

allocated Annual forecast

CIPs allocated to

date

Achieved to

date

Variance to

date

Local Services 3,442,099 3,687,147 1,698,385 1,145,606 552,779 In Month Cumulative

Planned

Position

Broadmoor 2,528,000 2,528,195 1,053,333 799,978 253,355 Broadmoor CSU (62) (170) 0

Specialist & Forensic 2,341,000 2,040,701 886,729 741,188 145,541

Local Services CSU 392 1,570 708

Estates & Facilities 1,508,000 387,000 355,845 147,511 208,333

Other Corporate 1,303,000 1,306,746 537,083 544,478 (7,394) Specialist & Forensic CSU 94 399 0

Clinical Service Units 424 1,799 708

Total 11,122,099 9,949,789 4,531,375 3,378,760 1,152,615

Estates & Facilities 86 491 500

Other corporate 3 280 0

Corporate & Estates 89 771 500

Central budgets (780) (3,839) (2,481)

Operational (under)/o'spend (267) (1,269) (1,273)

ITDA 0 (5) 0

Budget (under)/o'spend (267) (1,274) (1,273)

Run Rate 1.4% 1.4%

Cost improvement progress to date

Net Operational Income and Expenditure Budget Variances (£ 000s)


Director of Finance & Information

0

10000

20000

30000

40000

50000

60000

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Reprofiled plan Actual

Capital Programme Expenditure Profile £000s Table 6

12 16 20 24 28 32 36 40 44 48 52 56

Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15

Cash (£ millions) Forecast (annual plan) Actual


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Organisational Development and Workforce Executive Summary Data Month 5 (Aug 2014)

TRUST VACANCY RATE

The forecasted vacancy rate for August was 12.7%, an decrease from the previous month and slightly above the Trusts target

of 10%.

TRUST SICKNESS ABSENCE RATEThe sickness absence rate is for month 4 - July. The rate is 4.6% which can be split into 3% long term sickness and 1.6% short

term sickness. While the rate is above the Trust target of 4.1% it is significantly better when benchmarking against the other

High Secure MH Trusts whose projected rates are 5.7% and 5.3% for the last Financial Year.

MANDATORY TRAININGThe Scorecard is now produced on -line via the exchange giving 24/7 live reporting for managers to access, rather than

receiving a snapshot at the end of the month.

The June scorecard shows that 9 courses have increased, 8 remain the same and 5 have decreased.

CUMULATIVE TURNOVER RATEThe Trust turnover rate to Month 5 - August is 5.4%. This would provide an annual forecasted rate of 12.9%. The rate would

be above the Trust target of 12%. It should be noted that the rate includes those staff leaving through redundancy, if these

are removed then the rate falls to 11.9%.

AVERAGE NUMBER OF WEEKS TO RECRUITMENT

For August the Time to Hire (TTH) was 14.1 weeks which is inline with the TTH target of 14 weeks. The complexities

surrounding our resourcing needs have become clear since the initial outsourcing in April - the trust and Capita agree that

recruitment services should be moved in-house. Recruitment services will transfer back in house on 1 October 2014

KPI 025

KPI 026

KPI 028

KPI 030

KP1 031


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Organisational Development & WorkforceTrust Vacancy % Rate to Date ● Trust Sickness Absence % Rate to Date

Average number of weeks to fill a Vacancy ● Trust Cumulative Turnover % Rate to Date

Mandatory Training Scorecard & PDR Summary

Statutory and Mandatory Training -Compliance Trust Summary

LOCAL

SERVICES

SPECIALIST &

FORENSIC

SERVS CSU

HIGH SECURE

SERVICES CSU -

BROADMOOR

ESTATES &

CORPORATE

SERVICES

TRUST WIDE

Breakaway Broadmoor n/a n/a 95% 87% 93%

Breakaway London 84% 88% n/a 85% 86%

Basic Fire Awareness 80% 84% 90% 88% 85%

PSTS Theory 84% 88% 99% 91% 90%

Mental Health Law Update 83% 78% 85% 69% 82%

Automated External Defib 81% 90% 85% 57% 86%

Basic Life Support 94% 100% 100% 100% 96%

Equality and Diversity 84% 81% 93% 88% 86%

Health & Safety 89% 92% 95% 94% 92%

Information Governance 70% 72% 86% 76% 75%

Moving and Handling Patients 96% 95% n/a 75% 95%

Moving and Handling Loads 85% 88% 99% 90% 91%

Safeguarding Children Level 1 Non Clinical 90% 86% 93% 94% 93%

Safeguarding Children Level 1 Clinical 97% 99% 100% 97% 98%

Safeguarding Children Level 2 89% 87% 92% 79% 89%

Safeguarding Children Level 3 Specialist 68% 79% 71%

Safeguarding Adults 86% 81% 80% 79% 83%

PMVA Teamwork Broadmoor n/a n/a 96% 100% 96%

PMVA Teamwork London 94% 86% n/a 75% 89%

Clinical Risk Training 80% 81% 92% 72% 83%

Infection Control 81% 84% 95% 84% 86%

Security Update n/a n/a 95% 89% 94%

PDR End year reviews completed 2013/2014 86% 88% 87% 84% 86%

Objectives Agreed for 2014/2015 79% 88% 78% 80% 81%

Data Month 5 (AUGUST 2014)●

●

The vacancy rate for August was 12.7% , an increase by 2.3% from the previous month . This vacancy rate is 2.7% above the target rate. The number of funded posts for August was 3452.8 fte, this excludes those posts in Local Services that are held through vacancy rate reductions for CIP's. The number of staff in post at the end of August was 2979 fte or 3132 headcount (compared to 3013.6 fte and 3135 headcount the previous month) . In addition a further 353 bank staff were used during the month. The vacancy rates across the Trust for the month across the services was: High Secure Services at Broadmoor 11%, Local Services 12.4%, Specialist & Forensic Services 12.4% and Corporate Services 16.2%. The number of new starters to the Trust during August was 62.

The sickness absence rate is for month 4 - July. There was an increase in the rate to 4.6% . This rate can be shown as 3% long term sickness and 1.6% short term sickness. The rate is above the Trust target of 4.1% but owner than the same time last year (4.9%). The sickness absence figure is significantly better than that of other MH Trusts who average 5.5% for last Financial Year. The rates for July across the Trust are 6.2% in HSS Broadmoor Hospital, 3.1% in Local Services, 5.4% in Specialist & Forensic Services and 4.5% in Corporate Services and Estates. The HR Advisors are working with managers in monitoring the short term sickness and also with Occupational Health in the management of long term sickness cases in either returning staff to work out of patient contact where possible or looking at managing these cases through the Trust’s Managing Health and Attendance policy.

The Time to Hire data is provided by Capita as part of the contract management process for recruitment. The service level agreement period for the total time to hire is 14 weeks. Time to Hire (TTH) for August 2014 was 14.1 weeks which is inline with the 14 week TTH target. The trust and Capita continuously review the recruitment, payroll and pensions services Capita provide. During this joint review process, the complexities surrounding our resourcing needs have become clear and consequently the trust and Capita agree that recruitment services should be moved in-house. Recruitment services will transfer back in house on 1 October 2014. Capita will continue to provide payroll and pension services to the trust.

The Trust turnover rate for Month 5 - August is 5.38% which produces a forecasted annual rate of 12.9%. This would be above the target of 12%. It should be noted that the rate includes those staff leaving through redundancy, if these are removed then the rate falls to 11.9%. The total number of leavers during August was 74. 53 Qualified and 24 unqualified nurses have left this financial year so far. The main reasons given for staff leaving were primarily for voluntary reasons. There was one dismissal this month

The Scorecard is now produced on -line via the exchange giving 24/7 live reporting for managers to access, rather than receiving a snapshot at the end of the month. In addition, this has allowed some relevant courses to be divided either by site (Breakaway and PMVA) or by description (moving and handling patients or loads) and (Safeguarding Children Clinical and Non Clinical). The August scorecard shows that 10 courses have increased, 8 remain the same and 4 have decreased. The end of year reviews for 2013/14 completed have increased to 86% and the RAG rating is green. Objectives agreed for 2014/2015 has also increased to 81%, but the RAG rating remains in Amber. There are variations across CSU's in PDR compliance ratings.

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

13.0%

AP

R

MA

Y

JUN

E

JULY

AU

G

SEP

T

OC

T

NO

V

DEC

JAN

FEB

MA

R

% Vacancies 2013/14 % Vacancies 2014/15 Target % Vacancies

3.0%

3.5%

4.0%

4.5%

5.0%

5.5%

6.0%

AP

R

MA

Y

JUN

E

JULY

AU

G

SEP

T

OC

T

NO

V

DEC

JAN

FEB

MA

R

AV

ERA

GE

% Sickness Absence 2013/14 % Sickness Absence 2014/15 Target % Sickness Absence

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

AP

R

MA

Y

JUN

E

JULY

AU

G

SEP

T

OC

T

NO

V

DEC

JAN

FEB

MA

R

Turnover % 2013/14 Turnover % 2014/15 Target % Turnover

0

5

10

15

20

25

AP

R

MA

Y

JUN

E

JULY

AU

G

SEP

T

OC

T

NO

V

DEC

JAN

FEB

MA

R

Ave

rage

NO

. OF

WEE

KS

Time to Hire 2013/2014 Time to Hire 2014/15 Target Time to Hire


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Risk

Number

Risk

Owner

Affected

strategic

aim

Risk Description Jun-14 Jul-14 Aug-14

Date of

Last

Review**

5889 DLS SA3Inability to sustain Local Services due to failure to deliver savings in line with the Commissioners’

Intentions, as stated in 2012, resulting in service restrictions and/or closures (FT Strategic Risk B1) 25 25 25 25/04/14

5981 DepCEO SA3The Trust’s CIP programme detailed in the baseline plan does not achieve the required efficiencies

over the 5 year period of the IBP (FT Strategic Risk A1) 16 16 16 04/08/14

6754 MD SA1 Failure to manage clinical risk effectively, resulting in serious self-harm or suicide 16 16 16 04/09/14

6325 DoOD&W SA1Failure to provide good quality outsourced HR services, particularly recruitment, resulting in high

levels of employee and service manager dissatisfaction15 15 15 11/08/14

4182 DLS SA1 Risk of a major fire occurring in an inpatient unit, resulting in major loss 12 12 12 25/04/14

4186 DoOD&W SA5Staff not feeling sufficiently engaged or valued by the organisation, resulting in less than ideal work

performance and poor patient experience12 12 12 04/09/14

5170 DepCEO SA3Failure to achieve Foundation Trust status, resulting in uncertainty over whether the Trust will

continue to exist in its current form12 12 12 04/08/14

5802 DLS SA3Failure to ensure Trust Local Services meets the requirements for future funding arrangements

(known as Payment by Results), resulting in a significant loss of income12 12 12 25/04/14

7010 DepCEO SA3Failure to retain current levels of business, resulting in shrinkage in business activity and increasing

uncertainty over the Trust continuing in its present formNew 12 12 21/08/14

5563 MD SA1 Failure to manage organisational change effectively, adversely affecting the quality of clinical care 10 10 10 18/08/14

6755 MD SA1Failure to manage clinical risk effectively, resulting in serious interpersonal violence, including

homicide10 10 10 08/07/14

4127 DoOD&W SA1Failure to equip all staff with the skills and abilities to enable them to deliver a safe and effective

service, resulting in poor quality services, leading to complaints, incidents, etc.9 9 9 04/09/14

4198 DoHSS SA3Failure to maintain business continuity due to inadequate emergency and business contingency

planning, resulting in poor or no Trust service levels during a crisis9 9 9 04/09/14

4217 DoN&PE SA1Failure to respond effectively to service user feedback and to implement recovery-focussed practice,

resulting in poor service user and carer experience9 9 9 19/08/14

4239 DoOD&W SA2Inadequate maintenance of Trust buildings and premises, resulting in poor quality environment for

work and patient care9 9 9 11/08/14

5359 DLS SA2

Failure to reduce caseloads in Trust services (Secondary Care) in an appropriate manner, when

transferring patients to the Primary Care services, resulting in excessive and unfunded caseloads in

secondary care and a significant deterioration in service quality9 9 9 02/06/14

5551 MD SA3Failure to maintain effective Information Governance (IG) security arrangements resulting in an IG

breach of patient information9 9 9 04/09/14

5972 DepCEO SA4

Failure to receive the Land Sales receipts that support the Trust's large capital programmes either at

the appropriate time or at the expected value, resulting in an inability to deliver those capital

programmes as intended

9 9 9 04/09/14

6467 DoN&PE SA1 Failure to adequately control levels of legionella, resulting in an increased risk of harm 9 9 9 10/07/14

6757 DoOD&W SA4

Failure to manage the Trust’s land and building portfolio in a way that complements the Trust’s

strategic aims, resulting in a less than optimum portfolio held, an adverse effect on service quality

and poor value for money9 9 9 11/08/14

4190 DepCEO SA4Failure to complete the Three Bridges ‘Medium Secure’ campus in line with commissioner

requirements, resulting in a loss of Trust 'medium secure' business8 8 8 11/08/14

5406 MD SA4Failure to manage effectively the introduction of RiO7, resulting in major disruption to operational

services8 8 8 04/09/14

5801 MD SA4

Failure to implement an effective quality strategy, complemented by suitable quality performance

measures, leading to inconsistent quality of care resulting in poor patient experience and

commissioner dissatisfaction8 8 8 19/08/14

5917 DoHSS SA4Failure to re-organise, redevelop and modernise Broadmoor Hospital site, resulting in an adverse

impact on the quality of patient care and Trust services8 8 8 11/08/14

6960 MD SA3

Failure to achieve either a good or outstanding rating from a Chief Inspector of Hospitals visit,

resulting in significant reputational damage and a consequent adverse effect on stakeholder

confidence in Trust services8 8 8 04/09/14

7009 DepCEO SA3Failure to create and exploit new business opportunities resulting in no increase in business activity,

so impeding progress on the delivery on the Board’s strategyNEW 6 6 21/08/14

6756 MD SA1 Failure in care delivery, resulting in ‘Never Events’ 5 5 5 08/07/14

Trust-wide (Level 1) Risks - Current Risk Rating Month 5 (Aug) 2014*

Commentary

*Report prepared on 4 September 2014

**'Date of last review' - this is the most recent date the risk was recorded by the Exchange risk register as having been reviewed. In accordance with the Trust's Risk Management Policy, the

risk should be reviewed at least once every 31 days (month). Those cells highlighted in light blue identify those risks that have not been reviewed in the last 31 days

Changes to the Level 1 risk register are ratified by the Trust Management Team

New risks

None

Changes in the ratings of existing risks

None

Retired risks

None


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Glossary of terms

CCA -Capital Cost Absorption Duty

CIP - Cost Improvement Programme

CRL - Capital Resource Limit

EBITDA - Earnings Before Interest, Taxes, Depreciation and Amortization

EFL - External Financing Limit

I&E Margin - Income and Expenditure Limit

ROA - Return on Assets

Aged Debtors

Turnover

Stability

WTE

Dignity and Work reported (new cases)

MHMDS - Mental Health Minimum Data Set

CQC

Monitor Risk Assessment Framework

HSCIC - Health and Social Care Information Centre

FT Monitor

IAPT - Improving Access to Psychological therapies

CAMHS - Children and Adolescent Mental Health services

CRHT - Crisis Resolution Home Treatment Team

CPA - Care programme Approach

SITREP - Situation Reporting -

CQUIN - Commissioning for quality and innovation

IGT - Information Governance Toolkit

HCPs - Health Care professionals i.e. Medics, nurses, psychologists etc

Safety Thermometer

Glossary - Key Quality and Performance, KPI indicators

Whole time equivalent

Glossary - Workforce

Number of leavers during the reported period as a percentage of the average staff in post for the same period.

Number of new cases harassment and Bullying cases

Number of staff in post at the end of the reporting period who have been employed with the Trust for 1 year or more.

The Care Quality Commission is the independent regulator of health and social care in England that regulate care provided by the NHS, local authorities, private

companies and voluntary organisations.

Mental Health Minimum Data Set contains record level data about the care of adults and older people using secondary mental health services. The dataset

comprises of daily clinical and legal interventions for every patient.

Glossary - Finance

This is an annual measure that NHS trusts are required to achieve. A trust has a duty to absorb the cost of capital at the rate of 3.5% of its average relevant net

assets. There is an allowable tolerance of 0.5% either side of this target.

These are cost savings arising from improvements in Trust efficiencies which are readily convertible into real cash savings. Such savings arising under a scheme

may also be known as CIPs.

All debtors outside of payment terms are considered to be aged and are included in Table 11 in the finance report. The current payment terms of the Trust are 30

days.

This is a fundamental target of the NHS trust financial regime. It controls the amount of capital expenditure that a trust may incur in the financial year. It is an

accruals based control. Overspends against CRL are not permitted.

This measure is one of the main financial criteria that Monitor look at in assessing underlying Trust performance. It also gives a feel for cash flow before debt

financing, taxes and depreciation charges. It is a significant factor in Monitor's assessment

This is a fundamental target of the NHS Trust financial regime. It is a cash based control which trusts are not permitted to overshoot. A positive EFL arises where

Trusts draw on Government funding or spend cash resources.

I&E margin is the retained surplus or deficit ("bottom line") i.e. income less all costs for the accounting period. It has a rating of 12.5% in Monitor's assessment of

the Trust's financial risk rating.

The NHS Safety Thermometer provides a quick and simple method for surveying patient harms and analysing results so that you can measure and monitor local

improvement and harm free care (external) over time. From July 2012 data collected using the NHS Safety Thermometer is part of the Commissioning for Quality

and Innovation (CQUIN) payment programme.

This is calculated as net margin before dividend as a percentage of average net assets employed by the Trust over the financial period. As a measure of efficiency it

is an important factor (weighting 12.5%) contributing to the risk rating of an NHS founda

The HSCIC is the data, information and technology resource for the health and care system and plays a fundamental role in driving better care, better services and

better outcomes for patients. It is the trusted source of authoritative data and information relating to health and carries the trusted source of authoritative data and

information relating to health and social care. They support the delivery of IT infrastructure, information systems and standards to ensure information flows efficiently

and securely across the health and social care system.

Monitor use the RAF to monitor compliance by providers of NHS services with the continuity of service and governance conditions in their provider licences.The RAF

generate two risk ratings for each foundation trust; one based on the way it is managed (governance Risk rating (GRR)) and one on its financial health (continuity of

services - Financial Risk Rating (FRR)).

Monitor main duty is to protect and promote the interests of patients and plays a pivotal role in regulating the health sector. It has an ongoing role in assessing NHS

trusts for foundation trust status, and for ensuring that foundation trusts are well-led, in terms of both quality and finances

A key characteristic of an IAPT service is the effort individual therapists put into demonstrating the outcomes that are delivered. The data IAPT data set provides

evidence and care delivered by the service and impacts performance

SitReps are an internal Department of Health performance data collecting system/ Although intended primarily for internal use, the data are also used to answer

parliamentary questions, brief ministers and to inform national performance indicators

The aim of the CQUIN framework is to secure improvements in quality of services and better outcomes for patients, whilst also maintaining strong financial

management which have incentives, rewards and sanctions to drive improvements in care quality.

The IG Toolkit is an online system which allows NHS organisations and partners to assess themselves against Department of Health Information Governance

policies and standards. Failure to comply with standards impact the organisations reputation and CQC standards


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BOARD MEMBER VISITS - WARD FEEDBACK FORM

BMV–ward feedback form.V2. (April 2014)

To be completed by visiting Board Members and sent back to the Board Secretariat. This will be included and discussed at the next Board meeting. Service area visited

Meridian Ward Hammersmith & Fulham Date 23.07.14

Reason for visit i.e. scheduled, unannounced, Informal, follow up to SUI, requested, good practice, Quality Assurance Committee Recommendation

Quality Assurance Committee Recommendation

Board Members attending

Christine Higgins, Non-Executive Director & Barbara Byrne, Director of Finance & Deputy Chief Executive

Brief description of visit

Discussion with Acting Service Manager. Followed by meeting with some of the ward team. We then visited the ward male and female sections, spoke to some patients and staff.

OBSERVATIONS Welcoming:

Are staff photo boards with names on display?

Is there information visible and well presented and is it useful and reassuring? (examples might be visiting times, welcoming signs)

Is the environment clean and tidy?

Did staff make you feel welcome? Safe: On entering the ward

Can you identify staff? How?

Do notice boards have up-to date relevant information i.e. fire and safety procedure, complaints procedure?

Check with the Nurse in charge: is there a fire Marshall on the shift? Who is it?

Infection –possible questions to ask

Have you had an infection outbreak in the last 6 months?

o If yes what did you do? o If no what would you do if there was an

outbreak on the ward? Raising concerns

Ask staff what they would do if they had a concern about safety. How would they escalate?

What would they do for if there was a safeguarding

Yes Yes. There were a number of different notice board areas sometimes it is repeating information but that is deliberate. Excellent the ward team praised the domestic (Angela) who was on duty while we were there and she is an asset to the ward. Yes the consultant, registrar and senior nurse were part of the initial briefing. Yes Yes There was a noticeboard with the fire marshall name on in addition to other information. We discussed this. Last outbreak was over 12 months. Management of infection described very clearly. This was discussed due to a disclosure on a recent Board visit to Hammersmith & Fulham Mental Health Unit

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concern?

Ask staff if they feel safe; have they felt bullied from other staff or experienced violence from patients?

o If yes how was it handled?

What would they do if a patient raised a concern?

Ask staff what they know about the Whistle blowing policy?

Caring & Involving:

How do staff interact with service users?

How is privacy & dignity maintained?

What evidence is there of activities for service users?

Do the patients look well cared for?

Do staff help those who cannot feed themselves? Do patients have access to drinks throughout the day?

Well Organised & Calm:

What are the noise levels like on the wards?

Does the ward feel calm?

Is there clear signage to rooms WC etc?

Patients can be physically aggressive due to illness. This is dealt with in team meetings. There were quite a few staff visible and clearly engaging with service users. Bedroom doors have “Please knock before entering” signs, some of them were displaced. There are activity co-ordinators. These are not included in the ward numbers. They are all gym trained. The service users have to be encouraged to take part in activities but they are available. We observed a patient being helped to eat. Yes Acceptable Yes Yes

STAFF ENGAGEMENT (examples of useful prompt questions) Are you aware of the current Trust quality priorities?

How useful is the quality notice board?

How often do you meet as a team?

How often do you have staff supervision meetings and Do the meetings support your work?

How useful was your PDR discussion?

Do you enjoy your work?

How easy is it for you to complete your mandatory training?

How do you find out what happens across the

The quality notice board was clearly displayed. Some of the results e.g. for CPA involvement were low. We raised this with the consultant who confirmed that often service users have short term memory loss. They do however work with patients to improve outcomes. The consultant does weekly training updates. A junior doctor reported very positively on her experience and stated that she wanted to specialise in old age psychiatry.

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Trust?

Do you have any feedback for Board members?

Advised that Mental Health Act administration is greatly improved. Lead consultant (newly appointed) has ensured audits re compliance.

PATIENT / SERVICE USER ENGAGEMENT Do patients have any concerns/complaints? Do patients they feel safe, do they have someone

they can talk to?

The Mind User Involvement forum feedback to the ward service users concern. This is a valued independent service.

AREAS OF GOOD PRACTICE

1. Consultants very proactive regarding delayed discharge. Has gone to the London borough of Hammersmith & Fulham housing office to expedite matters. Also offers training to London Borough of Hammersmith & Fulham as quid pro quo.

2. Recovery model well understood – “living as well as can with illness”

3. Used initiative to procure an ECG machine to save costs as can do ECGs on the ward and also saves patients having to wait in Charing Cross hospital for

ECG.

4. Smoking cessation advice offered proactively.

AREAS OF CONCERN / REPORTED ISSUES REQUIRING ACTION FOR EDS

1. Care coordinators not able to contribute to CPA. This is a particular problem where patients are cross borough.

2. Lack of engagement by London Borough of Ealing delayed discharge (contrast to Hammersmith & Fulham).

3. Fixed screen projector in conference room would support CPA reviews.

4. Would like access to the clinic room used for clozapine clinics to take bloods – clozapine clinic room only used on certain days. Like ECG machine would save patients stress and Trust resource.

5. L&D to confirm what is required for the Trust to accept dual qualified can take bloods.

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Issue (Board member to complete)

Action to be taken (Board member to complete)

By whom (Service lead to complete)

By when (Service lead to complete)

Progress as at XXXXX (Service lead to complete)

Care coordinators not able to contribute to CPA

Raised with Paul Meechan, Associated Director of Local Services

Actioned

Lack of engagement by London Borough of Ealing delayed discharge

Raise with Sarah Rushton, Director of Local Services

Director will review escalation process.

Fixed screen projector in conference room would support CPA reviews.

IT providing cost estimate to equip MDT rooms with screens, look to prioritise from non-recurrent funds subject to agreement with CSU Director.

December 2014

Would like access to the clinic room used for clozapine clinics to take bloods – clozapine clinic room only used on certain days. Like ECG machine would save patients stress and Trust resource.

Raised with Paul Meechan and Local Services

Actioned

L&D to confirm what is required for the Trust to accept dual qualified can take bloods.

Raised with Andy Wells, Learning & Development

Action required Please select one option ED follow up visit (areas of concern)

Written follow up (minor areas of concern)

No action required (no areas of concern)

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SUMMARY REPORT - TRUST BOARD MEETING (PART 1:

24th September 2014

Report Title:

Nurse and Health Care Assistant Staffing Levels – Exception Report for July 2014

Executive Lead:

Dr Anne Aiyegbusi Interim Director of Nursing and Patient Experience

Report Author:

Dr Anne Aiyegbusi

Report discussed previously at: None


To advise the Board of all occasions during the month of July 2014, where in-patient ward staffing levels failed to meet planned requirements resulting in escalation to unit co-ordinators or site managers.

Approval

Discussion

Information


This is the third month that the Trust has formally reported on nurse and health care assistant staffing levels in accordance with national requirements. As part of national reporting requirements, the report provides the Board with details of exceptions. That is where shifts have been red rated against the following criteria; Green = staffing meets planned requirements Amber = staffing meets planned requirements but is safe Red = staffing does not meet planned requirements so has been escalated Of shifts, 56 (1.18%) were rated red. Of these: High Secure Services = 47 shifts within 5 of its 15 in-patient areas. Local Services = 14 shifts within 5 of its 14 in-patient areas.







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No



No



N/A


No significant financial implications


N/A


Ensuring safe staffing to deliver high quality services to service users and their friends and families


Managers to complete all requirements to report nurse and health care assistant staffing levels. Lessons require to be learned in anticipation of future cycles

Communication

Hourly fill rate reported on NHS Choices Shift data reported on Trust website


Strategy



Measurement


NHS National Health Service

HSS High Secure Services

SFS Specialist and Forensic Services

LS Local Services

RAG Red, Amber, Green

OT Occupational Therapist


For a shift by shift breakdown of staffing levels for each in-patient area within the Trust, please see the Trust website on the staffing levels web page. For details of hourly fill rates, please see NHS Choices

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TRUST BOARD MEETING (PART 1) –24TH SEPTEMBER 2014

NURSE AND HEALTH CARE ASSISTANT STAFFING LEVELS: EXCEPTION REPORT FOR JULY 2014

1. PURPOSE 1.1. The purpose of this exception report is to advise the Board of shifts within the

Trust’s in-patient areas where staffing levels fell below planned requirements and due to being regarded as unsafe, were escalated to senior nurses or site managers who employed contingency plans.

2. RECOMMENDATION(S) 2.1 The Board is asked to discuss the contents of this paper. 3. INTRODUCTION

3.1 This report is provided in accordance with the expectations set out in the National

Quality Board Guidance published in November 2013, that Trust Boards take full responsibility for nursing and care staffing capacity and capability.

3.2 All 51 in-patient areas within the Trust have reported the details of their staffing levels on a shift by shift basis for the month of July 2014.

3.3 Managers have been required to report their planned numbers of registered nurses

and health care assistants on duty against the numbers actually present on shift. Each shift was then RAG rated as follows:

Green Staffing meets planned requirement

Amber Staffing does not meet planned requirement but is safe

Red Staffing does not meet planned requirement and this has been escalated to a senior nurse or site manager

3.4 This exception report provides details of all shifts that were RAG rated red during

July 2014. 3.5 During July 2014, on the basis of three shifts per day (early, late and night) for 31

days on 51 in-patient areas, there were a total of 4743 shifts. Of those, 56 (1.18%) were RAG rated as red. This is a slight improvement on last month when 1.30% of shifts were RAG rated as red.

3.6 Details of red rated shifts are reported in the table below, along with reasons given

for the understaffing by the service areas. Where details of mitigation and impact on quality have been provided, these have been included in the table.

4. ANALYSIS AND CONCLUSION 4.1 Of 4743 shifts within in-patient areas during June 2014, 56 (1.18%) were RAG rated

red.

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4.2 During the three months that the Trust has been monitoring staffing levels, the overall number of red rated shifts has slightly reduced. Please see trend analysis below.

4.3 When the number of red rated shifts per CSU is considered. There has been a

reduction within Specialist and Forensic Services which had no red rated shifts this month. Local services reported 14 red rated shifts in 5 wards which compares with the previous month (14 shifts in 6 wards) and is a reduction on the May report (44 shifts in 8 wards). High secure services have reported an increase in the number of red rated shifts, with 47 reported this month, compared with 39 in June and 23 in May. However, the number of wards reporting red rated shifts in high secure services has reduced from 9 last month to 5 this month. Furthermore, of the 47 red rated shifts, 43 were in two wards.

4.4 With regard to incident reports raised as a result of staffing levels concerns, 32

were received. Of these, 30 were received from high secure services and 2 were received from local services. No incident reports were raised as a result of staffing concerns from specialist and forensic services. Please see the below graph.

32

17

9

2 2 1 10

10

20

30

40

Total Trust HSS Ascot HSSCranfield

HSSNewmarket

HSSWoburn

LS Hope LS Jubilee

Staffing Incidents July 2014

5. RECOMMENDATIONS 5.1. This is the third monthly exception report of nurse and health care assistant staffing

within the Trust’s in-patient areas. Regular staffing meetings are held which provide an opportunity to reflect on the data, the process and the learning from each cycle. An area identified for improvement from this report includes the CSU’s routinely recording of reasons for shortages, mitigation strategies and impact on quality of having less than planned numbers. It is anticipated that this will be improved for the August report of data.

Dr Anne Aiyegbusi

Interim Director of Nursing and Patient Experience Sept 2014

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Table : All WLMHT Red RAG rated shifts for July 2014

CS

U

Ward

Ward

Typ

e

No

Bed

s

Sh

ift

excep

tio

ns

Sh

ift

Pla

nn

ed

RN

Pla

nn

ed

HC

A

Actu

al

RN

Actu

al

HC

A

Co

mm

en

ts

LO

CA

L S

ER

VIC

ES

Horizon Male Assessment

14 1 x late L1 2 3 2 1 Bank shift cancellation. Unit co-ordinator provided support

The Limes Mixed Gender Dementia

20 3 x late L1 2 6 2 4 Sickness and incident. Could not cover

L2 2 6 2 4 Sickness and member of staff sent home. Could not cover

L3 2 6 2 4 Sickness. Could not cover. Mitigation - 2 empty beds.

Grosvenor Women’s Assessment

17 1 x night N1 2 2 1 3 RN Sickness. Unable to cover. Mitigation – Increased number of HCAs

Kingfisher Women’s Recovery

22 3 x early E1 2 2 1 2 Last minute sickness. Mitigation – Unit co-ordinator supported

E2 2 2 1 2 Last minute sickness. Mitigation – Unit co-ordinator supported


Askew Men’s PICU 12 1 x night N1 2 2 1 2 No comments recorded

HIG

H S

EC

UR

E S

ER

VIC

ES

Ascot Men’s Acute 12 11 x early

E1 4 3 3 4 No comments recorded



E4 4 3 3 2 Sickness. Unable to cover

E5 4 3 2 3 Sickness. Unable to cover. Mitigation – OT based on ward






E11 4 3 3 2 Sickness. Unable to cover. Adjacent ward offering support

Ascot Men’s Acute 12 16 x late L1 4 3 2 3 Emergency leave and sickness. Unable to cover

L2 4 3 2 3 Emergency annual leave. Unable to cover


L4 4 3 3 2 Vacancies. Unable to cover

L5 4 3 4 1 Sickness and vacancy. Unable to cover


L7 4 3 4 1 Sickness and vacancy. Unable to cover. OT staff based themselves on ward.

L8 4 3 3 2 Sickness and 1 x carer's leave.

L9 4 3 2 3 Sickness and 1 x carer's leave. Unable to cover

L10 4 3 2 3 Sickness - unable to cover.






Chepstow Men’s 12 1 x late L1 3 3 3 1 Emergency leave. Unable to cover.

Cranfield Men’s PICU 9 1x late L1 4 4 4 1 Special leave. Unable to cover.

Leeds Men’s Rehab

20 2 x late L1 2 3 2 1 Sickness. Unable to cover. Impact – 2 x ward activities cancelled.

L2 2 3 2 1 Sickness. Unable to cover. Impact – 2 x ward activities cancelled.

Woburn Men’s Acute 14 6 x early

E1 4 4 4 2 I RN cancelled bank shift and 1 HCA sick. Mitigation - 1 HCA redirected from Cranfield at 12:30.

E2 4 4 2 4 I HCA redirection to other ward.

E3 4 4 3 3 Sickness and 1 x HCA arrive on duty for back shift. Impact – restricted patient activities.

E4 4 4 2 4 Sickness and cancelled bank shift. Mitigation, 1 HCA changed from late to early shift.

E5 4 4 2 4 1 RN cancelled bank shift. Impact – restricted patient activities.


Woburn Men’s Acute 10 x late L1 4 4 3 3 Sickness.

L2 4 4 4 2 1 x sickness and 1 x cancelled bank shift. Mitigation - staff redirected from other ward at 1600.

L3 4 4 5 1 Sickness - Mitigation – 1 HCA changed from early to late shift.

L4 4 4 5 1 Sickness.

L5 4 4 4 2 Redirection and sickness. Impact -restricted patient activities.


L7 4 4 3 3 Sickness and 1 x HCA did not arrive for bank duties . Unable to cover. Impact – restricted patient activities.

L8 4 4 2 3 2 x redirections. Impact – limited patient activities.

L9 4 4 2 4 Impact – restricted patient activities.

L10 4 4 3 3 1 x bank staff did not arrive for duty. Unable to cover. Impact – restricted patient activities.

TOTAL TRUST EXCEPTIONS 56

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Table : All WLMHT Red RAG rated shifts for July 2014 C

SU

Ward

Ward

Typ

e

No

Bed

s

Sh

ift

excep

tio

ns

Sh

ift

Pla

nn

ed

RN

Pla

nn

ed

HC

A

Actu

al

RN

Actu

al

HC

A

Co

mm

en

ts

LO

CA

L S

ER

VIC

ES

Horizon Male Assessment

14 1 x late L1 2 3 2 1 Bank shift cancellation. Unit co-ordinator provided support

The Limes Mixed Gender Dementia

20 3 x late L1 2 6 2 4 Sickness and incident. Could not cover

L2 2 6 2 4 Sickness and member of staff sent home. Could not cover

L3 2 6 2 4 Sickness. Could not cover. Mitigation - 2 empty beds.

Grosvenor Women’s Assessment

17 1 x night N1 2 2 1 3 RN Sickness. Unable to cover. Mitigation – Increased number of HCAs

Kingfisher Women’s Recovery

22 3 x early E1 2 2 1 2 Last minute sickness. Mitigation – Unit co-ordinator supported



Askew Men’s PICU 12 1 x night N1 2 2 1 2 No comments recorded

HIG

H S

EC

UR

E S

ER

VIC

ES

Ascot Men’s Acute 12 11 x early











E11 4 3 3 2 Sickness. Unable to cover. Adjacent ward offering support

Ascot Men’s Acute 12 16 x late L1 4 3 2 3 Emergency leave and sickness. Unable to cover



L4 4 3 3 2 Vacancies. Unable to cover



L7 4 3 4 1 Sickness and vacancy. Unable to cover. OT staff based themselves on ward.

L8 4 3 3 2 Sickness and 1 x carer's leave.

L9 4 3 2 3 Sickness and 1 x carer's leave. Unable to cover







Chepstow Men’s 12 1 x late L1 3 3 3 1 Emergency leave. Unable to cover.

Cranfield Men’s PICU 9 1x late L1 4 4 4 1 Special leave. Unable to cover.

Leeds Men’s Rehab

20 2 x late L1 2 3 2 1 Sickness. Unable to cover. Impact – 2 x ward activities cancelled.

L2 2 3 2 1 Sickness. Unable to cover. Impact – 2 x ward activities cancelled.

Woburn Men’s Acute 14 6 x early

E1 4 4 4 2 I RN cancelled bank shift and 1 HCA sick. Mitigation - 1 HCA redirected from Cranfield at 12:30.

E2 4 4 2 4 I HCA redirection to other ward.

E3 4 4 3 3 Sickness and 1 x HCA arrive on duty for back shift. Impact – restricted patient activities.

E4 4 4 2 4 Sickness and cancelled bank shift. Mitigation, 1 HCA changed from late to early shift.



Woburn Men’s Acute 10 x late L1 4 4 3 3 Sickness.

L2 4 4 4 2 1 x sickness and 1 x cancelled bank shift. Mitigation - staff redirected from other ward at 1600.

L3 4 4 5 1 Sickness - Mitigation – 1 HCA changed from early to late shift.


L5 4 4 4 2 Redirection and sickness. Impact -restricted patient activities.


L7 4 4 3 3 Sickness and 1 x HCA did not arrive for bank duties . Unable to cover. Impact – restricted patient activities.

L8 4 4 2 3 2 x redirections. Impact – limited patient activities.

L9 4 4 2 4 Impact – restricted patient activities.

L10 4 4 3 3 1 x bank staff did not arrive for duty. Unable to cover. Impact – restricted patient activities.

TOTAL TRUST EXCEPTIONS 56

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24th September 2014

Report Title:

TDA Submission – Development Support Plan

Executive Lead:

Barbara Byrne, Deputy Chief Executive / Director of Finance

Report Author(s):

Hannah Parsons, Deputy Director of Business & Strategy

Report discussed previously at: FT Operations Group, ED meetings


The Trust Board is asked to discuss and approve the 30 September TDA submission ‘Annex G – Development Support Plan’.

Approval

Discussion

Information


On 30 September we are required to submit ‘Annex G – Development Support Plan’ to the Trust Development Authority (TDA). This is presented to the Board today for approval. The submission is a mandatory requirement, and has been developed in conjunction with them, in line with their technical guidance. The purpose of this submission is to identify the support required from the TDA to achieve our goals, and demonstrate our focus on improvement and development. We have worked with the TDA during our routine Integrated Delivery Meetings (IDMs) to identify where they can provide development support. The areas of organisational weakness/challenge within this plan were identified during discussion with the TDA on areas of potential risk and reflect existing risks within our own Board Assurance Framework (BAF). The themes identified were as follows:

1. Chief Inspector of Hospital’s visit 2. Delivery of our Cost Improvement Plans 3. Timing of external assessments 4. Staff engagement/culture 5. Delivery of our redevelopment plans 6. Key vacancies and recruitment 7. Maintaining commissioner support

In some cases no support was identified for the organisational challenges that we discussed.

Redevelopment plans - Our redevelopment plans are on course to deliver and we have an ongoing dialogue with the TDA in relation to those through the IDMs.

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Key vacancies and recruitment – Key posts such as the Director of Nursing and Patient Experience and Director of Finance have now been appointed.

Maintaining commissioner support – The Trust is proactively engaging commissioners on areas including the Trust’s strategy and Integrated Business Plan in order to maintain their support.

The template enclosed for Board approval is a mandatory template.









Yes

If yes, insert relevant risk reference: 6960, 5981, 4239, 5917, 4190


No


Legal and regulatory implications Yes

Financial Implications Yes

Equality and Diversity Yes

Public, Service User and Carer Yes

Performance Management Yes

Communication Yes


Strategy



Measurement


TDA Trust Development Authority

BAF Board Assurance Framework

CIH Chief Inspector of Hospitals

CQC Care Quality Commission

FT Foundation Trust

BGAF Board Governance Assurance Framework

MQGF Monitor Quality Governance Framework

IDM Integrated Delivery Meeting

IFR Independent Financial Review


N/A

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Annex G

NHS Trust Development Authority

Development Support Plan

No

Organisational weaknesses and challenges 1

Development intervention 2

Development support 3 Timescale Outcome 4

1 Chief Inspector of Hospitals (CIH) visit

Trust to share project plan and communication plan

Comments on project plan and communication strategy would be helpful.

November Robust preparation for CIH visit in Q4.

Clarity on timeline for CIH visit

TDA to support the Trust’s requests for confirmed timeline for CIH visit and liaise directly with Care Quality Commission (CQC).

November Confirmed date for CIH visit around which plans can be made. CIH visit anticipated in Q4.

2 Cost Improvement Programme (CIP) delivery

Identification of CIPs

TDA monitor CIPs for all NHS Trusts – support to be provided through sharing benchmarking data and success stories, particularly those relating to mental health and North West London (NWL).

October

Identification of CIPs in 15/16 and 16/17 to ensure robust three year plans in advance of any external financial review.

Name of NHS Trust: West London Mental Health Trust

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Annex G


3 Timing of external assessments

Clarity in relation to Foundation Trust (FT)/CIH timeline

Regular Integrated Delivery Meetings (IDMs) to discuss movements in timeline.

Ongoing Clarity in relation to FT/CIH timeline

Confirmation of scope of external finance review

Meeting between Trust and TDA to review historic evidence base against scope of the mandatory Independent Financial Review (IFR2).

October Agreement on scope of external finance review in January.

Confirmation of scope of internal governance reviews and agreement no external assessment is required

Meeting between Trust and TDA to review historic evidence base against the scope of Monitor’s Quality Governance Framework (MQGF) and the Well-led framework

October

Agreement as to the scope of Internal self assessment of MQGF and Board Governance Assurance Framework (BGAF) in November.

4 Staff engagement / culture

The Trust to share latest version of the staff engagement action plan and project plan

TDA to review and provide comments November

Robust plans to improve staff engagement and culture, to be demonstrated through improved staff survey results.

The Trust to share latest version of the staff engagement action plan and project plan

TDA to provide benchmarking data and share success stories, particularly those relating to mental health trusts and NWL.

November Staff engagement action plans deliver outcomes.

5 Redevelopment plan delivery

No support identified. N/A N/A

No support identified. Our redevelopment plans are on course to deliver and we have an ongoing dialogue with the TDA in relation to those through the IDMs.

6 Key vacancies and recruitment


No support identified. Key posts such as the Director of Nursing and Patient Experience and Director of Finance have already been appointed.

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Annex G


1. Describe the Trust’s needs analysis (i.e. the evidence the Trust has that led it to identify the need for a development intervention) 2. Description of what is required to address the development need that has been identified 3. How is the Trust undertaking or proposing to undertake the development initiative, including identifying what support from the TDA it might need to deliver it? 4. What does the Trust expect to deliver and by when?

7 Maintaining commissioner support


No support identified. The Trust proactively engage with commissioners on areas including the Trust’s strategy and Integrated Business Plan in order to maintain their support. ite

m 1

2: d

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SUMMARY REPORT - TRUST BOARD MEETING (PART 1)

24 September 2014

Report Title:

Communications & Engagement Strategy Update

Executive Lead:

Steve Shrubb, Chief Executive

Report Author(s):

Helene Feger, Director of Communications

Report discussed previously at: NA


This paper updates the board on progress against plan of the trust’s communications and engagement strategy and identifies areas for further development, new projects and timescales for delivering these. The Board is asked to note this report.

Approval

Discussion

Information


Significant progress has been made in improving our internal and external communications and engagement.

External communications via the traditional media and social media has also improved significantly.

Our public membership doubled through a major recruitment drive in early 2013 and further work is on-going to recruit an additional 440 members and ensure the demographic profile of our members matches the communities we serve.

The trust website is being redeveloped in two phases through October/March

The communications team successfully managed the publication and national press launch of the Jimmy Savile Investigation report at Broadmoor Hospital







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No



No







Communication


Strategy



Measurement



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TRUST BOARD MEETING (PART 1) – 24 SEPTEMBER 2014 UPDATE ON TRUST COMMUNICATIONS AND ENGAGEMENT STRATEGY 2013-2015

1 PURPOSE 1.1.1 The purpose of this report is to provide an update on progress in implementing the

Communications and Engagement Strategy approved by the Board in May 2013.

1.1.2 The Board is asked to note and discuss progress in delivering the objectives of the strategy in the first 16 months of its implementation.

2 INTRODUCTION 2.1 The strategy was developed following feedback received from a range of internal

and external stakeholders. This included staff feedback via the reporters’ project, an internal communications survey, feedback from stakeholders in the board governance assurance framework, and feedback from service users and carers about communication and engagement.

2.2 The strategy identified five stakeholder groups – service users, carers and the

public, staff, partners, stakeholders and members that are the target audiences of our communications and engagement activity plus a set of specific aims and SMART objectives. These are aligned to seven areas of focus or narratives upon which to base the trust’s communications and engagement activities. These include recovery, reducing stigma, local services, modernising, valuing staff, best value and innovating to improve care.

2.3 Progress against the aims and objectives is reported to the Strategic Projects

Programme Board regularly via a communications and engagement scorecard and FT membership report; a quarterly communications and engagement report to High Secure Services SMT; and regular communications and engagement updates to the local service transformation programme board, the Three Bridges MSU Redevelopment Programme Board and the Broadmoor Hospital Redevelopment Programme Board.

3 IMPLEMENTATION PROGRESS 3.1 Two summary communications and engagement scorecards are attached to this

report at Appendix 1 – for completeness these include an annual report for 2013-2014 and the second covers the first two quarters of 2014-2015. A Q2 scorecard will be reported to the October Strategic Projects Programme Board.

3.2 Significant progress has been made in improving our internal and external

communications and engagement. Highlights include the introduction of the chief executive’s blog, a strategic communication to staff and stakeholders, and regularly scheduled staff engagement via Listening Events across all service areas which now include executive directors as well as the chief executive. These have promoted better links between Board members and frontline staff, an issue identified in the fishbowl exercise as vital to improving staff engagement. It is also worth noting that the blog is interactive and allows staff to post comments and

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receive responses directly from Steve Shrubb and any issue raised the Listening Events is followed up with staff in a ‘You said, we did’ communication update.

3.3 External communications via the traditional media and social media has also

improved significantly. The communications team produces an average of four press releases per month and positive media coverage has increased month on month in that time period. The trust’s social media presence has grown impressively with the corporate twitter account increasing its followers by 48% in the past six months; a growing number of senior clinicians and service leads are also now active on twitter, engaging service users and carers and partners in regular discussions about our services. A landmark documentary at Broadmoor Hospital has been filmed this year and is due for transmission in November 2014. Further high profile documentaries in the gender service are due to air in October on Channel 4 and on BBC Radio 4. Other significant documentary projects with the BBC are in the early stages of planning and should be produced in 2015.

3.4 Our public membership doubled through a major recruitment drive in early 2013 and

further work is on-going to recruit an additional 440 members and ensure the demographic profile of our members matches the communities we serve. Introductory sessions were held last year with prospective governors and a newsletter for trust members was re-launched in an online format in July 2013, keep them informed and involved in trust progress toward FT status and developments within services and the organisation at large.

3.5 Further work is needed in other areas. We are currently undertaking a refresh of our

vision, values and behaviours with staff, which is due to be completed at the end of this month. A campaign to embed the trust’s revised vision and behaviours will be launched once we’ve agreed the results of the refresh. This will be important to launch in advance of the Chief Inspector of Hospitals visit.

3.6 The trust website is being redeveloped in two phases through October/March with a

view to introducing more digital communications such as videos of the Board meetings (more detailed plans for how this will be achieved will come back to the Board in January 2015) and films for service users and carers about our services. A CAMHS website and microsite for recruitment and IAPT services have either already been developed or are due to launch shortly.

3.7 Stakeholder communications is an area that requires further focus. The trust has

improved information sharing with CCGs via their own websites and GP portals. A stakeholder newsletter will be launched this month to keep commissioners, local authority partners, regulators, governmental authorities aware and informed of our key priorities and announcements.

3.8 The communications team has supported campaigns around improving the uptake

of the staff survey, the flu campaign, Don’t be a victim safety campaign at Broadmoor Hospital, Befrienders scheme, raising awareness of whistleblowing and the Speak out, speak up campaign, the introduction of RiO7 and reducing the risk of legionella infection. Further campaigns are planned for whistleblowing, recruitment, the flu campaign and staff survey among others.

3.9 The communications team successfully managed the publication and national press

launch of the Jimmy Savile Investigation report at Broadmoor Hospital. The trust’s messaging about improved safeguarding and patient and staff relations and safety

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since Savile’s time at the hospital were well received by the press, and stakeholders including the CQC, TDA, commissioners, ministers and the Health Secretary.

3.10 Public affairs is another area for further development. Engagement with our

stakeholders and notably ministers, MPs and local councillors is improving but more regularly scheduled meetings covering the breadth of strategic priorities for the trust are required. This work will be addressed in the latter part of 2014 and early 2015.

3.11 Responsibility for delivering involvement rests partly with the trust communications

and engagement team and progress has been made in delivering the trust involvement strategy, service user pay policy and a range of workshops and events to ensure service users and carers are engaged in planning, delivering and evaluating key priorities including notably local services transformation.

4 ISSUES FOR CONSIDERATION 4.1 The Board is asked to review the progress of the trust’s communications and

engagement strategy and to note the further work we are undertaking to improve how we engage and communicate with staff, the communities we serve, our stakeholders, members and partners.

5 CONCLUSION 5.1 Good progress has been made in delivering the key priorities set out in the trust’s

communications and engagement strategy and the accompanying appendices quantify the performance and evaluation of the team’s work. Increasingly communications and engagement is earning the respect of colleagues and more services are seeking support to ensure the whole organisation and the communities it serves are aware of the positive work of the trust and how we are improving services. However, there is much more to be done in improving internal communications and engagement, building a better dialogue and understanding of our work with stakeholders and partners and generally improving how we deliver engagement and communications to ensure we support the effective delivery of services via a high performing workforce.

Helene Feger Director of Communications & Involvement

September 2014

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Positive Negative

Apr 4 2

May 5 3

June 9 6

July 28 2

Aug 6 13

Sept 2 3

Oct 11 11

Nov 13 1

Dec 14 6

Jan 16 3

Feb 12 0

Mar 11 1

INTERNAL COMMUNICATIONS

Membership. Total members - 12,218 - increase of 17% (staff

4,009 and public 8,209) Targeted recruitment activities have taken

place to fill gaps in our membership at London Mela (Asian males),

AGM (males), recruitment at local Age UK events (men aged 80

and above) and through some local secondary schools (young

males).

Chief Executive's blogs - Since April 2013, Steve's Blog has received an average of 3,900

hits per month. The blogs that received the greatest number of hits included Changing

adult community services (3,462 hits) and Changing the culture (3,772 hits). Since the

new Exchange has been implemented, the hit rate has fallen slightly and the

Communications team is looking into why this is.

MEMBERSHIP AND ENGAGEMENT

PRESS COVERAGE BY MONTH

Facebook:

754 likes (increased by 10% since the

start of the financial year)

Twitter:

@WLMHT - 565 followers - up 48%

since the start of the financial year

@OpenMinds1 - 549 followers - up 9%

since the start of the financial year

Main themes:

- Dementia G8 R&D, Broadmoor

redevelopment, Olympian visits

inpatient unit, London Mela,

community shop, Back from the

Future seminar, AGM, becoming

a member.

Most popular pages:

1. Services

2. About the board

3. Complaints

Traffic sources:

1. Google

2. Direct

3. Other search engines

124 FoI requests received during this

period. Main issues: the number of

mental health patients the trust places out

of area; number of SUIs, suicides/bed

numbers in MSU, violence at Broadmoor,

money spent on refurbishing the John

Connolly and Wolsey Wings; number of

deaths in medium secure units.

Total visits: 249,893

New visitors: 66%

Returning visitors:

34%

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Appendix One: WLMHT COMMUNICATIONS SCORE CARD: April 2013 - March 2014

FOI WEB STATSSOCIAL MEDIA STATS

Total number of press releases issued: 43 Modernising - 12 press releases issued Redevelopment open days (BBC South Today, BBC Berkshire, Bracknell Times); Groundbreaking event (BBC South Today, BBC Berkshire, Bracknell Times); Mind CEO joins transformation board (Ealing Gazette), 24/7 helpline launched (Hounslow Gazette) Innovating - 6 press releases White City outreach (Hammersmith Gazette); PREVENT dementia study (Sunday Times); CRHT in Hounslow (Guardian) TOMORROW study (Daily Mail); Broadmoor clinical research approach (New Scientist) Local services - 7 press releases No Smoking Day (Ealing Gazette); IAPT in Hounslow (Hounslow Gazette) Reducing stigma - 6 press releases Broadmoor's 150th anniversary (Bracknell Times; BBC website); Sir Quentin Blake unveils hospital artwork (Ealing Gazette); Broadmoor Hospital on Great British Railway Journeys Valuing people - 4 press releases Hospital librarian retires (Ealing Gazette) Best value - 5 press releases Trust wins talking therapies contract (Hounslow Gazette) The most impactful stories were the Guardian's feature on the Hounslow CRHT service and the BBC South story on the groundbreaking ceremony at Broadmoor Hospital.

0

5

10

15

20

25

30

Positive

Negative

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Positive Negative

Apr 9 3

May 14 1

June 7 117

July 6 6

August 11 1

Up to 10 Sept 4 0

Appendix one cont'd - WLMHT COMMUNICATIONS SCORE CARD: Apr - 10 September 2014

FOI WEB STATSSOCIAL MEDIA STATSFacebook:

774 likes (increase of 2.5% since end of

March 2014)

Twitter:

@WLMHT - 767 followers - increase of

28% since beginning of April 2014

@OpenMinds1 - 584 followers - increase

of ~5% since beginning of April 2014

Key themes:

Membership recruitment; redevelopment

news; public events – AGM, service user

and carer forums; anti-stigma retweets;

research and development; conferences

and awards – HCA awards, nursing

conference, etc.

Most popular pages:

1. Broadmoor Hospital

2. Services

3. Gender Identity Clinic

Traffic sources:

1. Google

2. Direct

3. Other search engines

FOI requests for April - September

15- media/3 - MP/58 - public.

Media issues: incident on Epsom Ward in

2013; statistics relating to restraint; length

of time for people to receive an urgent

assessment; number of people

diagnosed and misdiagnosed with

Aspergers Syndrome; documents relating

to Rolf Harris.

Total visits: 131,477

New visitors: 68%

Pageviews: 389,053

Returning visitors:

32%

PRESS COVERAGE BY MONTH

INTERNAL COMMUNICATIONSMembership. Total members - 12,044 (staff 3,984 and public 8,060) This

quarter we have targeted older white and Asian males by attending the

AGM of the Hounslow Pensioners Forum, Wyevale Garden Centre and

Ealing Central Library. Our focus remains on recruiting younger males. We

will be attending the fresher’s week events at the University of West

London and also Bucks New University.

April to end August 34,541 hits on trust news. Biggest hits: quality award nominations, learning

lessons conference, heatwave alert, changes to parking at St Bernard’s, new recruitment service,

RiO7, Sarah Ruston’s appointment. Steve's blog. 1,428 hits for April, 1,520 for May, 1,865 for June,

1,838 for July and 2,576 for August. 'The next five years’ (a blog about our vision consultation);

'Taking more targeted action' (as a result of staff survey results) and 'the health of our colleagues

and our bank balance‘ (a blog about doing some work to address high levels of sickness absence)

were the most read during this period.

MEMBERSHIP

Total number of press releases issued: 24 Recovery - 2 press releases Trust leading the way to improve patient access to mental health services (Ealing Gazette). Reducing stigma - 2 press releases Trust pledges support to national Dementia Friends campaign (Ealing Gazette). Local services - 2 press releases Supporting victims of abuse during the World Cup (Ealing Gazette); Trust announces key director appointment to its local services (Ealing Gazette). Modernising - 8 press releases Final foundation stone laid for new unit (Ealing Gazette, BBC South Today, BBC Berkshire, Eagle Radio); Redevelopment open days for Crowthorne and Sandhurst (Bracknell Times) ; Virendra Sharma MP tours new Wolsey Wing (Ealing Gazette). Valuing staff - 4 press releases Ward manager awarded for excellent service (Ealing Gazette); World Cup glory comes to west London (Ealing Gazette); Trust leads the way in providing practical experience for junior doctors. Best value - 2 press releases Broadmoor siren activated due to electrical storm (BBC Berkshire, Bracknell Times). Innovating to improve care - 4 press releases New institute promotes excellence in mental health; trust’s researchers lead in dementia research (Ealing Gazette); New Zealanders visit trust to learn about IAPT services (Ealing Gazette). Jimmy Savile investigation - various national including BBC, Guardian, Independent, the Sun and Mirror

0

20

40

60

80

100

120

140

Apr May June July August Up to 10 Sept

Positive

Negative

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Appendix 2 Specific aims and SMART objectives

Audience Aim SMART objectives Progress to date

Public To increase brand recognition of the Trust as a provider of excellent, evidence-based mental health services that promote recovery and reduce stigma associated with mental health problems.

To proactively build our brand and reputation as an innovative, research-active and responsive market leader.

To increase public confidence in the Trust’s services at a local and regional level.

Increase proactive media coverage by issuing between 4 and 8 press releases per month. Increase numbers of people following corporate twitter account and individual twitter accounts. Increase in positive cuttings v negative coverage. Increase recognition of excellence via awards for Trust innovation and communication.

An average of 4 press releases per month are currently being issued. (See scorecard) Twitter followers have increased by 28% in the past six months, 48% in the last financial year. However, we need to continue to focus on growing our follower base. Positive coverage has been increasing, though June 2014 was notably negative as a result of the Savile investigation publication.

Service users, patients and carers

To increase recognition of the Trust as a provider of excellent, evidence based mental health services that promote recovery and reduce stigma associated with mental health problems.

To increase confidence in the Trust’s services

To ensure service users, patients and carers are involved in developing our services and influence our communications and engagement activities so that they meets their needs.

Audit service user, patient and carer publications and information and refresh publications. Refresh Open Minds campaign via traditional and social media Review web content. Improve navigation and accessibility. Involve service user, patient and carers through surveys, focus groups etc in regard to preferences for ways in which we communicate and engage with them. Ensure communications channels reflect preferences for written, video/audio, web-based communications including in translation.

An audit resulted in new publications and information for local services including workstreams within the transformation programme; improvements in web-based information, development of a video library. Work is in progress to integrate the Open Minds campaign into our corporate messaging. Web-site redevelopment underway.

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Staff To ensure our organisation, from the Board to ward, is responsive, open and engaging in discussions that result in continuous improvement in staff relations, quality of care and outcomes for patients.

To ensure that our staff understand the Trust’s vision, know their role in delivering the Trust’s strategic aims and live its values.

To provide ample opportunity for staff, service users and carers, and stakeholders and partners to be engaged in designing services and contributing to decisions about the future of our services.

10% improved uptake of staff survey. Improvement in the direction of results of the staff survey Increased attendance at Listening Events (staff forums)

10% improvement in staff understanding our vision, values and strategic aims. Increased and earlier engagement in service redesign/increased consensus around service redesign

Further work is underway to increase uptake and results of the staff survey. Attendance is being monitored as of January 2014. It varies from venue to venue, but we should be able to compare year on year results from the various venues and measure improvements. Work is in progress. Further work is being undertaken as part of the staff engagement project and is being monitored by the change management project within the staff engagement workstream.

Stakeholders To build the Trust’s reputation for providing excellent mental health services which promote recovery.

To communicate through a range of high-quality, relevant, timely and accessible publications to partners, members and stakeholders how the Trust provides excellent services that promote recovery.

To increase understanding of our vision and strategic aims, encourage contributions to our future development and generate support for them.

Demonstrate increasing confidence through stakeholder audit (using BGAF results as baseline) Demonstrate increased knowledge of services through audit. Demonstrate increased understanding of vision and strategic aims via stakeholder audit. Demonstrate increased support for and contribution to the trust’s future.

Further audit required. Stakeholder engagement in vision and values work is underway.

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Partners To increase understanding of our vision and strategic aims and generate support for them.

Evidence of effective partnership working Work is in progress.

Members To support the successful achievement of FT status, by acquiring and retaining 10,000 members who are representative of the staff and communities we serve.

To ensure members are informed and involved in the Trust’s development.

To support election of a robust Council of Governors.

Complete recruitment and deliver representative membership.

Demonstrate understanding of Trust strategic aims through information sharing/communication via member events, member publication. Numbers of candidates standing for Council of Governors and representativeness. Voter turnout for elections.

Public membership doubled. Final 400 members currently being recruited, and seeking to re-dress demographic imbalances. Members newsletter launched in July 2013 and governor sessions held autumn 2013. Further work to be reviewed and planned. Pending

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To improve the reputation of the Trust externally with service users and carers, the media, stakeholders and partners, so we are seen as the provider of choice for mental health services.

To build support within the Trust at all levels for our vision, values and strategic aims so that our workforce is engaged in delivering the priorities of the Trust.

Ove

rarc

hin

g

aim

Patients, service users, carers and the public• Increase brand recognition for excellent services that

promote recovery• Build our reputation for quality and innovation• Increasepublicconfidenceinourservices

StakeholdersBuild our reputation for excellence.

PartnersIncrease understanding of our vision and strategic aims

StaffEngage staff and involve them in decision making.

MembersSupport FT application, including governor elections, through information and involvement.

Strategy: To set the agenda on mental healthWe’ll proactively create and exploit opportunities to set the agenda on mental health care to convey our vision and strategic aims. To that end we will develop a set of themes (core narratives) around which our messaging will be targeted and delivered across all communications functions, including internal/staff, patients/service users/carers, media/public, external/stakeholder. We will use research and evidence to inform how we communicate and monitor and evaluate our communications activity to plan more effectively.

Principles• Everything we say and do should relate back to our core narratives.• Buildtheprofileofourstrategicandclinicalleadersfordeliveringqualityandinnovation..• Talk about people – use recovery stories with case studies that are proven effective methods of

engaging with audiences.• All Trust communications should be clearly badged as such.• Reflectthevoiceofserviceusersandcarersinourcommunicationsandusethevoicesoftrusted

partners where possible.• Our staff should be our best and most used communications channel.

Specific aims

Core narratives

RECOVERY REDUCING STIGMA

LOCAL SERVICES

MODERNISING VALUING STAFF

BEST VALUE

INNOVATING TO IMPROVE

CARE

g #h p n

We will create integrated packages of communications based on these core narratives that are delivered through all relevant channels.

,

Communications and engagement strategy

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24th September 2014

Report Title:

Register of Board Members’ Interests

Executive Sponsor:

Steve Shrubb, Chief Executive

Report Authors:

Barbara Wörts, Trust Secretary



To note formally the declared interests of Professor Sally Glen, Non-Executive Director

Approval

Discussion

Information


Following her appointment in July 2014, Professor Glen completed an entry for the Trust’s register of interests.

Relationship to Strategic Aims


SA2: To provide excellent personalised care, treatment and support.



SA5: To build an engaged workforce which is focussed on recovery and the needs of service users and carers.



No

If yes, risk reference


No

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Corporate Impact Assessment


Compliance requirement

Financial Implications None

Equality and Diversity None


None

Performance Management None

Communication

Information contained in this report will be included in the Trust’s Annual Report 2014/15


Strategy

Capabilities and Culture Yes


Measurement


Further Reading / Attachments

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REGISTER OF BOARD MEMBERS’ INTERESTS

1 PURPOSE 1.1 The Board is asked to note the interests declared.

2 BACKGROUND

2.1 The Chairman and all Board directors are required to declare any conflict of

interest that arises in the course of conducting NHS business. Guidance outlines the requirement for all NHS organisations to maintain a register of members’ interests to avoid any danger of board directors being influenced, or appearing to be influenced, by their private interests when exercising their public duties. All board members are therefore expected to declare any personal or business interest which may influence, or may be perceived to influence, their judgement. This should include, as a minimum, personal direct and indirect financial interests and should normally also include such interests of close family members. Indirect financial interests arise from connections with bodies which have a direct financial interest, or from being a business partner of, or being employed by, a person with such an interest.

2.2 It should be noted that although the requirement is for the interests of voting

members of the Board to be in the public domain, it is considered good practice for all Board Directors who speak at the Board and can therefore influence decisions to declare their interests.

2.3 The Register of Interests is a public document and may be inspected by anyone

at any time, by applying to the Trust Secretary.

3 RECENT CHANGE 3.1 On 20th July 2014, Professor Sally Glen, Non-Executive Director formally

registered the following interests: Ownership or part ownership of private companies, business or consultancies likely or possibly seeking to do business with the NHS:

Consultancy with Higher Education Quality Assurance Agency

Position of authority in a charity or voluntary body in the field of health or social care:

Lay Member – Samaritans, Waltham Forest

Lay Member – City & Hackney Children’s Safeguarding Board Any connection with a voluntary or other body contracting for NHS services:

Ex Non-Executive Director, East London Foundation Trust

Ex Non-Executive Director, Leeds Partnership NHS Trust

Visiting Lecturer, Greenwich University (School of Health)

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Ex Dean / Pro-Vice Chancellor, University of Wolverhampton

Ex Dean/Professor of Education of the School of Nursing and Midwifery, University of Dundee (Faculty / School of Health)

Ex Head of School of Health & Social Care, London South Bank University 4 RECOMMENDATIONS

4.1 The Board is asked to note the interests declared.

Barbara Wörts Trust Secretary

September 2014

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Date of Trust Board: 24th September 2014 Name of Meeting: Audit Committee Date of Reporting Meeting: 3rd September 2014 Name & Title of Chair: Christine Higgins, Non Executive Director Key Issues to highlight:

INTERNAL AUDIT & LCFS APPOINTMENT PROCESS The committee agreed the timetable, service specifications and evaluation criteria for the procurement of internal audit and counter fraud services for the next 3–5 years, from April ’15. EXTERNAL AUDIT The committee received the Annual Audit Letter from PWC which provided a high level summary of the results of the 2013/14 audit, including recommendations. The detailed findings had already been reported to the Audit Committee and the Board through other reports. The final fees were in line with the fee proposal previously advised to the Audit Committee. INTERNAL AUDIT PROGRESS REPORT It was noted the CIP audit had been replaced by a review of the Transformation Programme Board. All due recommendations from previous audits have been or are being implemented except for 2 medium priority recommendations relating to backlog maintenance which have now been prioritised by Estates. The findings of 3 recent audits were received: Staff Engagement: rated Amber/Green: 3 x medium priority & 1 x low priority recommendations: This was an audit of the controls in place to manage the Trusts staff engagement plan. It was noted the Trust was doing more work in this area than many other organisations, also the feedback to staff through the Action for Change newsletter was highlighted as good practice. However, despite this, staff survey results were still below the national average. Key recommendations were to ensure actions were assessed by their impact, to assign deadlines and responsible officers to actions and to include new long term actions in the work plan. Board Assurance Framework: advisory audit: 1 x medium priority recommendation As part of a rolling review of controls and assurances on the BAF, this audit reviewed the risk entries for the risk of fire (4182) and the risk of failure to manage clinical risk effectively (6754). The key recommendation is to address gaps in assurance – in relation to the ligature eradication programme there was no assurance that the programme was being implemented. It was also recommended that the key controls for each risk be expressed more clearly to make it easier for the Board and Audit Committee to assess whether they are appropriate. Governance: rated Amber/Green: 6 x medium priority & 2 x low priority recommendations This audit focussed on a sample of committees including QAC and its sub-committees and the 7 CSU groups reporting into the Trust sub-committees. Key recommendations were to streamline

Chair’s Report to the Board

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the committees to enable timely information flow, review terms of reference annually, ensure committees provide an annual review of their performance to QAC including a register of attendance and ensure meetings are quorate before commencing. Dr Broughton confirmed that much work was in train and he emphasised the important role of the new clinical directors and his confidence in the improvements their collaboration would bring. The committee received the following progress reports: IM&T Business Continuity & Disaster Recovery Plan Update The key issues raised in April were (i) no up-to-date business impact assessment in the Trust’s IT disaster recovery plans and therefore no prioritisation, (ii) no risk assessment in relation to 3rd party IT providers and (iii) although data back-up procedures were documented and approved, there was no formal data back-up/restore planning in place. A full disaster recovery plan is part of the ICT strategy for 2014-19. In the interim, the top 10 critical information systems have been identified and procedures are being put in place (completion by 31 October’14) to enable these systems to be recoverable within hours of a major IT failure. Other IT systems should be recoverable within one or two days. The Audit Committee asked that executive directors agree the priorities and ensure that Trustwide security systems are high priority. In relation to business continuity, IM&T emphasised that no disaster recovery solution is 100% guaranteed so each business unit must have its own business continuity plan. The Emergency Planning Committee will consider this at its next meeting on 9th September. Contracts Register Update Mr Syed Hasnain provided an update on the implementation of a central contracts register. The committee was pleased to note that good progress was now being made. COUNTER FRAUD REPORT To date 19 days have been delivered against plan - in line with expectations. The committee received an update on activity, including recent referrals and confidential investigations. The LCFS proactive review of mileage expense claims (1st January to 31st December 2013) was received. From the 64 claim forms examined, 4 issues were identified and 3 recommendations made to improve controls. Action to address the issues was noted to be in progress. PURCHASE CARD PAYMENTS The Committee noted the introduction of a direct debit system for the payment of purchase card balances. The purchase card policy is currently undergoing review and a revised version will be brought to the Committee in November for approval. BOARD ASSURANCE FRAMEWORK & RISK REGISTER Recent changes to the BAF were noted. Progress is being made with ensuring all BAF risk key controls have at least one source of assurance. A step-through of risk 5917 (failure to reorganise, redevelop and modernise Broadmoor Hospital site) from its first recording in 2010, was conducted. Changes to the risk wording and rating were noted as was the process of review. The risk is now scrutinised by the BHR Programme Board which reports to the Board. Miss McGee is vice-chair of the Programme Board, providing a direct link to the Board. External assurance is provided by the Gateway reviews (the next review, Gateway 4, is scheduled for 6 months before the patient move-in date) and the Cabinet Office’s Major Projects Authority who regularly scrutinise programme activity, publishing the information provided to them and requiring a specific assurance document as part of their process. In addition, one of the high secure commissioners (Ms Caroline Reid) is a member of the Programme Board. The Audit Committee felt it had been provided with good assurance that this risk was being well managed, appropriately rated and regularly reviewed.

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QUARTERLY SECURITY REPORT The committee received the quarterly security report for Forensic Services and Local Services - including an update on the recent use of ‘sniffer’ dogs which had resulted in the recovery of some prohibited items (some secreted medication and a quantity of cash). No illegal drugs were found. The use of ‘legal highs’ continued to be a cause for concern - campaigns are being carried out with the Police Liaison Officer to highlight the dangers such substances pose. In May’14 Forensic Services and Local Services had a Security Management audit by NHS Protect. The vast majority of standards were met and recommendations are being actioned. One particular recommendation was to publicise successful prosecutions. CHANGES TO STANDING ORDERS & STANDING FINANCIAL INSTRUCTIONS The committee received 2 proposed amendments to SO/SFIs: SFI 22.1.7 – relating to the Trust’s loan agreement with the DH To provide the DH with a negative pledge for the duration of any long term borrowing. SFI 24.1.8 – relating to the authorisation limits for the payment of invoices relating to the Broadmoor Hospital redevelopment contract An amendment and addendum to the SO/SFIs to reflect the amended authorisation limits that have been approved, by the Board, for the Broadmoor redevelopment programme. The Audit Committee recommends these amendments to the Board for approval. QUALITY GOVERNANCE UPDATE Dr Broughton provided an update on key governance work including improving the Trusts performance against the Monitor Quality Governance Framework, the external review of governance arrangements by Mr Malcolm Rae (report expected November’14), the review of governance in the CSU’s under the new service line structure and preparation for the Chief Inspector of Hospitals visit. The governance team and the new clinical leads are working with staff to ensure effective engagement in governance across all Trust services and at all levels. TDA SUMMARY FEEDBACK ON AUDIT COMMITTEE MEETING, 27TH MAY 2014 The Audit Committee received the TDA’s summary feedback from their observation of the meeting on 27th May 2014. The report was positive, concluding that the committee was operating effectively. There was one recommendation - to seek further clarity as to the link between the Annual Accounts and production of the Annual Report to ensure consistency.

Items of limited assurance: (detail any issues where there is limited assurance and what further action is being taken; state if any changes are needed to the risk register)

None

Board decision / referral required: (in respect of key issues indicate what the committee’s recommendations are, what referral is required and or what the Trust Board needs to do; indicate timescale)

The Board is asked to consider / approve the proposed amendments to the Trust’s Standing Orders / Standing Financial Instructions as appended to this report.

Items remitted to other committees:

There were no items remitted to other committees.

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AUDIT COMMITTEE MEETING – 3rd SEPTEMBER 2014

PROPOSED AMENDMENT TO STANDING ORDERS / STANDING FINANCIAL INSTRUCTIONS

1 PURPOSE 1.1 The purpose of this paper is to seek approval from the audit committee for a change

to be made to the Standing Orders (SO) / Standing Financial Instructions (SFI’s) in relation to the terms of a loan agreement with the Department of Health.

2 RECOMMENDATION 2.1 The audit committee is asked to approve the proposed changes to the Standing

Orders / Standing Financial Instructions. 3 INTRODUCTION 3.1 The Trust is currently awaiting final approval from the Department of Health for two

loan facility agreements in relation to two major capital redevelopments, the new Broadmoor Hospital and St Bernard’s MSU.

3.2 The facility agreement consists of a number of clauses that the Trust has been required to agree to in order for the loan to be approved. These clauses include a negative pledge that provides assurance to the lender over the security of the Trust’s assets, clause 16.3.

4. ADDITION TO STANDING FINANCIAL INSTRUCTIONS 4.1 It is proposed that under Section D: Standing Financial Instructions of the document

entitled; Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions, additional guidance should be included in relation to the aforementioned negative pledge.

4.2 The additional guidance will be included under heading SFI 22. External Borrowing

and form point 22.1.7. The proposed wording is as below;

22.1.7 For the duration of any long term borrowing agreement entered into with the Department of Health, the Trust must agree to a negative pledge clause protecting the security of its assets.

The negative pledge limits the Trust’s ability to: (a) dispose of any of its assets on terms whereby they are, or could be,

leased or re-acquired; (b) dispose of any of its receivables on recourse terms;

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(c) enter into any arrangement under which money or the benefit of a bank or other account may be applied, set-off or made subject to a combination of accounts so as to effect the discharge of any sum owed or payable;

(d) enter into any other preferential arrangement having a similar effect. Any deviation from the above is only permitted with prior written consent from the Department of Health.

5 RECOMMENDATION(S) 5.1 The Audit Committee is asked to recommend this amendment to Standing

Orders/Standing Financial Instructions to the Trust Board for formal approval.

Jim Phillips Head of Financial Services

August 2014

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AUDIT COMMITTEE MEETING – 3rd SEPTEMBER 2014

PROPOSED AMENDMENT TO STANDING ORDERS/STANDING FINANCIAL INSTRUCTIONS

1 PURPOSE 1.1 The purpose of this report is to request the committee to recommend an

amendment to Standing Orders/Standing Financial Instructions necessary to give effect to the Trust Board decision to approve special authorisation limits for payment of invoices on the BHR contract.

2 RECOMMENDATION(S) 2.1 The committee is asked to recommend the amendment to Standing Order/Standing

Financial Instruction 24.1.8, as set out in this report, to the Trust Board. 3 BACKGROUND 3.1 Current budget signatory limits are as shown in Table 1 below:

Table 1: Existing Authorisation Limits

Delegation to … Limit

Ward manager level £1,000

Team leader level £5,000

Service manager level £15,000

Director / Executive Director £50,000

Deputy CE / Director of Finance £75,000

Chief Executive Up to £1m

3.2 The committee considered at its meeting on 3rd July 2014 a proposal to introduce

special authorisation limits in respect of capital expenditure on the Broadmoor Hospital Redevelopment (BHR) project. An amended form of the proposal was recommended for discussion by the Trust Board.

3.3 The proposal was to apply special authorisation limits in respect of capital

expenditure on the BHR project, as set out in Table 2 below:

Table 2: Proposed Authorisation Limits – BHR Project Only


Project Support Team Manager (Band 7) £5,000

Governance Lead or Service Lead (Band 8a) £15,000

Design & Construction Manager (Band 8b) £50,000

Programme Managers (Band 8d) £75,000

Programme Director (or Deputy Director when ‘Acting’ Programme Director)

Up to £5m *

Chief Executive (or Deputy Chief Executive when ‘Acting’ Chief Executive)

£5m and above †

* if total for year to date is within approved projected cumulative cashflow † if total for year to date is within approved projected cumulative cashflow

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3.4 At its meeting on 30th July 2014, Trust Board considered the proposed authorisation

limits and agreed them subject to the following conditions:

an absolute maximum delegated approval limit of £10m, anything above that amount being reserved to the Board;

there being no further delegation down and, in the absence of any named signatory, invoices being passed to the next level up for authorisation;

the addendum to the SO/SFIs providing clear information on the cashflow or detailing where this can be found (document & page); and,

the provision of quarterly reports via the Programme Board, to the Trust Board on expenditure.

4 PROPOSED AMENDMENT TO STANDING ORDERS/STANDING FINANCIAL

INSTRUCTIONS (SO/SFIs) 4.1 SFI 24 relates to capital investment, private financing, fixed asset registers and

security of assets.

4.2 SFI 24.1.8 f) currently reads Once the contract has been completed, purchase orders in relation to interim payments or full payment under the contract may be authorised by one of the following postholders:

- an Executive Director - the Head of Procurement - the Director of Information Management and Technology - the Director of Capital Estates and Facilities

4.3 It is proposed that a final bullet point is added, as set out below:

“- for the Broadmoor Hospital Redevelopment Programme Only: specified members of the Redevelopment Team and the Chief Executive, up to the limits as set out in the Addendum to this document, subject to conditions also set out in the Addendum which includes the approved cashflow against which the determination to pay is made.”

4.4 The proposed Addendum to the SO/SFIs, which contains Table 2 above, and the additional conditions imposed by the Trust Board, is attached at Appendix A to this document.

5 RECOMMENDATION(S) 5.1 The committee is asked to recommend this amendment to Standing

Orders/Standing Financial Instructions to the Trust Board for formal approval. Vickie Holcroft Barbara Wörts Redevelopment Programme Director Trust Secretary August 2014

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APPENDIX A

ADDENDUM TO STANDING ORDERS / FINANCIAL INSTRUCTIONS For invoices in relation to the Broadmoor Hospital Redevelopment project, the postholders in the table below may authorise payment to the amount shown alongside each, subject to the following conditions:

an absolute maximum delegated approval limit of £10m, anything above that amount being reserved to the Board; and,

no further delegation is permitted and, in the absence of an authorised signatory, the invoice must be passed to the next level up for authorisation.

Authorisation Limits – BHR Project Only


Project Support Team Manager (Band 7) £5,000

Governance Lead or Service Lead (Band 8a) £15,000

Design & Construction Manager (Band 8b) £50,000

Programme Manager (service) (Band 8d) £75,000

Programme Director (or Deputy Director when ‘Acting’ Programme Director)

Up to £5m *

Chief Executive (or Deputy Chief Executive when ‘Acting’ Chief Executive)

£5m and above † To absolute maximum of £10m

No delegation (reserved to the Board) Above £10m * if total for year to date is within approved projected cumulative cashflow † if total for year to date is within approved projected cumulative cashflow

BROADMOOR HOSPITAL REDEVELOPMENT: KIER FORECAST CASHFLOW 2014/15 (exc VAT)

Apr-14 £770,000

May-14 £609,000

Jun-14 £780,000

Jul-14 £833,000

Aug-14 £1,168,000

Sep-14 £1,322,000

Oct-14 £1,771,000

Nov-14 £2,287,000

Dec-14 £1,566,000

Jan-15 £2,434,000

Feb-15 £2,638,000

Mar-15 £2,842,000

Total 2014/15 (exc VAT)

£19,020,000

These are the cashflow figures against which the payment of invoices will be monitored

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MINUTES OF THE

AUDIT COMMITTEE MEETING

Held on Wednesday 2nd July 2014

Present: Ms Christine Higgins Non Executive Director (Chair) Mr Neville Manuel Non Executive Director Mr Geoff Rose Non Executive Director In Attendance: Mrs Barbara Byrne Director of Finance/Deputy Chief Executive

Mr Charles Martin PricewaterhouseCoopers LLP (PwC) (to item 20.1) Mr Nick Atkinson Baker Tilly (to item 20.1) Mr Alex Hughes Mazars (to item 20.1) Ms Jo Smith Deputy Director of Finance Mr Robert Bolas Interim Head of Governance Mr Bryan Joseph Head of Risk, Health & Safety Mr Trevor Nelms Director of IM&T (item 7) Ms Pamela Farrow Head of Costing (item 8) Mrs Vickie Holcroft Redevelopment Programme Director (item 11) Mrs Barbara Wörts Trust Secretary (minutes)

Agenda items were discussed in the sequence they are recorded in the minutes

Item

Discussion Action

1 1.1

1.2

1.3

OPENING & WELCOME The Chair welcomed everyone to the meeting. Following best practice, the Audit Committee met with the internal auditors (Baker Tilly) and then with the local counter fraud service (Mazars) earlier in the morning, with no Trust officers present. Members of the committee and some regular attendees had then held a briefing/ discussion session, led by Mr Atkinson on “Monitor Licence and Expectations of Good Governance”. As a result of this session, Mr Bolas is to discuss the Monitor Licence briefing with the Strategic Projects Programme Board and report back to the Audit Committee on how the Trust will ensure compliance.

Mr Bolas

2 2.1

2.2

APOLOGIES FOR ABSENCE Apologies for absence were received from regular attendees Dr Nick Broughton Medical Director Dr Kevin Murray Acting Medical Director Ms Sarah Isted PricewaterhouseCoopers LLP (PwC) It was noted that Mr Bolas was representing the Medical Director.

3 3.1

DRAFT MINUTES OF THE PREVIOUS MEETING The minutes of the previous meeting, held on Wednesday 27th May 2014 were

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approved as a correct record, subject to the correction of one typographical error and the following amendment: Item 6.2: paragraph 6.2.4: Change: “…the initial deadline of 28th February 2014 had been challenging.” To: “…the initial deadline of 28th February 2014 had been, in her opinion, both unrealistic and detrimental to the process.”

4

4.1

4.2

4.3

4.4

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Committee discussed the action schedule, noting the completed actions which will now be archived and receiving the following updates: 08/01/2014: item 12.2 & 12.3: regulatory framework compliance Mr Bolas undertook to bring an update report to the next Audit Committee meeting. There was some discussion regarding the frequency with which this matter should be reported, a quarterly update having been suggested. However, it was agreed that 6 monthly would be more appropriate, with reports being presented in March and September. 27/05/14: item 4.2: preparation for Chief Inspector of Hospitals’ inspection Mr Bolas advised the Audit Committee that it was now unlikely that the Trust would receive its Chief Inspector of Hospitals’ visit during 2014/15. However, work was still ongoing to ensure that staff were prepared and that systems and processes were in place to ensure the CQC’s “Essential Standards of Care” were embedded within services as ‘business as usual’. It was noted that the project board overseeing this work reported to the Strategic Projects Programme Board and that it was also providing update reports to the Quality Assurance Committee (QAC). In order to eliminate duplication, the Audit Committee agreed to receive its updates on this work through the QAC chair’s reports (this action will now be closed and archived). Matters Arising There were no other matters arising from the minutes of the last meeting.

Mr Bolas Mr Rose

5 5.1

ACTIONS FROM THE BOARD OR OTHER COMMITTEES No items had been remitted.

6 6.1

6.2

EXTERNAL AUDIT OF QUALITY ACCOUNT 2013/14 Mr Martin presented this report to the Committee. He outlined the scope of the work, as required by the Audit Commission, to assess the content of the Quality Account and to review two performance indicators. He was pleased to report that, as a result of this work, PwC were able to provide an unqualified limited assurance report in respect of the content and the mandated specified indicators. He reminded the Committee that the opinion was called a ‘limited’ opinion because the audit is limited in scope as compared to the external audit of the accounts). Mr Martin was pleased to report that the process for the Quality Account’s production was much improved compared to the previous year. However, the testing of indicators had taken longer than expected and had resulted in one recommendation for improvement. Mr Martin explained that not all of the information required to test the ‘delayed transfers of care’ indicator was available on RiO and, therefore, paper records had to be requested from the

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6.3

6.4

6.5

6.6

6.7

wards. Mrs Byrne confirmed that the Trust’s operating procedures required such information to be routinely entered onto RiO but that non compliance was a long-standing issue. Mr Bolas said he was in the process of establishing a quarterly ‘pulse check’ and he would ensure that this included data entry non-compliance. The Audit Committee noted that issues relating to data quality had been raised at the Finance & Investment (F&I) Committee and that Mr Manuel was working with Babs Dhillon to commission detailed ‘step throughs’ of some key indicators, including delayed transfers of care, for their next meeting. Mr Manuel said this was an area that the F&I Committee intended to monitor to ensure improvement was achieved. Mr Bolas said the Trust’s Quality Account 2013/14 had been published on the NHS Choices website as required and that the summary document for staff would be ready within the next 10 days. He thanked Mr Martin and PwC for their invaluable support and advice throughout the whole process. Ms Higgins asked if there was anything that might need to be done differently in future. Mr Bolas said he thought the process might need to be started earlier. Mr Martin commented that everything was almost complete by late May, but there had been an issue with key external stakeholders fulfilling their obligation to comment on the Quality Account. It was noted that Mr Shrubb was to raise this with the CCGs. Mr Rose confirmed that, as requested by the Board, the QAC would be considering the external stakeholders comments, published within the Quality Account and how the Trust would respond to these. In conclusion, and having ascertained that PwC would have no further recommendations for the Trust had it been an FT, Ms Higgins thanked the Governance Team and PwC for all of their endeavours in respect of the Quality Account’s production and the successful outcome of the audit.

Mr Bolas

7 7.1

7.2

7.3

7.4

INTERNAL AUDIT PROGRESS REPORT Mr Atkinson presented the internal auditors’ progress report to the Committee. He reminded members that he had referred, in summary, to some of the audits it contained, within his annual report (meeting of 27/05/14 item 8 refers). It was noted that the staff engagement audit had been finalised recently and would be brought to the next meeting. It has resulted in an amber/green assurance rating. Mr Atkinson said there were no major issues regarding follow-up work. He reported that since Mr Eric Munro had left the Trust, Mr Michael Harbour had assumed responsibility for ensuring the completion of outstanding actions relating to the backlog maintenance programme. Ms Higgins asked who was overseeing the development of the central contracts register and this was noted to be the responsibility of the new interim head of procurement, Mr Syed Hasnain (item 20.3 refers). Mr Atkinson presented the reports that had been finalised since the Committee’s meeting in March 2014.

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7.5

7.6

7.7

7.8

7.9

7.10

7.11

7.12

I.T. Disaster Recovery & Business Continuity Planning: rated Amber/Red: 1 x high priority recommendation and 4 x medium priority recommendations It was noted that, for a number of reasons, key personnel been absent from the Trust during this audit. A number of issues had been identified; the absence of detailed business impact assessments and, therefore, a lack of recovery time objectives for contingency planning prioritisation and also the absence of a disaster recovery testing strategy. Mr Nelms outlined how the report’s recommendations were being addressed. He agreed that the business analysis was key but said the I.T department did not have the capacity to undertake this large piece of work. He therefore proposed to develop a business case to seek funding for a business continuity analyst. In the meantime, a systems testing solution was available and he proposed putting together a list of what might been considered the ‘top 10’ systems and testing these before the end of July 2014. Mrs Byrne suggested that, rather than seeking to employ an external consultant, a workshop approach, seeking organisational input into key system identification might be sufficient. Mr Atkinson agreed that key systems could be identified in this manner. Mrs Byrne and Mr Nelms agreed to further discuss the merits of proceeding in this way. Mr Nelms stressed that although I.T was responsible for data recovery, each service needed its own business continuity plan in the event of a system failure. It was confirmed that the Emergency Planning Forum (EPF) had responsibility for ensuring this was done and Mr Joseph said the EPF would be tracking implementation of the audit’s recommendations. The risks identified were contained within the BAF, he said. The Audit Committee asked that a short report be brought to its next meeting, outlining how the risks were identified and reported and how the Trust wide business continuity plans were supported by CSU / corporate services’ plans to ensure the required minimum level of service is maintained. Cyber Attacks: Ms Higgins made reference to this issue, raised in the ‘client briefing’ information circulated by Baker Tilly and asked how the Trust responded to such an event. Mr Nelms explained that regular penetration tests of systems were conducted and virus monitoring software was in place. Mr Manuel asked if NHS organisations had data on the number of malicious attacks their system experienced and if this was benchmarked or shared. Mr Nelms said that was not. He commented that the NHS wide area network N3 was supplied by BT and Mr Manuel thought that this system may track attacks. It was noted that all clinical information went via N3 and that there were no external connections to the Trust’s network outside of its own control. Mr Atkinson suggested that it was the penetration tests that were critical. Mr Nelms confirmed these were carried out annually and the 2013 report had been generally positive with only minor recommendations. Mr Manuel felt it would be helpful to have this reported to the Informatics Committee. Information Governance Toolkit: 2 x medium priority recommendations Mr Atkinson explained that the review of the Trust’s self assessment against the standards of the Information Governance Toolkit (version 11) (IGT) had been undertaken earlier in the year. Against the 10 sample standards assessed, the auditors’ opinion was that the Trust had ‘overstated’ compliance

Mrs Byrne / Mr Nelms Mr Joseph / Mr Nelms Mr Nelms

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7.13

7.14

7.15

7.16

7.17

7.18

7.19

7.20

in one area and one standard was unsubstantiated. However, subsequently, both these two scores were substantiated and the auditors were able to agree with the Trust’s self-assessment scoring. Overall, Mr Atkinson said, auditors had noted an improvement on last time, significant activity had been reported and there was evidence to demonstrate this was the case. There was some discussion regarding the level the trust should seek to achieve. Mr Atkinson said he was aware that a number of organisations had conducted a risk or cost benefit analysis of achieving the higher Level 3 compliance but that Level 2 (satisfactory) showed an acceptable degree of good practice and this was sufficient for FT status. Mrs Byrne commented that the Trust seemed to just achieve the standard required for level 2 each year (the Trust achieved 71% and the threshold for level 2 is 69%) and so there may be some benefit in looking at an incremental improvement, rather than striving for Level 3 itself. Mr Bolas felt this would be a suitable course of action and recommended reviewing the Level 3 standards for areas where improvement might be secured at minimal or no cost. It was noted that IGT Version 12 had just been released and the Trust would undertake a baseline assessment in October and develop an appropriate improvement plan. This will be brought to the Audit Committee’s meeting in November 2014. Mr Atkinson reminded members that the Trust could fail to achieve a pass mark if, in some areas, its compliance slipped to Level 1 standard because it had focussed on securing Level 3 quality in other areas. Mr Joseph, who has assumed responsibility for information governance, advised members that Mrs Edwina Withe would be retiring shortly and that plans were in place to recruit an interim replacement. CQUIN Targets: rated Amber/Green: 3 x medium priority recommendations Mr Atkinson summarised the findings of this audit and confirmed that systems were being put in place to address the areas of identified weakness. In Local Services, CQUIN action plans had been developed but not followed through and there was no clear evidence that issues were being identified and addressed. However, he reported that managers had now identified this as an issue and put measures in place to improve the process. Ms Higgins asked how the Trust could be assured that these processes would deliver improvement. Mrs Byrne advised that Ms Sarah Rushton was reporting more positive relationships with commissioners and had addressed the disconnect found within the Trust’s monitoring processes. She had put in place an alert system but felt that, until a full quarter had passed, it would not be possible to test whether these arrangements worked successfully. It was agreed that Ms Rushton would be invited to the Committee’s September meeting to provide an update. Francis Report - Trust’s self assessment – phase 2: rated Amber/Green: no recommendations Mr Atkinson explained that this phase 2 audit focused on the governance arrangements in place to support the Trust’s action plan in response to the Francis report in combination with a review of progress with those actions. The key finding was that whilst progress is being made, many of the timescales

Mr Bolas / Mr Joseph Ms Rushton

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7.22

are not being met. He said the auditors had noted that the Quality Assurance Committee had already identified and was addressing these issues. It was also noted from the QAC minutes of 7 May that an in-depth review is due at the 9 July QAC meeting.

8 8.1

8.2

DATA ASSURANCE FRAMEWORK MENTAL HEALTH REVIEW REPORT Ms Pamela Farrow was welcomed to the meeting. She reminded the Committee that the Trust had volunteered to participate in this audit in order to gain a degree of assurance regarding its processes in relation to reference costs payments and pricing activity. The audit had concluded that the Trust’s cluster activity data error rate was 35.2% and overall returned a rating of “adequate” (possible outcomes were ‘good’, ‘adequate’, ‘poor’). Ms Farrow summarised progress that was being made to address the report’s recommendations some of which formed part of CQUIN work for this year. It was noted that guidance had been issued to managers on how to use the clustering information provided via the IDT effectively and a follow-up audit had been planned to see if this had improved data quality..

9 9.1

9.2

9.3

COUNTER FRAUD ANNUAL REPORT 2013/14 The Audit Committee received and noted the Counter Fraud Annual Report 2013/14. In relation to the annual report, Mr Hughes commented that the proactive exercise in respect of accounts payable data had found only 4 duplicate invoices in the circa 32,000 reviewed which could have potentially resulted in an overpayment of £6,891. This, he said, was a very positive outcome. In addition, an exercise regarding expenses had also been undertaken but no discrepancies were identified. The applying of appropriate sanctions during 2013/14 (4 dismissals and 1 criminal sanction) showed that the Trust took fraud issues seriously.

10

10.1

10.2

10.3

10.4

COUNTER FRAUD PROGRESS REPORT & COUNTER FRAUD (CONFIDENTIAL) INVESTIGATIONS UPDATE Mr Hughes presented his reports to the Committee. It was noted that the person who had misappropriated I.T. equipment had been successfully prosecuted and was awaiting sentencing. The locum doctor who had been involved in false prescribing was noted to have been suspended from the register by the GMC which, Mrs Byrne said, was a most positive outcome. This case will now be closed. Mr Hughes highlighted an allegation of falsifying expenses claims and advised the Committee that a sum of £679 did not appear to have been claimed consistently with the Trust’s travel and subsistence policy and the matter had been referred to HR to consider recovery and, possibly, disciplinary action. In the event, whilst recovery had been agreed, it transpired that a number of staff in this particular unit claimed in the same way and there is a possibility that people in other areas might also. Work would be undertaken to discover how widespread the anomalous practice was and, in liaison with the

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Communications Team, an explanation would be sent to all staff regarding what is permissible. Thereafter, follow-up work will be planned. Mr Hughes suggested that the Trust’s policy may be amended to include illustrative scenarios for clarification.

11

11.1

11.2

11.3

11.4

11.5

11.6

BROADMOOR HOSPITAL REDEVELOPMENT – INVOICE APPROVAL LIMITS Mrs Holcroft joined the meeting and presented her paper, which set out the process for payments to Kier under the contract for the Broadmoor Hospital redevelopment and also sought the Committee’s endorsement of proposals for increasing delegated approval limits to permit payments to be made without recourse to the Chief Executive or the Board on every occasion. Mrs Holcroft explained in some detail, the governance process for ensuring the work for which invoices were submitted was checked to ensure its completion, its value and its quality, prior to payment. It was noted that the majority of the invoices would be in the region of £5million which, under current Standing Financial Instructions required Board approval. Mrs Holcroft said the Redevelopment Programme Board had discussed this issue and proposed that for this project only approval limits should be raised so that either

Option 1 invoices up to £5million could be approved by the Redevelopment Programme Director (or deputy) and anything above that amount would require authorisation by the Chief Executive (or deputy)

OR

Option 2: where the amount was within the approved projected cashflow (+10%) for the month in which the works took place, invoices above £5million could be approved by the Redevelopment Programme Director (or deputy) and in the event of an exception to the projected cashflow (+ 10%), authorisation by the Chief Executive (or deputy) would be required

Members supported Option 2. There was some discussion regarding the definition of ‘projected cashflow’ and whether this should be month by month or the cumulative for the year. There was support for the latter and Ms Smith suggested that, in that case, there should be no 10% tolerance level applied. The Audit Committee endorsed this suggestion. It was noted that a range of approval limits had been proposed for other members of the redevelopment team. These were largely supported except, it was agreed that the Programme Manager required to sign off works completion should not, for reasons of good governance, be an authorised signatory for invoice approval. The Audit Committee requested that, for clarity, names of post-holders should be included in the document, not just roles and, in the event of anyone ‘acting up’ or e.g. covering someone on annual leave, they would not be able to assume the increased delegated limit and the invoice would be escalated up. Mrs Byrne suggested that the Audit Committee review the working of this process in 6 month’s time and this was agreed. The Audit Committee agreed to recommend the revised authorisation levels to the Board, subject to Mrs Holcroft submitting a revised paper that took account of these issues. The revised report will be circulated to Audit Committee members prior to its submission to the Board.

Mrs Holcroft / Audit Committee Mrs Holcroft

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11.8

In the event of Board approval, it was noted that a very specific addendum would be appended to the Trust’s Standing Orders / Standing Financial Instructions. Mrs Holcroft sought the Committee’s endorsement to apply the same process to the Three Bridges MSU Campus Redevelopment but the Committee requested that a separate report and proposals would be necessary for this.

12 12.1

12.2

12.3

12.4

BOARD ASSURANCE FRAMEWORK Mr Joseph presented his report to the Audit Committee. He drew members’ attention to the new additions to the BAF, which included a risk relating to the Chief Inspector of Hospitals visit. It was noted that the wording of this risk had been discussed at the Board meeting in June and changes proposed. There was also some debate regarding the risk rating (2 x 4 = 8), which was thought to be low. Mr Bolas advised that Acting Medical Director Dr Kevin Murray had considered the likelihood to be low. However, as the BAF entry was completed and refined, the availability of assurance relating to likelihood would be used to refine the rating. It was agreed that the rating would be reviewed. As previously requested, Mr Joseph provided a list of the BAF risk key controls that currently had neither internal nor external assurances listed against them Ms Higgins emphasised that the Committees responsible for the risks should identify sources of assurance when they reviewed their risks. Mrs Byrne commented that assurances for risk 5972 relating to land sales receipts would be amended as BNP Paribas had been appointed as professional advisers and were the source of external assurance. Mr Joseph agreed to provide an update report to the Committee’s next meeting.

Mr Manuel / Mr Rose / Mrs Kerin Mrs Byrne / Mr Joseph Mr Joseph

13 13.1

13.2

13.3

13.4

RISK 4205 STEP THROUGH The detailed step though of risk 4205 ‘loss of competitiveness and business activity through losing current business and failing to develop other business opportunities was considered. Ms Higgins reminded members that the purpose of this process was to understand how risks were identified and reviewed and to consider if the right assurances were being captured. It was noted that this risk had been scrutinised at a recent Finance & Investment Committee meeting and a recommendation made that the risk be divided into its two constituent parts; one relating to failure to acquire new business and one relating to failure to retain existing business. This proposal would be discussed by the Trust Management Team in July. The Committee took assurance that the risk was actively managed and scrutinised.

14 14.1

ASSURANCE: CLARIFICATION OF THE GOVERNANCE PROCESS Ms Higgins said she felt there had not been enough time to consider the proposals contained in this report. It was agreed that she would meet with Mr Manuel and Mr Rose to draft an assurance map of information flows between committees and from the committees to the Board. Any resulting issues would

Ms Higgins / Mr Manuel / Mr Rose

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then be brought back to the Audit Committee if required. Mr Atkinson confirmed that he would be available to attend Quality Assurance Committee meetings, should this be required.

15 15.1

QUARTERLY REPORT OF TENDER WAIVERS The Audit Committee noted that there had been no requests for tender waivers in quarter 4 2013/14 or quarter 1 2014/15.

16 CHANGES TO STANDING ORDER & STANDING FINANCIAL INSTRUCTIONS Item 11 refers.

17

17.1

AUDIT COMMITTEE EFFECTIVENESS SURVEY 2013/14 – KEY RESULTS & ACTIONS The report outlining the results and key findings of the Audit Committee’s effectiveness survey 2013/14, and the resulting actions that had been agreed, was noted.

18 18.1

FINANCE & INVESTMENT COMMITTEE The Audit Committee received and noted the Finance & Investment Committee’s annual report 2013/14 and the Chair’s report of its meeting in June 2014.

19 19.1

QUALITY ASSURANCE COMMITTEE The Audit Committee received and noted the Quality Assurance Committee’s annual report 2013/14 and the Chair’s report of its meeting in May 2014.

20

20.1

20.2

20.3

20.4

ANY OTHER BUSINESS Chief Inspector of Hospitals (CIH) Visit Mr Bolas said he and Ms Edghill had visited Nottinghamshire Healthcare NHS Trust regarding their recent CIH inspection and arrangements had been made for the Director of Nursing from Solent NHS Trust to come and speak to the Trust’s leadership forum. Much information had been gathered, Mr Bolas said and this would now be used to inform the project plan to ensure compliance with the CQC’s essential standards of care was embedded in the Trust as ‘business as usual’. He advised those present that the Trust’s CIH visit would not be happening in quarter 4 as had been expected and it was likely to be early 2015/16 before it took place. Contracts Register and Appointment of Internal Audit & Counter Fraud Services Mr Syed Hasnain, Interim Head of Procurement joined the meeting. Ms Higgins asked him for an update on the implementation of a central contracts register. Mr Hasnain, who had been in post since Monday, advised that the register was in place and partially populated. He said there appeared to be a 2 or 3 month gap in the data but he would look to address this. Ms Higgins asked Mr Hasnain to provide an update at the Committee’s next meeting. Ms Higgins asked Mr Hasnain if he was familiar with the process that his predecessor had proposed regarding the process for appointing internal

Mr Hasnain

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auditors and counter fraud services when the contracts with the current providers came to an end in 2015. Mr Hasnain confirmed that he was familiar with the process and, having seen the specification Mr Wright had been working on, was confident that the delay caused by his departure would not impact on the ability to appoint within the required timescales. Mr Hasnain undertook to provide a service specification to members and, thereafter to make contact with the previously identified list of suppliers.

Mr Hasnain

21 21.1

ANY NEW RISKS IDENTIFIED OR CHANGES TO RISKS PROPOSED No new risks were identified or changes to risks proposed.

22

22.1

22.2

22.3

ACTIONS TO THE BOARD OR OTHER COMMITTEES Quality Assurance Committee

monitor progress with preparation for Chief Inspector of Hospitals’ inspection / compliance with CQC standards

ensure sources of assurance are identified as part of BAF risk scrutiny Finance & Investment Committee

ensure sources of assurance are identified as part of BAF risk scrutiny Property & Land Sales Committee

ensure sources of assurance are identified as part of BAF risk scrutiny

23 23.1

KEY POINTS FOR CHAIR’S REPORT TO THE BOARD The items for the Chair’s report were agreed.

24 DATE OF NEXT MEETING 3rd September 2014 0845 hrs Audit Committee members meeting with PwC 0900 hrs Briefing: Greater Risks & Wider Responsibilities (Baker Tilly) 1000 hrs Audit Committee Meeting

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MINUTES OF THE FINANCE & INVESTMENT COMMITTEE

Held on Wednesday 4 June 2014

In White Room, Trust Headquarters, Armstrong Way, Southall UB2 4SA

Present: Mr Neville Manuel Non-Executive Director (Committee Chairman) Ms Christine Higgins Non-Executive Director Ms Elizabeth Rantzen Non-Executive Director Mrs Barbara Kerin Non-Executive Director Mrs Barbara Byrne Director of Finance / Deputy Chief Executive Ms Sarah Rushton Interim Director of Local Services Ms Angela Dolan Interim Head of Community Services

Attending: Mrs Jo Smith Deputy Director of Finance Dr Kevin Murray Acting Medical Director Mr Eric Munro Director of Capital, Estates & Facilities (items

5 - 8) Mr Trevor Nelms Director of IM&T Mr Bryan Joseph Head of Risk, Health & Safety Ms Natasha Hurhangee Head of Finance, Business Management &

Performance Mr David Stacey Director of Business Strategy Mrs Babs Dhillon Head of Knowledge Management (item 11) Mrs Gillian Henry Deputy Trust Secretary (minutes)

Items were considered in the sequence they are recorded in the minutes. Ref: Discussion: Action: 1. WELCOME AND APOLOGIES 1.1 Mr Manuel welcomed everyone to the meeting. 1.2 Apologies for absence were noted from: Dr Anne Aiyegbusi Interim Director of Nursing & Patient

Experience

Dr Nick Broughton Medical Director Miss Leeanne McGee Director of High Secure, Specialist &

Forensic Services (Ms Dolan was

noted to be representing Miss McGee).

Mr John Killeen Interim Director of Capital, Estates & Facilities

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Mrs Rachael Moench Director of OD & Workforce Ms Mary Jane Kerr Service User Representative 2. DRAFT MINUTES OF THE PREVIOUS MEETING 2.1 The minutes of the meeting held on 2 April 2014 were agreed as a

correct record subject to minor amendments.

3. ACTION SCHEDULE AND MATTERS ARISING Action Schedule update 07/03/13 Ref. 4 Capitalisation of Costs: Mr Manuel reported that

discussions on this matter had now been concluded. This closed this action.

02/04/14 Ref. 8.3 Risk Review 5406 (RiO 7 training): The training needs for current RiO users are not extensive and the e-learning package is sufficient, however, the package is not yet available for testing and the project team need to demonstrate that they can train sufficient numbers of staff by the go live date of 11 August 2014.

02/04/2014 Ref. 8.3 Risk Review 5406 (RiO7 training): Mr Wood agreed to forward the detailed training plan to Broadmoor to see if it was doable. ACTION: Ms Harris

02/04/14 Ref 11.2 Risk Review 4205 (Loss of competitiveness and business activity): The work has been completed and the matter will go to TMT. The original action was to split the risk into two different items. BAF 7010 (shrinking the business) has a current risk rating of 12 and BAF 7009 (failure to win new business) has a current risk rating of 6.

Matters Arising 02/04/14 Item 6 Reference Cost Process: Ms Higgins asked which Committees the paper would be submitted to. It was confirmed that the paper, produced annually, would go to F&I and QAC.

4. ACTIONS FROM BOARD AND/OR OTHER COMMITTEES 4.1 The Board requested that a briefing session be held to discuss

operational cashflow and capital. This will be rescheduled for September.

Mrs Byrne

5. 5.1

CAPITAL PRESENTATION Mr Munro presented highlights of the 10 year capital plan. The plan will be revised every 6 months, is linked to the long term financial model and currently plans £335m of capital expenditure to 2022/23. The Committee were asked to note that the Estates Liaison Committee is now called the Capital Programme Steering Group.

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5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10

Mr Munro reported that in terms of the next 3 years, capital expenditure was heavily constrained due to the cashflow requirements for the redevelopments. The Hounslow reconfigurations were being completed this year and the Trust was looking at pushing forward the recovery house development with the refurbishment of the Lammas Centre, Cassel Hospital and the site infrastructure at Broadmoor. S1 and S2 have now been sold.

The sale of the Penny Langham site had been agreed at £1.8m and Cricketfield Grove is yet to be completed. It was hoped that the anticipated sum for Cricketfield Grove in the FBC would be exceeded, given the rising market.

Mr Munro confirmed that there were 25 main properties, Old Oak Road being two houses joined together (one leasehold and one freehold). He presented a league table demonstrating operating costs for the Trust’s Estate which included the utilities that have been seeded back into the CSUs.

The Heart of Hounslow service has not, to date, charged rent for occupation of the premises and this may be a risk as they could decide to claw back the money in the future.

Ms Higgins stated that the figures presented did not include capital charges and depreciation and asked if we had an accurate reflection of costs across the Trust. It was confirmed that service line reporting figures include these costs and so reflect the total costs.

Ms Rantzen said it would be helpful to have some KPIs, such as what the per sq ft cost per patient at each of the facilities was, ie the number of beds and the fill rate %. Mr Killeen agreed to come back with this information. Miss Rushton stated that as Community Service was a fundamentally different model to Local Service in patients, any sq ft comparison would need to be explained as a like for like comparison would not be possible.

The Committee reported that the overview presented was a really helpful analysis and further analysis could be done on the lines of:

a) What does this look like over the next 3 years, not just a point in time analysis?

b) What does the unit cost look like per patient or appropriate unit?

c) Are there any further elements of the estate that could be potentially sold?

In process terms, the Capital Programme Steering Group will do this with analysis, conclusions and recommendations for F&I for September meeting.

Mr Munro suggested that the Estates strategy should be done at the end of the calendar year as it will incorporate this analysis.

Mr Killeen Mr Killeen / Mr Stacey

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BENCHMARKING COST REPORT Mr Munro presented the Benchmarking Cost Report which included an analysis on the cost of individual services on a per bed basis. He stated that significant savings could only be realised if the Trust reduced its footprint: the 3-1 model.

F&I noted the report.

7. 7.1 7.2

CAPITAL PROGRAMME 2013/14 Mr Munro reported that the numbers in the report were erroneously transposed and should read:- 1. At the start of the year the Broadmoor Redevelopment budget

was £16,073k and was later revised to £19,612k following FBC approval. The actual outturn was £18,703k.

2. At the start of the year the Three Bridges Medium Secure Unit budget was £12,837k and later revised to £9,657k following FBC approval. The actual outturn was £9,849k.

The Committee approved the report.

8. 8.1 8.2 8.3 8.4

CAPITAL DASHBOARD – MONTH 12 Mr Munro confirmed that when there is no budget, the figures in the report show costs that are allocated back to the individual projects. They are budgeted monthly, but are put back into the capital costs at the end of the year.

Mr Killeen will provide sufficient budget detail to understand the cashflow against budget, and also to ensure that there is sufficient headroom in each category for the provisions that are going to be added to that item. This will be allocated monthly, starting from September’s meeting.

The Committee noted and approved the Capital Dashboard.

Mr Manuel thanked Mr Munro for all the work he had done and wished him well in his new role.

Mr Killeen

9.1 9.1.1 9.1.2

YEAR END OUTTURN Mrs Byrne summarised the year end outturn and drew attention to the Capital section of the report which highlighted that although capital would be strained over the next year, there would need to be further prioritisation of urgent capital demands. Mrs Byrne reported that funding for Local Services was unlikely to go up. The Trust had been successful in delivering CIPS over the years but it was going to be increasingly difficult to identify CIP schemes and the EDs were giving this more thought. Whatever model for CIPS was put in place, there needed to be someone responsible for driving the changes for delivering the cash

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9.1.3 9.1.4 9.1.5 9.1.6 9.1.7

reductions. The F&I Committee asked that the Board be involved in the capital prioritisation governance once the EDs had a concrete proposal via CAPMG (below).

CAPMG are to identify the process by which calls on the capital budget are prioritised and approved by the appropriate body.

Also, for consideration by TMT, as to where the specific risk associated with having a very constrained capital budget should be located in the BAF.

Mrs Byrne confirmed that the accounts had been signed on 3.6.14, well in advance of the deadline.

The Committee noted the report.

Mr Shrubb Mrs Moench

9.2 9.2.1 9.2.2 9.2.3 9.2.4 9.2.5 9.2.6

FINANCE REPORT – MONTH 1 Including QIRP budgets There has been a £74k medical overspend in Local Services as the necessary job adverts to recruit 4 speciality grade posts had not been placed and locums were still being used. It was also pointed out that it was difficult to recruit speciality grade doctors.

A conversation will be had with Dr Michael Phelan on the recruitment of speciality staff. Ms Rushton reported that the market had improved slightly and it was still worthwhile attempting to recruit.

Ms Rushton expressed concern at the inpatient overspend, but stated that improvements would be seen.

Mr Manuel pointed out that the month 1 variance against budget for the Trust overall was £220k surplus, having used £960k from centrally held budgets. Within that, Local Services were £427k overspent, Broadmoor £82k overspent and Specialist and Forensic £69k overspent. QIPP plans will take time to come into effect and month 4 figures will be provided at September’s F&I.

If the variance against budget has continued at that point, we would need a substantive discussion with options available at that F&I meeting to fulfil our assurance that this is being managed.

With regard to debtors reporting, Ms Higgins stated that there appeared to be a few invoices (late receipts) that were in dispute with commissioners and asked how we stop that happening. Ms Rushton explained that she had raised this at the monthly performance contract meetings with CCGs as it was very unclear what their CQUIN signoff procedure was and asked that a system be put in place whereby we receive early warning issues and for invoices to be signed off at the meeting where CQUIN has been agreed. The CCGs have now agreed to set up a clear process. Ms Rushton to confirm this has been done at the next F&I meeting

Dr Murray/Dr Broughton Ms Rushton Ms Rushton

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Specialist & Forensic are to make any intra business unit cross subsidy clear and transparent and our rationale clear for sustaining them. This will be brought back to the October meeting.

Miss Hurhangee

10. 10.1 10.1.1 10.2 10.2.1 10.2.2 10.2.3

CONFIRMATION ON THE POSITION OF THE HEALTHCARE CONTRACTS FOR: LOCAL SERVICES The level of activity to be associated with the Shifting Settings of Care QIPP was recognised by the CCGs and £400k of the non-recurrent Transformation Incentive of £900k was moved back into the baseline to offset the risk associated with shifting settings of care. The contract was not able to be signed this week as the commissioners had not produced the final version. It will now be signed early next week. HIGH SECURE & FORENSIC SERVICES In terms of Forensic services, the Heads of Agreement had been received and agreed to, but the commissioners have had issues with the Wells Unit (which has resulted in the Trust losing £96k. As the funding is based on a 3 year rolling average, we will receive funding for 7.2 beds instead of the planned 7.4 beds. The issue with WEMSS was to remove the CQUIN. The budget was being adjusted for the loss of £96k and we were now in a position to sign. Ms McGee has made it clear to the commissioners that there are currently 10 patients but in terms of occupancy, the Trust is only being funded for 7.2 patients. As patients are being discharged, no new ones will be taken on until we have reached the 7, but there have been separate negotiations around the necessity to purchase more than 7.2 beds and whether they would be paid for as it is not stipulated in the contract, although the Trust would not be exposed to a cost if there were more than the number of patients agreed to. With regard to High Secure Services, although the contract had been agreed by the Trust and the commissioners, it had not yet been signed.

11. 11.1 11.2 11.3

DATA QUALITY ASSURANCE REVIEW Mrs Dhillon reported that the Trust had received assurance about the process in place as various steps of data quality had been identified and she was assured that, as an organisation, we had the mechanism to identify when they happen and that there was a route for escalation. She confirmed that analysts run local performance reports every month which they escalate to their senior leads to look at things on an exception basis, ie any variance.

The data on RiO was checked weekly and a core set of reports were run by the analysts which contributed to the overall performance

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11.4 11.5 11.6 11.7 11.8 11.9

report and identified any variance.

The following were highlighted as weaknesses in the system:

When there are new indicators we need to report on

When manual verifications have to be done (data not on the system)

CSU variations as to how they look at data

Training – new staff member on board.

There are two information analysts per CSU and they are supported with a Business and Information Performance Lead. Recruitment of permanent staff was still being looked at.

Key themes are:-

trying to understand the most important areas that need to be focused on

Benchmarking

Increase in acknowledging data was important and needed to be put on the system on time.

There had been an audit on the Trust’s approach to PBR and costing. This will be discussed at Audit Committee once finalised.

Mrs Dhillon to come back with a recommendation (at the September F&I) on what aspect of data governance should be reviewed next by F&I in October and provide an analysis of that aspect in the following F&I.

The Chairman to review 1 October meeting and move to a later date as it was too close to the rescheduled September F&I.

Mrs Byrne Mrs Dhillon Mr Manuel

12. 12.1 12.2

GOVERNANCE PROCESS FOR BIDS Mr Stacey presented the governance process for bids. There were 4 stages to the bid sign off process:

Pre-bid

Risk assessment

Submission

Debrief

The Finance & Investment Committee will approve bids for all new business above a £100k de minimis limit, and Mr Stacey stated he was requesting approval of the bid governance process now, in advance of the bid tender adverts coming out.

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12.3 12.4 12.5 12.6 12.7 12.8 12.9 12.10

Ms Rantzen said we needed to strike a balance between a governance process which enabled the Trust to respond in a timely way to bid opportunities and ensuring that sufficient independent NED scrutiny took place. She was also concerned whether we have sufficient staff to manage this additional work.

Mrs Byrne pointed out that the Business Strategy team had not been established when the F&I Terms of Reference was written and that was the reason for the limit of £100k being set.

Ms Higgins suggested that a report should be presented to F&I on what had been bid for. Mr Manuel confirmed that to see the full extent of the opportunity and the obligation of any bid we will need to review both total contract value and annual impact.

Mrs Byrne suggested a compromise to ensure we have both responsive bid governance and independent NED scrutiny we adopt a process similar to that of the Land Sales Committee where we have ad hoc meetings, ie by phone with a minimum of two NED’s.

Mr Stacey stated that thresholds needed to be agreed by F&I and shared with the Board and the process to close is to maybe have a meeting/conference call and use the gateway process.

F&I agreed that it made sense for us to act before the next meeting was scheduled. The Committee was comfortable with the gateway description given but needed target contribution levels made explicit. Mr Manuel stated that written governance was required around this before it was implemented and that bid papers cannot go public for a competitive commercial bid.

Proposed governance will be drawn up and approved offline with a quorate of NEDs. A dummy run will also be carried out.

Due to sensitive information, page 62 needed to be removed from the report before it went on the Exchange.

Mr Stacey Mrs Henry

13. 13.1 13.2 13.3 13.4

BOARD ASSURANCE FRAMEWORK & RISK MANAGEMENT Mr Joseph informed the Committee that there were no new risks, no changes and no risks archived.

Risk 4205 (loss of competitiveness and business activity, through losing current business and failing to develop other business opportunities): will be split into two risks by the next meeting.

Risk 6757 (failure to manage the Trust’s land and building portfolio in a way that complements the Trust’s strategic aims, resulting in a less than optimum portfolio held, an adverse effect on service quality and poor value for money): better reference will be made in the BAF entry to the existence of the Capital Programme Steering Group.

F&I noted the update.

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14. 14.1 14.2 14.3 14.4 14.5 14.6

RISK REVIEW 5406 (re RiO) Mr Nelms reported that the project plan is scheduled to be implemented fully by the end of December 2014, but Ms Rantzen stated that the Programme Board minutes were not assuring. Mr Nelms explained that the meeting had taken place after deciding not to go live at Broadmoor on the given date. Communications had not been as good as hoped but were now picking up. The web page was due to be updated and there would be a weekly update on Monday Matters from now until go live. An announcement will be made today that e-learning was available. The team is working on how new people are doing training and are using the Trust’s e-learning facilities to monitor this. There will be a revised training plan and champion users located in each area to assist people with training.

It was estimated that training would take a maximum of two hours for current users and Mr Nelms stated that there were around 1000 untrained people. Ms Rushton felt the timescale was unrealistic as there was less than a four week window to deliver it. Mr Nelms confirmed that the system would be available 24 hours a day for those who wanted to train outside working hours, but training would still be available after the go live date.

Mr Manuel stated that even though untrained staff would still be able to access the system, how well would they be able to use it and asked if there were any other risks apart from the benefits realisation risk if all staff had not been trained by 7 July. Ms Rushton said there was financial risk to the CSUs, as on wards people would have to be released to attend training, but local champions would encourage individuals to do training.

Mr Manuel reported that given the likelihood that not all the training would be complete, somewhere within the governance there should be identification of the risk and also identification of financial, operational, data quality and availability risks and mitigations put in place to make sure they are limited and training and the target benefits realisation should be driven through.

Mr Nelms confirmed that a governance structure was in place for reviewing this risk. There was an external project group who could make decisions, floor walkers would be available to services and a training module would also be available. Mr Nelms reiterated that this was a migration and not a new system. Mr Manuel stated that the governance around this would be that we needed to capture the benefits we intended to realise from this programme and if they were delayed or not forthcoming, what the impact would be.

The Committee decided that they had only limited assurance of this risk but that it was not necessary to change the risk rating.

Mr Nelms

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15. 15.1 15.2 15.3 15.4 15.5

RISK REVIEW 5551 (re Information Governance security arrangements) The Committee were asked to note both the arrangements in place to manage the risk and the actions being taken to secure more effective control over that risk. Dr Murray reported that there had been a discussion about the level of assurance that a score of 71% provided when the cut-off point is 69%. The assurance that came back was:-

Standards are increasing year on year and it was unrealistic to anticipate a stepped change in the scores we get because the standards are getting higher and 71% was the kind of score that should be anticipated

Gaps in existing controls arising from IG incidents at the Gender Identity Clinic have now been completed.

Mr Joseph reported that reviews had been undertaken to achieve better control regarding agency staff but new software and more robust arrangements had been embedded. Ms Rantzen noted that looking at the actual risk, exposure remained high because of people not taking ownership, poor attendance at meetings and not sticking to policies.

The Committee felt that 71% was not good enough as there was not enough of a buffer between that score and the minimum score of 69%.

Limited assurance was provided, but the Committee noted that the matter was going back to the EDs with a proposal on more robust arrangements for monitoring compliance with policies.

Mr Joseph

16. 16.1 16.2 16.3

RISK REVIEW 5981 (re CIP programme) This risk was currently RAG rated Red and would only reduce by a small amount. 2014/15 plans were due to be implemented and there has been regular reporting on the CIP delivery – the biggest risk was identifying new schemes which were going to be carried out through the Quality Cost Improvement Group. Mrs Byrne did not foresee any problems with the NTDA approving the CIPS process and the Trust was aiming to bring a comprehensive rolling plan to F&I in September, which would be continually reviewed. Mr Stacey reported that the future needs to be much more around service redesign and thinking about models of care and care pathways. The service lines would be critical to this and the Business Strategy team is planning targeted intervention work with service line heads. Mr Stacey confirmed that the risk is wider, but the clinical leadership model would allow for more creative thinking about pathways. In this respect he felt there would be a gap in

Mr Stacey

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assurance. The table will be updated along the lines described.

Mr Manuel stated there was an overall level of assurance and that the issue wasn’t that the risk was being adequately managed but that the task of transforming the service may not be achieved, not for any failure of risk management but because of more fundamental challenges than that. The committee agreed they had assurance for this risk and the risk rating was supported.

17. 17.1 17.2 17.3 17.4 17.5 17.6

RISK REVIEW 5889 (re inability to sustain Local Services) Mrs Kerin queried the wording of the risk, ie failure to deliver savings. Mr Stacey confirmed that this was an old risk on a 2 year programme and instead of the word ‘savings’, ‘activity shifts’ would be more appropriate. Mrs Byrne confirmed that this was actually two risks - a CIP and a QIPP risk.

Work has been done by the Transformation Board and Mr Stacey is assisting Ms Rushton and Mr Meechan with the transformation of the QIPP and CIP delivery.

Mr Manuel said there were two interdependent pieces of work to be presented in September:-

1. 24 month review of Local Services transformation

2. Linked to that would be the overall Trust transformation which would show what the plan is to remove the inter business unit subsidy.

The first piece of work would give us greater assurance, ie seeing a timeline. The committee agreed that the level of assurance provided at the meeting for this risk was incomplete. It was agreed that the risk description would be discussed at the EDs meeting and should remain a Local Services risk.

F&I supported the level of the risk.

Mrs Kerin asked if there were any other IT systems that would need replacing in a period of time. Mr Nelms replied that there were but priority would have to be given as to where to apply the capital that the Trust has. Mrs Byrne stated that relevant parties would be invited to the prioritisation meeting which was currently being arranged.

Ms Rushton

18. 18.1

INFORMATICS SUB-COMMITTEE The Chair’s Report and Minutes were noted.

19. 19.1

CAPITAL AND ASSET PLANNING MANAGEMENT GROUP MEETING The Minutes were noted.

20. 20.1

RiO7 PROGRAMME BOARD The Chair’s Report and Minutes were noted. Ms Higgins observed

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that training had not been discussed as a high risk in the Chair’s Report. Mr Nelms explained that a detailed training plan was not available at the meeting and that this was a migration. The Broadmoor training was not considered to be a high risk as there was an agreed plan and an extended timescale.

21. 21.1

CONSIDER IF ANY NEW RISKS WERE IDENTIFIED OR CHANGES TO RISKS PROPOSED

1. CAPMG to identify a specific BAF risk around the governance and prioritisation of calls on the capex budget.

2. Governance surrounding the authorisation of spend against that.

3. P1 – Chairs Report will report on this. After the next meeting, we may need to take additional action

4. The additional risk around RiO training and potential of failing to realise the benefits planned when the investment was planned and authorised will go on the risk register.

22. 22.1

ACTIONS TO THE BOARD & OTHER COMMITTEES 1. CAPMG to identify a specific BAF risk around the governance of

calls on the capex budget and a meeting is to be held with the Director of Capital, Estates & Facilities once the costs relating to other projects are received.

2. RiO review – governance to ensure benefits realisation was defined and our achievement of that benefits realisation accurately understood.

23. 23.1 23.2 23.3

AGREE KEY POINTS FROM MEETING FOR CHAIR’S REPORT TO THE BOARD Review and agree business development bid governance so that these arrangements can be put into force asap.

Mr Manuel and Gillian Henry to review how to better capture risks and action capture during F&I minutes.

IG Toolkit risk - 71% was not good enough as there was not enough of a buffer between that score and the minimum score of 69%. The Committee noted that the matter was going back to the EDs with a proposal on more robust arrangements for monitoring compliance with policies.

24. ANY OTHER BUSINESS There was no other business.

Date/Time of next meeting 3 September 2014 0830 – 1130 White Room, Armstrong Way

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Date of Trust Board 24 September 2014 Name of Meeting: Strategic Projects Programme Board, 26 August 2014 Name & Title of Chair: Steve Shrubb, CEO Key Issues to highlight (points from the meeting(s) being highlighted for the Trust Board’s attention and why)

PUBLIC Chief Inspector of Hospital (CIH) visit Rob Bolas and Liz Edghill would be starting two day walk around in each CSU inpatient area,

starting with Broadmoor in September to talk about quality, the CIH visit, trust values and vision. All inpatient sites would be visited by the end of the calendar year and there would then be some targeted engagement with community sites.

Now that peer reviews had been started in each of the three CSUs, these will be used to run mock CQC inspections. This will be facilitated by the governance team.

The CIH project group had discussed perceived current risks in the respective areas. Staffing levels and caseloads were noted as a concern for staff, as well as recruiting delays.

The ToR for the CIH project group was approved. Foundation Trust application A draft revised timeline has been worked up between the Change Management Office and

the Trust Development Authority which focused on trying to complete as much work as possible whilst the date for the CIH remained unclear.

The revised timeline includes the Trust completing an external financial review, an internal Monitor Quality Governance Framework (MQGF) self-assessment and a Board Governance Assurance Framework self-assessment. The dates of these are being confirmed with the TDA and the scope of each will be agreed in meetings between the TDA and the Trust.

If this revised timeline was implemented without any delays the Trust is likely to achieve approval by Monitor in December 2015.

The IBP summary has been circulated to members of the group and will be circulated to commissioners prior to their meetings with the TDA.


The Trust had been informed that Merseycare were due to have their CIH visit in Qtr 3 which would support the Trust in having our visit in Qtr 4, however the agreed sites for Qtr 3 have been released and Merseycare are not it. This risk is that they could be seen in Qtr 4 which may mean the Trust is pushed into Qtr 1. The Trust are discussing this with the TDA.

Chair’s Report

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Committee / Board decision / referral required: (in respect of key issues indicate what the committee’s recommendations are, what referral is required and or what the Trust Board needs to do; indicate timescale)

None

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1

Strategic Projects Programme Board – Public Meeting P1

29 July 2014 Armstrong Way, White Room C

Draft Minutes

Membership Title Present Apologies Absent

Steve Shrubb (SS) Chair

Chief Executive (Chair)

Amlan Basu (AB) Clinical Director of High Secure Services

Anne Aiyegbusi (AA) Interim Director of Nursing & Patient Experience

Barbara Byrne (BB) Deputy Chief Executive & Director of Finance

Charlotte Langford (CL)

Strategic Projects Coordinator

David Stacey (DS) Director of Business and Strategy

Hannah Parsons (HP)

Deputy Director of Business and Strategy

Helene Feger (HF) Director of Communication and Engagement

Jose Romero-Urcelay (JRU)

Clinical Director of Forensic Services

Jo Smith (JS) Deputy Director of Finance

Leeanne McGee (LM)

Director of High Secure Services and Forensic Services

Michael Phelan (MP) Clinical Director of Local Services

Nick Broughton (NB) Medical Director

Rachael Moench (RM)

Director of Organisational Development & Workforce

Rob Bolas (RB) Interim Director of Governance

Sarah Rushton (SR) Interim Director of Local Services

Hannelie Mathee (HM)

PA Director of Business and Strategy (Minutes)

In Attendance Title Present

Dawn Harwood Ward Manager

Viv Mowatt (VM) Deputy Redevelopment Programme Director

PART 1 – Public Part

Item Action Date

Apologies for Absence

It was noted as above.

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1. Minutes of the Previous Meeting

1.1 The minutes of the previous meeting were agreed with the following amendment: 3.1 To be actioned by CL on 29.07.14 – completed. The group discussed if a NED attending this group would be useful. The group noted it was useful. The group noted it had been discussed at Trust Board and it had been agreed that once the new NED was in post, a review of responsibilities for NEDs would be completed.

2. Action Tracker

2.1

2.2

Action 5.6 – DS to review the High-level IBP summary. DS to raise the Mental Health Administration Risk with Sarah Rushton and Paul Meechan. RB noted that the corporate governance team were extending the audit on section 136 until September 2014. BB added that an audit of Mental Health Act documentation had been added to the internal audit schedule.

DS DS

01.08.14 01.08.14

3. CIH Visit Programme

3.1 3.2 3.3 3.4 3.5 3.6

Project Plan RB confirmed that this was at a high level and these were more granular detail that sat underneath HP. HP to share notes regarding Project Plan with RB. Terms of Reference The group discussed the draft Terms of Reference and agreed the following amendments:

An IT representative is included on the membership of this group;

Deputy Directors of Nursing are key to taking this forward and need to be included in membership;

Service User and Carer representative is required and needs to be included in membership.

The group discussed making the Leadership Forum meet more frequently as a way to engage with senior staff about the CIH Visit. HF to meet with RM to discuss if it is feasible for the Leadership Forum to meet monthly. The group discussed the issue regarding Wi-Fi access for the

inspectors and transport challenges to improve more

synchronised geographical visits. RB to check with Liz Edghill if

the relevant IT staff were aware of Wi-Fi requirements. The

Trust should ensure that there is wi-fi access in at least one

room in every site and inspectors should be made aware of the

fact that in some areas there will be no wi-fi access.

RB to amend and re-submit the Terms of Reference to this group for approval. RB confirmed that Nottinghamshire Healthcare felt that the involvement of the Deputy Directors of Nursing are key but the Trust still has a vacant post in Local Services. SS requested that AA finds someone to fill the post of Deputy Director of

HP HF&RM RB RB

26.08.14 26.08.14 26.08.14 26.08.14

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3.7 3.8 3.9 3.10 3.11 3.12 3.13

Nursing in Local Services by the 8 August 2014 on an interim basis. It was noted that this was an excellent secondment opportunity. Chairs Report RB presented the Chairs Report to the group. RB confirmed he had received the 96 page document that the CQC had prepared for Nottinghamshire Healthcare. RB added that the feedback from the CQC indicated that the CIH Visit could happen in Quarter 1 of 2015/16 but the team were planning for an inspection in Quarter 4 2014/15. The group noted that the timeline for confirmation of a CIH Visit had increased to 20 weeks. RB confirmed that the CQC Compliance Project Group was meeting on a monthly basis. The appointment of the admin support was delayed until nearer to the inspection. DS confirmed that there had been a meeting between the CMO, Communications and Rachael Moench who had agreed that updating the vision and values pyramid timeline for the triangle pyramid, is mid-October. RB noted that the pyramid should be part of the Communication Strategy. The group discussed this timeline and how engaging with staff was a priority. SS requested that this timeline was discussed outside this meeting and a suitable solution was identified for moving this forward. Assurance regarding this to be provided to SS. SS emphasised the importance of communicating to staff to emphasise the Trust’s Strategic Vision and Aims. SS noted that as part of the CIH visit, inspector would approach staff and ask them about the Trust’s vision, values and aims and they would need to say ‘ ‘what they meant to them’. HF noted that she had requested the communication pack from South West London & St George’s, Camden and Islington which is based around the five domains. SS raised concerns regarding communicating with service user groups as they are fragmented and urgent thought should be given to how the Trust communicates with disparate service users and the mechanism being used for this purpose. BB mentioned that it is more of an issue in local services. SS felt that further interaction with certain service users may be beneficial and provide further and better engagement. SS requested that HF speak with Pat McGrath and ask her to draft a map to reflect the different service user groups and who the identified lead was. Comms to work closer with Jane McGrath and Flippa Watkeys but also to broaden this group to establish communication channels by involving people that have close contact with service users, for example John Viner and Nash in Forensics. SS confirmed that the ED lead on this was AA. CL noted that it was difficult to engage with service users as the channels were not in place for communicating.

AA CMO/Comms HF

08.08.14 26.08.14 26.08.14

4. Foundation Trust Programme

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4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9

Exception Report DS presented the FT Programme Exception Report and noted that initial feedback was received from the TDA on the IBP and LTFM following the submission on the 20 June 2014. DS noted that the TDA had raised six areas of risk on the conference call with Mark Brice in July. DS confirmed that these risks were already reflected in the BAF and Risk Register and a summary of this had been included in the papers and had been submitted to the TDA. VM wanted clarification on number six but was reassured by DS that this point was only included because it is such a large scale project. VM to catch up with Caroline Reid to ensure she is up-to-date with the Broadmoor redevelopment programme from high secure commissioning. SS noted that he is confident that Monitor did not have any capacity issues following a vigorous recruitment process. SS noted that he had circulated the “Mutual Model” which would be discussed further at EDs. Ops Chairs Report – 08.07.14 DS presented the Ops Chairs Report during which the group discussed the feedback from the March 2014 TDA submission. The group discussed the revision of the Integrated Business Plan ahead of future submission as part of the readiness review which was also discussed on the 18 June at the Board Development Day. A forward plan in preparation of this review was put in place. HP to add the date of the Operational Workstream to this report. Quality and Governance Report – 16.07.14 Meeting was cancelled. TDA Monthly Self Certification Returns CL presented the TDA Monthly Oversight Self Certification Compliance Returns to this group for assurance that in this group’s view the Trust was still compliant in all areas. The group approved both returns. TDA Identified Risks Discussed at 4.3

VM HP

End of Sept ‘14 12.08.14

5. AOB

5.1 Following notification of Ian Cox secondment to another trust, the group would like to thank Ian Cox for his support and wish him well with his secondment.

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Date of Trust Board: 24th September 2014 Name of Meeting: Staff Engagement Committee Date of Reporting Meeting: 31st July 2014 Name & Title of Chair: Rachael Moench Director of OD & Workforce Key Issues to highlight (points from the meeting(s) being highlighted for the Trust Board’s

attention and why)

The Committee was presented with the newly updated staff engagement action plan following feedback that the milestones in the plan were unclear. The new plan includes clear quarterly milestones with an associated RAG rating. This will allow clearer monitoring of progress against the plan. Following feedback from the organisation temperature check conducted by reporters it has been agreed that the 6 workstreams will be reduced to 4. These being leadership and vision, management of change, leadership and management and culture and behaviours. The committee received the. On the quarter one milestones of the action plan three actions are amber and all others are green. Progress against the amber actions will be confirmed at the next meeting. In addition the overarching action plan has now incorporated the CSU action plans which also have quarterly milestones. The Committee heard about the work under way in each CSU, particularly around the hot spot areas. This includes questionnaires being sent to staff to ascertain the effectiveness of their line managers. The feedback from the questionnaires will be provided directly to managers with plans for further support and development.

The Committee received the recent internal audit report on staff engagement which had received a green/amber rating meaning that the Board could take reasonable assurance that the controls around staff engagement are being suitably managed. It was noted that the actions requiring attention had been picked up in the updated staff engagement action plan, which now has much clearer auditable milestones.

The Committee received a report on the temperature check feedback. The report confirmed that 13 focus groups had been held by reporters and participation at the groups had been variable, with some only having a couple of attendees. The feedback had both positive and negative aspects with the negative areas very much concurring with the results of the staff survey. The negative themes were around lack of visibility of senior management, a culture of bullying and harassment, poor management of change, poor quality managers, not enough recognition for staff, workplace stress due to high workload, poor career development for BME staff and concerns about the appraisal system. The findings had been discussed at length with the reports and it was agreed that the current staff engagement workstreams did cover the key areas of feedback. The action plans have however been strengthened as covered above and the worksteam action plans have been reinvigorated with reporters assigned to each of the groups.

Chair’s Report to the Board

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The Committee receive the workforce KPI report which demonstrated that sickness rate and the use of temporary staffing is consistently higher in our services which have poorer staff survey results. The committee considered this information and agreed that a clearer KPI report will be generated for the committee in the future.

The Committee received a detailed report on the Trusts compliance with PDR and mandatory training, which had previously been presented to the Board. It was agreed that the green rating for mandatory training would be increased to 90%in January 2015 and that a major objective for the coming year will be to review the appraisal system and consider the introduction of a performance rating into the appraisal process.

The Committee received an update from Tara Ferguson Jones on all of the actions underway to improve the staff survey completion rate. This includes the use of posters, more regular communication on completion rates, protected time for staff to complete forms, staff survey champions and the possibility of a prize draw.

The Committee received an update on quarter one progress on the milestones within the OD and Workforce Strategy. Most actions are under way with the outstanding action of the review of the PDR process now covered.

The Committee received the first draft of the Health at Work Strategy which is a key document outlining all the strands of work underway to improve the health and wellbeing of staff. The strategy will be formally approved at the next meeting.

The Committee received a report from Margaret Morgan–Valentine on the progress we are making on our BME leadership action plan to improve the representation of BME staff on band 8a and above. She also informed the Committee that the befriender scheme has been successfully re-launched and that there are now 20 befriender staff.


Results of the staff survey are disappointing and intensive work is now underway to address the areas of poor performance. The actions will be monitored by the staff engagement committee

Board decision / referral required: (in respect of key issues indicate what the committee’s recommendations are, what referral is required and or what the Trust Board needs to do; indicate timescale)

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Trust Headquarters, 1 Armstrong Way, Southall, UB2 4SA | Tel: 020 8354 8354 | Web: www.wlmht.nhs.uk

Staff Engagement Committee Meeting Minutes

Date : 16th April 2014

Time : 1.30pm – 4.30pm Venue : THQ Board Room, White room A&B

Chair : Rachael Moench

ATTENDEES PRESENT TITLE Aidan Lewis Staff Reporter / Project Manager Transformation Programme Board Andy Wells Head of Learning & Development Anne Aiyegbusi Interim Director of Nursing Bryan Joseph Head of Risk, Health & Safety Craig Jarmin Workforce Information Manager Donna Pereira Head of staff health and welfare Jayne Shanks HR Business Partner John Kitching Interim Head of HR Consultancy Julie Gamble PA in attendance Maninder Walia HR Business Partner Michael Neville Staff Side Representative (Unite)

Paul Meechan Deputy Director of Specialist and Forensic

Prof. Colin Martin Professor of Mental Health, Bucks University & WLMHT

Rachael Moench Chair - Executive Director of Organisational Development & Workforce Sian Mahadevan HR Business Partner Steve Shrubb Chief Executive

APOLOGIES RECEIVED TITLE Carolyn Gray Non Executive Director Geoff Rose Non-Executive Director Helene Feger Director of Communications

Jimmy Noak Deputy Director of Nursing

Leeanne McGee Executive Director of Specialist & Forensic Linda Dyson Deputy director of Organisational Development & Workforce

Maggie Morgan-Valentine Diversity Consultant Maureen Clapson Staff Reporter / Admin support

Nick Broughton Medical Director Sandra Bailey Staff Reporter / Senior Nurse

Sarah Rushton Acting Director of Local Services Wiz Magunda Service Director

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Page 2 of 5

No

Decision/Action

Lead

1

Introduction: Welcome and apologies RM welcomed attendee’s to the meeting and apologies were noted as recorded above. The previous minutes of 30.01.14 were agreed as an accurate record of the last meeting. Matters Arising: The Committee were to note that this meeting was not quorate.

Chair

2

Terms of Reference No change.

Chair

3 Update on CSU Staff Engagement Action Plans JK provided a brief overview of the summary report from the information he had received from the HR ODBP’s. 3.1 High Secure Services JS provided the Committee with an update on the targeted action plans. A spreadsheet detailing the data comparison she had collated, containing statistics 10% above and below the national average from which it would be possible to see whether targeted action plans had been successful. Most targeted actions showed an improvement, however, in all key findings for Violence and Harassment and Equality and Diversity, MI showed a substantive negative increase against their last year’s results. The MI figures, for the percentage of staff experiencing B&H and discrimination, were the highest at Broadmoor and significantly above the Trust and National Average. Although the majority (39%) of discrimination was from patients, relatives and the public, there was still a level of (18%) of discrimination from managers, team leaders or other colleagues. Areas that continue to produce poor results will have further targeted action plans put in place. PD had shown a 10% improvement in equal opportunities where there was targeted action last year. Security and management (now combined) showed a 13% reduction of B&H from patients, relatives and the public following targeted action including a Zero Tolerance campaign. 3.2 Specialist & Forensic Services MW informed the Committee that the targeted action plans had seen a positive result in certain areas such as Women’s Directorate, however in the Men’s Directorate there had been a decline. There was also the difficulty in narrowing down the results from areas such as Adolescents and The Cassel. 3.3 Local Services SM informed the committee of the revised detailed action plan, and that there had been some positive outcomes. The committee felt that timescales for completing actions required more specific time lines.

4

Leadership & Management Development 4.1 A brief verbal update was provided by AW in which the following was stated:

1 full cohort of 13 members of staff have completed the leadership and management development programme.

2nd cohort is currently underway and will complete in May 2014. 17 applications have been received for the 3rd cohort.

Leadership Academy Programme – 7 places secured on Elizabeth Garret Anderson course.

AW to provide TJF with names to promote on Trust Intranet.

75% of participants are from a BME background.

AW

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Coaching bid successfully secured through London Leading for Health which has enabled 2 coaching cohorts with a further 2 more planned this financial year.

5 5.1 5.2 5.3 5.4 5.5

Staff Engagement Workstream Action Plans RM provided the Committee with an overview of the quick wins action plan stating that the majority of actions have now been completed, and will no longer be essential, just two updates from the Patient care workstream required. Members of the committee were requested to provide updates from their respective workstream groups Leadership & Vision

Feedback provided by TFJ to the committee informing them that executive directors and Chief Executive have been attending listening events around the Trust, which is advertised via the Exchange, encouraging staff to come forward with any questions or issues they wish to raise. Staff whom may feel intimidated in raising issues publicly also have an opportunity to pose their questions electronically. Events have been scheduled at times which may be more convenient to staff in order that as many staff as possible can attend, such as lunch times.

Annual Communications Survey to be available shortly.

Senior management structure charts to be issued shortly in all reception areas, in order to raise the profile of executive and non-executive directors following recent changes in the structure.

Board visits have evolved into a less formal meeting, has been positive. Areas to visit will be extended, as well as raising the profile on the Exchange.

Once the ‘vision’ has been signed off, there will be a communications plan to share this information.

AHP leadership – SS, RM to meet with Rod Holland, Head of Psychology and Psychological Therapies, to meet to refresh and update the approach to this

Culture & Behaviours Two secondment roles are to be signed off shortly, and will be led by MMV and DP. The role is to support reporters to obtain information from staff such as what do you think, what do you expect, linking in with the Health at Work team and MMV in order to be able to create a culture statement for the Trust. It is anticipated that this secondment will last 4 months. Invest in our Infrastructure No update available - RM to pick up with SR regarding the IMT issues across the Trust and when Windows 7 will be rolled out across the Trust. Management of Change

Consultation on the Change Management Policy requires feedback and the format agreed format. Draft document to be brought back to the next Staff Engagement Committee meeting.

Patient Care

Dementia - Natalie Waterfield - updated design programmes for dementia services. Leads had training, working to implement them.

Anne Aiyegbusi outlined ideas for introducing Schwartz rounds as the evidence is that this enhances empathy and compassion. There is also evidence that Schwartz rounds have been

RM RM/SR JK

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Page 4 of 5

effective in changing cultures through improving staff morale and engagement. A mental health trust has introduced Schwartz rounds in Derbyshire and the approach is now being taken forward in in other MH trusts. The committee endorsed the approach.

6 Staff Survey Results 6.1 RM outlined the staff survey results report which had been presented to the Board. She confirmed that the emphasis this year will be on triangulating information and addressing ‘hot spots’ and developing targeted actions. The action plans for this will be presented to the next meeting. 6.2 SS stated that he would like to see the response rate for the next survey increased to 70%. TFJ agreed to lead some work on improving the response rate to the staff survey.

RM TFJ

7

Family and Friends Test 7.1 AW provided a brief overview of his report. The Friends and Family Test (FFT) which the Prime Minister announced in 2012 was to encourage improvements in service delivery and to increase transparency. The FFT is a feedback tool is administered by Quality Health. NHS England have recommended that a return is completed quarterly with the exception of quarter 3 as this is when the staff surveys are completed. The questions posed are:-

1. How likely are you to recommend WLMHT to friends and family if they needed care or treatment?

2. How likely are you to recommend WLMHT to friends and family as a place to work? The implementation of the staff FFT makes up 30% of the national CQUIN Target. SS stated that this is an important piece work and AW recommended that a random ‘sample’ group of staff should be targeted to complete the FFT questionnaire, and this should be completed online. The committee approved the proposal

AW

8 Temperature Check 8.1 The reporter focus groups are proving problematic due to low attendance and staff worried about being identifiable. Questionnaires will go onto the Exchange shortly for completion by the end of April and results from the analysis of the questionnaires available in May. The results of the temperature check will be reported to the next meeting.

RM

9

Consultation Template 9.1 JK provided an overview of the circulated draft template, which has been trialled in 3 areas in the Trust. It was agreed that feedback and comments should be sent to JK with a deadline of 2 weeks.

All

10 OD & Workforce Strategy 10.1 Updated strategy showing an update on quarter 4 actions had been circulated in the agenda, which was for information as previously discussed in more detail at the previous meeting.

ALL

11

Workforce Performance Indicators 11.1 CJ presented the workforce KPIs relating to short and long term sickness and turnover as requested from the previous SEC meeting. Our benchmarked sickness figures are higher in comparison to other mental health trusts but low when compared to Trusts with high secure services. Turnover is lowest within Specialist and Forensic however this service has the highest sickness. Further analysis on the workforce KPIs is required.

CJ

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12 Francis Report Action Plan Update 12.1 The Committee was informed that this action plan is due for final completion. There has been slippage on the culture statement as we have decided to take a bottom up approach with staff seconded to lead this work.

RM

13

Health & Wellbeing Strategy Update 13.1 DP provided the Committee with a verbal update on the strategy. A fuller report will be provided to the next meeting.

DP

14

Early Intervention Pilot 14.1 DP gave an overview of the Early Intervention proposal. The proposal details how the Health at Work Team (HAWT) will proactively contact staff who are off work for 5 days or more to offer advice and support. Broadmoor is currently trialling the pilot for six months prior to rolling out across the Trust. HAWT team now receive information in relation to assaults on staff, in order to offer immediate support within 24 hours. SS stated that he would like to discuss the options for an online stress assessment tool, similar to the tool which is used by BT, and that a non-executive director would be able to assist with this.

DP

15 Schwartz Rounds As discussed in 5.5 Above.

AA

16 Review BAF The committee agreed that the current BAF rating of 12 (amber risk) should remain unchanged.

All

17 Items for Chairs report

18 AOB None received

Meeting Dates 2014/2015:

Date Time Venue Paper Deadline 31st July 2014

9.00 – 12.00 White A&B 21st July 2014

16th October 2014 9.00 – 12.00 White A&B 6th October 2014

2015

Date Time Venue Paper Deadline 22nd January 2015 9.00 – 12.00 White A&B 12th January 2015

16th April 2015 9.00 – 12.00 White A&B 6th April 2015

9th July 2015 9.00 – 12.00 White A&B 29th June 2015

15th October 2015 9.00 – 12.00 White A&B 5th October 2015

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Date of Board Meeting: 24th September 2014 Name of Meeting: Trustwide Service User & Carer Forum –

Workshop Date of Meeting: 2nd September 2014 Name & Title of Chair: Workshop was facilitated by Jane McGrath,

Service User Consultant and Flippa Watkeys, Head of Recovery and Involvement, Local Services

Key Issues to highlight (points from the meeting(s) being highlighted for the Trust Board’s attention and why)

The meeting was opened by Jane McGrath and Flippa Watkeys who explained to the group that as the West London Collaborative (WLC) was taking over the forum that we wanted to look at the forum more closely to see if we felt that there might be a better way for the forum to run. This would be the start of a longer process that would ask not just the people in the room but also seek out the opinions of those that don’t attend to try to understand why that was. We would also be following up with people who attend regularly but were not in the room today. It was noted that during the two months that the forum was being used as a working group that action points from previous agendas and action plans were not being lost - just put on hold. The meeting opened with a presentation by Hannah Parsons who presented the project that is looking to develop the trusts new vision. Hannah explained why the trust was looking again at its vision, that the website was available and how to access it and how the opinions there would be used. She also explained that there was a way to engage if you didn’t want to or could not go on line. Questions were raised around the way the final vision would be decided and if service users would have a say. Hannah explained that it would be a voting system but it was pointed out that the vision with the most votes might not be the best one. It was also pointed out that this should be proactively taken around to patients who should be asked to fill it in. Another issue was around if we would be able to tell how many of the respondents were service users and if this methodology worked. The workshop then began. Attendees were asked to think about the purpose of a forum and if the last model worked? Questions were asked. What did we want to achieve? Did people feel that talking and listening was enough or did we want outcomes that were measured and recorded? Was it accessible; was it necessary to go to all boroughs and how if this is trust wide do we involve high secure and forensic services? Was there a feedback loop so that people knew if they had made a difference? Who decided what action would be taken around concerns. The focus then turned to issues of power and power relations of an effective forum. Jane McGrath presented information from non-governmental organisations and citizen participation

Chair’s Report to Trust Board

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projects that suggested that without a clear understanding of where power sits within an organisation and how it is addressed it was very difficult for groups to have any meaningful impact on outcomes. The group broke into table work and was asked to decide the types of power being displayed in some animations and then to draw an image of a time they felt they held power and a time they felt they did not. This produced some helpful contributions about the nature of power and how it can be positive or negative and the feelings that it can create. Different types of power were discussed with emphasis on “empowerment” rather than power over and how people had personal power The group then broke off again to think in groups about what the ideal forum would look like for them and how might it operate. The group tried to think creatively and not be tied down to what we had already. Flippa Watkeys thanked the groups for their input and said that the individual projects groups will continue into the next forum where the ideas will be developed further. It was noted that this was part of a longer journey that will take longer than two workshops to complete but starting the conversation was key. The group was invited to feed back ideas and suggestions and 1 email was received.


None.

Committee / Board decision / referral required: (in respect of key issues indicate what the committee’s recommendations are, what referral is required and or what the Quality Committee needs to do; indicate timescale)

None.

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TRUST BOARD MEETING IN PUBLIC (PART 1) on Wednesday 24th September 2014 - from 1330 to 1630 hrs

AGENDA Approx. Timing

Agenda No.

Title Objective Lead Enclosed or Verbal

Item

1330 1 Opening & Welcome To note Chairman Verbal

2 Apologies for Absence To note Chairman Verbal

3 Declaration of Interests To note Chairman Verbal

4 Minutes of the Last Meeting To approve Chairman Enclosed

5 Board Action Schedule & Matters Arising To note Chairman Enclosed

1350 6 Chairman’s Report To note Chairman Verbal

7 Chief Executive’s Report To note Chief Executive Enclosed

1405 8 8.1 8.2

8.3

Executive Directors’ Reports Director of Local Services’ Report Director of High Secure & Forensic Services’ Report Medical Director’s Report

To note Executive Directors

Enclosed

9 Integrated Performance Report To note Director of Finance / DCEO

Enclosed

1455 10 Board Members’ Visits Meridian Ward – 23/07/2014

To note Various Directors Enclosed

11 Nurse and Health Care Assistant Staffing Levels – Exception Report for June 2014

To note Interim Director of Nursing & Patient Experience

Enclosed

1525 12 Development Support Plan To note Director of Business & Strategy

Enclosed

1535 – 5 minute break 1540 13 Communications Strategy Update To note Director of

Communications & Involvement

Enclosed

14 Register of Members’ Interests To note Trust Secretary Enclosed

1600 15 15.1

15.2

Audit Committee Chair’s Report of meeting on 03/09/2014 inc. Proposed Amendments to Trust Standing Orders & Standing Financial Instructions Approved Minutes of meeting of 02/07/2014

To approve

Committee Chair Enclosed

16

Finance & Investment Committee Approved Minutes of meeting of 04/06/2014


17 17.1 17.2

Strategic Projects Programme Board Chair’s Report of meeting on 26/08/2014 Approved Minutes of meeting of 29/07/2014


18 18.1 18.2

Staff Engagement Committee Chair’s report of the meeting on 31/07/2014 Approved Minutes of meeting of 16/04/2014


19

Service User Forum Chair’s report of the meeting on 02/09/2014


20 Consider if any new risks were identified during the meeting or changes to risks proposed


21 Actions for Committees identified during the meeting


22 Any Other Business Previously notified to the Chairman

Verbal

23 Questions from Members of the Public Verbal

Date of Next Trust Board Meeting in Public: Wednesday 29

th October 2014