PUBLIC MEETING OF THE TRUST BOARD 1.00pm, Thursday, 6 … · 2017-07-10 · PUBLIC MEETING OF THE TRUST BOARD . 1.00pm, Thursday, 6th July 2017 . The Board Room, Canalside . AGENDA

PUBLIC MEETING OF THE TRUST BOARD

1.00pm, Thursday, 6th July 2017

The Board Room, Canalside AGENDA

Culture and Conduct Protocol

We are a values-led Board. We place quality of care and safeguarding the needs of our patients at the heart of everything we do. We work consciously as a team to support and constructively challenge each other in the best

interests of service users, their carers and families. We champion the interests of staff and acknowledge that they are working well in challenging times. We seek to ensure value for money at all times through efficient use of our

resources in the delivery of services and achievement of standards. We welcome the rigour of debate with fellow Board members, drawing upon a range of different experiences and perspectives and applying the Nolan principles of

Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership.

ITEM Purpose Board Lead Format Timings

1. EBE Reflection Assurance Mr Axcell Presentation 1.00pm

2. Apologies Mr Reid Oral 1.30pm

3. Declarations of Interest For Board members to declare any relevant interests in items on the agenda

Mr Reid Oral

4

Minutes of the Previous Meeting To approve the minutes of the Board meeting held on 1st June 2017 & 21st June 2017

Approval Mr Reid Enc 1

5. Matters Arising/Action Schedule Continuity Mr Reid Enc 2

6. Summary Report of Confidential session of Trust Board held on 4th May 2017 Information Mr Reid Enc 3

7.

Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)

Information

Mr Axcell

Enc 4

1.35pm

8. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

8.1 Trust Integrated Performance Dashboard (Month 2) including the Performance Dashboard and Contract Performance Report Dashboard

Assurance

Mr Davies Enc 5 1.40pm

8.1.1 a b c d. e.

Quality Quality and Safety Committee Chairs Report Quality & Safety Committee Minutes from meeting held on 10th May 2017 Mental Health Act Scrutiny Committee Chair’s Report Mental Health Act Scrutiny Committee Minutes 8th June 2017 Quality Report

Assurance Assurance Assurance Assurance Assurance

Dr Murphy Dr Murphy Mrs Cooper Mrs Cooper Ms Musson

Enc 6 Enc 7 Enc 8 Enc 9 Enc 10

1.45pm


8.1.2 a b c d e f

Finance & Performance Finance & Performance Committee Chairs Report Finance & Performance Committee Minutes from meeting held on 22 May 2017 Audit Committee Chair’s report and Annual Report Draft Audit Committee Minutes from meeting held on 22 May 2017 and 21 June 2017 Finance Report – Month 2 2017/18 Cost Improvement Programme (CIP) Progress Report

Assurance Assurance Assurance Assurance Assurance Assurance

Mr Rana Mr Rana Mr Lancaster Mr Lancaster Mr Davies Mr Davies

Enc 11 Enc 12 Enc 13 Enc 14 Enc 15 Enc 16

2.00pm

8.1.3 a b c

Workforce Workforce Committee Chair’s Report Workforce Committee Minutes from meeting held on 23 May 2017 Workforce Performance Report – Month 2 2017/18

Assurance Assurance Assurance

Ms Clymer Ms Clymer Mrs Williams

Enc 17 Enc 18 Enc 19

2.15pm

8.2 Medical Directors’ Report

Assurance Dr Gingell /Dr Weaver

Enc 20 2.25pm

8.3 Director of Nursing Report

Assurance Ms Musson Enc 21 2.30pm

8.4 Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Assurance Ms Musson Enc 22 2.35pm

8.5 CQC Inspection – Lessons Learnt and Action Plan Approval Ms Musson Enc 23 2.40pm

8.6 Quality Improvement Priorities and CQUIN Update - Q4 2016/17

Assurance Mrs Musson Enc 24 2.50pm

8.7 Director of Operations Report Assurance Mrs Writtle Enc 25 3.00pm

8.8 Service Experience Desk Annual Report 2016/17 Assurance Mr Axcell Enc 26 3.05pm

9. STRATEGIC DEVELOPMENT & DIRECTION

9.1 Review of Board Sub-Committees Terms of Reference

Approval Mr Lewis-Grundy

Enc 27 3.15pm

9.2 High Level Operational Risk Register Assurance Mrs Musson Enc 28 3.20pm

10. FOR ASSURANCE

10.1 MExT Chair’s Report from 27th June 2017 Assurance Mr Axcell Enc 29 3.25pm

11. ANY OTHER BUSINESS

12. QUESTIONS FROM MEMBERS OF THE PUBLIC


Questions from members of the public pertaining to agenda items.

Oral

3.30pm

14. DATE AND TIME OF THE NEXT MEETING

1.00pm on Thursday 3rd August 2017, Conference Room 1, Trafalgar House

Enc 1 MINUTES OF THE TRUST BOARD MEETING OF

DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST

Held at 1.00pm on Thursday, 1st June 2017 Conference Room 1, Trafalgar House, King Street, Dudley

PUBLIC SESSION Present Mr B Reid Chair Mr M Axcell Chief Executive Officer Ms O Clymer Non-Executive Director Mrs G Cooper Non-Executive Director Mr R Davies Interim Director of Finance, Performance and IM&T

(Deputy Chief Executive) Dr K Gingell Joint Medical Director Mr J Lancaster Non-Executive Director Dr S Murphy Non-Executive Director Ms R Musson Acting Director of Nursing Mr H Turner Associate Non-Executive Director Dr M Weaver Joint Medical Director Mrs A Williams Acting Director of People In Attendance Mr M Hirons Staff Engagement and Freedom to Speak-up Guardian

(Minute 56.1 only). Mr P Lewis-Grundy Company Secretary Mrs L Wix Corporate Governance Support Officer (minutes) ITEM ACTION 42. Patient Story Mr Axcell introduced the patient story. The patient was a 45

year old female and an audio of her experience had been recorded to play to the Board. The patient had mental health issues from an early age, had been in and out of hospital and had tried to commit suicide on a number of occasions. The turning point had been when she had been allocated a CPN who had provided support and that had increased the patient’s self-confidence. The CPN had also referred her to the Trust’s employment services enabling her to get a job and accommodation and live a normal life. She had taken the decision to share her experiences to help other sufferers. Ms Musson advised that the employment services had been key to the patient’s recovery and the safeguarding of children, intervention where a child had mental health issues would not have happened 20 years ago when this individual was a child which explains the delay in the patient accessing

Page 1 of 20

mental health services. Dr Gingell concurred, adding that it was important that children’s mental health services were appropriate and effective to minimise if possible the long term effects of emotional and physical abuse. Mr Turner stated that the patient had had a positive experience with the CPN and queried whether staff at that grade remained in post over long periods to ensure consistency for the patient. Dr Weaver stated that there was pressure to refer patients back to primary care once they were well and stable which often resulted in a relapse and re-referral to mental health services. He appreciated that not every patient could remain indefinitely within the service although they were more likely to remain stable under the care of a consultant. although he would like to see an improvement of care. RESOLVED: That the Board received the patient story for information and assurance.

43. APOLOGIES & WELCOME

Apologies had been received from Mr P Rana, Non-Executive Director and Mrs L Writtle, Interim Director of Operations.

44. DECLARATIONS OF INTEREST

Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. Dr Murphy reminded the meeting that he had been appointed as a Non-Executive Director at Birmingham Community Healthcare NHS Foundation Trust start date to be determined. There were no other interests declared in addition to those already recorded on the Register of Interests.

45. MINUTES OF THE PREVIOUS MEETING

To approve the minutes of the meeting held on 4 May 2017 and 22 May 2017, subject to an amendment to the Board Resolution regarding the reference costs item.

Page 2 of 20

RESOLVED: That the minutes of the meeting held on 4 May and 22 May 2017 be approved and signed by the Chair, subject to the proposed amendments,

46. MATTERS ARISING/ACTION SCHEDULE 46.1

Minute 179.10 Contract Performance Report Mr Axcell confirmed that clustering had been discussed at length by the Finance & Performance Committee and was referred to in the Committee Chair’s report. A report on clustering would be submitted to the Finance & Performance Committee in July and to the Board in August through the Committee Chair’s Report. ACTION: Board to receive an update report on clustering in August 2017 through the Finance & Performance Committee Chair’s Report in August. All other items were either complete or had a future completion date. RESOLVED: That the matters arising and the assurance given where those actions have been completed be noted.

47. SUMMARY REPORT OF THE CONFIDENTIAL SESSION OF TRUST BOARD HELD ON 4th MAY 2017

Members noted the content of the confidential summary of the meeting held on 4th May 2017. RESOLVED: That the Board received the report for information.

48. CHIEF EXECUTIVE OFFICER’S OVERVIEW

In presenting his report, Mr Axcell provided an update on the following: Transforming Care Together (TCT) Mr Axcell confirmed that listening events had been held and the opportunities for staff to engage in the development of the TCT partnership had been highlighted. Feedback from the listening events across all three Trusts had been positive with clear enthusiasm for the clinical and quality benefits that working together could bring.

Page 3 of 20

Cyber Security – Mr Axcell referred to the international cyber-attack that had taken place on 12 May 2017 and had affected a number of organisations in the NHS. Whilst the Trust was not directly affected, external email and a number of systems had been disconnected immediately following the attacks as a precautionary measure. The Trust’s IT contractors worked around the clock following the attack to ensure systems were secure and normal services had been resumed by Monday afternoon on 15 May 2017. Both Mr Davies and Dr Gingell had written to them thanking them for their support. Mr Davies confirmed to the Chair that the Trust had applied the software updates to its systems as nationally prescribed required and assured the Board that the Trust had taken all the measures it could to minimise the disruption from such an attack. The attack and any lessons learnt would be discussed at the Information Governance Committee meeting and for additional assurance Audit Committee would also receive a report including assurance that there is a robust process in place with Terrafirma keeping the Trust’s IT department appraised of any issues. Action: Audit Committee to review the report on the cyber-attack to include assurance that there is a robust process in place with Terrafirma keeping the Trust’s IT department appraised of any issues. NHS e-Referral Service: Paper Switch-Off Programme – The e-RS Paper Switch-off Programme had been developed to support Trusts and CCGs to move to full use of e-RS for all consultant-led first outpatient appointments. The programme would help Trusts meet the conditions of the NHS Standard Contract. The programme will also help Trusts meet the requirements of the national CQUIN target for e-RS in 2017/18 and will be implemented across England in a phased way from now until October 2018. The regional e-RS programme team would be contacting the Trust and Dudley and Walsall CCGs over the coming weeks to undertake initial engagement activities, establish a baseline position for each Trust and agree timescales for taking part in the programme. Trust’s were being asked to undertake a readiness assessment for adopting the NHS e-Referral Service across all consultant led 1st outpatient appointments, and to allocate an Executive Director to be accountable to the Trust Board for delivery of full use of e-RS ahead of October 2018. Mr Davies confirmed that OASIS had the functionality to adopt the e-Referral Service. Ms Clymer queried the short timeframe for the transfer to the e-Referral service and Mr

Page 4 of 20

Davies confirmed that a project report would be received by the Board in July 2017. Action: e-Referral Service project report to be received by the Board in July 2017. Mr Lancaster queried whether the Trust was compliant with IR35 regulations and Mrs Williams advised that HMRC had strengthened their guidance on the implementation of the regulations which were being reviewed. An update was being received by the Workforce Committee in July and to the Board in August. Action: Provide an update report on IR35 regulations to the Board in August 2017. RESOLVED: That the Board noted the report for information and the actions contained therein.

QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

49. Trust Integrated performance Dashboard & Contract Performance (Month 1)

Mr Davies summarised the main points advising that the finance, performance and workforce reports included greater detail on the items referred to, although he highlighted that there had been one serious incident, that the Trust would not be paid for the over-activity in Walsall due to the block contract and that one post in seven was vacant across the Trust. The Chair queried the psychological hub waiting time breaches and Mr Davies advised that he would ask the Interim Director of Operations to investigate these and provide and update; Dr Murphy advised that the breaches would be reviewed by the Quality & Safety Committee.

Action: Provide an update on the reasons for the psychological hub waiting time breaches and Quality & Safety Committee to review.

RESOLVED:

That the Board noted the content of the report.

49.1 Quality & Safety Committee Chair’s Report

In presenting the report, Dr Murphy advised that the Committee had received reports as follows:

Deep Dive – Post CQC

The Committee received a comprehensive presentation

Page 5 of 20

which informed a review of the risks currently held on the Trust operational risk register which were identified as part of the February 2016 CQC inspection, and themes or risks identified as part of the November 2016 visit. In response to the Chair, Ms Musson advised that she was confident of a positive outcome should a further unannounced CQC visit occur and that improved mechanisms were in place to measure that good practice was embedded across the Trust.

He advised that the following risk had been downgraded:

• 313 (Fit and Proper Persons Requirements)

Other risks had been retained on the Risk Register or referred to the appropriate Committee for their opinion on downgrading or closure of the risks.

Risk 321 (number of outstanding policies) had been closed and newly identified potential risks and themes were noted and included in the report.

The Committee agreed that risk registers would be updated accordingly and recommended that the Board had sight of the presentation and received a summary of the discussions. The Committee received the following reports:

• Quality Report • Quality & Safety High Level Risks • Draft Quality Account • Project Management Office (PMO) Governance

Framework for the delivery of CIPs, QIPP and Partnership Projects

• Fire Safety Action Plan • Service Experience Quarter 4 Report • Annual Medicines Management Report- attached for

info

Referring to the Fire Safety Action Plan, the Chair sought assurance that appropriate procedures and processes were in place and that the Trust had the requisite number of Fire Marshalls. Mr Davies confirmed that he would continue to hold monthly Fire Safety meetings until he was satisfied that the processes were embedded across the Trust at which time the meetings would be held every three months. He advised that fire training was a desk top exercise and it may be necessary for staff on wards to have practical training. Mr Turner advised that whilst assurance had been given that reactive action had been taken, it was unclear what had led to the failure initially. For further assurance, Mr Davies suggested, and it was agreed, that a scoping exercise be undertaken to be reviewed by Audit Committee.

Action: Undertake a scoping exercise related to the fire issues to be reviewed by the Audit Committee and

Page 6 of 20

reported back to the Board via the Audit Committee Chair’s Report in October.

Mr Axcell concurred, adding that the fire and water issues had occurred despite investment in estates and external contractors. The Chair queried whether the Trust could utilise the expertise within partner organisations and Mr Axcell confirmed that he had already discussed the possibility of this and would take this further forward with his counterpart at Birmingham Community Healthcare and Black Country Partnership Trusts and members approved of this approach.

Action: Explore the possibility of utilising the expertise of partner organisations related to estates.

RESOLVED:

That the Board accepted the report for assurance about the exercise of delegated authority by the Quality and Safety Committee.

Mr Davies

49.2 Quality & Safety Committee Minutes from the meeting held on 12th April 2017.

The Chair of the Committee presented the minutes to the meeting for assurance

RESOLVED:

That the Board received the minutes for information and assurance.

49.3 Mental Health Act Scrutiny Committee Chair’s Report

Mrs Cooper advised that she had provided a verbal update at the Board meeting in May and the report was for information only. She confirmed that the Board had been supportive in principle to an increase in the payment made to ALM’s in line with payment made by other Trusts and this had now been implemented.

RESOLVED:

That the Board

• received the report for information and assurance • noted the implementation of the increase in the

payment to to ALMs

49.4 Mental Health Act Scrutiny Committee Minutes from the

Page 7 of 20

meeting on 16 February 2017.


RESOLVED:


49.5 Quality Report

Mrs Musson presented the Quality report for month 12 which detailed:

• A summary of incidents • Operational Service Line Reports • Safety Alert Broadcasts (SABs) • Safeguarding Performance Framework

Dr Murphy confirmed that the incidents had been reviewed by the Quality & Safety Committee, he confirmed that it was a small number of patients that had caused the increase in disruptive aggressive incidents and that changes to those patient’s care plan were being made to address their behaviour.

RESOLVED:

That the Board received the report for information and assurance.

49.6 Finance & Performance Committee Chair’s Report

In the absence of Mr Rana, Mr Lancaster presented his report and made reference to the key items discussed:

Performance The following had been noted:

• Activity overall was 6.1% above contract • KPIs – Under-performance against 4 of the agreed 27

KPI’s, namely achievement of adult inpatient length of stay within Dudley of less than 40 days (red), proportion of CRS patients seen within 6 weeks in Dudley (red), PT Hub patients seen within 18 weeks in Dudley (amber) and finally the number of patients receiving IAPT therapy (both localities – both amber)

PbR Update It was noted that the month 1 data was not yet available in full. A paper in relation to ‘cluster reviews’ was received and whether or not the Trust should continue to undertake this

Page 8 of 20

reporting/recording in light of the uncertainty of cluster reviews being used as a payment vehicle for mental health was discussed. The Committee determined that as cluster reviews for areas such as benchmarking and completion of annual Trust reference costs were still required, members agreed that the use of cluster reviews should continue. Finance Report & Income Report Mr Davies advised that the Committee had reviewed the financial position to the end of April 2017 which showed a £200k surplus which was £33k ahead of the plan to date. Agency spend had been discussed and the position year to date as of month 1 was reporting an underspend of £111k against the NHSI agency cap of £4.05m for the year. CIP Paper An overview of the 19 CIP schemes for the year identified that there were 7 specific schemes that were currently RAG rated as red. These schemes totalling £1.27m were being reviewed on a fortnightly basis by the Executive Team. Vacancy Reduction Plan Mr Davies advised that a review of vacancies and posts for recruitment had identified a recruitment pipeline of around 25 whole time equivalent staff and work had progressed outside of the workstream with vacancies as part of the annual budget setting process that could be used to support the ‘vacancy reduction’ CIPs for the year. Mr Turner queried the variance in vacancies reported in two of the reports and Ms Williams confirmed that the figures had been reviewed after they had been presented to the Workforce Committee and the Trust was recruiting to 83 whole time equivalent vacant posts. The Committee reviewed the Risk Register and the minutes from the Estates and Capital Planning Group meeting. RESOLVED: That the Board received the report for assurance and information and noted the content.

49.7 Finance & Performance Committee Minutes from the meeting held on 21st April 2017.


Page 9 of 20

RESOLVED:


49.8 Finance Report

Mr Davies presented the report and referring to the highlights he advised that:

• The Trust had delivered a month 1 surplus of £200,000 which represented a favourable variance of £33,000 against the planned surplus of £1.839m for the financial year.

• Pay expenditure was £81,000 in surplus against budget to date, and this was driven by vacancies across the Trust.

• Bank & Agency spend equated to £378,000 in month • Agency spend was currently ahead of plan by

£111,000 in relation to the overall £4.05m Agency target for the year.

• Non-Pay expenditure was £78,000k in deficit against budget to date and £58,000 of this was driven by over-spending by budget holders against their non-pay lines

• Overall Income was reflecting a favourable variance in the month of £30,000 although the Trust wide Contracted Activity position at month end was reflecting an under-performance of £30,000

• In order to meet the in year cost pressures the Trust had identified CIP schemes equating to £3.78m and all but four of the 19 schemes in total have been devolved down to service lines.

• The Capital Programme had been agreed at £3.8m for the year and of this £2.4m related to the replacement EPR system which included £1.0m carried over from last year’s Capital plan.

Mr Axcell advised that the spend on nursing agency had reduced in May and this was a continuing trend and due to the increased use of the staff bank staff and he commended Ms Williams and Ms Musson for their work in this area.

RESOLVED: That the Board received the report for assurance and noted the content.

49.9 Review of Contractual Delivery against Service Lines

Mr Lewis-Grundy advised that this item contained commercially sensitive information that if published could prejudice the activity of the Trust and the Chair therefore confirmed that the item would be taken in the private

Page 10 of 20

session.

RESOLVED: That the report be deferred for consideration at the Private meeting of the Board on 1 June 2017

49.10 CIP PMO Report

In presenting the report, Mr Davies advised that the current status of the Cost Improvement Programme 2017/18 was that there were 19 schemes identified for 2017/18 to meet the CIP Target of £3,780,000. Of these 19 schemes, four schemes had been approved, seven had had the quality impact assessments approved at MExT on 23 May 2017 and eight schemes were still in development.

Mr Axcell confirmed that Executive Directors were reviewing CIPs on a fortnightly basis and advised that the majority of schemes were transformational in nature and were not expected to come on stream until October. He advised that a review of vacancies was being undertaken given the £1.2m underspend and the Executive Team would have a list by individual cost centre and pay line and decisions taken about vacancies based on service delivery.

The Chair queried the level of confidence in the achievement of CIPs in part by October 2017 and full achievement of CIPs in March 2018. Mr Axcell confirmed that the CIPs would be achieved in part by October but that achievement of the transformational CIPs would be challenging during the second half of the financial year. Mr Davies provided assurance that the finance team had already identified alternative schemes of £200,000-£300,000 in the event of a shortfall.

RESOLVED: That the Board received the report for assurance and information and noted the content.

49.11 Workforce Committee Chair’s Report

In presenting the report Mr Turner referred to the key messages advising that:

- There were currently 155 FTE contracted vacancies across the Trust decreasing the vacancy rate slightly to 13.5% during Month 1 (2017/18).

- The 12 Month Turnover rate had increased 11.56%. - The rolling 12 month sickness rate had decreased in

Month 1 to 4.24% which was within the Trusts target and the sixth consecutive month of being so.

- Appraisal compliance had decreased to 85.5% and this was above Trust target of 85% being the third

Page 11 of 20

time this has been achieved in the last 12 months. There were 126 employees in the Trust that have not had an appraisal recorded in the last 12 months.

- Mandatory Training compliance decreased to 88.0% in Month 1 and this was just below the target of 90% agreed at MEXT for all mandatory training.

- IG compliance for Month 1 is 82.0% which was below the 95% target and the reason for this was compliance expiry of a significant number of staff on 31st March 2017. HT actions being taken service leads and execs getting results so two risks modified split out.

The Committee received updates on the Workforce Risk Register, WRES Standards/Recruitment Audit and Apprenticeship Levy. The Committee had received limited assurance related to Safe Staffing Levels and Board would receive a further report at its private meeting on 1 June 2017 for assurance. Mr Turner confirmed that the Committee was performing well and was having a positive impact on workforce related issues. RESOLVED: That the Board received the report for assurance and information and noted the content.

49.12 Workforce Committee Minutes from the meeting held on 25th April 2017.

RESOLVED:


49.13 Workforce Performance Report

Ms Williams presented the report and advised that the Workforce Committee Chair’s report had covered the pertinent points of the Workforce Performance Report.

RESOLVED: That the Board noted the updates on key current workforce agenda items

50. Medical Directors’ Report In presenting the Medical Directors report, Dr Weaver

referred to the “Working together to take revalidation forward ”initiative and advised that following Sir Keith Pearson’s review of medical revalidation in January, the

Page 12 of 20

GMC had received feedback from across the UK. The following priorities had been identified:

• Increasing oversight and support for locum doctors • Reducing burdens • Increasing the quality of appraisal • Improved information sharing when doctors move

designated bodies • Increasing public involvement in revalidation

Dr Weaver advised that the GMC Employment Liaison Service had conducted a survey asking Responsible Officers whether morale had declined within the profession with the following results:

• 82% felt the morale across the profession had declined and this appeared to be across all grades and roles.

• 3% of responsible officers disagreed that morale had decreased.

• 33% indicated that although morale had declined, it was not at the levels being widely reported in the media. Feedback also suggested that a decline in morale was less pronounced in the independent sector and in Scotland.

Solutions included holding meetings with doctors of all grades to discuss pressures arising from workloads, finances, recruitment, contracts and to consult on service reconfiguration. The appointment of a Guardian for Safer Working in Trusts had also had a positive impact on morale. Dr Weaver referred to the changes to the Section 75 arrangements in Walsall which were likely to have a significant impact on the clinical capacity in the community teams which were dependent on social care and health care staff. Additionally, Walsall Commissioners were looking for a significant reduction in medical outpatient activity which had been over performing the current commissioning arrangements. The impact of this and the mitigations were being reviewed in the outpatient project group. Dr Weaver confirmed that outpatient lists were being reviewed and that the Transformation Board had recommended fast tracking patients with mild to moderate conditions. He confirmed that there were financial implications of £250,000 for the Trust if a 30% reduction in activity could not be realised by October. Mr Axcell confirmed that the Executive Team were reviewing other models across the country to realise efficiencies within the Trust and contract negotiations would then be re-opened with Walsall CCG. Dr Weaver advised that MExT had approved the Transcranial Magnetic Stimulation Therapy (TMS) pilot

Page 13 of 20

project based in Walsall, although it would be open to referrals from across the Trust and also those funded externally. TMS was an innovative treatment now approved by NICE with a range of therapeutic indications in mental health and offered another treatment option to patients with a range of disorders but predominantly depressive spectrum disorders. The communications team was in the process of increasing awareness of the service in localities with General Practitioners and beyond the Trust.

Dr Weaver advised the Board that there would be a shortage of junior psychiatric trainees from the August rotation because of recruitment challenges. This had been included on the risk register and would be closely monitored and it may be necessary to review the on call arrangements if the shortfall was not addressed. Additionally sourcing suitable agency locum cover remained a challenge following the imposition of the agency cap nationally and other changes in locum short term employment arrangements. Mr Turner suggested, and it was agreed that a potential shortage of junior psychiatric trainees from the August rotation should be reviewed and the risk was such that it be red RAG rated on the Workforce Committee’s Risk Register.

Action: the potential shortage of junior psychiatric trainees from the August rotation should be reviewed and the risk was such that it be red RAG rated on the Workforce Committee’s Risk Register.

The Chair queried the timeframe for investigating the two deaths investigated as serious incidents and Ms Musson advised that they would be reviewed as part of the revised Serious Incident process with reports produced within 60 days and that any exceptions were reported to the Quality & Safety Committee. In response to Ms Clymer, Dr Gingell advised the Board that the Mortality Review Group was well embedded and would focus on embedding lessons learnt from mortality reviews. RESOLVED: That the Board received the report for assurance and information and noted the content.

51. Director of Nursing Report

In presenting her report, Mrs Musson referred to the Trust Support Visits that had taken place on the 4th and 15th May with Multi-disciplinary Teams from across the Trust attended each of the wards reviewing the care, environment, the leadership, safety and effectiveness of the wards. An action plan addressing any areas of concern would be developed and a detailed report is scheduled to be presented to the Trust CQC Steering Group in June, with a further update

Page 14 of 20

report to Quality and Safety Committee in July 2017 and Trust Board. The NMC were holding workshops in July with a focus on what professionalism looks like with work undertaken nationally scrutinising behaviours and environment. RESOLVED: That the Board received the report for assurance and information and noted the content.

52. Enhancing Quality through Safer Staffing Levels – Monthly Exception Report

Mrs Musson presented the report advising that across the inpatient areas the overall fill rates are 99.66%, with 98.78% for registered staff and 100.23% for care staff. This indicated that the Trust was meeting the optimum level of fill rates. Typically where the Trust’s care staff rates exceeded 100%, this was due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads were empowered to be responsive and flex staffing to meet patient acuity. Where staff had concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In April there were no incidents reported related to safer staffing in inpatient services. RESOLVED:

That the Board: • noted and discussed the monthly data return

submitted, providing details of planned and actual staffing at ward level.

• noted the work underway to enable the most efficient safe and effective use of nurse staffing in inpatient service, this will focus on all professional groups, including therapists

53. Director of Operations Report

In the absence of Mrs Writtle, Mr Axcell presented the report providing updates on the four service lines, highlighting that the Dudley Access/ Mental Health Assessment Service went live on the 1st May 2017, and offered a 24 hour access/assessment point for all working age adult referrals. The Trust in partnership with Black Country Partnership NHS Foundation Trust and Birmingham Community Healthcare

Page 15 of 20

NHS Foundation Trust had submitted a bid for NHSE Wave 2 CAMHS new care models for tertiary mental health services, and this had been supported by a range of providers and STP commissioning leads. Referring to community services, Mr Axcell advised that there was concern across Walsall relating to the proposed plans for disintegration of the existing Section 75 arrangements and especially how the case work of the integrated Social Work would be managed with allocation of Care Coordinators. Meetings at a senior level between the Trust and the Local Authority were happening urgently and the Director of Operations was undertaking a review of risks from a service delivery/impact perspective and once completed would be shared with MExT and Quality and Safety Committee Mr Axcell advised that work had commenced to review the issues around Delayed Transfers of Care (DToC) which identify action to be taken to ensure timely discharge of service users. He confirmed that in-patient demand was at a premium due to the refurbishment work at Bushey Fields Hospital. RESOLVED: That the Board received the report for assurance and information and noted the content.

54. Service Experience Desk Quarterly Report – Quarter 4

In presenting the report Mr Axcell advised that the Service Experience Desk received 281 new cases, 246 of which were attributable to service lines, the remainder were attributable to corporate functions, trust generic or non-specific and “poor communication” generated the highest number of complaints and a number of these complaints related to Dudley Talking Therapies which was being investigated. 16 out of 29 responses were breached (55%) and this was an increase of 14% compared to 41% of breaches in the third quarter. He stated that compliments continued to make up the largest feedback category with 96 received this quarter. He advised that the format and content of the report was being reviewed to ensure more concise reporting going forward. Dr Murphy advised that the Experts by Experience (EBEs) had highlighted to the Quality & Safety Committee that doctors were requesting leave at short notice and Mr Axcell confirmed that the process for applying for leave was under review. RESOLVED:

Page 16 of 20

That the Board received the report for assurance and information and noted the content.

55. STRATEGIC DEVELOPMENT & DIRECTION

55.1 Annual Plan Action Plan – Quarter 4 Update 2016/17

The Trust had submitted its Annual Plan to NHS Improvement in June 2016 and shared a summary version with staff and the wider public. Mr Axcell confirmed that at the end of each quarter progress against the priority activities defined in the plan were reviewed and as this was the closing quarter details of those priority activities that were completed or would be carried forward into 2017/18 plans were provided.

Of the 54 Priority Activities for 2016/17, 42 had been completed and 12 had been carried forward to 2017/18 financial year and form part of the Trust’s priorities.

RESOLVED:

That the Board received the report for assurance and information and noted the content.

55.2 High Level Operational Risk Register

Ms Musson introduced the report advising that the Quality & Safety Committee had downgraded risk reference 313 (Fit and Proper Persons Requirements) and risk reference 321 (number of outstanding policies) had been closed. The escalation process would be utilised in relation to mandatory and essential training. Ms Williams confirmed that mandatory and essential training would be split in future reports to provide more granular reporting.

RESOLVED: That the content of the High Level Operational Risk Register be reported

56. LEADERSHIP & CULTURE

56.1 Staff Engagement Quarterly Update Report

Michael Hirons staff engagement and freedom to speak up guardian joined the meeting. In presenting the report Mr Hirons advised that the staff results were very positive for the Trust with improvements

Page 17 of 20

realised in a number of areas and 80% of the 2016 responses are the same or better than the mental health sector average and the 52% response rate was higher than the sector average. Following a review of the Staff Survey results four areas were identified as priorities:

• Harassment, Bullying and Abuse • Staff Health and Well Being • Senior Management Communications • Appraisals

Referring to Staff Health and Wellbeing, Mr Hirons advised that the impact of the TCT partnership on staff wellbeing should not be underestimated

Whilst the completion of appraisals was an issue, the qualitative scores on appraisals was positive. There were Trust wide initiatives to encourage appraisal completion and Mr Hirons was working with individual service lines to support this. Mr Turner stated that the feedback from the CQC had been clear and individuals should have annual appraisals.

The Chair queried whether there were many concerns being raised by Staff and Mr Hirons confirmed that in his role as Freedom to Speak Up Guardian had had 12 contacts to date and these largely concerned HR issues rather than concerns about clinical care and all contacts would be captured in quarterly reporting. The Chair asked what the escalation process was in response to a whistleblowing incident. Mr Hirons outlined the process including raising the issue with the Chair, and the Senior Independent Director and ultimately through the National guardians office and/or the CQC and the Health & Safety Executive. This process accompanied the Trust’s raising Concerns and Freedom to Speak Up Policy and would be shared with Board members at the next meeting of Board.

Action: Include a copy of the Freedom To Speak Up and Raising Concerns Policy and associated flow diagram with the Freedom to Speak Up Guardian’s quarterly update Report to Board in July 2017.

Ms Clymer queried whether a different approach was being taken related to bullying and harassment and Mr Hirons confirmed that he had drilled down to service lines and had identified that cases of violence against staff were limited to certain areas and the focus would be on those areas and an action plan for Heads of Service and Line Managers would be formulated. Informative notices advocating zero

Page 18 of 20

tolerance of violence were posted throughout the Trust.

RESOLVED: That the Board received the report for information and assurance.

57. FOR ASSURANCE

57.1 MExT Chair’s report from 28th March 2017

Mr Axcell referred to the items discussed at MExT:

• Chief Executive’s Update • Service Line Review • Joint Medical Directors’ Report • Nursing Director’s Report • Operations Director’s Report • Director of People Report

- Including updates on the Staff Survey, Freedom to Speak Up and Equality & Diversity

• Director of Finance Report - Including CIP and Month 1 position updates

MExT received the following business cases/service proposals

• Outpatient/discharge headlines update • TMS Pilot Proposal which had been approved • Home Treatment Model • Smoking Free Business Case, upon which further

work would be undertaken • Professional Forum proposal

RESOLVED: That the Board noted the content of the report for information and assurance.

58. Questions from members of the public

The Chair invited Mr Parsons who was in attendance at the meeting to raise any questions with Board Members

Mr Parsons said that whilst he did not have any specific questions he would like to make an observation:

He agreed with Dr Weaver that the discharge of patients into primary care did often result in those patients being re-referred to the Trust and he hoped that a resolution could be found.

The Chair thanked Mr Parsons for attending, and his

Page 19 of 20

contribution to, the meeting.


There were no items of any other business.

60. DATE AND TIME OF NEXT MEETING

The next Trust Board meeting would take place at 11.00am on Wednesday 21st June, Conference Room 1, Trafalgar House (sign off of Quality Accounts). The next regular Trust Board meeting would take place at 1.00pm on Thursday, 6th July 2017 in The Board Room, Canalside, Bloxwich

Signature……………………………………………………….. Date……………. Mr B Reid, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board

Page 20 of 20

Enc 1 MINUTES OF THE TRUST BOARD MEETING OF


Held at 11.00am on Wednesday, 21st June 2017 Conference Room 1, Trafalgar House, King Street, Dudley

PUBLIC SESSION Present Mr B Reid Chair Mrs G Cooper Non-Executive Director Mr R Davies Interim Director of Finance, Performance and IM&T

(Deputy Chief Executive) Mr J Lancaster Non-Executive Director Ms R Musson Acting Director of Nursing Mr H Turner Associate Non-Executive Director In Attendance Mr P Lewis-Grundy Company Secretary Mrs L Wix Corporate Governance Support Officer (minutes) ITEM ACTION 61. APOLOGIES & WELCOME

Apologies had been received from Mr M Axcell, Chief Executive Officer, Ms O Clymer, Non-Executive Director, Dr S Murphy, Non-Executive Director, Mr P Rana, Non-Executive Director, Dr K Gingell, Joint Medical Director, Dr M Weaver, Joint Medical Director, Mrs A Williams, Acting Director of People and Mrs L Writtle, Interim Director of Operations


Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. There were no other interests declared in addition to those already recorded on the Register of Interests.

63 QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

63.1 2016/17 Quality Accounts

The Chair advised that the purpose of the meeting was to receive and adopt the Quality Accounts 2016/17. Ms Musson presented the 2016/17 Quality Accounts and confirmed that the Audit Committee had reviewed them and

Page 1 of 3

had made the recommendation that the Board formally adopt the quality account for publication.

The quality account had been compiled in line with national guidance and in consultation. Ms Musson confirmed to the meeting that the Quality Accounts had been through due process and reviewed by the CCGs, HOSC and Healthwatch and whilst stakeholders were not required to provide feedback the response had been very positive. The Quality & Safety Committee had also reviewed the Quality Account and they had been audited by the Trust’s external auditors.

The Audit Committee had met on 21 June 2017 and recommended that the Trust Board formally adopt the Quality Account 2016/17. The overarching positon was positive and reinforced by the CQC rating of “good” given to the Trust as a whole. Ms Musson confirmed that red RAG ratings included within the account were monitored with appropriate mitigations in place. Delivery of the Trust priorities and CQUINNs had been challenging, especially the Staff Health & Wellbeing priority related to the take up of the flu vaccination, and she anticipated that this would be the same in 2017/18.

Ms Musson stated that the CQUINNs for 2017/18 included “risky behaviours” and evidencing that service users were provided with advice on alcohol and smoking. She confirmed that smoking cessation formed part of the Trust priorities for 2017/18 coming into effect in December 2018. Mr Davies advised that there were concerns associated with the management and delivery of CQUINNs and the Chair commented that a different approach may be needed with individuals responsible for delivery being identified. Mr Davies confirmed that he was responsible for the financial aspect with operational issues being monitored by Ms Musson and Mrs Writtle. Ms Musson was concerned that a potential risk to delivery was organisational capacity given the competing demands on staff. Mr Lancaster Chair of the Audit Committee advised that the external auditors had tested two KPIs:

• Enhancing the Quality of Life for People with Long Term Conditions:

• Preventing People from Dying Prematurely The auditors had not identified any issues and had provided positive feedback related to both data quality and the staff input. The quality improvement priorities had been cross referenced with feedback from the comments made by the CQC following the unannounced visits and reflected issues that had been raised regarding patient records. In response to the Chair’s question Ms Musson confirmed to

Page 2 of 3

the Board that the CQC action plan would include actions that would drive forward the Trust’s aspiration to be rated as “outstanding”.

The Chair commended this, however referring to the CQC’s inspection report of the Trust in 2016 reflected on the level of assurance given in Board papers which didn’t necessarily reflect the regulators view of the organisation. The ensuing discussion focused on the role of the Board Committee’s in scrutinising data and how exception reporting to the Board could improve the level of assurance given to the Board that it was performing at the level required to be rated an outstanding Trust. Executive Directors agreed to review existing reporting to develop more exception reporting and strengthen Board assurance through the Integrated Performance Report.

RESOLVED:

That the Board adopted the Quality Account 2016/17 for publication.


There were no items of any other business.

65. DATE AND TIME OF NEXT MEETING

The next Trust Board meeting would take place at 1.00pm on Thursday, 6th July 2017 in The Board Room, Canalside, Bloxwich

The meeting closed at 11.27am Signature……………………………………………………….. Date……………. Mr B Reid, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board

Page 3 of 3

Enc 2 MATTERS ARISING FROM PUBLIC MEETINGS

RAG Action Outstanding Completion date in the future Action Completed

Item No.

Date Added Action Responsibility Due Date Update

49.1 1 June 2017

Quality & Safety Committee Chair’s Report Explore the possibility of utilising the expertise of partner organisations related to estates.

Mr Axcell August

2017

Discussions taken forward as part of potential early implementation of TCT. Further update at August Board

49 1 June 2017

Trust Integrated Dashboard Provide an update on the reasons for the psychological hub waiting time breaches and Quality & Safety Committee to review.

Mrs Writtle

August 2017

179.10 & 46.1

5 January 2017, 2 March 2017 & 1 June 2017

Contract Performance Report Board to receive an update report on clustering in August 2017 via the Finance & Performance Committee Chair’s Report.

Dr Weaver/Dr Gingell August

2017

24.1 4 May 2017

Quality & Safety Committee Chair’s Report Approach Engagement Champions for input on potential improvements to the

Mr Lewis-Grundy

September 2017

Engagement Champions meeting on 5 July. An outline of the onBoard Walks will be given to the meeting for them to feedback on how a framework around the onBoard Walks might look to write into

1

Item No.


Board Walkabout process for capturing actions taken.

a proposal for Board members to consider.

48 1 June 2017

Chief Executive’s Overview Report Provide an update report on IR35 regulations to the Board in August 2017. Audit Committee to review the report on the cyber-attack in September to include assurance that there is a robust process in place with Terrafirma keeping the Trust’s IT department appraised of any issues.

Mr Davies Mr Davies

August 2017 October 2017

Quality & Safety Committee Chair’s Report Undertake a scoping exercise related to the fire issues to be reviewed by the Audit Committee with a report back to Board via the Audit Committee Chair’s Report

Mr Davies

October 2017

48 1 June 2017

Chief Executive’s Overview Report e-Referral Service project report to be received by the Board in July 2017.

Mr Davies

July 2017

The Trust has made formal contact with the Head of Digital Technology Midlands & East. It has been confirmed that letter of 15.5.17 from Dale Bywater and Paul Watson does not relate to Mental Health Trust. Completed. Closed.

2

Item No.


56.1 1 June 2017

Staff Engagement Quarterly Report Include a copy of the Freedom To Speak Up and Raising Concerns Policy and associated flow diagram with the Freedom to Speak Up Guardian’s quarterly update Report to Board in July 2017.

Ms Williams

July 2017

Appended to the Chief Executive’s Report. Completed. Closed.

3

Board meeting date: 6 July 2017

Agenda Item number: 6 Enclosure: 3

Report Title:

Summary Report of Confidential Session of Trust Board held on 1 June 2017 and 19 June 2017

Accountable Director:

Ben Reid, Chair

Author (name & title):

Paul Lewis-Grundy, Company Secretary

Purpose of the report: Best practice in corporate governance requires that business considered in private session is reported into the public session as soon as possible. Given the arrangement of the Board meetings, the earliest opportunity is at the public session of the following month. This report outlines the business considered in private at the meeting of the Board held on 1 June 2017 and 19 June 2017

Action required from the Board Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report?

Committee: None

Date reviewed: N/A

Key points or recommendations from Committee:

N/A

Strategic Objective(s) to which this paper relates:

High quality services

Inclusive partnerships

Leadership culture

Responsible workforce

Supporting strategies

Effective/efficient resources

The CQC domains that this report relates to are:

Please give brief details:

Caring

Best practice in corporate governance requires that business considered in private session is reported into the public session. Responsive

Effective Well-led Safe Enc 3 confidential session 1.6.17 (Final) Page 1 of 2

Title Summary Report of Confidential Session of Trust Board

held on 1 June 2017 and 19 June 2017 Introduction This report outlines the business considered at the meeting of the Board held in private on 1 June 2017 and 19 June 2017 Summary of key points, issues and risks On 1 June 2017 the Board received the following reports: • Chief Executive’s Update Report including an update on the governance of the Black

Country STP • Transforming Care Together (TCT) Integration Progress Report, Full Business Case the

TCT Risk Register • Update on the Electronic Patient Record Procurement Exercise • Service Development & Growth Progress Report • Director of Nursing Report • Water Management Report • Review of Contractual Delivery against Service Lines • Ratified minutes of the MExT meeting held on 18 April 2017 On 19 June 2017 the Board received, debated and approved the Transforming Care Together Full Business Case.

Recommendation

The Board is invited to note the business transacted in the private session held on 1 June 2017 and 19 June 2017.

Board action required The Board is asked to receive this report for information.

Enc 3 confidential session 1.6.17 (Final) Page 2 of 2


Agenda Item number: 7 Enclosure: 4

Report Title: Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)

Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary Purpose of the report: This report summarises recent reports, publications and

information, which are of relevance or interest to the Trust. It sets out the key points of each item and identifies the officer accountable for any action required and appraising the Board where appropriate.

Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: None

Date reviewed: N/A Key points or recommendations from Committee:

N/A




Leadership culture

Accountable workforce





Caring The report provides information regarding latest news and relevant strategic developments that may impact all 5 CREWS domains. Responsive

Effective

Well-led

Safe

Enc 4 CEOStrategicBrief-July2017-(Final) Page 1 of 10

Title: Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)

Introduction This report provides a summary of internal news from the Chief Executive and recently announced legislation, publications and information that is of interest and relevance to the Board. It identifies the Trust officer accountable for any action the Trust may be required to take and for appraising the Board where appropriate.

Summary of key points, issues and risks CHIEF EXECUTIVE UPDATE Transforming Care Together – The Trust’s Board have approved the Full Business Case for the 3 organisations coming together. Discussions have now started with NHS Improvement. The process for naming the organisation is underway. Both the Chief Executives from Dudley and Walsall Mental Health Partnership NHS Trust and Birmingham Community Healthcare NHS Foundation Trust and Black Country Partnership NHS Foundation Trust will continue the listening events across the 3 organisation during July and events to shape the visions and values will be held. Action: To note for assurance. MERIT and Dudley CCG Vanguard – The tender process for the Dudley MCP has now recommenced. The MERIT Vanguard continues to make excellent progress with a clear plan for a number of innovative developments to improve services for our service users. Action: To note for assurance. Walsall CCG Healthy Walsall Partnership Board – The Walsall Provider Board continues to make excellent progress in working together to develop the Walsall Model of Care. A borough wide event was held last week with representation from all provider organisations across the borough to start clinical discussions on the model Action: To note for assurance. Freedom to Speak Up – Quarterly Update There is a quarterly update at the end of this report detailing activity of the Trust’s Freedom to Speak up Guardian in the past three months and a copy of the Trust’s Freedom to Speak Up and Whistleblowing Policy together with the accompanying Escalation Flow diagram is appended for Boards assurance. Action: To receive the report for assurance. Enc 4 CEOStrategicBrief-July2017-(Final) Page 2 of 10

NATIONAL POLICIES & STRATEGIES The following national strategies and policies have recently been issued. They are potentially relevant to the future strategic, planning and operational management of the Trust and the implications should be taken into account. Each document has been considered with the respective executive directors. This summary is not intended to incorporate all national publications, for instance those issued by National Patient Safety Agency, National Institute for Clinical Excellence or every operational directive issued by Department of Health which should be considered within the Trust by the appropriate department and necessary action taken. 1. Excellence by Design: Standards for Postgraduate Curricula

Published by: General Medical Council Date Published: 22 May 2017

The GMC’s vision for postgraduate training is one that supports the aspirations and commitment of today’s medical professionals to help them meet the needs of patients and the services they receive. Excellence by design: standards for postgraduate curricula replace the previous standards for curricula and assessment systems. The new standards provide a framework for the approval and provision of postgraduate medical education and training in the UK, supporting greater flexibility in postgraduate training, giving doctors more freedom and choice as their interests in medicine develop, while at the same time meeting the changing patterns in the health needs of patients, ensuring they receive high quality care. The GMC’s new standards also aim to shift the focus of postgraduate training towards helping doctors achieve high-level learning outcomes. Colleges and faculties will now be required to update their 103-existing postgraduate medical curricula against the GMC’s new standards – with the process set to be completed by 2020. Action: For contents to be duly noted and medical education leads, Clinical Tutor and College Tutors to work with the School of Psychiatry; Foundation Schools and GP training schools to ensure the Trust is able to meet the new standards. Web-link http://www.gmc-uk.org/Excellence_by_design___standards_for_postgraduate_curricula_0517.pdf_70436125.pdf Executive Director: Joint Medical Directors Board Committee: Workforce Committee 2. Education consultation

Published by: Nursing and Midwifery Council (NMC) Date Published: 13 June 2017

This consultation seeks views on a review of the standards that UK trained nurses will need to meet before they can work as a registered nurse. It also sets out proposals for a new education framework for nursing and midwifery education. The proposed framework details a range of new outcome focused standards for education institutions and practice placement partners. The NMC are also consulting on changes to our prescribing standards that would enable nurses and midwives to be able to prescribe much earlier in their careers than they can at the moment. The closing date for responses is 12 September 2017.


http://www.gmc-uk.org/Excellence_by_design___standards_for_postgraduate_curricula_0517.pdf_70436125.pdf

http://www.gmc-uk.org/Excellence_by_design___standards_for_postgraduate_curricula_0517.pdf_70436125.pdf

Action: To assess impact of proposed changes and participate in consultation. To provide briefing to Trust Board on impact. Web-link https://www.nmc.org.uk/education/education-consultation/?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8373041_NEWSL_HMP%202017-06-13&dm_i=21A8,4ZGOH,M5T16P,J0KMH,1 Executive Director: Acting Director of Nursing Board Committee: Quality & Safety Committee 3. Long Stay Rehabilitation Services

Published by: Centre for Mental Health Date Published: June 2017

This briefing reviews evidence from Care Quality Commission inspection reports of inpatient rehabilitation services in England. It finds that while many people receive high quality care close to home from rehabilitation services, a minority spend periods of many months and sometimes years in hospital. Some are placed far from home in locked wards and become isolated from their families and dislocated from their local health and care services. It calls on the government and the NHS to provide clear direction for the development and improvement of local community and hospital services for people with complex mental health needs. It also calls on NHS providers and CCGs to ensure they offer local services to people requiring rehabilitation support and that they maintain contact with people admitted to hospitals out of their local area. Action: To utilise the content of the report in discussions with commissioners regarding rehabilitation services in both the localities of the Trust. Web-link https://www.centreformentalhealth.org.uk/Handlers/Download.ashx?IDMF=0a7ee3d2-11d0-4293-b90e-09c3e78c8f3d&utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8397186_NEWSL_HMP%202017-06-20&dm_i=21A8,4ZZB6,M5T16P,J2G27,1 Executive Director: Joint Medical Director Board Committee: Quality & Safety Committee 4. CQC Consultation on next phase of regulation

Published by: CQC Date Published: 12 June 2017

The Care Quality Commission (CQC) is consulting on a further set of proposals to shape the next phase of regulation for health and social care across the country. The proposals include: • Changes to the regulation of primary medical services and adult social care services, including the

frequency and intensity of its inspections and how CQC monitors providers and gathers its intelligence

• Improvements to the structure of registration and CQC’s definition of ‘registered providers’. • How CQC will monitor, inspect and rate new models of care and large or complex providers. • Updated approach to the ‘fit and proper persons’ requirement.

The consultation closes on Tuesday 8 August 2017. The CQC has also published its responses to its first consultation on the next phase of regulation, Trusts who responded wanted to see further details about how and when the new regime would be implemented, as well as assurances that the approach would be flexible enough to respond to changes


https://www.nmc.org.uk/education/education-consultation/?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8373041_NEWSL_HMP%202017-06-13&dm_i=21A8,4ZGOH,M5T16P,J0KMH,1



https://www.centreformentalhealth.org.uk/Handlers/Download.ashx?IDMF=0a7ee3d2-11d0-4293-b90e-09c3e78c8f3d&utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8397186_NEWSL_HMP%202017-06-20&dm_i=21A8,4ZZB6,M5T16P,J2G27,1



in the health and social care landscape. Respondents were optimistic the proposals put forward for the new phase will result in a reduction of administrative burden. The CQC has said the changes will mean it works closer with its national partners to share information appropriately and avoid overlap where possible. The CQC will hold a third consultation, focusing on how it will regulate and rate independent healthcare services, as well as a further joint consultation with NHSI on how the ratings for its ‘use of resources’ assessments could be combined with CQC’s ratings of NHS trusts in the autumn. Action: To participate in further consultations and to review proposals and assess impact on Trust and present to Quality and safety Committee. Further detail is included in the Acting Director of Nursing Update Report separately on the Agenda. Web-link http://www.cqc.org.uk/get-involved/consultations/our-next-phase-regulation-consultation-2 Executive Director: Acting Director of Nursing Board Committee: Quality & Safety Committee 5. Well Led framework: new guidance for developmental reviews of leadership and governance

Published by: NHS Improvement Date Published: June 2017

Following the recent joint consultation with the Care Quality Commission (CQC), this guidance from NHS Improvement replaces the previous well-led framework for governance reviews, and applies to both NHS trusts and foundation trusts.

NHS Improvement has maintained the ‘comply or explain’ basis but have increased flexibility around timescales to account for individual trust circumstances. Trusts are strongly encouraged to use the new framework to undertake developmental reviews as part of their own continuous improvement. Action: To prepare briefing for the Trust Board, including exploration of option for Board to utilise self-assessment. Web-link https://improvement.nhs.uk/uploads/documents/Well-led_guidance_June_2017.pdf Executive Director: Acting Director of Nursing Board Committee: Quality & Safety Committee 6. Acting without delay – how the independent sector is working with the NHS to reduce delayed

discharge Published by: NHS Confederation Date Published: June 2017

This report from the NHS Partners Network highlights examples where the independent sector is working with the NHS to avoid delayed discharges of care. Action: To note the report and use in the Trust’s work to reduce the Delayed Transfer of Care Web-link http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/NHSPN%20helping%20the%20NHS%20reduce%20delayed%20discharge.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8384155_NEWSL_HMP%202017-06-16&dm_i=21A8,4ZP97,M5T16P,J129E,1 Executive Director: Interim Director of Operations Board Committee: Quality & Safety Committee


http://www.cqc.org.uk/get-involved/consultations/our-next-phase-regulation-consultation-2

https://improvement.nhs.uk/uploads/documents/Well-led_guidance_June_2017.pdf

http://www.nhsconfed.org/%7E/media/Confederation/Files/Publications/Documents/NHSPN%20helping%20the%20NHS%20reduce%20delayed%20discharge.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8384155_NEWSL_HMP%202017-06-16&dm_i=21A8,4ZP97,M5T16P,J129E,1



7. Department of Health Group Accounting Manual 2017 to 2018

Published by: Department of Health Date Published: 23 June 2017

The Department of Health group accounting manual (GAM) includes mandatory accounting guidance for DH group bodies (including clinical commissioning groups, NHS trusts, NHS foundation trusts and arm’s length bodies) completing statutory annual reports and accounts for 2017 to 2018. Action: This will be reviewed and applied by the Financial Accounting team as part of the preparation for undertaking 2017/18 accounts Web-link https://www.gov.uk/government/publications/department-of-health-group-accounting-manual-2017-to-2018 Executive Director: Director of Finance, Performance and IM&T Board Committee: Audit Committee 8. National Guardian’s Office Case Review

Published by: National Guardians Office Date Published: 12 June 2017

The National Guardian’s Office are initially conducting a 12 month pilot of the case review process, after which they will assess and refine the process, taking into account the feedback received from case referrers and others. Case reviews will identify areas where the handling of NHS workers’ concerns does not meet the standards of accepted good practice in supporting speaking up and recommendations will be made to NHS organisations to take appropriate action where they have failed to follow good practice. Case reviews will also commend areas of good practice. Reviews won't change the outcome for individuals, but they will help to ensure learning and create a culture where everyone feels able to speak up. Completed reviews will be reported on and published in the case review section of the National Guardian's Office (NGO) website. Action: To be incorporated as part of Freedom to Speak up Role Web-link http://www.cqc.org.uk/national-guardians-office/content/case-reviews Executive Director: Chief Executive Board Committee: Board 9. Sustainability and transformation plans: how serious are the proposals? A Critical Review

Published by: London South Bank University, School of Health and Social Science Date Published: May 2017

This report argues that in order to deliver a better future for the NHS, all 44 STPs would need to be given legislative powers and support necessary to achieve effective collaboration, plus some much-needed clarification on their role. It also recommends that STP leaders need to plan ahead based on the reality of their current situation, identify changes that are evidence-based, develop workforce plans that match their ambitions, and focus on reducing demand before removing resources from the acute sector. Alongside the main report, 44 sub-reports are available, each critically reviewing the plans for each STP locality. Action: To be considered at the STP steering group. Web-link https://improvement.nhs.uk/uploads/documents/Well-led_guidance_June_2017.pdf


https://www.gov.uk/government/publications/department-of-health-group-accounting-manual-2017-to-2018

http://www.cqc.org.uk/national-guardians-office/content/case-reviews

https://improvement.nhs.uk/uploads/documents/Well-led_guidance_June_2017.pdf

Executive Director: Chief Executive Board Committee: Board 10. CCG lay members, non-executive directors and STP governance and engagement

Published by: NHS Clinical Commissioners Date Published: 13 June 2017

This report, published in partnership with NHS England, summarises the discussions at four regional workshops which focused on the role of lay members and non-executive directors in STPs. It discusses the importance of governance and accountability and developing working relationships across STP footprints. It also captures a number of case studies highlighting where there has been good practice in involving lay members and non-executive directors across STPs. Action: To be considers as part of STP Memorandum of Understanding Web-link https://445oon4dhpii7gjvs2jih81q-wpengine.netdna-ssl.com/wp-content/uploads/2017/06/Report-from-network-events-organised-by-NHS-England-and-NHS-Clinical-Commissioners-in-February-2017.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8373041_NEWSL_HMP%202017-06-13&dm_i=21A8,4ZGOH,M5T16P,J0K9N,1 Executive Director: Chief Executive Board Committee: Board 11. Working through intermediaries: NHS employees on substantive contracts – Update to

guidance on IR35, agency and locum rules starting on 1 April 2017 Published by: NHS Improvement Date Published: 30 May 2017

NHS Improvement had revised its previous position on the HM Revenue and Custom’s intermediaries’ legislation known as IR35 and in particular the application of these rules such that providers must assess whether IR35 rules apply on a case by case basis, rather than take a blanket approach. Action: HR and Finance are working jointly to ensure continuing adherence to HMRC and NHSI guidance Web-link https://improvement.nhs.uk/uploads/documents/IR35_Update_30May1.pdf Executive Director: Acting Director of People Board Committee: Workforce Committee Recommendation It is recommended that the Board: • Considers and discuss the information contained within this report, and note for assurance the

actions identified throughout the report. • Receive the quarterly report on the Freedom to Speak Up

Board action required The Board is asked to:

• Note the information and actions contained within the report. • Identify any further specific action required and agreed timeframe for completion.


https://445oon4dhpii7gjvs2jih81q-wpengine.netdna-ssl.com/wp-content/uploads/2017/06/Report-from-network-events-organised-by-NHS-England-and-NHS-Clinical-Commissioners-in-February-2017.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8373041_NEWSL_HMP%202017-06-13&dm_i=21A8,4ZGOH,M5T16P,J0K9N,1




https://improvement.nhs.uk/uploads/documents/IR35_Update_30May1.pdf

Freedom To Speak Up Quarterly Report – July 2017. Contents: 1. Freedom To Speak Up – Concept & Purpose of the Role 2. Freedom To Speak Up – Progress & practice at DWMH 3. Freedom To Speak Up – Raised Concerns Analysis 1. Freedom To Speak Up – Concept & Purpose of the Role

• The F2SUG (Freedom To Speak Up Guardian) role is a statutory requirement, supported by the National Guardians’ Office (NGO) as recommended in The Francis Report following events at Mid Staffs.

• The role is intended to create, support & maintain a culture where staff can raise patient safety / potential whistleblowing concerns through complementing and supporting existing channels or directly via the local F2SUG.

• The FTSUG will act independently to facilitate raising concerns internally through liaising with relevant teams, departments, managers & individuals, typically reporting directly to the CEO

• They retain the option of raising concerns externally to the CQC, National Guardians’ Office, professional bodies, police etc. and becoming the whistleblower themselves in the event that this were to become necessary.

• To be seen to maintain their independence and impartiality they do not personally investigate raised concerns

• Concerns are raised in confidence except where there is a legal or moral imperative overriding that commitment – ordinarily they would work with those raising the concern to agree a course of action that is appropriate and proportionate. This is a deliberate approach to mitigate the fear some staff have that any issue raised will immediately be formally acted upon and taken out of their hands and escalated, which often acts as a bar on them seeking guidance or raising the concern at the earliest opportunity.

• In practice F2SUGs are frequently contacted with concerns that do not meet the criteria for whistleblowing or patient safety in the strictest sense. These are usually essentially standalone grievance, HBA, behavioural & process concerns and issues or concerns that incorporate both patient safety and what might be regarded as wider cultural, managerial, structural and staff engagement issues.

• This was anticipated and is still seen as a positive in that staff who would otherwise not raise these issues are now at least seeking support – in these instances the F2SUG offers guidance, sign-posing and offer pastoral support to staff and work with other teams, HR, senior managers etc. to find a solution – the concerns are still logged and tracked and feedback given where appropriate / possible.

• The combining of the F2SU role with that of Engagement Lead has proved fortuitous given the proportion of concerns that have been raised which are primarily staff engagement rather than patient safety related, notwithstanding the overlap between the two.

• Concerns raised are to be logged for reporting purposes, for use internally and as and when required by the National Guardians’ Office and CQC.

• Interviews with F2SU Guardians and reviews of raised concerns are now also formally part of the CQC Inspection process.

• The F2SU role is still new, only recently has at least one been appointed to all NHS Trusts, as such it remains an evolving role.


2. Freedom To Speak Up – Progress & Practice at DWMH

• F2SUG works with Service Lines, senior and team managers, HR, Staff Side, HR and others, utilising all communication means to increase the profile of the F2SU role as well as facilitate the creation of a positive culture of raising concerns within the organisation through the provision of a confidential advice and support service to staff in relation to concerns they have about patient safety and potential whistleblowing issues and/or the way their concern has been/is being handled where already raised through existing channels, or other issues for which they are seeking guidance and support.

• FTSU Guardian reports directly to the CEO monthly with the option to escalate concerns as appropriate and necessary at any time; as a safeguard and for assurance the F2SUG retains the option of escalating to the relevant NED and/or Trust Chair internally and externally to CQC, NGO etc. A copy of the Trust’s policy and process flow charts are appended to the report.

• For the nature and severity of the concerns raised so far it has been appropriate and sufficient to liaise with senior managers/ Heads of Service / HR & Staff Side – this is preferable where appropriate as it facilitates the most local resolution of a concern, working with staff and managers via existing mechanisms to promptly and satisfactorily resolve the issue at the earliest opportunity.

• Concerns can be raised directly to the F2SUG in person, by telephone, email or via a dedicated email accessed via the intranet [email protected] .

• Where concerns raised via HR, Staff Side, Patient Safety, in writing, the Speak Up email etc. and it also relates to patient safety/whistleblowing issues the F2SUG is advised for reporting purposes and involved as appropriate.

• The F2SUG attends the Embedding Lesson & Triangulation meetings – designed to triangulate data with other teams (SED / Patient Safety) to spot trends, highlight hotspots and pre-empt issues and concerns and ensure lessons are learnt, actioned and feedback provided.

• F2SUG has attended National Conference and West Midlands Regional Guardian’s meetings, which are particularly important in a role that is still new & evolving.

• Staff engagement is crucial to the prompt reporting of concerns, engaged staff care about what they do, where they work, recognise their impact and are motivated to do the best they can at all times, as such they are more likely to raise a concern promptly and appropriately, being motivated by improving outcomes and patient safety. Periods of change and transition, as now, typically bring greater uncertainty about roles, jobs and responsibilities with potential consequences for patient experiences and outcomes. As such combining the F2SU role with Engagement is an astute move and they neatly complement one another.

3. Freedom To Speak Up – Raised Concerns analysis:

o 12 concerns raised between March and June o 9 have been closed o 3 are ongoing o None have met actual whistleblowing criteria and none have had an immediate direct impact

on patient safety, although they may tangentially via impacting on staff engagement for instance.


mailto:[email protected]

o 1 concern was related to Staffing Levels o 1 concern was related to Quality & Safety o 1 concern was related to Patient Experience o 9 concerns were related to Attitudes & Behaviours o 7 concerns were raised anonymously via the patient Safety route and logged & tracked by

F2SU o 4 concerns were raised directly to the F2SUG o 1 concern was raised to the F2SUG via an intermediary’s introduction

It remains a moot point whether the absence of genuine whistleblowing concerns indicates that there are none to report or that staff are as yet still unwilling to raise them. What we can say is that the ongoing publicity around the role and its involvement in what are primarily behavioural concerns is:

o Highlighting the fact that there are staff who are unwilling to access existing channels for raising concerns but who now have a means of having them addressed.

o Will continue to raise the profile of the role and make it more likely that staff would utilise this route in the event of an actual whistleblowing concern.

o Is a shared experience with other F2SUGs across NHS England – most Guardians are finding that the vast majority of concerns raised to them technically fall under the broad heading of ‘grievance’ issues.

This ancillary function was anticipated at the role’s inception and has proven to be the case, but perhaps more so than expected. However, it still speaks to the fact that staff have issues and concerns that they have previously not been raising but are now. There are as yet few nationwide F2SU results, and the NGO is currently discussing the value of sharing nationwide findings in case they become a proxy benchmark or target, which it is felt would be counterproductive. However, the most recent self-reporting on concerns raised shows that this year 2850 issues have been reported – of which 737 were related directly to patient safety, around 28.5%.


1

Lead Author(s)

Ashi Williams Associate Director of People and Workforce Development

Change History – Version Control

Version Date Comments

4.0 Oct 2012 Provisionally approved by Staff Partnership Forum but agreed to wait until Francis Report available before final approval

4.1 Feb 2013 Addition of Trust responsibilities to Roles & Responsibilities section following recommendations by Francis Report

4.2 (Draft) Additional information added in respect to the “Speak Up” form on the Trust intranet. Ratified 31/03/2016

4.3 03/11/2016 Local Policy reviewed in light of National NHS Improvement Policy to be complied with by all NHS Trusts

Link with National Standards

National Health Service Litigation Authority

Care Quality Commission

National Institute of Clinical Excellence (NICE) Guidance

National Patient Safety Agency

West Midlands Quality Review

Essence of Care

Aims Standards

Key Dates Day Month Year

Ratification Date 03 11 2016

Review Date 03 11 2019

Document Title

Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure

Document Description

Document Type Human Resources

Service Application Trust Wide

Version 4.3

Policy Reference No. POL 182

2

Executive Summary Sheet

Document Title: Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure

Please tick () as appropriate

This is a new document within the Trust

This is a revised document within the Trust

What is the purpose of this document?

To support employees to have the freedom to speak up and raise a concern about risk, malpractice or wrongdoing which is harming the service we deliver.

What key issues does this document explore?

Provides an overview of raising a concern, freedom to speak up and “whistleblowing”, where to seek advice and how to make a protected disclosure under the Public Interest Disclosure Act 1998.

Who is this document aimed at?

All employees and workers at the Trust including temporary agency workers and volunteers. Employees, workers, and / or contractors who this policy applies to will be expected to uphold the Values of the Trust and exhibit the expected Trust behaviours aligned to the Trust’s values. Individuals have a responsibility to ensure that they display Trust values and behaviours in applying this policy and that individual’s feel able to challenge (or raise a challenge) when other colleagues’ behaviours breach the spirit of Trust value.

What other policies, guidance and directives should this document be read in conjunction with?

Disciplinary Procedure

Grievance Policy

Bullying and Harassment Policy

National Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure

How and when will this document be reviewed?

Annually or as and when legislation changes

Board Promise

We, the Trust Board, promise to value and support our staff and to be excellent role models of the values designed by them. We will not tolerate bullying, will take action when this occurs and will encourage and support staff speaking out through a culture where it is safe to challenge. This will ensure that staff are empowered to deliver the best possible care to our service users. We will evidence this through staff and patient/service user surveys, listening and acting on staff feedback and living and reviewing our trust values with all our staff.”

3

Document Index Pg. No

1.0 Introduction 4

2.0 Speak up we will listen 4

3.0 This Policy 4

4.0 What concerns can I raise? 5

5.0 Feel safe to rasie your concern 6

6.0 Confidentiality 6

7.0 Who can raise concerns? 6

8.0 Who should I raise my concern with? 6

9.0 Roles and Responsibilities 7

10.0 Advice and Support 9

11.0 How should I raise my concern 10

12.0 What will we do? 11

13.0 Investigation 11

14.0 Communicating with you 11

15.0 How will we learn from your concern? 11

16.0 Board Oversight 12

17.0 Review 12

18.0 Raising your concern with an outside body 12

19.0 The Legal Framework: The Public Interest Disclosure Act 1998 13

20.0 National Guardian Freedom to Speak Up 14

Appendix 1 Stages for Raising Concerns 15

Step One: Raising an Informal Concern 15

Step Two: Making an Internal Formal Concern 16

Step Three: Making a Regulatory External Disclosure 17

Step Four: Making a Wider External Disclosure 18

Annexes

Annex A: Local Escalation Process

Annex B: A vision for raising concerns in the NHS

4

1.0 INTRODUCTION Dudley and Walsall Mental Health Partnership NHS Trust (“The Trust”) is committed to creating a culture of openness and accountability and encourages employees to raise genuine concerns about malpractice, serious risk or wrongdoing as early as possible to mitigate against any potential damage to service users, staff, the wider public and the organisation. All employees, not just medical and clinical staff, are encouraged to raise concerns as soon as they arise. This purpose of this policy is to ensure that where employees have genuine concerns about risk, malpractice or wrongdoing may raise those concerns via a number of avenues within the Trust, without fear of reprisals. The policy also seeks to balance the need to provide safeguards for employees who raise genuine concerns about risk, malpractice or wrongdoing against the need to protect others and the Trust against malicious and vexatious allegations. A whistleblowing concern generally regards a risk, wrong doing or malpractice that affects service users, the wider public or other staff. Where the complaint is of a personal nature, as opposed to a concern for the public interest, the Grievance Policy and Procedure should be followed. If you are not sure which policy is the most appropriate to your concern, contact your line manager, Human Resources Department or Staff Side who will be able to advise you.

2.0 SPEAK UP WE WILL LISTEN Speaking up about any concern you have at work is really important. In fact, it’s vital because it will help us to keep improving our services for all patients and the working environment for our staff. You may feel worried about raising a concern, and we understand this. But please don’t be put off. In accordance with our duty of candour, our senior leaders and entire board are committed to an open and honest culture. We will look into what you say and you will always have access to the support you need.

3.0 THIS POLICY The Trust has adopted this ‘standard integrated policy’ which was one of a number of recommendations of the review by Sir Robert Francis into whistleblowing in the NHS, aimed at improving the experience of whistleblowing in the NHS. This policy applies to everybody who is employed by or works for the Trust including temporary agency staff, professional contractors and volunteers. Wherever the term “employee” of “staff” is used, it applies to all of the above as well as substantive staff. The Trust recognises the diversity of its staff and undertakes to apply this policy equitably and fairly irrespective of an employee’s protected characteristics. In the application of this policy the Trust will recognise its duty to each and every individual employee and will respect their human rights. However, as an employer it also expects that its employees will respect and treat each other and service users in the same way.

5

4.0 WHAT CONCERNS CAN I RAISE? You can raise a concern about risk, malpractice or wrongdoing you think is harming the service we deliver. Just a few examples of this might include (but are by no means restricted to):

unsafe patient care

unsafe working conditions

inadequate induction or training for staff

lack of, or poor, response to a reported patient safety incident

suspicions of fraud, which can also be reported to:

o our local anti-fraud team Don Ferguson, Anti-Fraud Specialist Tel: 0121 612 3914 Email: [email protected]

o the Trust’s Director of Finance

o There is also a confidential telephone hotline, “NHS Fraud and Corruption Reporting

Line” on 0800 028 40 60 which may be used to report suspicions of fraud or corruption

in the NHS

a bullying culture (across a team or organisation rather than individual instances of bullying).

For further examples, please see the Health Education England video. There are a variety of mechanisms for staff to raise concerns which are detailed in section 8.0. Remember that if you are a healthcare professional you may have a professional duty to report a concern. If in doubt, please raise it. Don’t wait for proof. We would like you to raise the matter while it is still a concern. It doesn’t matter if you turn out to be mistaken as long as you are genuinely troubled. This policy is not for people with concerns about their employment that affect only them – that type of concern is better suited to our grievance policy Link to Policy page - DWMH Intranet


https://www.youtube.com/watch?v=zjau1Ey0di8

http://theexchange.dwmh.nhs.uk/policies/Home.aspx?atoz=G

6

5.0 FEEL SAFE TO RAISE YOUR CONCERN If you raise a genuine concern under this policy, you will not be at risk of losing your job or suffering any form of reprisal as a result. We will not tolerate the harassment or victimisation of anyone raising a concern. Nor will we tolerate any attempt to bully you into not raising any such concern. Any such behaviour is a breach of our values as an organisation and, if upheld following investigation, could result in disciplinary action. Provided you are acting honestly, it does not matter if you are mistaken or if there is an innocent explanation for your concerns.

6.0 CONFIDENTIALITY We hope you will feel comfortable raising your concern openly, but we also appreciate that you may want to raise it confidentially. This means that while you are willing for your identity to be known to the person you report your concern to, you do not want anyone else to know your identity. Therefore, we will keep your identity confidential, if that is what you want, unless required to disclose it by law (for example, by the police). You can choose to raise your concern anonymously, without giving anyone your name, but that may make it more difficult for us to investigate thoroughly and give you feedback on the outcome.

7.0 WHO CAN RAISE CONCERNS? Anyone who works (or has worked) in the NHS, or for an independent organisation that provides NHS services can raise concerns. This includes agency workers, temporary workers, students, volunteers and governors.

8.0 WHO SHOULD I RAISE MY CONCERN WITH? In many circumstances the easiest way to get your concern resolved will be to raise it formally or informally with your line manager (or lead clinician or tutor). But where you don’t think it is appropriate to do this, you can use any of the options set out below in the first instance. If raising it with your line manager (or lead clinician or tutor) does not resolve matters, or you do not feel able to raise it with them, you can contact one of the following people:

our Freedom to Speak Up Guardian– this is an important role identified in the Freedom to Speak Up review to act as an independent and impartial source of advice to staff at any stage of raising a concern, with access to anyone in the organisation, including the chief executive, or if necessary, outside the organisation

our Compliance and Safety Team Tel: 01384 65200

7

If you still remain concerned after this, you can contact:

our Executive Director with responsibility for whistleblowing : Marsha Ingram Director of People and Corporate Development [email protected] 01384 324 522

our Non-Executive Director with responsibility for whistleblowing Simon Murphy Email: [email protected] Tel 01384 325002.

All these people have been trained in receiving concerns and will give you information about where you can go for more support. If for any reason you do not feel comfortable raising your concern internally, you can raise concerns with external bodies, listed in Section 10 Advice and Support.

9.0 ROLES & RESPONSIBILITIES 9.1 The Trust

The Trust is expected to promote and uphold the Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure at all times, leading by example and proactively engaging with staff to promote a culture of openness.

The Trust is committed to ensuring that any person properly using this policy to raise concerns about serious risk, malpractice or wrongdoing does not suffer any detriment.

The Trust will monitor adherence to the policy, ensuring investigations into whistleblowing complaints are dealt with properly and thoroughly and in a timely manner.

The Trust will ensure that any lessons learnt from the investigation of whistleblowing concerns are effectively cascaded through the organisation, maximising the opportunity for the Trust to improve standards of care and service delivery on a continual basis.

The Trust will ensure that staff have a avenues to raise their concerns and have the freedom to speak up if they have a concern.

9.2 Employees

Employees are expected to raise any public interest concerns as soon as practically possible to their line manager, explicitly stating that they are raising the concern under the Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure.

Employees are expected to cooperate fully in any investigation or inquiry following a public interest disclosure.


8

Employees are expected to uphold the policy by treating fellow colleagues that make a qualifying disclosure without detriment; any employee failing to uphold this standard will be subject to the Disciplinary Policy and Procedure.

Employees are expected to make disclosures in ‘good faith’. Employees making a disclosure that is proven to be vexatious or malicious will be subject to the Disciplinary Policy and Procedure. However, employees making a disclosure are not expected to ‘prove’ the allegations themselves; having a reasonable suspicion is sufficient to warrant making a disclosure.

9.3 Line Managers

Line Managers are expected to promote and uphold the Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure at all times, leading by example and proactively engaging with staff to promote a culture of openness.

Line Managers are expected to handle any protected or qualifying disclosures in a timely, confidential and efficient manner, escalating concerns as appropriate to Senior Management, Local Counter Fraud Specialist, Human Resources and/or Clinical Governance as appropriate.

Line Managers are expected to report back to the disclosing employee within 5 working days the outcome of any informal concerns raised, whilst maintaining confidentiality of other parties where applicable.

Any allegations of clinical malpractice reported to managers must be notified to the Clinical Governance Department as soon as possible who will retain a central record of incidents. Any allegations of (potential) misconduct must be notified to the Human Resources Department to ensure that appropriate procedures are followed.

9.4 Freedom to Speak up Guardian (FTSUG) The FTSUG will be a point of contact for individuals across the Trust who require advice and

support when raising concerns

The FTSUG will inform individuals of the options available, whether informal or formal and

direct individuals to support available.

The FTSUG will be the Trusts link person to other NHS organisations and the national guardian

to developing best practice across the healthcare community.

The FTSUG will work with the executive team and board of directors to help create an open culture which is based on listening and learning and not blaming.

The FTSUG act in an independent and impartial capacity, listening to staff and supporting them to raise concerns they may have by using the available structures and policies, both within the organisation and outside.

The FTSUG will ensure that information about those who speak up is kept confidential at all times, subject to requirements around safeguarding and illegality.

The FTSUG will report at least every six months to the Board and the organisation as a whole.

9

9.5 Staff Side

The Trust acknowledges the role that trade union organisations and their representatives can play in working with managers in partnership to foster a culture of honesty and openness. Any disclosures made directly to Staff Side must be escalated as appropriate to Senior Management, Local Counter Fraud Specialist, Human Resources and/or Clinical Governance.

10.0 ADVICE AND SUPPORT Details on the local support available to you can be found here DWMH Speak Up Intranet Page. Employees can raise a concern regarding serious risk, malpractice or wrong doing in instances where they do not feel confident raising concerns via the line management structure through the following means:

Completing the Speak Up Form - Intranet held on the Trust Intranet.

Contact the Trust’s Freedom to Speak up Guardian

Contact a Workplace Advisor Workplace Advisor Intranet site

Compliance and Safety Team Intranet Link

The national Whistleblowing Helpline provides free, independent and confidential advice to all staff and contracted workers within health and social care. While the helpline cannot investigate concerns on behalf of individuals, it can provide invaluable advice on whether your concern is indeed a whistleblowing one and to talk you through the process to ensure it is followed correctly. They are also able to advise on how you can escalate the concern with a relevant prescribed body if needed. To speak to a helpline advisor call 08000 724 725 between 8am and 6pm Monday to Friday. An answer machine and ring-back service is available for calls outside of these times. Alternatively you can email [email protected]. Where there is doubt as to the way forward (i.e. the employee is not sure whether to make a formal disclosure), an employee may seek a confidential meeting with one of the designated officers detailed in Appendix 1 Section 2.1 to discuss whether it would be appropriate to make a formal disclosure under PIDA 1998. An individual seeking or taking part in such a meeting is guaranteed the same protection against personal detriment as is given under the procedure to someone making a formal disclosure, whether or not a formal disclosure follows. Employees have the option to share their concerns in the first instance with colleagues or other representatives including trade union officials. Staff may also be accompanied by a colleague or representative when discussing allegations and suspicions with management.

http://theexchange.dwmh.nhs.uk/Pages/SpeakUp.aspx


http://theexchange.dwmh.nhs.uk/healthandwellbeing/Pages/WorkplaceAdvisors.aspx

http://theexchange.dwmh.nhs.uk/ourservices/clinicalgovernance/Pages/ReportingofIncidentsandSeriousUntowardIncidents(SUIs).aspx


10

Although it is far more effective for management to discuss matters with an identified person it is permissible for concerns to be shared anonymously, where a disclosure would not otherwise be made. The legislation allows employees to seek legal advice about any malpractice concerns they may have. Professional staff may also contact their professional registration bodies e.g. GMC, NMC for guidance about any malpractice concerns. In instances where fraud or corruption is suspected to have occurred, there is a confidential telephone hotline, “NHS Fraud and Corruption Reporting Line” which may be used to report suspicions of fraud or corruption in the NHS – this can be accessed on 0800 028 40 60.

The national Whistleblowing Helpline provides free, independent and confidential advice to all staff and contracted workers within health and social care. While the helpline cannot investigate concerns on behalf of individuals, it can provide invaluable advice on whether your concern is indeed a whistleblowing one and to talk you through the process to ensure it is followed correctly. They are also able to advise on how you can escalate the concern with a relevant prescribed body if needed.

To speak to a helpline advisor call 08000 724 725 between 8am and 6pm Monday to Friday. An answer machine and ring-back service is available for calls outside of these times. Alternatively you can email [email protected].

Alternatively, employees may contact Public Concern at Work, a charity offering free advice on raising whistleblowing concerns. Their contact details are:

Confidential Telephone: 020 7404 6609 Website: www.pcaw.co.uk Email: [email protected]

Employee may also wish to contact citizen’s advice Link to Citizens Advice Website

11.0 HOW SHOULD I RAISE MY CONCERN? You can raise your concerns with any of the people listed above in person, by phone or in writing (including email). Whichever route you choose, please be ready to explain as fully as you can the information and circumstances that gave rise to your concern. Please also see Appendix 1 Stages for Raising a Concern and Annex A Flowchart.


http://www.pcaw.co.uk/


https://www.citizensadvice.org.uk/healthcare/nhs-and-social-care-complaints/whistleblowing-how-a-staff-member-can-report-a-problem-in-the-nhs-or-an-adult-social-care-service/

11

12.0 WHAT WILL WE DO? We are committed to the principles of the Freedom to Speak Up review and its vision for raising concerns, and will respond in line with them (see Annex B). We are committed to listening to our staff, learning lessons and improving patient care. On receipt the concern will be recorded and you will receive an acknowledgement within two working days. The central record will record the date the concern was received, whether you have requested confidentiality, a summary of the concerns and dates when we have given you updates or feedback.

13.0 INVESTIGATION Where you have been unable to resolve the matter quickly (usually within a few days) with your line manager, we will carry out a proportionate investigation – using someone suitably independent (usually from a different part of the organisation) and properly trained – and we will reach a conclusion within a reasonable timescale (which we will notify you of). Wherever possible we will carry out a single investigation (so, for example, where a concern is raised about a patient safety incident, we will usually undertake a single investigation that looks at your concern and the wider circumstances of the incident1). The investigation will be objective and evidence-based, and will produce a report that focuses on identifying and rectifying any issues, and learning lessons to prevent problems recurring. We may decide that your concern would be better looked at under another process; for example, our process for dealing with bullying and harassment. If so, we will discuss that with you.

Any employment issues (that affect only you and not others) identified during the investigation will be considered separately.

14.0 COMMUNICATING WITH YOU We will treat you with respect at all times and will thank you for raising your concerns. We will discuss your concerns with you to ensure we understand exactly what you are worried about. We will tell you how long we expect the investigation to take and keep you up to date with its progress. Wherever possible, we will share the full investigation report with you (while respecting the confidentiality of others).

15.0 HOW WILL WE LEARN FROM YOUR CONCERN? The focus of the investigation will be on improving the service we provide for patients. Where it identifies improvements that can be made, we will track them to ensure necessary changes are

1 If your concern suggests a Serious Incident has occurred, an investigation will be carried out in accordance with the Incident, Near Miss and Serious Incident Reporting Policy .

https://www.england.nhs.uk/patientsafety/serious-incident/

https://www.england.nhs.uk/patientsafety/serious-incident/

12

made, and are working effectively. Lessons will be shared with teams across the organisation, or more widely, as appropriate.

16.0 BOARD OVERSIGHT The board will be given high level information about all concerns raised by our staff through this policy and what we are doing to address any problems. We will include similar high level information in our annual report. The board supports staff raising concerns and wants you to feel free to speak up.

17.0 REVIEW We will review the effectiveness of this policy and local process at least annually, with the outcome published and changes made as appropriate.

18.0 RAISING YOUR CONCERN WITH AN OUTSIDE BODY Alternatively, you can raise your concern outside the organisation (see also Appendix 1 section 3) with:

NHS Improvement for concerns about:

o how NHS trusts and foundation trusts are being run

o other providers with an NHS provider licence

o NHS procurement, choice and competition

o the national tariff

Care Quality Commission for quality and safety concerns

NHS England for concerns about:

o primary medical services (general practice)

o primary dental services

o primary ophthalmic services

o local pharmaceutical services

Health Education England for education and training in the NHS

NHS Protect for concerns about fraud and corruption.

18.1 Making a ‘protected disclosure’ There are very specific criteria that need to be met for an individual to be covered by whistleblowing law when they raise a concern (to be able to claim the protection that accompanies it). There is also a defined list of ‘prescribed persons’, similar to the list of outside bodies in Section 10 Advice and Support, who you can make a protected disclosure to. To help you consider whether you might meet these criteria, please seek independent advice from the Whistleblowing Helpline for the NHS and social care, Public Concern at Work or a legal representative.

https://www.gov.uk/government/organisations/monitor/about/complaints-procedure

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/441473/REGISTER_OF_LICENCE_HOLDERS_-_01072015.csv/preview

http://www.cqc.org.uk/content/who-we-are

http://www.england.nhs.uk/

https://hee.nhs.uk/about/how-we-work/what-we-do/

http://www.nhsbsa.nhs.uk/3350.aspx

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/431221/bis-15-289-blowing-the-whistle-to-a-prescribed-person-list-of-prescribed-persons-and-bodies-2.pdf

http://wbhelpline.org.uk/

http://www.pcaw.org.uk/

13

19.0 THE LEGAL FRAMEWORK: THE PUBLIC INTEREST DISCLOSURE ACT 1998 The Public Interest Disclosure Act 1998 (“PIDA 1998”) protects workers who ‘blow the whistle’ about wrongdoing or malpractice and places a clear responsibility on public sector employers to remind staff of their responsibility to disclose suspected malpractice without fear of recriminations. PIDA 1998 protects workers from being subjected to a detriment by their employer as a consequence of making a whistleblowing disclosure. Detriment may take a number of forms, such as denial of promotion, facilities or training through to direct intimidation or harassment. A disclosure qualifies under PIDA 1998 if it regards a risk, wrong doing or malpractice that affects service users, the wider public or other staff. A qualifying disclosure is a disclosure of information which, in the reasonable belief of the worker making the disclosure, tends to show one or more of the following:

That a criminal offence has been, is being or is likely to be committed (e.g. assault, bribery, theft);

That a person has failed, is failing or is likely to fail to comply with any legal obligation to which he or she is subject. This could include professional malpractice or a failure to comply with any rules, regulations or codes of practice;

That a miscarriage of justice has occurred, is occurring or is likely to occur;

That the health and safety of any individual has been, is being or is likely to be endangered;

That the environment has been, is being or is likely to be damaged; or

That information tending to show any of the above has been, is being or is likely to be deliberately concealed.

Examples of malpractice which qualify as protected disclosures under PIDA 1998 include (but are not limited to) the following:

Abuse or mistreatment of service users;

Exposing service users to unacceptable or unnecessary risk;

Acts of fraud and theft against the organisation or service users;

Procuring or accepting bribes from service users, staff or other third parties (e.g. suppliers of goods or services);

Dangerous Health and Safety situations and breach of fire regulations;

Deliberately concealing information relating to any malpractice; and

Staff working under the influence of alcohol or drugs.

PIDA 1998 provides statutory protection, including compensation, against employer reprisals to all employees who disclose information reasonably and responsibly in the public interest. A qualifying disclosure will be legally protected where it is made:

To the worker’s employer, either directly to the employer or by procedures authorised by the employer for that purpose; or

14

To another person whom the worker reasonably believes to be solely or mainly responsible for the relevant failure

PIDA 1998 places responsibilities upon the worker making a disclosure. In most cases, the worker must raise the matter internally first. The matter must be raised in ‘good faith’ – it must be done from a reasonable and honest (even if mistaken) belief, and must not be motivated by personal antagonism. If the employee making the disclosure has not complied with the conditions of PIDA 1998 by following internal procedures first, he or she may have committed a fundamental breach of contract by disclosing confidential information belonging to the employer. As an employee, the whistleblower may also have fundamentally breached the duty of trust and confidence owed to the employer and may therefore be liable to the Trust’s disciplinary procedures. It is therefore strongly advised that employees follow the internal procedure before considering other options. Employees are encouraged to contact the Royal Mencap Society or Public Concern at Work if they have any questions or concerns about making a disclosure under PIDA 1998

20.0 NATIONAL GUARDIAN FREEDOM TO SPEAK UP The new National Guardian (once fully operational) can independently review how staff have been treated having raised concerns where NHS trusts and foundation trusts may have failed to follow good practice, working with some of the bodies listed above to take action where needed.


Version 4.3 Page 15 of 18

APPENDIX 1 - STAGES FOR RAISING A CONCERN

1.0 Step One: Raising an Informal Concern 1.1 If employees have a concern about serious risk, malpractice or wrongdoing they are

required to raise the matter immediately with their line manager. If the manager is suspected to be involved or is condoning malpractice, employees are required to raise the matter with the next in line manager in the first instance. This may be done verbally or in writing. Employees are required to explicitly state that they are making a disclosure under the Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure to assist the Trust to accurately record and track progress of any whistleblowing concerns.

1.2 If you feel unable to raise the matter with your line manager, lead clinician or tutor, for

whatever reason, please raise the matter with our Freedom to Speak up Guardian Michael Hirons 07717 630 345 [email protected]

This person has been given special responsibility and training in dealing with whistleblowing concerns. They will:

treat your concern confidentially unless otherwise agreed

ensure you receive timely support to progress your concern

escalate to the board any indications that you are being subjected to detriment for raising your concern

remind the organisation of the need to give you timely feedback on how your concern is being dealt with

ensure you have access to personal support since raising your concern may be stressful.

If you want to raise the matter in confidence, please say so at the outset so that appropriate arrangements can be made.

1.3 Employees may also raise a concern by completing the Speak Up Form - Intranet held on

the Trust Intranet. This can be done anonymously, however, in such circumstances the Trust will not be able to provide direct feedback to the individual.

Feedback will be given on the management action being taken within 5 working days, with

due regard to the Trust’s duty of confidence and without infringing the rights of other parties, for example where disciplinary action is being taken against another employee.





2.0 Step Two: Making an Internal Formal Disclosure 2.1 If the concerns have not been dealt with satisfactorily at Step 1 or the matter is deemed

too serious for the informal stages, employees are encouraged to raise the matter formally immediately to one of the following designated officers:

The Chief Executive

The Director of Finance, IT and Procurement

The Director of Nursing, Operations and Estates

The Medical Director

The Director of People and Corporate Development

The Trust Freedom To Speak Up Guardian 2.2 Contact can be by telephone, via email or in writing to Trust Headquarters, 2nd Floor

Trafalgar House, 47-49 King Street, Dudley. All correspondence should be marked “in confidence to be opened by the addressee only” and again employees are required to explicitly state that they are making a disclosure under the Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure.

2.3 The person making a formal disclosure should as soon as practicable disclose in confidence the grounds for the belief of malpractice or serious risk to one of the designated officers identified above. Any disclosure under this procedure shall, wherever possible, be in writing. The person making the disclosure should provide as much supporting evidence as possible about the grounds for his or her belief although there is no requirement to ‘prove’ the malpractice allegations.

2.4 If the person receiving the formal disclosure does not feel that this policy is appropriate to

use they may make reference to other Trust policies that exist for dealing with concerns. For example:

Being Open policy

Safeguarding Vulnerable Adults

Disciplinary Policy

Grievance Policy

Bullying and Harassment Policy

2.5 A designated officer may decline to become involved on reasonable grounds. Such grounds include previous involvement or interest in the matter concerned, incapacity or unavailability or that the designated officer is satisfied that a different designated officer would be more appropriate to consider the matter in accordance with this procedure.

2.6 On receipt of the disclosure, the designated officer will offer to interview, in confidence,

the person making the disclosure. Such an interview will take place as soon as practicable after the initial disclosure. The purpose of the interview will be for the designated officer



to obtain as much information as possible about the grounds of the belief of malpractice and to consult about further steps which could be taken. The person making the disclosure may be accompanied by a local trade union representative or work colleague at the interview. The designated officer may be accompanied by an administrative assistant to take notes. Due regard will be given to confidentiality.

2.7 Where the designated officer is satisfied that the Freedom to Speak Up: raising concerns

(whistleblowing) Policy and Procedure is appropriate, they shall decide on the nature of the investigation of the allegations. This may be an internal investigation by Trust staff; or referral of the matter to the police or other appropriate public authority; or the commissioning of an independent enquiry, for example by the Trust’s auditors or Local Counter Fraud Officer.

2.8 If the designated officer decides that the Freedom to Speak Up: raising concerns

(whistleblowing) Policy and Procedure is not appropriate in respect of the matter disclosed, they shall so inform the discloser, giving reasons in writing. These could be on grounds that:

The matter should be, is already or already has been the subject of appropriate proceedings under one of the Trust’s other procedures;

The matter is already the subject of legal proceedings, or has already been referred to the police or other public authority;

There is reasonable doubt as to the discloser’s good faith and/or reasonable belief about malpractice or serious risk.

2.9 If the discloser is not satisfied with the designated officer’s decision, they may ask the Chair

of the Trust Board to review the matter of the disclosure, the information and evidence presented, the process followed and the grounds for the decision. If the Chair of the Trust Board decides that the matter should be investigated under the Freedom to Speak Up: raising concerns (whistleblowing) Policy and Procedure, they shall direct a second designated officer to arrange an appropriate investigation. If they decide to uphold the view of the original designated officer, no further action will be taken under the Trust’s processes. The discloser may then consider whether to refer the allegations of malpractice or serious risk to an external agency (Section 6.3).

3.0 Step Three: Making a Regulatory External Disclosure 3.1 While it is hoped that this policy gives employees the confidence to raise their concern

internally, there may be circumstances where they can report the concern to an appropriate outside body. Ones relevant to the NHS include:

The Care Quality Commission (CQC)

NHS Improvement

The Audit Commission

The Health and Safety Executive; or

The National Patient Safety Agency



3.2 Disclosures to regulatory bodies may also be ‘protected disclosures’ under certain circumstances; for example the discloser must make the disclosure in good faith, must reasonably believe the allegations are substantially true, does not make the disclosure for personal gain and if the disclosure is considered reasonable. It is recommended that advice is sought from the Royal Mencap Society or Public Concern at Work if considering making an external disclosure before exhausting internal procedures (Section 7.6).

3.3 If your concern is about fraud and corruption you can also contact the NHS Fraud Hotline.

4.0 Step Four: Making a Wider External Disclosure 4.1 Examples of wider external disclosures include Police, Media, MPs and Non-Prescribed

Regulators. Employees are advised that wider disclosures may also be ‘protected disclosures’ under very particular circumstances. As with regulatory disclosures, the discloser must make the disclosure in good faith, must reasonably believe the allegations are substantially true, does not make the disclosure for personal gain and the disclosure is considered reasonable.

4.2 In addition a further pre-condition to secure protection for a wider disclosure must be met.

This is either:

The person reasonably believed he/she would be victimised if the matter was raised either internally or with a prescribed regulator; or

There was no prescribed regulator and he/she reasonably believed the evidence was likely to be concealed or destroyed; or

The concern had already been raised with the employer or a prescribed regulator without being addressed in a timely manner; or

The concern is of an exceptionally serious nature. 4.3 It is strongly recommended that advice is sought from the free, confidential services

provided by Public Concern at Work (PCAW) (Section 7.8) if considering making a wider external disclosure before exhausting internal and regulatory disclosure procedures.

4.4 Employees should note that failure to meet these requirements means that they would not

qualify for protection under this policy and may be subject to disciplinary action for fundamental breach of contract and/or disclosure of confidential Trust information.

Individual has concern/

whistleblowing and raises

verbally or in writing to:

If unable to raise with line

manager, report concern to:

Senior manager

Manager/senior clinical/tutor looks into concern and responds to the individual with an outcome

within 5 working days (if a concern is raised anonymously the Trust will not be able to respond

directly to the individual but will still look into the matter).

Line manager in first instance

Senior clinical/lead tutor

‘Speak Up’ form on intranet can be anonymous

Ste

p 2

: R

ais

ing

a f

orm

al co

nce

rn

Ste

p 1

: R

ais

ing

an

info

rma

l con

ce

rn/w

his

tleb

low

ing

Individual raises formal

concern/whistleblowing to

Designated Officer (DO)

DO meets with individual

to understand concerns

DO recommends

investigation and appoints

Investigating Officer (IO)

as appropriate:

Internal investigator

Antifraud/NHS Protect

External body

IO reports outcome of

investigation to DO

DO provides individual with

feedback/outcome

If informal concern is not resolved to satisfactory outcome or concern is very serious and warrants formal escalation

Individual has a concern/whistleblowing

Appendix 1—Raising concerns/whistleblowing flowchart

Workplace Advisor

Freedom to Speak Up Guardian

Non-executive director

Compliance and safety team

Executive Director

Ste

p 4

: M

akin

g a

wid

er

exte

rna

l d

isclo

su

re

Ste

p 3

: M

akin

g a

reg

ula

tory

exte

rna

l d

isclo

su

re

Police

MPs

Non prescribed regulator

Media

Individual raises concern/

whistleblowing to:

CQC

Health and Safety Executive

National Patient Safety Agency

External audits

Individual reports concern/

whistleblowing to:

When steps 1 and 2 have been exhausted or if concern/

whistleblowing cannot be reported internally, concern

should be reported to appropriate external regulatory

body

Where steps 1-3 are not appropriate, concerns/

whistleblowing can be reported to wider external bodies

NHS Improvement

Annex B: A vision for raising concerns in the NHS

Source: Sir Robert Francis QC (2015) Freedom to Speak Up: an independent report into creating an open and honest reporting culture in the NHS.

http://webarchive.nationalarchives.gov.uk/20150218150343/http:/freedomtospeakup.org.uk/the-report/




Agenda Item number: 8.1

Enclosure: 5

Report Title:

Trust Integrated Performance Dashboard (Month 2) including the Performance Dashboard and Contract Performance Report Dashboard


Rupert Davies – Interim Director of Finance and Performance


Makhan Singh (Principal Consultant, Information & Performance)

Purpose of the report: To update the Board on all aspects of Trust performance at

month 2 of 2017/18

• Quality and Safety • Service User Experience • Efficiency • Resources


Decision / Approval

Gain assurance

Discussion

Information


Committee: • Quality and Safety Committee on 14 June 2017

considered elements from within the Quality and Safety domain, and the Service User Experience domain.

• Finance and Performance Committee on 26 June 2017 considered elements from the Efficiency, Resource and Quality and Safety Domains

• Workforce Committee on 27 June 2017 considered elements from the Resource and Quality and Safety Domains


Any points will be raised in the respective Committee Chair’s reports.




Leadership culture




Enc 5 Cover Sheet 17_18 IPD Month 2 Page 1 of 4

What impact or implications does this report have on any of the following:


Caring

The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources Responsive

Effective Well-led Safe


Title Trust Integrated Performance Dashboard (Month 2) including the Performance Dashboard and Contract Performance Report Dashboard

Introduction

• This paper presents the Trust’s performance at the end of month two 2017/18 financial year.

• The 2017/18 Integrated Dashboard allows comparison and triangulation across Quality and

Safety, Service User Experience, Efficiency, and Resources to give a comprehensive picture of the performance of the Trust.

• The 2017/18 Integrated Dashboard also includes performance, and exception commentary, by service line, so that the Board is better able to see achievements as well as any adverse performance within the overall aggregate level.

Summary of key points, issues and risks

• For 2017/18 the Trust Integrated Performance Dashboard (IPD) has been reviewed by

Operational and Corporate Teams. The IPD has been amended in accordance with the changes to the service lines. Where appropriate the 18 month trends are shown in the IPD and for any new KPI’s under a service line, the in-month position is reported.

Quality and Safety Domain • In May, the Trust reported 371 incidents similar to the number reported in April and

demonstrating a healthy reporting culture in the Trust, 258 of which were Patient Safety Incidents.

• The Trust reported four Serious Incidents (SI’s) during May (2 for Urgent Care and Access, 1 for Inpatients Older Adults and 1 for Early Intervention). There are no immediate identified risks to other patients. All SI’s were considered for Duty of Candour Criteria but only 1 met specific criteria. The other cases all had full family engagement / being open principles applied with any feedback received being incorporated into the investigation. All the investigations have now commenced and support mechanisms for patients, relatives and staff are in place. Any identified areas for improvement will be managed through the Trust Embedding lessons procedures.

• CPA Performance at month two: The Trust is above target for Copies of Care Plan at 95.12% and slightly below the threshold for CPA Formal Reviews at 94.82%.

• Inpatient Services (Acute) continues to report high levels of Disruptive and Aggressive behaviour - Care provided to mitigate the risks posed to other patients and staff is appropriate with any restraints being independently scrutinised by Trust MAPA Leads. Community Services has low levels of reported incidents – work to improve staff understanding of thresholds to ensure appropriate numbers of incidents are completed is underway.

• There were 13 Safety Alert Broadcasts received by the organisation via the Central Alerts. • System. Two pharmacy related alerts required action to be taken – this has now been

completed and both alerts subsequently closed. Efficiency Domain • Activity against contract (NHS Activity) – NHS contracted activity remains above the target as at

month two. In May, the Trust is reporting 55,874 units of activity against a target of 51,183. Activity against contract is above target for all service lines.


• The Trust’s Cost Improvement target for the year is £2,500k, however, in order to ensure the required level of funding to support in year Cost Pressures schemes have been developed to the value of £3,765k.

• At this early stage of the year schemes are being embedded and to date all but £929k of the total £3,765k identified schemes have been devolved down to individual service lines. These remaining schemes are currently being phased into the monthly finance position and are being covered non-recurrently through the overall surplus finance position to date.

• Based on the agreed ‘Agency Cap’ ceiling of £4.05m for the financial year this equates to an overall target of 8.24% based on the Trust’s planned annual pay costs. Current position to date is reflecting a favourable position to plan of 6.54%. Total agency spend in financial terms has out turned at a spend level of £543k across the Trust against a planned spend of £689k (giving a position of £146k ahead of plan).

• Vacancies – There are currently 155 FTE contracted vacancies across the Trust meaning the vacancy rate hasn’t changed in month two from the 13.5% reported in month one. Of the 155 FTE vacant, approximately 87 FTE being actively recruited at present.

• The TRAC recruitment system is currently being used within the Trust giving increased control and oversight to recruiting managers and allows the Trust to performance manage against recruitment KPIs.

• Turnover – The 12 Month Turnover rate has decreased from 11.56% to 11.40%. The Trusts percentage turnover (excluding junior Medics) is average compared to other Mental Health organisations in the NHS.

• Sickness Absence – The rolling 12 month sickness rate has decreased from 4.24% in month one to 4.14% in month two, this is within the Trusts target and the seventh consecutive month of being so. In month sickness has decreased from 3.59% in month one to 3.40% in month two.

• Appraisal – Compliance has decreased from 85.5% to 83.1%, this is below the Trust target of 85%. There are 147 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 223 reported in month six. Weekly/Bi Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements. As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake in order to remain compliant.

• Mandatory Training - Mandatory Training compliance increased slightly from 88.0% in month one to 88.6% in month two and remains just below the target of 90% agreed at MEXT for all mandatory training.

Further detail

• Please see enclosed Integrated Performance Dashboard and underpinning reports for finance, contractual performance, quality and workforce.

Recommendation

• It is recommended that the Board note the performance of the Trust as at month two and debate

accordingly. Board action required

• Debate the content of the reports accordingly.


Contract Performance Report Month 2 – 2017/18

Enc 5: Appendix 1

2

Contractual Quality Requirements – Trust and CCGs (In month performance and monthly trends)

KPI No KPI Detail and Target Trust Dudley CCG Walsall CCGTrust Monthly

TrendDudley CCG

TrendWalsall CCG

Trend

1Percentage of Service Users on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from Referral. (Target: Above 92%)

100.00% 100.00% 100.00%

2 Zero tolerance RTT waits over 52 weeks for incomplete pathways 0 0 0

3Care Programme Approach (CPA): The percentage of Service Users under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care. (Target: Above 95%)

95.40% 95.20% 94.90%

4Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS (Target: Above 99%)

99.86% 99.90% 99.97%

5Completion of Mental Health Minimum Data Set ethnicity coding for all detained and informal Service Users. (Target: Above 90%)

90.20% 91.20% 92.20%

6 Sleeping Accommodation Breach 0 0 0

7Percentage of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. (Target: Above 50%)

100.00% 100.00% 100.00%

8Completion of IAPT Minimum Data Set outcome data for all appropriate Service Users. (Target: Above 90%)

100.00% 100.00% 100.00%

9The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 75%)

94.21% 90.66% 99.36%

10The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 95%)

99.28% 98.80% 100.00%

11a IAPT - number of people who receive psychological therapies. (Target Dudley: 477 per month) 377

11bIAPT - number of people who receive psychological therapies. (Target Walsall: Q1, Q2 & Q3-1082, Q4-1212)

305

12IAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50%)

61.22% 57.94%

13 Percentage of patients who are provided a copy of their care plan. (Target: Walsall - Above 95%) 95.12% 94.44%

3

Contractual Quality Requirements – Trust and CCGs (In month performance and monthly trends)

KPI No KPI Detail and Target Trust Dudley CCG Walsall CCGTrust Monthly

TrendDudley CCG

TrendWalsall CCG

Trend

14 Delayed Transfer of Care (All Reasons). (Target: Below 7.5%; Walsall - TBC) 3.70% 4.50% 2.90%

15 Inpatient Admissions Gate kept by CRHT. (Target: Walsall - Above 95%) 100.00%

16 Adult Inpatient stays less than 40 Days. (Target: Dudley - Above 95%) 78.00%

17 Proportion of in-scope patients assigned to a cluster. (Target: (Dudley - Above 95%) 95.99%

18Proportion of patients within cluster review periods. (Target: Dudley Q1 - 80%; Q2 - 90%; Q3 - 95%; Q4 - 95%)

83.55%

19Dudley and Walsall Recovery Outcome Measure - Number of CPA patients assessed using DWROM (Target: Dudley Only: Q1 - >85%; Q2 - >90%; Q3 & Q4 - >95%)

90.63%

20Eating Disorders - % of children & young people who receive treatment within four weeks of referral for routine cases. (Target: Walsall - Above 95%)

100.00%

21Eating Disorders - % of children & young people who receive treatment within one week of referral for urgent cases. (Target: Walsall - Above 95%)

100.00%

22 PLT - number of patients seen on the wards within 24 hours. (Target: Dudley - Above 85%) 100.00%

23 PLT - number of patients seen in A&E assessed within 4 hours. (Target: Dudley - Above 95%) 98.00%

24 CRS - proportion of patients seen within 6 weeks. (Target: Dudley - Above 75%) 57.78%

25 PT Hub - proportion of patients seen within 18 weeks. (Target: Dudley - Above 95%) 96.92%

26 Duty of Candour --- --- ---

Integrated Performance Dashboard Month 2 – 2017/18

Enc 5 Appendix 2

2

Inpatients Service Line Summary • Inpatient Services have moved into a deficit position of £21k at month two.

This is due to increased staffing costs within Holyrood and Ambleside wards due to increased patient acuity / special observation needs.

• There has been a slight decrease in month two sickness to 3.92% (3.95% in month one).

• There has been a slight increase in performance for Mandatory Training to 86.95% in month two (85.33% in month one).

3

Community Service Line Summary • CPA Reviews – Community service (CRS, Older Adult CMHT’s) is

performing at 96.30% and Copies of Care Plan performance is 95.55%. • Community & Recovery Services position at month two is £66k

underspent. Various vacancies across Psychological Therapies Hub and Older Adult Community are the main drivers for the underspend Sickness – this service sickness levels have remained stable for month two at 2.41% (2.40% reported in month one).

• Mandatory training performance has slightly increased to 88.01% in month two (87.91% in month one).

4

Urgent Care & Access • IAPT Project team is in place to review and take action on the needs of delivering an IAPT service, where the Trust needed to increase the target for IAPT KPI’s during

the year in order to meet the end of year target that now only applies to IAPT and can only be met by IAPT recognised staff and IAPT therapies for depression and anxiety only. The thresholds are extremely difficult for an element of the service to meet compared with the previous position where the service met their KPI’s and also measured against the prevalence for depression and anxiety in the local communities. There is a robust communication campaign on going to encourage more people to access the service.

• This service line has underspent by £18k to month two. This is being driven by slippages within Dudley Primary Care and Dudley Access services. • There has been a decrease in sickness performance for month two to 3.86% but remain within the set threshold (4.08% in month one). • There has been a decrease in performance for mandatory training to 89.90% in month two (90.57% in month one). 5

Indicator Period Target Actual RAG Trend Indicator Period Target Actual RAG Trend

CQC Compliance YTD 0 0 G Activity Against Contract (NHS Activity) YTD 7,028 8,433 G

7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 95.40% G

CPA - Review in 12 months YTD 95% 88.97% R

CPA – Copies of Care Plans YTD 95% 91.06% A Indicator Period Target Actual RAG Trend

Never Events YTD 0 0 G Income Against Plan (£000) YTD £2,084 £2,086 G

Incidents Monthly N/A 70 N/A Performance against Budget (£000) YTD B/Even £87 G

Serious IncidentsMonthly N/A 1 N/A

Cumulative Agency Spend as a % of Total Employee Benefits

YTD 8.24% 7.17% G

Falls Resulting in Severe Injury/Death Monthly 0 0 G Vacancy Rate Monthly 10.00% 7.84% G

Grade 3 or 4 Pressure Ulcers (whilst in our care) Monthly 0 0 G Turnover - Rolling 12 Month Apr 16 - May 17 8-14% 6.14% A

Sickness - in Month Monthly 4.68% 1.81% G

Sickness - Rolling 12 Month Apr 16 - May 17 4.68% 2.65% G

Indicator Period Target Actual RAG Trend Appraisals Monthly 85% 76.85% R

Friends and Family Test - % of Promoters (CQUIN) Monthly N/A 100.00% N/A Mandatory Training (Aggregated) Monthly 90% 89.27% A

New Complaints Monthly N/A 3 N/A N/A

New Concerns Monthly N/A 5 N/A N/A

% Complaints/Concerns regarding Care/Treatment Monthly <80% 50.00% G

Complaints Upheld/Partially Upheld YTD <75% 50.00% G

Compliments (Month) Monthly N/A 2 N/A N/A

Response Breaches YTD <30% 0% G

Early Intervention Performance Dashboard 2017/18 Month 2

Quality and Safety Efficiency

Resources

Service User Experience

Early Intervention Service Line Summary • Early intervention service is reporting EI Teams and CAMHS Services • The Early Intervention service line is underspent by £87k at month two, which

is due to slippages against new funding streams. • Early Intervention sickness has seen a slight decrease to 1.81% in month two

(2.18% in month one). • Performance for appraisals has decreased at 76.85% in month two (78.90%

reported in month one). • Mandatory training has increased at 89.27% in month two (89.27% in month

one).

6


Agenda Item number: 8.1.1a

Enclosure: 6

Report Title:

Quality and Safety Committee Chair’s Report Committee:

Quality and Safety Committee

Author:

Simon Murphy – Non Executive Director Tom Jinks – Compliance and Safety Manager

Introduction The Quality and Safety Committee met on the 14 June 2017. Summary of key points, issues and risks Deep Dive Red Risk HR002 – Section 75 Partnership with Walsall MBC The Committee received a detailed presentation of the current situation in respect of the Section 75 working arrangements in Walsall with the Trust. The risks to service users, viability of Trust activities, and the potential to undermine recruitment and retention of staff were all highlighted. The Committee agreed to the recommendations contained in the report:

• To consider the risks associated with the Council’s decision and potential impact on services.

• To note the Council’s departure from the current legislation, the Care Act, this promotes bringing services and disciplines together to provide a seamless service.

• Agree the implementation of a risk management plan, to mitigate the potential reduction in the quality of service that is delivered to our service users.

Deep Dive Session – Treatment / Provision of Care for Cross locality Patients. Following discussions that had occurred during a previous Quality and Safety Committee, it was agreed to hold a deep dive session in order to formally receive the results of a clinical audit that had been undertaken in relation to the care provided to patients who are treated in a location not local to where they reside (i.e Walsall residents being treated in Bushey Fields Hospital and Dudley Patients treated at Dorothy Pattison Hospital).


Gain assurance

Discussion

Information

Enc 6 QS Committee Chair's Report-Revised - July 2017 Page 1 of 6

The audit was agreed following receipt of some noted concerns which had been raised by clinicians, patients, carers and EBEs. The concerns related to perceived problems with care provided, when patients were admitted to a different locality in the Trust from where they lived. It had also been reported that this was also affecting working relationships, causing stress amongst staff and loss of goodwill which in turn had the potential to affect patient care and outcomes. The aim of the session was to receive the outcome of the audit and to agree any required mitigating actions. A summary of the outcome of the session / planned actions is summarised below:

• The Audit reviewed the inpatient care provided to 26 patients (23 patients were treated out of their local area and 3 patients were treated local to the area they normally reside).

• The audit acknowledged that there is likely to be an increased possibility of patients receiving their care further afield following the implementation of TCT and it was therefore important to identify any risks to this practice and associated mitigating actions to ensure high levels of care / outcomes are provided.

• It was identified that there is a need for a project group to be established to further explore this area and conduct a regular and robust review, utilising a sample of locally treated patients to act as a benchmark.

• The results of the audit would be submitted to the Executive Communications Meeting

for information / discussion. The meeting is scheduled to take place at the end of June 2017.

• The audit highlighted that the Trust needed to have dedicated policies and procedures on how cross locality / out of area patients should be treated to ensure they receive optimum care and are not negatively affected by location and that there is continuity of care.

• Project group to explore whether the Trust has the correct number of inpatient beds at

each locality.

• Identified need for Commissioners in Walsall to fully understand Trust bed usage and presenting issues / complexities. This is to be a CQRM deep dive topic.

• New Bed Management Post will help with the situation – the post is currently in

recruitment with the new postholder expected to be in place by July 2017.

• Agreement that Benchmarking of Black Country Partnership NHS Foundation Trust needed. The FT also treats patients in other localities and it was agreed that the same audit applied to these patients would provide a useful comparison of data.

• Audit highlighted that there is an identified need for patients to be treated at home or as

close to their home as possible. Enc 6 QS Committee Chair's Report-Revised - July 2017 Page 2 of 6

• The Audit concluded that Walsall patients treated in Dudley locality is not ideal but is

perceived to be a better option than treating patients further afield / outside of the Trust.

• It was agreed that an update would be brought back to the committee in August 2017, following the recruitment of the Bed Manager.

The Committee agreed

• The development of a clear protocol that defines communications standards including timeframes for informing teams.

• The routine audit of adherence to the protocol. • To avoid moving patients who are currently on the wards to accommodate new

admissions. The Committee discussed the contents of the report; it was acknowledged that a large amount of work had been completed but further work was required. The Committee noted that the report is to be presented to MExT in June. Quality Report The Quality Report was presented to the Committee for information and assurance. The report format has been updated, which was endorsed by the Committee to reflect service lines and included additional benchmarking information. There are higher than average numbers of reported incidents on Clent and Linden Wards relating to disruptive / aggressive behaviour of inpatients. Ambleside Ward also has the highest number of reported incidents relating to patient self-harming behaviour. Contracted Safeguarding Training remains low against target which is being further scrutinised to target improvements in compliance. A Recovery Action Plan (RAP) has been developed to address this compliance issue. Quality and Safety High Level Risks The Committee was advised that there are currently ten operational red risks and two new risks were presented to the Committee that were in relation to: a) Changes to the local interagency 136 Policy may leave to Trust open to reputational risks around its implementation. b) Failure of the Trust to achieve its mandatory and essential training which may result in staff not being appropriately skilled to undertake their role. The Committee also recommend to Trust Board that one risk relating to appraisal and supervision is split into two risks and both elements downgraded to Amber status.


Draft Quality Account The Committee received the final Draft of the Quality Account as part of the consultation process. The Committee noted that the Draft Account had been circulated for comment to stakeholders including, CCGs, Health Watch and Health Overview and Scrutiny Committees. It was reported that External Audit had concluded the review of two Key Performance Indicators with no concerns highlighted. The Committee therefore recommends the Quality Account to the Board for formal adoption. Risk Register Deep Dive Review – Pharmacy Services Risk Register The Committee undertook a deep dive review of the pharmacy services department risk register. The committee held discussions in relation to the following areas:

• Medicines Optimisation – the Committee was informed that medicines optimization

continues to be regularly discussed at Medicines Management Committee. This allows benchmarking to occur and regional solutions to be identified.

• The Committee was informed that there is an ongoing Medicines Management Audit schedule that undertakes a wide range of audit topics that alternate between inpatient reviews and outpatient medication issues.

• One risk held on the register relating to capacity was reviewed – the Trust CQC

report highlighted that it was good practice for pharmacists to fully input into Community Teams / Services – the capacity of the Pharmacy Team limits this involvement.

• A query was raised regarding a noted trend in serious incidents relating to the

amount of prescribed drugs that had been issued in cases of overdose / suicide. The pharmacy team confirmed that they were aware of the issue and that this was being addressed via MAC

Project Management Office (PMO) Quality Impact Assessments Committee members were presented with twelve new Quality Impact assessments (QIA’s) relating to the 2017/18 Cost Improvement Programme (CIP) The Committee received assurances that all the schemes had been risk assessed and that there were mitigating actions in place for each scheme to ensure there was no impact on the quality or safety of services provided. The twelve presented QIA’s were noted by the Committee. Enc 6 QS Committee Chair's Report-Revised - July 2017 Page 4 of 6

Fire Safety Action Plan The Committee received assurance on the positive progress that is continuing to be made against the Fire Safety Action Plan. Fire Risk Assessments had been completed for the three hospital sites with three additional risks having been prioritised for action. The three priority risks relate to:

• CRIB 3 mattresses • Electrical testing • Fire doors

The Committee was also informed that it had been agreed that CW Audit (Trust Internal Auditors) would be undertaking an audit to test the Trust against the newly developed fire safety standards. Service Experience 2016/17 Annual Report The Committee received, discussed and endorsed the report for Trust Board Approval. The report is a full agenda item for Trust Board. Progress against Equality and Diversity Delivery System The Committee received the Progress against Equality and Diversity Delivery System Report which gave an overview of key aspects of progress made against the agreed plan The report highlighted to the Committee that:

• All actions on the plan were rated as green apart from one action which was rated as red which is in relation to interpretation services. An interim solution is now in place whilst a replacement provider is procured

• The Trust’s Freedom to Speak Up Guardian is now successfully in place

• Work is underway to establish support networks and benchmarking processes via the Transforming Care Together work streams.

• The Chaplaincy Service Level Agreement has been reviewed and extended and now

incorporates Bloxwich Hospital site CQC Action Plan The Committee received and endorsed the latest version of the Trust CQC action plan Clinical Audit Forward Plan The Clinical Audit forward Plan for 2017/18 was presented and was endorsed by the Committee. Enc 6 QS Committee Chair's Report-Revised - July 2017 Page 5 of 6

Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• Audit Committee • Finance and Performance Committee • MExT • CARM / CQR • Clinical Audit and Effectiveness Committee • Embedding Lessons Group • Regulation and Risk Working Group • Safeguarding Strategic Group • Suicide Prevention Group • Equality and Diversity Steering Group • R&D Committee • Health & Safety Committee • Infection Prevention Control Committee • Medicines Management Committee • Mental Health Forum • Policy & Procedures Group • Resuscitation Committee

Recommendation The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Quality and Safety Committee. Board Action Required As recommended.


QUALITY AND SAFETY COMMITTEE

MINUTES OF MEETING HELD ON 10 MAY 2017 BOARD ROOM, CANALSIDE HOUSE

START TIME 9:00 AM

Members Present Dr Simon Murphy Non-Executive Director (Chair) Mr Mark Axcell Chief Executive Mr Harry Turner Non-Executive Director Mrs Rosie Musson Interim Director of Nursing Dr Mark Weaver Joint Medical Director In Attendance Ms Margaret Barnsley Serious Incident Co-ordinator Mrs Debbie Cooper Vulnerable Adults and Children’s Lead Mr Tom Jinks Patient Safety and Compliance Manager Mrs Rebecca Temple-Purcell Senior Workforce Development Manager Mr Neil Tong Patient Safety Facilitator Mr Graeme Welsh Patient Safety Analyst) Mr Noel Aslett Deputy Chief Pharmacist (item 17) Mrs Amanda Rose Directorate Admin Lead (Note Taker) Mr David Miles Quality Improvement Facilitator Ms Tracy Cross SED (items 14 & 15) Ms Jasdeep Dhillon PMO (item 11) Mr Makhan Singh IMT(item 16) Mr Rupert Davies Interim Director of Finance (item 13) Mr Terry Inglefield STK Fire Safety Contractor (item 13) Mr Phil Clarke Head of Estates (item 13) Apologies Dr Kate Gingell Joint Medical Director Dr Ananta Dave Consultant Child Psychiatrist Mrs Julie Adams Service Experience Lead Dr Andrew Campbell Chief Pharmacist Mrs Olive Hewitt Clinical Quality Improvement Manager Ms Lesley Writtle Acting Director of Operations Mrs Ashi Williams Associate Director of People Mr Liam Dolan Associate Director of Operations Ms Wendy Pugh Director of Nursing, Operations and Estates


Agenda Item number: 8.1.1b

Enclosure: 7

Enc 7 Final QS Minutes - 10 05 17 - v1.0 Page 1 of 14

The Committee noted that Mr Axcell would be leaving the meeting early.

25 WELCOME AND APOLOGIES

The Chair reminded the Committee that it was Mental Health week. The Committee welcomed Mr Miles to the meeting. Mr Miles was observing the Committee to gain a broader understanding of governance and compliance requirements within the organisation. Apologies for absence were noted as above.

26 DECLARATION OF INTERESTS

Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. Dr Murphy declared his membership as a Non-Executive Director on the Board of Birmingham Community Health Care Foundation Trust. No further declaration of interests was declared at the time of the meeting.

27 MINUTES OF THE PREVIOUS MEETING

The Minutes of the meeting held on 12 April 2017 were agreed as an accurate record.

28

MATTERS ARISING ACTION SHEET

The Chair asked whether there were any actions from the Minutes which were not included in the Matters Arising schedule. No further actions were raised. The Chair thanked everyone for their efforts in moving these forward.

Action updates were noted as follows:

Item 255.1 – Trusts Criteria for Admissions from a risk to self and others due to Aggressive and Disruptive Behaviour. Work is continuing and a full report will be presented to the Committee in July 2017. In relation to Complex Cases and Dangerousness it is clear that other Trusts also have similar experiences regarding the response from the Police when staff request their intervention. Mr Axcell informed the Committee that in a recent discussion with Mr Russell the responsiveness of the Police was discussed and Mr Russell asked Mr Axcell to raise any issues directly to him


and he would in turn discuss these with West Midlands Police contacts.

Item 9.2 – Mortality Review Group Report. Mr Jinks advised the Committee that further work is required on ensuring the Action Plan is robust and similar items are grouped together. The Action Plan will be presented to the June Committee in its current format without the grouping being completed. Mr Tong informed the Committee that the final Action Plan will be the same format that Birmingham Community Health Care Trust uses.

Item 9.4 –Safer Staffing Report. Mrs Musson informed the Committee that the metrics for Safer Staffing are being incorporated in to the dashboard and this will be reported and monitored through the Workforce Committee as well as directly to Trust Board through the dash board. The Trust now has a rolling plan of recruitment to Band 5 RMN posts on the inpatient areas. Mrs Musson explained that regular meetings with the Ward Managers were now being held focussing on how Safer Staffing will be managed going forward. Action closed.

Item 111.4 – 2017/18 Income and Expenditure Financial Plan. Mr Axcell reminded the Committee of the need to ensure that the Trust learnt lessons from the refurbishment of Clent following staff feedback. Mrs Cooper informed the Committee that the full plans for refurbishment of Bushey Fields wards had been explained and the initial concerns now addressed. This action is now closed.

Item 197 –Dual diagnosis. Mr Turner noted that the completion date had changed several times and asked for an update. Mrs Musson explained that due to difficulties with diary management a small working group had been meeting to move this forward and a paper will be presented to the Committee in July. Mr Turner asked if a comment could be entered in the “notes” column if a date slips in future. Dr Weaver reminded the Committee that when the Trust lost the contract to provide Substance Misuse Services it also lost the people with the knowledge, and of the importance to build links with our partners who now deliver the service so that we can move forward together.

Items 226.1, 252, 284, 307.2, 318 and 326 are all completed and therefore closed. The Committee agreed that the completed green actions could be closed. Action: Mrs Tyrell-Haye to update the log.

29 FEEDBACK FROM BOARD / Q&S COMMITTEE REPORT FROM PREVIOUS MEETING

The Chair gave an oral update as follows: • Staff feedback being gained during the “On Board” visits needs to be


gathered whilst maintaining the informal atmosphere that the visits currently encourage. The Staff Champions are to be consulted on this topic.

• TCT Risk Register is under construction. • Trust Board acknowledged that the Quality & Safety Report showed a

spike in incidents and this was related to several patients. Board also noted that the number of compliments received were down month on month. In order that any trends are identified and acted upon further investigations are to be made and findings reported through to this Committee. During the Supportive Visits the team are talking to patients and relatives and there is no feedback that causes concern.

• Ms Writtle is investigating how the Trust currently delivers services that are not commissioned and do not attract any payment or where funding may be frozen but expected activity increased.

• The Trust’s allocation of Junior Doctors is extremely low. Dr Weaver explained that this is more of an issue for Dudley due to the low number of allocated CT1’s, however Dr Iqbal is in regular contact with the Deanery and is assured that the Trust will receive sufficient notice to implement contingency plans. Dr Weaver will update the Committee in June. The Chair asked that the allocation of Junior Doctors form part of the Medical Directors Update to Committee until the outcome is known.

30 DEEP DIVE

POST CQC (NOV 2016) VISIT

The Chair noted that this was an impressive and comprehensive report and asked Mr Tong to take the Committee through the report. Mr Tong took the Committee through the presentation and explained that the document included risks identified following the February 2016 visit along with emerging risks from the November 2016 visit. The report identifies any common themes or issues from the February 2016 visit and looks at progress made. A number of updates were proposed to the following risks by the committee: 313 (Fit and Proper Persons Requirements) – It was felt following discussion that this risk should be closed as it would also be subject to regular ongoing audits from CW Audit. 314 (Interface between electronic and paper records) – It was noted that this would need to remain a red risk at this moment in time until a more appropriate solution was agreed. 315 (Care plan development and clinical risk assessments) – Following discussions, it was noted that as the CQC did not provide the Trust the necessary assurances it required to downgrade this risk, as such it was felt by all concerned that this should remain on the risk register. 316 (Records in relation to the use of long term segregation). – It was


agreed by members of the committee that this risk could be downgraded due to the assurances received and further ongoing sources of assurance in particular audit work being completed as and when the Trust records a case of long term segregation 317 – (in relation to staff failing to receive regular appraisals and supervision) – Quality and Safety Committee concluded that whilst this risk should would remain on the risk register, it was felt that the Workforce Committee would be best placed to decide upon whether this risk needed to be downgraded. 318 – (In relation to medication issues) – It was noted that this risk had already been closed by the Trust’s CQC steering group 319 (Use of blanket restrictions) – It was felt that this risk could be downgraded (as had already been agreed by Mental Health Act Scrutiny Committee), however should remain an Amber risk at this moment in time and that the focus of the risk should be targeted upon ensuring implementation of the Trust’s Search Policy. 320 (Protocols regarding staff safety) – Following some discussion it was felt that this would need to be tested by the Trust’s program of supportive visits and as such should remain on the risk register until the Trust had further sources of assurance. 321 (number of outstanding policies) – It was concluded that this risk could be closed following discussion at the committee, noting that issues in relation to the application of Section 136 and its associated policy would be included within a (to be developed risk) in relation to that topic. 322 (timely response to Crisis Calls) – A benchmarking audit has taken place and the results are to be reviewed under a later agenda item. 323 (training issues / mandatory & essential training) – Following discussion at the committee it was noted that this risk might be applicable for escalation as a red risk due to a number of training issues being noted within the report and its implications that the risk has on ensuring its workforce are trained for the task in hand. It was felt that this should only be done however in agreement with the Trust’s Workforce Committee. 324 (immediate improvements to the Bloxwich ward environment). It was noted that this risk had already been downgraded/closed by the Trust’s CQC steering group. Risk 325 and 326 – following discussion it was agreed that both risks should remain on the risk register to ensure that progress is maintained and the teams have ownership of the action plan. Mr Tong took the Committee through the newly identified potential risks. Topics noted as being potential risks included:

• Risks around emergency equipment and emergency medicines • Risks in relation to Physical Health Monitoring


• Risks in relation place of safety / 136 suites • Ward handovers • Risks around staff safety • Risks around staff failing to document capacity in a decision specific

manner • Medication Risks (controlled drugs) • Patient activity provisions out of hours

In relation to the emergency equipment and emergency medicines, Mr Aslett informed the Committee that this was being addressed via the Resuscitation Committee. Mrs Temple-Purcell updated the Committee on progress made by the Resuscitation Committee. Mr Aslett went on to explain that this equipment was not familiar to staff because it was not called upon regularly. Mr Tong informed the Committee that the current risks would be updated to reflect the Committee’s comments and the new risks would be added, following which the risk register would then be presented to the CQC Steering Group. The Committee asked that the discussions were reflected in the Report to Board. Mrs Musson reminded the Committee of the need for the risks to be owned by the Service Lines so that the hard work completed becomes part of everyday practice. Mr Axcell informed the Committee that it would be helpful for MExT to receive a copy of this report for information. Mr Turner asked what would stop the Trust achieving “outstanding” from future visits. Mr Jinks explained the scoring matrix used by the CQC, the Trust must ensure that the standards are maintained and the good practice is embedded across all service areas in a consistent manner. Mrs Musson informed the Committee that innovation needs to be clearly identified and embedded.

QUALITY AND SAFETY

31 QUALITY REPORT

Mr Welsh informed the Committee that the report is now based on the areas covered by the new service lines which are in line with the Trust’s Informatics Reports as from 1 April 2017. The report also includes additional information regarding the level of harm / injury incurred; ongoing bench marking; and on an exception report basis detailed information from the Clinical Service Development and Medical Services will be included. Mr Welsh presented the April 2017 Quality Report and the following were highlighted:

• There were a total of 367 incidents during the month, which


represents a decrease when compared to March 2017. A total of 4 Serious Incidents were report; 252 incidents relating to patient safety; and 68 security incident reports.

• 157 Disruptive / Aggressive Behaviour incidents were recorded. • Of the 252 PSI recorded 141 incidents resulted in no harm; 104

resulted in low harm; 5 incidents of moderate harm were recorded; and 2 deaths have been recorded.

• 1 Duty of Candour case. • 7 Safety Alert Broadcasts had been received.

2.1 Inpatient Service – there have been a total of 265 incidents reported across the service. Adult Inpatients have recorded 122 of which 59 relate to Dudley and 63 to Walsall wards. Older Adults Inpatients recorded 143 incidents which remain consistent with previous months; 79 incidents were recorded by Dudley and 64 incidents were recorded by Walsall wards. 68 incidents resulted in the use of Physical Intervention. The Adult Inpatient service reported 19 incidents which involved 11 patients. The Older Adult service reported 49 incidents involving a total of 12 patients. The service lines have no RIDDOR. 2.2 Urgent Care and Access Services – there were 29 incidents reported by the service; 10 related to Dudley and 19 to Walsall services. The PLT services in both localities are showing an increase in the number of Serious Harming Behaviour incidents being recorded, all incidents have been reviewed and are either Low or No Harm. 2.3 Community Services – 22 incidents were recorded by the service in April 2017. The Dudley locality recorded 14 incidents and the Walsall locality reported 8 incidents. There were 7 deaths recorded; these patients had passed away due to physical health issues or natural causes. The Mortality Review Group will review these 7 cases in accordance with Trust policies. The Chair acknowledged the detail of the information contained within the new formatted report. Mr Jinks complimented Mr Welsh on the new format and detail contained within in the report. A discussion was then held regarding how the key messages from the report could be relayed through to Board. Mr Axcell asked if the Disruptive / Aggressive Behaviour incidents reported by Clent were linked to the refurbishment works currently being completed on the ward. Mrs Cooper assured the Committee that the works were in no way attributed to incidents. 3 Serious Incidents - A total of 4 Serious Incidents raised during April 2017, 3 for Community Services and 1 for Inpatient Services. The Committee noted the detailed summary of active serious incidents and their current status.


The Committee went on to discuss the level of detail contained within the table in Section 3.2 Serious Incidents. The Committee were assured that all service lines have detailed incident reports on a monthly basis and these are presented to the service line meetings as a standard agenda item. Mr Tong reported that there were 7 alerts issued by the CAS; 2 required no further action; 3 are being assessed for relevance; 1 has been circulated for information; and 1 requires action to be completed by October 2017 and work is ongoing. Safeguarding – Mrs Cooper updated the Committee on training compliance, DOLs, Domestic Violence, MARAC and Vulnerable Adults. The Committee received the report for information, discussion and assurance.

32 QUALITY AND SAFETY HIGH LEVEL RISKS

Mr Tong informed the Committee that the Risk Register had been reviewed and updated by Mr Lewis-Grundy and himself. Mr Tong took the Committee through the report advising that there were currently 9 operational risks. Risk Scoping has been completed in relation to the TCT work, as requested by the Committee, and identified 5 areas where there are potential risks of which 2 were already being reported to the Trust’s Workforce Committee. Mr Axcell asked the Committee to note that risks identified in relation to TCT work should be expected to grow as progress is made. The Chair informed the Committee that the newly identified risk in relation to TCT work regarding “impact upon the Quality and Safety” will be owned by the Committee.

33 INTERIM DIRECTOR OF NURSING/JOINT MEDICAL DIRECTORS UPDATE

Dr Weaver gave an update as follows:

• A Zero Suicides event is being held in Coventry and Dr Dave and Professor Afghan have been nominated to attend the event on behalf of the Trust. Further feedback is to be provided to the Committee in future Medical Director Updates.

• The lack of written protocols and pathways for the treatment of people with Korsakoffs has been raised by doctors. Mrs Cooper informed the Committee that this subject is on the agenda at the next CQRM. Dr Weaver and Mrs Musson will complete a piece of work regarding the Trust’s position.

Action: Dr Weaver and Mrs Musson to develop a position statement for the Trust relating to Korsakoffs


• Professor Joy Duxbury’s approach to reducing restraints on ward areas is looking for implementation sites. The program is based on 6 core areas of strategy.

The Chair thanked Dr Weaver for his update. Mrs Musson provided the following update: • Work continues in relation to the Safer Staffing requirements. Nurse

vacancies are being monitored and the impact of same on staffing needs and patient care. Mrs Cooper assured the Committee that the Ward Managers are meeting regularly to monitor and address any issues that may arise.

• The Trust currently has very successful Band 5 and Band 6 Nurse Development programs in place; a Ward Manager program is being developed to compliment the two existing programs.

• CQUINS – a new reporting system is being implemented based on the learning from last year’s process.

• NMC Registrations are the responsibility of the individual nurse but the Trust needs to have a robust system in place to ensure that all qualified nurses are “live” on the register. The current policy on managing professional registration is currently being updated.

34 DRAFT QUALITY ACCOUNT

Mrs Musson informed the Committee that the Quality Account was now in draft form for comments and feedback. The Committee were reminded that there is an expected format for the Quality Account. Mr Turner noted that section 2.8 “What others say about the Trust” only contained information from the CQC and Royal College of Psychiatrists. Mrs Musson explained that our local partners have received a copy of the draft report for comment and a deadline of end of May for feedback to be returned to the Trust. Mrs Musson asked that the Committee members read the report and submit their feedback by end of May. The report needs to go to Board for approval before it can be published. The Chair asked for the final draft Quality Account to be brought back to the June Committee before submission to Board. Action: Mrs Musson to present the final draft of the Quality Account to the Committee before submission to Board.

35 PMO GOVERNANCE FRAMEWORK FOR THE DELIVERY OF CIP, QIPP AND PARTNERSHIP PROJECTS

The Chair welcomed Ms Dhillon to the meeting. Ms Dhillon presented the PMO Governance Framework paper to the Committee. The proposed changes will mean that the CIP, QIPP and


partnership projects are subject to the same Governance arrangements under the Framework. Deloitte have completed a review of the PMO and made a number of recommendations to the Governance Framework which have been incorporated in this paper. The Framework also promotes ownership and accountability at all levels. The Medical Director and Director of Nursing will receive Quality Impact Assessments for review and sign off. The Quality and Safety Committee will receive Quality Impact Assessments and any adverse risks affecting quality will be highlighted to the Committee. The monthly reporting cycle with Project Leads completing highlight and exception reports is to be implemented; the PMO will escalate any red risk projects to the Executive Sponsor for the project. The exception reports will be reviewed by the Director of Finance, Clinical Development Director and the Deputy Director of Finance prior to the CIP, QIPP and Partnership Programme Board. The Chair confirmed that the Quality Impact Assessments would be a standing agenda item for the Committee. Mr Axcell reminded the Committee that both the Medical Director and Acting Director of Nursing have to be assured of the safety and quality of service delivery; holding the leads to account and challenging appropriately until the required assurances have been received. Dr Weaver and Mrs Musson acknowledged that this was an important area for the roles of Medical Director and Acting Director of Nursing. The Chair reiterated the importance of the Committee’s role in challenging and raising concerns regarding quality and/or safety during service transformation, the implementation of a robust reporting process will allow the Committee to fulfil its role in this area. The PMO Governance Framework Report was endorsed by the Committee. Ms Dhillon was thanked for her attendance and left the meeting.

36 CRISIS CALL LOGS RE-AUDIT

The Committee discussed the audit report which detailed response times for crisis calls. Mrs Musson informed the Committee that all responses were within the hour but there were variations in delivery between the two localities due to the differences in commissioning. Mrs Cooper explained to the Committee that the agreed response time was set by the Trust following a number of complaints being made in this respect. The response rate is within 1 hour from when Switchboard takes the phone call. A robust call logging process has been established and is being followed by the team.


The Committee were informed that as from the start of May the team would only take calls from patients known to Mental Health services who are in a Crisis, allowing staff to focus on patients who are in Crisis. This audit would serve as a baseline for future audits to be measured against. The Committee discussed the viability of having 1 central team handling the Crisis element of our services but acknowledged this would require further exploration because the team were required to attend various other places of safety outside of the hospital sites. The Committee agreed that Mrs Carey should be invited to a future meeting to provide assurances on the safety and effectiveness of the remodelled service. Dr Weaver informed the Committee that following the implementation of the new way of working staff are reporting that the service is more responsive Action: Mrs Musson to liaise with Mrs Carey regarding a report on the Crisis Service remodel. Action: A re-audit of the Crisis Call Logs is to be completed at the end of quarter 1.

37 FIRE SAFETY PLAN UPDATE

Mr Davies, Mr Inglefield and Mr Clarke were welcomed to the Committee. Mr Davies updated the Committee on the strong progress made on the Fire Safety Action Plan, specifically: the minimum number of Fire Marshall for all sites; and all qualified nurses on the inpatient areas to attend the Fire Marshall training. Bloxwich Hospital is also training HCA staff as Fire Marshalls too. The non-hospital sites have a deadline of the end of August to ensure that sufficient staff are trained. Mr Davies informed the Committee that the Fire Risk Assessments had been completed for the 3 hospital sites and that 3 common risks had been rated as red risks. Mr Inglefield explained that funding had been identified for 2 of the risks and it was expected that work would be completed within 3 months. However in terms of the replacement of bedroom fire doors funding still needs to be identified. Mr Davies informed the Committee that the current spending plans for the Capital Budget would be reviewed and reprioritised to complete the upgrading of the bedroom doors. The Committee agreed that the 3 red risks identified would be included in the exception report to Trust Board and asked that timescales for completion of work be included in the Fire Safety Report for June’s Committee.


Mr Inglefield acknowledged the progress made against the action plan and reminded the Committee of the need to ensure that work continues to ensure the Trust meets its obligations under Fire Safety. Mrs Musson assured the Committee that fire safety processes are in place and are monitored by the Fire Safety Group, chaired by Mr Davies. The Committee thanked Mr Davies, Mr Inglefield and Mr Clarke for their report.

EXPERIENCE AND EFFECTIVENESS

38 EBE’S REPORT

Ms Cross presented the EBEs report to the Committee on behalf of the EBEs and advised that the EBEs attended a number of corporate events and MERIT / Vanguard work groups throughout April 2017. The EBEs also continue to undertake ward visits and attend Drop In sessions. During April the PLACE assessments were completed. Mrs Musson thanked the EBEs for their involvement. Monitoring of PLACE assessment actions will be incorporated into the Supportive visits. Work continues with the Patient Reported Experience Measure (PREM) pilot and the Committee were informed of the positive work that is being undertaken with CAMHS regarding the delivery of service experience days for children.

REGULATATION AND COMPLIANCE

39 SERVICE EXPERIENCE QUARTERLY REPORT Q4 2016/17

Ms Cross took the Committee through the report. Compliments continue to make up the largest feedback category, with the EI service line receiving the highest number. The Trust has received 58 complaints regarding poor communication, 41 specifically relating to messages being left for Talking Therapies and no return calls being made. A number of complaints regarding “staff attitude” have been received. Some bespoke training for staff has been developed based on staff learning lessons from a patient story. There have been breaches in the complaints response times and more training is to be provided to increase the number of people able to investigate complaints. The Chief Executive is being provided with weekly updates to enable him to monitor the situation. As part of the Outpatients Project Team the group have looked at DNAs and the EBEs have suggested that that text reminders could be sent to service users, and the need to raise awareness of DNAs and the impact on everyone’s care that they have.


Mrs Cooper reminded the Committee of the complex nature of the complaints received and the limited number of staff able to investigate complaints. The number of compliments initially increased in line with the “You said, We did” communication strategy and Ms Cross informed the Committee that this strategy it to be re-energised. There was discussion regarding the Benchmarking against other Trusts and how this could be more meaningful and that when previous Benchmarking has been undertaken the Trust scored middle of the road. Mrs Musson noted that the good triangulation of service user feedback, incidents and other feedback allowed trends to be highlighted. The Committee thanked Ms Cross for her time and she left the meeting.

40 PERFORMANCE REPORT

Mr Singh was welcomed to the Committee. Mr Singh presented the report to the Committee, drawing attention to the following areas: CPA - The Trust remains above the 95% threshold for Copies of Care Plan at 96.5% and CPA Formal Reviews performance is at 96.9%. An audit of CPA is being completed. PDRs – Data now indicates that appraisals rates are at 86.97% as of the end of March 2017, this is above the Trust target of 85%. Sickness – The sickness rate for the Trust has reduced to 3.33% as of the end of March 2017. Mandatory Training – Remains below the Trusts target of 90% at 89.82%. The Safer Staffing metrics have been included on the Dashboard from April 2017. Mr Turner acknowledged the outstanding performance identified by the report and noted the limited yellow highlighted areas. Mr Singh left the Committee.

SUB-GROUP EXCEPTION REPORTING / MINUTES

41 MEDICINES MANAGEMENT COMMITTEE

Mr Aslett took the Committee through the Annual Medicines Management Report which gave an overview of key aspects of the work of the Medicines Management Team during 2016 /2017.


The report identified and supported the need for the Trust to move to an electronic prescription format. Dr Campbell will develop a strategy for this. Mr Aslett explained the current Pharmacy arrangements across the TCT and that the proposed arrangements are being worked through. Mrs Musson asked if any trends had been identified regarding medication error incidents. Mr Aslett informed the Committee that many of the incidents were reported because the cards were illegible and the nursing staff raised the incidents to stop any future errors. Mr Welsh updated the Committee on this and discussion was had around this. It was agreed that any risks in relation to such incidents would sit with the Medicines Management Committee and should be reviewed by them. The Committee received and adopted the report.

42 CLINICAL AUDIT AND EFFECTIVENESS COMMITTEE

Mrs Musson informed the Committee that no new audits have taken place and that the new audit plan is to be agreed at the July CAEC.

43 AGREEMENT OF NEXT QUALITY AND SAFETY COMMITTEE AGENDA

The Chair confirmed that there were certain standing agenda items and that there were matters arising that were to be removed from the matters arising as discussed earlier. Two Deep Dives have been identified for presentation to the June Committee however Mrs Musson is to seek clarification from Mr Axcell regarding the appropriateness of the Section 75 deep dive being undertaken by the Q&S Committee given the other areas this reports into. Mrs Tyrell-Haye is exploring the possibility of rescheduling the Committee dates but due to competing priorities the June Committee date cannot be moved.

44 ANY OTHER BUSINESS

The Chair informed the Committee that were no items for discussion.

45 AGREEMENT OF ITEMS TO BE INCLUDED IN REPORT TO THE BOARD

The Chair informed the Committee that the report would be put together from the discussions held in the meeting.

46 DATE AND TIME OF NEXT MEETING

Wednesday, 14 June 2017, 9.00 am – 12.30 pm, Conference Room 1, Trafalgar House, Dudley



Agenda Item number: 8.1.1c Enclosure: 8

Report Title:

Mental Health Act Scrutiny Committee Chair’s Report

Committee:

Mental Health Act Committee

Author:

Gill Cooper – Non Executive Director Tom Jinks – Compliance and Safety Manager

Introduction The Mental Health Act Scrutiny Committee met on the 08th June 2017. Key issues discussed at the meeting included:

• Joint Associated Lay Managers Feedback / Meeting – Positive feedback and discussions held • MHA Committee Annual Report – Draft report endorsed by Committee • Updated Mental Health Act related risks – Risks updated to reflect recent CQC Outcomes • CQC Action plan – Review of MHA related actions – Actions updated to reflect current position • Terms of Reference review – Revised version of Terms of Reference were endorsed • Change of Committee Chair - Committee acknowledgement and thanks to the Chair of the

Committee who is stepping down from this role. Summary of key points, issues and risks Associated Lay Manager (ALM) Joint meeting A joint update meeting was held between the Trust ALM’s and the members of the Mental Health Act Scrutiny Committee. During the meeting, the following areas were discussed:

• Paperwork -Feedback was given from the ALM’s that the quality of paperwork used in panel meetings had improved and that the clinicians reports were helpful to providing context and summary of issues / care provided

• Attendance at Panels – Some concerns were raided about the fact that sometimes the staff attending the panel with the patient have had limited direct involvement in the care provided


Gain assurance

Discussion

Information

MHA Scrutiny Committee Chairs Report to Trust Board Page 1 of 4

• Discharge planning – The process of discharge planning post panel meetings was discussed and it was acknowledged that sometimes delays in discharge do occur where complex arrangements to support the patient are required.

• 136 suite staffing – Discussion around the need to staff the 136 suite – it was noted that this is

currently an action being addressed via the Trust CQC action plan.

• Physical health and mental health act process – Discussion occurred regarding the interdependencies and complexities that sometimes exist regarding a patients physical and mental health needs

• Supportive visits - The ALM’s requested that they are considered for inclusion in the next round of Trust Supportive Visits

• Communication regarding TCT on a quarterly basis – The ALMs requested that for their own information that they are included in all Trust issued TCT related communications.

MHA Quality Report The Quality Report was presented to the Committee for information and assurance. The Committee was informed that during May 2017 there had been:

- 66 restraints recorded – all restraints had been reviewed independently by the MAPA Leads and were assessed as being appropriate intervention for the needs of the patients.

- 18 active cases of DoLS across the Trust.

- 6 incidents for failure to return from Section 17 leave, and 4 absconds. - It was noted that no harm had been sustained by any of the patients concerned during these periods.

- 1 MHA specific incident had taken place in month. The case had not resulted in any harm and

was a process issue which is being addressed through staff training. Quality and Safety High Level Risks The Committee was advised that there are currently ten operational red risks and two new risks were presented to the Committee that were in relation to: a) Changes to the local interagency 136 Policy may leave to Trust open to reputational risks around its implementation. b) Failure of the Trust to achieve its mandatory and essential training which may result in staff not being appropriately skilled to undertake their role. The Committee also recommend to Trust Board that one risk relating to appraisal and supervision is split into two risks and both elements downgraded to Amber status. CQC Action Plan The Committee received and endorsed the latest version of the Trust CQC action plan.


Clinical Audit Forward Plan The Clinical Audit forward Plan for 2017/18 was presented and was endorsed by the Committee. Mental Health Act Annual Report 2016/17 The Committee received, reviewed and endorsed (subject to minor amendments) the draft Mental Health Act Annual report for 2016/17. The Annual Report is a separate Trust Board Agenda item Mental Health Act Committee Risk Register The Committee reviewed and endorsed the latest updates of the Mental Health Act related risks contained on the Trust Risk Register. The risk scores had been reviewed so align with the findings of the recently published CQC Report following the Trusts CQC assessment that occurred in November 2016. Report on Incidents where Police have been called to assist staff with hostile and aggressive patients A report that provided a summary of incidents where the police had been called to hospital sites in order to support staff with the management of “hostile” or severely aggressive patients was presented to the Committee The Committee were informed that the frequency of incidents where police support was required was increasing and whilst in the majority of cases the police had offered very supportive and quick assistance, there had been some noted delays relating to a few incidents where the timeliness of police attendance was deemed to be inappropriate in supporting staff to effectively manage the presenting risks. It was agreed that this issue would be discussed with the Partnership Board and feedback provided to the Committee at the next meeting. Review of Mental Health Act Scrutiny Committee Terms of Reference The Committee reviewed and endorsed the latest version of the Terms of Reference. Acknowledgement and Thanks to Committee Chair The members of the Committee expressed their sincere thanks and gratitude to the Chair of the Committee who had announced that she was relinquishing her role as Chair of the Committee. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• MEXT • Quality and Safety Committee


Recommendations and requests for direction The Trust Board is asked to:- Accept this report for assurance about the exercise of delegated authority by the Mental Health Act Scrutiny Committee Endorse the decisions and recommendations made by the Mental Health Act Scrutiny Committee .



Agenda Item number: 8.1.1c

Enclosure: 8 Appendix 1

Report Title: Mental Health Act (MHA) Scrutiny Committee Annual

Report Accountable Director: Gill Cooper, Non-Executive Director Author (name & title): Hassan Omar, Head of Social Care Purpose of the report: Annual MHA Scrutiny Committee Report to the Trust Board


Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report MHA Scrutiny Committee on 08/06/17.

Key points or recommendations from Committee or Group: Present to the Trust Board for assurance.




Leadership culture





Please give brief details: (Improvements / Risks to current position)

Caring

To provide high quality of care underpinned by statutory requirements.

Responsive

Act at all times to respond to patients / service users’ needs.

Effective

Organisation and care to patients / service users.

Well-led

Leadership, understand and mindful of the appropriate legislation

Safe

Patients / service users and organisation is kept safe by the use of the appropriate legislation

Enc 8 Appendix 1 MHASC Annual report - 14.06.17 Page 1 of 14

Title Mental Health Act Scrutiny Committee Annual Report Foreword This year’s 2016-2017 Mental Health Act Scrutiny Committee report again confirms the Trust’s commitment to ensuring the effective delivery of its statutory responsivities across all service lines. This commitment remains at the heart of our core business. Due to the nature of Trust business leading on and providing high quality mental health care within the Black Country, we come into contact on a daily basis with some of the most vulnerable adults and children in society. We take our responsibility to promote the safety of those for whom we provide services very seriously and in order to positively impact on this we provide high level consistent support, guidance and training to our front line staff to equip them with the daily challenges they face in this area of their practice. Our Trust Board accountability as Non-Executive and Executive Leads has never been more important, with a growing number of cases needing a high level of support, intervention and expert guidance. Partnership working with our colleagues from neighbouring services including the Police, Clinical Commissioning Groups and local authorities remains vital. Effective communication is the cornerstone to making sure that we deliver on our commitment to protect the vulnerable. We are pleased to endorse this Mental Health Act Scrutiny Committee Annual Report for the period 2016/2017. Gill Cooper Rosie Musson Non-Executive Director Acting Director of Nursing Chair of MHA Scrutiny Committee Executive Summary This is the third Annual Report of the Dudley and Walsall Mental Health Partnership Trust’s Mental Health Act Scrutiny Committee. It sets out the framework within which the Committee operates, provides an overview of its activities in 2016/7 and the outcomes of its deliberations, and looks ahead to developments and the changing role in 2017/8. The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services, the quality of service user and carer experience, and the long term protection of stakeholder interests. Good governance emanates from the Board but pervades the entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial and organisational aspects of governance and enables key risks to be identified and managed, in both operational and strategic terms. The Mental Health Act Scrutiny committee ensures the organisation is working within the legal requirements of the Mental Health Act (1983), as amended by the 2007 Act and Mental Capacity Act 2005.


An important feature of the Trust’s governance structure from the outset was the Mental Health Act Scrutiny Committee (MHASC) which, by contrast with some other trusts, reports directly to the Trust Board and is chaired by a Non-Executive Director. Its principal responsibilities lie in ensuring the Trust’s compliance with all aspects of the Act and that significant reports from the Care Quality Commission, are actioned appropriately. Introduction Dudley and Walsall Mental Health Partnership Trust (“the Trust”) was established in 2008 with a commitment to improving local mental health services. It has specific responsibilities in terms of the conduct, administration and application of the Mental Health Act 1983 (“MHA 1983”), as amended by the Mental Health Act 2007 (“MHA 2007”), more generally “the Act”. It operates under the guiding principles as set out in the Code of Practice and associated legislation including the Mental Capacity Act, Deprivation of Liberty Safeguards and the Care Act 2014. The MHA scrutiny committee ensures that policies and processes in relation to the various acts are in place and appropriately scrutinised for its application across all services. The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary. This is the third Annual Report of the Trust’s MHASC. In particular, it: • sets out the framework within which the MHASC acts; • looks back over the year 2016/17; and • looks ahead to the future. Summary of key points, issues and risks 1. The Framework within which the MHASC operates

1.1. Membership of the MHASC The nominal core membership of the committee is set out in the Terms of Reference. In practice organisational developments within the Trust meant a number of these roles and the individuals within them changed, so that the current de facto core membership is:

Non-Executive Director (Chair) Non-Executive Director (Vice-Chair) Director of People & Corporate Development Director of Operations, Nursing & Estates Clinical Director, Acute Services Head of Acute Services Head of Older Peoples Services Head of Social Care Approved Mental Health Professional (AMHP) Lead Learning & Development Lead Equality and Diversity Manager Mental Health Act Manager


1.2. Reporting The Chair of the Committee reports on a regular basis to the open session of the Trust Board identifying any issues that require disclosure, or require executive action. Due to the nature of the issues considered, it may be necessary for the committee to liaise directly with other sub-committees, in which case specific and appropriate arrangements will be agreed.

All members of the MHASC continued to oversee the effective delivery of the mental health act and have ensured the Trust remain compliant with all requirements of the Act.

2. AMHP Activity.

The purpose of the report is to provide the MHA Scrutiny Committee with detailed information on the use of the Mental Health Act in Dudley and Walsall. DWMHPT utilise an agreed template which ensures the collation of relevant data. The data is initially presented to MHASC for discussion and approval. Once approved, the data is again included on the agenda for the Partnership Operations Group (POG), Mental Health Act Partnership Group meeting and the Social Care Forums.

3. Mental Health Act Partnership Group Update

The Mental Health Act Partnership Group (MHAPG) is accountable to the Mental Health Act Scrutiny Committee (MHASC) who in turn is responsible for the discharge all statutory requirements of the Mental Health Act 1983 as amended in 2007 (MHA) legislation. The MHAPG also provides assurance to the MHASC of partnership working across all MH service lines and with partner agencies. External members of the MHAPG such as the police and ambulance service utilise their own governance arrangements as per its organisations protocols.

3.1. The Group Membership is made up of;

Representative from West Midlands Police - Walsall Representative from West Midlands Police - Dudley Representative from West Midlands Ambulance Service Representative from Emergency Department (Manor & Russells Hall Hospitals) Head of Acute Services (DWMHPT) Head of Social Care (DWMHPT) (Chair) Clinical Director of Acute Services (DWMHPT) Senior Clinical Lead – Inpatient Services (DWMHPT) CRHT Team Manager - Acute Services AMHP – Walsall AMHP – Dudley MHAct Manager (When Required)

The MHAPG work collaboratively to monitor and maintains an overview of the application of the MH Act, thus ensuring compliance with legislation and the Code of Practice.

As such, the MHAPG endeavour to: • Work in Partnership to ensure best outcomes for patients and partners • Improve service delivery • Review operating procedures to ensure they are fit for purpose • Provide a forum to debate and challenge procedures • Share data • Monitor performance • Solve blockages preventing efficiency


• Identify training needs

3.2. Additional Duties/Responsibilities of the MHAPG • Reviewing and overseeing the implementation of joint multiagency collaboration. • Reviewing and monitoring the use of Sections 135/136 of the Act noting and ensuring

investigation of any emerging trends with respect to the detention and conveyance patients as required.

• Receiving the results of AMHP audits and other relevant reviews of the MHA and oversee the development and implementation of recommendations.

• Monitoring the role and functioning of this group and liaise with partner agencies as appropriate.

• Safeguarding – sharing of information.

3.3. Key updates, issues and risks Mental Health Triage Team - Mental Health Triage team is represented by the Triage Supervisor who provides a general update with reference to the number of interventions that result in the use of the Section 136 of the MH Act. Evidence of the actual numbers is detailed within the MH Act quarterly activity report.

The Triage team delivers bespoke training to their police colleagues with particular emphasis around the use of Section 135 warrants. The team also provides training to other organisations pertaining to the appropriate use of s.135/6. The staff utilise real case examples of the varied situations where the Triage team can be called upon to intervene.

A continuous discussion point for the group is the outstanding finalisation of Section 135/6 Place of Safety policy which is awaiting sign off by the police and CCGs.

The introduction of the Super Cell block which is located in Sandwell Borough had led to the decommissioning of many local police cell units within the Black Country. This change has meant that our medical and AMHPs assessing team will now travel to Sandwell on the occasions when a members of the public is deemed too risky to attend the s.135/6 suite. It is agreed and supported by both local authorities and Trust that the AMHP and the medic(s) from the area in which the patient was arrested would attend the Super Cell block and undertake the assessment. It is acknowledged that in some cases, there may be a delay in transporting detained patients to hospitals

Doctors - One of the main issues for Doctors is the confusion around their responsibility to the Super Cell Block. Whilst doctors are readily available attend the Super Cell Block for the purpose of undertaking Mental Health Act assessment, they state that they are not commissioned to attend for a general mental health assessment. The partnership members all acknowledge that this does not conform to a Least Restrictive practice and in effect forces all police requests down the MH Act route. This matter clearly is a commissioning issue which requires resolution if the Trust is to embrace the notion of Least Restrictive intervention.

The MHASC will recall earlier discussions relating to a MH Act assessment in a Dudley police station where the assessing team was prevented from leaving the police station for some hours. In essence, the assessing team felt the patient in question was not detainable under the MH Act. However, the duty sergeant disagreed with their assessment and took action by


not allowing the staff to leave the police station until they had a change of mind. The team was finally allowed to leave following many telephone discussion between the ‘on call’ consultant and other police seniors. Following a complaint by Trust staff, the police undertook an investigation which concluded some 12 months later and found that both the Trust staff and the police officers were equally at fault. I understand the clinical director is pursuing the matter on behalf of the team.

Acute Services - The unavailability of a Psychiatric Intensive Care Unit (PICU) bed is a consistent discussion item in the fact that when it is difficult to obtain a bed, who is responsible for the mentally ill patient during their long wait in the police cell. Another issue of discussion has been the response to incidences.

AMHPs - AMHPs have noted that since the introduction of the Mental Health Triage team there has been a decrease in the overall number of assessments taking place in the Section 136 suites in both Dudley and Walsall. It was also noted that the relationship between the police, ambulance service and AMHPs had significantly improved with response times for both police and ambulances being quicker. The AMHP’s in general are complimentary good working relationship between AMHPs and police, particularly the Mental Health Triage around their support in conveying patients to hospital.

Police - Police are represented by a Partnership Liaison Officer from both Dudley and Walsall. Both Dudley and Walsall Police inform the group of the number of calls per month taken by each area from hospital staff which range from reporting a missing person to requesting assistance on the wards.

4. Changes to the Mental health Act 1983

The Policing and Crime Bill received Royal Assent on 31 January 2017. Sections 80 to 83 of the Policing and Crime Act 2017 will significantly amend sections 135 and 136 of the Mental Health Act 1983.

The mental health provisions of the Policing and Crime Act 2017 were due to come into effect in May 2017 however this has been delayed due to the general elections taking place in June 2017. The changes may now commence in mid July 2017.

The following changes will be made to s.135 and s.136:

• Reducing the detention time from 72 hours to 24 hours – with provision for an extension of time on clinical grounds alone to a maximum of 36 hours

• A person can now be kept at a place of safety (and not solely removed). Broadly this applies across both sections 135 and 136. This means that under section 135 someone may be kept at home for a mental health assessment if it is appropriate and they consent.

• Extending section 136 powers to anywhere other than a domestic dwelling • Enabling mental health assessments under section 135 to take place in the person’s own

home rather than having to remove them • New powers of search for safety purposes in homes or places of safety under s135 and 136


• Under section 136 the requirement of being found has been removed, so someone may be kept at a police station potentially where they are no longer liable to be detained under PACE.

• The police officer must consult a registered medical practitioner, registered nurse or approved mental health professional if practicable before removing someone to or keeping them at a place of safety under this section.

• Stop the detention in police cells of children and young people under 18 who are experiencing a mental health crisis The guidance has not been published yet. The main issues will be- A possible increase in the use of s136 putting pressure on staff as currently the place of safety is unmanned, timely access to appropriate beds and the availability of section 12 approved doctors to facilitate timely access to Mental Health Act assessments.

5. Care Quality Commission Compliance.

During 2016/17, the Trust received reports (in relation to a number of core services) from its February 2016 visit, against which a robust action plan was created. A number of actions were implemented as part of a robust and comprehensive action plan into the outcomes of the visit, against which the Trust was rated as requires improvement. There were a number of actions implemented in relation to the application of the Mental Health Act, concerns and “must do actions” noted in relation to these are outlined in appendix 1:

All of the actions in appendix 1 were completed within the agreed timescales and further to the Trusts February 2016 visit, the Trust received a further visit from the CQC in November 2016, with the Trust moving from requires improvement to an overall rating of good.

Whilst the Trust did receive a rating of good, there were a number of actions identified which form part of the Trusts new CQC action plan. Areas applicable relating to the MHA against which further actions have been identified are as follows: • To ensure that staff follow good practice in relation to the Mental Capacity Act, in relation

to assessing capacity to consent to treatment on a decision specific basis. There must be clear documentation detailing how capacity is sought to consent or refuse treatment, and the reasons for the capacity decisions that are made.

• To ensure that the multi-agency operational policy for place of safety is updated and is in line with the MHA Code of Practice (2015). To ensure that effective processes are in place to monitor the quality of recorded information for all patients assessed in the health based place of safety. Information about rights given to patients when they commence on S136 of MHA must be constantly recorded.

6. Least Restrictive Practice and Governance / Quality Exception Report


All of the above incidents have been reported to the Trusts Mental Health Act Scrutiny Committee for discussion as part of the Governance Exception report to the committee. In addition to this, the committee continues to review the categorisation of these incidents and seek further assurances as and when required.

7. Care Act 2014 Update/Engagement/Triangle of Care (ToC) Implementation and Potential

Risks The Care Act 2014 was implemented on 1st April 2015 and sets out in one place, duties in relation to assessing people’s needs and their eligibility for publicly funded care and support. The Care Act has replaced much of the legislation which has guided our professional practice and represents the most significant reform of care and support in more than 60 years - putting people and their carers in control of their care and support.

The new Care Act is intended to help to make care and support more consistent across the country. ‘Care and Support’ is the term used to describe the help some people need to live as well as possible with any illness or disability they may have. The new national changes are designed to put people ‘in control’ of their care and make it easier for them to make plans for their care and support now, and in the future.

To aid the Care Act implementation process, DWMH initiated a project group called the Care Act Readiness Group (CARG) which met monthly to oversee and measure the agreed actions against the project plan. I am pleased to report the Trust’s achievements following which the CARG meetings were no longer required and the group dissolved. The outstanding areas noted below under ‘areas for further work’ is addressed within the Triangle of Care (ToC) work group to ensure on going compliance. For assurance, the leads identified within this report are included within the ToC membership.

Current Position Statement (CARG) and Summary of key points, issues and risks This section of the report is intended to evidence the Trust’s implementation of the Care Act and progress by each of the CARG Work Streams as identified below and provides the details relating to specific areas for improvement.

7.1. Assessment and Eligibility Work stream Progress Achieved: CARG has reviewed the newly rolled out Assessment Tool and have fed back suggested changes to the Clinical Process manager to ensure the document is user friendly and Care Act compliant. The suggested amendments are now incorporated. The Trust is in the process of developing a new assessment tool (DWROM) which is intended to incorporate the holistic needs of the service user and care planning. This document was presented to POG who, in principle, support the direction of travel. POG requested evidence from a sample of completed Needs Assessments from across the service lines. This is to include both low and higher Needs Assessments. DWROM members are working with the developers to ensure its compliance with the Care Act. The Trust’s Assessment and Care programme Approach (CPA) documentation is now fully Care Act compliant and will be reviewed to include future minor adjustment while ensuring they are written from a service user’s perspective.


Areas for further work - • Amend documentation - including the review forms and Care plans/Support plans. • Obtain sign off for the DWROM from both LA’s • Greater use of “I” statements in format of Care and Support plans - placing the person at

the centre of the process • Need for Separate S117 Support Plan identifying what services are being provided under

s.117.

7.2. Carers Work stream Progress Achieved: Both Local Authorities are very different. • The process to refer for Carer’s assessment in Dudley has been shared with staff and it

now links into Local Authority generic Carers team. Whereas in Walsall, the dedicated Mental Health Carers team undertake the required assessment for known service user’s carers

Areas for further work - • Young Carers – clarity about what services we offer. • Develop a review and audit process for mental health users of service in both authorities.

How do we evidence if carers are being supported in accordance with the Care Act • There is very little evidence from both LAs that Personal Budgets are being considered for

carers. What budget would they come out of? • Continue to embed Triangle of Care.

7.3. Safeguarding Progress Achieved: • Respective Local Authorities lead on Safeguarding and closely work with the Trust’s SG team. Trust is compliant in this area. All processes and training have been updated accordingly.

7.4. Information and Advice Work stream Progress Achieved: • Good amounts of information shared on the website. Links to LA are there to access on Trust Website. The intranet page of the Care Act had 629 internal visitors and the Internet web page had received 196 external visitors between March and October 2015.

Areas for further work – • Are practitioners using the community resource directory/information to support preventative work?

7.5. Transition Work stream Progress Achieved: • CARG members attend the Transition Care Act Group in each locality.


Areas for further work - • Arrangements in place for preplanning meeting with CAMHS/EI/Commissioning to explore

the required work within Dudley • Further links needed in Walsall. • Young carers in transition

7.6. Commissioning Work stream Progress Achieved: • Continued work to develop market – links with Local Authority. • Walsall has a range of preventative services and continue to develop the market • Dudley LA Commissioning Strategy has been provided and is at the early stages of

developing the market.

Areas for further work – • Will remain amber and continue to review trends & understanding of the local

market/future needs. Links to Transition. • Consistency over Dudley and Walsall.

7.7. Training Work stream Progress Achieved: The Trust has facilitated individual developmental sessions to the leads of each service line and will during the new financial year commence bespoke training programmes for the front facing staff in each service line. Will need to ensure alignment of the DWROM with the Assessment tool and the two complement each other.

• Expectations that all staff have accessed E learning • Doctor’s training delivered and the feedback from the medics has been positive particularly

given the required cultural shift to delivering a holistic care model where wellbeing is embedded.

• Corporate training delivered • Bespoke training sessions planned for each service line. • Work Stream will continue to develop specific training.

Areas for further work – • Identify numbers who have accessed training. • Can the Trust provide mandatory Care Act Training? • Continue conveying the message that the Care Act affects all areas of the service and how

everybody should be working – not just CPNs and Social Workers. • Specific bespoke training to all front line staff in the new year.

7.8. Summary

The headline message remains - the Care Act builds upon the Personalisation agenda and represents a cultural shift towards holistic assessment and partnership working with other providers including the 3rd sector to deliver outcome based support in partnership with service user. The requirements of the Care Act are not immediately quantifiable in terms of additional assessments etc. It is less about what we do and more about how we do it, placing the person


at the centre of their care and making the support offered relevant to them. The intervention focuses on developing and measuring outcomes so that the support offered can be evidenced as meeting the Care Act requirement to prevent, reduce and delay support needs.

CARG was formulated to oversee the Trust’s compliance with the commencement of the new Act. Its members are made up from a cross section of staff worked collaboratively to ensure the Trust is enabled to implement the new duties and principles of the Care Act, which are closely aligned to the Recovery philosophies already embedded within Mental Health. CARG has since been disbanded and incorporated into the ToC working group.

ToC group will continue to inform and assist in the development of practice and awareness of the Act. This is particularly relevant with the development of the Recovery model which is based on the individual’s holistic needs.

8. Reports from the Care Quality Commission

The Trust receives CQC MHA visits on a regular basis from Mental Health Act Assessors. During 2016/17 the Trust received 5 of these all in relation to the Trusts Acute inpatient wards. Visits occurred on the following dates:

Ward Date of visit Ambleside Ward 4th August 2016 Clent Ward 17th August 2016. Kinver Ward 18th August 2016 Langdale Ward 3rd August 2016 Wrekin Ward 20th July 2016

Against each of these, a local action plan was developed to improve practice in the areas identified. Common areas for improvement / themes were identified as follows along with the following actions / assurances:

• Some pieces of statutory information (CQC posters) not available on the wards

A piece of work was undertaken to review the quality of written information (both in leaflet form and poster form) on the wards. The Trusts recent supportive visits, which assess and review the quality of services offered on the wards, noted an improved picture against this with statutory information being available on wards and an improved availability of leaflets.

• Some noted areas with “blanket restrictions”

Communications were issued to ward staff in respect to what is / isn’t acceptable from the point of view or blanket restrictions with the aim of ensuring that inappropriate blanket restrictions were not in operation. Upon their review of the Trusts inpatients wards in November 2016, the CQC highlighted the improved position of the Trust in respect to this issue with the CQC noting that “The trust had made improvements to the documentation of long-term segregation and the management of blanket restrictions on the adult acute wards. The trust had revised all blanket restrictions and new protocols were now in place.”

• Quality of care planning ensuring they were patient centred The Trust has recently revised the style of care plans utilised within inpatient areas, with the wards reverting to a new style “my care plan”. These care plans were reviewed by the CQC in their November 2016 visit however it was noted that there was still some work to


be done to ensure that these were person centered. The Trusts most recent round of supportive visits conducted in May 2017 noted that there had been some further improvements in ensuring care plans were patient centered. This issue does however still form part of the Trusts CQC action plan as a measure designed to further improve the person centred nature of the inpatient care plans.

• Changes to the Trusts 2 stage functional test for capacity

The Trusts 2 stage functional test for capacity was reviewed and revised in respect to the recommendations noted from the Trusts CQC MHA visits. As a result, the Trusts Mental Capacity Policy was reviewed, revised and re-ratified. Further inspections by the CQC in November 2016 and the Trusts supportive visits noted no issues with the Trusts 2 stage functional test for capacity documents. They did however note that staff were not always documenting capacity in a decision specific manner and that as such further action was required to ensure that this was brought up to the standard required. As a result of this actions have been included on the Trusts CQC action plan to ensure this is addressed.

9. Issues raised by the MHA Associate Lay Managers

The ALMs have an opportunity to raise any issues in the quarterly ALM meetings and the joint biannual meetings with MHASC. They previously raised concerns about the timeliness of hearings after section renewals and CTO extensions being completed by the RCs. There has been improvement in this area.

There were unfortunately some delays in the ALM reviews being carried out which should take place biennially. Thanks to the hard work of the MHASC chair as of June 2017 all of the ALMs will have had a review of the contract. As a result of some ALMs not attending ALM reviews/meetings or leaving due to ill health we have had 4 ALMS leave the Trust.

The ALMS also raised issues about the changes to the panel expenses system and the issues they had been having with that system. In order to streamline the process and to stop two different claim methods, the ALMs now have one single expenses system. However as a result of the changes to this system and to following taxation rules, there has been a slight reduction in the amount paid for mileage. The ALMs have requested an increase in the fee (currently £55 for a 3.5 hour session) that they receive.

The ALMs expressed concern about the differences in practice in the use of the CTOs in Walsall and Dudley teams. There are considerably more CTO’s being used in Dudley than in Walsall. Nationally practice does vary and there is nothing to suggest that either side is not following the MHA. There have been many discussions in MHASC about the best way to look at the reasons for the difference in use of CTOs. This is being kept under review and the reasons for differences in practice will be looked at by the medical team.


10. Mental Health Act Administration key areas of focus Issue Action Measure Help service users to understand their legal rights and be involved in treatment Service user/ staff awareness of and access to IMHA Service

Review relevant local policies, training and audits to ensure staff understand the specific needs of service users and their families or carers, and their role in making sure that people are informed of their rights. MHA administration to continue to send weekly update to show whether rights information has been provided to the patient. Raise awareness of IMHA service in MHA training sessions, posters and leaflets

MHA audit Repeat EBE questionnaire for service users about IMHA and s.132 rights awareness

MHA Champions Work with MHA champions to encourage staff to comply with the MHA policies and processes

MHA Audit

MHA audits MHA administration to continue to complete MHA audits on CTT, S.17, s.136 etc. Copies MHA audit reports will be submitted at MHA SC meetings.

MHA audit reports

Hearings- Tribunals and Managers hearings

To review the hearings processes to ensure that the patients are clear of their rights and they are given opportunity to engage with the process. To gather information about the reasons for non–attendance at hearings for patients

Report to MHASC

Recommendation The MHASC wish to assure the Board of the positive and effective multiagency cooperation and adherence to the principles as outlined within the MH Act and code of practice. There are a number of areas as outlined within this report that would undoubtedly benefit from the Board’s intervention in promoting a least restrictive service delivery and patient care. Action required The Board is requested to receive this report and be aware of both the areas of good work alongside those that require improvement.


Appendix 1

Point of concern Action taken The provider must ensure that blanket restrictions are not in use and that staff act in accordance with the 2015 Mental Health Act Code of Practice and the Trust Search Policy when justifying the use of searches of patients on their return from community leave.

- Communications to staff in relation to LRP policy and procedures - LRP training to be delivered across all inpatient areas - Audit of “patient searches” to be carried out to determine levels of compliance against policy. - Report to be submitted to Mental Health Act Scrutiny Committee. Action Completed – September 2016

The provider must ensure that staff are aware of the rights of informal patients and that they are not routinely delayed from leaving the acute ward environment

- Review of all informal clients and their rights to be undertaken. - Communications to staff in relation to rights of informal patients - Visual and written communication to be reviewed to ensure it is fit for practice and that a programme of maintenance and checks is in operation - LRP (right of informal patients) training to be delivered across all inpatient areas and all staff groups - Audit of “rights of patients” to be carried out to determine levels of compliance against standard. - Reports to be submitted to MHASC. Action Completed – July 2016

The provider must ensure that where people's rights under the Mental Health Act are explained to them, this is recorded consistently within care records.

- Communications / briefing note to be issued to staff reminding them of their responsibility to clearly explain to patients their rights and to document this process. - EBE review to be undertaken to check with patients that they - have had their rights explained to them. - Review of recording standards and documentation to be undertaken to evidence that patients are explained their rights. - Audit of completion of standards to be incorporated into ward documentation audits. Action Completed – July 2016

The Trust should address issues relating to care records and the use of Long Term Segregation, including chronological filing and legal documentation relating to the use of the Mental Health Act. Links to Regulation Action 17(2)(C)

- A review of the implementation plan of the Long Term Segregation policy to be undertaken. - A documentation audit, that includes a review of the chronological filing of notes to be undertaken. - A MHA documentation audit is to be undertaken, that reviews all MHA documentation for cases of Long Term Segregation included in patient files and ensures that paperwork has been completed appropriately and in line with the Act requirements. - Least Restrictive Practice training programme to form part of the Trusts Learning and Development programme. Action Completed – September 2016

The provider must ensure that all relevant policies are updated in accordance with the revised Mental Health Act Code of Practice (2015)

- To complete a review of all policies against the identified policy list detailed in MHA Code of Practice. - To develop any identified policies that are needed/need revision. - Policy requirements to be monitored by MHASC/Policy & Procedures Group. Action Completed – October 2016


MENTAL HEALTH ACT SCRUTINY COMMITTEE MEETING

MINUTES OF A MEETING HELD ON 8TH JUNE 2017 AT 14:00 HRS

CONFERENCE ROOM 1, TRAFALGAR HOUSE, DUDLEY

Members In Attendance: Mrs Gill Cooper (Chair) Mrs Deb Cooper Dr Mohammad Iqbal Mr Neil Tong Mr Hassan Omar Ms Nageena Bibi Ms Rosie Musson Ms Becky Temple Purcell Mr Paul Singh Mr Tom Jinks Ms Anne Marie Carey

Non-Executive Director Vulnerable Adults and Childrens Lead Consultant Psychiatrist/Clinical Director Clinical Governance Assistant / NHSLA Facilitator Head of Social Care Mental Health Act Manager Acting Director of Nursing Senior Workforce Development Manager Equality and Diversity Lead Compliance & Safety Manager Head of Early Intervention, Access and Urgent Care Services

In Attendance: Ms Helen King (note taker)

Personal Assistant

Apologies: Mr Liam Dolan Ms Wendy Pugh Ms Olive Hewitt Mr Steve Nash Ms Olivia Clymer Dr Mark Weaver Ms Lesley Writtle

Associate Director of Operations Director of Operations & Nursing Clinical Quality Improvement Manager Carers Service Non-Executive Director Joint Medical Director Acting Director of Operations

Minute No

Agenda Item Action

18. APOLOGIES FOR ABSENCE

Apologies were noted as above. The Chair welcomed Ms Carey to the meeting.


Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. No interests were declared.


Agenda Item number: 8.1.1d

Enclosure: 9

Enc 9 MHASC Minutes 08.06.17 v0.1(Final) Page 1 of 11

20. NOTES FROM PREVIOUS MEETING

The minutes from 13th April 2017 were agreed as a true and accurate record.

21. MATTERS ARISING

21.1 The actions were discussed and the following updates provided: Item 56.1 – Section 136 Policy (i) Ms Pugh to negotiate with senior police and CCG colleagues and take outstanding issues forward. Mr Omar to liaise with Ms Pugh.

Ms Writtle was unfortunately not present at the meeting to provide an update on this action. Dr Iqbal advised that discussions were ongoing with TCT partners with regards to Section 136 matters. It was noted that Wolverhampton had a 136 suite which could accommodate children. Action to remain open.

21.2 Item 58.2 (i) Mr Omar to flag the operational issues with MH Act Assessments carried out at the new custody block (Oldbury) with the CSD Director & Clinical Processes Manager via the Clinical Processes Group. A verbal update will be provided at the next meeting.

Mr Omar advised that Mrs O’Sullivan, Clinical Development Director, and Mr Byng, Liaison and Diversion Service Manager, were presently reviewing the pathway into Mental Health services from the custody block. Good progress was being made.

Action to remain open.

It was noted that the Trust was not commissioned to carryout MHA assessments at the custody suite; if an assessment was required the person needed to be transported to hospital. With regards to the complaint discussed at previous meetings, a formal response was still awaited. If this was not received then the matter would be escalated. The Committee needed absolute assurance that the situation would not happen again. The next MHA Partnership Group was being held on 12th June 2017.


21.3 Item 4.2 Re: use of Section 2 for anyone assessed in a Police station who fitted the criteria for mental health treatment (to ensure detention until the arrival of an ambulance). Dr Iqbal, Mr Omar, Ms Bibi and Mrs D Cooper to discuss the matter outside of the meeting and provide an update at the next Committee meeting in June 2017.

A meeting had been arranged to discuss this issue further. Action to remain open.

21.4 Item 4.3 Ms Bibi to link the CTO work in with the wider piece of work Dr Weaver was undertaking regarding bed usage and bring an update to the next Committee meeting. This item was regarding the practice of using CTOs versus keeping patients detained for a longer period of time with longer leave periods, the latter was generally the practice in Walsall. It was about looking at different ways of working and agreeing practice pan Trust. The Committee were reminded that Dr Weaver was undertaking a piece of work in relation to bed usage in general. The above issues needed to be looked at in conjunction with this work. Action to remain open. Action: Ms Musson to chase up a position statement from Dr Weaver regarding the CTO and bed usage work.

Ms Musson

21.5 Item 6.1. Mr Tong to look in to the 6 reported incidents of ‘MHA lack of assessment’ for 2016/17 and to advise the Committee of what the outcomes were in these cases. Mr Tong had reviewed the cases, of which there were 7 in total, not 6 as previously identified. They were all followed up with an incident report and managed appropriately. No particular trend was apparent. It was noted that although the incidents sounded alarming, when the detail was looked at they were not as they first appeared, and were not a lack of a MHA assessment. The issues were more around capacity and inappropriate admission. The position needed to be made clear; if a patient lacked capacity they should be assessed under DoLS or MHA provision. Action closed. Action: Mr Tong and Mr Jinks to look at the drop down options on the Safeguard system. Incident classification needed to be re-categorised to better reflect the incidents which were currently being reported erroneously as ‘MHA lack of assessment’.

Mr Tong / Mr Jinks


21.6 Item 8.1 Committee to make recommendation to Trust Board to increase the ALM session fee from £55 to £60 due to the agreed changes being made to the ALM agreement regarding Chairing panels, and the need to bring fees in line with those paid by neighbouring Trusts.

The Chair advised that Trust Board had supported the recommendation and agreed the session fee increase. Payments would be backdated from 1st April 2017. This increase was linked to the changes being made to the ALM contract, which would be submitted to the Committee prior to its implementation.

Action closed.

21.7 Item 15.1 Information on number of diagnosis of schizophrenia (F20) and schizoaffective disorders (F25) for Walsall to be looked in to and information brought back to the Committee.

Item deferred to the next Committee. Information to be sought for Dudley and Walsall for comparison.

22. CARE QUALITY COMMISSION COMPLIANCE - ACTION PLAN

22.1 Mr Jinks took the Committee thought the relevant actions. The report included updates from the recent CQC Steering Group, and was on the Quality and Safety Committee agenda. It would also be submitted to Trust Board.

‘Must Do’ actions were considered as follows:

- Action 8 This matter was identified in the February 2016 report, and the re-inspection in November 2016. An improvement had been seen but there was still work to be undertaken with regards to recording. The report provided details on the planned actions. The next supportive visits would provide further assurances. Staff training in this area was discussed. Ms Temple Purcell advised that although staff had completed their mandatory training they still felt they needed the knowledge further embedding. Ms Bibi was picking this up, utilising the excellent training resources the Trust had already worked upon. Thought was being given to the introduction of a MCA Lead to further embed knowledge and change culture.

- Action 9 (Section 136, Place of Safety) The Trust was still waiting for the joint policy to be approved. Concerns regarding the delay had been escalated appropriately. The Chief Executive was sending a letter to the Chief Inspector regarding this matter.


‘Should Do’ actions were considered as follows:

- Action 4 (positive behavioural support plans) A considerable amount of work was being undertaken in this area, and was being picked up this week by ward managers. The Trust were on target to meet the action delivery date of September 2017.

The Chair was satisfied that the specified actions were on track.

The Committee received the plan for assurance, and endorsed the actions recommended.

23. MHA QUALITY DASHBOARD REPORT

23.1 Mr Tong took the Committee through the report and the following was highlighted:

- During May there had been 66 restraints recorded. - There were currently 18 active cases of DoLS across the Trust. - There had been 6 incidents for failure to return from Section 17

leave, and 4 absconds. It was noted that no harm had been sustained by any of the patients concerned during these periods.

- 1 MHA specific incident had taken place in month. This was due to a ‘MHA transfer issue’ on Langdale Ward. It was clarified that this was an incident as a transfer should not have been undertaken whilst a patient was on DoLS. Learning had taken place; further education was needed on acute wards concerning DoLS, and joint learning required with the Manor Hospital.

- With regards to the restraint information in table 1.2, it was noted that due to an issue during the upgrade to the Safeguard system the position of restraint had not been recorded during April 2017. This had led to the high number of ‘not recorded’ figures (19 for adult inpatients, and 49 for older adult inpatients). Mrs Deb Cooper had picked this matter up, the incidents had been passed back to the managers involved in order to ascertain the information required as soon as possible.

Ms Temple-Purcell explained that the Trust was making progress with regards to training. As at the 30th May 2017 compliance had been reported as 63% for MHA training, which was an improvement, 87.2% for Prevent training, and 82.8% for MCA training. It was noted that the CCGs had set training targets of 90% for Prevent, MCA, DoLS, and safeguarding. As the Trust had not achieved the targets last month a Remedial Action Plan had been requested. If the Trust did not stay on target, as per the plan, then penalties could be incurred. Action: Training Remedial Action Plan to be brought to this Committee for the foreseeable future. Mrs Deb Cooper to circulate the document to the Committee in the meantime.

Mrs D Cooper


The Committee received the report for information.

24. AMHP ACTIVITY AND AUDIT REPORT – QUARTER 4

24.1 Mr Omar took the Committee through the quarter 4 report, and highlighted the main areas as follows:

- Dudley had seen a decrease in assessments in the last quarter, bringing it closer to the number of assessments undertaken in Walsall.

- There had been a significant drop in Section 3 assessments (in Dudley 15, and Walsall 12).

- It was noted that there had been a drop in the use of the Section 136 place of safety suite in quarter 3.

- In quarter 4 Dudley had seen a slight decrease in the use of the 136 suite, from 13 to 9, with 44% of assessments resulting in hospital admissions (11% informal and 33% formal). In Walsall the number of times the 136 suite was used had increased from 12 to 21, with 38% of assessments resulting in hospital admissions (14% formal and 24% informal).

- The percentage of those assessed in Dudley of White ethnic origin was significantly lower than the percentage population for the borough. Mixed, Asian and Black ethnic origins had seen an over representation. In Walsall there had been a significant under representation of Asian ethnic origin with over representation of White and Black ethnic origins.

- The data would be looked at again next quarter to see what the position was as the figures had seen significant reductions in quarter 4. And it needed to be ascertained whether this was an emerging trend.

The Committee received the report for information.

25. CQUIN AVOIDABLE ADMISSIONS MONITORING – QUARTER 4

25.1 Mr Omar and Dr Iqbal led on this particular CQUIN. A report had been submitted to a previous Committee and actions had been discussed in terms of substance misuse, and Care Co-ordinators. With regards to substance misuse and duel diagnosis, a pathway was being developed. The CPA clinical audit would follow up on the action point concerning the Care Co-ordinators. The Chair was satisfied with the work being carried out in this area and considered the matter closed with regards to this Committee. The item was being monitored by the Quality and Safety Committee.

26. RISK REGISTER REPORT

26.1 Mr Tong talked through the Risk Report, which provided the MHA


Scrutiny Committee with information on the red risks pertaining to the application of the MHA within the organisation for the period ending 26

th May 2017. All the changes in the report were reflective of the review undertaken at the last Committee. The narrative was still being worked upon for the risk regarding MHA training. This would be completed for the next Committee. As discussed at the previous Committee meeting Risk 289 would be escalated to the status of a red risk and presented to Trust Board. The Chair had already informed the Board about this risk. Mr Omar flagged up that Walsall Council were taking back the AMHP function. He queried whether it would be a risk if the Trust could not get the information it required regarding the AMHPs. The Committee would wait to see whether an issue presented itself and take any action accordingly. The Committee approved the Risk Register.

27. INCIDENTS OF POLICE BEING CALLED TO DEAL WITH HOSTILE PATIENTS – REPORT

27.1 Mr Tong presented the report, which attempted to triangulate the Trust reported incidents with the Police logs in each locality. In Dudley there had been a total of 20 incidents over a 5 month period. The full details of which were set out within the report. There was one case which had resulted in moderate harm, but this had been self-inflicted. In Walsall there had been 21 incidents. 3 of which were listed as unknown in location as the Police log did not contain sufficient detail to ascertain the location, and they could not be triangulated to any incidents reported within the Trust, The amount of cases were similar in each locality. There were no issues to note from a Trust perspective. It had been clarified from the Police that all the calls had been appropriate. Mr Tong directed attention to the conclusions drawn within the report. From the report there was no indication of the response time of the Police. Discussion was held around the level of patient risk and the issue of security. The Trust was looking to see whether there was a way of flagging up dangerous patients with the Police before, or upon, being admitted to hospital. Action: Ms Musson to raise the issue of Police call outs with the Chief Executive at the Executive Communications Meeting on 12th June 2017 and ask about the possibility of it being raised at

Ms Musson


Partnership Board. Mr Omar advised he would share the work done here with established partnership groups. The Committee received the report for information and assurance.

28. CTO WORK UPDATE

28.1 This item had already been discussed earlier within the meeting under matters arising.

29. ALM MEETING FEEDBACK

29.1 The Chair advised that an ALM meeting had taken place immediately prior to the joint ALM and MHA Scrutiny Committee meeting held today. There was one more ALM appraisal left to carry out. It was hoped by September 2017 that more of the ALMs would be chairing panels.

30. SPOTLIGHT SESSION – MCA PROJECT

30.1 The Committee were advised that the project was still ongoing. Slides had been presented to the Committee on this during 2016. Ms Bibi would forward the slides to the Chair.

31. INTERNAL AUDIT PLAN

31.1 The Committee were informed that MCA restricted practice and DoLS were being audited again. Following this the auditors would then look at the terms of reference. Elements of the search audit had been incorporated within the ward manager document, and so this matter was in hand. It needed to be ensured that the Trust was evidencing what it was doing. Auditors needed to have a clear understanding of these complex issues.

32. POLICY UPDATES

32.1 Mr Tong advised that no policies had been updated this month relating to the MHA.

33. MHA SCRUTINY COMMITTEE – ANNUAL REPORT TO TRUST BOARD

33.1 The Chair thanked Mr Omar, and all who had contributed to the report, for an excellent piece of work. Mr Omar took the Committee through the draft report and asked for comments.


The report was lengthy but the Committee agreed that all the information was relevant. It was thought that information on assurances which the Committee had asked for could be strengthened within the report. Action: Mr Omar to strengthen information within the report regarding assurances the Committee had asked for. Action: Mr Tong to provide detail on the MHA CQC issues, and how the Trust had responded, and send this to Mr Omar to include within the report. Action: The Chair and Ms Musson to write the forward for inclusion within the report. The Committee received the report for assurance and subject to the above additions being made the report would be submitted to Trust Board in July 2017.

Mr Omar

Mr Tong

Chair/ Ms Musson

34. REVIEW OF COMMITTEE EFFECTIVENESS

34.1 It was explained that, as per the Terms of Reference, the Committee was required to undertake a review of its efficiency and effectiveness. A survey was uploaded to an online tool and Committee members were asked to complete the survey. There were many positives to highlight such as the support for the MHA Manager and assurance of the ALM’s effectiveness. However, it was noted that for the following 5 statements at least one person selected ‘neither agree nor disagree’:

- ‘The Terms of Reference are reviewed at least annually’ The Committee undertook this annually.

- ‘The Committee has an annual forward plan of matters to be considered’ The Committee had a forward plan, and those present considered it to be a very structured Committee. Action: Miss King to re-circulate the forward plan to members. Members to feedback any changes required.

- ‘Committee papers are distributed in sufficient time for members to give them due consideration’ The Chair highlighted that this was an issue which members struggled with and improvement needed to be seen. However, it was recognised that Committee members were frontline focussed and had many competing priorities.

- ‘The Committee considers how it integrates with other relevant committees and groups’ Interaction was mainly with the Quality and Safety Committee,

Miss King


with many of the same reports being addressed at both Committees. The Committee also interacted with the CQC Steering Group.

- ‘The Committee works effectively with external partners’ The Committee felt it did work effectively with external partners. Thought would be given to inviting someone from the CCG to observe the meeting and to inviting ALMs as part of their induction.

The Committee received the report for assurance.

35. TERMS OF REFERENCE – ANNUAL REVIEW

35.1 The Committee reviewed the Terms of Reference and were happy that they were fit for purpose. Action: Head of Early Intervention, Access and Urgent Care Services to be added to the Committee membership. Dr Iqbal left the meeting. The Committee approved the Terms of Reference, subject to the one addition to membership as above, and recommended submission to the Board for ratification.

Miss King


36.1 MHA Scrutiny Committee The Chair advised all that this was the last MHA Scrutiny Committee she would Chair as she would leave the Trust in July 2017. The Committee expressed their heartfelt thanks to the Chair for her excellent leadership of the Committee over the last several years. Ms Clymer would take over as Chair of the Committee. CQC MHA Unannounced Visit There had been an unannounced visit at Bloxwich during May 2017. No report had been received to date. Action: CQC MHA visits to be a standing agenda item from this point forward so that reports and action plans could be monitored. Safeguarding Strategic Group. It was explained that the exception report was submitted to Quality and Safety Committee. Action: Safeguarding section of the quality report to be submitted to future Committee meetings. 136 Monitoring Form This had been devised with the Police, however the form was not being

Miss King

Mrs Deb Cooper


completed as it should be or not at all. Without having a manned 136 suite, governance was difficult to enforce. A meeting was due to be arranged with Black Country regarding this, how other matters regarding 136 were aligned, and where responsibilities lay for different things. The Chair requested that a meeting be held in order to look at the Trust’s internal plans and governance before any external discussions were held. Mr Omar would raise the issue at the Partnership Group on 12th June 2017. Assisted Visits – Bloxwich It was advised that 4 patients at Bloxwich had not received authorisation visits. Managers and Clinical Leads had been asked to raise these as incidents. Evidence was being gathered so this issue could be addressed.

37. DATE, TIME, AND VENUE OF NEXT MEETING

37.1 Thursday 10th August 2017 at 2.00pm Conference Room 1, Trafalgar House, Dudley

Signed by Chair Mrs G Cooper Signature…………………………………………………… Date ………………………….


Meeting date: 6 July 2017 Agenda Item number: 8.1.1e Enclosure: 10

QUALITY REPORT (MONTH 2)

1

Section 1 Summary of Trust Incidents and

Serious Incidents

2

Section 1 Summary of Trust Incidents and Serious Incidents

●High●Low

21 12 0 0

5 18 0 0

141552316

103262018473133

28644

2293 ● 1402 ● 1067 ● 106 ● 05 ● 23 ● 0331100

Top

5 Ca

use

Grou

ps &

top

3 In

cide

nt C

ause

s

Benchmarking

5257 23 70

Physical Assault - Pt On StaffBehavioural - Disruptive

Patient Accident - Cuts / Skin Tear

Serious Harming BehaviourSelf Harm - Medication OverdoseAttempted Suicide - Medication OverdoseSelf Harm - CutClinical Care, Quality And TreatmentClinical - Treatment / Care RelatedDeath - Unexpected - Cause UnknownDeath - Expected - Natural Causes

4 258

Other

12 months incident data

Trust Incidents

May 2017 Incidents by Serviceline

Serious Incidents Patient Safety Incidents

12 months SI data 12 months PSI

371May 2017

CommunityInpatient UCAS

Patient AccidentFall - Unobserved Fall Mobilising AloneFall - Controlled / Lowered To Ground With Support

Skin IntegrityMental Health ActDocumentation & Electronic Records ManagementInfection Control

Access, Admission, Transfer DischargeFailure To Return From Leave / Missing (Informal)Absconded (Sectioned Patient)Failure To Return From Agreed Sec 17 LeaveMedicationHealth & Safety

Equipment

Information Governance And ConfidentialityFireSecurity / Cyber Security

Security Incidents Reports92

12 months SIRS

5 0 0 0

Physical Assault - Pt On StaffMay 2017 Incidents by CategoryDisruptive / Aggressive BehaviourBehavioural - Aggressive

Harm

No

Low

Mod

Seve

re

115E.I. CSD

Top 3 Incident Categories

Active Serious Incident Investigations 9

4 Severe Harm5 DeathUngraded

Behavioural - Aggressive

Verbal Abuse - Pt On Staff

May 2017 PSI incidents1 No Harm2 Low Harm3 Moderate Harm

Serious Incidents category in the last 12 months

Serious Harming Behaviour

Access, Admission, Transfer Discharge

Patient Accident

Infection Control

Disruptive / Aggressive Behaviour

Clinical Care, Quality And Treatment

Fire

0%

50%

100%

Jun Jul

Aug

Sep

Oct

Nov De

cJa

nFe

bM

ar Apr

May

2016 2017

PSI Incidents level of Harm

Section 1 - This section looks to provide a summary of all of the Incidents and Serious Incidents occuring within the Trust.

Trust Incidents - there have been 371 incidents reported within the Trust during the month of April this represents a decrease when compared to the previous month.

Distruptive / Agressive Behaviour is the highest reported category with 141 incidents reported

Further breakdown by service lines and Analysis can be found in Section 2

Serious Incidents - 4 Incidents have been reported during the month of April and are currently under investigation. There are currently 9 Active Investigations open to the Trust.

A further summary of the Serious Incident cases can be found in Section 3.

0.0% 50.0% 100.0%

None

Low

Moderate

Severe

Death

PSI -

Har

m

DWMH Previous Year

DWMH Previous month

55 Mental Health Organisations -12 mth

3

Section 2 Individual Operational

Service line Reports

4

Section 2 - Service Line Reports

Wal Dud Dud Dud Wal Dud Wal Wal Wal Dud DudF F mix M M Func Org Func Org

Ambl

esid

e

Kinv

er

Wre

kin

Clen

t

Lang

dale

Ceda

rs

Lind

en

Mal

vern

Holy

rood

9 19 0 11 11 1 1 52 18 46 8 13 851 11 0 0 2 0 0 14 9 21 10 0 403 3 0 2 2 0 0 10 5 12 2 0 190 0 0 2 3 0 0 5 2 6 0 3 11

15 6 1 0 2 0 0 24 1 3 2 17 236 1 0 0 0 0 0 7 0 3 16 1 205 1 0 0 0 0 0 6 1 0 0 0 11 2 1 0 1 0 0 5 0 0 0 1 14 3 0 3 9 0 0 19 2 6 6 7 213 2 0 1 3 0 0 9 1 1 1 1 40 0 0 0 3 0 0 3 1 2 0 0 30 0 0 0 2 0 0 2 0 1 1 1 30 3 1 4 2 0 0 10 0 1 0 1 20 1 1 3 2 0 0 7 0 1 0 0 10 1 0 1 0 0 0 2 0 0 1 0 10 1 0 0 0 0 0 1 0 0 0 0 02 1 1 0 0 0 0 4 0 0 0 1 11 0 1 0 0 0 0 2 1 0 0 0 10 1 0 0 0 0 0 1 0 0 0 1 12 1 1 0 0 0 0 4 1 0 0 0 10 3 0 0 0 0 0 3 0 0 0 0 00 1 0 1 1 0 0 3 0 0 0 0 00 0 1 0 1 0 0 2 0 0 0 0 00 1 0 1 0 0 0 2 0 0 0 0 00 0 0 0 1 0 0 1 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0

Disruptive / Aggressive BehaviourBehavioural - Aggressive

Insufficent Communication - Internal

Failure To Return From Agreed Sec 17 LeaveClinical Care, Quality And TreatmentClinical - Treatment / Care RelatedStaffing - Agency Staff Usage

Clinical - Lack Of Clinical Or Risk AssessmentPatient AccidentFall - Controlled / Lowered To Ground With SupPatient Accident - Cuts / Skin Tear

Physical Assault - Pt On StaffBehavioural - DisruptiveClinical Care, Quality And TreatmentClinical - Treatment / Care RelatedInsufficent Communication - External

Adult Inpatients

Self Harm - Medication Overdose

May 2017

Older Adults Inpatient

Behavioural - AggressivePhysical Assault - Pt On PtBehavioural - Substance Misuse RelatedSerious Harming Behaviour

Hom

e Tr

eatm

ent

Hom

e Tr

eatm

ent


Older Adults Inpatient

All Inpatient Incidents257

Infection Control

59

Security / Cyber SecurityHealth & SafetyEquipmentMental Health ActSkin Integrity

Fall - Unobserved Fall Mobilising AlonePatient - Faint/ Fit / UnwellMedicationFire

Dudley Walsall

Self Harm - CutSelf Harm - Ligature

Access, Admission, Transfer DischargeSkin Integrity

IG And Confidentiality

Access, Admission, Transfer DischargeFailure To Return From Leave / Missing (Informal)Absconded (Sectioned Patient)

MedicationPrescription - Incorrect DrugAdministering - Incorrect Dose/Strength/FormuAdministering - Drug Early/Late/DuplicatedIG And Confidentiality

Fall - Unobserved Fall From Bed

Patient Accident

FireMental Health ActInfection Control

Dudley Walsall122 135

Tota

l

Tota

l

63 56 7912 month All - Dud - Wal

Adult Inpatients

Health & SafetyEquipmentSerious Harming BehaviourSecurity / Cyber SecurityDocumentation & Electronic Records Mgmt

60.00%

80.00%

100.00%

Acute Bed Occupancy

Older Adults Bed Occupancy

2.1a Inpatient Service Line

Section 2.1 This section is focused on Inpatient services and looks to show the number of incidents reported during the previous month against a comparision for the last 12 months. This section also looks to provide information in relation to the types of incidents reported, and their risk and impact. This section also shows high level information in relation to Incidents reported to the NHS Safety Thermometer, HSE (RIDDOR) and Trust Incidents resulting in the use of Physical Interventions.

5


All Inpatient Incidents

Patient Injuires Staff Injuries12 month trend

May 2017

90.00%

95.00%

100.00%

DWMH DWMH 12 month Average

National 12 month Average

Minor 15 19

Moderate 1 1

Major 0 0

Physical Intervention

Injury

Benchmarking NHS Safety Thermometer - Harm Free Care

17

65

48

13 11

Inpatients

Adult Older

Patients Involved

Patients Involved

0 Injuries occured as a

result of Physical Intervention

Commentary on Section 2.1a

Within the Adults Inpatient Service Line, there has been an increase of incidents reported for Kinver under the Disruptive/Aggressive Behaviour category. However, on review it has been noted that Patient A is attributed to 7 of the 19 incidents. The patient was mainly aggressive towards staff and has therefore been transferred to a PICU due to her increased aggression. There have been no other trends noted on the ward and the rest of the incidents are unrelated and not specific to particular patients. The incidents for Clent have decreased when compared to the previous month and Langdale remains consistent. However, Patient B on Langdale is responsible for 4 of the 11 incidents, although all 4 incidents are dissimilar and the patient has been transferred to a PICU following an assault on another patient.

The Serious Harming Behaviour category has seen a slight rise in incidents for Ambleside. Although there have been no particular trends identified, Patient C is related to 4 of the incidents and is using ligatures as a form of self-harming. The patient’s care plan is being reviewed and the Compliance and Safety Team are to review the ligature points in the communal areas outside of the wards to address any concerns.

In the Older Adults Service Line, there has been an increase of incidents reported under the Disruptive/Aggressive Behaviour category in Bloxwich Hospital. On Cedars, Patient D is responsible for 11 of the 18 incidents and this is due to the patient being aggressive whilst requiring assistance with personal care. It has been identified in his care plan that he requires 2-3 staff to assist with personal care due to the patient making allegations against staff. Patient E is responsible for 6 incidents, he is an out of area admission and is verbally aggressive towards staff which includes racial abuse and threats.

On Linden Ward there are 3 particular patients who are attributed to the majority of the 46 incidents reported. Patient F has 12 incidents as when he sees his reflection in the mirrors, it causes agitation. The patient also attempts to enter fellow peers’ bedrooms and thus requires clinical holds. Patient G has 10 incidents where she is having increased aggressive behaviour and therefore the medical team are to review this issue. The patient also requires clinical holds due to incontinence and personal care. Patient H is a new admission and has 10 incidents whereby clinical holds are required to assist with the patient’s personal care. The use of the clinical holds are regularly being reviewed in line with Trust policy.

The Clinical Care category on Holyrood has been identified as particularly high when compared to previous months. Although the incidents seem unrelated, the use of clinical holds and the trend noted in unobserved falls is being reviewed by the Compliance and Safety Team and the Clinical Lead. An informal patient who was being provided with end of life palliative care had passed away on the ward. The family have been involved and have been particularly complimentary of the ward.

2.1b Inpatient Service Line

Health & Safety Excetive 0

6


Department & Incident Category MayPsychiatric Liaison Team - Dudley 9

Serious Harming Behaviour 8Access, Admission, Transfer Discharge 1

EAS (Walsall) 3Disruptive / Aggressive Behaviour 1Serious Harming Behaviour 1Information Governance And Confidentiality 1

Psychiatric Liaison Team - Walsall 2Serious Harming Behaviour 2

Crisis Resolution - Walsall 2Serious Harming Behaviour 1Access, Admission, Transfer Discharge 1

PC MH & TTS 2Serious Harming Behaviour 1Health & Safety 1

Dudley Talking Therapy Service 2Information Governance And Confidentiality 1Disruptive / Aggressive Behaviour 1

Crisis Resolution - Dudley 2Serious Harming Behaviour 1Health & Safety 1

EAS (Dudley) Sandringham 1Serious Harming Behaviour 1

Grand Total 23

May 2017

Reported Injuries0

23All Urgent Care & Access Services

14Dudley Locality Walsall Locality

9

2.2 Urgent Care & Access Services

Commentary

Section 2.2 This section is focused on the Urgent Care & Access Servies and looks to show the number of incidents reported during the previous month against a comparision for the last 12 months. This section also gives a break down of the incidents by Locality, and also shows the number of Injuries. • The monthly (mean) average for incidents relating to Urgent Care & Access Services

(calculated using data from the last 12 months, and as a combination of the previousindividual Services) is 26 .

• There are 2 Incidents within this service line which are now under investigation details ofthese incidents can be found in section 3.

• There are no further trends or significant incidents relating to this service.

7


Department & Incident Category MayCMHTOP Walsall 7

Clinical Care, Quality And Treatment 5Disruptive / Aggressive Behaviour 1Equipment 1

Woodside (CMHTOP) 3Clinical Care, Quality And Treatment 1Disruptive / Aggressive Behaviour 1Patient Accident 1

Psychological Therapies Hub (Pops) 3Disruptive / Aggressive Behaviour 1Information Governance And Confidentiality 1Patient Accident 1

Memory Services (BVC) 1Clinical Care, Quality And Treatment 1

Out Patients (HLC) 1Clinical Care, Quality And Treatment 1

Grand Total 15

000

Minor InjuryModerate InjuryMajor Injury

310

Patient StaffInjuries

May 2017All Community Services Dudley Locality Walsall Locality

15 7 8

Reported Injuries4

2.3 Community Services

Commentary

Section 2.3 This section is focused on the Community Servies and looks to show the number of incidents reported during the previous month against a comparision for the last 12 months. This section also gives a break down of the incidents by Locality, and also shows the number of Injuries. • The monthly (mean) average for incidents relating to Community Services (calculated

using data from the last 12 months, and as a combination of the previous individualServices) is 26.

• 1 of the Incidents is in relation to a patient known to our service who suffered a fracturedwrist as a result of a fall, the patient is currently residing in a care home.

• There are no Serious Incidents for this Service.• There are no further trends or significant incidents relating to this service.

8


Department & Incident Category MayICAMHS Dudley (Elms) 32

Serious Harming Behaviour 29Clinical Care, Quality And Treatment 3

CAMHS Walsall (Canalside) 18Serious Harming Behaviour 16Disruptive / Aggressive Behaviour 1Patient Accident 1

ICAMHS Walsall (Canalside) 10Serious Harming Behaviour 10

CAMHS Dudley (Elms) 6Serious Harming Behaviour 4Disruptive / Aggressive Behaviour 1Information Governance And Confidentiality 1

Early Intervention In Psychosis (Dudley) 4Serious Harming Behaviour 3Medication 1

Grand Total 70

Injuries Patient Staff

May 2017All Early Intervention Services Dudley Locality Walsall Locality

70 42 28

Reported Injuries5

Major Injury 0 0

Minor Injury 5 0Moderate Injury 0 0

2.4 Early Intervention Services

Commentary

Section 2.4 This section is focused on the Early Intervention Servies and looks to show the number of incidents reported during the previous month against a comparision for the last 12 months. This section also gives a break down of the incidents by Locality, and also shows the number of Injuries. • The monthly (mean) average for incidents relating to Early Intervention Services (calculated

using data from the last 12 months, and as a combination of the previous individual Services)is 37.4

• The number of incidents for this service are at there highest for the last 12 months.• There is one case of Serious Harming Behaviour which has is currently under investigation.

This case is a patient known to our service who took a medication overdose. Further detailsof this case can be found in Section 3

• All other Incidents have been recorded as Impact: Low or No Harm• There are no further trends or significant incidents relating to this service.

9

Section 3 Serious Incidents

10

Section 3.1 - Serious Incidents Duty of Candor

SI Number Date of Incident Service Line Incident DescriptionLevel of

RiskDoC

applicableFamily

Engagement Level of response Locality

2017/13871 26/05/2017 Crisis Resolution - Walsall Completed Suicide - Asphyxiation High No Yes Comprehensive Walsall

2017/12392 08/05/2017 Early Intervention In Psychosis (Dudley) Attempted Suicide - Medication Overdose Low No Yes Consise Dudley

2017/12423 10/05/2017 EAS (Dudley) Sandringham Completed Suicide - Ligature High No Yes Comprehensive Dudley

2017/11290 27/04/2017 Holyrood Physical Assault - Pt On Pt Moderate Yes Yes Comprehensive Dudley

● 140

● 106

● 10

● 0

● 2

● 0

May 2017 PSI incidents

1 No Harm

2 Low Harm

3 Moderate Harm

4 Severe Harm

5 Death

Ungraded

Duty Of Candour Chart 3.2 - Total number of Serious Incidents during the last 12 months

0

1

2

3

4

5

Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

Serious Incidents Trust Average Mean + S.D. Mean - S.D.

Table 3.1 - List of Serious Incident raised during the month of May 2017

Commentary

• The monthly (mean) average for Serious Incidents across the Trust (calculatedusing data from the last 12 months) is 3.08.

• Table 3.1 shows a list of the Serious Incidents logged on STEIS during the previous month, this includes details of the service line and nature of the incident.

• There have been 4 Serious Incidents reported for the month of May 2017.• Chart 3.1 illustrates the types of the Serious Incidents that have been reported

over the previous 12 months.

• Details of all of the Active Serious Incidents can be found in the section below.

Chart 3.1 - Summary of the Serious Incident types during the last 12 months

51%

24%

8%

6% 5%

3% 3%

Serious Harming Behaviour

Access, Admission, Transfer Discharge

Patient Accident

Infection Control

Clinical Care, Quality And Treatment

Fire


This section looks to summarise the Trust's approach to Duty of Candour in relation to all of the incidents which have occurred during the previous month. There has been one case which has fulfilled the requirements to trigger the Duty of Candour process. This patient sustained an Injury of Moderate harm whilst under the direct care of the Trust. This case is a Serious Incident and is being investigated accordingly.

All other cases which have partially met the criteria, have been reviewed and despite not meeting the criteria for Duty of Candour, family engagement and being open will still be undertaken accordingly. Duty of Candour Definition

11

http://www.cqc.org.uk/sites/default/files/20150327_duty_of_candour_guidance_final.pdf

Section 3.1 - Serious Incidents and Duty of Candor

SI NumberDate of Incident

Service Line Incident Description Deadline Current Status

2017/13871 24/05/17 EAS – Walsall

Voicemail received from Mother stating that her son had taken his own life. Coroner's confirmed this, and method used - asphyxiation by helium. Patient also left a suicide note.Patient came into services in September 2016, following a Crisis referral from his GP, and was discharged in November 2016. Patient was seen by CRHT throughout this period, however, he was also referred to Employment Services and WPH Counselling. Patient was also attending Relate for marriage counselling. Patient stated that he was experiencing suicidal thoughts due to the breakdown of his marriage. Patient was diagnosed with a Moderate Depressive Episode.

23.08.17Strategy Meeting to be arranged

2017/12423 10/05/17 Crisis – Dudley

Patient was open to CRHT in August 2011, however, was discharged back to the care of her GP in September 2011. Patients family made contact with the Crisis Team in April 2017, to say that their Mother's mental health had deteriorated since Christmas 2016. Reported by Street Triage that patient had been found deceased, allegedly by hanging.

07.08.17 Investigation remains on-going

2017/12392 08/05/17 EIS – DudleyPatient open to our Early Intervention service since September 2016, took an overdose and was admitted to a general hospital, where he received paracetamol antidote via IV

07.08.17Strategy Meeting arranged for the 8th June 17

2017/11290 27/04/17 BFH – Holyrood Ward

Patient was pushed by another patient and unfortunately fell to the floor landing on her hand. Both patients are subject to DoLS. On Duty Medic attended the scene immediately and advised that hospital treatment would be required. Patient was then transferred to the general hospital.

26.07.17 Investigation remains on-going

Serious Incident Case Summaries - Reported Previous Month

12




2017/10696 22/04/17 HTT – Dudley

Patient was found by his friend in bed with a plastic bag over his head and a bottle of helium nearby.Patient had only recently come into services in April 2017, due to the breakdown of his relationship. Patient was referred for an EAS appointment, and was then taken onto Home Treatment's caseload.

19.07.17

Investigation report currently being prepared for final approval.Findings have not identified any actions which would have prevented this incident.

2017/9873 09/04/17 Assertive Outreach – Walsa

E-mail received from Coroner informing us that patient was found deceased at home by his Father. Coroner's Report states that patient was found hanging with extension cable tied around his neck.Patient was open to CRS Walsall North and Outpatients.

11.07.17

Investigation report currently being prepared for final approval.Findings have not identified any actions which would have prevented this incident.

2017/9157 03/04/17 CRS – Walsall

Patient who is currently open to CRS Walsall South and Outpatients, took an overdose of prescribed medication and was found at home unconscious by her parent. Patient has not made any previous attempts to end her own life, however, currently, she remains in Intensive Care.

04.07.17

Investigation report currently being prepared for final approval.Findings have not identified any actions which would have prevented this incident, however learning has been identified regarding the care being delivered is reflected in the Risk Assessment.

Serious Incident Case Summaries - Ongoing / Open Cases

13




2017/8909 30/03/17 BLX – Cedar Ward

Patient came into services in March 2017 and was assessed as low risk of falls. On the day of the incident, patient attempted to pick up a foot stool, however, unfortunately, she lost her balance and fell onto her right hip.

30.06.17

Investigation report currently being prepared for final approval.Findings have identified the fall wasn’t preventable, however the degree was due to hip protectors not offered inline within with Trust Policy.

2017/7608 15/03/17 BFH – Clent Ward

On the 14th March 2017, a Section 3 patient absconded from a ward by damaging an exit fire door. On the 15th March 2017, the ward was contacted by the Police to inform that the patient was under investigation for two charges of shop lifting, he was also reported to have been seen carrying a knife whilst wandering on the roadside. The Police advised to instantly telephone 999 if the patient returned to the ward so that they could proceed with the arrest. The patient later returned to the ward but was not allowed entry into the ward because of the risks posed to others due to the alleged possession of the knife.

15.06.17 Awaiting final approval

Serious Incident Case Summaries - Ongoing / Open Cases

14

Section 4 National Guidance

Central Alerting System

15

Section 4: CAS Alerts

Table 4.1 – Summary of Alerts received during May 2017 Type of Alert

Number of Alerts in May

Action not Required

Assessing Relevance

Action Required

Circulated for Information

MDA 5 3 2 0 0 MHRA 2 0 0 2 0 CMO 0 0 0 0 0 DDL 0 0 0 0 0 EFN 6 6 0 0 0 DH – EFA 0 0 0 0 0 DH 0 0 0 0 0 SDA 0 0 0 0 0 NHS – PSA 0 0 0 0 0 Total 13 9 2 2 0

• During May 2017 there were 13 alerts issued via the Central Alerting System, of these 13 alerts:o The Trust is assessing the relevance of 2 alertso 2 actions required no action takingo 9 alerts required no action takning.

• The table below (4.2) outlines a summary of the alerts issues and any action taken.

Table 4.2 –Alerts issued during May via the Central Alerting System Alert Number

Alert Date Description of Alert Status Notes / action taken / assurance

MDA/2017/010 02-May-2017

Manufactured by Roche Diabetes Care – Replacement and update to MDA/2015/029 with new instructions to improve battery lifetime and prevent unexpected pump shut down or rapid battery depletion.

Action not required

The Trust does not use these particular devices

MDA/2017/011 03-May-2017

Biological replacement pericardial aortic heart valve: Mitroflow LX (sizes 19mm and 21mm) – risk of early structural valve deterioration

Action not required

The Trust does not issue these devices

EFN/2017/07 09-May-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Siemens - Argus 1 Platform – Protection

Action not required

The Trusts authorising officer acknowledged receipt of the alert and that no action was required by the Trust

EFN/2017/08 15-May-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Siemens - Argus 1 Platform – Protection

Action not required


EFN/2017/09 16-May-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - Prysmian - 11 kV Single Core 300mm2 XLPE Insulation – Cable

Action not required


16

Section 4: CAS Alerts

Alert Number

Alert Date Description of Alert Status Notes / action taken / assurance

EFN/2017/10 16-May-2017

High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Reyrolle - ROKSS/CC - Ring Main Unit

Action not required


MDA/2017/012 17-May-2017

V60 ventilator – potential for unexpected shutdown Action not required

The Trust does not use these particular devices

EL (17) A /06 18-May-2017

Drug alert class 2 (action within 48 hours); fdc international ltd; sodium cromoglicate 2% w/v 13.5 ml eye drops; pl 15872/0010

Action Required: Action Complete

The Trusts pharmacy supplier did hold affected stock; however none had been supplied to any of the Trusts Wards. As such the affected stock has been quarantined

MDA/2017/013 18-May-2017

All LIFEPAK 1000 automatic external defibrillators (AEDs) - risk of device shutting down unexpectedly during patient treatment and possible failure to deliver therapy

Assessing relevance

The Trust is currently assessing whether it has any of these devices

EL (17) A /06(v2)

19-May-2017

Drug alert class 2 (action within 48 hours); fdc international ltd; sodium cromoglicate 2% w/v 13.5 ml eye drops; pl 15872/0010; update to instruction for returns

Action Required: Action Complete

The Trusts pharmacy supplier did hold affected stock; however none had been supplied to any of the Trusts Wards. As such the affected stock has been quarantined

MDA/2017/014 24-May-2017

All HeartStart MRx defibrillators – possible failure to deliver a shock, cardioversion, pacing or monitoring Assessing relevance

The Trust is currently assessing whether it has any of these devices

EFN/2017/11 31-May-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - UPDATE - Areva T&D Automation & Information Services - MICOM P123 – Protection

Action not required


EFN/2017/12 31-May-2017

High Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDER) - Lucy Switchgear - Sabre VRN2a - Ring Main Unit

Action not required


17

DWMHT Safeguarding Performance Framework 2017/18

Section 1 • Safeguarding Training Compliance

Section 2 •Deprivation of Liberty (DoL’s)•Domestic Violence

Section 3 •Safeguarding Children (including CAMH’s – LAC)•Vulnerable Adults

18

Safeguarding Training Compliance Safeguarding Performance Framework for May 2017

Training Data Month 1

Compliance Target Compliant Required compliance

Compliant % Compliant Required compliance



Compliant %

Safeguarding Induction 100% 13 13 100% 4 4 100% 5 5 100% 4 4 100%Safeguarding Adults Lvl 1 90% 271 291 93% 68 76 89% 73 80 91% 130 135 96%Safeguarding Adults Lvl 2 90% 636 719 88% 252 282 89% 264 295 89% 120 142 85%Safeguarding Adults Lvl 3 90% 413 486 85% 156 183 85% 179 209 86% 78 94 83%Safeguarding Adults Lvl 4 90% 3 4 75% 0 0 - 0 0 - 3 4 75%Safeguarding Children Lvl 1 90% 263 290 91% 66 76 87% 71 80 89% 126 134 94%Safeguarding Children Lvl 2 90% 626 720 87% 253 282 90% 252 295 85% 121 143 85%Safeguarding Children Lvl 3 90% 412 491 84% 161 183 88% 166 209 79% 85 99 86%Safeguarding Children Lvl 4 90% 4 5 80% 0 0 - 0 0 - 4 5 80%Mental Capacity Act 90% 601 727 83% 250 299 84% 257 303 85% 94 125 75%PREVENT 90% 645 727 89% 260 298 87% 278 305 91% 107 124 86%Domestic abuse & Violence 60% 369 653 57% 143 268 53% 162 275 59% 64 110 58%

DWMH Corporate / Pan Trust12 month

Trend

High pointLow point

Dudley Walsall

Exceptions / Commentary This section shows the latest Training requirement and compliance levels as set out in the Commissioner Contract for 2017/18 , related to Safeguarding and Vulnerable Adults. Within the contract there are agreed trajectory requirements.

Adult Safeguard Training - Children's Safeguarding Training - Q1 - 90% Q1 - 90%Compliance as detailed in the table above. Q2 - 90% Q2 - 90% Q3 - 90-95% Q3 - 90-95% Q4 - 90-95% Q4 - 90-95% Mental Capacity Act (MCA) and Deprivation Of Liberty (DOL’s) Prevent Domestic Abuse Q1 90% Q1 - 90-95% Q1- 60% Q2 90% Q2 - 90-95% Q2- 70% Q3 90-95% Q3 - 90-95% Q3- 80% Q4 90-95% Q4 - 90-95% Q4- 90%

19

NHS

Dudley

NHS

Walsall

0 6

0 0

4 0

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May 1 0

NHS Dudley 3 3 4 6 1 5 2 1 2 6 Adult 0 3

DOL's Applied For 1 1 1 1 1 5* 9

DOL's Closed 2 2 4 6 1 5 1 2 5

NHS Walsall 2 5 7 5 6 7 4 3 11 5 4

DOL's Applied For 2 4 3

DOL's Closed 2 5 7 5 6 7 4 3 9 1 1

Grand Total 5 8 11 11 7 12 6 4 13 11 0 4

26 2 29 0

10

9

Active DoL's

Total

92

9

Linden

Cedars

Holyrood

Malvern

Langdale

Safeguarding Performance Framework for May 2017

Grand

Total

33

5*

50

Old

er A

du

lt

2016 2017

Referral

Dudley

Alert Only

Walsall

28

59

Referred

into

MARAC

May-17Safeguarding Cases Internally reported as

Domestic Abuse

Open To

Mental

Health

Referred

into

MARAC

Open To

Mental

Health

MARAC

Section 2 - DoL's and Domestic Violence

2.2 Domestic Abuse

Total number of cases of Domestic Violence for the current month, these include cases reported within the Trust and Externally notified by MARAC (Multi-Agency Risk Assessment Conference)

2.1 Deprivation Of Liberties (DOL's) - This shows the total number of active cases of DOL's, broken down by Locality

Commentary Table 2.1 This table shows the activity in relation to cases of Deprivation Of Liberties (DOL's). This information is broken down by locality and shows the current number of Active cases, and activity for the last 12 months. There are currently 15* active cases of DoL's across the Trust

Further information relating to Older Adults, health related legal restrictions / provisions (Ward breakdown provided above).

• Dudley - 6 patients• Walsall - 9 patients

* 1 DoL's Case - April 2016 which is not shown on the table above due to the date range

Table 2.2 Domestic abuse cases are reported as separate figures to display the prevalence within the service. Case figures are also shown for MARAC (multi agency risk assessment conference), these figures demonstrate how many cases are heard at MARAC where the victim, perpetrator or children are open cases to mental health. • The first table provides information on Cases reported Externally of the Trust which are then checked to see if these

Patients are open to Dudley and Walsall Mental Health.• The second table provides information on Domestic Abuse cases which have been reported internally into our Trust

20

Referral Alert Only Referral Alert Only

5 25 1 14 450 0 0 0 00 0 0 0 00 0 0 0 00 0 0 0 00 0 0 0 00 0 0 0 00 0 0 0 05 25 1 9 40

259

Grand TotalNumber of Looked after Children

Total 107 152

Patient considered High Risk Position of Trust InternalPosition of Trust External

Dudley Walsall


Dudley Walsall Grand Total

Child Safeguarding Case

Under 18 AdmissionUnder 18 Death FGMSerious Case Review (Child)Grand Total

3.1 Safeguarding Children

Graph 3.1 - This graph provides information relating to the last 12 months and shows a breakdown of Safeguarding cases which are just for alert only and those which have been progressed to be continued under Safeguarding

Table 3.1 -This shows that the number of Safeguarding cases broken down by case type and showing the locality . This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency.

Table 3.1.1 -This table provides information in relation to Looked after Children (LAC), who have been referred or in receipt of our services.

• The Trust has been invited to attend a Practitioner Seminar Event to review the 1st draft report regarding the recent complex sexual abuse SCR involving three LAC children who were or had been known to CAMHS in Dudley next month.

• There has been no further update regarding information required from the Trust for the Dudley murder.• The Position of Trust case regarding the transportation and inappropriate video recording of a CAMHS service user out of borough is

still ongoing.

Graph 3.1 - Total number of Safeguarding Children incidents reported during the last 12 months

Table 3.1 Total number of Safeguarding Children cases for the current month

Table 3.1.1 Looked after Children (LAC) Total number of cases of Looked after Children

0

10

20

30

40

50

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

2016 2017Alerts Referral

New Performance indicators - 2017/18

As part of the new Commissioner Contract for 17/18 additional indicators have been introduced (shown below) for which the trajectors have yet to be agreed, and will be based on the data set in Q1.

• There have been no Child Protection Cases during Month 2

Number of invitations to Initial Child Protection Conferences Rate of attendance at Initial Child Protection Conferences Rate of report submission to Initial Child Protection Conferences Rate of report-sharing with parent/child prior to Initial Child Protection Conferences Number of invitations to Review Child Protection Conferences Rate of attendance at Review Child Protection Conferences Rate of report submission to Review Child Protection Conference

21

Referral Alert Only Referral Alert Only

15 77 22 87 2010 2 0 2 40 0 1 0 10 0 0 0 00 0 0 0 00 1 0 0 10 0 0 0 00 0 0 0 0

15 80 23 89 207


Dudley Walsall Grand Total

Grand Total

AdultPatient Considered High RiskPosition Of Trust InternalPosition Of Trust ExternalPrevent CaseSerious Adult Review DHRFGM

3.2 Vulnerable Adults

Graph 3.2 Total number of Vulnerable Adults incidents reported during the Last 12 Months

Graph 3.2 -This graph provides information relating to the last 12 months and shows a breakdown of Vulnerable Adults Cases which are just for alert only and those which have been progressed to be continued under Safeguarding.

Table 3.2 This shows that the number of Vulnerable Adults cases broken down by case type and showing the locality. This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency.

• The Trust has been invited to attend an information sharing meeting to consider a case that may be investigated under the SAR process but may also meet the criteria for a DomesticHomicide Review

• An internal Position of Trust case has been opened within our inpatient services and this and is currently being investigated.

Table 3.2 - Total number of Vulnerable Adults incidents for the current month

0

50

100

150

200

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

2016 2017

Alerts Referral

22



Enclosure: 11

Report Title:

Finance and Performance Committee Chair Report

Committee:

Finance and Performance Committee (F&P)


Pawiter Rana – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Key issues & risks The Finance and Performance committee met on the 26th June and considered the Finance and Performance information for May (Month 2). The committee reviewed the following items of business: Performance The report tabled was accepted and the following areas were noted:

• Activity overall is 9.2% above contract • KPIs – Under-performance against 5 of the agreed 27 KPI’s, namely % of patients

receving a copy of their care plan in Walsall (amber), achievement of adult inpatient length of stay within Dudley of less than 40 days (red), proportion of CRS patients seen within 6 weeks in Dudley (red), CPA 7 day follow up in Walsall (amber) and finally the number of patients receiving IAPT therapy (both localities – both amber)

Discussions were had around the need to flex our resources across the Dudley and Walsall contracts to ensure that we are not over-achieving in activity terms in those service lines which give us no chance (either in year or in future years) of recovering income to cover costs incurred – this was particularly highlighted in areas such as CRS. SLR Overview Report presented to committee around the use of SLR: Key message was that all service lines make a contribution to overheads, however, Older Adults do not make a ‘profit’ as such once overheads are taken into account. It was also pointed out that this service line has not made a significant contribution to the CIP programme over the last few years despite commissioners reducing services and funding. It was also evident that Dudley is more profitable than Walsall in terms of SLR.

Enc 11 FandP Chairs report July Board Meeting (M02) Page 1 of 3

TCT partners have well established and frequent reports with clinical engagement which is a culture that we at DWMH will have to adopt. PbR Update The report tabled was accepted and the following areas were noted:

• Team clustering performance – still showing areas of under-performance in terms of clustering across several areas, particularly within Older Adults in Walsall and Crisis in both localities.

Finance Report & Income Report The finance report was presented. The financial position to the end of May 2017 showed a £381k surplus which was £52k ahead of the plan to date (based on the planned annual surplus of £1,839). In May Contracted Income reflected an adverse variance of £31k. This has been driven in part by the additional CIP of £200k FYE placed on Non Contract Activity which has been slow to start at the beginning of the year, as well as the shortfall in Detox bed use. Agency spend was discussed in light of the NHSI agency cap of £4.05m. The position year to date as of month 02 is reporting an underspend of £146k and has been a good start to the financial year. Overall Pay spending is in surplus and is continuing to follow the trend of underspends as experienced throughout the previous financial year. CIP Paper An overview of the 19 CIP schemes for the year was tabled and focus was placed on 8 specific schemes that are currently rag rated as red. Members of the committee expressed concern around levels of assurance in delivering the CIP programme on a recurrent basis, especially in light of the comments made within the financial due diligence report undertaken by Assista (next agenda item). The Committee was updated on the vacancy review process currently underway and that identified posts would be released and reflected within the June finance reports against the outstanding CIP targets. TCT Financial Analysis A paper was presented to the committee in relation to the financial historical due diligence undertaken to support the TCT FBC. The committee agreed that the review undertaken by Assista was a true and fair view of the financial performance of the Trust over the past few years. Enc 11 FandP Chairs report July Board Meeting (M02) Page 2 of 3

Risk Register The report on the risk register was tabled and it was noted that there had been an update to one of the risks around CQUINs. Discussion was held around where additional risks should be included, for example fire risks and CQUINs, and it was reported that a draft list of potential finance risks had been circulated to senior finance leads for review – potential risks will be added to the risk register accordingly following review by the finance team. Review of Terms of Reference The committee ToR were reviewed and amended to take account of the fact that ‘workforce’ data/reports now fall under the remit of the Workforce committee. A slightly revised membership was agreed. The Terms of Reference are subject of a separate report to Board for approval. E&CPG Minutes The minutes from the Estates & Capital Planning Group were tabled and accepted. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• MEXT • Audit Committee • Quality & Safety Committee • CARM • CQR

Recommendations and requests for direction The Trust Board is asked to:- Accept this report for assurance about the exercise of delegated authority by the Finance and Performance Committee Endorse the decisions and recommendations made by the Finance and Performance Committee.

Enc 11 FandP Chairs report July Board Meeting (M02) Page 3 of 3



Enclosure: 12

FINANCE & PERFORMANCE COMMITTEE MEETING

Minutes of a Meeting Held on

22nd May 2017

Conference Room 1, Trafalgar House, Dudley

START TIME 14:00 HOURS

Present: Pawiter Rana Non Executive Director (Chair – part attendance) John Lancaster Non Executive Director (Acting Chair) Mark Axcell Chief Executive Officer Rupert Davies Interim Director of Finance Dr Kate Gingell Joint Medical Director Ashi Williams Acting Director of People Rosie Musson Acting Director of Nursing In Attendance: Mark Banks Deputy Director of Finance Paul Chamberlain Head of Financial Planning Dan Howard Head of Business Intelligence and IM&T Makhan Singh Principal Consultant, Information & Performance Steve Byng Clinical Lead for Care Cluster & Tariff Development (agenda items 6

& 6.1 only) Nahid Younis BCHC Safeguarding Named Nurse (in attendance for observation

purposes) Emma Jackson Note Taker Apologies: Dr Mark Weaver Joint Medical Director Lesley Writtle Acting Director of Operations Wendy Pugh Director of Operations, Nursing & Estates Liam Dolan Associate Director of Operations ACTION 10. Apologies For Absence

10.1 Apologies noted as above.

11. Declarations of Interest

11.1 No Declarations of Interest noted.

Enc 12 FPC Minutes_22.05.17 Page 1 of 8

12. Minutes of Previous Meeting held on 21st April 2017

12.1 The minutes of the previous meeting held on 21st April 2017 were agreed as an accurate record.

13. Matters Arising

13.1 13.2 13.3 13.4 13.5

The actions were discussed and an update was provided where appropriate: Action point 109.2 – KPI Priority List Update provided as per the actions sheet. Action completed and closed. Action point 111.1 – Finance Report – Month 11 – IAPT Paper to Trust Board Update provided as per the actions sheet. Action closed. Action point 111.1 – Finance Report – Month 11 - Dual Diagnosis Patients Discussions had started to take place between Dr Gingell and Mr Parker and some work had also been undertaken with Mr Chamberlain. Scoping exercise underway to determine the number of qualifying patients for detox (patients needed to be on CGL waiting list) vs the amount of work involved. Update to be provided to the Committee in August 18. Action point 109.1 – Performance Report – Month 11 – Commissioners Response re; IAPT KPI Targets Action linked to IAPT action point 111.1. It had been agreed with Commissioners that the Trust would not receive any financial penalties with regards to IAPT whilst the Mental Health Strategies Review was underway. Action closed. Action point 99.4.1 (b) – PbR Update – Double Counting Issues mainly related to the Psychological Therapies Hub with no other service areas affected. Action completed and closed. Mr Rana joined the meeting.

14. PERFORMANCE

14.1 Performance Report – Month 1

Mr Singh talked through the key messages as reflected on page 5 of the report. The following points were raised and noted:-

• NHS contracted activity recorded in Month 1 was 6.1% above the contractual PAM.

• Inpatient activity was above by 2.4% in Month 1 compared to above by 7.3% in Month 12. Mr Lancaster


expressed his disappointment with the Trusts Month 1 position. Mr Singh provided his perspective of the position, acknowledging that there had been a bank holiday period during Month 1.

• In relation to KPIs, the Trust was non-compliant against 4 KPIs, three of which were new KPIs (Adult Inpatient stays less than 40 days, CRS & PT Hub). Mr Singh advised that the three new KPIs had been scrutinised via CARM - Mr Singh expected that the Trust would perform well against these 3 KPIs moving forward. A discussion was had around KPI - Adult Inpatient stays less than 40 days. In response to Mr Axcell, Mr Singh noted that the KPI was measured in month with the 2017/18 target based on 95% of patients staying less than 40 days after a hospital admission. Mr Singh highlighted that the Trust had achieved over 95% against this KPI in 2016/17, adding that the Trust was not subject to any financial penalties against this KPI at the current time. Dr Gingell was of the view that the target of 95% was not achievable, given that some of the patients admitted were extremely unwell.

• In relation to Delayed Transfers of Care performance, it was questioned if the one episode reported represented the whole Trust. Mr Singh provided assurance to the Committee that this was currently being reviewed by Mrs Cooper to ascertain if this data was correct or not.

• In relation to the Trust and CCG Contractual Quality Requirements, Mr Lancaster was keen to understand if there were any areas where the Trust was not performing well. Mr Singh commented that there were no issues to report at Q1. However, expected some challenges to arise in Q2/3 as targets increased.

• A discussion was had around KPI – CRS and proportion of patients seen within 6 weeks. Mr Singh acknowledged that the Trust was not achieving target from a Dudley perspective, providing assurance that the Service Standards meeting would be receiving and reviewing the activity data for both CRS teams, following which the necessary actions would be put in place to address the underperformance. It was noted that the Trust needed to review and understand the care pathways and process across both localities.

The Committee discussed and noted the contents of the report.

14.2 CQUIN Update

In the absence of Mr Parker, Mrs Musson provided a verbal update as follows:-

• In relation to the sign off of 2017/18 CQUINs, evidence continued to be compiled, to be submitted to Commissioners by end May 17. The Trust was planning and learning lessons from 2016/17, particularly around the physical health CQUIN. A challenge arising related


to the smoking and alcohol CQUIN/audit of case notes. It was noted that a CQUIN exception report would be brought to the Committee as and when necessary.

• In relation to the Trust’s performance against 2016/17 CQUINs:- - Medicines Management – on target. - Voluntary Sector – on target. - DW ROM – on target. - MDT, Dudley – a potential challenge noted – Dudley

CCG working with the Trust re; evaluation. - Unavoidable MH Act Admissions – on target. - Staff Health & Wellbeing – remained a challenge – flu

vaccination target not achieved and therefore the Trust was likely to receive part payment. Mrs Williams advised that in 2017/18, there would be a flu vaccination target increase of 5%.

- Physical Health – remained a challenge.

The Chair requested a progress update to be provided to the Committee at the end of Q1.

Mr Parker

15. PbR Update

15.1 Mr Byng was in attendance to provide the Committee with a PbR update. It was noted that the Trust was on target in Q1 with regards to cluster review performance. However, some work was required to improve performance given the trajectory increase in Q2. Mr Byng noted that the Committee had agreed to reduce the overall financial risk of Cluster 99 to £700,000 in 2016/17. Mr Byng recommended that the Committee agreed a 2017/18 target for un-clustered activity. The Chair was mindful that no improvements had been made to clustering performance over the last 6 month period, questioning what the data was actually telling the Committee. The Chair was keen to understand that action needed to be taken to resolve the issues and what the obstacles were, preventing teams from achieving a “Green” performance status. Mr Byng was requested to meet with two selected teams - PT Hub and Adult Outpatients (Dr Chawda or Dr Edwards) to ascertain the “true” reasons for poor clustering performance. Mr Byng to also select and discuss with two well performing teams how they were able to achieve a “Green” performance status/enablers for achievement. Results to be fed back to the Committee in July 18.

Mr Byng

15.2 Implications of DWMH not using Care Clusters


Mr Byng talked the Committee through the paper which considered the financial, clinical and data aspects of not using care clusters as a currency for funding mental health services and the impact and risks associated with this. The following points were raised and noted:-

• MCPs would result in outcome based contracts. • Care clustering supported reference costs and also

IAPT. • The Chair questioned if there was any drive to change.

Mr Davies advised that care clustering had simply not worked and no suitable alternative had been devised.

• BCPFT used clusters. However, the extent of monitoring and reporting was not clear.

• Mr Byng was of the view that the Trust should continue to use care clusters given that the clinical use of clusters to understand patient groups and needs remained valid whilst allowing for national benchmarking and development of care packages and outcomes.

• Dr Gingell wished to see more positive outcomes from clustering, from both a staff and patient perspective.

• The Committee agreed that a piece of work was required to look at how the Trust could improve the outcomes as a result of care clustering. The Chair requested that Mr Byng met with Dr Gingell and Mrs Musson to discuss next steps.

Mr Byng left the meeting.

Mr Byng/Dr Gingell/Mrs Musson

16. FINANCE

16.1 Finance Report – Month 1

Mr Banks talked through the key messages as reflected on page 5 of the report, highlighting a Month 1 surplus of £200k and a favourable variance of £33k against the planned surplus of £1.839m for the financial year. The following points were raised and noted:-

• The Trust’s bank and agency spend position was at its lowest, based on the previous 12 month period. Mr Axcell expressed his thanks to all involved in the agency related work.

• The Trust’s summary income and expenditure statement was now reflective of the new service lines in place. Mr Axcell noted that the Trust was reporting a net surplus of £167k which incorporated Month 1 phased CIP schemes. Whilst the Trust had made good progress at the start of the new financial year, Mr Axcell expressed the importance of continuing to monitor CIP plans closely.

• Shift breaches were bearing no consequences on the


Trust at the current time. • Mr Rana suggested consideration being given to the

implementation of a system whereby the finance team were notified via the performance team of any early warnings that may impact on the Trust’s financial position in any given month.

The Committee discussed and noted the contents of the report.

16.2 Income and Activity Report – Month 1

The Committee received and noted the Income and Activity Report for Month 1.

16.3 CIP Paper

Mr Davies gave a presentation to the Committee on 2017/18 CIP Schemes. The following points were raised and noted:-

• Seven CIP schemes had been rated as a red risk in terms of successful financial delivery. Out of the red rated schemes the Trust was in a position to control and influence only four of the seven schemes.

• The red CIP schemes were owned by the Executive Team who would review and discuss the schemes on a fortnightly basis up until the point the red ratings had changed to green.

• With regards to the step down beds for DGoH, Mr Davies explained the proposal to sell 4 step-down beds to DGoH. However, the new CEO of DGoH had recently announced that their average length of stay was too high and needed to be reduced. Should this be the case, the step down beds would not be required. Mr Davies advised that Mrs Writtle would be seeking formal notification from the CEO of DGoH re; whether the 4 step down beds were required or not. The Chair made it very clear that the Trust needed to look at alternative solutions in a timely manner if there was a risk that the Trust would not achieve any of the 2017/18 CIP red rated schemes. A suggestion was made that the 4 step down beds be offered to an alternative organisation.

• With regards to the urgent care pathway, this was a small scheme to the value of £75k and was reliant upon Walsall CCG engaging their GPs and GPs agreeing to act upon a new pathway for urgent care patients. Mr Davies advised the Committee that he would be requesting evidence from Walsall CCG to demonstrate that they had taken reasonable steps to engage with their GPs. Mr Davies added that should no evidence be produced, the Trust would be requesting a rebate. The Chair asked if it would be beneficial to agree an alternative scheme at this stage. Mr Chamberlain


explained that this would be risky, suggesting that the Trust continued to preserve with this scheme at the current time.

• With regards to Dudley Primary Care and IAPT decommissioning, the outcome of the Mental Health Strategies Review was being awaited.

• The most complex schemes related to those that changed the current ways of working i.e. shift pattern review and efficient recover pathway review.

16.4 Vacancy Reduction Plan

Mrs Williams updated the Committee on the recruitment plans per service for 2017/18 Q1. The following points were raised and noted:-

• 26 posts had been identified in Q1 (posts that the Trust could recruit to). Mrs Williams advised that should these 26 posts be filled, the Trust’s vacancy rate would decrease from 13.5% (based on Month 1) to 11%.

• Mr Banks noted that the vacancies within inpatient areas had been omitted from the list.

• The Chair questioned if the Trust required those vacancies which had been left unfilled for a significant period of time. As a result, it was agreed that Mr Banks and Mrs Williams would do some further work to review the vacancies list, incorporating the Band 5 posts and removing all those vacancies that were not required by the Trust at the current time. It was acknowledged that a QIA would need to be undertaken. Mrs Musson also requested that a balanced approach be taken when considering the removal of any vacancies.

Mr Banks/Mrs Williams

17. Risk Register

17.1 Mr Davies provided a summary as follows:-

• The same 3 significant risks remained on the risk register in relation to CIP, Section 75 funding and electronic paper clinical records. Mr Davies noted that an addition amber risk had been added to the risk register relating to Walsall Older Adults QIPP/CIP Project.

18. Any Other Business

18.1 Minutes of the Estates and Capital Planning Group Meeting held on 29th March – for information

The minutes of the Estates and Capital Planning Group held on


29th March 17 were received and noted by the Committee.

18.2 No items of any other business noted.

19. Date and Time of Next Meeting

19.1 Monday 26th June 2017 14:00 to 17:00 hours Board Room, Canalside House, Walsall.




Enclosure: 13

Report Title:

Audit Committee Chair’s report and Annual Report – 2016/17

Committee:

Audit Committee


John Lancaster, Non-Executive Director Annalee Russell, Finance Manager – Audit & Assurance


Decision / Approval

Gain assurance

Discussion

Information

This report incorporates the Chair’s report and annual report from the Audit Committee to the Board outlining the work the Committee performed during 2016/17. Key issues and Risks Introduction The Audit Committee is established under Board delegation with approved Terms of Reference which last approved by the Board in 2016. The Terms of Reference have been reviewed by the Committee again at the May 2017 meeting and subject to a couple of minor amendments have been approved for ratification by the Board. These will be presented to Board in July 2017. The Committee has met on five occasions throughout the financial year and has discharged its responsibilities for scrutinising the risks and controls which affect all aspects of the organisation’s business. Principal review areas 1. Trust Financial Statements, Annual Governance Statement and Annual Report

• The Committee reviewed the Trust’s 2016/17 Accounts. The Committee reviewed management’s assertion that the Accounts should be prepared on a going concern basis and considered this appropriate. The Trust received an unqualified audit opinion on the financial statements from external audit in their 2016/17 Audit Findings Report (see section 4). Accordingly, the Committee recommended to the Board for approval the Management Letter of Representation to the external auditors in respect of the Accounts and recommended formal adoption of the 2016/17 Accounts;

• The Committee reviewed the Annual Governance Statement (AGS) together with the Head of

Internal Audit Opinion, External Audit Opinion and other appropriate independent assurances at its meeting on 22nd May 2017. It considered that the AGS for the year ended 31st March 2017 was consistent with the Committee’s views on the Trust’s system of internal control and recommended it to the Board for approval.;

Enc 13 Board Sub Committee Chair Report - Audit Committee - Annual 2016-17 Page 1 of 4

• The Committee reviewed the Trust’s Annual Report and supported Board approval of it. All of the documents above (Accounts, Management Letter of Representation, Annual Report and AGS) were presented to Board for review, formal adoption and/or approval at the extra-ordinary Board meeting held on 22nd May 2017.

2. Risk Management and Internal Control • The Committee has reviewed the Board Assurance Framework. It believes that the Framework

used during the year was fit for purpose and has reviewed evidence to support this. The Framework is in line with Department of Health expectations and has been reviewed by internal audit (and graded “A”) to provide additional assurance that this opinion is well founded;

• The Committee has received a verbal update from the Chair of Governance and Quality Committee to provide it with assurance over the Trust’s clinical audit arrangements and its’ fitness to register with the Care Quality Commission.

3. Internal Audit Throughout the year the Committee has worked effectively with internal audit to strengthen the Trust’s internal control processes. This year the Committee has:

• Reviewed and considered the effectiveness of internal audit and considers the provision of the internal audit service sufficient in supporting the Committee in fulfilling its role;

• Considered the major findings of internal audit, assured itself that management has responded in an appropriate manner and that the Head of Internal Audit Opinion (which overall provides “significant assurance”) and AGS reflect the Trust’s control environment. The 2016/17 audits completed by Internal Audit and their assurance levels are provided in the table below:

Review Level of

assurance Board Assurance Framework Level A Financial Systems (Key Controls) Significant Partnership Working Significant Compliance with Fit and Proper Person Regulations Significant Recruitment (Efficiency) Processes Moderate Care Records: Least Restrictive Practice – Part 2 Moderate Care Records: Mental Health Capacity Act / Deprivation of Liberty Safeguards Limited Care Records: Least Restrictive Practice Limited

The Committee ensures that actions falling out of internal and external audit reviews are implemented and monitored. The age and risk ranking of outstanding recommendations is reported allowing the Audit Committee to focus attention on the oldest and most significant recommendations in terms of risk. This has helped ensure trust officers have implemented recommendations in a timely manner.

In addition, the Committee considered a number of non-assurance related pieces of work undertaken by the Internal Audit team, these included:

• Programme Management Office / Cost Improvement Plan: Diagnostic Report • Information Government Toolkit Compliance: ‘Action Required’ assessment

• Well Led Framework: non-assurance work

The Committee has reviewed and approved internal audit’s draft plan for 2018/19. A full operational plan is expected to the Committee scheduled for September 2017. Enc 13 Board Sub Committee Chair Report - Audit Committee - Annual 2016-17 Page 2 of 4

4. External Audit

• The Committee has reviewed and considered the effectiveness of External Audit and considers the provision of the External Audit service sufficient in supporting the Committee in fulfilling its role;

• The Committee has reviewed and commented on external audit’s 2016/17 Audit Findings Report. The report gives an unqualified opinion on the 2016/17 financial statements and an unqualified value for money conclusion;

• The Committee has reviewed and agreed external audit’s 2017/18 annual plan; • The Committee has also sought the views of external audit where appropriate in relation to the

governance of the organization.

5. Anti-Fraud

• The Committee has reviewed and considered the effectiveness of Anti-Fraud and considers the provision of the Anti-Fraud service sufficient in supporting the Committee in fulfilling its role;

• The Committee has received and reviewed reports from the Trust’s Anti-Fraud officer throughout 2016/17 and has satisfied itself that the Trust has adequate arrangements in place for countering fraud;

• The Committee has received and approved the Anti-Fraud 2016/17 annual report and the Trust’s Anti-Fraud 2017/18 Operational Plan.

6. Management • The Committee has challenged the assurance process when appropriate and has requested

and received assurance reports from Trust management and various other sources both internally and externally throughout the year. This process has also included calling managers to account when considered necessary to obtain relevant assurance;

• The Committee has received an up-to-date register of losses and special payments incurred by the Trust, a list of waivers signed off by Trust management and a list of ‘No order’ purchases made by the Trust at each Committee meeting.

• The Committee has reviewed the Trust’s Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions in the financial year, and these were approved by the Board at its meeting in April 2016 (subject to a number of minor amendments).

7. Other matters worthy of note The Committee has reviewed the process and controls that the Trust has put in place to achieve its financial obligations throughout the year. It further notes that the Trust has achieved these financial obligations. 8. Review of the effectiveness and impact of the Audit Committee The Committee has been active during the year in carrying out its duty in providing the Board with assurance that effective internal control arrangements are in place. Specifically, the Committee has reviewed its compliance with the revised 2014 NHS Audit Committee Handbook and has undertaken a self-assessment (via completion of the Measuring the Effectiveness of the Audit Committee on-line survey). Actions arising from this self-assessment are incorporated into the Audit Committee 2017/18 plan and will be addressed over the next financial year. Interfaces with other Committees

• Finance & Performance Committee Enc 13 Board Sub Committee Chair Report - Audit Committee - Annual 2016-17 Page 3 of 4

• Quality & Safety Committee • Mental Health Act Scrutiny Committee • MExT

Recommendations and requests for direction The Board is asked to receive and note this report from Audit Committee.

Enc 13 Board Sub Committee Chair Report - Audit Committee - Annual 2016-17 Page 4 of 4



Enclosure: 14

DRAFT

Audit Committee

Minutes of meeting held on Monday 22 May Conference Room 1, Trafalgar House

Start time: 10:30hrs

Present: Mr John Lancaster Non-Executive Director (Chair) Mrs Gill Cooper Non-Executive Director In Attendance: Mr Mark Axcell Chief Executive officer Mr Rupert Davies Interim Director of Finance, Performance & IM&T Mr Mark Banks Deputy Director of Finance Ms Annalee Russell Finance Manager Mr Mark Stocks Engagement Lead, Grant Thornton Ms Joan Barnett Manager Grant Thornton Mr Paul Westwood Head of Anti-Fraud Services Mr Will Tyrrell Audit Manager, CW Audit Services Mr Lewis-Grundy Company Secretary Mrs Linda Wix Corporate Governance Support Officer (Minutes)

Ms Nahid Younis (shadowing the Chief Executive)

Safeguarding Lead, Birmingham Community Healthcare Trust

Apologies: Mr Paul Dudfield Ms Rosie Musson Ms Sarah Swan

Consortium Director, CW Audit Services Acting Director of Nursing Assistant Director, CW Audit Services

Minute Item Action

1. Welcome

The Chair welcomed everyone to the meeting.

2. Apologies Apologies were noted as above.

3. Minutes

3.1

The Minutes from the meeting held on 20 March 2017 were noted as a true and accurate record.

4. Matters Arising

4.1

The following items were discussed:

Enc 14 Audit Minutes 22.5.17 minutes (DRAFT) Page 1 of 11

4.2 4.3

Minute 4.4 & 20.7 Internal Audit Management Letter – Older Adults services 2015/16

Mr Davies advised that the first service line analysis would be reported to this month’s MExT and would focus on the expenditure budgets income. The next stage would be to commence income and expenditure reporting by service line. The confirmed that the item could be removed from the Action Schedule. Minute 44 Welcome Mr Davies confirmed that the Board had requested the compilation of a TCT Risk Register and that this would be reviewed regularly by Board Sub-Committees and that it was an agenda item for the Board meeting taking place in June. The Chair confirmed that the item could be removed from the Action Schedule. Minute 51.2 IR35 Compliance Mr Davies advised that a meeting had been diarised with the Interim Director of People to discuss the implications for the Trust. The Chair queried the potential financial impact for the Trust and Mr Davies advised that workforce implications were of greater concern with medical locums seeking work in other organisations. Mr Axcell confirmed that the Trust was liaising with MERIT partners to ensure that IR35 was being implemented consistently across the four Trusts. The Chair stated that the Trust’s strategic position and the internal position could be addressed and Mr Davies agreed to provide a status report to the Workforce Committee in June and to the Trust Board in July. Action: IR35 status report to be submitted to the Workforce Committee in June and to the Trust Board in July with an update to the Audit Committee in September. Estates Strategy Action Plan The Chair queried the status of the Estates Strategy Action Plan and Mr Davies advised that the five key areas of the strategy were being approached in a systematic way and monitored by the Estates & Capital Planning Group.

Mr Davies

5.

INTERNAL AUDIT

5.1 Final Annual Report & Head of Internal Audit Opinion for 2016/17


Mr Tyrrell took the Committee through the report advising that the overall opinion was that “significant assurance” could be given and that there was a generally sound system of internal control, designed to meet the organisation’s objectives, and that controls are generally being applied consistently. However, some weakness in the design and/or inconsistent application of controls, put the achievement of particular objectives at risk and that whilst a number of reviews received significant assurance, limited assurance was provided for Care Records MCA/DoLS and the initial assessment of Care Records Least Restrictive Practice. In a second audit improvements were noted with Least Restrictive Practice Care Records and Moderate Assurance was provided. Moderate Assurance was also provided in relation to Recruitment (Efficiency) Processes. The Chair queried the limited assurance provided in relation to care records and Mr Tyrrell advised that an initial report had provided limited assurance although a subsequent report had given moderate assurance indicating an improvement in the completion of care records. He confirmed that a further review of care plan completion would be undertaken in the first quarter to identify whether further improvements had been realised. Mr Davies confirmed that the findings of the audits triangulated with evidence contained in the CQC report and highlighted the inconsistency in completion of care records between the two hospital sites. The Committee noted the report.

5.2 Outstanding Recommendations Report

Mr Tyrrell advised that there were no outstanding or overdue recommendations and there were four recommendations that were not yet due. In response to a query from Mr Cooper, Mr Tyrrell advised that a further audit of the recruitment process would be undertaken. The Chair queried whether any improvements in the time taken to recruit would impact negatively on the Trust’s finances and Mr Banks advised that savings would be realised given that the Trust would have substantive staff in post instead of paying premium rates for agency staff. Mr Axcell confirmed that the Workforce Committee was focussed on reducing the recruitment process and time would be given for the TRAC recruitment system implemented in January to become embedded in the organisation before the recruitment process was reviewed again. Mrs Cooper commented that she had been advised during the Trust Supportive Visits she had been involved in


the previous week that recruitment had improved and Mr Axcell stated that this was demonstrated by the lowest spend on agency during April for two years. The Committee noted the report.

5.3 Information Governance Toolkit Compliance Report

Mr Tyrrell advised that an interim review of the evidence available to support the Trust’s 2016/17 Information Governance Toolkit (IG Toolkit) submission had been completed and the report provided a status update at the point when the work was undertaken (February 2017) and as such did not provide a formal opinion on the completed submission. The interim review had identified a number of gaps in the evidence available to support the target level of compliance for 2016/17 and some minor actions were required to ensure the evidence was in place to demonstrate compliance against the IG Toolkit, although it should be noted that the majority of evidence was in place at the time of the review as demonstrated in the evidence assessment section of the report. In response to both Mr Davies and Mr Axcell, Mr Tyrrell confirmed that the typographical errors within the report would be corrected. Mr Davies advised that the overall score for 2016//17 was lower than that for 2015/16. This had been discussed at the Information Governance Committee. The reduction had been attributed to the time constraints of the Head of Information Governance, added to which controls were likely to weaken with TCT requirements and the Executive Team would need to consider a standardised approach to be taken going forward. The Committee noted the report.

6. EXTERNAL AUDIT UPDATE

6.1 Audit Findings

Mr Stocks took members through the report, highlighting a number of areas, advising that the value for money conclusions had taken into account the potential acquisition by Birmingham Community Healthcare NHS FT Trust. He advised that the key messages arising from the audit of the Trust’s financial statements were:

• there were no significant issues arising from the audit

• both the accounts and audit working papers were of good quality


• Trust staff were helpful and responsive to requests and he commended the finance team.

An area of audit focus was to review the Trust’s accounting entries that arose as a result of it adopting Modern Equivalent Asset (MEA) valuation methods for its land and building assets on 1 April 2016. This resulted in an impairment in the value of the assets totalling £19,645k. Some enhanced disclosures had been agreed with regard to the MEA valuation to more accurately reflect the substance of the related transactions restating the value of land and buildings. Due to the significance of the value of the impairment the auditors had sought representation from Management to confirm the view that it was reasonable to value the Trust's property as a MEA- alternate site basis. Mr Stocks congratulated the Trust on its achievement of an overall “good” rating from the CQC. Referring to “value for money”, the auditors were satisfied that, in all significant respects, the Trust had proper arrangements in place to secure economy, efficiency and effectiveness in its use of resources. The definition of “going concern” was the ability to continue to trade for year and day from when accounts signed. The Trust had contracts in place for the 2017/18 financial year and a substantial cash reserve and the assumption had been made the service provision would continue until May 2018. In response to the significant risks identified it was found that:

• the CIP target for the year was achieved, although £986k of 2016/17 CIP schemes were delivered on a non-recurrent basis. The Trust would need to move to recurrent CIPs wherever possible

• there were a number of risks to the Trust’s long term financial sustainability and these had been reviewed and the auditors were satisfied that the Trust was taking actions to minimise the impact of these risk.

• the Trust’s financial plans indicated that it had sufficient cash to trade for the next two years even if it moved to a revenue deficit

• the Trust had delivered the actions arising from the CQC inspection and was re-graded as “good” on 28 March 2017

• the Trust had adequate arrangements in place to consider its potential acquisition by Birmingham Community Healthcare NHS Trust, and the other options available to it.

Mr Stocks advised that no reference had been made in the financial statement to the acquisition of the Trust by BCHC


as Management had advised that a paper containing the Full Business Case for integration was due to be presented to the Trust Board meeting in June 2017. In response to a query from the Chair, Mr Stocks advised that overall he was satisfied that appropriate arrangements were in place to allow the Trust to consider the options available to it for securing both the quality of healthcare and its long term financial sustainability. The timetable for the acquisition was constrained and it was recommended that the Trust ensures all appropriate procedures, including due diligence of its partners and of the merged organisation’s business and financial plans are undertaken before proceeding. Adequate consultation of staff and with the public is also needed. On that basis the auditors had concluded that the risk was sufficiently mitigated and the Trust had proper arrangements to work with other parties to deliver strategic priorities and the action plan provided greater detail. Mr Axcell advised that the contents of the Annual Report that related to TCT were consistent with that of strategic partners. The Chair commented that the Full Business Case had yet to be reviewed by Board members and as such it could not be assumed that the that the FBC would be signed off. The Committee noted the report.

6.2 2016/17 Management’s Letter of Representation to Auditors (tabled)

Mr Stocks advised that the document was a standard letter of representation. Mr Stocks due attention to two additional disclosures specific to the Trust – requiring Management to confirm that they believed it reasonable to:-

• value the Trust’s property as a modern equivalent asset on an alternate site basis,

• prepare the accounts on a going concern basis regardless of the potential impact of the Dudley MCP contract and the potential acquisition of the Trust’s services by BCHC.

The Committee noted the report.

7. ANTI-FRAUD

7.1 Anti-fraud Annual Report

Mr Westwood advised that the report provided a summary of the anti-fraud activities undertaken during the 2016/17 financial year for Dudley and Walsall Mental Health Partnership NHS Trust. The Anti-Fraud Specialist had


undertaken seven investigations during the year and each matter had been discussed with the Director of Finance, Performance and IM&T prior to investigation. The Audit Committee had been updated on the investigations via the Anti-Fraud Progress reports throughout the year and all investigations had been conducted in line with NHS Protects Anti-Fraud Manual and recorded on the FIRST Case Management System. He drew attention to the summary of the investigations included in the report. Mr Westwood advised that there had been an increase in the number of referrals and that this demonstrated a positive change in the Trust’s culture with staff having a willingness to report any concerns. He advised the Chair that there were no recommendations to be made related to strengthening of controls. Mr Davies advised that Mrs Cooper had previously queried whether the Trust would be in a position to pursue a legal case against a fire protection company that had been engaged by the Trust and he confirmed that there was insufficient evidence to support the case. Mr Axcell referred to case reference 2016-06 – attempt to obtain fraudulent bank payment, advising that this had been prevented due to the close working relationships between the finance team and executive colleagues and this should be considered as part of the finance “safe landing” to ensure enhanced scrutiny of any requests that were deemed to be unusual. The Committee noted the report.

7.2 NHS Protect Self Review Tool

Referring to the report Mr Westwood advised that all health bodies were required to submit an annual self-review of their position against NHS Protects anti-fraud Standards for Providers. Ratings were based on a Red / Amber / Green rating scale with the option against a number of Standards to declare a neutral rating if the Standard does not apply. Some Standards also carried a greater weighting than others within the overall assessment for each area. The 2016/17 annual self-review of anti-fraud work had recently been carried out in conjunction with the Trust’s Director of Finance (DoF) and submitted to NHS Protect by the required deadline of 1 April 2017. The Trust had been RAG rated green overall in each of the four strategic areas defined by NHS Protect, and these were:

• Strategic Governance • Inform and Involve • Prevent and Deter


• Hold to account The Committee noted the content of the report.

8. TRUST BUSINESS

8.1 Management Papers

Mr Davies referred to the key messages:

• Waivers: 8 waivers had been authorised with a value of £61k in the last month of the 2016/17 financial year

• No Orders: There had been 20 instances of invoices being received without orders having been raised since the last Audit Committee meeting with a total value of £14k Deaf CAMHS interpreting.

• Losses and Special Compensations: Since the last Audit Committee meeting, there had been 2 bad debts / claims abandoned with a value of £1,538.53. There had been a rise in losses and compensations due to a one off ex gratia severance payment of £24,000

Referring to the No Orders, Mr Davies confirmed that a number of these related cancellations of interpreters in the Deaf CAMHS service and he had asked the Management Accountant for this service to undertake a review and he would provide a substantive report to the Audit Committee in September. Action: Provide a detailed report on the reasons for the high level of losses due to the cancellation of interpreters in Deaf CAMHS to the Audit Committee in September. The Committee noted the report.

Mr Davies

8.2 Consideration of Going Concern Report

Mr Davies introduced the report and advised that as part of the financial statements preparation process the management and directors of the Trust had considered the basis on which to prepare the accounts of Dudley & Walsall Mental Health Partnership NHS Trust for the financial accounting period ending 31 March 2017 and after due consideration, management believed the accounts should be prepared on a going concern basis and supporting evidence included:

• Previous Retained I&E surpluses and forecast future I&E surpluses

• The Trust’s strong cash position • Statement of the financial position


• Transforming Care Together (TCT) • Dudley Multi-speciality Community Provider (MCP)

Contract Having given due consideration to the above, Trust management and directors were satisfied that the preparation of the Trust’s accounts on a going concern basis is appropriate and that there were no material uncertainties related to events or conditions that may cast significant doubt over the ability of the Trust to continue as a going concern. The Committee formally recommended that the Trust Board formally sign off the document.

8.4 Draft Annual Report & Accounts 2016/17 (including Annual Governance Statement)

Mr Davies presented the Annual Report and Accounts 2016/17 advising that the Trust had performed well and had achieved the key financial targets. The Trust had delivered a year end surplus of £1,703,000 and this represented a favourable variance of £3,000 against the planned surplus of £1.7m for the financial year. This position was improved by receipt of a bonus payment by NHSI increasing the reported surplus figure to £2.2m which was an excellent position given the challenges over the year.

The Trust had been required to deliver capital expenditure within predefined capital budgets at £2.6m and had subsequently achieved £1.6m which was £1m below CRL and this slippage would be carried forward into 2017/18.

A minor target that had not been fully met was the Better Payment Policy which included the requirement to settle invoices within 30 days.

Mr Lewis-Grundy tabled a “Table of Amendments” Version 16 to Version 17 advising that there were a few minor drafting amendments to the report, including an amendment on page 91 (paragraph 5.1.7) where the pay differential between the highest paid and the median had decreased not increased as stated in the report.

The Committee recommended that the Trust Board approves the Annual Report (incorporating the Annual Governance Statement) and Accounts for 2016/17 incorporating the amendments tabled.

9. Self-certification against the NHS provider licence

In presenting the report, Mr Lewis-Grundy advised that it


outlined a new requirement placed on NHS Trusts following the implementation of the Single Oversight framework to make an annual self-declaration against two specific conditions within the standard NHS Provider Licence. The two conditions against which the Trust was required to make a self-declaration were:

• The provider has taken all precautions necessary to comply with the licence, NHS Acts and NHS Constitution (Condition G6(3)) – deadline 31 May 2017

• The provider has complied with required governance arrangements (Condition FT4(8)) – deadline 30 June 2017

Mr Lewis-Grundy advised that since writing the report, NHSI had confirmed that the level of detail in the report was appropriate for the submission. Members discussed the inclusion of the Supportive Visits to strengthen the assurance of the quality of services in both the 31 May and 30 June submissions.

Action: Include Supportive Visits to strengthen the assurance of the quality of services in both the 31 May and 30 June submissions.

The Audit Committee should make a recommendation to Board, based on the evidence available to the Committee

The Committee agreed to recommend the Board make the declarations as outlined in the tables included in the report, subject to the additional reference in the submissions as appropriate, of the supportive visits in assuring the quality of services.

10. Annual Review of Audit Committee Terms of Reference

Mr Lewis-Grundy advised that all committees of the Board should review their terms of reference on an annual basis to ensure fitness for purpose. The Terms of Reference had been reviewed in accordance with ‘The Foundations of Good Governance – A compendium of Good Practice, Third Edition’ and were also in line with the HFMA guidance on the Terms of Reference for an Audit Committee. The Terms of Reference had been comprehensively reviewed in May last year and there had been no change to legislation or national guidance that necessitated significant amendment to the current Terms of Reference. The Terms of Reference were in the standardised format and the only minor amendment was of a clerical nature.


The Audit Committee reviewed and approved the revised Terms of Reference and made a recommendation for their approval to the Board.


Mr Davies referred to the recent countrywide Cyber-attack advising that the Head of IT had produced a paper outlining the issues and the Trust’s response which he was in the process of reviewing. He provided assurance that the Trust was in strong positon due to the systematic approach taken to update anti-virus software and there had been no evidence of any breaches. The Trust systems were supported by Terafirma and their team had worked comprehensively to ensure the Trust’s systems were not compromised. He confirmed that the Trust was not one of 40 Trusts included on the national list of those at risk. Mr Axcell advised that the attack provided an opportunity to reflect on the reliance on email to communicate and identify potential back up procedures. Mr Davies confirmed to the Chair that a report on the status of the electronic patient procurement exercise would be reported to the Trust Board at the meeting in June.

12. Date of next meeting: Wednesday 21 June 2017 at 11.00am, (Review and sign off of Quality Accounts) Conference Room 1, Trafalgar House, King Street, Dudley DY2 8PS

Meeting closed at 12.01pm




Enclosure: 14A

Audit Committee

Minutes of meeting held on Wednesday, 21st June 2017

Conference Room 1, Trafalgar House Start time: 10:00hrs

Present: Mr John Lancaster Non-Executive Director (Chair) Mrs Gill Cooper Non-Executive Director In Attendance: Mr Rupert Davies Interim Director of Finance, Performance & IM&T Ms Rosie Musson Acting Director of Nursing Mr Mark Stocks Engagement Lead, Grant Thornton Ms Sarah Swan Assistant Director, CW Audit Services Mr Lewis-Grundy Company Secretary Mrs Linda Wix Corporate Governance Support Officer (Minutes)

Apologies: Mr Mark Axcell Mr Paul Dudfield Ms Annalee Russell Mr Will Tyrrell Mr Mark Banks Ms Joan Barnett Mr Paul Westwood

Chief Executive Officer Consortium Director, CW Audit Services Finance Manager Audit Manager, CW Audit Services Deputy Director of Finance Manager, Grant Thornton Head of Anti-Fraud Services

Minute Item Action

13. Welcome

The Chair welcomed everyone to the meeting.

14. Apologies Apologies were noted as above.

15. Minutes

15.1

The Minutes from the meeting held on 25 May 2017 were deferred to the meeting being held on 19th September 2017.

16. Matters Arising

All items were either complete or had a future completion date.

Enc 14A Audit Minutes 21.6.17 (DRAFT) Page 1 of 3

17. TRUST BUSINESS

17.1 Quality Account 2016/17

In presenting the Quality Accounts, Ms Musson confirmed that they had been prepared in accordance with national guidance and had completed the formal process of consultation with CCGs, HOSC and Healthwatch and had been reviewed by the Quality & Safety Committee and external audit. She confirmed that the feedback from stakeholders had been positive. The Quality Accounts were positive in terms of quality which was further demonstrated by the Trust being rated as “good” by the CQC. Delivery of CQUINNs had been challenging through the year and Ms Musson anticipated that this would continue into 2017/18. In response to a query from Mr Davies, Ms Musson advised that the format was dictated by the toolkit that was utilised in the compilation of the Quality Report and included sets of mandated statements. She confirmed that an Executive Summary would be made available to the general public. Ms Musson confirmed to Mr Lancaster that near misses formed part of the incident reporting process and over reporting of incidents was encouraged and part of the Trust’s culture. The incidents were reviewed and managed by the Quality & Safety Committee and reported to the Trust Board by the Committee Chair’s Report. Mrs Cooper agreed that the over-reporting was encouraged as part of the open culture of the Trust. Ms Musson reiterated that the CQUINNs for 2017/18 included “risky behaviours” and evidencing that service users were provided with advice on alcohol and smoking. She confirmed that the smoking cessation formed part of the Trust priorities for 2017/18 coming into effect in December 2018. Ms Musson confirmed that the Trust’s Quality Accounts were sent to NHS Choices for publication on their website and also to NHSI and the latter contributed to the national oversight framework. External Auditors Report and opinion Referring to the report and the opinion contained therein, Mr Stocks advised that the draft report to be updated after it had been received and adopted by the Trust Board and signed off by the Chief Executive. He confirmed that the audit process had been smooth and the Quality Accounts complied with the completion guidance and regulations.


In line with the auditor guidance, the following indicators had been reviewed:

• Enhancing the Quality of Life for People with Long Term Conditions:

• Preventing People from Dying Prematurely He confirmed that no issues had been identified. Mr Stocks commended the report and advised that an “unqualified” opinion had been given. In response to Mrs Cooper, Mr Stocks confirmed that the Trust’s Quality Account compared favourably with those submitted by other Trusts. The Committee recommended that the Trust Board approves the Quality Accounts 2016/17.


Mr Lancaster advised that Mrs Cooper was standing down from her post as a Non-Executive Director and this would be her last Audit Committee meeting. He commended the contribution that Mrs Cooper had made to the Trust over a considerable number of years and wished her well for the future.

19. Date of next meeting: 11.00am on Tuesday, 19th September 2017 Conference Room 1, Trafalgar House, King Street, Dudley DY2 8PS


Trust Board Meeting date: 6th July 2017

Agenda Item number: 8.1.2e Enclosure: 15

Finance Report – Month 2 2017/18

2017/18 DWMHPT Finance Report Month 02 Page

• Key Messages: Current Performance 1

• Single Oversight Framework (NHS Improvement) 2

• Overall Summary and RAG Assessment 3-4

• Trust Summary Income & Expenditure Statement: Functional Analysis 5-8

• Cost Improvement Programme 9

• Agency Cap / Agency Spend by Staff Group / Reported Shift Breaches (weekly) 10-12

• Capital Programme 13

• Payables Performance & Aged Debt 14

• Cash Flow Statement 15

• Statement of Financial Position (Balance Sheet) 16

Key Messages : Current Performance

Financial Position £381k surplus at M02 £52k Favourable variance

• The Trust has delivered a month 2 surplus of £381k.

• This represents a favourable variance of £52k against the planned surplus of £1.839m for the financial year.

Expenditure – Pay £133k Favourable variance

• Pay expenditure is £133k in surplus against budget to date, which has been driven by vacancies across the Trust.

• Bank & Agency spend equates to £491k in month (split £310k for Agency and £181k for Bank) which is up on the previous months spend of £378k (split £233k for Agency and £145k for Bank).

• Despite this increase in costs within the month, agency spend is still currently ahead of plan by £146k in relation to the overall £4.05m Agency target for the year (actual spend of £543k against £689k plan).

Expenditure – Non Pay

£167k Adverse variance

• Non-Pay expenditure is £167k in deficit against budget to date:

• £90k of this is driven by over-spending by budget holders against their non-pay lines;

• The balance of £77k relates to an over-commitment of budget reserves - reflecting the impact of un-devolved CIP not allocated down to service lines (£154.8k of CIPs are being phased into the position to date based on a FYE of £928.5k).

Income & Activity– 2017/18 outturn

£86k Favourable variance (incl £31k contract activity under-performance)

• The Trustwide Contracted Activity position at month end is reflecting an under-performance of £31k and is explained as:

• Both Dudley CCG and Walsall CCG are now on block and as such are reflecting a breakeven position.

• Other smaller CCG contracts in total (such as Worcester) have under-performed by £2k

• NCAs have under-performed against plan by £17k

• The activity in the Detox beds at Bushey Fields has under performed by £12k

• Non-contracted Income such as SLA’s and Education Income are ahead of expected plan and are mitigating against the current under-performance in contracted income mentioned above, giving an overall favourable income position for the year to date of £86k (which includes Interest Receivable of £2k).

CIP plans delivered for 2017/18

£1,322k transacted to date

• In order to meet in year cost pressures the Trust has identified CIP schemes equating to £3.78m.

• All but four of the 19 schemes in total have been devolved down to service lines – of these schemes devolved £1,322k have been transacted so far.

• The four schemes held centrally are being phased into the finance position each month to the tune of £77.4k (£154.8k YTD / £928.5k FYE) and could be deemed to being met non-recurrently through the overall favourable (surplus) finance position to date.

• Executive focus is particularly on those schemes rated as red

Expenditure - Capital

£48k spend YTD • The Capital Programme has been agreed at £3.8m for the year.

• Of this £2.4m relates to the replacement EPR system which includes £1.0m carried over from last years Capital plan.

• At month 2 only £48k has been spent to date.

1

Single Oversight Framework – Trust Performance

Commentary

• The Single Oversight Framework is designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’. The Framework doesn't give a performance assessment in its own right.

• The Framework will help NHSI identify NHS providers' potential support needs across five themes: - quality of care - finance and use of resources - operational performance - strategic change - leadership and improvement capability

• NHSI will segment individual trusts according to the level of support each trust needs. NHSI can then signpost, offer or

mandate tailored support as appropriate.

• Scoring a ‘4’ on any financial metric will mean the overall rating is at least a ‘3’, triggering a concern.

• Current month position and position for the Trust to date is giving a maximum rating of 1.

2

M01 M02 Forecast Outturn

subcode Plan Actual Plan Actual Plan Actual

Liquidity Rating PRR0170 1 1 1 1 1 1

Capital Service Cover Rating PRR0160 1 1 1 1 1 1

I&E Margin Rating PRR0180 1 1 1 1 1 1

Distance from Financial Plan PRR0190 1 1 1 0 1 1

Agency Rating PRR0200 1 1 1 1 1 1

Overall Use of Resources PRR0220 1 1 1 1 1 1

Overall Summary and RAG Assessment

Commentary

Revenue Position • The plan for the year currently reflects a planned surplus position

of £1.839m, as per the agreed Control total with NHSI.

• As at month 02 the Trust has delivered a surplus of £381k, which is £52k ahead of plan.

• Total Income is reflecting an over-recovery of £88k to date which includes a current level of under-performing contracted income with CCG’s of £31k.

CIP 2017/18 Delivery • The Trust has a declared an internal plan of £3,776k for 2017/18

and has schemes in place totalling £3,765k.

Budgetary Reserves • £727k has been allocated to Trustwide Reserves. At month 02

they are over-committed by £77k – this is due primarily to un-devolved CIP schemes that are being phased into the finance position on a monthly basis.

3

Statement of Comprehensive Income - Financial Position to 31st May 2017 Annual In Month Year To Date Plan Plan Actual Variance Plan Actual Variance

Income £000 £000 £000 £000 £000 £000 £000 Revenue From Activities Revenue-NHS Clinical 60,792 5,069 5,073 4 10,132 10,113 (19) Revenue-Non NHS Clinical 681 57 37 (20) 113 102 (11) Total Revenue From Activities 61,473 5,126 5,109 (17) 10,246 10,215 (31) Other Operating Revenue Revenue-Employee Benefits 307 26 52 26 51 48 (3) Revenue-Education & Training 961 86 130 44 173 261 88 Revenue NHS Non-Clinical 1,365 148 137 (11) 217 241 24 Other Revenue 522 44 59 16 87 98 11 Total Other Operating Revenue 3,156 305 378 74 528 647 119 Total Revenue 64,629 5,429 5,487 58 10,773 10,862 88 Expenditure Pay (51,382) (4,283) (4,202) 81 (8,442) (8,309) 133 Non Pay (9,579) (890) (983) (93) (1,687) (1,777) (90) Trustwide Reserves 727 119 95 (24) 111 34 (77) Total Operating Expenditure (60,234) (5,054) (5,091) (38) (10,018) (10,052) (35) EBITDA 4,395 375 395 20 755 809 54 Depreciation (1,475) (123) (123) 0 (246) (246) 0 Amortisation (256) (21) (22) (1) (43) (43) 0 Net Operating Surplus 2,664 230 250 20 466 520 54 PDC (865) (72) (72) 0 (144) (144) 0 Interest Receivable 40 3 2 (1) 7 5 (2) P/L Disposal 0 0 0 0 0 0 0 Net Surplus /(Deficit) 1,839 162 181 19 329 381 52

Technical Adj - Impairment 0 0 0 0 0 0 0 Technical Surplus 1,839 162 181 19 329 381 52

Overall Summary and RAG Assessment Continued

4

4,778

3,765

2,500

0 1,000 2,000 3,000 4,000 5,000 6,000

Identified Schemes(FYE)

Identified Schemes(PYE)

CIP Target as perNHS Improvement

£'000

CIP 2017/18

14,000

14,500

15,000

15,500

16,000

16,500

17,000

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

£'00

0

Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18Revised Plan 14,047 15,304 15,324 15,607 15,588 15,153 15,484 15,509 15,507 15,832 15,852 15,295

Original Plan 14,697 14,682 14,702 14,985 14,966 14,531 14,862 14,887 14,885 15,210 15,230 14,791

Actual 16,161 16,501

Forecast vs Actual Cash Balance 2017/18

1,839

381

0

250

500

750

1,000

1,250

1,500

1,750

2,000

£'00

0

Run Rate 2017/18

CumulativePlannedRun Rate(Surplus)

Actual RunRate

3,800

48 0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

£'00

0

Capital Programme 2017/18

Planned Spend

RevisedPlanned Spend

CumulativeActual Spend

Trust Summary Income & Expenditure Statement Including Functional Analysis

Commentary

• The Trust is showing a £31k under-performance position against contracted activity levels. This is due to under-recovery on non contract activity to date coupled with a shortfall against Detox bed activity.

• Corporate areas have overspent in month due to additional costs incurred in relation to TCT staffing support and investigation costs.

• Central Reserves are reflecting the impact of CIP schemes that have not been devolved down to service lines.

• Urgent Care & Access are in surplus due to slippages within Dudley Primary Care and Access.

• Inpatient Services have moved into an overspent position in month and Year To Date following an increase in costs within Holyrood and Ambleside wards, which is reflective of patient acuity needs.

• Community areas remain in surplus due to slippages within Psychological Therapies Hub and Dudley CRS.

• EI reflects unwinding accruals previously entered into M01 against additional funding – these have been released to support CIP plans in year, subject to service line discussions.

• Medical Service lines are reporting a marginal surplus position in month.

• The Trust is currently reflecting a surplus position of £52k ahead of the trajectory to deliver the £1.839m planned surplus at year end.

5

Annual Plan In Month Year to Date

2017/18 Plan Actual Var Plan Actual Var £'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS Revenue-Activities 61,292 5,111 5,114 3 10,215 10,196 (19) Revenue from LAs 681 57 52 (4) 113 102 (12) Total Revenue from Activities 61,973 5,168 5,167 (1) 10,329 10,298 (31) Corporate Functions Corporate Departments (14,038) (1,183) (1,217) (34) (2,358) (2,355) 3 Central Reserves 727 119 95 (24) 111 34 (77) Total Corporate Functions (13,311) (1,064) (1,122) (58) (2,248) (2,321) (74)

Operational Services Urgent Care & Access (6,039) (510) (507) 3 (1,004) (986) 18 Inpatient Services (Acute & OA) (11,689) (994) (1,031) (38) (1,969) (1,990) (21) Community Services (8,237) (697) (674) 23 (1,382) (1,316) 66 Early Intervention (6,273) (528) (442) 85 (1,046) (958) 87 Medical Services (12,031) (1,000) (995) 4 (1,926) (1,918) 8 Total Operational Services (44,270) (3,728) (3,650) 79 (7,326) (7,168) 159 Total Expenditure (57,581) (4,793) (4,772) 21 (9,574) (9,489) 85 Sub Total 4,392 375 395 20 755 809 54 Interest Receivable 40 3 2 (1) 7 5 (2) PDC Dividend (865) (72) (72) (0) (144) (144) 0 Depreciation (1,729) (144) (144) (0) (288) (288) 0 Net Surplus/(Deficit) 1,839 162 181 19 329 381 52

Trust Income Statement – Income

Commentary

• The Trust is now operating on a block contract with Dudley CCG and Walsall CCG across all service lines.

• Non-Contract Activity reflects an under-performance of £17k to date, which indicates a slow start to the expected additional £200k CIP target (based on actual performance delivered last financial year).

• In patient detox service at Bushey Fields is currently £12k adrift against the annual target.

• Overall the Trust is under-performing by £31k against its target to date.

• If the Trust were to report actual activity undertaken under a ‘shadow’ reporting arrangement then the Trust would actually be over-performing by £432.4k.

• This level of over-performance would primarily be reflected as:

• Walsall CCG £300.1k over

• Dudley CCG £94.7k over

• Sandwell & West Birmingham CCG £97.6k over

• Wolverhampton CCG £16.9k over

• Birmingham Cross City CCG £16.2k under

• Remaining CCGs £22.4k under

• = Total CCG over-performance of £470.7k

• Offset by under-performance on NCAs and Detox beds mentioned above (£38.2k)

6



Revenue From NHS Activities Dudley CCG 28,208 2,354 2,354 (0) 4,701 4,701 (0) Walsall CCG 27,220 2,268 2,268 0 4,537 4,537 0

Sandwell & West Birmingham CCG 1,894 158 158 0 316 316 (0) Wolverhampton CCG 338 28 29 1 56 58 2

Birmingham Cross City CCG 498 42 42 0 83 84 1 Birmingham South Central CCG 29 2 4 2 5 7 2

South East Staffs & Seisdon CCG 144 12 12 0 24 24 0 Stafford & Surrounds & E Staffs CCGs 2 0 1 1 0 1 1

Cannock Chase CCG 142 12 12 0 24 24 0 East Staffs CCG 4 0 0 (0) 1 1 0

Redditch & Bromsgrove CCG 17 1 1 0 3 3 1 Wyre Forrest CCG 33 3 2 (1) 6 5 (1)

NHS South Worcester CCG 2 0 2 2 0 2 2 NCA - Adult Neuro 418 35 48 13 70 80 10

Income Generation CIP 0 0 0 0 0 0 0 NCAs 442 37 22 (15) 74 37 (36)

CAMHs Deaf 1,401 117 117 (0) 233 233 0 Total NHS Revenue-Activities 60,792 5,069 5,073 3 10,132 10,113 (19)

Revenue - Local Authorities

Walsall MBC 0 0 0 (0) 0 0 (0) Dudley MBC 497 41 41 0 83 83 0

Sandwell MBC 0 0 0 0 0 0 0 Wolverhampton MBC 0 0 0 0 0 0 0

Stafford MBC 0 0 0 0 0 0 0 Detox Beds 184 15 11 (4) 31 19 (12) Dudley CRI 0 0 0 0 0 0 0

NCA - Other HC 0 0 0 0 0 0 0 Total Revenue from LAs 681 57 52 (4) 113 102 (12)

STF Funding Income - DoH 500 42 42 0 83 83 0

Total Revenue from Activies 61,973 5,168 5,167 (1) 10,329 10,298 (31)

Trust Income & Expenditure Statement - Corporate Functions

Commentary

• CEO – Formation of a central TCT cost centre which has several employees doing joint work. This is not funded and is the driver behind the overspend to date. Gains from PA team and CEO non-pay Consultancy underspend have partly reduced the overall overspend.

• Corporate Affairs – Post slippage from a temporary

secondment along with some short term slippage against Business Development.

• Corporate HR – Agency for the DBS project continues but is

being mitigated by non-rec income from the LDA along with a benefit from the movement of staff to TCT work. Additional costs have hit from the long term investigation (16k).

• Corporate Medical – Agency usage against Pharmacy (covering a vacancy).

• Corporate Estates – non pay spend has increased in the

month but overall is still within the YTD budget. Some agency is still being used.

• Acute Estates – Utility costs have been low again this month which offsets the slippage on vending machine income.

• Corporate Operations – Underspends on Compliance / Head

of Service/ Infection Control have supplemented overspend generated by unmet CIP 201718 and the E-rostering project costs.

• Corporate Finance – Membership Cost pressures are partly

met by some vacancy slippage . • Corporate IT/Performance – Vacancy slippage at managerial

level have been offset by larger communication charges for the trust up to M2.

7

Annual

Plan In Month Year to Date

2017/18 Plan Actual Var Plan Actual Var

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Corporate Functions

Chief Executive (919) (77) (88) (11) (158) (190) (31)

Corporate Affairs (542) (46) (40) 5 (90) (75) 15

Corporate Human Resources & Dev. & People (1,212) (102) (112) (10) (202) (207) (5)

Corporate Medical (1,135) (95) (99) (4) (189) (196) (7)

Estates - Acute (1,603) (134) (140) (6) (267) (264) 3

Estates - Corporate (1,268) (110) (121) (11) (220) (213) 7

Corporate Operations (3,648) (306) (300) 6 (608) (593) 15

Corporate Finance (1,182) (102) (106) (4) (202) (203) (0)

Corporate Performance & IT (2,528) (211) (210) 1 (421) (415) 6

Total Corporate Functions (14,038) (1,183) (1,217) (34) (2,358) (2,355) 3

Trust Income & Expenditure Statement - Operational Services

Commentary

• The Access & Inpatients service lines have overspend by £35k in May, comprising £3k Access underspend and £38k Inpatients overspend. Acute inpatients overspent by £18k (mainly Ambleside), Older Adults inpatients overspent by £30k (£40k overspend Holyrood, net of underspends on other wards), whilst there was a £10k underspend on inpatient management vacancies (including the new bed manager post).

• Medical services have generated a small underspend in

May, mainly against non pay budgets (training budgets are not spent in equal twelfths).

• Community Services & Recovery – Various vacancies across PT Hub and Older Adult Community are the main drivers for the underspend. It is anticipated that this is short term in nature and these roles will be recruited to going forward. This is offset in part by Older Adult CIP schemes which are still outstanding.

• Community Management – £49k of NP Travel CIP and £39k of Old year Travel CIP currently sits on here. As of yet no plans have been discussed around the achievement of the Travel element.

• EI – position has benefited in month from the unwind of accruals on newer projects within the CAMHS team. This is to facilitate a larger piece of work to mitigate spend plans for the year and support CIPs. It is anticipated that further slippage will continue in the coming months whilst services become established.

8



Operational Services

Urgent Care & Access

Acute Access (5,429) (458) (455) 3 (902) (881) 21 Hospital Support (610) (51) (52) (0) (102) (105) (3)

Total Urgent Care & Access (6,039) (510) (507) 3 (1,004) (986) 18

Inpatient Services (Acute & OA) (11,689) (994) (1,031) (38) (1,969) (1,990) (21)

Community Services

Community Estates (556) (46) (44) 3 (93) (90) 3 Community Management (CIP) 79 7 (1) (7) 13 (1) (14)

Community & Recovery Services (7,760) (658) (630) 28 (1,303) (1,225) 78 Total Community Services (8,237) (697) (674) 23 (1,382) (1,316) 66

Early Intervention (6,273) (528) (442) 85 (1,046) (958) 87

Medical Services (12,031) (1,000) (995) 4 (1,926) (1,918) 8

Total Operational Services (44,270) (3,728) (3,650) 79 (7,326) (7,168) 159

Cost Improvement Programme

Commentary

• The Trust had initially declared a plan to NHSI of £2.5m in order to deliver the planned surplus of £1.839m

• However, internally in order to deliver the required plan in year (meeting requirements around cost pressures, etc) the Trust has had to identify CIP schemes of £3.78m

• In total 19 separate schemes have been identified in order to deliver the £3.78m CIP target.

• The table opposite identifies these schemes and the current expectations and performance to date.

• At the beginning of the new financial year all but four schemes have been devolved down to service lines.

• Of these four schemes two relate specifically to vacancy control and finance will be monitoring and identifying appropriate vacancies on a monthly basis (in arrears) to offset against these vacancy control CIP schemes.

• The four schemes that are being held centrally in reserves are currently being phased into the finance position equally over the year, so as at M02 a total of £154.8k is within the current overall Trust wide surplus financial position – thus could be deemed to being met non-recurrently.

9

Annual Schemes Schemes Transacted to Date

(against original scheme) Likely

Achievement

Cost Improvement Programmes (by POD) Ref Plan Devolved Held

Centrally Recurrently Non-Rec Variance (incl.

mitigations) At Risk Current

RAG

£ £ £ £ £ £ Recurrently

4 Step Down Beds from DGoH CIP001-17 178,500 0 178,500 0 0 178,500 178,500 178,500

Walsall QIPP Access Pathway (Urgent Care) CIP002-17 75,000 75,000 0 0 0 75,000 75,000 75,000

Dudley Primary Care & IAPT Decommissioning CIP003-17 200,000 200,000 0 0 33,333 166,667 166,667 200,000

Operational Budget Reserves CIP004-17 150,000 150,000 0 150,000 0 0 150,000 -

Increase NCAs CIP005-17 200,000 200,000 0 0 0 200,000 200,000 -

Corporate Operations CIP006-17 170,000 170,000 0 0 0 170,000 170,000 170,000

Shift Pattern review CIP007-17 125,000 125,000 0 0 0 125,000 125,000 125,000

Estates Review CIP008-17 50,000 50,000 0 0 0 50,000 50,000 -

Efficient Recovery Pathway Review CIP009-17 125,000 125,000 0 0 0 125,000 125,000 125,000

MEA Revaluation of Fixed Assets CIP010-17 400,000 400,000 0 0 0 400,000 400,000 400,000

Inflation Topslice CIP011-17 125,000 125,000 0 125,000 0 0 0 -

Vacancy Review CIP012-17 200,000 0 200,000 0 0 200,000 200,000 -

Apprenticeship Levy CIP013-17 60,000 60,000 0 0 0 60,000 60,000 -

TCT Back Office Review CIP014-17 50,000 0 50,000 0 0 50,000 50,000 -

Non Recurrent Savings CIP015-17 500,000 500,000 0 500,000 0 0 0 -

Non Pay Review (Travel savings) CIP016-17 100,000 100,000 0 14,044 0 85,956 85,956 -

Budgetary Reserves CIP017-17 500,000 500,000 0 500,000 0 0 0 -

Casual Vacancy Deductions (Non Recurrent) CIP018-17 500,000 0 500,000 0 0 500,000 500,000 -

Walsall Carers Service CIP019-17 56,250 56,250 0 0 0 56,250 56,250 -

Total CIPs 3,764,750 2,836,250 928,500 1,289,044 33,333 2,442,373 2,592,373 1,273,500

Annual Target 17/18 3,776,246 3,776,246

(Deficit) / Excess of Schemes Above Plan -11,496 -1,183,873

NHS Improvement – Agency Expenditure Cap 17/18

Commentary

• For 2017/18 the Trust has been tasked with working within an overall agency expenditure cap of £4.05m for the year,.

• The planned spend across the year has been profiled across the new service lines based on the spend patterns from the previous year with an assumed level of reduction in spend in order to meet the required cap.

• The Trust has also been tasked with further reducing its Medical Locum spending by £86,760 in year in order to support the national drive to reduce locum spending – this expectation is embedded within the £4.05m cap but will be monitored against last financial years Medical Locum spend of £1.284m.

• If the Trust is able to work within the Medical Locum spend plan of £1.1m it will more than deliver the required spending reduction expected.

• In month the Trust has spent £310k on Agency and Year To Date the spend equates to £543k, which is below the planned spend position and is therefore £146k ahead of the cap.

10

Annual Profile Agency Agency DistanceService Line To Meet Cap Actuals M1-M2 Plan M1-M2 from Target

£000s £000s £000s £000s

Urgent Care & Access £504 £81 £86 £5InPatient Services £1,046 £122 £178 £56

£1,550 £203 £264 £61 ahead of plan

Community Services £66 £18 £11 -£7Early Intervention £1,034 £71 £176 £105

£1,100 £88 £187 £98 ahead of plan

Dudley Medical £540 £73 £92 £19Walsall Medical £560 £107 £95 -£12

£1,100 £180 £187 £7 ahead of plan

Corp IT Services £4 £0 £1 £1Corporate Affairs £11 £0 £2 £2Corporate Estates £98 £27 £17 -£10Corporate Operations £61 £16 £10 -£6Corporate-CEO £26 £3 £4 £1Corporate-Finance £11 £6 £2 -£4Corporate-HR £32 £6 £5 -£1Corporate-Medical £10 £13 £2 -£11Corporate-Performance £48 £0 £8 £8Corporate-Reserves £0 £0 £0 -£0

£300 £71 £51 -£21 behind plan

Grand Total £4,050 £543 £689 £146 ahead of plan

for 2017/18 there is an embedded expectation that Medical locum spending would reduce compared to 2016/17 levels in orderto support the national delivery of a £150m Medical locum reduction.

For the Trust we have been tasked with reducing our Medical locum spend by £86,760 over our 2016/17 levels of £1.284mThe 'plan' above of £1.1m would ensure that this target is fully achieved

Agency Spend by Staff Group

Commentary

• This view of the agency spending looks at the staff groups categories that are reported to NHSI on a monthly basis.

• A further breakdown is provided around the ‘other’ staff category which identifies the main service line / budget areas that contribute to this category.

• As experienced last financial year some of the spending in month has been the result of additional support needed to cover areas such as:

• 1-2-1 observations

• Support for one-off project works, such as E-rostering and Water Management

• Delivery of in year waiting list schemes funded non-recurrently by commissioners, for example, CAMHs.

• These additional costs will continue to be a pressure to the Trust in terms of delivery against the agency cap target.

11

In Mth (£000) Year End (£000) Plan Act Variance Plan Act Variance

Agency Staffing Qualified Nursing £117 £116 £1 £234 £193 £41 Medical £81 £97 -£16 £162 £175 -£13 Other (Incl. Admin, Estates, HCA's , AHP's) £146 £97 £49 £292 £174 £118

£344 £310 £34 £688 £542 £146

Other' represented by: Unqualified Nursing £12 £25 note 1 Admin & Clerical / Maint & Works £37 £75 note 2 Scientific & Technical £49 £75 note 3

£97 £174

note 1 note 2 note 3 Malvern £1.4 Estates £26.7 Walsall CAMHs £16.9 Wrekin £0.5 E-Rostering £16.1 Pharmacy £0.0 Clent £0.2 IM&T £0.4 Dudley CAMHs £23.9 Kinver £2.4 DPH / BF Med Secs £3.5 Dudley Primary Care £14.0 Langdale £2.7 Finance / HR £12.1 Walsall Primary Care £7.5 Cedars £2.9 PA's Exec Office £0.0 PT Hub £0.0 Linden £1.6 Various (incl. £15.9 OA Malvern / OT / £12.7 Ambleside £3.3 Primary Care / Mgmt / EAS Holyrood £5.4 CAMHs / SED) Adult In-Pats £0.0 Dudley Access £4.3

£24.8 £74.7 £75.0

Agency – Reported Shift Breaches to NHSI (weekly)

Commentary

• The above graph represents the reported shift breaches in terms of agency staff who are charging hourly prices above the mandated agency cap rates.

• The graph also represents the level of total shifts reported each week to NHSI as part of the revised agency returns – this gives some indication therefore of the level of breaches as compared to total shifts worked.

• Reporting is reflective of staff groups as per TFIMS headings – Medics do not appear on this analysis as they are covered under StaffFlow which ensures that agencies used and rates paid are in line with the mandated agency rules.

12

0

10

20

30

40

03-Apr 10-Apr 17-Apr 24-Apr 01-May 08-May 15-May 22-May 29-May 05-Jun 12-Jun 19-Jun 26-Jun 03-Jul 10-Jul 17-Jul 24-Jul

No

of S

hift

s

03-Apr 10-Apr 17-Apr 24-Apr 01-May 08-May 15-May 22-May 29-May 05-Jun 12-Jun 19-Jun 26-Jun 03-Jul 10-Jul 17-Jul 24-JulMedical (Price) 0 0 0 0 0 0 0 0 0

Nursing (Price) 24 21 19 16 25 26 25 25 25

HCAs (Price) 0 0 0 0 0 0 0 0 0

Admin & Estates (Price) 6 6 5 5 5 5 5 6 5

Total Shifts 238 212 186 204 219 195 207 216 225

No of Shift Breaches by Week/Staff Group

180

190

200

210

220

230

240

250

Capital Programme

Commentary

• The Capital Programme for the financial year has been set at £3.8m.

• The budget for the Clinical Systems Development has been reduced in year by £1,700k. This has been used to fund additional Estates projects and to create a contingency for further capital works that may be required in year.

• There has been a minimal spend of £48k against the programme at Month 2 .

13

Payables Performance & Aged Debt

Commentary on Payables

Better Payment Practice Code • The Trust has achieved the required target for non-NHS invoices by value and number within the

current month and Year To Date, with amber performance across the remaining NHS metrics.

• The NHS metrics can vary dramatically in terms of percentage achievement as the number of NHS invoices processed each month is on average around 30 invoices in total. Thus a delay in payment of 2 invoices will cause the percentage to drop below the required 95%.

Commentary on Aged Debt

Aged Debt Profile by Value • 23.7% of debt was aged 91 days or older at the end of the period equating to £167k in total, and this

is explained by:

• Debt between 91-120 days (totalling £3k) relates in the main to:

• ISS Mediclean recharge for repairs of £2.3k

• Recovery of salary overpayment £0.8k

• Debt over 120 days old (totalling £164k) relates in the main to:

• Various CCGs re Q1/Q2/Q3 1617 NCAs of £30.2k

• Walsall MBC £132.6k re Q3/Q4 1617 S.75

14

Better Payment Practice Code

Agreed Tolerances Transactions by

Number Value

Non-NHS <75% 75% - 95% >95%

Apr 94.63% 98.56%

May 96.08% 96.44%

Jun

Non-NHS YTD 95.32% 97.71%

NHS <75% 75% - 95% >95%

Apr 90.32% 94.51%

May 85.19% 89.96%

Jun

NHS YTD 87.93% 91.94%

21.6%

48.6% 6.0%

0.5% 23.3%

Aged Debt as of May 2017

Current 31-60 days 61-90 days 91-120 days 120+ days

Debt Profile and Value Current 31-60 days 61-90 days 91-120 days 121+ days Total £000 £000 £000 £000 £000 £000 £152 £342 £42 £3 £164 £703

Aged Debt Value % of Total

Agreed

Tolerances £000 Debt Over 91 days >20% 10% - 20% <10% £167 23.7% Over 120 days >10% 5% - 10% <5% £164 23.3%

Cash Flow Statement

Commentary

Cash Flow • The Trust has made an operating deficit of £521k in

2017/18 and received cash of £289k in respect of depreciation and amortisation

• Trade and Other Receivables have increased over the period (a negative impact on cash)

• Trade and Other Payables have decreased over the period (a negative impact on cash)

• The Trust has received £4k of interest, and spent £562k on capital (reducing capital payables from the 2016/17 year end). Total capital expenditure in cash terms was less than the cash received for depreciation and amortisation (a positive impact on cash)

• The impact of all these movements was to reduce the Trust’s cash balance Year To Date by £465k

15

Statement of Financial Position

16

Commentary

Non Current Assets • Amortisation and depreciation exceeds capital expenditure

for the year decreasing the value of the Trust’s Non-Current Assets in the year

• Final outturn against capital schemes is reviewed later in this report

Current Assets • Receivables have increased by £519k in 2017/18

• Cash is £465k lower than the balance at 31 March 2017

• An analysis of cash flows can be seen elsewhere in this report

Current Liabilities • Payables have reduced by £567k in the financial year

• There has been a decrease in the value of provisions held in the year of £2k

Tax Payers’ Equity

• The Current Year I&E figure represents the surplus for the year to date of £381k

• This is ahead of the revised plan for month 2 2017/18


Agenda Item number: 8.1.2f

Enclosure: 16

Report Title: Cost Improvement Programme (CIP) Progress Report

Accountable Director: Rupert Davies, Interim Director of Finance, Performance, IM&T and

Estates Author (name & title): Jacky O’Sullivan, Clinical Development Director/Acting Associate

Director of Operations Purpose of the report: To present to the Board a summary of the current status of the Cost

Improvement Programme for 2017/18. Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report CIP Programme Board 20th June 2017 Finance and Performance Committee 26th June 2017 MExT 27th June 2017 Key points or recommendations from Committee or Group: 19 schemes were identified in 2017/18 to achieve the CIP target of £3,780,000. Of these 19 schemes, 4 have delivered, 7 are being progressed, 6 schemes are under development and 2 schemes were presented to MExT on 27th June for sign off of the quality impact assessments. Strategic Objective(s) to which this paper relates:



Leadership culture




Quality Impact Assessment Domain Comment Patient Safety

Will be considered as part of the Quality Impact Assessment for each scheme

Patient Experience


Clinical Effectiveness / Outcomes


Workforce Experience – Efficiency & Productivity


Continuous Improvement in the Quality of Care


Enc 16 CIP Update June 2017 v2 Page 1 of 12

The CQC domains that this report relates to are: Caring

Plans use evidence based practice to ensure improvements in quality, outcomes and patient experience.

Responsive

Plans are developed to ensure responsiveness to service user needs.

Effective

Plans represent best value to ensure CIP plans are met through efficiency and effectiveness

Well-led

All transformational and service development plans have a project team approach to both development and implementation.

Safe

All plans are assessed for the need for a Quality Impact Assessment and where indicated a full assessment including risks and mitigations is undertaken and monitored.


CIP ideas brainstormed and scoped by Management Executive Team (MExT) and wider

Yes

Idea developed and presented to MExT MExT approve/reject

No Idea archived

Project Workbooks developed & submitted to CGI Programme Board for approval & sign off –

including QIA, EIA, PIA & risks

Implementation Stage

Final QIA and risks presented to MExT for project closure

Summary of schemes including Quality Impact Assessment (QIA) & risks submitted to MExT and

Trust Board

Review of all strategic themes by Trust Board to agree which proceed further within these

parameters: • High Quality Services • Inclusive Partnerships • Supporting Strategies • Effective & Efficient Resources • Leadership Culture • Responsible Workforce

QIA & risks on delivered projects presented to CGI Programme Board for sign off including Director of Nursing & Medical Directors

All projects – complete Workbook Completed workbooks & QIA signed off by Director of Nursing and Medical Directors and MExT

Final QIA and risks presented to Trust Board for final sign off

Idea archived No


Title Cost Improvement Programme (CIP) Progress Report

June 2017 Introduction The purpose of this report is to present to the Board a summary of the current status of the Cost Improvement Programme for 2017/18. Executive Summary of key points, issues, financial impact and risks There are 19 schemes were identified in 2017/18 to achieve the CIP target of £3,780,000. Of these 19 schemes, 4 schemes have delivered, 7 are being progressed, 6 schemes are under development and 2 schemes were presented to MExT on 27th June for sign off of the quality impact assessments. Summary of key points, issues and risks 1.0 CIP 2016/17 4 schemes were carried over into 2017/18 (appendix 1), these are: Dudley Older Adult Service Early Intervention Service Line Developments Medical Services Establishment Review Payroll

The Payroll scheme has delivered, and will be reviewed for closure. The Early Intervention Service Line Development scheme is being reviewed for delivery. The Dudley Older Adult Service scheme is dependent on the implementation of the new service model, and is expected to deliver in quarter 3. The Medical Services Establishment Review scheme is being progressed and is expected to deliver throughout the year. The schemes are being monitored by the CIP, Growth and Improvement Programme Board (formerly named CIP, QIPP and Partnership Programme Board). 2.0 CIP 2017/18

£ Target for 2017/18 3,778,000 Full year value of identified schemes 3,778,000 Planned part year effect of identified schemes 3,764,750 There are a total of 19 schemes for 2017/18. 3 schemes have delivered and will be reviewed for closure, these schemes are: Inflation Top slice Non recurrent Savings Budgetary Reserves

A fourth scheme, Operational Budget Reserves has delivered and will be monitored until the end of quarter 2. 7 schemes are being progressed and the quality impact assessments for the following two schemes were presented to MExT in June for sign off: Dudley Primary Care & IAPT Decommissioning Increase in NCA Activity

Page 4 of 12

The remaining 6 schemes are under development and the quality impact assessments will be presented to the joint Medical Director and Director of Nursing when completed, these schemes are: 4 Step down Beds for DGoH Walsall New Urgent Care Pathway Corporate Operations Budget Shift Pattern Review Efficient Recovery Pathway Review Walsall Carers Service

A full list of projects can be found in appendix 2. The CIP, Growth and Improvement Programme Board will be monitoring and tracking the progress of these schemes to report risks, and mitigations to the Finance and Performance Committee and the Board. 3.0 CIP 2018/19 3 schemes have been identified to realise savings in 2018/19 (appendix 3). These schemes are: Walsall QIPP Rehab Savings Walsall QIPP Bloxwich Costs Productivity Growth in Dudley Locality

Work is already under way for the first 2 schemes and work throughout the current financial year will contribute to the development of the third scheme. Further detail (if required) Appendix 1, 2 and 3 contain further details of the schemes. Recommendation Trust Board members are asked to note the contents of this report and receive it for information and assurance. Board action required As recommended.


Appendix 1 – 2016/17 CIP schemes

Division Type Ref. Project Title Exec Lead

Balance to FYE Value

(£)

Implementation Progress Report

Ove

rall

Proj

ect

Stat

us

Plan

Fina

nce

KPI

s

Ris

ks

QIA

Operations Transformational CIP007-16 Dudley Older Adult Service

LW 61,000 R A R N/A A A £61k to be delivered recurrently

Operations Transactional CIP009-16 Early Intervention Service Line

Developments

LW 42,476 R A R N/A A A £42,476 to be transacted in month 3

Medical Transformational CIP010-16 Medical Services – Establishment

Review

MW / KG

150,000 R A A N/A R A £150k to be delivered recurrently

Corporate Transformational CIP017-16 Payroll AW 12,000 A A A N/A G A Scheme delivered, to be reviewed for closure

Key: KPIs = Key Performance Indicators QIA = Quality Impact Assessment


Appendix 2 – 2017/18 CIP schemes Project Status ‘Green’

Scheme Executive Lead

Links to other

projects

Value £

Overall Project Status Pl

an

Fina

nce

Ris

ks

QIA

EI

A

PIA

KPIs Implementation Month

Planned Recurrent FYE Value

(£)

Planned PYE

Value (£)

Inflation Topslice Topslice of inflation dependent on budget setting. The scheme has delivered and will be reviewed for closure.

Rupert Davies

None 125,000 G G G G G

No

impa

ct

No

impa

ct N/A April 2017 125,000 125,000

Non Pay Review

Deliver savings via a review of the travel expenditure.

Rupert Davies

None 100,000 G G G G G

No

impa

ct

No

impa

ct N/A

April 2017 100,000 100,000


Project Status ‘Amber’


Links to other

projects

Value £


an

Fina

nce

Ris

ks

QIA

EIA

PI

A KPIs Implementation

Month Planned

Recurrent FYE Value

(£)

Planned PYE Value

(£)

Operational Budget Reserves

Removing an uncommitted reserves budget. The scheme has delivered and will be monitored until the end of quarter 2.

Lesley Writtle None 150,000 A G G A A

No

impa

ct

No

impa

ct N/A April 2017 150,000 150,000

Estates Review Review the Trust’s portfolio of properties across Dudley and Walsall with a view to minimizing the use of leased properties and maximising the use of owned properties.

Rupert Davies

None 100,000 A G G A A

No

impa

ct

No

impa

ct N/A 100,000 50,000

Vacancy Review Long term vacant posts will be assessed for continued requirement and removal.

Ashi Williams ECT project 400,000 A G G A A

No

impa

ct

No

impa

ct N/A

400,000 200,000

Maximising Apprenticeship Levy

This project will look at opportunities to introduce apprenticeships with scope to generate non recurrent savings. Succession planning framework developed to include apprenticeships into workforce establishments in the future.

Ashi Williams TCT Back Office review

240,000 A G G A G

No

impa

ct

No

impa

ct

N/A

240,000 60,000


TCT Back Office Review

This project will reduce the requirement of redeployment/redundancy when the TCT Trusts merge in coming months/years. This will contribute to current and future cost saving schemes.

Rupert Davies / Ashi

Williams

None 100,000 A G G A A

No

impa

ct

Yes

N/A

100,000 50,000

Non recurrent Savings

A non-recurring contribution to the recurring shortfall of the 2016/17 QIPP. This relates to end of year provisions which may not be required in 2017/18, and can therefore be used to offset slippage on the QIPP. The scheme has delivered and will be reviewed for closure.

Rupert Davies None 500,000 A G G A A

No

impa

ct

No

impa

ct N/A

April 2017 0 500,000

Budgetary Reserves

Savings from budgetary reserves. The scheme has delivered and will be reviewed for closure.

Rupert Davies None 500,000 A G G A G

No

impa

ct

No

impa

ct N/A

April 2017 500,000 500,000

Casual Vacancy Reduction (Non recurrent)

Non recurrent savings from vacancies

Rupert Davies / Lesley Writtle

None 500,000 A G G G A

No

impa

ct

No

impa

ct N/A

0 500,000

Walsall Carers Service

Decommissioning of the carers service by the CCG will deliver savings. The scheme is expected to deliver in month 4.

Lesley Writtle None 75,000 A G G A A

No

impa

ct

Yes

N/A

July 2017 75,000 56,250


Project Status ‘Red’


Links to other

projects

Value £


an

Fina

nce

Ris

ks

QIA

EIA

PI

A KPIs Implementation

Month Planned

Recurrent FYE Value

(£)

Planned PYE

Value (£)

4 Step down Beds for DGoH

Income generation through the provision of step down beds. Scoping for this scheme is ongoing.

Lesley Writtle None 238,000 R R R R A

No

impa

ct

No

impa

ct N/A 238,000 178,500

Walsall New Urgent Care Pathway

Remodeling of the urgent care pathway in Walsall as part of a QIPP will potentially deliver this scheme.

Lesley Writtle None 150,000 R R R R R

No

impa

ct

Yes

N/A

150,000 75,000

Dudley Primary Care and IAPT Decommissioning

Reduce expenditure on service by £200K in line with CCG reductions. The scheme is being transacted non recurrently.

Lesley Writtle None 200,000 R R R R R

No

impa

ct

No

impa

ct N/A 200,000 200,000

Increase in NCA Activity

Income generation through non contracted activity.

Lesley Writtle / Rupert Davies

None 200,000 R R G A A

No

impa

ct

No

impa

ct

N/A 200,000 200,000


Corporate Operations Budget

Savings to be realised from the Corporate Operations budget. Scoping for this scheme is ongoing.

Rosie Musson /

Lesley Writtle

None 300,000 R R R R R

No

impa

ct

No

impa

ct N/A 300,000 170,000

Shift Pattern Review

Rostering review or changing work patterns to deliver savings. Scoping and cost modelling is ongoing.

Rosie Musson

None 250,000 R R R R R

No

impa

ct

No

impa

ct N/A 250,000 125,000

Efficient Recovery Pathway Review

Savings to be realised from reduction in activity and new service model. Scoping for this scheme is ongoing

Mark Weaver Urgent Care

Outpatient Review

250,000 R R R R R

No

impa

ct

No

impa

ct N/A 250,000 125,000

MEA Revaluation of Fixed Assets

PDC savings and IT depreciation moving to 7 years

Rupert Davies None 400,000 R R R G G

No

impa

ct

No

impa

ct N/A April 2017 400,000 400,000

Key: QIA = Quality Impact Assessment EIA = Equality Impact Assessment PIA = Privacy Impact Assessment KPIs = Key Performance Indicators


Appendix 3 – 2018/19 CIP schemes

Division Type Project Title Exec Lead Project Lead FYE Value (£)

Operations Transformational Walsall QIPP Rehab Out of Area Savings Lesley Writtle Nick Stephens £300,000

Operations Transformational Walsall QIPP Bloxwich Cost Savings Lesley Writtle / Mark Weaver Jacky O'Sullivan / Debbie Cooper £312,000

Operations Transformational Productivity Growth in Dudley Locality Lesley Writtle James Parker £500,000




Enclosure: 17

Report Title:

Workforce Committee Chair’s Report

Committee:

Workforce Committee

Author:

Harry Turner – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Introduction The Workforce Committee met on the 27th June 2017 and considered and discussed key topics around the Trust’s Workforce The Workforce committee agenda is categorised under 4 main areas, i.e.

- Workforce Performance - Staff Wellbeing - Organisational Development - Workforce Compliance

Summary of key points, issues and risks WORKFORCE PERFORMANCE Workforce Performance Report Key messages from the Workforce Performance Report were:

- There are currently 155 FTE contracted vacancies across the Trust. The vacancy rate has remained the same for Month 2 as Month 1 at 13.5%.

- The TRAC recruitment system is currently being used within the Trust giving increased control and oversight to recruiting managers. A report on performance against recruitment KPIs was expected in July 2017 but in line with audit plans this has been moved to September 2017.

- Service recruitment plans are a working progress with Star Chamber Meetings organised with all Head of Service and Executive Leads.

- The 12 Month Turnover rate has decreased from 11.56% to 11.40%. - The rolling 12 month sickness rate has decreased in Month 2 to 4.14% from 4.24% in Month 1,

this is within the Trusts target and the seventh consecutive month of being so.

Enc 17 WFC Chairs Report M2 17 Page 1 of 4

- Appraisal compliance has decreased from 85.5% to 83.1%, this is now below Trust target of 85%. There are 147 employees in the Trust that have not had an appraisal recorded in the last 12 months. Weekly/Bi Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements. A message from the CEO has been sent to all managers with the expectation of compliance by 31 July 2017.

- Mandatory Training compliance increased slightly to 88.6% in Month 2 from 88% in Month 1 and remains just below the target of 90% agreed at MEXT for all mandatory training.

- IG compliance for Month 2 is 83.3% which is below the 95% target for that competence, the month 12 figure was 97.2%. The reason for the drop is many members of staff compliance expired on the 31st March 2017.

- As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake in order to remain compliant.

- Staff who are not complaint with 7 or more Mandatory Training Modules will be managed in accordance with the Trust Capability Policy

Estates Sickness Absence Deep Dive Having explored the sickness absence within the Estates function; there were deemed to be no operational issues or concerns with the team itself. The reasons for higher sickness absence percentage was due to this being a small team of 9 people with 3 individuals taking long term sickness absence. 2 of the staff are back at work and the other remains off sick. The sickness absence policy has been complied with; occupational health referrals have been made and the underlying causes of the absence are unconnected and not work related. HEALTH AND WELLBEING A Health and Wellbeing implementation plan was presented by the Trusts Health and Wellbeing Committee for the Workforce Committee’s information. The plan was designed around the Workplace Wellbeing Charter, to which the Trust was not currently seeking accreditation. Many aspects of the plan addresses action being taken to achieve the Health and Wellbeing 2017/18 CQUIN. However, it was noted that the CQUIN for the year is based on a 5% improvement on specific staff survey questions; ones that the Trust already performs well on and therefore would be difficult to achieve. Workforce Committee noted the planned actions and requested a costed version. The committee also advised that a review on what is achievable is required. STAFF SURVEY The committee received an update on the work that is currently being undertaken to address staff survey responses. Overall the Trust performed well in the staff survey but there are still some areas for the Trust to address including; Culture/Bullying and Harassment, Health and Wellbeing and Senior Management Communication. Acton plans are being developed within each service line. WORKFORCE COMPLIANCE Workforce Risk Register The Committee received the workforce risk register and the Committee was assured that the risks are being appropriately managed.


Risk 317 has been closed and now split out and added as new risks as follows:

o Risk 375 “Some staff may not be receiving a regular appraisal of their performance impacting upon their ability to carry out their role”

o Risk 376 “Some staff may not be receiving appropriate ongoing or periodic supervision. Where this is occurring the Trust cannot always evidence this due to a lack of central monitoring mechanism for supervision.”

The following new risks were also added:

• Risk 377 “Trust not compliant with Right to Work Checks for existing staff. ESR is missing some key information around Nationality and Residence Status for approximately 70 staff”

• Risk 378 “Current arrangements for monitoring fixed term contracts are not adequate to provide assurances that statutory dismissal processes are being followed.”

• Risk 379 “Shortage of National Junior psychiatric trainees from August's rotation may impact on patient care due to reduced workforce capacity”. – It was recommended by Trust Board that this may represent a red risk, therefore it is asked that the committee approves this risk as a red risk for presentation to Trust Board.

The Committee asked for updates at the next workforce committee regarding risk 375 (following the Chief Executives message as described above) and also for an update on the progress with the Right to Work checks. WRES Standards/Recruitment Audit An update position of the Trusts progress to meet the WRES standards was provided. The committee was assured that actions were on track. An audit of recruitment activity is being undertaken and the outcomes were presented at the meeting. The snap shot sample taken consisted of 15 cases. For this sample, we were informed (1st June 2017) that no data was held for any of the candidates either shortlisted or appointed, as the Trust retain recruitment data only for 12 months. After discussion with the audit Assistant Director, to determine how best to proceed with the audit. A list of all appointments made since the introduction of the new TRAC recruitment system was obtained. From this, a further listing was obtained, which was split by ethnicity and then a further sample was selected, again to consider arrangements up to shortlisting and from shortlisting to appointment. The sample data highlights that for the positions of Vocational Specialist, Bank HCA’s and Acute Staff Nurse, there was higher number of BME applications with higher number of BME candidates being shortlisted. However, when looking at other positions where there was a high level of White applicants, there was also a higher number of White applicants shortlisted compared to BME applicants.


The sample data highlights that BME Staff are less likely to be appointed from shortlisting compared to White staff. However, when you look at the recruitment of Bank Health Care Assistants (HCA’s), out of the 7 appointed, 4 were BME staff compared to 3 White staff. Safe Staffing Levels

The safe staffing level report was presented to include: • Across the inpatient areas the overall fill rates are 100.04%, with 99.19% for registered staff and

100.55% for care staff. This indicates the Trust is meeting the optimum level of fill rates. • Typically where our care staff rates exceed 100%, this is due to temporary staff being used to

support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity.

• Where staff have concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In May there were 0 incidents reported related to safer staffing in inpatient services.

• Interventions to ensure temporary staffing is used effectively are also being implemented and the Trust is already seeing the benefits of closer integration between the Rostering and the Bank Office.

• The Trust has in place a locally agreed standard of the minimum of 2 qualified members of staff per shift. Due to inpatient vacancies the Director of Nursing has sought further assurance that when the ward plans to drop below this standard, mitigations are in place to maintain patient safety. Assurance has been provided that full consideration is given to skill mix when using temporary staff however on night shifts this has resulted in with one qualified member of staff being on duty with back up from the night coordinator as a qualified senior nurse and experienced HCAs.

Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• MEXT • Finance & Performance Committee • Quality & Safety Committee

Recommendation and requests for direction The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Workforce Committee




Enclosure: 18

WORKFORCE COMMITTEE MEETING

Minutes of a Meeting Held on

23rd May 2017

Board Room, Canalside House, Walsall

START TIME 13:30 HOURS

Present: Harry Turner Associate Non Executive Director (Acting Chair) Mark Axcell Chief Executive Officer Dr Mark Weaver Joint Medical Director Rupert Davies Interim Director of Finance Ashi Williams Acting Director of People Rosie Musson Acting Director of Nursing In Attendance: Jacky O’Sullivan Clinical Development Director/Acting Associate Director of

Operations Mark Banks Deputy Director of Finance Hannah White Senior HR Business Partner Becky Temple-Purcell Senior Workforce Development Manager Nick Stephens Head of Community Services Daniel Peniket ESR Systems Manager Paul Singh Equality and Diversity Manager James Parker Commissioner Liaison Manager Emma Jackson Note Taker Apologies: Olivia Clymer Non Executive Director (Chair) Dr Kate Gingell Joint Medical Director Anne Marie Carey Head of Urgent Care and Access/Early Intervention Services Lesley Writtle Acting Director of Operations Andrew Campbell Chief Pharmacist Peter Hayward Consultant OT Hassan Omar Head of Social Care Michael Hirons Staff Engagement Lead/FSUP Guardian

Enc 18 Final WFC Minutes 230517 Page 1 of 7

Mr Turner conveyed Ms Clymer’s apologies for not being able to attend/Chair the Committee meeting today. ACTION 11. Apologies For Absence

11.1 Apologies noted as above.

12. Declarations of Interest

12.1 No Declarations of Interest noted.

13. Minutes of Previous Meeting held on 25th April 2017

13.1 The minutes of the previous meeting held on 25th April 2017 were agreed as an accurate record.

14. Matters Arising

14.1 14.2 14.3 14.4

The matters arising were discussed and an update was provided on those actions where appropriate: Item No 19.1 – Healthy Buildings Update provided as per action sheet. Action linked to various initiatives including PLACE. No further update to be provided to the Committee. Standing item on the ECPG agenda. Action closed. Item No 27.4 – Midlands and East Agency Report Update provided as per action sheet. Mrs Temple-Purcell advised the Committee that no data was held on ESR hence direct contact being made with Black Country Partnership. Current status = awaiting information from Black Country Partnership. It was noted that this was an item on today’s Workforce Committee agenda (Review of BCP and DWMH Medical Workforce). However, Dr Weaver required clarity and context around the action. Mr Banks explained that the action had arisen following a discussion at a previous committee meeting around the Midlands and East Agency report/benchmarking exercise tabled re; locum and agency spend. Mr Axcell referred to the respective minute of the discussion held, acknowledging that neither of the Joint Medical Director’s were present at the committee meeting held in March. Dr Weaver agreed to link with the Medical Director in the Black Country, following which a paper would be brought to the Committee in June. Item No 5.1 – Workforce Report Month 12 – Sickness Trigger Raw Data Month 1 updated raw data to be circulated today. It was agreed that data would be shared on an ongoing basis. Action closed. Item No 5.2 – Essential Training Compliance Process in place with regards to future training reports highlighting all individuals achieving compliance of 50% or less. Action completed and closed.


14.5

Item No 5.2 – Essential Training Compliance – Interpreter’s Incident Discussion held between Mr Davies and Mrs Carey. Issue also arose during the Audit Committee held this week with regards to the Deaf CAMHs team being subject to control failures (invoices being received with no orders raised). Mrs Carey had agreed to discuss with the CAMHs Team. Issue to be progressed by Mr Davies via the Audit Committee.

Mr Davies

15. WORKFORCE PERFORMANCE

15.1 Workforce Report

The Committee reviewed the Workforce Performance Report at Month 1. The following points were raised and noted:-

• The Trust’ vacancy rate had decreased slightly in Month 1 to 13.5%. With regards to the service recruitment plans included within the papers, Mrs Williams advised the Committee that the plans were now out of date. Mrs Williams noted that the Band 5 vacancies within inpatient areas had been omitted from the list and therefore the number of posts identified (which the Trust could recruit to - 26 posts) was incorrect. Following the F&P Committee meeting held this week, it was noted that Mr Banks and Mrs Williams would be doing some further work to review the list, removing those vacancies not required by the Trust at the current time. Mr Turner highlighted the importance of the Trust being clear of its number of vacancies, from a TCT perspective. Mr Axcell advised that he would be asking the Executive Team to work with the Heads of Service and their respective finance leads to consider what roles were needed/not needed. Mr Axcell expected this piece of work to be completed within the next 2 weeks following which Mrs Williams would be in a position to bring the “true” vacancy position to the F&P and Workforce Committee in June. Mr Parker highlighted the importance of factoring in the impact of QUIPP.

• The Trust’s 12 month turnover rate had increased from 10.53% to 11.56% in Month 1. Mr Peniket explained that the increase was due to the number of leavers in Month 1, counteracted with an increase in the number of new starters. Mr Turner suggested that the Trust closely monitored its turnover position, particularly in relation to staff moving to other organisations due to the TCT Partnership. Mr Peniket agreed to monitor the reasons for staff leaving the Trust (via termination forms). Mr Turner requested that Mr Peniket flagged any concerns with the Committee with any risks captured via the Risk Register. Mrs Williams asked the Committee to be mindful that with regards to any corporate vacancies, these would be advertised internally between the three TCT organisations, which could result in some promotion opportunities for staff.

• The Committee were pleased to note that the Trust’s 12

Mrs Williams Mr Peniket


month sickness rate had decreased in Month 1 to 4.24% compared to 4.31% in Month 12. Mr Axcell was mindful of the high levels of sickness within the Estates Department, suggesting a deep dive was undertaken. Mr Davies acknowledged that the Estates Department was only a small department, noting that 2 members of staff had recently returned from sick leave – within a week of their return, 2 other members of staff had gone off due to sickness related absence. It was agreed that Ms N Dixon would work with Mr P Clark to undertake a deep dive. Findings to be fed back to the Committee in June.

• Appraisal compliance had decreased from 87% to 85.5% in Month 1.

• A discussion was held around mandatory training and IG compliance being below target. Mr Davies advised that appraisal and mandatory training compliance had been discussed at MExT this week where issues were raised with records to incorrect data being held amongst the Workforce team. MExT acknowledged that pressure needed to remain on teams, in these two areas. Mrs Temple-Purcell highlighted the steps being taken to address mandatory training non- compliance as discussed and agreed at the previous committee meeting. Mr Turner was of the view that future workforce reports should also include the statistics of BCPFT and BCHC against key metrics i.e. sickness/vacancy rate/turnover. This was agreed by the Committee.

The Committee received, discussed and accepted the report.

Ms N Dixon/Mr P Clark Mr Peniket

15.2 Service Recruitment Plans

Refer to first bullet point under item 15.1 – Workforce Report.

16. WORKFORCE COMPLIANCE

16.1 Workforce Risk Register

The Committee received the Workforce Risk Register which detailed 1 red operational risk for presentation at Trust Board and a further 10 current risks. The Committee were asked to consider risks 317 and 323 in view of the discussions held at the Quality & Safety Committee and the outcomes/actions arising from the CQC visit to the Trust in November 2016. Agreed Actions:-

• Risk 317 (Appraisal & Supervision). It was agreed that risk 317 needed to be split into two areas as detailed below:- - 1). Appraisal – it was the view of Mr Turner and Mr Axcell

that the Trust’s appraisal position had not been sustained.

Mrs Williams


However, it was the view of the Committee that appraisal should be down-graded to an amber risk (based on reduced likelihood).

- 2). Supervision – whilst the Trust had made progress in the area of supervision, the Trust lacked overall assurance from a monitoring perspective. The Committee proposed that this risk be rated an amber risk.

• Risk 323 (Training). The Committee agreed that risk 323

needed to be reworded to make specific to mandatory and essential training. The Committee proposed that risk 323 was rated a red risk.

Mrs Williams

16.2 Compliance to WRES Standards

Mr Singh provided the Committee with an Equality and Diversity update, focusing on the WRES action plan and progress to date. The following points were raised and noted:-

• Through MERIT /TCT currently exploring aligning WRES action plans / objectives.

• NHS England dashboard report – Black Country Partnership Trust fair better on some of the metrics – workshop to be held to share best practice and how to take this work further through TCT/new organisation.

• Reviewed current development opportunities for BME staff and Promoted NHS Leadership Academy “Stepping up Programme” within the Trust. 5 BME members of staff applied with 3 accepted onto the programme. Programme commenced in May.

• To further explore a Talent Management initiative through MERIT. This will be discussed further at the E&D Work-stream on the 22nd May 17.

• With regards to carrying out an audit on recruitment campaigns in particular focusing on data relating to shortlisting and appointments for BME staff – to identify any issues / concerns:- - TOR has now been amended to look at data held on the

new TRAC system. - Look at sample of appointments from application to

shortlist. - Then sample from shortlisting to appointment.

• Reviewing staff networks (including BME staff) via TCT partnership.

• Working with freedom to speak up guardian on reviewing any concerns relating perception/experience of BME staff.

• Reviewing WPA role / link with Cultural Ambassadors role for supporting BME staff.

In response to Mr Turner, Mr Singh confirmed that action 8.2 was complete despite the timeline of 31st December 2017. Mr Singh to amend.

Mr Singh


In relation to action 9.2, Mr Singh was asked to liaise with Mr Lewis-Grundy with regards to an alternative Board Development date to discuss WRES and Board responsibility. The Committee congratulated Mr Singh, recognising the work he had undertaken/sharing of best practice.

Mr Singh

16.3 Apprenticeship Levy Funding 2017/18

Mrs Temple Purcell provided an update to the Committee on the plans for use of the Apprenticeship Levy funding for 2017/18. The following points were raised and noted:-

• The detail and tangible information of apprenticeships, where the Trust would want to be involved, was still not available.

• The Trust was achieving the HEE apprenticeship target. The target for 2017/18 was 25, similar to previous years. The Trust employed 20 apprentices at the current time with 2 apprentices in the pipeline. The Trust also had 3 existing staff accessing training through a Business and Admin apprenticeship. However, there was no levy value to this apprenticeship activity.

• Mrs Temple-Purcell raised her concerns around how the apprenticeship funding was utilised, expressing her view that the funding should be utilised to develop existing staff.

• BCHC was now an approved apprenticeship provider which was positive.

• Mrs Temple-Purcell and Mrs Musson were currently reviewing nursing career pathways.

• A change was noted within the Workforce Team resulting in reduced capacity. However, following a re-organisation of the team, Mrs Temple-Purcell was hopeful that the team could now start to re-focus on the work around apprenticeships.

• The Committee acknowledged that a balanced approach needed to be adopted (skill mix & analysis) when looking at the prioritisation of training.

The Committee received, discussed and accepted the report, supporting the recommendations/actions list.

16.4 Safer Staffing and Dashboard

The Committee received the Safer Staffing Levels Monthly Exception Report. The key messages raised and noted:-

• Overall fill rates indicated the Trust was achieving the optimum level of fill rates.

• In April there were zero incidents reported relating to safer staffing in inpatient areas.


• With regards to only one qualified member of staff being on

night duty, Mrs Musson provided assurance to the Committee that safety was being maintained with resources being managed by Ward Managers to maintain patient safety. Mrs Musson acknowledged that close monitoring of the position was required. Mr Turner questioned how this was measured, highlighting the need for triangulation i.e. what were the number of incidents in any given month. Mrs Musson commented that Mr Jinks was progressing this, reemphasising there had been no incidents during April due to safer staffing. Mrs Temple Purcell acknowledged some feedback that had been received previously from B5 nurses, indicating that they had felt vulnerable due to the lack of staffing. In response to Mr Parker, Mrs Musson explained the reasons for the significant differences in staffing levels across Dudley and Walsall. Mrs Williams made the suggestion of a targeted recruitment campaign for night shift workers. Mrs Williams also questioned if the CIP linked to shift hours could support safer staffing. Mr Axcell thanked Mrs Musson for her hard work in collating the data. Mr Axcell continued to question if full assurance could be provided to the Committee that there were no quality and safety issues with the staffing arrangements in place at the current time. Mrs Musson commented that whilst the position was not ideal, Heads of Service and Ward Managers were assured that there were no quality and safety issues. However, Mrs Musson agreed to gather staffs views re; staffing levels on their respective ward/s, following which a full assurance report would be brought to the Committee in July including a risk mitigations plan. Mrs Musson was also requested to raise the issue, as an emerging issue in the private session of the Trust Board in June.

The Committee received, discussed and accepted the report.

Mrs Musson Mrs Musson

16.5 Review of BCP and DWMH Medical Workforce

Refer to item 14.2.


17.1 No items of any other business were noted.

18. Date and Time of Next Meeting

18.1 Tuesday 27th June 2017, 13:30pm to 15:30pm, Board Room, Canalside House, Walsall.


Board Meeting date: 6 July 2017


Enclosure: 19

Workforce Performance – Month 2 – 2017/18

Workforce Report - Contents Page

• Key Messages • Workforce Dashboard • Recruitment • Turnover • Sickness • Appraisal • Mandatory Training

3-4 5 6 7

8-9 10 11

Vacancies – There are currently 155 Full Time Equivalent (FTE) contracted vacancies across the Trust meaning the vacancy rate hasn’t changed in Month 2 from the 13.5% reported in Month 1. Of the 155 FTE vacant, approximately 87 FTE being actively recruited at present. The TRAC recruitment system is currently being used within the Trust giving increased control and oversight to recruiting managers and allows the Trust to performance manage against recruitment KPIs. Turnover – The 12 Month Turnover rate has decreased from 11.56% to 11.40%. The Trusts percentage turnover (excluding junior Medics) is average compared to other Mental Health organisations in the NHS.

3

Sickness Absence – The rolling 12 month sickness rate has decreased from 4.24% in Month 1 to 4.14% in Month 12, this is within the Trusts target and the seventh consecutive month of being so. In month sickness has decreased from 3.59% in Month 1 to 3.40% in Month 2. Appraisal – Compliance has decreased from 85.5% to 83.1%, this is below the Trust target of 85%. There are 147 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 223 reported in Month 6. Weekly/Bi Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements. Mandatory Training - Mandatory Training compliance increased slightly from 88.0% in Month 1 to 88.6% in Month 2 and remains just below the target of 90% agreed at MEXT for all mandatory training. As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake in order to remain compliant.

4

5

445 Dudley and Walsall Mental Health Partnership NHS Trust

Staff in PostTarget Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

Headcount 1018 1021 1025 1036 1055 1058 1060 1074 1088 1089 1088 1092Funded Establishment 1113.9 1129.4 1134.1 1141.5 1138.9 1128.9 1142.6 1138.3 1150.2 1148.2 1148.2 1151.2Staff in Post FTE (Contracted) 926.3 928.4 933.1 944.2 961.9 964.1 966.5 978.8 991.8 992.2 992.7 996.0WTE Variance 187.6 201.0 201.0 197.2 177.0 164.8 176.1 159.5 158.4 156.0 155.4 155.2Vacancy % 10.0% 16.8% 17.8% 17.7% 17.3% 15.5% 14.6% 15.4% 14.0% 13.8% 13.6% 13.5% 13.5%Worked FTE (Substantive) 927.2 929.8 932.8 952.0 954.6 966.0 964.5 965.1 983.2 981.0 992.5 992.7Worked FTE (Temp) 174.3 138.7 146.1 145.7 135.6 139.7 147.4 135.8 138.5 150.1 126.2 125.7Worked FTE (Total) 1,101.4 1,068.5 1,078.8 1,097.7 1,090.2 1,105.6 1,111.9 1,100.9 1,121.7 1,131.1 1,118.7 1,118.4Turnover % (12 Months) 8-14% 12.47% 12.12% 11.74% 10.71% 11.47% 11.62% 11.27% 10.72% 10.33% 10.53% 11.56% 11.40%

Pay SpendTarget Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

Funded £ £4.14m £4.30m £4.17m £4.16m £3.91m £4.18m £4.16m £4.34m £4.39m £4.49m £4.16m £4.28mSubstantive Spend £ £3.44m £3.58m £3.61m £3.64m £3.60m £3.63m £3.45m £3.63m £3.70m £3.60m £3.73m £3.73mTemp Spend £ £0.54m £0.48m £0.47m £0.46m £0.48m £0.56m £0.52m £0.54m £0.58m £0.58m £0.38m £0.38mTotal Pay Spend £ £3.98m £4.06m £4.08m £4.10m £4.08m £4.18m £3.96m £4.16m £4.28m £4.18m £4.11m £4.11mVaraince - Budget to Actual £ £160K £245K £86K £58K -£173K £K £200K £171K £111K £307K £52K £176K

AbsenceTarget Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

Sickness % (Month) 4.68% 4.39% 4.72% 4.74% 4.92% 3.90% 3.72% 3.66% 4.89% 4.57% 3.34% 3.59% 3.40%Sickness Days Lost FTE (Month) 1,218 1,361 1,363 1,391 1,152 1,071 1,095 1,476 1,263 1,030 1,069 1,049No of Sickness Episodes (Month) 144 161 140 177 163 179 176 223 166 144 128 128Cost of Sickness (Month) £127K £116K £122K £130K £95K £85K £82K £114K £102K £90K £90K £81KMaternity % (Month) 1.63% 1.62% 1.50% 1.45% 1.64% 1.61% 1.85% 2.12% 2.19% 2.23% 2.05% 2.23%Sickness % (12 Months) 4.68% 4.82% 4.81% 4.80% 4.85% 4.73% 4.57% 4.43% 4.42% 4.39% 4.31% 4.24% 4.14%Long Term Sickness % (12 Months) 67.8% 66.8% 68.9% 69.6% 68.3% 68.0% 66.3% 64.0% 63.2% 62.9% 62.6% 63.5%Cost of Sickness (12 Months) £1,454K £1,423K £1,430K £1,457K £1,418K £1,359K £1,303K £1,292K £1,271K £1,260K £1,249K £1,208K

DevelopmentTarget Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17

Appriasals Completed 606 622 649 626 694 691 669 687 744 761 740 722Appraisals Outstanding 262 245 218 223 174 183 193 178 121 114 126 147Appraisals Required 868 867 867 849 868 874 862 865 865 875 866 869Appraisal % 85% 69.8% 71.7% 74.9% 73.7% 80.0% 79.1% 77.6% 79.4% 86.0% 87.0% 85.5% 83.1%Mandatory Training % 90% 81.4% 84.2% 84.1% 83.8% 85.4% 89.3% 89.7% 88.9% 88.9% 89.8% 88.0% 88.6%Essential Skil ls Training % 90% 58.3% 60.0% 60.1% 61.3% 62.1% 64.6% 65.6% 58.3% 66.1% 66.9% 68.3% 69.6%Number of Training DNAs 52 119Training DNA Rate % 14.1% 22.0%

May-17

6

The table above shows the number of adverts published on NHS jobs in April and the associated WTE by Staff Group. 31 of the Whole Time Equivalent (WTE) advertised for Nursing & Midwifery Registered were for Band 5 Ward Staff Nurses, and therefore more than 31 WTE could be recruited to the position due to it being a rolling recruitment advert.

Staff GroupNo of

advertsWTE

AdvertisedAdvert views Applications

Application to advert view rate

Applications per WTE

Avg no of days

advertisedAdditional Clinical Services 0 0.0 0 0 - - -Additional Professional Scientific & Technical 0 0.0 0 0 - - -Administrative & Clerical 6 5.8 3307 91 2.8% 15.7 7.5Allied Health Professionals 4 4.0 2112 82 3.9% 20.5 13.0Estates & Ancillary 0 0.0 0 0 - - -Medical & Dental 0 0.0 0 0 - - -Nursing & Midwifery Registered 8 34.8 5618 55 1.0% 1.6 24.5Total 18 44.6 11037 228 2.1% 5.1 16.3

7

12 Month Turnover has decreased to 11.40% in Month 2. This is within the Trusts targeted range and could be considered a good indicator that the Trust in general retains its staff.

12.5% 12.1%11.7%

10.7%11.5% 11.6% 11.3%

10.7% 10.3% 10.5%

11.6% 11.4%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

13.0%

14.0%

15.0%


DWMH Turnover % by Month

Target Range Turnover %

ServiceStarters FTE

(Month)Leavers FTE

(Month)Turnover %(12 Months)

445 CAF Corporate Affairs Level 3 0.0 0.0 16.0%445 CDP Corporate Development and People Level 3 0.0 0.0 0.0%445 CDS Clinical Development Level 3 0.4 0.0 14.0%445 CHX Chief Executive Level 3 0.0 0.0 0.0%445 FIN Finance Level 3 2.0 1.5 14.7%445 HR Human Resources Level 3 0.0 0.0 29.7%445 OPS Operations Level 3 1.3 0.0 19.3%445 MED Medical Level 3 1.0 1.0 13.8%445 AOMGT Acute & Older Adults Management Level 3 0.0 0.0 4.0%445 COM Community Services Level 3 2.0 2.8 12.0%445 EIN Early Intervention Level 3 2.0 1.0 6.1%445 INP Inpatient Services Level 3 2.0 1.0 9.4%445 UCA Urgent Care & Access Level 3 0.0 0.0 10.6%445 Dudley and Walsall Mental Health Partnership NHS Trust 10.7 7.3 11.4%

8

The rolling 12 month sickness rate has decreased slightly in Month 2 to 4.14% from 4.24% in Month 1. This within the trusts target 4.68%. In month sickness has decreased from 3.59% in Month 1 to 3.40% in Month 2.

4.39%

4.83% 4.85%5.03%

3.81% 3.89%

3.62%

4.80%4.59%

3.33%

3.59%3.40%

3.00%

3.50%

4.00%

4.50%

5.00%

5.50%


Sickness Absence % v Trust Target

Target Sickness % Sickness % 12mth

445 UCA Urgent Care & Access Level 3 4.04% 3.86% 4.13%445 Dudley and Walsall Mental Health Partnership NHS Trust 3.59% 3.40% 4.14%

4.28% 3.92% 4.65%445 INP Inpatient Services Level 3

445 AOMGT Acute & Older Adults Management Level 3 4.10% 4.28% 2.89%445 COM Community Services Level 3 2.40% 2.41% 4.31%445 EIN Early Intervention Level 3 1.55% 1.81% 2.65%

445 OPS Operations Level 3 5.38% 7.20% 5.64%445 MED Medical Level 3 4.97% 3.74% 4.44%

445 HR Human Resources Level 3 3.27% 0.68% 1.52%445 FIN Finance Level 3 4.49% 1.60% 2.44%

3.74%445 CDS Clinical Development Level 3 2.67% 3.36% 7.81%

445 CAF Corporate Affairs Level 3 0.30% 1.33%

Service Apr-17 May-17Sickness %

(12 Months)0.94%

445 CDP Corporate Development and People Level 3 0.00% 0.00% 1.56%

445 CHX Chief Executive Level 3 0.54% 0.00%

9

Long term sickness accounts for 64% of sickness for the rolling 12 month period to May 2017. The number of open Long Term sickness cases is 19 in Month 2. The top 3 reasons for sickness based on Full Time Equivalent days lost for Month 2 were: 1. Anxiety/Stress – 344 2. Other musculoskeletal

problems - 154 3. Back problems – 104

1.3% 1.6% 1.2%1.9%

1.3% 1.5% 1.5%

3.00% 2.75%

1.46%

2.70%3.12% 2.63% 2.63%

0.00%0.50%1.00%1.50%2.00%2.50%3.00%3.50%4.00%4.50%5.00%

445 CorporateLevel 2

445 COMCommunity

Services Level 3

445 EIN EarlyIntervention Level

3

445 INP InpatientServices Level 3

445 MED MedicalLevel 3

445 UCA UrgentCare & Access

Level 3

445 Dudley andWalsall Mental

Health PartnershipNHS Trust

Short Term/Long Term Sickness % (Rolling 12 Months)

ST% LT%

Add ProfScientific and

Technic

AdditionalClinicalServices

Administrativeand Clerical

Allied HealthProfessionals

Estates andAncillary

Medical andDental

Nursing andMidwiferyRegistered

DWMH

Apr-17 2.21% 3.98% 4.89% 4.48% 8.58% 4.09% 2.24% 3.59%May-17 0.12% 4.86% 3.24% 8.76% 14.85% 2.13% 2.43% 3.40%

0.00%2.00%4.00%6.00%8.00%

10.00%12.00%14.00%16.00%

Sickness Absence Comparison by Staff Group

10

Appraisal compliance is tracking at 83.5% at the end of May 2017. This is above the Trust target but is reduction on the previous two months. There are 144 employees in the Trust that haven't had an appraisal recorded in the last 12 months.

69.8% 71.2%74.9% 73.7%

80.0% 79.1% 77.6% 79.4%

86.0% 87.0% 85.5% 83.5%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%


Appraisal % v Trust Target

Target Appraisal %

ServiceAppraisals Required

445 CAF Corporate Affairs Level 3 9445 CDP Corporate Development and People Level 3 4445 CDS Clinical Development Level 3 13445 CHX Chief Executive Level 3 6445 FIN Finance Level 3 33445 HR Human Resources Level 3 15445 OPS Operations Level 3 79445 MED Medical Level 3 93445 AOMGT Acute & Older Adults Management Level 3 23445 COM Community Services Level 3 166445 EIN Early Intervention Level 3 108445 INP Inpatient Services Level 3 230445 UCA Urgent Care & Access Level 3 95445 Dudley and Walsall Mental Health Partnership NHS Trust 874 85.5% 83.5%

78.9% 76.9%84.5% 83.9%

76.9% 100.0%83.3% 100.0%

74.7% 73.4%

96.9%85.7%

93.9%80.0%

100.0% 75.0%

Apr-17 May-17

87.5% 88.9%

+/-

92.4%

87.0% 78.9%

89.2%78.3% 56.5%90.3% 91.6%

11

445 Dudley and Walsall Mental Health Partnership NHS Trust

Training Compliance

Competence Target Completed Required % Completed Required % +/-Mandatory Training 90% 7332 8331 88.0% 7365 8315 88.6%Essential Skil ls 90% 4232 6198 68.3% 4423 6359 69.6%Combined Training % 90% 11564 14529 79.6% 11788 14674 80.3%

kMandatory Training

Competence Target Completed Required % Completed Required % +/-Equality, Diversity and Human Rights 90% 916 1013 90.4% 924 1012 91.3%Fire Safety 90% 894 1013 88.3% 903 1012 89.2%Health and Safety 90% 922 1013 91.0% 930 1012 91.9%Infection Control (Clinical) 90% 598 704 84.9% 597 704 84.8%Infection Control (Non Clinical) 90% 285 310 91.9% 286 309 92.6%Information Governance 95% 831 1013 82.0% 843 1012 83.3%Moving and Handling (Foundation) 90% 927 1013 91.5% 928 1012 91.7%Moving and Handling (Patient Handling) 90% 163 232 70.3% 161 230 70.0%Safeguarding Adults Level 1 90% 271 291 93.1% 267 291 91.8%Safeguarding Adults Level 2 90% 636 719 88.5% 641 715 89.7%Safeguarding Children Level 1 90% 263 290 90.7% 261 290 90.0%Safeguarding Children Level 2 90% 626 720 86.9% 624 716 87.2%

Essential Skills

Competence Target Completed Required % Completed Required % +/-Clinical Risk Assessment (Suicide Training) 90% 236 460 51.3% 266 496 53.6%Conflict Resolution (Personal Safety) 90% 429 644 66.6% 462 678 68.1%Domestic Violence and Abuse 90% 369 654 56.4% 410 689 59.5%Medicines Management (Competency Framework) 90% 155 343 45.2% 170 341 49.9%Mental Capacity Act 90% 602 729 82.6% 607 727 83.5%Mental Health Act 90% 277 460 60.2% 321 496 64.7%PREVENT - No Renewal 90% 647 729 88.8% 645 727 88.7%Rapid Tranquilisation 90% 57 173 32.9% 56 170 32.9%Resuscitation Level 2 with AED (BLS) 90% 410 639 64.2% 435 673 64.6%Resuscitation Level 3 (ILS) 90% 59 167 35.3% 72 162 44.4%Safeguarding Adults Level 3 90% 412 485 84.9% 412 485 84.9%Safeguarding Children Level 3 90% 407 485 83.9% 387 487 79.5%Violence & Aggression Module A (MAPA®) 90% 172 230 74.8% 180 228 78.9%

Apr-17 May-17

Apr-17 May-17

May-17

Apr-17 May-17



Enclosure: 20

Report Title:

Medical Directors’ Report


Dr Gingell and Dr Weaver, Joint Medical Directors


Dr Gingell and Dr Weaver, Joint Medical Directors

Purpose of the report: To update the Board on matters pertaining to the joint medical

directors’ portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


N/A

Strategic Objective(s) to which this paper relates: High quality

services


Leadership culture






Caring There is a potential impact across all the CQC domains. Responsive

Effective Well-led Safe Enc 20 MD Board Briefing Paper (Final) Page 1 of 4

National and Regulatory guidance Reports on changes to the medical postgraduate curriculum have been highlighted in the Chief Executive report. In essence it outlines changes to make postgraduate training more flexible and allows for changes in training pathways, and also recognises the artificial dichotomy of mental cf. physical specialty training, in a bid to ensure better mental and physical health integration. Recent Publications and Hot Topics A survey by the mental health charity MIND has found that public sector workers are less likely than their private sector counterparts to feel supported when they disclose mental health problems. The UK public sector employs over 5.4 million people and about 1.2 million work in the NHS. The charity surveyed 5746 public sector employees and 7191 private sector employees. 15% public sector workers cf. private sector workers (9%) said their mental health was poor and more likely to say that they had felt anxious at work on several occasions over the past month (53% vs. 43%). They took on average 3 days’ sick leave in the past year because of their mental health whereas workers in the private sector took less than a day. 48% of respondents from the public sector but 32% from the private sector have had time off because of their mental health. Again support in the private sector when problems were disclosed was 61% but only 49% of those in the public sector stated they felt supported. In a trainee-led review into morale and training within psychiatry entitled “Supported and valued?” the Royal College of Psychiatrists reported on junior doctors training in psychiatry. The PTC, which represents and supports more than 3500 psychiatric trainees across the UK, has initiated a review into morale and training within psychiatry, and engaged with trainees across both core (CT1–CT3) and specialty (ST4–ST8) training. 2000 responses were collected. Nearly half of all responses indicated that trainees valued their supervision time, the support of their seniors and peers, and the opportunity to work collaboratively as part of a multidisciplinary team. Regular weekly supervision, protected educational time and time for training in psychotherapy were not always available across the board and became the cornerstone of recommendations. The report concluded that “We were touched by the expressions of gratitude from trainees towards their seniors and their multidisciplinary colleagues throughout the focus groups. We would like to thank all those who work every day towards an environment where trainees feel supported and valued”. A report in the BMJ stated that antidepressant use in young people under the age of 18 reached 166510 in June 2016 up by 12% from April 2016. Among those treated with antidepressants were 10595 children aged 7-12 and 537 aged 6 or younger. The increasing use of psychotropic medication is concerning, together with the findings of a survey by the BMA that 70% of admissions of young people to mental health facilities are out of area.

Title Medical Directors’ Report

Enc 20 MD Board Briefing Paper (Final) Page 2 of 4

Local Matters We continue to face difficulties with filling junior doctor training posts in August with implications for the on-call rota and service delivery. Through the efforts of the College Tutor we have been able to fill one or two vacancies with Trust locums but this national shortage is felt acutely in the Black Country as doctors rank preferences for placements and we lose out, although feedback from trainees is excellent. Mortality Report Mortality Data for May 2017 There are 11 cases applicable for inclusion within this month’s figures which are outlined within the table below. Information in respect to these cases has been collected from the Safeguard Reporting system and the Informatics and Performance Department. The information from each electronic system complements the other and through cross referencing within other clinical information on OASIS, information from the coroner’s office and information from partner agencies, are aligned via the agreement of the Trusts mortality review group with one of the 4 following definitions: Natural deaths - ones from a recognisably incurable condition. Expected death - one where prognostic features have been identified leading to a reasonable expectation of death within an identified timescale Unexpected death - one occurs at a time that is sooner than may reasonably have been predicted from a non-natural cause or where the cause in unknown Preventable death - one that should not have occurred given current medical knowledge and technology’ 2 of the 11 deaths falling under the scope of this report were identified as being a serious incident. There are 11 cases falling inside the scope of this report and can be summarised as follows:

Age Team Diagnosis Summary Definition

76 CMHTOP Walsall

Dementia in Alzheimer’s disease with late onset

HH passed away on Ward 17 at Walsall Manor Hospital on 05/05/2017 Cause of Death Listed as:- 1a) Respiratory failure 1b) Aspiration Pneumonia 2) Vascular Dementia

Natural Causes

28 Crisis Resolution - Walsall

Moderate Depressive Episode

Phone call received from Mother (voicemail) advising that her son had taken his own life. Further Confirmed following call to District Coroner that patient had taken his own life by method of Asphyxiation by Helium. Patient had also left a suicide note left. Pt came into contact with the service on 29/09/16 - a direct referral from GP into Crisis. Patient was seen by CRHT throughout October 16 and was referred to Employment Services and WPH counselling. Cause of Death Asphyxiation by Helium Incident being investigated as a Serious Incident

Unexpected Death


Recommendation To note and discuss the report Board action required To receive the report for assurance

Age

Team Diagnosis Summary Definition

50 EAS (Dudley) Sandringham

Adjustment disorders Street Triage officers were attending Bushey Fields Hospital and requested information regarding whether this patient was known to services as she has been found deceased allegedly by hanging. Cause of Death Hanging Incident being investigated as a Serious Incident

Unexpected Death

69 Woodside (CMHTOP)

Recurrent depressive disorder, current episode mod

Daughter telephoned to inform care coordinator that mom passed away in Russells Hall Hospital of natural causes. Still awaiting formal confirmation of the Exact Cause of Death

Natural Causes

90 CMHTOP Walsall

Unspecified dementia

ECMHTOA Walsall was informed by Parklands Court Nursing home that RA had deceased on May 7th 2017. RA was an in-patient at Walsall Manor Hospital and his death was reported to be related to acute breathing issues/problems. Still awaiting formal confirmation of the exact Cause of Death

Natural Causes

70 Memory Services (BVC)

Dementia in Alzheimer’s disease with late onset

Patient passed away at Walsall Manor Hospital, which was believe to be of natural causes Still awaiting formal confirmation of the exact Cause of Death

Natural Causes

82 Holyrood Ward Unspecified dementia

Death of Patient on ward. Patient Receiving Palliative care on Ward at time of Death. DNAR in Situ but supportive treatment on-going at time of death.

Expected Death

92 CMHTOP Walsall

Dementia in alzheimer's disease, atypical or mixed

Patient passed away in a nursing home following transfer from acute hospital. Death was related to natural causes Still awaiting formal confirmation of the exact Cause of Death

Natural Causes

88 CMHTOP Walsall

Vascular dementia of acute onset

Telephone call received from Walsall Manor Hospital informing the team the patient had been discharged to a nursing home from hospital on Friday 12th Informed by Orchard care home on Monday 15th at lunchtime that paramedics had been called and that the patient had been readmitted where they subsequently passed away Cause of Death Listed as:- 1(a) Myocardial Infarction (b) (c) II Dementia

Natural Causes

81 CMHTOP Walsall

Vascular dementia, unspecified

Fusion identifies date of death as 30/05/2017. Still awaiting formal confirmation of the exact Cause of Death

Unexpected Death

88 Memory Services (BVC)

Mild cognitive disorder

Notified of patient death by Oaks Medical Centre, cause of death noted to be of natural causes Still awaiting formal confirmation of the exact Cause of Death

Natural Causes




Enclosure: 21

Report Title:

Director of Nursing Report


Rosie Musson, Acting Director of Nursing


Rosie Musson, Acting Director of Nursing

Purpose of the report: To update the Trust Board on key issues pertaining to portfolio

of the Director of Nursing Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: None


N/A




Leadership culture






Caring

The report relates to all CQC Domains

Responsive Effective Well-led Safe

Enc 21 DoNs Report for Board - July 17 Page 1 of 5

Title Director of Nursing Report

Introduction This report for the Director of Nursing aims to update the Board on pertinent issues and challenges relating to the nursing portfolio. Summary of key points, issues and risks CQC Assessment Framework

The CQC have published a response to their recent consultation regarding their proposals to amend their assessment framework. The consultation period ran from 20 December 2016 to 14 February 2017. (The Trust provided a response) The CQC received 496 responses, which have subsequently been analysed by OPM Group, an independent research and consultancy organisation. For information, a hyperlink to the consultation outcome is provided below: http://www.cqc.org.uk/sites/default/files/20170612_next%20phase%20consultation%201%20response_final.pdf New Assessment Framework Summary The headlines / main proposals for the new assessment framework are as follows: There will now be two CQC assessment frameworks (instead of the current multiple provider handbooks) - one for healthcare organisations and a separate one for adult social care. NHS Trusts are expected to implement the new assessment frameworks from June 2017, whilst adult social care providers and GPs will need to implement by November 2017 with independent sector providers allocated additional time (until 2018/19) to implement the new framework. It has been agreed that there will be a new monitoring, inspection and ratings regime for NHS Trusts, meaning that all NHS Trusts can expect each year to have a well-led assessment and at least one core service inspection. Similar changes are expected to be implemented for other providers - including independent sector providers - following further planned CQC consultations which are scheduled to occur later this financial year. The new assessment frameworks for all providers which replaces the existing provider handbooks will continue to ask the same 5 Key Questions (Are services safe, effective, caring, responsive and well-led) but there are various revisions and additions to the existing Key Lines of Enquiry and Guidance Prompts. For example, there are new KLOEs/Prompts in relation to medicines management, end-of-life care, use of technology, response to external alerts/reviews and involvement of families and carers.


http://www.cqc.org.uk/sites/default/files/20170612_next%20phase%20consultation%201%20response_final.pdf

http://www.cqc.org.uk/sites/default/files/20170612_next%20phase%20consultation%201%20response_final.pdf

In order to help providers update systems/processes which may be aligned to the existing assessment frameworks, the CQC has published versions of the frameworks with the changes clearly marked Monitoring and Frequency of Inspections In terms of how the CQC will monitor NHS Trusts and decide when and which core services are to be inspected, a new 'CQC Insight' system will be initiated which will initially focus on existing National data collections. The new, annual Provider Information Requests (PIRs) will also be implemented, and the first batch of NHS Trusts (identified on a risk basis plus those not inspected in the last 12 months) can shortly expect to receive a new-style PIR, with targeted inspections likely to follow in the following 6 months after a PIR request. There will also be quarterly relationship management meetings with Trusts, which will help inform the CQC's regulatory planning. Having received broad support from the consultation process the CQC will implement its plan for NHS Trusts to have a well-led assessment and an assessment of at least one core service each financial year (with frequency of core service inspections subject to how services were rated at the last inspection). Trust level well-led assessments will take place approximately once a year. Trusts will be informed of the timing of these following the CQC's internal regulatory planning meetings. The CQC has indicated that the scope/depth of these well-led inspections may vary according to the nature of the individual Trust. In relation to core services, each year the CQC will inspect all core services rated 'inadequate', half of those rated 'requires improvement', a third of those rated 'good' and a fifth of those rated 'outstanding'. In order to address concerns expressed in the consultation that long gaps between inspections for some core services could prevent Trusts being able to demonstrate improvements, some core service inspections will be triggered by information suggesting that the quality of care has improved. A consultation on monitoring/inspection regime changes for the adult social care and primary medical care sectors has also recently been launched, and there will be a similar consultation later in 2017/18 on proposed changes to how independent sector providers are regulated and rated. Ratings A common concern expressed by those who responded to the CQC's consultation related to the need for improved transparency about how ratings are arrived at. The new assessment frameworks contain revised guidance about what 'outstanding', 'good', 'requires improvement' and 'inadequate' look like for each of the 5 Key Questions. The CQC has committed to setting out clearly in each report how it reached the rating for each question, including factors considered and how this impacted on the CQC's decision-making.


The next steps A further consultation has just been launched about a number of issues relevant to all sectors - including how providers are registered, new models of care/complex care providers and proposals for provider-level assessments - plus proposed regulatory regime changes for adult social care and primary medical care (closing date 8 August 2017), with a third consultation in relation to CQC regime changes for independent sector providers expected later in 2017/18. Meanwhile, the first new-style information requests will be sent out to NHS Trusts in June, with the first of the 'next phase' NHS Trust inspections likely to take place between September and November 2017. The new system for NHS Trusts is expected to be fully embedded by Spring 2019. Nursing Workforce – Retention NHSI have launched a programme to support trusts with retention of staff. This is in the context of the National Workforce Challenges facing the NHS in the immediate, medium and longer term. There will be a specific retention programme for mental health trusts moving forward. From our workforce data there are a number of challenges facing our workforce including the aging nursing workforce. The DON will be working looking how the trust can engage in the programme and also work with partners. Ofsted inspection Walsall Childrens Services The Trust is participating as a partner organization in the Ofsted inspection of Children services which commenced on the 20th of June 2017. The inspection will take place across a 4 week period and evaluate the effectiveness of services for children in need of help and protection, looked after children and care leavers in Walsall. The outcome from the inspection report will be published on Ofsted’s website https://www.gov.uk/find-ofsted-inspection-report six weeks after the inspection has concluded. Nurses and AHP Visit to the Netherland Three inpatient nurses and the interim Professional Lead for Occupational Therapy will be visiting the Dimence Group in the Netherlands in September. The opportunity will enable nurses to spend time to gain a deeper understanding of how they deliver acute in-patient care. The visit is an opportunity to spend time in different types of clinical settings and bring back learning. NMC Consultation on education framework: standards for education and training The NMC are consulting on the education framework, a document that sets out the education and training standards that all approved education institutions (AEIs) and practice placement providers must meet in order to deliver an NMC approved programme. These standards contain the requirements that signify what good education looks like. The safety of people is central to these standards, as students will be in contact with people, carers and families throughout their education and training.


https://www.gov.uk/find-ofsted-inspection-report

Having considered the proposals it is encouraging that the five pillars of education are linked to Code of Conduct and are configured at putting patient centered care at the heart of training The Director of Nursing will coordinate a response to the consultation. Recommendation The Board is asked to note the updates within Director of Nursing Portfolio. Board Action Required As recommended.




Enclosure: 22

Report Title:

Enhancing Quality through Safer Staffing Levels - Monthly Exception Report


Rosie Musson – Acting Director of Nursing


Rosie Musson – Acting Director of Nursing Makhan Singh – Principal Consultant, Informatics and Performance

Purpose of the report: This report provides the Trust Board with:

• A summary report of planned and actual staffing for

May 2017, which has been submitted to NHS Choices as part of a national staffing return and is available on the Trust’s website.

• Exception reporting for variances and any concerns relating to safer staffing

• Trend analysis monthly average fill rate • Bank and agency actual hours analysis v’s

substantive hours • Number of qualified staff per shift

Action required from the Committee Decision / Approval

Gain assurance

Discussion

Information


Committee: Workforce Committee

Date reviewed: 27th June 2017 Key points or recommendations from Committee:

This is reported through the Committee Chairs report.




Leadership culture




Enc 22 Safer Staffing Report - July 2017 Page 1 of 13



Caring

Responsive

Ensuring staffing levels are responsive to meeting patient need

Effective

Well-led

Safe

Ensuring staffing levels are adequate to deliver safe care


Title Enhancing Quality through Safer Staffing Levels

- Monthly Exception Report Introduction This report provides the Committee with: • A summary report of planned and actual staffing which has been submitted to NHS

Choices as part of a national staffing return and is available on the Trust’s website. • Exception reporting for variances and any concerns relating to safer staffing. • Trend analysis monthly average fill rate. • Bank and agency actual hours’ analysis against substantive hours. • In addition data relating to trust standard of minimum of two registered RMNs on

duty by shift. • Update on the integration of safer staffing data into the Trusts integrated dashboard.

Summary of key points, issues and risks The Data represents May 2017 and a monthly trend analysis for a 12 month period. Across the inpatient areas the overall fill rates are 100.04%, with 99.19% for registered staff and 100.55% for care staff. This indicates the Trust is meeting the optimum level of fill rates. Typically where our care staff rates exceed 100%, this is due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity. Where staff have concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In May there were 0 incidents reported related to safer staffing in inpatient services. The Trust has in place a locally agreed standard of the minimum of 2 qualified members of staff per shift. Due to inpatient vacancies the Director of Nursing has sought further assurance that when the ward plans to drop below this standard. Assurance has been provided that when developing the rosters the Ward Managers are ensuring that skill mix does not compromise safety and the roster is risk assessed when they allocate one qualified nurse to be on duty at night. Mitigations include the use of experienced HCA to the ward, which provides a safer option than the use of temporary staff. Feedback has also been gathered from newly qualified nurses that indicates that consideration is being given to safety and skill mix. There have no issues raised through the Trusts governance systems that safety is being compromised. There will continue to be an ongoing monitoring process with Ward mangers overseen by the Head of Service to provide continued assurance.


In the longer term to achieve the local standard of two qualified each shift the following actions are being taken:

• Ongoing recruitment campaign. • Alignment with local university to provide job opportunities for newly qualified staff • Establishment review. • Continue to optimise efficiency of rosters – monthly one to one sessions with ward

managers. • Monitor progress through the Workforce Committee and full review in September.

Page 6 details Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates. There has been a reduction of agency staff in the months of April and May. The reduction can be attributed to the e rostering, improving temporary staffing processes and bank recruitment. Recommendation To note and discuss the monthly data return submitted providing details of planned and actual staffing at ward level. Board action required The Board are asked:

• To note and discuss the monthly data return submitted, providing details of planned and actual staffing at ward level. Data represents May 2017 and a 12 month trend analysis.

• To note the work underway to enable to most efficient safe and effective use of nurse staffing in inpatient service, this will focus on all professional groups, including therapists.

• Note and discuss the data relating to internal Trust standard of two qualified staff per shift and to discuss and receive assurance on mitigations in place.


1. Nursing and healthcare staffing fill rates May 2017 The data submission was made on 13th June 2017 of May data. The following table provides a summary of the planned verses actual staffing levels on the inpatient wards. Ward Return

Planned Actual Planned Actual Planned Actual Planned Actual

Cedars 930.00 896.00 1210.50 1213.50 526.75 526.75 516.00 516.00 96.34% 100.25% 100.00% 100.00%Linden 945.00 907.50 1568.50 1576.00 612.75 612.75 817.00 817.00 96.03% 100.48% 100.00% 100.00%Ambleside 924.70 924.70 1644.00 1644.00 655.75 655.75 935.25 935.25 100.00% 100.00% 100.00% 100.00%Langdale 903.35 893.10 1369.50 1368.25 666.50 666.50 763.25 763.50 98.87% 99.91% 100.00% 100.03%Clent 1142.50 1142.50 1179.75 1179.75 344.00 344.00 999.75 999.75 100.00% 100.00% 100.00% 100.00%Kinver 870.75 873.00 1175.00 1220.00 430.00 430.00 903.00 984.25 100.26% 103.83% 100.00% 109.00%Wrekin 870.00 863.65 717.70 688.85 333.25 333.25 666.50 671.15 99.27% 95.98% 100.00% 100.70%Holyrood 976.50 978.50 2791.00 2787.00 483.75 483.75 2096.25 2096.25 100.20% 99.86% 100.00% 100.00%Malvern 1005.00 982.50 1277.00 1299.50 451.50 451.50 926.25 915.50 97.76% 101.76% 100.00% 98.84%Grand Total 8567.80 8461.45 12932.95 12976.85 4504.25 4504.25 8623.25 8698.65 98.76% 100.34% 100.00% 100.87%

May-175ay Night 5ay Night

RMN Care Staff RMN Care Staff Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Lowest range – less than 80% Highest range – greater than 150%

Low range – greater than 80% but less than 90%

High range – greater than 120% but less than 150%

Greater than 90% but less than 120%

Comments Across the inpatient areas the overall fill rates are 100.04%, with 99.19% for registered staff and 100.55% for care staff. This demonstrates an optimum range of fill rate for qualified and care staff for the demand (number of staff identified as required by the ward to meet patient acuity).


2. Exception Report on Variance – May 2017 No safer staffing incidents reported in May 2017 via the Trusts incident reporting system. 3. Trend Analysis average fill rate

The following table shows a monthly trend of the total average fill rates planned verses actual for the Trust. This demonstrates that staffing levels are flexed to meet the increases and decreases in patient acuity, which is currently informed by clinical expertise.


4. Registered Nurse Hours – Substantive v’s Temporary Staff fill rates

The below table shows percentage of hours from April 2016 split by bank hours, agency hours and substantive hours for all registered nurses. Further work is being undertaken to enable this data to be triangulated and ensure we are utilising temporary staffing in the most effective and efficient way.


5. Registered Nurse Hours – Substantive V’s Temp Staff Fill Rate The below table shows percentage of Registered Nurse Hours – Substantive V’s Temporary Staff Fill Rate for individual wards. Further work is being undertaken to enable this data to be triangulated and ensure we are utilising temporary staffing in the most effective and efficient way. Vacancy rates are impacting on fill rates alongside increased patient acuity requiring increased observations.


6. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates

The below table shows percentage of hours in 2016/17 split by bank hours, agency hours and substantive hours for all care staff. Vacancy levels and increased patient acuity requiring high level observations are impacting on use of temporary staff. The Board is asked to note the reduction of agency staff for the month of April and May. The reduction can be attributed to the e rostering, improving temporary staffing processes and bank recruitment.


7. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates

Further analysis of registered nurse hours by ward for May month is presented in the below table.Vacancy levels and increased patient acuity requiring high level observations are impacting on use of temporary staff. Holyrood Ward in May had high levels of temporary staff fill rate, this can be explained by increased patient acuity and raised levels of obervations.


8. Minimum of two qualified nurses per shift Standard

The Trust has a safer staffing standard, where there is a minimum of two qualified nurses per shift. The information sourced from HealthRoster shows that in May 2017 across the inpatient areas the overall day and night compliance rates are 81.96% (previous month - 79.01%), with 98.21% (previous month – 97.78%) for day shifts and 49.46% (previous month – 41.48%) for night shifts. The below table shows the May 2017 compliance rate by ward:


The below table shows the May 2017 Day shift compliance rate by ward:

Where compliance falls below 100%, this is predominantly around short notice sickness. Where there are shortfalls, this is managed by support from the supernumerary Ward Managers, Band 6 staff who are on supervisory days or bleep holders.


The below table shows the May 2017 Night shift compliance rate by ward: There is significant variance on the compliance. It is evidence that the impact of vacancies is leading to one qualified member of staff being rostered into the numbers for nights on wards, however assurance provided by the Head of Service and Ward Managers is that their preference to maintain a safe environment and continuity of care is to utilise experiences HCA staff in some instances. It is evident that where Ward managers feel temporary qualified staff are required they are requesting and this is being met by bank/ agency or on occasion’s overtime. Work continues to recruit to the qualified vacancies, supported by a rolling programme and communication campaign. The Trusts staffing safety escalation process remains in place should there be any concerns staff wish to raise. Alongside the recruitment campaign, work continues to maximise the efficiency of the workforce through e rostering. The Committee are also asked to note that qualified nurse support is also available in addition to the rostered staff through the night coordinator who is on site.




Enclosure: 23

Report Title: Care Quality Commission (CQC) Action Plan - June

2017 Accountable Director: Rosie Musson – Interim Director of Nursing Author (name & title): Tom Jinks – Compliance and Safety Manager Purpose of the report: To inform the Board on the progress made by the Trust in

response to the areas requiring improvement as identified by the CQC, following the November 2016 assessment.


Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report The CQC Action Plan has been reviewed and endorsed by the CQC Steering Group, The Quality and Safety Committee and the Mental Health Act Scrutiny Committee. Key points or recommendations from Committee or Group: The main area of focus has been in respect to the local ownership and accountability of actions. In order to fully embed the improvements and ensure sustainability and consistency in delivery across all services, it was agreed by the CQC Steering Group that local management of the implementation of agreed actions was required. In order to achieve this, each of the services have now received their own version of the action plan, with the Managers now required to locally implement the actions and provide a monthly position statement to the CQC Steering Group. This has been well received and supported from the Managers, with the first update having successfully been recently received. Strategic Objective(s) to which this paper relates:



Leadership culture




Quality Impact Assessment Domain Comment Caring The Trust was assessed on all of the CQC Domains

and the Trust action plan is designed to fully address areas that required further improvement to ensure ongoing compliance with the CQC Standards.


Enc 23 Trust Board report CQC Action Plan - June 2017 Page 1 of 31

Title Care Quality Commission (CQC) Action Plan - June 2017 Introduction The purpose of this report is to provide the Trust Board with a copy of the Trust’s updated CQC Action Plan, that has been developed in response to the Trusts published CQC report following the CQC assessment of the Trust that took place in November 2016. The action plan aims to address all the findings / areas for improvement highlighted in the report Executive Summary of key points, issues, financial impact and risks The CQC action plan aims to address all of the identified areas of concern and will provide assurance to the Trust, public, CQC and partners that the Trust is taking appropriate action. By demonstrating that the Trust will fully address the areas of concern, the action plan indicates that the Trust is confident that it will maintain required standards. It should be noted that where longer term actions are required, immediate short term solutions have been instigated to ensure the Trust is compliant with all of the regulations whilst the longer term solutions are being developed and implemented. Further detail Information For further details Committee members are advised to refer to CQC published reports. Quality Impact The CQC standards have been developed to ensure that the quality of care provided to patients is effective and that services are delivered in a consistent manner. Financial Impact The delivery of the CQC action plan is likely to have some financial impact, mainly relating to the identified environment factors, such as anti-barricade doors. The financial impact and mitigating actions of the delivery of the action plan is being overseen and managed by the CQC steering Group.


Legal Comment The Trust is required to maintain its CQC registration in order to be able to deliver its registered services. Compliance with the CQC standards is a core requirement of the registration requirements. Risk Assessment The risk assessments / risk register entries related to the CQC action plan have been fully developed and are detailed on the Trust Wide Risk Register . Recommendation It is recommended that the Trust Board endorse the CQC action plan and are assured by the continuing progress made in relation to the actions being taken to address the areas for improvement as identified by the Care Quality Commission during the November 2016 assessment.


DWMH CQC - Trust Action Plan June 2017

CQC Action Plan v3.0 – June 2017 Page 1 of 28

Dudley and Walsall Mental Health CQC Action Plan – June 2017 Following a re-inspection of the Trust in November 2016, and the subsequent report of findings received in February 2017, the Trust has commenced a new CQC detailed action plan which aims to address all of the identified regulation actions and areas for improvement, with the aim to provide assurance to the public, CQC and partners of the actions the Trust are taking to address these concerns. By demonstrating that the Trust will fully address the areas of concern, the action plan indicates that the Trust is confident that it will be fully compliant with all of CQC regulations. It should be noted that where actions are required, immediate short term solutions, based on risk, have been implemented to ensure the Trust is providing safe and effective care, whilst the longer term solutions are being developed and implemented. All of the action points within this report have been given an appropriate lead, aligned with appropriate group(s) committee(s) and given an identified executive lead. As agreed by the CQC Steering Group, the action plan will be supported by individual local ownership of actions from Inpatient Services. The Trusts action plan also aligns these actions with a CQC regulation where appropriate. As such the action plan addresses all regulatory points within the Trusts reports which have been issued by the CQC. In line with these reports the Trusts CQC action plan divides these actions into those which are considered as “must do actions” and those which are considered as “should do actions”, in line with the recommendations made by the CQC. Current Status Key: Red – Action not completed and outside of agreed timescales. Amber - Action underway but not yet completed but within agreed timescales Green - Action completed Grey - Action not commenced and within date


Ref ID

CQC Area of Concern Planned Action

Responsible Committee

Exec Lead

Lead for action

Suggested Completion

Date

Current Status of Action

Monitoring Method

Measure of Success / Impact

Update / Current Status

Link to regulation action and Quality Priorities

MUST DO ACTIONS

1.1 To ensure Fit and Proper Person Requirements for directors are up to date, regularly reviewed and any gaps acted upon (Source Quality Report) Previously identified concern from Feb 2016 CQC Report

To review all files and ensure that the required standards are met. To undertake regular audit to ensure standards are maintained.

Workforce committee

Acting Director of People

Company Secretary

June 2017 Audit results Spot check of files

All files that meet Fit and Proper Person requirements

Checks have been made and discussed at Quality and Safety Committee Recommended to close action Report to be submitted to Trust Remuneration Committee in July 2017 Process will remain under ongoing scrutiny and review by Trust Board Secretary

N/A

2 To ensure that emergency equipment are checked consistently and managed

To provide a summary from the Resuscitation Council guidelines.

Resus Committee

Acting Director of Nursing

Clinical Quality Improvement Manager Patient Safety Facilitator

July 2017 Spot checks Proactive work with ward managers and Patient safety Facilitator.

Completed audit demonstrating compliance against

Discussed at Inpatient Service Line meeting Allocated for local ownership at ward level

Links to regulation 12(2) (e) (g) Pages 36 & 37 Quality


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




in line with the recommendations of the resuscitation council. This includes: • Storage of

Emergency medicines

• Signage for Oxygen on Wards

• Checking of emergency equipment and medicines

• Sealing of Resuscitation bags

• Recording of room temperatures

• Recording of medicines that determined an expiry date

(Source Quality Report & Acute Wards Report) Previously identified concern from Feb 2016 CQC Report

To develop an audit tool for checking of emergency equipment. To commission CDW Audit to undertake external scrutiny Review results and actions. Local ownership of issue by Ward Managers

On-going checks by clinical lead

standards Assurances currently being received from each award area Resuscitation Committee reviewing a standardized list of equipment to enable consistency across all wards

Report (Page 32 Acute Ward Report )


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




3 To ensure that risk assessments are present, up to date and regularly reviewed for all patients. The risk assessments must be detailed enough to capture all risks and formulate an effective risk management plan. Includes • Failure to

act and evidence internal audit findings.

(Source Quality Report & Acute Wards Report ) Previously identified concern from Feb 2016 CQC Report

Targeted review of every patients risk assessment and management plan within the Inpatient and Crisis/ Home Treatment service. Action findings of review. Where a training need is identified, specific support and targeted actions and supervision implemented to monitor. Clinical Process Manager to review inpatient guidance and reissue instructions to staff Risk formulation training for staff to be reviewed


Acting Director of Nursing /Acting Director of Operations

Head of Inpatient Service Senior Clinical Lead Ward Managers Clinical Process Manager

August 2017

CPA Audit Spot checks Documentation Audit Trust Support Visits

Risk assessment and management plans meeting high quality standards in line with Trust expectations and policy requirements

Discussed at Inpatient Service Line meeting in June Allocated for local ownership at ward level Assurances currently being received from each award area Latest Trust Support visits highlighted inconsistencies in practice currently remain Work ongoing Communication to be sent out to IP Managers and Deputies

Links to Regulations 12 (1) (2) (a) (b) (Page 37 Quality Report ) (Page 32 Acute Ward Report ) Links to quality priority “Improving the Quality of Record Keeping”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




4 To ensure that all staff receive and are up to date with mandatory and essential training (Source Quality Report & Acute Wards Report ) Previously identified concern from Feb 2016 CQC Report

To review and agree current essential training requirements for staff groups including compliance targets Ensure that correct training provision and methods for essential training requirements are in place To implement an effective monitoring system for essential training in line with current mandatory training monitoring methods

Workforce Committee


Senior Workforce Development Manager Acting Head of Inpatient Service

July 2016 Training compliance reports

Agreed target met

Mandatory training levels compliance currently set at 90% Active management monitoring of individual services / teams compliance be undertaken on monthly basis Reports to MEXT and Workforce committee Essential Training processes to be reviewed in line with the above. Currently a risk on Trust Risk register whilst work relating to essential training compliance continues

Links to Regulation 18 (2) (a) (Page 38 Quality Report ) (Page 33 Acute Ward Report )


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




5 To ensure that staff follow the Trusts rapid tranquilisation policy by carrying out physical health observations and completing monitoring forms. (Source Quality Report & Acute Wards Report )

To re-issue briefing sheets to staff stating clear standards, accountabilities and requirements of physical health monitoring following the use of rapid tranquilisation medication. Meeting to be held with all clinical managers to reiterate required standards and for them to cascade requirements to all inpatient staff. Undertake re- audit of rapid tranquilisation clinical audit Target areas of non -compliance through supervision and performance processes Local Ownership by Ward Managers

Medicines Management Committee Physical Healthcare Steering Group

Acting Director of Nursing Joint Medical Directors

Chief Pharmacist Acting Head of Inpatient Service Clinical Quality Improvement Manager Ward Managers

July 2017 Clinical Audits results and action plans Report to medicines management committee Progress / Update reports from medicines management committee / physical health group to Quality and Safety Committee

Evidence of all post rapid tranquilisation having appropriate physical health monitoring processes in place in line with Trust Policy requirements

Rapid Tranquilisation policy and physical healthcare standards policy has been review and ratified and is available to all staff via intranet site Initial audit undertaken following Nov 2016 verbal feedback Discussed at Inpatient Service Line meeting Allocated for local ownership at ward level Assurances currently being received from each award area

Links to Regulation 12 (2) (a) (b) (Page 37 Quality Report ) (Page 32 Acute Ward Report )


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




6 To ensure that staff carry out on-going physical health monitoring for all patients in line with the Trust policy and National guidance (Source Quality Report & Acute Wards Report )

To undertake a review of the standards of physical health care intervention / monitoring and recording requirements Cascade requirements to ward managers and medical staff Develop / review audit tool to ensure fit for purpose Agree frequency of audits To undertake audit To take action on any identified deficiencies including the identification of staff training needs / gaps in knowledge. Local Ownership by Ward Managers

Quality and Safety Committee Physical Health Steering Group

Acting Director of Nursing Joint Medical Directors

Acting Head of Inpatient Service Clinical Director for Quality and Safety Clinical Director Inpatients Clinical Quality Improvement Manager Senior Workforce Development Manager Senior Clinical Leads

August 2017 Progress / Update reports from medicines management committee / physical health group to Quality and Safety Committee Audit results / reports Spot checks Trust Supportive Visits

Physical Healthcare checks and interventions in place with all patients receiving appropriate physical healthcare interventions / treatment

Physical Healthcare Group in place. Discussed at Inpatient Service Line meeting Allocated for local ownership at ward level Assurances currently being received from each award area .

Links to regulation 12 ( 2)(a) (b) Page 37 Quality Report) (Page 32 Acute Ward Report )


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




7 To ensure that care plans are collaboratively produced up to date and are detailed, holistic, person centred and recovery focussed. (Source Quality Report & Acute Wards Report & Crisis and HBPOS Report) Previously identified concern from Feb 2016 CQC Report

Targeted review of every patients Care Plan within the Inpatient and Crisis/ Home Treatment service. Action findings of review. Where a training need is identified, specific support and targeted actions and supervision implemented to monitor. Further implementation of My Care Plan Nurse Development training to be implemented


Acting Director of Operations

Acting Head of Inpatient Service Senior Clinical Leads Senior Workforce Development Manager Nurse Revalidation Lead

July 2017 CPA Audit Spot checks Documentation Audit Trust Support Visits

Personalised Care plans meeting high quality standards in line with Trust expectations and policy requirements

My Care Plan launched Following verbal feedback in Nov 16, meetings with ward managers have taken place to review ward care plans and address concerns through supervision Briefing sheets for staff issued Internal Training on wards led by ward managers in place Discussed at Inpatient Service Line meeting Allocated for local ownership at ward level Assurances currently being received from each award area

Links to Regulation 9 (3) (a,b) (Page 35 Quality Report ) (Page 31 Acute Ward Report) (Crisis & HBPOS Report page 10 and 25 ) Links to Quality Priority “ Person Centred Care Planning”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




8 To ensure that staff follow good practice in relation to the Mental Capacity Act, in relation to assessing capacity to consent to treatment on a decision specific basis. There must be clear documentation detailing how capacity is sought to consent or refuse treatment, and the reasons for the capacity decisions that are made. (Source Quality Report & Acute Wards Report ) Previously identified concern from Feb 2016 CQC Report as part of Least Restrictive Practice

Review standards and staff understanding relating to documentation of decision specific areas of capacity Re-issue Briefing and guidance notes Undertake spot check reviews Undertake a clinical audit against requirements / standards Provide targeted training through Trust MCA project leads

MHASC Acting Director of Nursing Joint Medical Directors

Clinical Director of Inpatient Services Clinical Quality Improvement Manager Mental Health Act Manager Head of Social Care

July 2017 Training records Audit results and action plans Documentation reviews CQC MHA Visits

Decision specific capacity clearly documented and actioned

All Training resources available MCA Training forms part of Trust Essential training – monitored via workforce committee Audit tools available Trust support visits highlighted improvements in documentation but more person centred / specific capacity assessment required

Links to regulation 11 ( 1) (3) (Page 35/36 Quality Report ) (Page 31 Acute Ward Report ) Links to Quality Priority “Improving the Quality of record keeping” and Person Centred Care Planning”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




9 To ensure that the multi-agency operational policy for place of safety is updated and is in line with the MHA Code of Practice (2015) To ensure that effective processes are in place to monitor the quality of recorded information for all patients assessed in the health based place of safety. Information about rights given to patients when they commence on S136 of MHA must be constantly recorded (Source Quality Report ) Previously identified concern from Feb 2016 CQC Report re 136 suite

Ti0 work with partners to finalise policy in line with MHA Code of Practice 2015 requirements Top communicate agreed policy To develop and agree internal; processes for the effective management and monitoring of 136 activity and standards To review written information that is provided to patients Develop guidance to staff on the recording and provision of information pertaining to patient’s rights and recording of key identified requirements

MHASC Acting Director of Operations

Acting Head of Inpatient Service Mental Health Act Manager Head of Social Care

August 2017 Reports to MHASC To be determined once process in place

Appropriate 136 monitoring process in place Recording of patients’ rights

Policy in development 136 recording form has been reviewed and is fit for purpose in line with MHA requirements Concerns regarding delay in policy have been escalated to MHASDC and Quality and Safety Committee and Partnership Board.

Links to regulation 17 (2) (a) (c) (Quality Report Page 38) (HBPOS Report page 10 & 25)


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




10 To ensure Governance systems are effective and robust to monitor, identify and address gaps in the quality of service provided. Includes • Staff

Training • Physical

Healthcare • Rapid

Tranquilisations

• Care Plans • Risk

assessment • Care Plan (Acute Wards Report )

To undertake a Review of the inpatient management structure, implementing any required changes. To establish effective leadership and governance structures that allow for effective escalation and management of identified concerns



Acting Head of Inpatient Service Compliance and Safety Manager Senior Clinical Leads Ward Managers

August 2017 Reports to Quality and Safety Committee QPR Spot-checks

Clear management and escalation structures in pace Evidence of action to address CQC action compliance

Recruitment plans in Inpatient Services continue to progress with positions currently being advertised Once recruited. Additional resource will assist with addressing any identified gaps in service. The areas detailed in this action have been discussed at service line meeting and allocated for local ownership.

Links to regulation 17 (1) (2) (a) (b) (f) (Page 33 Acute Ward Report ) Links to Quality Priority “Ensure organisational learning is embedded and sustained” & “Improving the Quality of Record Keeping”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




SHOULD DO ACTIONS

1 The provider should ensure maintenance and checks of all equipment used by patients is recorded in agreed schedules in older peoples wards (Source Quality Report Page 12) (Source Wards for Older People Report - Page 8) Previously identified concern from Feb 2016 CQC Report

To review agreed schedules of equipment checks To undertake a review of all inpatient equipment against agreed checks and standards To develop a localised schedule of checks that is overseen by local ward managers

Quality and Safety Committee Health and Safety Committee


Acting Head of Inpatient Service Senior Clinical Leads

June 2017 Compliance reports to Health and Safety Committee

Equipment check fully in place – all equipment checked in line with Trust standards.

Current standards agreed across all inpatient wards Discussed at Inpatient Service Line meeting Allocated for local ownership at ward level Assurances currently being received from each award area

N/A


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




2 To ensure training completed by staff is captured promptly by the Trust in order to accurately identify training needs (Source Quality Report - Page 12) (Source inpatient Older adults Report - Page 8) Previously identified concern from Feb 2016 CQC Report

To review systems for capturing all types of training to ensure centralised system is accurate and updated in a timely manner

Workforce Acting Director of People

Senior Workforce Development Manager ESR System Manager

June 2017 Monthly reports to Workforce Committee and MEXT

Fully updated training records for all staff

System in place to monitor mandatory training which allows for checks to be undertaken by managers This system now needs to be replicated for all essential training Progress is being made and Essential training requirements are being identified Central system for monitoring of essential training in development

N/A


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




3 To ensure that the Trust Fire extinguishers are inspected within specified times. (Source Quality Report - Page 12) (Acute Wards Report page 12)

To commission a programme of work to check all fire equipment in all areas To implement a monitoring system to allow equipment to be flagged that needs to be inspected prior to the date lapsing

Health and Safety Committee Estates and Capital Planning Fire Prevention meeting

Director of Finance

Head of Estates and Technical Services

April 2017 Spot checks Evidence of suitable programme for the management of fire equipment being implemented

All fire equipment has been checked and remains in date

All equipment has been checked as part of the review of the fore contract Trust Support visits did not highlight any unchecked equipment May need to progress some actions relating to the safe location of fire extinguishers in ward areas – outcome of supportive visits

N/A


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




4 To ensure that positive behavioural support plans are in place for patients with behaviours that challenge (Source Quality Report - Page 12) (Acute Wards Report page 12

To review and update the least restrictive action plan To review the Trust paperwork to ensure it meets the needs of the patient and is fit for purpose in line with requirements To review and address any gaps in staff skills and knowledge To develop an on-going method of training and support for staff To develop suitable audit tool To undertake a clinical audit and feed results to clinical audit and effectiveness group and then to MHASC

MHASC Acting Director of Operations

Clinical Trainer Senior Clinical Leads Clinical Inpatient Manager (OA) Senior Workforce Development Manager Patient Safety Facilitator Ward Managers

September 2017

Clinical Audit Positive Behavioral Support Plans in place for all patients that present with behaviors that challenge Meeting National Standards

The Trust Least Restrictive Practice Group well established and has a current work plan in place to address requirements and actions to ensure PBS is embedded across inpatient service. Development of Positive Behavioral support plans currently being led by Ward Managers

Links to Quality Priority “Person Centered Care Planning”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




5 To ensure that all handovers are detailed, all staff attend and fully discuss individual patient risks (Source Quality Report - Page 12) (Acute Wards Report page 12

Review individual ward processes for handover with a view to developing a standardised approach across all inpatient ward areas. Develop standardised documentation to support the implementation of standardised process Communications to be issued to all staff explaining roles responsibilities and expectations Spot check to be undertaken to determine staff understanding / levels of compliance



Acting Head of Inpatient Service Senior Clinical Leads Inpatient Services Manager Deputy Ward Managers

August 2017 Clinical Audit to be undertaken on handover process

Standardised process for handover which ensures all staff received a consistent and detailed handover with clearly identified patient risk history and presentation n

Handovers in place on all wards Handovers reviewed as part of Trust Support visits Excellent quality of handover observed but an inconsistency of process noted Handover policy to be developed Deputy Ward Managers meeting to develop consistent processes

Links to Quality Priority “Improving the Quality of Record Keeping”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




6 To ensure that all patients receive a copy of the care plan (Source Quality Report - Page 12) (Acute Wards Report page 12 Previously identified concern from Feb 2016 CQC Report

Staff to be reminded of the importance of sharing copy of the care plan with the patient / relative / carer and recording this appropriately in the care record. Audit of documentation to be undertaken to check if the provision of the care plan to the patient / relative / carer is being recorded in line with trust expectations / standards. Local Ownership by Ward Managers



Acting Head of Inpatient Service Ward Managers

April 2017 Clinical Audit on documentation KPI Spot Checks EBE Feedback

Documentation evidences copies of care plans have been provided to patients / relatives / carers

Documentation has been reviewed to ensure this evidence is captured Checks are built into the monthly documentation audit completed by deputy ward managers - this is monitored via the clinical audit team Trust support visits highlighted some concerns about documentation where a care plan has been offered but refused Discussed at Inpatient Service Line meeting Allocated for local ownership at ward level Assurances currently being received from each award area

Links to Quality Priority “Person Centred Care Planning”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




7 To ensure that patient activities are planned for the weekends (Source Quality Report - Page 12) (Acute Wards Report page 12 Previously identified concern from Feb 2016 CQC Report relating to activity on wards

To undertake a review of current activity provided across all inpatient areas To progress the therapeutic day work to ensure best practice, consistency and scope capacity to agree and implement a suitable 7 day programme.



Clinical Quality Improvement Manager Senior OT Lead Ward Managers

August 2017 Rota of available activity EBE Feedback Patient feedback Care plans Increased activity

7 day programme of activity in place across all inpatient areas

Ward activities in place across inpatient areas – but no agreed consistency Therapeutic day focus group being established Trust support visit identified good practice and improvement but inconsistency across areas remains Therapeutic Day Meetings have commenced, lead identified

N/A


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




8 To ensure that information is provided in easy read format to meet the need of patients with severe cognitive impairment. (Source Quality Report - Page 12) (Acute Wards Report page 12

To review all current patient leaflets and seek support from appropriate experts by experience to address required format



Service Experience Officer

September 2017

EBE reports to Q&S Revised Leaflets

Relevant leaflets available in a number of formats to meet patients’ needs

The Trust has a suite of patient leaflets that will require reviewing to ensure it meets the needs of all patients. Leaflets are available in different languages


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




9 To ensure patients receive crisis plans in addition to care plans. (Source Quality Report - Page 12) (Crisis and HBPOS Report page 10)

To review

current crisis information that

is included within care plans

and given to patients

Seeking to gain example formats from other Trust

via CQC engagement

manager

To develop electronic

version of crisis plan

Quality and Safety


Clinical Process Manager

October 2017 Robust documentation to address crisis plan

Crisis plans provided to all patients

Clarification is required in relation to this action Awaiting CQC feedback

Linked to Quality Priority “person centred care/care planning”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




10 The provider should have consideration for patient’s privacy and dignity by ensuring that patients are able to lock the toilet door in the Health Base Place of Safety suite. (Source Quality Report - Page 13) (Crisis and HBPOS Report page 10)

Reviewing National Standards for 136 suites to determine environmental requirements To undertake a review of the 136 suite against requirements To make alterations to environment to ensure suite meets the needs of the requirements To undertake spot checks of environment on an on-going basis

Health and Safety Committee


Head of Social Care Head of Estates and Technical Services H&S Lead Acting Head of Inpatient Service

July 2017 Spot checks on environment against national standards

Compliance with National requirements No reported incidents

Risk mitigations currently in place to protect privacy and dignity Spot checks to be undertaken June 2017


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




11 To ensure that people who use crisis services have access to psychology based therapies (Source Quality Report - Page 13) (Crisis and HBPOS Report page 10)

Review of psychology based therapies is being undertaken to ensure pathways for patients using CRHT are developed

Quality and Safety


Clinical Development Director / Acting Associate Director of Operations Commissioner Liaison Manager

August 2017

To be determined Psychological therapies offered as part of CRHT interventions

Current review of home treatment being undertaken to scope National required standards and therapeutic intervention required to meet these Review of PT hub currently underway

N/A Links to Quality Priority “Refocus / Recovery model”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




12 To ensure that staff are aware of the operational protocol to support the introduction of cardio metabolic risk assessment (Source Quality Report - Page 13) (Source Community Older People Report - Page 10)

To review current cardio metabolic risk assessment processes To amend if required to meet national standards To communicate requirements and roles and responsibilities to staff To undertake an audit on completion of the quality of care provided against requirements / risk assessments

Quality and Safety Committee with input from Physical health steering group and medicines management committee

Acting Director of Nursing Mark Weaver Kate Gingell

Chief Pharmacist Head of Community Services Clinical Director of Community Services

September 2017

Report to Q&S Committee Audit results via clinical audit and effectiveness committee

All staff aware and adhering to cardio metabolic risk assessment requirements

Discussed at inpatients service line meeting and form sent back out to all managers to ensure that they are part of the initial clinical documentation. Inpatient documentation audit is in the process of being updated to incorporate checks around this.


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




13 To ensure that staff undertake personal safety training tailored to the potential risks of the services patient group (Source Quality Report - Page 13) (Source Community Older People Report - Page 10)

To review staff training records to determine the number of staff who have received and who require training To review training content to ensure it is specific to staff groups and make amendments as required To deliver training to all staff requiring the training To ensure ESR appropriate captures reports and monitors compliance per service line

Workforce Committee


Clinical Trainer Senior Workforce Development Manager

August 2017 ESR Training records Training content

Low levels of incidents All staff who require training have had training

System and process in place regarding training. Training sessions available for staff to attend. Forms part of essential training requirements

N/A


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




14 The Trust should provide education on physical health assessment to support the recognition of physical health problems (Source Community Older People Report - Page 10) Previously identified concern from Feb 2016 CQC Report

To review physical health training packages and provision to staff To identify staff requiring physical health training To deliver training to identified staff To update ESR and produce regular training reports

Physical Health Steering Group


Clinical Quality Improvement Manager Senior Workforce Development Manager

September 2017

ESR Constancy of staff knowledge relating to physical healthcare requirements

Physical health Steering group in place Training needs analysis required Staff have received training and physical healthcare is being provided where required Trust support visits did not highlight any concerns re physical health monitoring

Links to Quality Priority Person Centered Care Planning”


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




15 To ensure that staff manage medicines properly and safely and that the system for recording and dispensing of controlled drugs is not complicated (Acute Wards Report page 12 Previously identified concern from Feb 2016 CQC Report

To review the consistency across all areas of the use of the controlled drug processes

Medicines Management Committee

Joint Medical Directors

Chief Pharmacist

July 2017 Via spot checks on processes of controlled drugs and reports to medicines management committee

Consistent process in place for the dispensing of controlled drugs

A review was undertaken in 2016 - further work to ensure consistency across all areas required to be undertaken Trust support visits gave extremely positive feedback in relation to this area Controlled drugs processes now well embedded

N/A


Ref ID



Exec Lead

Lead for action


Date


Monitoring Method




16 Carried over from February 2016 Action plan The provider should ensure caseload levels are manageable allowing staff to effectively care for Patient’s in CRS.

To agree and develop a case load management policy.

Quality & Safety Committee

Wendy Pugh

Clinical Process Manager Associate Director of Operations

August 2017 Minutes of Clinical Process Group. Clinical audit reports.

Ratified policy and procedures for managing caseloads embedded across the CRS service line. Audit outcomes relating to adherence to policy and demonstrating appropriate caseload levels across CRS.

Pilot stage is now complete. Feedback on the whole has been reported to be positive. Cardiff University in the process of seeking advice regarding sharing of this tool. A Trust Policy on caseload management and supervision is in the process of being constructed. Awaiting confirmation of expected completion date. Currently in process of trial within the Trust. and developing Implementation Plan.




Enclosure: 24

Report Title: Quality Improvement Priorities and CQUIN Update -

Q4 2016/17 Accountable Director: Rosie Musson – Interim Director of Nursing

Rupert Davies – Director of Finance, Performance and IM&T Author (name & title): Rosie Musson – Interim Director of Nursing Purpose of the report: The purpose of presenting this report to the Board is to provide a quarterly

update on: • End of year progress against Trust Quality Improvement Priorities

2016/17 by exception • End of year Progress against CQUINs by exception • Identify risks to delivery and mitigations.


Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report Quality & Safety Committee through receipt and recommendation of the Quality Account Key points or recommendations from Committee or Group: Any comments will be reflected in the Committee Chair’s report. Strategic Objective(s) to which this paper relates:



Leadership culture




Quality Impact Assessment Domain Comment Patient Safety Aims to improve patient safety Patient Experience Clinical Effectiveness / Outcomes Workforce Experience – Efficiency & Productivity

Continuous Improvement in the Quality of Care Promote continuous Quality Improvement The CQC domains that this report relates to are:

Please give brief details: (Improvements / Risks to current position)

Caring

CQUINs and Quality Improvement priorities support all CQC domains. Risks identified for individual projects Responsive

Effective Well-led Safe

Enc 24 Q4 CQUIN and QIP for TB Page 1 of 8

Title Quality Improvement Priorities and CQUIN Update -

Q4 2016/17 Introduction The purpose of this report is to provide the Board with a quarterly update by exception on:

• End of year progress against Trust Quality Improvement Priorities 2016/17 • End of year progress against CQUINs 2016/17 • Identified risks and mitigations to delivery, which will be taken forward into

2017/18 Where appropriate recommend risks to the Finance and Performance Committee in terms of delivery of CQUINs and Quality Improvement Priorities Executive Summary of key points, issues, financial impact and risks End of year progress regarding the Trusts quality improvement priorities for 2016/17 have been included in the Trusts Quality Account. Quality Improvement Priorities All quality improvement priorities made progress, however: Smoking Cessation Smoking Cessation has continued forward as a priority for 2017/18. The project proved to be complex and requires further work to embed in clinical services and also to explore the costs associated with implementation. A report will be presented to MEXT later in the summer for consideration from which further work is required to scope the cost implications. Opportunities are being explored to work with partners in the delivery of smoking cessation. Improving the quality of clinical documentation The Trust acknowledges it has further improvements to make in the quality of clinical records. It is proposed that both person centred care planning and record keeping remain a key focus the Trust in 2017/18. This is cross referenced with the CQC action plan. CQUINs The Trust during 2016/17 worked to deliver the prescribed CQUINs. In this year there was a mixture of national and locally agreed CQUINs. The majority of CQUINs have been delivered with the exception of: CQUIN- Improving physical healthcare to reduce mortality in people with severe mental illness The physical health CQUIN part 3a continued to be a risk for the Trust in terms of sufficient achievement against the requirements of the CQUIN for cardio metabolic


risk factor recording. This relates to both community and inpatient services. The results received from the Royal College of Psychiatrists indicate that we will receive 25% payment for inpatients service but nothing for community services. A rapid improvement plan is in place for 2017/18 as this continues to be a CQUIN with higher thresholds for the coming year. CQUIN- Improving health and wellbeing of NHS staff Part 1C of the health and wellbeing for staff CQUIN did not reach the required target of 75% uptake of flu vaccinations by frontline staff, however there was a significant increase in uptake from the previous year. A robust plan is in place for 2017/18 which included working with partners and optimizing peer vaccinators. Financial Impact The financial income is still to be concluded as certain CQUIN results were only released mid-June following the election process. Meetings are scheduled with commissioners in July to review the results and determine the end of year position. Risk Assessment The risks identified are listed in the individual project plans this includes risks surrounding failure to achieve full requirements of CQUIN milestones. Recommendation Trust Board to note the progress made in relation to the 2016/17 Quality Improvement Priorities and CQUINs and note the reported exceptions.


CQUIN & Quality Improvement Overview 2016/17

1. Q4 End of year exception report This section provides an overview report of CQUINs and Quality Improvement Priorities. All projects have made progress and where risks to project delivery have been escalated project managers are putting in place risk mitigations plans. Table 1: Overall Project Risk Score (CQUINs)

CQUIN Exception Project RAG rating

Total Value Dudley

Total Value Walsall

1.Improving physical healthcare to reduce mortality in people with severe mental illness

3a The audit results have been received from the Royal College of Psychiatrists which indicate that we will receive 25% payment for inpatients service and 0% for community services. A rapid improvement plan is in place for 2017/18 as this continues to be a CQUIN with higher thresholds for the coming year. In particular focus will be on cardio metabolic monitoring and delivering brief interventions.

£69,146 £66,332 Enc 24 Q4 CQUIN and QIP for TB Page 4 of 8

Table 1: Overall Project Risk Score (CQUINs) – Cont’d

CQUIN Exception Project RAG rating

Total Value Dudley

Total Value Walsall

2.Improving health and wellbeing of NHS staff

Although significant improvement in uptake from previous year the Trust failed to achieve the required 75% uptake of flu vaccinations by frontline staff (CQUIN part 1c) Plans in place for 2017/18 to improve uptake.

£207,439 £198,995 3.Medicines management

On target

£69,146 £132,663 4.Voluntry sector working (Walsall)

On target

£0 £132,663 5.Dudley and Walsall Recovery Outcomes Measure(DWROM) (Walsall)

On target

£0 £132,663 6.Mental Health MDT pilot(Dudley)

On target £207,439 £0

7.Avoidable Mental Health Act Admissions and standardising care plans

On target

£69,146 £0 8.Johns Campaign (Dudley)

On target

£69,146 £0


Table 2: End of year exception report Quality Improvement Priority

Exception Project RAG rating

1.Smoking Cessation

MEXT overseeing project. Full business plan developed which will be presented to MEXT in April. Further work is required to scope costings. Project rated amber as uncertainties relating to complexity of delivery including cost implications. The project at the end of the year was rated as AMBER and has continued as Trust priority for 2017/18

2.Dementia Care Initiative

During 2016/17 the Trust has continued to focus on improving dementia care in line with emerging best practice standards. Key quality improvement initiatives have included;

• Formation of Dementia Steering Group led by the Head of Service to oversee workplan.

• Implementation of Dementia Care Mapping (DCM) on dementia inpatient wards. DCM is an evidenced based observational tool. It usually involves one or two trained mappers sitting in areas such as a lounge or dining area and observing what happens to people with dementia over the course of a typical day. A map of care is then produced against best practice standards. These enable improvement to be made. A programme of remapping is in place to enable on-going quality improvement. The Trust has now trained 6 dementia care mappers.

• Mental health Nurse practitioner for Care Homes has started to introduce Dementia care mapping in care homes as a quality improvement tool. Implementation of enhanced dementia training programme for inpatient staff.

Improvements made to the environments of both dementia care wards in line with national best practice standard for dementia friendly environments. This has included improved dementia friendly signage, sensory materials, lighting, sensory room.

3.Improving the quality of our clinical documentation

The Trust continually improves the quality of clinical documentation. During 2016/17 the Trust has;

• Strengthened its approach to person centred care planning through the introduction of newly published national best practice standards by the Care Coordination Association on Person Centred Care Planning

• Introduced a revised rolling programme of clinical audit to monitor and improve standards

• Professional Nurse Forum held a targeted spotlight session on record keeping

• Amended inpatient paperwork to enhance person centred approach to care planning

The Trust acknowledges it has further improvements to make the quality of clinical records, which will be enhanced by the introduction of a Trust wide electronic patient record. It is proposed that both person centred care planning and record keeping remain a key focus the Trust in 2017/18.


Table 2: End of year exception report - Cont’d Quality Improvement Priority


4.Demistyfying care pathways

The Trust has continued to streamline pathways and processes to support the patient’s journey through their care. During 2016/17 this has included:- Mental Health Assessment Service

• Bringing together Crisis, Urgent Care and Early Access into one 24/7 service to provide a seamless service with standardisation across the whole team and time span Simplified pathways for both referrer and patients to navigate

• Introducing a single point of entry for routine referrals through primary care mental health

• Separating Crisis from Home Treatment to provide clarity on roles and functions

Home Treatment • Aligning Home Treatment with the in-patient wards so that it

truly becomes the ward in the community • Work is in progress to clarify and strengthen the gate

keeping function and provide in-reach and timely step down • Working with commissioners to identify alternatives to

admission • Pathways and interface with a number of teams is being

reviewed and developed as a part of this programme of work Outpatients

• A review of outpatients has taken place and work is now in progress to implement a more efficient and effective service that promotes recovery, partnership working with primary care and standardisation across services. This includes developing a set of standards which includes discharge criteria. An operational policy will also be developed and implemented

Older Adult Services • Developing alternatives to admission such as crisis and

home treatment and a reduced reliance on beds • A review of pathways, particularly out of hours has been a

feature of this work with the older adult teams aligning with the adult service pathways


Table 2: End of year exception report – Cont’d Quality Improvement Priority


5.Improving the service experience of our recovery pathways in the community

• Current processes on communication and appointments have been reviewed and discussions are in progress to identify potential and actual blockers and make improvements

• Both Dudley and Walsall CCGs are supporting the Trust in developing relationships with primary care to overcome obstacles to recovery and discharging patients back to primary care

• Mental Health as part of the wider Multi-Disciplinary Teams are being piloted in Dudley with GPs and are due to be rolled out across all GPs. This provides a forum and an interface between primary and secondary care to help GPs manage patients in primary care and help Consultants to discharge patients back to primary care

• Work has commenced with the Community Recovery Service teams to review their role, function, and capacity to enable an increased focus on patients who have complex needs. Pathways and interfaces with others teams, both internally and externally are being reviewed with an increasing focus on shared care with primary care and the development of protocols

• Discharge criteria has been developed to assist staff in decision making

• Primary care mental health have been in-reaching into outpatients to review patients on clusters 1-3 which are for people with milder mental health problems, to offer treatments in IAPT (Improving Access to Psychological Therapies) or help facilitate discharge to primary care if appropriate




Enclosure: 25

Report Title:

Director of Operations Report


Lesley Writtle, Interim Director of Operations


Lesley Writtle, Interim Director of Operations James Parker, Commissioner Liaison Manager

Purpose of the report: To update the Trust Board on key issues pertaining to service

delivery in the directorate of operations.


Decision / Approval

Gain assurance

Discussion

Information


Committee: None


N/A




Leadership culture






Caring

Service delivery issues relate to all aspects of the CQC domains.


Enc 25 Director of Operations Report July Page 1 of 4

Title Director of Operations Report Introduction The report for the Directorate of Operations aims to update the Board on pertinent issues and challenges relating to operational service delivery. Summary of key points, issues and risks Urgent and Access: Early Access Service (EAS) Mental Health Assessment Service Crisis Resolution teams Psychiatric Liaison and Urgent Care Street Triage Section 136 Suites

Early Intervention: Child and Adolescent MH Services, including i-CAMHS Eating Disorder services Regional Deaf CAMHS service Primary MH Services, including IAPT Early Intervention in Psychosis teams

Community: Community Recovery Services Employment Services Psychological Therapies ‘Hub’ Community MH Teams for Older People Older People Day Services Dudley Memory Assessment Service Walsall Carers’ Service TALCS

Inpatients: All Inpatient Services (4 wards for Older People, 5 wards for working age Adults) Home Treatment Services Bed Management

1) Early Intervention Services

• The Dudley Access/ Mental Health Assessment Service went live on the 1st May 2017,

offering a 24 hour access/assessment point for all working age adult referrals. Since the commencement we have seen an increase in referrals into the service, which is being monitored via the ongoing snagging meetings to ascertain the drivers. In addition the service has also successfully launched electronic referrals.

• IAPT: Work is well underway with Mental Health Strategies review and the internal

project group continues to meet on a fortnightly basis. Mental Health Strategies are hosting a modelling workshop on the 13th July where they will present their work to date.

• CAMHs: We are currently in the first phase of Implementing Tier 2 ‘Positive Steps’ in both localities. The service offers low level earlier interventions with the intentions of preventing escalation of mental health issues which in turn should help to reduce the number of crisis cases that come into CAMHS Tier 3. The services will operate within school community settings and will be based external to CAMHS in order to prevent


stigma around mental health for young people. It is expected the services will be fully functional by September 2017.

• CAMHS: National non recurrent monies were made available in October 2016 to

support CAMHS services across the country in reducing waiting times. We have successfully reduced waiting times by up to 75% using this investment and we are now in dialogue with commissioners about sustainability plans to ensure the waiting times do not increase once the non-recurrent monies cease.

2) Community Services

• CRS & CMHT across Walsall remain very concerned with the expected plans for

disintegration of S75 and especially how the case work of the integrated Social Work will be managed with allocation of Care Coordinators. A risk assessment was presented at June Quality and Safety Committee with the outcome being for a risk management plan to be implemented and monitored via the Quality and Safety Committee. Meetings at a senior level between the Trust and the Local Authority are happening urgently to improve dialogue during this very difficult period.

• Dudley Older People Transformation - A 30 Day Public consultation hosted by Dudley

CCG commenced on Monday 19th June for the proposed redesign of Older People Mental Health services. The proposed changes include the commissioning of a dedicated Older People Home Treatment function, coinciding with the de commissioning of the Elderly Day Services, and Inpatient bed reductions. Once the plans are approved it is expected the transformation will take up to 6 months.

3) Inpatient Services

• Head of Service Structure has been agreed and now out to advert to support the head

of service, this will ensure there is adequate capacity to deliver safe services but also to concentrate on CIP delivery and transformation project work.

• The teams working in inpatient services in both boroughs continue to work hard to

manage access and bed pressures on a day-to-day basis. Work has commenced both within the Trust and with BCPFT linked to the STP work stream to look at how we can efficiently manage our beds and prevent out of area placements.

• Bed Occupancy: In May, the Trust bed occupancy including home leave increased to

85% compared to the previous month (83.5%). Adult Services are reporting a 0.7% decrease compared to the previous month at 97.2%, and in Older Adult services, there is a 4.5% increase this month to 69.8%.


• Work continues in reviewing the issues around DTOC; this work will look at how we

ensure timely discharge to ensure service users are cared for in the best environment but it will also put in place a clear standard operating procedure that defines a delay and structures how this should be managed and how concerns should be formally escalated for action. A draft process is expected for July.

• The refurbishment of Clent Ward at Bushey Fields Hospital was completed in June and the ward functioning to its full establishment. The Plans are progressing for the next phase of ward refurbishment on the Bushey Fields site.

Recommendation The Board is asked to note the updates within operation services. Board Action Required To receive the report.




Enclosure: 26

Report Title:

Service Experience Desk Annual Report 2016/17


Mark Axcell, Chief Executive


Julie Adams, Service Experience Lead

Purpose of the report: To present the Trust Board with a draft Service Experience

Desk Report 2016/17 for approval. Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: Quality & Safety

Date reviewed: 14 June 2016 Key points or recommendations from Committee:

The Committee recommended the annual report for approval.




Leadership culture






Caring

Listening to feedback of our services and responding appropriately, providing channels for service users, carers and stakeholders to share their views with us

Responsive

Feedback is timely and appropriate, actions are taken to address issues

Effective

Investigations and reviews are thorough and balanced. This report is considered as part of each service line’s quarterly performance review

Well-led

Provides information to Board and its committees in order to support effective action and decision making about service experience feedback

Safe

Triangulation with Safeguarding and serious incidents supports safe service delivery and resolution

Enc 26 SED Annual Report front sheet TBPage 1 of 2

Title Service Experience Desk Annual Report 2016/17

Introduction This report aims to provide the Trust Board with a draft Service Experience Desk Annual Report 2016/17. Summary of key points, issues and risks The annual report gives details about: • The Trust vision, values, strategy, strategic aims and services and how they relate to service

experience. • Service Experience Activity • The full picture of service experience • The key achievements 2016/17 • The priorities for 2017/18

Further detail (if required) Please see the appended Service Experience Desk Annual Report 2016/17. Recommendation The Board receives the annual report for discussion and approval. Board action required To approve the Annual Report.

Enc 26 SED Annual Report front sheet TBPage 2 of 2

Service Experience Desk Annual Report 2016/17 (Incorporating Complaints, Compliments and PALs)

Dudley and Walsall Mental Health Partnership NHS Trust Service Experience Desk Annual Report 2016/17 1

Contents

1 INTRODUCTION ........................................................................................................... 3 1.1 CHAIR’S AND CHIEF EXECUTIVE’S FOREWORD .................................................................... 3 2 ABOUT THE TRUST ..................................................................................................... 4 2.1 OUR VISION ..................................................................................................................... 4 2.2 OUR VALUES ................................................................................................................... 5 2.3 OUR STRATEGY ............................................................................................................... 5 2.4 OUR SERVICES ................................................................................................................ 7 3 SERVICE EXPERIENCE DESK ACTIVITY ................................................................... 8 3.1 CELEBRATING POSITIVE FEEDBACK ................................................................................. 10 3.2 COMPLAINTS MANAGEMENT ............................................................................................ 11 3.3 OUTCOME OF COMPLAINTS ............................................................................................. 15 3.4 LEARNING FROM FEEDBACK ............................................................................................ 15 4 SERVICE EXPERIENCE - THE FULL PICTURE ........................................................ 16 5 KEY ACHIEVEMENTS 2016/17 .................................................................................. 16 6 PRIORITIES FOR 2017/18 .......................................................................................... 17 7 JARGON BUSTER ......................................................................................................... 17


1 Introduction

1.1 Chair’s and Chief Executive’s Foreword

Welcome to the Service Experience Desk annual report from Dudley and Walsall Mental Health Partnership NHS Trust. As a provider of services, we are committed to ensuring that representatives of those people who use our services and their carers are fully integrated within our decision-making and governance structures. On a day-to-day basis, we work closely with a wide range of Service User and Carer organisations across the two boroughs, seeking their views and ensuring their participation in the planning and delivery of services. Patient knowledge and experience are essential for understanding how best to improve care. The very best user and carer involvement harnesses a passion for making things better and over the past year, we have made enormous progress with implementing and expanding our involvement strategy. Our commitment to putting service users and carers at the heart of everything we do is demonstrated by the way that service user and carer involvement is taken into consideration at the forefront of new projects, initiatives and developments. We try to focus on the things that matter the most for patients, communities and staff and emphasise a culture of genuine engagement, involvement and transparency. The contents of this report specifically meet the requirements set out for Complaints Annual Reports in section 18 of the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. The requirements state that the report should specify:

• the number of complaints which the responsible body received • the number of complaints which the responsible body decided were well-founded • the number of complaints which the responsible body has been informed have been

referred to • the Health Service Commissioner to consider under the 1993 Act; or • the Local Commissioner to consider under the Local Government Act 1974

And the report should summarise:

• the subject matter of complaints that the responsible body received • any matters of general importance arising out of those complaints, or the way in

which the complaints were handled • any matters where action has been or is to be taken to improve services as a

consequence of those complaints

Ben Reid – Chair Mark Axcell – Chief Executive


2 About the Trust The Trust is a multi-site provider (26 sites) serving the Black Country boroughs of Dudley and Walsall within the West Midlands. The Trust’s headquarters are situated in Dudley, approximately 10 miles north-west of Birmingham. The Black Country region demonstrates cultural, economic and educational diversity. Walsall, along with Sandwell and Wolverhampton, experience high levels of multiple deprivation. Since formation, the Trust has made significant progress in the development of the organisation, engaging with its communities and taking stock of service quality and performance. We are proud of: • Being a small and flexible organisation, respond to change and challenge, quickly and

effectively • Openness and transparency • Robust relationships with commissioners and excellent local health economy

knowledge • Reputation for good service quality and governance • Good engagement with service users, carers, agencies and community groups • Consistent high performance • Successful integration of two culturally and operationally different services Figure 1

Statistic 2016/17

Population Served Dudley – 314,000; Walsall – 272,000

Total Employees Health Staff: 1,088; Social Care Staff: 92

Number of Sites 26

Total Inpatient Beds 177

Number of Main Commissioners 2

Total Income £66.3m

CCG Income from activities £59.7m (90%)

Income from non-healthcare sources 7.41%

Service User activities 349,895

Total Outpatient Attendances 17,812

Total Inpatients Treated 1,294

No. of patients referred to services by their GP 33,708

2.1 Our Vision The Trust’s vision is one of a recovery oriented service. The vision, encapsulating the concept of the benefits arising from a single mental health trust for the populations of Dudley and Walsall, is shown below: Dudley and Walsall Mental Health Partnership NHS Trust Service Experience Desk Annual Report 2016/17 4

The Trust’s vision has been guided by national, regional and local intelligence and strategies where there is a growing emphasis on the well-being of the population and a focus on prevention, together with early detection and intervention. 2.2 Our Values Our values are the essence of our identity. They describe what we are and what we stand for. In 2015/16 we refreshed our values in close partnership with staff. This was a process that engaged all staff in revisiting what they felt were important values for us and that would shape our guiding principles and underpin the way we work. In 2016/17 we embedded these values through our behavioural framework that is used in recruitment, appraisals and supervision. The framework describes the behaviour.

Figure 2 Our Values 2.3 Our Strategy The Trust has a clear, focused strategy that underpins the delivery of mental health services for the populations of Dudley and Walsall. In protecting its long term viability, the Trust explores opportunities that support the delivery of mental health services across the wider health economy, building on the skills of the Trust and meeting unmet or emerging needs. In developing its strategy, the Board stated its commitment to be flexible in its on-going consideration of the scope of services it provides in order to reflect the genuine needs of service users and carers and delivery of the Five Year Forward View (5YFV). The Trust’s strategy has three overarching domains that together, achieve the Trust’s vision:

1. Transform services to improve the patient experience and the quality of services

2. Become the preferred provider of prevention and recovery services for mental health and wellbeing within the Black Country and beyond

3. Develop the organisational culture and capabilities to support high quality service delivery

Better Together - delivering flexible, high-quality, evidence-based services to enable people to achieve recovery.


2.3.1 Strategic Partnerships The Trust has been successful in embedding a robust reputation across the local health economy and beyond through proactive engagement in a number of strategic partnerships. These partnerships play a fundamental role in our future organisational development and form the basis on which we will support new models of care and long terms sustainability of local services. In particular in 2016/17, we approved an outline business case to explore how we integrate services with those of Birmingham Community Healthcare NHS Foundation Trust (BCHT) and Black Country Partnership NHS Foundation Trust (BCP). This was following a wide range of engagement events with our stakeholders and staff. In 2017/18 our Board will receive a full business case. They are described in a little more detail below: Figure 1 Strategic Partnerships

Transforming Care Together Partnership - a partnership agreement between the Trust, Birmingham Community Healthcare NHS Foundation Trust and Black Country Partnership NHS Foundation Trust to develop an integrated model of care that supports local service delivery and long-term sustainability Dudley and Walsall Mental Health Partnership NHS Trust Service Experience Desk Annual Report 2016/17 6

Mental Health Alliance for Excellence, Resilience, Innovation and Training (MERIT) Vanguard – an Acute Care Collaboration to develop new ways of working in mental health and reducing variation in care, involving the Trust, Black Country Partnership NHS Foundation Trust, Coventry and Warwickshire Partnership Trust and Birmingham and Solihull Mental Health NHS Foundation Trust All together better Vanguard - a multi-speciality community provider (MCP) to develop new ways of working in community care in Dudley involving the Trust, Dudley Group of Hospitals NHS Foundation Trust, Dudley CCG, Dudley MBC, Black Country Partnership NHS Foundation Trust and Dudley Community Voluntary Sector Walsall Together- To improve the health of the people of Walsall through the establishment of an integrated health and social care system for the borough. The integrated system will develop health and social care services to meet needs of people by providing more cohesive and person centred support that maximises independence and well-being. Local Authority Partnerships - Section 75 arrangements in Dudley and Walsall to support close partnership working and seconded social care staff within the Trust Sustainability and Transformation Plan - we are partners in the Black Country Sustainability and Transformation footprint covering commissioner and provider organisations in Dudley, Walsall, Wolverhampton and Sandwell and West Birmingham. The aim of this plan is to address on a larger scale the gaps in health and well-being, quality and care and finance and efficiency. 2.4 Our Services Mental health conditions are very common with 1 in 4 people experiencing some kind of mental health problem in the course of a year. These are split into two categories; “common mental health problems”, which include conditions such as depression and anxiety, and “severe and enduring mental health problems” such as schizophrenia and bipolar disorder. The Trust provides a full range of mental health treatment and rehabilitation services that manage both categories of mental health conditions. The Trust’s range of services spans GP based primary care counselling and psychological therapies for common mental health problems through to the treatment and care of people detained under the Mental Health Act. Core services are provided predominately to Dudley and Walsall, but also to neighbouring Trusts in Worcestershire, Staffordshire, Birmingham and Warwickshire. We provide: • Community mental health services for children, adults & older people • Inpatient services for adults and older people • Primary Care Mental Health services (including IAPT) • Mental Health Social Care Services (via local authority partnerships) • Psychological Therapies • Employment, education and training support for people with mental health problems • Specialist Deaf CAMHS (national hub) Dudley and Walsall Mental Health Partnership NHS Trust Service Experience Desk Annual Report 2016/17 7

3 Service Experience Desk Activity The Trust’s Service Experience Desk (SED) is the central point of contact for all concerns and enquiries whether these are formal or informal, complaints, compliments or requests for information. The Trust welcomes feedback about its services and considers this a valuable source of insight into the quality of our services. Being a patient, relative or carer can be a difficult, confusing and stressful time and the Service Experience Desk is there to offer advice, help and support. During the period April 2016 to March 2017, we received a total of 150 formal complaints, 270 concerns, 411 compliments and handled 954 new cases. This includes complaints, concerns, compliments, suggestions and requests for information. This feedback comes from service users, carers or their representatives and from other organisations such as commissioners or MPs. Figure 2 SED Activity by Type Case type 2016/17 2015/16 2014/15

Compliments 411 321 375

Informal concerns 270 215 208

Informal enquiries 114 107 89

Formal complaints 150 139 127

Suggestions 9 10 4 Figure 2 above shows SED activity type for the Trust for 2016/17 along with the previous two years. The Trust is structured into four operational service lines as shown in figure 3: Inpatient, Early Intervention, Community, Urgent Care and Access. The service line portfolios are shown below. Contact through SED is proportionate to the size of the service and the nature of the service users in those services, for example, the Trust finds that older adults and young people are less likely to complain than working age adults. The Trust reports SED activity by Service Line and this is discussed at Service Line Meetings which a member of the team attends and is scrutinised at the Quality and Safety Committee and quarterly performance reviews alongside all other performance data. The service lines are shown below in figure 3. Figure 3 Our Services

Early Intervention Services

Community Services

Urgent Care and Access Services Inpatient Services


Children & Adolescent Mental Health including Home Treatment

Deaf Child and Family Mental Health

Early Intervention in Psychosis

Primary Care Mental Health

Community Recovery Service Teams (CRS)

Therapeutic Hub

Liaison and Diversion

Employment and Vocational services

Carers service

ASD assessment and diagnosis

Memory Service

Outpatients

Community Mental Health Teams

Day Services

Early Access service (EAS)

Crisis Resolution

Psychiatric Liaison

Urgent Care Centre

Street Triage

Adult inpatient wards

Older adult inpatient wards

Home Treatment

Place of Safety (136 Suite)

Figure 4 SED Feedback Received 2016/17

Figure 4 above shows the number of complaints, concerns and compliments received by quarter during the year 2016/17 for the four service lines. The number of complaints received is relatively small compared to the number of patients we see and treat each year. Figure 5 SED activity by type


The chart above shows SED activity by type for the four service lines. It is pleasing to see that compliments continue to be the highest type of activity that the Trust receives. 3.1 Celebrating Positive Feedback Compliments are the largest category of activity that the Trust receives. Over the last twelve months we are very pleased to say that we have received 411 compliments from patients/families/carers who have accessed our services, highlighting cases where the quality of our services has been recognised and appreciated. The detail of the compliments received highlights that the Trust staff provide quality care and are considered to be extremely helpful, supportive, kind and caring. SED shares this feedback with staff through our feature “On a Happy Note” which highlights the positive comments made by service users about their care by posting a selection of experiences from service users on the Trust intranet every month. Individual members of staff who have received a compliment are praised and receive a “recognise card” from the Chief Executive which is personally signed. Some examples of what people have said about our services are shown below.

The best experience I have ever had in any NHS Mental Health service in the UK. I have been attending the feeling better group, it has helped me with my anxiety. I have enjoyed the course thoroughly. Also Kings Hill centre is clean and have lovely staff who are very helpful and understanding. I cannot thank them enough for their help There are two members of staff who have been visiting me weekly for over a year. They were always kind and considerate and I feel supported. I would find it difficult if I did not receive this support.


Just wanted to thank you from the bottom of our hearts for all your efforts on my daughter’s behalf. We were all quite overwhelmed at the review and I felt that we did not fully express our appreciation to you for the work that you have done. My daughter knows I am writing to you so please accept thanks from all of us for your care and diligence. A member of staff has always shown professionalism, but more importantly seems to genuinely care about my mom. She is always positive and speaks in a caring way. She is also always open to my questioning and answers as honestly as she can. She has been a point of contact for us during a worrying and difficult time, we feel she is supporting us as a family unit. I would like to thank you and the team for all the attention and help I have received. I hope and pray I will continue to improve. The staff in the hospital were all so pleasant and helpful and I thank them for their hard work and dedication. I am grateful for the care I have received. Not enough praise is given to such a dedicated team. Since this member of staff was assigned to my case she has been nothing but supportive and helpful right from the start. She reacted quickly to my situation and with her excellent care and assistance it has been a tower of strength, for which I will always be grateful. I took to this member of staff immediately and always looked forward to her visits. She is the most sympathetic, and is a good listener. I found I could talk to her easily and frankly. Her visits extremely helped me We as a family cannot praise Holyrood Ward at Bushy Fields Hospital highly enough. All of the staff provided excellent care for my father, they established his potential for aggression and treated him and us with complete dignity. The staff remained professional at all times but also became a friend to us in our times of despair. Nothing was ever too much trouble for anyone and we always felt extremely confident that our dad was receiving excellent care. Well done to all I suffered so bad mentally but with patience I owe my life to this doctor. She was the one who got all my medicines right. Patiently she persevered. I could live instead of just exist I would like to thank you for all of the support you have given me over the last few months in helping me overcome the anxiety that I have been experiencing for a number of years. You clearly have a wealth of knowledge and experience and I feel very lucky to have had you as my therapist.

3.2 Complaints Management Despite our focus on quality, we recognise that sometimes people’s experience of our services is not as positive as we would hope.


In October 2007, the Health Service Ombudsman published ‘Principles for Remedy’ as an overall good practice guide for public bodies in dealing with complaints. Our complaints policy is based around these principles which are:

1 Getting it right 2 Being customer focused 3 Being open and accountable 4 Acting fairly and proportionately 5 Putting things right 6 Seeking continuous improvement

In response to the Francis inquiry into the failings of Mid Staffordshire NHS Foundation Trust, the PHSO, LGO and Healthwatch England committed to developing a user-led “vision” of the complaints system and produced a report entitled “My Expectations for Raising Concerns”. This report presents the vision/framework that was created and the findings of the primary research with patients, service users, frontline staff and stakeholders that lay behind it. There are five main areas to the framework which the Trust aims to follow and achieve which has been incorporated into the SED induction programme, complaints training and promoted throughout the Trust. 3.2.1 Number of Formal Complaints Received During the period April 2016 to March 2017, we received a total of 150 formal complaints Trust wide, 146 of which related to our four main service lines, 39 were withdrawn or closed. At the time of writing this report we had responded to 58 cases within the target timescale of 45 working days and 9 cases remained open. Figure 6 2016/17 Complaints and Concerns Summary for the 4 service lines

Informal Concerns Formal Complaints PHSO

Community 68 52 2

Early Intervention 36 17 0

Inpatient 49 51 0

Urgent care & access 52 26 2

Total 205 146 4

3.2.2 Complaints referred to the Parliamentary and Health Service Ombudsman

(PHSO) Four notifications were received from the Ombudsman during 2016/17 in relation to formal complaints that had been responded to by the Trust. Two cases were dismissed and no action taken with two cases, one partially upheld and one is awaiting the outcome. The partially upheld case was mainly due to a communication failure and poor record keeping and actions were put in place in order to improve in these areas.

3.2.3 Nature of Complaints and Concerns Received


The charts below show both primary and secondary categories of the complaints and concerns received by the four service lines for the Trust in 2016/17, separating formal from informal concerns. Care and treatment, as with most Trusts, is the highest category of concerns, followed by communication and attitude of staff. Figure 7 Complaints and Concerns by cause group

Figure 8 Care and treatment drill down


The chart above shows care and treatment breakdown (clinical), highlighting that inadequate support and medication issues were the highest clinical concerns. Figure 9 below shows both primary and secondary categories of complaints and concerns received by the Trust in 2016/17. Primary category refers to the main concern raised and secondary categories include any additional concerns. The top 3 categories are care and treatment (clinical), communication and staff attitude. Figure 9 Primary and secondary concerns


3.3 Outcome of Complaints Of the cases investigated and closed, 70% of complaints were upheld or partially upheld. The decision to uphold a case or not is made following a full investigation that involves the scrutiny of notes and records, interviews with staff and service users as appropriate. Figure 10 below summarises this. Figure 10

*Partially upheld outcomes are counted as upheld for KO41 reporting purposes. KO41 is the complaints data reported quarterly to the Department of Health. 3.4 Learning from Feedback The Trust takes an active approach to resolving concerns before they escalate to formal complaints. We also provide feedback to staff about what changes have been made as a result of complaints and concerns. We receive essential and valuable feedback through the function of our Service Experience Desk. Service users, carers, staff and others contact the service experience desk for advice, support and to report concerns and complaints directly to us. Over the past twelve months our Expert By Experience service users (EBE’s) have been directly and significantly involved in raising awareness of Trust activities as well as gaining valuable feedback from service users and carers. The team of EBE’s are aligned to special areas of interest, with each EBE bringing different skills and experience to the role. Each of our EBE’s has considerable knowledge and experience of using Trust services and have helped hundreds of service users and carers in various ways, simply by listening to them and representing their interests. Our experts provide the Trust with vital knowledge gained through their experience of using mental health services or caring for someone who has. The work of our EBEs forms a significant part of the Trust’s Service User and Carer Involvement Strategy, which aims to deliver our vision of involving service users and carers in all areas of our work – from policy development, attending board meetings, taking part in the recruitment process to the training of clinicians.

Outcome of Complaints Number

Not upheld 29

Upheld 15

*Partially Upheld 55

Withdrawn/closed 39

On-going 12

TOTAL 150


Here are just a few of the selected actions that have been carried out as a result of feedback from those who use our services, their relatives and carers. Figure 11 Comments and Actions Taken

You Said: We did:

Clients want some calming music in background

Purchased a variety of CDs that will be accessible to all

Patients said they often forgot what food they had ordered the day before and would like to see the

menu on the notice board

Menus now displayed on the notice boards

Patients wanted to know more about medication and treatment options but did not know where to obtain

this information

We produced cards to promote our Medicine Management Team contacts and other useful resources such as the Choice and Medication

website to signpost people to additional support

Patient would like to have a take away night/bring in cooked food by family members

Patients are now allowed takeaways on Saturdays between the hours of 4-8pm. Food must meet a

certain criteria and standard

Patient requested to have the option of relaxation groups at night as well as in the morning

Relaxation and sleep hygiene groups are carried out at night time by ward staff

4 Service Experience - the full picture As well as gathering feedback about our services through SED, the Trust also has a Service Experience Co-ordinator who reports on other forms of service experience feedback, for example:

• Patient Stories for Trust Board • Friends and Family Test (Net Promoter) • National Surveys • Local Surveys (run by teams) • Focus Groups • Ward and service visits by our Experts by Experience, Community Development

Workers and local mental health support groups • Feedback from Trust members

The findings of this work triangulate with SED activity and feeds into our embedding lessons process described in section 3.4.

5 Key Achievements 2016/17 2016/17 was a busy year for the Trust’s Service Experience Desk. As well as efficiently handling around 950 new cases, the team also achieved a number of improvements in how SED operates including:

• Closer monitoring in place to ensure responses to complaints are provided in a reasonable timescale whenever possible


• Increasing complaints training across the Trust and bespoke training sessions arranged for specific needs of teams

• Extending the number of available complaints investigating officers • Improving the detail of the recording of compliments so that we could capture

positive practice more meaningfully • Improving our website in order to make it as easy as possible to find how to make a

complaint • Increasing the number of ways a complaint can be made in order to cater for all

needs

6 Priorities for 2017/18 In 2017/18 the Trust will focus on:

• Further improvements to the embedding lessons processes, actions taken as a result of recommendations and the effectiveness of those actions

• Improving compliance against our complaint response targets • Further promoting and embedding the LGO and Healthwatch vision framework for

complaints

7 Jargon Buster

Term Definition CAMHS Child and Adolescent Mental Health Service.

A multi-agency and multi-disciplinary service specialising in the assessment and treatment of moderate to severe mental health difficulties for children and young people up to the age of 16 years. The service helps with a vast range of problems / concerns including bullying resulting in school refusal, eating disorders, Attention Deficit Hyperactivity Disorder, Autism, Psychosis and Deliberate Self-Harm.

Carers (also known as ‘informal support’)

A person who provides support to a partner, family member, friend or neighbour who is ill, struggling or disabled and could not manage without this help.

CDW Community Development Workers (CDW’s) work in a number of different ways to challenge discrimination and stigma, and to promote mental wellbeing. Their aim is to:-help patients to access mental health services, that are appropriate to need; ensure cultural needs are met when accessing statutory services ; provide a range of self-help materials, that could help with milder forms of anxiety, depression and stress ; sign post service users of community and voluntary groups in area, that could aid recovery ; provide links to agencies, who can help with employment, benefits, child care and education; provide training / workshops regarding mental health, to Black and Minority Ethnic, and Voluntary organisations.

Commissioners / Clinical Commissioning Groups (CCG’s)/

Dudley and Walsall CCGs took over responsibility from Dudley and Walsall Primary Care Trusts in April 2013. CCG’s are run by GPs and are responsible for the purchasing of healthcare for people living in Dudley and Walsall boroughs and to ensure that care services are provided effectively and that they meet the needs of the population. This process is called commissioning.

Complaint An expression of dissatisfaction that requires a response.

Compliment Comments received in writing about the good service received from the Trust.

Corporate Function Services within the Trust that provide support to the clinical teams and services but do not directly provide services to patients.

EBE’s Service users and carers who are Experts by Experience (EBE). Our experts provide the Trust with vital knowledge gained through their experience of using mental health services or caring for someone who has. The work of our EBEs forms a significant part of the Trust’s Service User and Carer Involvement Strategy, which aims to deliver our vision of involving service users and carers in all areas of our work – from policy development or attending board meetings, to the training


of clinicians.

Embedding Lessons Process System through which we ensure we make sustained changes and learn lessons from the

feedback we receive about our services.

KO41 Reporting Process The KO41 data collection is the statutory based mechanism for collating written complaints data about NHS care and treatment, across all NHS organisations in England. This is mandatory and performed on behalf of the Department of Health.

Informal concern A concern raised that can be resolved quickly and does not require a formal response/investigation.

Outcome The outcome in relation to complaints is whether the complaint was upheld, not upheld and partially upheld and what actions were put in place.

PALS The Patient Advice and Liaison Service (PALS) offer confidential advice, support and information on health-related matters. They provide a point of contact for patients, their families and their carers.

PHSO Parliamentary and Health Service Ombudsman

The Parliamentary and Health Service Ombudsman investigates complaints where individuals feel they have been treated unfairly or have received poor service from government departments, other public organisations and the NHS in England.

Primary Care and IAPT Primary Care and Improving Access to Psychological Therapies. This service aims to provide an accessible service for people experiencing mild to moderate mental health problems. Help patients identify the underlying cause of their distress or concern. They offer information and support on a range of issues including; health education and advice, redirection to appropriate services, problem solving advice, self-help advice to raise awareness about common mental health problems and the cause of distress. This service provides an opportunity to talk and to be listened to when experiencing problems.

Primary/Secondary/category of complaint Categories of complaints refers to the specific type/cause of concern raised, for instance

waiting times, staff attitude etc.

Primary categories refers to the main concern raised

Secondary categories, refers to all concerns raised Safeguard System

This is the Trust’s Risk Management database whereby all complaints and concerns are recorded and data extracted.

SED Service Experience Desk.

This is the central point of contact for all concerns, complaints, enquiries, suggestions and compliments. The team are on hand to offer support and guidance to patients, carers and their families when problems may arise.

SED Activity Type Type of issue raised to the Service Experience Desk – Informal concern, formal complaint, compliment, suggestion.

Service Lines Services the Trust provides are grouped into service lines: - . Inpatient, Early Intervention, Community, Urgent Care and Access.

Service user A person who uses our mental health services, whether they are in their own home, in residential care or in hospital. They may also be described as ‘patients’ or ‘clients’.

Specialist Deaf CAMHS The Deaf Child and Adolescent Mental Health Service provides a specialist mental health service for deaf and hearing impaired children with a range of emotional, behavioural and developmental problems.

The team treats children with a mental health condition and either: a severe or profound hearing loss; British Sign Language (BSL) as their preferred/first language; a significant language impairment related to moderate to profound hearing loss.

Trust Generic / non specific Complaints that are not specific to a service line




Enclosure: 27

Report Title:

Review of Board Committees Terms of Reference

Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary

Purpose of the report: As part of good governance all Board Committee Terms of Reference should be reviewed annually. Committee members are asked to review and approve the revised Terms of Reference.

Action required from MExT Decision / Approval

Gain assurance

Discussion

Information


Committee: Quality & Safety Committee on 14 June 2017 Audit Committee on 22 May 2017 Finance & Performance Committee on 26 June 2017 Mental Health Act Scrutiny Committee on 8 June 2017 Workforce Committee on 27 June 2017 MExT on 27 June 2017


All the Committees have reviewed their respective Terms of Reference. The appended Terms of Reference reflect the amendments recommended by the respective Committees.




Leadership culture






Caring Responsive Effective Well-led

The annual review of committee terms of reference by each committee and by the board is part of effective governance.

Safe

Enc 27 BoardCommittee-ReviewTermsOfReference Page 1 of 2

Title Review of Board Committees Terms of Reference Introduction All committees of the Board should review their terms of reference on an annual basis to ensure fitness for purpose. Summary of key points, issues and risks During the annual review of the Committee Terms of Reference they have been considered through the respective Board Committees in May and June 2017. The review and proposed changes to the Terms of Reference should reflect any legislative changes, updated guidance, advice and best practice and they have been updated where appropriate to standardise format and practice across all the Committees. The Terms of Reference of the Committees appended to the report have all been agreed through their respective meetings and have been reviewed in accordance with ‘The Foundations of Good Governance – A compendium of Good Practice, Third Edition’ Further detail The Committee Terms of Reference are attached at Appendices 1 - 6. Recommendation The Board is recommended to approve the Committee Terms of Reference appended. Action required The Committee Terms of Reference are presented to Board for approval.

Enc 27 BoardCommittee-ReviewTermsOfReference Page 2 of 2

Enc 27 BoardCommittee-ReviewTermsOfReference-Appendix1-Q&SCttee-ToR-AgreedQ&S-14June2017.docx

Page 1 of 7

DUDLEY AND WALSALL MENTAL HEALTH NHS PARTNERSHIP TRUST

QUALITY AND SAFETY COMMITTEE

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services the quality of service

user and carer experience and the long term protection of stakeholder interests. Good governance emanates from the Board but pervades the entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial

and organisational aspects of governance and enables key risks to be identified and managed, in both operational and strategic terms.

This committee will therefore ensure that:

The Trust has established a sound framework of clinical governance comprising those processes, systems and controls that enable NHS organisations to demonstrate accountability for

continuously improving the quality of services and safeguarding high standards of care. That arrangements are in place to support staff to deliver safe and quality patient care. That

consultation and involvement by service users, carers and stakeholders effectively informs continuous improvement. That clinical governance, clinical/operational risk management and safeguarding systems and processes are operating effectively, provide robust information and

comply with statutory and regulatory guidance, standards and reporting requirements. That learning from feedback is embedded throughout the organisation. That all aspects of information governance relating to clinical and patient information are in place to meet IG Toolkit standards.

TERMS OF REFERENCE 1. Authority

1.1 The Quality and Safety Committee is constituted as a standing committee of the Trust's board of directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future board of directors meetings.

1.2 The Quality and Safety Committee is authorised by the Board of directors to instruct

professional advisors and request the attendance of individuals and authorities from outside the Trust with relevant experience and expertise if it considers this necessary for or expedient to the exercise of its functions.

1.3 The Quality and Safety Committee is authorised to obtain such internal information as is

necessary and expedient to the fulfilment of its functions. 2. Purpose

2.1 To enable the board to obtain assurance that high standards of care are provided by the Trust and, in particular, that adequate and appropriate governance structures, processes and controls are in place throughout the Trust to:

• Promote safety and excellence in the care and experience of service users and carers.

• Identify, prioritise and manage risk arising from clinical care.

Enc 27 Appendix 1


Page 2 of 7

• Ensure the effective and efficient use of resources through evidence-based clinical practice.

• Protect the health and safety of Trust employees. 3. Membership

3.1 The membership of the Quality and Safety Committee shall consist of:

• A minimum of 2 Non-Executive or Associate Non-Executive Directors who will act as the

Chair and Vice-chair

• Joint Medical Directors

• Chief Executive

• Director of Nursing, Operations and Estates (also the DIPC)

• Director of People and Corporate Development 3.2 The Quality and Safety Committee will be deemed quorate when 4 members are present

including at least one Non-Executive / Associate Non-Executive Director and one Executive Director.

3.3 The Chair will be appointed by the Trust Board.

3.4 For the avoidance of doubt, Trust employees who serve as members of the Quality and

Safety Committee do not do so to represent or advocate for their respective department, division or service area but to act in the interests of the Trust as a whole and as part of the Trust-wide governance structure.

3.5 Core mMembers of the Committee may nominate an appropriate deputy to attend the

committee on their behalf. However, it is expected that any nominated deputy will be fully briefed and have the necessary authority to participate fully in the debate and any subsequent decisions arising.

3.6 Additional members or associates may be co-opted to attend the Committee as necessary.

4. Attendance

4.1 The following participants are required to attend meetings of the Quality and Safety

Committee

• Chief Pharmacist

• Clinical Director Governance and Quality

• Head of GovernanceCompliance and Safety Manager

• Head of Nursing, Quality and Innovation

• Head of Strategic PlanningAssociate Director of Corporate Development

• Trust Safeguarding LeadVulnerable Adults and Childrens Lead

• Deputy Director of Finance and or the Head of Business Intelligence and IM&T as appropriate

4.2 The Trust values the contribution of Experts by Experience to Quality and the importance of

their independent role. Nominated Experts by Experience are encouraged to attend meetings and report to Quality and Safety Committee as regularly as possible.


Page 3 of 7

4.3 Others that may be invited to attend the Committee:

• Service User and Carer Representatives/Governors

• Associate Director of Operations

• Risk and Assurance Facilitator

• Patient Safety Analyst

• Any nominated deputy attending in place of a member of the Quality and Safety Committee.

• Any other person who has been invited to attend a meeting by the Quality and Safety Committee so as to assist in deliberations.

4.4 The Senior Administrator for Clinical Governance, or another administrator within the

Clinical Directorate, will act as secretary. 4.5 Other than as set out in paragraphs 4.1 to 4.4, only members of the Quality and Safety

Committee are entitled to be present at its meetings. 4.6 Members listed at paragraph 3.1 and attendees listed at paragraph 4.1 are, respectively,

required to attend at least 75% of the meetings held annually. 5. Frequency of Meetings

5.1 Meetings shall be held monthly. Additional meetings may be held on an exceptional basis at the request of the Chair or any three members of the Quality and Safety Committee.

6. Duties

In particular, in respect of general governance arrangements:

6.1 To ensure that all statutory elements of clinical governance are adhered to within the Trust.

6.2 To agree Trust-wide clinical governance priorities and give direction to the clinical

governance activities of the Trust’s services, not least by reviewing and approving each service's annual clinical governance, patient safety and quality plan.

6.3 To approve the Trust's annual quality priorities and account before submission to the Board.

6.4 To approve the terms of reference and membership of its reporting sub-committees (as may

be varied from time to time at the discretion of the Quality and Safety Committee) and oversee the work of those sub-committees and working groups, receiving reports from them as specified by the Quality and Safety Committee in the subSub-committees’ Committees’ terms of reference for consideration and action as necessary.

6.5 To consider matters referred to the Quality and Safety Committee by the Board.

6.6 To consider matters referred to the Quality and Safety Committee by its subSub-

committeesCommittees


Page 4 of 7

6.7 To receive and approve the annual clinical audit programme, ensuring that it is approved by the board of directors consistent with the audit needs of the Trust.

6.8 To oversee the Trust’s policies and procedures with respect to the use of clinical data and

patient identifiable information to ensure that this is in accordance with all relevant legislation and guidance including the Caldicott Guidelines and the Data Protection Act 1998.

6.9 To make recommendations to the Audit Committee concerning the annual programme of

internal audit work, to the extent that it applies to matters within these terms of reference. 6.10 To monitor the assessment of compliance, assurance and evidence against the Well Led

Framework 6.11 To review and approve clinical, governance and corporate policies and procedures relevant

to these terms of reference 6.12 To foster clinical governance and quality links with primary care and other stakeholders

including mental health forum members. 6.13 In respect of safety and excellence in patient care, in particular:

• To have overview responsibility for the following outcomes as described by the Care

Quality Commission:

• Outcome 1 – respecting and involving people who use the services; and

• Outcome 7 – safeguarding people who use the services from abuse; 6.14 To agree the annual safety plan and monitor progress.

6.15 To ensure that internal standards are set and monitored, including (without limitation):

• to To commission the setting of standards by the board (e.g. in Trust policies) and

ensure that a mechanism exists for these standards to be monitored

• to To ensure the standards outlined in national service frameworks are implemented and monitored.

• to To ensure the trust Trust complies with NHS Resolution (the operating name of NHS Litigation Authority) standards.

• to To ensure the registration criteria of the Care Quality Commission continue to be met.

• To ensure the Care Quality Commission fundamental standards are implemented and monitored

6.16 To implement an engagement programme with the leaders of clinical services to ensure

regular and constructive scrutiny of activities relating to quality assurance and enhancement.

6.17 To promote within the Trust a culture of open and honest reporting of any situation that may

threaten the quality of patient care in accordance with the trust's policy on reporting issues of concern and monitoring the implementation of that policy.

Deleted: NHSLA


Page 5 of 7

6.18 To oversee processes to ensure the review of patient safety incidents (including near- misses, complaints, claims and Rule 43 coroner reports) from within the trust and wider NHS to identify similarities or trends and areas for focused or organisation-wide learning.

6.19 To identify areas for improvement in respect of incident themes and complaint themes from

the results of national patient survey/SED and ensure appropriate action is taken. 6.20 To oversee the system within the Trust for obtaining and maintaining any licenses relevant

to clinical activity in the Trust, receiving such reports as the Quality and Safety Committee considers necessary.

6.21 To monitor the Trust’s compliance with the fundamental standards of quality and safety of

the Care Quality Commission that are relevant to the Quality and Safety Committee’s area of responsibility, in order to provide relevant assurance to the Board so that the Board may approve the Trust’s annual declaration of compliance and annual governance statement.

6.22 To ensure that quality and governance risks to patients are identified and minimised

through the application of a comprehensive risk management system including, without limitation:

• To ensure that processes are in place to ensure the escalation of patient safety and

quality risks from team and service line risk registers to the corporate risk register and receive reports from the Trust’s risk manager.

• To identify areas of significant clinical risk, suggest priorities and actions to the Board.

• To ensure the Trust incorporates the recommendations from external bodies (e.g. the National Confidential Enquiry into Patient Outcomes and Death or Care Quality Commission, as well as those made internally e.g. in connection with serious incident reports and adverse incident reports) into practice and has mechanisms to monitor their delivery. (Assurance will be provided to the Board).

• To maintain and monitor the Trust’s operational risk management policy

• To assure the Board that those areas of patient safety and quality risk within the Trust are regularly monitored and that effective disaster recovery plans are in place.

• To ensure implementation of the National Patient Safety Agency reporting system.

• To assure the Board that there are processes in place that safeguard children and adults within the Trust.

• To escalate to MExT and/or Audit Committee and/or Board any identified unresolved risks arising within the scope of these terms of reference that require executive action or that pose significant threats to the operation, resources or reputation of the Trust.

6.23 To agree the annual patient experience plan and monitor progress.

6.24 To assure that the Trust has reliable, real time, up-to-date information about what it is like

being a patient experiencing care administered by the Trust, so as to identify areas for improvement and ensure that these improvements are effected.

6.25 In particular, in respect of efficient and effective use of resources through evidence-based

clinical practice:

• To agree the annual quality plan and monitor progress.


Page 6 of 7

• To monitor the impact on the Trust's quality of care of cost improvement programmes and any other significant re-organisations (ensuring that there is a clear process for staff to raise associated concerns and for these to be escalated to the committee) and report any concern relating to an adverse impact on quality to the board of directors.

• To ensure that care is based on evidence of best practice/national guidance.

• To assure that procedures stipulated by professional regulators of chartered practice (i.e. General Medical Council and National Midwifery Council) are in place and performed to a satisfactory standard.

• To ensure that there is an appropriate process in place to monitor and promote compliance across the trust with clinical standards and guidelines including but not limited to NICE guidance.

• To assure the implementation of all new procedures and technologies according to Trust policies.

• To review the implications of confidential enquiry reports for the Trust and to endorse, approve and monitor the internal action plans arising from them.

• To monitor trends in complaints received by the Trust and commission actions in response to adverse trends where appropriate.

• To monitor the development of quality indicators throughout the Trust.

• To generally monitor the extent to which the Trust meets the requirements of commissioners and external regulators.

• To help the Board identify and monitor delivery of quality improvement priorities for the Trust

• To identify and monitor any gaps in the delivery of effective clinical care ensuring progress is made to improve these areas, in all specialties.

• To ensure the research programme and governance framework is implemented and monitored.

• To ensure that there is an appropriate mechanism in place for action to be taken in response to the results of clinical audit and the recommendations of any relevant external reports (e.g. from the Care Quality Commission).

• To ensure that where practice is of high quality, that practice is recognised and propagated across the trust.

• To ensure the Trust is outward-looking and incorporates the recommendations from external bodies into practice with mechanisms to monitor their delivery.

7. Minutes and Reporting

7.1 The minutes of all meetings of Quality and Safety Committee shall be formally recorded. 7.2 The Quality and Safety Committee will report to the full Trust’s bBoard after each meeting.

7.3 The following reports will also be made by the Quality and Safety Committee:

• Quarterly quality report covering all elements of quality (including issues arising from the

minutes of reporting committees and groups);

• Annual clinical governance and quality report including highlighting areas for improvement.

• Twice-yearly updates of compliance with CQC fundamental standards

• Service line clinical governance and quality reports at twice-yearly intervals


Page 7 of 7

7.4 Sub-committees Committees relevant to these terms of reference shall report to the Quality and Safety Committee and the effectiveness of these subSub-committees Committees will be monitored by the Quality and Safety Committee.

7.5 Sub-Committees and Sub- gGroups will submit their minutes to the Quality and Safety

Committee and will report on progress on a monthly, quarterly or annual basis. Key issues will be reported by exception.

8. Review 8.1 The terms of reference of the Committee shall be reviewed by the Board of Directors at

regular intervals, but at least annually. 8.2 The Quality and Safety Committee will undertake an assessment of its overall effectiveness

and compliance with these terms Terms of reference Reference at least annually. This review process will be in the form of a self-assessment checklist and will include the development of the following year’s reporting cycle. The terms Terms of reference Reference will be formally reviewed by the committee Committee as part of this assessment.

APPROVED BY THE BOARD OF DIRECTORS ON 7 JULY 2016TBC

Enc 27 BoardCommittee-ReviewTermsOfReference-Appendix2-AuditCttee-ToR-AgreedAudit-22May2017.docx Page 1 of 7


AUDIT COMMITTEE

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services

the quality of service user and carer experience and the long term protection of stakeholder interests. Good governance emanates from the Board but pervades the

entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial and organisational aspects of

governance and enables key risks to be identified and managed, in both operational and strategic terms.

The Audit committee will therefore ensure that:

There is robust scrutiny of the relevance and rigour of the organisational governance structures in place and the assurances the board receives. It will support the Board in its

responsibilities for issues of risk, control and governance by reviewing the comprehensiveness of assurances and reviewing the reliability and integrity of these

assurances. There is an adequate and effective risk management and assurance framework in place. The scheme of reservation and delegation adequately details who

the Trust empowers to take actions or make decisions on its behalf and that the standing orders (SOs) provide a comprehensive framework for carrying out activities and

translation of statutory powers into a series of practical rules designed to protect the interests of both the organisation and its staff.

TERMS OF REFERENCE

1. Authority

1.1 The Audit Committee is constituted as a standing Committee of the Trust's board of directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future board of directors meetings. The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these terms of reference.

1.2 The Committee is authorised by the board of directors to investigate any activity

within its terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out its functions.

Enc 27 Appendix 2


2. Purpose

2.1 The Audit Committee has primary responsibility for monitoring and reviewing financial and other risks and associated controls, corporate governance and financial assurance. The Audit Committee shall provide the Board with a means of independent and objective review of financial and corporate governance, assurance processes and risk management across the whole of the Trust’s activities (clinical and non-clinical) both generally and in support of the Annual Governance Statement.

2.2 In addition the Audit Committee shall:

Provide assurance of independence for external and internal audit.

Ensure that appropriate standards are set and compliance with them is monitored, in non-financial, non-clinical areas that fall within the remit of the Committee.

Monitor corporate governance (e.g. compliance with constitution, codes of conduct, standing orders, standing financial instructions, maintenance of registers of interests).

3. Membership

3.1 The committee shall be composed of not less than three independent non-executive directors / Associate Non-Executive Directors, at least one of whom should have recent and relevant financial experience. The Chair of the organisation shall not be a member of the Committee.

3.2 Any non-executive director may deputise for an appointed member of the

Committee. 3.3 The appointment of the Chair of the Audit Committee will be a Non-Executive

Director member of the Committee and should be made by the Trust’s Board. 3.4 Members of the Audit Committee must attend at least 75% of all meetings each

financial year but should aim to attend all scheduled meetings. 3.5 A quorum shall be two members. One of the members, other than in exceptional

circumstances will be the appointed Chair of the Audit Committee. 4. Attendance

4.1 Only members of the Audit Committee have the right to attend meetings, but the Chief Executive, Director of Finance, Performance and IM&T, Director of People and Corporate Development and appropriate internal and external audit representatives of the Trust shall generally be invited to attend routine meetings of the Audit Committee.

4.2 The Trust Chair may be invited to attend meetings of the Audit Committee as

required. 4.3 A representative of the local anti-fraud service may be invited to attend meetings of

the Audit Committee. 4.4 The Chief Executive should discuss at least annually with the Audit Committee the

process for assurance that supports the annual governance statement. He or she


should also attend when the Committee considers the draft internal audit plan and the annual accounts.

4.5 All other Trust directors and/or staff should be invited to attend those meetings in

which the Committee will consider areas of risk or operation that are their responsibility.

5. Frequency of Meetings

5.1 Meetings shall be held at least five times a year, with additional meetings where necessary. The Trust’s Board, Accounting (or Accountable) Officer, external auditors or Head of Internal Audit may request an additional meeting. The internal and external auditor shall be afforded the opportunity at least once per year to meet with the Audit Committee without executive directors present.

6. Duties

6.1 The duties of the Committee can be categorised as follows: 7. Governance, Risk Management and Internal Control

7.1 To ensure the provision and maintenance of an effective system of financial risk identification and associated controls, reporting and governance.

7.2 To maintain an oversight of the Trust’s general risk management structures,

processes and responsibilities, including the production and issue of any risk and control related disclosure statements.

7.3 To review processes to ensure appropriate information flows to the Audit

Committee from executive management and other board committees in relation to the Trust's overall internal control and risk management position.

7.4 To review the adequacy of the policies and procedures in respect of all anti-fraud

work. 7.5 To review the effectiveness of the arrangements in place for allowing staff to raise

(in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensure that any such concerns are investigated proportionately and independently.

7.6 To review the adequacy of underlying assurance processes that indicate the

degree of achievement of corporate objectives and the effectiveness of the management of principal risks.

7.7 To review the adequacy of policies and procedures for ensuring compliance with

relevant regulatory, legal and conduct requirements. 7.8 The Committee shall seek assurance that there is an effective system of integrated

governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives.

7.9 This will be evidenced through the Committee’s use of an effective assurance

framework to guide its work and that of the audit and assurance functions that report to it.


8. Internal Audit

8.1 The Committee shall ensure that there is an effective internal audit function that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will include:

Review and approval of the internal audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation.

8.2 Overseeing on an on-going basis the effective operation of internal audit in respect

of:

Adequate resourcing.

Its co-ordination with external audit.

Meeting relevant internal audit standards.

Providing adequate independence assurances.

Having appropriate standing within the Trust.

Meeting the internal audit needs of the Trust. 8.3 Consideration of the major findings of internal audit investigations and

management’s response and their implications and monitor progress on the implementation of recommendations.

8.4 Consideration of the provision of the internal audit service, the cost of the audit and

any questions of resignation and dismissal of internal audit staff and conduct an annual review of the internal audit function.

8.5 Ensure that the internal audit function has appropriate standing within the

organisation and the co-ordination between the internal and external auditors to optimise audit resources.

9. External Audit

9.1 The Committee shall review the work and findings of the external auditors and consider the implications and management’s responses to their work. This will include:

Consideration of the performance of the external auditors.

Discussion and agreement with the external audit, before the audit commences, of the nature and scope of the audit as set out in the annual plan, and ensuring coordination, as appropriate, with other external auditors in the local health economy.

Discussion with the external auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee.

Review of all external audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Board and any work undertaken outside the annual audit plan, together with the appropriateness of management responses.

9.2 The Trust’s separately constituted Auditor Panel carries out the functions required under the Local Audit and Accountability Act 2014, including advising Board on the

Deleted: Oversight

Deleted: of

Deleted: Considering


appointment of external auditors, maintaining an independent relationship with the External Auditors and on any decision regarding the removal or resignation of the external auditors.

10. Annual Accounts Review

10.1 To review the annual statutory accounts, before they are presented to the board of directors, in order to determine their completeness, objectivity, integrity and accuracy. This review will cover but is not limited to:

The meaning and significance of the figures, notes and significant changes.

Areas where judgment has been exercised.

Adherence to accounting policies and practices.

Explanation of estimates or provisions having material effect.

The schedule of losses and special payments.

Any unadjusted statements.

Any reservations and disagreements between the external auditors and management which have not been satisfactorily resolved.

10.2 To review the annual report and annual governance statement before they are

submitted to the board of directors to determine completeness, objectivity, integrity and accuracy.

10.3 To review all accounting and reporting systems for reporting to the board of

directors, including in respect of budgetary control. 11. Standing Orders, Standing Financial Instructions and Standards of Business

Conduct

11.1 To review on behalf of the board of directors the operation of, and proposed changes to, the standing orders and standing financial instructions, the constitution, codes of conduct and standards of business conduct; including maintenance of registers.

11.2 To examine the circumstances of any significant departure from the requirements

of any of the foregoing, and whether those departures relate to a failing, an overruling or a suspension.

11.3 To review the scheme of delegation. 12. Other

12.1 The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications for the governance of the organisation.

12.2 To review performance indicators relevant to the remit of the Audit Committee. To

examine any other matter referred to the Audit Committee by the board of directors and to initiate investigation as determined by the Audit Committee.

12.3 To review each year the accounting policies of the Trust and make appropriate

recommendations to the board of directors. 12.4 To develop and use an effective assurance framework to guide the Audit

Committee's work. This will include utilising and reviewing the work of the internal


audit, external audit and other assurance functions as well as reports and assurances sought from directors and managers and other investigatory outcomes so as fulfill its functions in connection with these terms of reference.

12.5 To consider the outcomes of significant reviews carried out by other bodies which

include but are not limited to regulators and inspectors within the health and social care sector and professional bodies with responsibilities that relate to staff performance and functions.

12.6 To review the work of all other Trust Committees in connection with the Audit

Committee's assurance function. The committee may also request specific reports from individual functions within the organisation (for example, clinical audit) as they may be appropriate to the overall arrangements.

13. Minutes and Reporting

13.1 The minutes of all meetings of the Audit Committee shall formally be recorded and the ratified minutes submitted, together with recommendations where appropriate to the board of directors. The submission to the board of directors shall include details of any matters in respect of which actions or improvements are needed. This will include details of any evidence of potentially ultra vires, otherwise unlawful or improper transactions, acts, omissions or practices or any other important matters. To the extent that such matters arise, the chair of the Audit Committee shall present details to a meeting of the board of directors in addition to submission of the minutes.

13.2 The Audit Committee will report annually to the board of directors in respect of the

fulfillment of its functions in connection with these terms of reference. Such report shall include but not be limited to functions undertaken in connection with the following:

The annual governance statement

The assurance framework

The effectiveness of risk management within the Trust

The integration of and adherence to governance arrangements

Its view as to whether the self-assessment against standards for better health is appropriate.

Any pertinent matters in respect of which the Audit Committee has been engaged.

13.3 The Trust’s annual report shall include a section describing the work of the Audit

Committee in discharging its responsibilities. 13.4 The Company Secretary will act as secretary to the Committee and will provide

advice and ensure administrative support. The duties of the secretary in this regard include but are not limited to:

Agreement of the agenda with the chair of the Audit Committee and attendees together with the collation of connected papers.

Taking the minutes and keeping a record of matters arising and issues to be carried forward.

Advising the Audit Committee as appropriate.


14. Review

14.1 The Committee will undertake an assessment of its overall effectiveness and compliance with these terms of reference at least annually. This review process will be in the form of a self-assessment checklist and will include the development of the following year’s reporting cycle. The terms of reference will be formally reviewed by the Committee as part of this assessment.

14.2 The terms of reference of the Audit Committee shall be reviewed by the board of

directors at least annually. APPROVED BY THE BOARD OF DIRECTORS ON TBC

Enc 27 BoardCommittee-ReviewTermsOfReference-Appendix3-F&PCttee-ToR-AgreedF&P-26June2017.docx Page 1 of 4


FINANCE AND PERFORMANCE COMMITTEE

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services

the quality of service user and carer experience and the long term protection of stakeholder interests. Good governance emanates from the Board but pervades the

entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial and organisational aspects of

governance and enables key risks to be identified and managed, in both operational and strategic terms.

Finance and Performance committee will therefore ensure that:

The Trust has established sound financial, performance, workforce and IT arrangements which provide robust information and comply with statutory and regulatory reporting

requirements. Prime financial policies, also known as standing financial instructions, are in place and clearly set out the organisation's detailed financial procedures and

responsibilities. That all staff are safe and supported to deliver quality patient care, that fair and effective management arrangements exist for all staff and there are methods in

place to develop staff to meet the objectives of the organisation. That all aspects of information governance relating to finance, workforce and performance are in place to

meet IG Toolkit standards.

TERMS OF REFERENCE 1. Authority 1.1 The Finance & Performance Committee is constituted as a standing Committee of

the Trust's board of directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future Board meetings.

1.2 The Committee is authorised by the Board to investigate any activity within its

terms of reference. It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

1.3 The Committee is authorised by the Board to obtain outside legal or other

independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

2. Purpose 2.1 To review the Trust’s financial management arrangements and performance and

make recommendations and provide advice to Trust Officers and the Trust Board. 2.2 To review the Trust’s performance against key financial, operational and workforce

targets.

Enc 27 Appendix 3


2.3 To review the Trust’s key financial performance strategies, associated risks and mitigations.

2.4 To ensure appropriate financial and performance governance arrangements are in

place and functioning effectively. 3. Membership 3.1 Membership of the Committee will consist of: Three Non-Executive / Associate Non-Executive Directors of the Trust Chief Executive Director of Finance, Performance and IM&T Director of People and Corporate Development Director of Nursing, Operations and Estates Medical Director(s) 3.2 The Committee will be chaired by a Non-Executive / Associate Non-Executive

Director of the Trust as determined by the Trust Board. 3.3 A member may nominate an appropriate deputy to attend a meeting of the

Committee on their behalf. However, it is expected that the deputy will be fully briefed and have the necessary authority to participate fully in the debate and any subsequent decisions arising.

3.4 A quorum will consist of at least three members, of which at least one must be a

non-executive director and at least one must be an executive director. 3.5 It is expected that members of the Committee will attend a minimum of 75% of

Committee meetings each year but should aim to attend all scheduled meetings. 4. Attendance 4.1 Senior staff from Finance and Performance & Informatics will be available to be in

attendance at all meetings of the Committee, unless requested to be excluded by the Chair of the Committee, due to the nature of the business to be discussed.

4.2 Additional colleagues will be invited to attend for specific items on the agenda, as

and when required. 4.3 The Committee has the authority to require the attendance of any officers of the

Trust and hold them to account for financial and operational performance. 5. Frequency of Meetings 5.1 The Committee will normally meet monthly during the course of the financial year. 5.2 The Chair of the Committee may call ad-hoc meetings of the Committee, as

appropriate. 6. Duties and Responsibilities 6.1 The Committee will review all aspects of the Trust’s financial management

arrangements. It will receive reports on the following key areas:

Income and expenditure (including links to related activity).

Cash management.

Deleted: and workforce

Deleted: ,


Deleted: 3.4 The Joint Medical Directors may also be in attendance, unless requested to be excluded by the Chair of the Committee, due to the nature of the business to be discussed.¶¶

Deleted: 5

Deleted: Attendance of the Joint Medical Directors does not count towards the quorum.

Deleted: 6

Deleted: ,,

Deleted: and Human Resources

Deleted: ¶

Deleted: and manpower targets


Capital programme.

Financial metrics.

Forecasting.

Working capital management.

Cost improvement programme.

Key financial risks. 6.2 The Committee will provide an oversight against the Trust’s statutory financial

targets. 6.3 The Committee will review reports from appropriate officers or any advisors

engaged by the Trust regarding the efficiency of services and functions across the Trust including:

Reference cost data.

Capacity and productivity data.

Benchmarking data.

Workforce data.

6.4 The Committee will also review the performance management arrangements for each service (including any shared service, agency or consortium arrangement) within the Trust. In particular it will receive reports from:

The Trust’s executive directors concerning the arrangements they have put in place to ensure each service meets their financial and operational targets.

Appropriate senior staff from each service line concerning their financial and operational performance.

6.5 The Committee will receive reports and presentations on the financial regime

within which the Trust operates and will review the Trust’s arrangements for complying with the regime.

6.6 The Committee will review key financial and performance strategies, policies and

plans. It will provide advice and make recommendations on these to appropriate Trust Officers and to the Trust Board.

6.7 The Committee will review the Trust’s performance management arrangements

and provide oversight against mandated and statutory performance targets. 6.8 The Committee will review the Trust’s performance against key operational and

contractual targets. Whilst not exhaustive this will encompass:

Activity performance

Contractual statutory KPI’s reported externally as a measure of Trust performance

Internal targets designed to improve/optimise performance, use of resources and clinical practice/quality

Monitor KPI’s 6.9 The Committee will receive and review benchmarking data and associated

comparative reports.

Deleted: ,


Deleted: <#>Workforce KPIs¶


6.10 The Committee will review the management of key risks to the delivery of financial, and performance strategies, targets and duties and report to Trust Board as appropriate.

7. Minutes and Reporting 7.1 A summary report will be presented to the Trust Board following each meeting of

the Committee, which will be prepared by the Director of Finance and Performance and agreed with the Chair of the Committee.

7.2 The Chair of the Committee shall draw to the attention of the Board any issues that

require disclosure to the full Board, or require executive action. 7.3 The minutes of all meetings of the Finance & Performance Committee shall

formally be recorded and the ratified minutes submitted, together with recommendations where appropriate to the board of directors.

7.4 The Trust’s Risk Manager will be appraised of any recommendations regarding

changes to assurances, controls and management of risks, or any new risks, arising as a result of Committee review of risks.

7.5 The Estates and Capital Planning Group will report to the Finance and

Performance Committee and the effectiveness of this sub-committee will be monitored by the Finance and Performance Committee.

7.6 The Estates and Capital Planning Group will submit their minutes to the Finance &

Performance Committee and will report on progress as appropriate. 7.7 The Company Secretary will act as secretary to the Committee and will provide

advice and ensure administrative support. The duties of the secretary in this regard include but are not limited to:

Agreement of the agenda with the chair of the Committee and attendees together with the collation of connected papers.


Advising the Finance & Performance Committee as appropriate. 8. Review 8.1 These terms of reference will be formally reviewed by the Committee at least

annually. Any proposed amendments to the terms of reference will be approved by the Trust Board.

8.2 The work and effectiveness of the Committee will be subject to scrutiny by the

Audit Committee. The Committee will also consider its effectiveness at least annually.

APPROVED BY THE BOARD OF DIRECTORS ON TBC


Enc 27 BoardCommittee-ReviewTermsOfReference-Appendix4-MHASCttee-ToR-AgreedMHASC-8June2017 Committee.docx Page 1 of 4


MENTAL HEALTH ACT SCRUTINY COMMITTEE

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services the quality of service user and carer experience and the

long term protection of stakeholder interests. Good governance emanates from the Board but pervades the entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial and organisational aspects of governance and enables key risks to be identified and managed,

in both operational and strategic terms.

The Mental Health Act Scrutiny committee will therefore ensure that:

The organisation is working within the legal requirements of the Mental Health Act (1983), as amended by the 2007 Act and Mental Capacity Act 2005, and with reference to guiding principles as set out in the Code of

Practice and associated legislation as it applies to the Mental Health Act, the Mental Capacity Act and Deprivation of Liberty. It will ensure policies and processes in relation to the Mental Health Act and Mental Capacity Act

across the Trust are in place and appropriately scrutinised and applied throughout the Trust.

TERMS OF REFERENCE

1. Authority

1.1 The Mental Health Act Scrutiny Committee is constituted as a standing Committee of the Trust's board of directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future Board meetings.

1.2 The Committee is authorised by the Board to investigate any activity within its terms of reference.

It is authorised to seek any information it requires from any employee and all employees are directed to co-operate with any request made by the Committee.

1.3 The Committee is authorised by the Board to obtain outside legal or other independent

professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

2. Purpose

2.1 To maintain an overview of the operation and application of the Act within the Trust. 2.2 To be responsible for the development, review, implementation and monitoring of Mental Health

Act policies and procedures to support and ensure compliance with Mental Health Act legislation. 2.3 To review and monitor the use of the Act within the Trust, noting and ensuring investigation of any

emerging trends with respect to service, age, gender, ethnicity and cultural background. 2.4 To ensure that the Trust complies with the Mental Capacity Act (MCA) and Deprivation of Liberty

Safeguards (DOLS) requirements and to monitor their interface with the Mental Health Act 1983. To review and monitor statistical information on DOLs referrals from the Trust.

Enc 27 Appendix 4

Deleted: trust


2.5 To receive and review reports from the Care Quality Commission and other relevant external

bodies, ensuring that appropriate actions and responses are undertaken. 2.6 Receive the results of clinical audits and other relevant reviews of the Act and oversee the

development and implementation of recommendations. 2.7 To review and oversee the implementation of any subsequent amendments to Mental Health Act

legislation, guidance and best practice. 2.8 To monitor the role, functioning and performance of the Mental Health Act Lay Managers and to

liaise with them on all pertinent issues. 2.9 To support the role of the Mental Health Act Administration offices. 2.10 The Committee will consider as a regular item pertinent issues arising from the Associate Lay

Managers’ Peer Group. 2.11 At the discretion of the Chair, the Committee will be responsible for establishing and receiving

reports from working sub-groups to investigate specific issues or trends, as required. 3. Membership

3.1 Membership of the Committee will consist of the following Board members:

Non-Executive Director / Associate Non-Executive Director – (Chair)

Non-Executive Director / Associate Non-Executive Director – (Vice-Chair)

Director of People and Corporate Development

Medical Director/s

Director of Operations, Nursing, & Estates 3.2 The Committee will be chaired by a Non-Executive Director / Associate Non-Executive Director of

the Trust as determined by the Trust Board. 3.3 Any Non-Executive Director / Associate Non-Executive Director may deputise for an appointed

Non-Executive Director / Associate Non-Executive Director. However, it is expected that the deputy will be fully briefed and have the necessary authority to participate fully in the debate and any subsequent decisions arising.

3.4 A quorum will consist of at least two members, of which at least one must be a non-executive

director and one an executive director and at least five of those required to attend listed in paragraph 4.1 below.

3.5 It is expected that members of the Committee will attend a minimum of 75% of Committee

Meetings each year but should aim to attend all scheduled meetings. The attendee list will be reviewed on an annual basis and any concerns will be highlighted to the Trust Board.

Deleted: (formerly the Mental Health Act Commission)

Deleted: group


4. Attendance

4.1 The following members will also be required to attend the Committee:

Associate Director of Operations

Clinical Director – Acute Services

Head of Acute Services

Head of Older Peoples’ Services

Head of Early Intervention, Access and Urgent Care Services Head of Social Care

An AMHP Lead

Mental Health Act Manager

Equality and Diversity Manager

Learning & Development Manager

Head of Nursing, Quality and Innovation Vulnerable Adults and Childrens Lead

Compliance & Safety Manager 4.2 Staff from the Trust or representatives from other agencies may be invited to attend the

committee for specific discussions, as required. The perspectives and contributions of Expert Service Users and Carers are recognised and valued by the Trust and therefore, they may be invited to attend the Committee, at the discretion of the Chair.

5. Frequency of Meetings

5.1 The Committee will normally meet every other month during the course of the financial year.

5.2 The Chair of the Committee may call ad-hoc meetings of the Committee, as appropriate. 6. Duties and Responsibilities

6.1 The committee is responsible for discharging all requirements of the Mental Health Act (“the Act”),

the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) requirements. 7. Minutes and Reporting

7.1 The Company Secretary will make arrangements for the administration of the Committee. He or

she will ensure that the minutes of the Committee meeting are formally recorded, the ratified minutes submitted to the Trust’s Board and shall ensure that appropriate support is provided to the Chair and Committee members.

7.2 The Chair of the Committee will report on a regular basis to the Trust Board identifying any issues

that require disclosure, or require executive action. A summary report will be presented to the Trust Board following each meeting of the Committee Due to the nature of the issues considered, it may be necessary for the committee to liaise with other committees, in which case specific and appropriate arrangements will be agreed.

Deleted: Safeguarding

Deleted: Governance

Deleted: shall be


8. Review

8.1 The terms of reference will be formally reviewed by the Committee as part of this assessment.

Any proposed amendments to the terms of reference will be ratified by the Trust Board. 8.2 The Committee will undertake an assessment of its overall effectiveness and compliance with

these terms of reference at least annually. This review process will be in the form of a self -assessment checklist and will include the development of the following year’s reporting cycle.

APPROVED BY THE BOARD OF DIRECTORS ON (TBC)

Enc 27 BoardCommittee-ReviewTermsOfReference-Appendix5-WorkforceCttee-ToR-ApprovedWorkforceCttee-27June2017 Committee.docx Page 1 of 5

Deleted: BoardCommittee-ReviewTermsOfReference-Appendix5-WorkforceCttee-ToR-ApprovedWorkforceCttee-27June2017 Committee.docx

DUDLEY AND WALSALL MENTAL HEALTH NHS PARTNERSHIP TRUST

WORKFORCE COMMITTEE

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services the quality of service user and carer experience and the long term protection of stakeholder interests. Good governance emanates

from the Board but pervades the entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial and organisational aspects of governance and enables key risks to be identified and managed, in both operational and strategic

terms.

This committee will therefore ensure that: The Trust has established a sound framework of clinical governance comprising those processes,

systems and controls that enable NHS organisations to demonstrate accountability for continuously improving the quality of services and safeguarding high standards of care. That arrangements are in place to support staff to deliver safe and quality patient care. That consultation and involvement by service users, carers and stakeholders effectively informs continuous improvement. That clinical governance, clinical/operational risk management and safeguarding systems and processes are

operating effectively, provide robust information and comply with statutory and regulatory guidance, standards and reporting requirements. That learning from feedback is embedded throughout the

organisation. That all aspects of information governance relating to clinical and patient information are in place to meet IG Toolkit standards.

TERMS OF REFERENCE

1. Authority

1.1 The Workforce Committee is constituted as a standing committee of the Trust's board of directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future board of directors meetings.

1.2 The Workforce Committee is authorised by the Board of directors to instruct

professional advisors and request the attendance of individuals and authorities from outside the Trust with relevant experience and expertise if it considers this necessary for or expedient to the exercise of its functions.

1.3 The Workforce Committee is authorised to obtain such internal information as is

necessary and expedient to the fulfilment of its functions. 2. Purpose: 2.1 To enable the Board to obtain assurance that there is a coordinated strategic response

to the workforce needs of the organisation and ensure the delivery of the Trusts strategic objectives in relation to “People” and ensure that there is an appropriate response to the strategic workforce risks and performance against workforce key performance indicators

Enc 27 Appendix 5



2.2 The Staff Side Forum will remain the formal forum for discussion and consultation with

the staff side representatives. 3. Membership: 3.1 The membership of the Workforce committee shall consist of:

A minimum of 2 Non-Executive or Associate Non-Executive Directors who will act as the Chair or Vice Chair

Chief Executive Director of People and Corporate Development Director of Nursing, Operations and Estates Director of Finance, Performance & IM&T Joint Medical Director(s)

3.2 The Workforce Committee will be deemed quorate when 4 members are present

including at least one Non-Executive / Associate Non-Executive Director and one Executive Director.

3.3 The Chair will be appointed by the Trust Board. 3.4 For the avoidance of doubt, Trust employees who serve as members of the Workforce

Committee do not do so to represent or advocate for their respective department, division or service area but to act in the interests of the Trust as a whole and as part of the Trust-wide governance structure.

3.5 Core members may nominate an appropriate deputy to attend the committee on their

behalf. However, it is expected that any nominated deputy will be fully briefed and have the necessary authority to participate fully in the debate and any subsequent decisions arising.

3.6 Additional members or associates may be co-opted to attend the Committee as

necessary. 4. Attendance 4.1 The following participants are required to attend meetings of the Workforce Committee:

Associate Director of Operations Associate Director of People and Workforce Development Chief Pharmacist Heads of Service Senior Workforce Development Manager Senior HR Business Partner ESR Systems Manager Senior Finance Manager Communications Manager



Equality and Diversity Manager Head of Nursing, Quality and Innovation Head of Social Care Interim Professional Lead for Occupational Therapy Interim Professional Lead for Psychology Contracts Manager Engagement Lead and F2SU Guardian

4.2 Other people may be invited to attend on an ad hoc basis. 4.3 Administrative support to the Committee will be provided and maintain minutes/actions

of the meetings. 4.4 Other than as set out in paragraphs 4.1 to 4.3, only members of the Workforce

Committee are entitled to be present at its meetings. 4.5 Members listed at paragraph 3.1 and attendees listed at paragraph 4.1 are,

respectively, required to attend at least 75% of the meetings held annually. 5. Frequency 5.1 Meetings shall be held monthly. 6. Duties 6.1 To develop a Workforce Strategy and Implementation Plan. 6.2 To support the coordination of the various streams of strategic workforce activity and to

monitor progress specifically in the following areas: Human Resources Management Temporary resourcing Workforce Planning Education and Learning Organisational Development Staff Engagement Equality, Diversity and Human Rights

6.3 To provide a forum for Service Line strategic workforce issues to be considered.

6.4 To consider national and local workforce developments and influence the organisation’s

response.

6.5 To ensure strategic workforce planning and development is embedded in the organisation and appropriate workforce planning and assurance systems are in place.

6.6 To have an oversight of national and regional LDAs and delivery of education.

Deleted: <#>Professional Leads¶

Formatted: Font: (Default) Arial

Formatted: Font: (Default) Arial

Formatted: Font: (Default) Arial, 12 pt



Deleted: Contracting

Deleted: and will be subject to review after the first 6 months



6.7 To ensure Trust meets Regulatory / mandatory workforce requirements.

6.8 To support the Trust’s Library knowledge services.

6.9 To support the Trust’s Organisational and Leadership Development. 6.10 To receive reports and review progress in relation to HR Management, Temporary

Staffing, Recruitment Workforce Planning, Education and Learning Development, Organisational Development, Staff Engagement, Equality, Diversity and Human Rights.

6.11 To oversee the Trust’s vacancy reduction plans.

6.12 To oversee the Trust’s approach to managing temporary labour and Agency usage.

6.13 To monitor compliance in respect of CQC KLOE the Workforce Race Equality Standard (WRES), Staff Engagement and other Workforce Standards.

6.14 To receive reports and review progress of Service Line and Professional group updates strategic workforce activity, plans and issues.

6.15 To review Trust wide and service level performance against workforce KPI’s, and ensure an appropriate response.

6.16 To monitor workforce risks and the Board Assurance Framework as it relates to the

Terms of Reference of the Committee.

6.17 To receive the annual Staff Survey and agree and monitor any resulting action plan to address the outcomes from the staff survey.

6.17 To oversee Staff Health and Wellbeing performance.

7. Minutes and Reporting 7.1 A summary report agreed with the Chair of the Committee will be presented to the Trust

Board following each meeting of the Committee. 7.2 The Chair of the Committee shall draw to the attention of the Board any issues that

require disclosure to the full Board, or require executive action. 7.3 The minutes of all meetings of the Workforce Committee shall formally be recorded and

the ratified minutes submitted, together with recommendations where appropriate to the board of directors.

7.4 The Company Secretary will act as secretary to the Committee and will provide advice

and ensure administrative support. The duties of the secretary in this regard include but are not limited to:



Agreement of the agenda with the chair of the Committee and attendees together with the collation of connected papers.


Advising the Workforce Committee as appropriate.

7.5 The Health and Wellbeing Group will report to the Workforce Committee and the effectiveness of this Group will be monitored by the Workforce Committee.

7.6 The Health and Wellbeing Group will submit its minutes to the Workforce Committee

and will report on progress on a monthly, quarterly or annual basis as appropriate. Key issues will be reported by exception. The Terms of reference of the Health and Wellbeing Group will be subject to Workforce Committee approval on an annual basis.

8. Review 8.1 These terms of reference will be formally reviewed by the Committee at least annually.

Any proposed amendments to the Terms of Reference will be approved by the Trust Board

8.2 The Workforce Committee will undertake an assessment of its overall effectiveness and

compliance with these terms of reference at least annually. This review process will be in the form of a self-assessment and will include the development of the following year’s reporting cycle. The Terms of Reference will be formally reviewed by the committee as part of this assessment.

APPROVED BY THE BOARD OF DIRECTORS ON TBC

Deleted: terms

Deleted: reference

Deleted: 2 February 2017

Enc 27 BoardCommittee-ReviewTermsOfReference-Appendix6-MExT-ToR-AgreedMExT-27June2017.docx Page 1 of 3


MANAGEMENT EXECUTIVE TEAM (MExT)

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services the quality of service

user and carer experience and the long term protection of stakeholder interests. Good governance emanates from the Board but pervades the entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial

and organisational aspects of governance and enables key risks to be identified and managed, in both operational and strategic terms.

MExT will therefore ensure that:

Robust policies, systems and processes exist and are appropriately applied to ensure effective and efficient operational stewardship of the organisation. It will ensure policies and processes in

relation to operational management are in place and appropriately scrutinised and applied throughout the Trust.

TERMS OF REFERENCE

1. Authority 1.1 The Management Executive Team reports to the Trust Board of Dudley and Walsall Mental

Health Partnership NHS Trust. 2. Purpose 2.1 To oversee the operational delivery of Trust strategy within Dudley and Walsall Mental

Health Partnership NHS Trust. 2.2 To provide executive and senior management input and discussion into key decisions with

regard to the implementation of Trust strategy. 2.3 To oversee the interface between clinical and non-clinical services and to ensure effective

operational performance. 3. Membership 3.1 The following are members of MExT:

Chief Executive (Chair)

Director of Finance, Performance and IM&T (Vice Chair)

Joint Medical Directors

Director of Operations, Nursing and Estates

Director of People and Corporate Development

Clinical Development Director

Clinical Director for Acute Services

Clinical Director for Community & Recovery Services

Clinical Director for Early Intervention Services

Clinical Director for Governance & Quality

Clinical Director for Older Peoples Services

Deputy Director of Finance

Enc 27 Appendix 6


Associate Director of Corporate Development

Associate Director of Operations

Associate Director of People and Workforce Development

Head of Community Services

Head of Early Intervention Services

Head of Estates & Technical Services

Head of Inpatients

Head of Informatics and Performance Management

Head of Nursing, Quality and Innovation

Head of Recovery Services

Head of Social Care

Head of Urgent Care & Access

Chief Pharmacist

Communications Manager

Compliance and Safety Manager

3.2 MExT will be deemed quorate to the extent that 3 of the Executive Directors carrying a vote at Board are present.

3.3 Meetings of MExT may be attended by:

Any nominated deputy attending in place of a member of MExT.

Any other person who has been invited to attend a meeting by MExT so as to assist in deliberations.

3.4 A member of the Corporate PA team will act as secretary. 3.5 Only those members set out in paragraph 3.1 are entitled to be present at its meetings. 3.6 Members listed at paragraphs 3.1 are required to attend at least 75% of the meetings held

annually. Frequency of Meetings 4.1 Meetings shall be held monthly in line with the reporting timescales to the Trust’s Board and

usually in the 4th week of the month. Additional meetings may be held on an exceptional basis at the request of the Chair

4.2 The agenda and papers will be circulated in line with the Trust Standing Orders. 5. Duties and Responsibilities 5.1 MExT will act as a key forum for the delivery of key strategic and operational issues. In

particular, MExT will:

Ensure the effective implementation of Trust strategy, monitoring outcomes and providing assurance of progress against key operational performance indicators.

Receive reports from and monitor the work of heads of service and professional leads including receiving service line performance dashboards.

Receive reports from other meetings and functional leads as appropriate to monitor progress in implementing Trust strategy, including the receipt of the notes from Service Line Business Meetings

Deleted: <#>Associate Director of Psychology & Psychological Therapies¶


Receive and agree formal business cases to deliver strategic plans and generate business opportunities.

Act as the forum in which senior managers can formally raise concerns and issues for discussion with colleagues, making decisions on these issues, where appropriate.

Highlight and discuss any significant risks to operational services, the impact and the mitigating actions. Escalate to Board or relevant committee as required.

Oversee the operational planning and delivery of all Cost Improvement Plans and ensure sign off of quality impact assessments by the Joint Medical Directors and Director of Operations, Nursing and Estates.

6. Minutes and Reporting 6.1 The minutes of all MExT meetings shall be formally recorded. 6.2 The minutes of MExT meetings shall be submitted to the Trust Board. 6.3 The Chair of MExT will provide a report to the public session of board each month. 7. Review 7.1 These terms of reference will be formally reviewed by MExT at least annually. Any

proposed amendments to the terms of reference will be approved by the Trust Board. APPROVED BY THE BOARD OF DIRECTORS ON TBC


Agenda Item number: 9.1 Enclosure: 28

Report Title: High Level Operational Risk Register

Accountable Director: Rosie Musson (Acting Director of Nursing)

Author (name & title): Neil Tong (Patient Safety Facilitator)

Purpose of the report: • The purpose of this report is to provide the Trust Board with the Red Risks for the period ending 28th June 2017 and in doing so provides the committee with information on: o Any new red risks being escalated to the High Level

Operational Risk Register o Any red risks being downgraded from the High Level

Operational Risk Register. o Any updates to red risks currently held on the Trust

High Level Operational Risk Register.

Action required from the Committee

Decision / Approval

Gain assurance

Discussion

Information



Committee: The detail within this report was reviewed by:

• Quality and Safety Committee • Finance and Performance Committee • Workforce Committee • Mental Health Act Scrutiny Committee

Date reviewed: 14/06/2017 – Quality and Safety Committee 26/06/2017 – Finance and Performance Committee 27/06/2017 – Workforce Committee 08/06/2017 – Mental Health Act Scrutiny Committee The risks enclosed within this risk register were approved by Quality and Safety Committee with a number of risks referred to Finance and Performance Committee, Mental Health Act Scrutiny Committee and Workforce Committee in line with the requirements of the Trusts risk management strategy. Following discussion at these committees it was agreed that risks 289 should be escalated as a red risk to the High Level Operational Risk Register and that a new risk (379)

Enc 28 High Level Operational Risk Register Page 1 of 16

should also be added to the risk register as a red risk. The details of these risks are further outlined within the report.

Strategic Objective(s) to which this paper relates: High quality

services


Leadership culture






Caring Some of the risks held on the register have the ability to directly or indirectly impact upon the care/services offered

Responsive The Trust Wide Risk Register Provides a representation of the Trusts “Red Risks” and the responses to managing/action planning these risks; some (due to the nature of the risk) provide a response to a short term or long term issue

Effective Some of the risks held on the Trust Wide Risk Register impact upon the future viability / effectiveness of the Trusts operations.

Risk FINAN 1 specifically relates to the long term outlook in relation to CIP

Well-led Some risks held on operational risk registers Pertain to issues around service redesign and may have impacts upon leadership and staffing issues

Safe The appropriate management of risk is central to the provision of a quality, safe service. In particular CQC Outcome 16 – Assessing and monitoring the quality of service provision


Title High Level Operational Risk Register Introduction

It is the purpose of this report is to provide the Trust Board with the Red Operational risks held across the Trusts Risk Registers (for the period 28th June 2017) and in doing so provides Trust Board with information on: • Any new red risks being escalated to the High Level Operational Risk Register. • Any red risks being downgraded from the High Level Operational Risk Register Any

updates to red risks currently held on the High Level Operational Risk Register. There are currently 10 risks being presented as part of this report. This is being done in line with the Trusts risk management strategy and further details of these are included within table 1.1.

Summary of key points, issues and risks There are 10 risks included within this report which are applicable for presentation to the Trust Board. A summary of these risks are detailed within table 1.1. The full details of these risks are articulated in appendix 1 It is recommended by the Trusts sub committees that 1 risk should be escalated as a red risk for inclusion on this risk register (Risk 289 and is outlined below). In addition it was proposed by workforce committee that a further red risk should be added in relation to risk 379 (outlined below). Table 1.1. – Summary of risks

Risk ID

Risk Description

Impacts Opaerationally (and updates)

Status of risk

FINAN 1 Inability to meet CIP targets, funding for Mental Health, QIPP (and in longer term the Dudley MCP) have the potential to impact upon the long term financial viability for DWMH. Issues Include: * CIP and QIPP requirements from existing baselines * Reduction in investment by Local Authorities * In longer term, the Dudley MCP plans can be expected to require on-going efficiencies through internal CIPs * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward (Risk related to long term challenges around CIP and not

Source – Financially driven risk with quality implications. Existing

Addition information This risk has been updated by the Acting Director of Finance to include information in relation to MCP and QIPP requirements

=


Risk ID

Risk Description


Status of risk

HR 002 Reduction in Local Authority Funding for Mental Health Social Care Workforce. This has the potential to impact on service delivery and on the viability of the S75 agreements and has the potential to place operational pressures on

Source – Risk to quality of service driven by a reduction in local authority funding. Existing risk already reported to Quality and Safety Committee Addition information Risk has been updated to include impact on

=

314 A complex interface between electronic and paper clinical records presents challenges to staff when assessing and caring for patients across inpatient and community services. This may lead to an inconsistent approach being taken to clinical risk management, having implications upon continuity of patient care planning and risk management.

In addition to this a decision regarding the procurement of the Clinical System has been delayed for it to be considered by the relevant TCT workstream, in the context of the decision for the 3 TCT partners to look actively at how we might work as one combined organisation.

Source – Major project already enacted by the Trust to replace existing clinical system. CQC assessment highlighted that interface between electronic and paper system is a clinical risk and as such interim measures are being put in place to mitigate the risk along with long term measures (the replacement of OASIS) Addition information / update Board were advised that the decision regarding the procurement of the Clinical System has been delayed for it to be considered by the relevant TCT workstream, in the context of the decision for the 3 TCT partners to look actively at how we might work as one combined organisation.

Whilst an IT solution will help there was however some discussion that an IT solution is not the cure all for the issues that have been picked up through the CQC inspection about our medical record keeping, so we should still be actioning what we can to strengthen our record keeping within the

=

315 An inconsistent approach is being taken to the management of clinical risk management and care plan development was identified by the CQC. This is likely to have implications upon continuity of patient care planning and risk management.

Source – CQC visit highlighted that this is a recurrent issue

Addition information Trust has purchased a license agreement for writing person centered care plans. The standards are supported by the CCA and NHS improvement.

Trust supportive visits have noted that whilst the updating of risk assessments on OASIS has improved, there are still issues within inpatient areas of care plans not being patient centered.

=

320 The Trust has a lack of clearly defined processes and policies in respect to the use of personal alarms, the provision of call alarms which allied to an additional need for personal safety training for staff has the ability to impact upon the health and safety of both staff and patients, especially when staff are working on their own.

Source – The Trusts CQC visit highlighted this as a risk to the Trust.

Addition information Supportive visits noted that there are still issues with alarm protocols within certain inpatient areas,

=


Risk ID

Risk Description


Status of risk

322 The Trusts assessment by the CQC noted that there may be a lack of evidence to support that calls within the Trusts Crisis team are responded to in a timely manner

Source – The Trusts CQC visit highlighted this as a risk to the Trust.

Addition information As noted a new crisis call log has been established and a standard for incident reporting has been agreed Whilst no incident forms have been entered in relation to this issue since the CQC visit, there is at this stage audit results to indicate the number of calls which are being returned and the average response time for these. Audit has been completed and has been presented

=

323 Failure of the Trust to achieve its mandatory and essential training may result in staff not being appropriately skilled to undertake their role and impact upon the Trust meeting compliance with CQC standards and impact upon the quality of patient care

Source – CQC highlighted that this was a risk to the Trust

Risk reviewed by Quality and Safety Committee. It was noted that due to further work being required in relation to this (as identified by the Trusts November 2016 CQC visit and its associated action plan) it was felt that this risk should be upgraded to a red risk.

This decision was further approved by the Trusts workforce committee and a decision was made to re- score the risk as a red risk.

The additional actions in relation to this risk are currently being aligned to the Trusts CQC action plan

=

EF002 Fires Safety Management within the Trust and lack of assurances in respect to certain arrangement regarding fire safety

Source – Gap analysis of assurances undertaken within estates. Issue escalated via Estates Risk Register

Addition information Fire safety working group has now been convened and is meeting on a weekly basis to address the

=

289 Changes to the local interagency 136 policy may leave to Trust open to reputational risks around its implementation. It is noted that only one doctors was required for a Section 12 and an AMHP. Should an instance arise where a second doctor was required they would be called. There were also noted issues documented as part of the Trusts November 2016 CQC Visit. Namely in relation

Source – Following discussion at the Trusts MHASC in light of the findings of the November 2016 CQC visit it was noted that this risk should be escalated to the status of a red risk.

Addition information It is acknowledged that the controls will require aligning with the Trusts CQC action plan

▲

379 Shortage of National Junior psychiatric trainees from August's rotation may impact on patient care due to reduced workforce capacity

Addition information / update Risk added following discussion at Trust Board and Quality and Safety Committee

New


Further detail (if required)

Further details of the risks are outlined in Appendix 1 Recommendation

It is recommended that the Trust Board approve the enclosed copy of the High Level Operational Risk Register and approve the recommendation to escalate risks 289 and 379

Board Action required

To approve the risks included within this report and note the action taken to date in managing these and to agree the recommendation to escalate risks 289 and 379.


R isk N o .

R isk D esc rip tion

S o u rce o f R i s k

D a te Iden tified

P r i n c i p l e O w ne r o f R i s k

O t h e r C o n t r i b u t o r s

In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L

Fu rthe r A c tio ns R equ ired

R e s id u a l

S c o r e

S L

S o u rces o f A ssu rance

D a te o f R ev ie

Fu rthe r C o m m en ts

F INA N 1 Inab ility to m ee t C IP ta rge ts , fund ing fo r M en ta l H ea lth , Q IP P (and in longe r te rm the D ud ley M CP ) have the po ten tia l to im pac t upon the long te rm financ ia l v iab ility fo r D W M H . Issues Inc lude : * C IP and Q IP P requ ire m en ts fro m ex is ting base lines * R educ tion in investm en t by Loca l A u tho r ities * In longe r te rm , the D ud ley M CP p lans can be expected to requ ire on -go ing e ffic ienc ies th rough in te rna l C IP s * E ffic iency o f 4 pe rcen t has been expe rienced fo r a nu m be r o f yea rs and w ill be expe rienced go ing fo rw a rd (R isk re la ted to long te rm cha llenges a round C IP and no t "In Y ea r P os ition ")

F in a nc e P ro jec tions / D a t a

28 /02 /2011

M a rk A xce ll Rupert Davies 5 4 R ed

20 D e ta iled deve lop m en t o f cos t im p rove m en t p rog ra m m e A pp roach to C IP has been ag reed a t F inance C o m m ittee P M O B oa rd es tab lished

Leve l o f C IP has been co m m un ica te to ope ra tiona l tea m s fo llo w ing LTF M re fresh (Ju ly 2013 )

A rrange m en ts fo r m on ito ring p rog ra m m e o f C IP no w in p lace C IP ta rge ts be ing m e t th rough ag reed d ises tab lish m en t C on tinue to m anage locu m m ed ica l cos ts as ag reed th rough F & a m p ;P Q ua lity Im pac t A ssess m en t fo r a ll 2014 /15 and 2015 /16 and 2016 /17 sche m es a ll upda ted F inance tea m m e m be rs o f S e rv ice T rans fo rm a tion w o rk g roups and a lso dec is ion m ak ing P rog ra m m e B oa rd A c tive pa rtne r o f the M en ta l H ea lth P rog ra m m e B oa rd m a in fo ru m fo r co m m iss ione r lia ison . S ens itiv ity ana lys is bu ilt in to cu rren t p lans and fu rthe r deba te had rega rd ing m on ito r assum p tions and T rus t app roach to m itiga tion . R e m ode lled e ffic iency p lan due to changes in M on ito rs requ ire m en ts , ag reed by T rus t boa rd , F inance and P e rfo rm ance co m m ittee and M E x T

R epo rting a rrange m en ts to boa rd enhanced s ince A ugus t 2013 to p rov ide m o re de ta il on sche m es as w e ll as qua lity im pac t assessm en ts M on ito ring o f bank , agency and locu m s no w fo rm s pa rt o f finance repo rt and d iscuss ion a t bo th F and and M E X T .

5 3 15 R ed d

T rus t B oa rd to cons ide r ne w co m m un ica tion on C IP th rough tea m b rie f, bu ild ing on p rev ious co m m un ica tions , to ensu re tha t the m essage is w e ll unde rs tood rega rd ing the sca le o f the cha llenge

W o rk requ ired to ensu re P O D s and repo rting fra m e w o rk is linked e ffec tive ly in to co m p le ted Q ua lity Im pac t A ssess m en ts (O ngo ing ).

R ev ie w o f repo rt fro m rev ised P O D s and repo rting fra m e w o rk accord ing ly

E xp ressions o f in te res t fo r an ex te rna l pa rtne r in deve lop ing C IP p lans fo r 2017 /18 , 2018 /19 and 2019 /20

5 1 G reen

5 V a rious F inance and P e rfo rm ance repo rts inc lud ing :

R epo rts to B oa rd

R epo rts to F & P C o m m i tt e e inc lud ing ind iv idua l ac tion p lans on p ressure a reas .

R epo rts to M EX T

R ev ie w s by ex te rna l assessors inc lud ing T D A , H D D and M on ito r

In te rna l aud it repo rts a round C IP g iv ing fu rthe r as s u ranc e

E x te rna l bench m a rk ing o f p lans

22 /05 /2017

R isk rev ie w ed by F inance and P e rfo rm ance C o m m ittee . R isk to re m a in a red risk .


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L


D a te o f R ev ie w


H R 002 R educ tion in Loca l A u tho rity F unding fo r M en ta l H ea lth S oc ia l C a re W o rk fo rce . T h is has the po ten tia l to im pac t on se rv ice de live ry and on the v iab ility o f the S 75 ag ree m en ts and has the po ten tia l to p lace ope ra tiona l p ressures on c lin ica l tea m s and ope ra tiona l v iab ility o f so m e se rv ices

F eedback F ro m S takeho lde rs / P

30 /05 /2012

L e s l e y W r i t tl e

Rosie Musson

Hassan Omar

4 4 R ed

16 S ec tion 75 ag ree m en ts p rov ide fo rm a l p la tfo rm as the bas is fo r any fu rthe r nego tia tions in fund ing and resou rce changes

Jo in t app roach ag reed w ith W a lsa ll M B C rega rd ing im p le m en ta tion o f fund ing reduc tions . R isk A ssess m en ts on loss o f pos ts has been co m p le ted R egu la r d iscuss ions be ing he ld a t P a rtne rsh ip O pe ra tions G roup . A dd itiona l sho rt te rm capac ity has been co m m iss ioned

4 4 R ed

16 D iscuss ions ongo ing a t P O G (M on th ly )

4 2 A m be r

8 R epo rts to M EX T

U pda tes to B oa rd

01 /02 /2017

R isk has been upda ted to inc lude im pac t on se rv ice p rov is ion and add itiona l requ ired ac tions


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




314 A co m p lex in te rface be tw een e lec tron ic and pape r c lin ica l reco rds p resen ts cha llenges to s ta ff w hen assessing and ca ring fo r pa tien ts ac ross inpa tien t and co m m un ity se rv ices . T h is m ay lead to an inconsis ten t app roach be ing taken to c lin ica l risk m anage m en t, hav ing im p lica tions upon con tinu ity o f pa tien t ca re p lann ing and risk m anage m en t.

In add ition to th is a dec is ion rega rd ing the p rocu re m en t o f the C lin ica l S ys te m has been de layed fo r it to be cons ide red by the re levan t T C T w o rks trea m , in the con tex t o f the dec is ion fo r the 3 T C T pa rtne rs to look ac tive ly a t ho w w e m igh t w o rk as one c o m b ined o rgan isa tion .

F eb 2016 C Q C V is i t

19 /05 /2016

R up e rt D a v i e s

Dan Howard

IM&T

David Crook

Bob Yardley

4 4 R ed

16 R ev ie w o f risk assessm en t te m p la te has been co m p le ted in line w ith CP A requ ire m en ts to ensu re tha t s ta ff p rac tice is in line w ith bes t p rac tice T ra in ing needs ana lys is has been looked a t ac ross the T rus t to ensu re tha t inpa tien t s ta ff can upda te e lec tron ic risk assessm en ts on O A S I C onsu lta tion w ith ove r 60 c lin ica l an c lin ica l ad m in s ta ff to deve lop the bus iness case and spec ifica tion fo r the ne w c lin ica l sys te m has been unde rtak en S upp lie rs have sub m itted responses to the Inv ita tion to T ender (ITT ) Inpa tien t a re be ing tra ined to upda te FA C E risk assessm en ts on the O A S sys te m , to ensu re tha t co m m un ity s ta ff a re a w a re o f risks w h ich m ay have e m e rged du ring the pa tien ts inpa tien t s tay R e fe rence S ite V is its have occured S ys te m D e m ons tra tions unde rtaken

s4 4 R ed

S

d IS

16 F u ll bus iness case app roved and con trac t s igned

R o ll ou t o f ne w c lin ica l sys te m c o m m enc es

Iden tifica tion o f p re fe rred supp lie r

Q ua lity im p rove m en t p rio rity in re la tion to "Im p rov ing the Q ua lity o f reco rd keep ing " and P e rson C en tred C a re P lann ing " to be unde rtaken du ring the 2017 /18 yea r.

4 1 G reen

4 R epo rts to M E x T R epo rts to IG IM & T co m m ittee

01 /05 /2017

R isk rev ie w ed by Q ua lity and S a fe ty C o m m ittee as pa rt o f risk deep d ive

It w as ag reed tha t the risk shou ld re m a in on the risk reg is te r as a red risk , ho w eve r con tinued im p rove m en ts shou ld be m ade to the qua lity o f reco rds as and w he re possib le to im p rove pa tien t c a r e .


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




315 A n inconsis ten t app roach is be ing taken to the m anage m en t o f c lin ica l risk m anage m en t and ca re p lan deve lop m en t w as iden tified by the CQ C . T h is is like ly to have im p lica tions upon con tinu ity o f pa tien t ca re p lann ing and risk m an a g e m e n t.


19 /05 /2016

R o s ie M usson

Dr Mark Weaver

Dr Kate Gingell

Patient Safety and Compliance Team

Bob Yardley

4 4 R ed

16 R ev ie w o f risk assessm en t te m p la te has been co m p le ted in line w ith CP A requ ire m en ts T ra in ing needs ana lys is has been looked a t ac ross the T rus t S po t check o f ca re inpa tien t ca re p lans have been unde rtaken O u tco m e o f spo t checks in re la tion t risk assessm en ts has been p resen te to M HA S C

s4 4 R ed o d

16 T a rge ted rev ie w o f eve ry pa tien ts risk assessm en t and m anage m en t p lan w ith in the Inpa tien t and C ris is / H o m e T rea tm en t se rv ice . (A ug 2017 )

A c tion find ings o f ta rge ted rev ie w in to pa tien ts risk assessm en ts (A ug 2016 )

W he re a tra in ing need is iden tified , spec ific suppo rt and ta rge ted ac tions and supe rv is ion im p le m en ted to m on ito r. (A ug 2017 )

T a rge ted rev ie w o f eve ry pa tien ts C a re P lan w ith in the Inpa tien t and C ris is / H o m e T rea tm en t se rv ice (A ug 2017 )

F u rthe r im p le m en ta tion o f M y C a re P lan (O ngo ing )

R egu la r spo t checks o f risk assessm en ts to be co m p le ted (S ep t 2016 and ongong )

4 1 G reen

4 R epo rts to M H A S C

C lin ica l A ud it o u tc o m es

01 /05 /2017

I t w as ag reed by Q ua lity and S a fe ty C o m m ittee fo llo w ing a rev ie w as pa rt o f a risk deep d ive , tha t th is risk shou ld re m a in as a red risk to the T rus t.


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L


D a te o f R ev ie


320 T he T rus t has a lack o f c lea rly de fined p rocesses and po lic ies in respect to the use o f pe rsona l a la rm s , the p rov is ion o f ca ll a la rm s w h ich a llied to an add itiona l need fo r pe rsona l sa fe ty tra in ing fo r s ta ff has the ab ility to im pac t upon the hea lth and sa fe ty o f bo th s ta ff and pa tien ts , especia lly w hen s ta ff a re w o rk ing on the ir o w n .


19 /05 /2016


Phil Clark (Head of Estates)

Andrew Foley (Health and Safety Officer)

Team Manager

Tom Jinks

4 4 R ed

16 C o m m un ica tion has been issued to tea m m anage rs rega rd ing the use o f pe rsona l a la rm s w ith a reques t to deve lop an ind iv idua l loca l p ro toco l. A g ile w o rk ing po licy has been deve loped w h ich h igh ligh ts ro les and responsib ilities in respect to the use o f m ob ile dev ices w hen lone w o rk ing Lone w o rk ing po licy has been re -co m m un ica ted co m m un ica ted to s t a f f . P rov is ion o f ca ll a la rm s a t A ncho r M eado w and pop la rs has been rev ie w ed R ev ie w o f a ll trus t p re m ises to be co m p le ted and assessed aga ins t ag reed s tanda rds fo r a la rm sys te m s (co m p le ted ) A T NA has been co m p le ted in respect to iden tify ing w ha t s ta ff requ ire pe rsona l sa fe ty tra in ing , inc lud ing a rev ie w o f the con ten t o f such tra in ing F unding has been iden tified and tw o ne w sys te m s have been ins ta lled an tw o sys te m s upg raded , a ll p rocedu re have been rev ie w ed . R ev ie w has been co m p le ted ac ross the tw o co m m un ity s ites . P e rsona l S a fe ty tra in ing needs a re re flec ted in the T rus ts T NA m a trix . T h is has been rev ie w ed a longs ide M A P A ® tra in ing . R epo rt on M H A and M A P A tra in ing co m p liance sub m itted to the M HA S c ru tiny C o m m ittee m ee ting 17 .08 .16

4 4 R ed

d s

16 R isk to be tes ted by nex t round o f T rus ts suppo rtive v is its , w ith a focus upon co m m un ity se rv ices (S ep t 2017 )

4 1 G reen

4 C o m p le tion o f loca l p ro toco ls

A ud it resu lts

E s ta tes and C ap ita l P lann ing P ape rs

01 /05 /2017

I t w as ag reed as pa rt o f a deep d ive in to the T rus ts red risks tha t th is risk shou ld re m a in on as a red risk , bu t shou ld be s tress tes ted as pa rt o f the nex t round o f T rus ts suppo rtive v is its (w ith a focus upon co m m un ity se rv ices )


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L




322 T he T rus ts assessm en t by the C Q C no ted tha t the re m ay be a lack o f ev idence to suppo rt tha t ca lls w ith in the T rus ts C ris is tea m a re responded to in a tim e ly m anne r


19 /05 /2016


Rosie Musson

Crisis team

3 5 R ed

15 A ne w c ris is ca ll log has been dev e loped A s tanda rd has been ag reed tha t if a ca ll is no t re tu rned w ith in the hou r an inc iden t fo rm w ill be sub m itted P rocesses have been co m m un ica ted to s ta ff A ud it in to co m p liance has been c o m p le ted

3 5 R ed

15 C a ll log to be re -aud ited and a risk deep d ive to be p resen ted to Q ua lity and S a fe ty C o m m ittee (A p ril 2017 )

R epo rt in to co m p liance to be p resen ted to C lin ica l A ud it and E ffec tiveness C o m m ittee

3 1 G reen

3 Inc iden t figu res C lin ica l A ud it R e s u lt s

03 /04 /2017

A 2nd aud it has been co m m iss ioned in re la tion to assessing the response tim es a round c ris is ca lls .

T he ins ta lla tion o f a c ris is ca ll log is m en tioned w ith in the T rus ts CQ C repo rt (fro m N ov 2016 v is it) as a pos itive s tep . W h ils t the in itia l issue a round a "lack o f log " has been add resse the w ill need conc lude w he the r the response tim e is app rop ria te . T h is is to be fu rthe r rev ie w ed in ligh t o f the CQ C repo rt by the C Q C s tee ring g roup .

d


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L


D a te o f R ev ie


323 F a ilu re o f the T rus t to ach ieve its m anda to ry and essentia l tra in ing m ay resu lt in s ta ff no t be ing app rop ria te ly sk illed to unde rtake the ir ro le and im pac t upon the T rus t m ee ting co m p liance w ith CQ C s tanda rds and im pac t upon the qua lity o f pa tien t ca re


19 /05 /2016

A sh i W il l ia m s

Becky Temple-Purcell

3 3 A m be r

9 R ev ie w o f T ra in ing tra jec to ries and co m p liance leve ls to be co m p le ted fo r bo th m anda to ry and essentia l tra in ing has been co m p le ted P e rsona l S a fe ty T ra in ing and M HA T ra in ing a re no w inc luded as pa rt o f the T rus ts tra in ing ca lenda r P e rsona l S a fe ty tra in ing needs a re re flec ted in the T rus ts T NA m a trix . T h is has been rev ie w ed a longs ide M A P A ® tra in ing . L R P gu idance cove red in recen t tra in ing sess ions de live red has been inco rpo ra ted w ith in M A P A ® tra in ing fo r fu tu re sess ions ensu ring tha t a ll s ta ff tha t jo in the T rus t to w o rk w ith in Inpa tien ts w ill rece ive th is in fo rm a tio T ra in ing needs ana lys is has been unde rtaken ac ross inpa tien t a reas . R ev ie w o f M HA tra in ing unde rtaken by M HA m anage r and W o rk fo rce D e v e lo p m e n t. T ra in ing needs ana lys is has no w been co m p le ted and is be ing rev ie w ed ac ross O lde r A du lts S e rv ic line .

4 4 R ed n e

16 T o rev ie w and ag ree cu rren t essentia l tra in ing requ ire m en ts fo r s ta ff g roups inc lud ing co m p liance ta rge ts (Ju ly 2017 )

E nsu re tha t co rrec t tra in ing p rov is ion and m e thods fo r essentia l tra in ing requ ire m en ts a re in p lace (Ju ly 2017 )

T ra jec to ries ag reed fo r each se rv ice a rea to m a in ta in a ll yea r round c o m p l ia nc e .

S ta ff no t co m p lian t w ith 7 -8 M T m odu les o be m anaged in accordance w ith the C apab ility P o licy

Heads of Service be sent an email from CEO detailing the requirement to bring essential and mandatory training up to the agreed compliance level. Heads of Service will be required to attend workforce committee where this is not the case

4 1 G reen

4 T ra in ing repo rts to co m m ittees

T ra in ing da ta on E S R

10 /05 /2017

R isk rev ie w ed by Q ua lity and S a fe ty C o m m ittee . it w as no ted tha t due to fu rthe r w o rk be ing requ ired in re la tion to th is (as iden tified by the T rus ts N ove m be r 2016 C Q C v is it and its associa ted ac tion p lan ) it w as fe lt tha t th is risk shou ld be upg raded to a red risk (w ith the ag ree m en t o f the T rus ts w o rk fo rce co m m ittee ).

F u rthe r ac tions shou ld be upda ted in line w ith the T rus ts ne w CQ C ac tion p lan .

T h is dec is ion w as fu rthe r app roved by the T rus ts w o rk fo rce co m m ittee and a dec is ion w as m ade to re -sco re the risk as a red r i s k .

T he add itiona l ac tions in re la tion to th is risk a re cu rren tly be ing a ligned to the T rus ts CQ C ac tion p la

n


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L


D a te o f R ev ie


341 F ire S a fe ty M anage m en t w ith in the T rus t

E x is ting R epo r ting S y s t e m s

19 /05 /2016


Phil Clark STK (Fire Safety Advisors)

Marsha Ingram

Rosie Musson

Neil Tong

5 4 R ed

20 A ll s ites m a in ta ined by the T rus t have a spec ific F ire R isk A ssess m e in P lace . P P M s a re in p lace as requ ired by H T M s A ll m a ttresses a re 5 and o r 7 C rib ra te d . M anda to ry tra in ing is in p lace . F ire S a fe ty P o licy has been upda ted and re -ra tified N u m be r o f fire requ ired fire m a rsha ls has been iden tified A D T and M id w es t F ire S e rv ices hav been co m m iss ioned to p rov ide a se rv ice w h ich add resses so m e o f th gaps in assurance . S u itab le and su ffic ien t assessm en t fire risk assessm en ts to be unde rtaken a long w ith an aud it o f doc u m en ta tion .

5 4 nts R ed

e

e

o f

20 A ssu rances to be w o rked up in re la tion to E lec tric ity a t w o rk regu la tions and the associa ted 5 yea r tes ting . (A con trac to r has a lready been con tac ted rega rd ing the co m p le tion o f th is w o rk , co m p le tion da te TB C )

P rog ra m o f m a ttress rep lace m en t to be co m p le ted to ensu re tha t a ll m a ttresses a re ra ted as C rib 7 (C o m p le tion da te TB C )

A g reed nu m be r o f fire m a rsha ls to be tra ined . T h is has been co m p le ted fo r the T rus ts hosp ita l s ites . The nex t phase o f th is w o rk w ill focus on co m m un ity a reas

P rog ra m o f fire doo r rep lace m en t fo r the D o ro thy P a ttison S ite (da te TB C )

5 2 A m be r

10 S T K F ire M anager

F ir e c o m p a r tm e n ta tio n a s s e s s m e n ts

F ire R isk a s s e s s m e n ts

T ra in ing figu res

01 /05 /2017

R isk to re m a in on the risk reg is te r as a red risk . F ire sa fe ty g roup m anag ing th i risk and con tinue to m ee t on a fo rtn igh tly bas is

s


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L


D a te o f R ev ie


289 C hanges to the loca l in te ragency 136 po licy m ay leave to T rus t open to repu ta tiona l risks a round its im p le m en ta tion . It is no ted tha t on ly one doc to rs w as requ ired fo r a S ec tion 12 and an A M HP . S hou ld an ins tance a rise w he re a second doc to r w as requ ired they w ou ld be c a lle d .

T he re w e re a lso no ted issues docu m en ted as pa rt o f the T rus ts N ove m be r 2016 C Q C V is it. N a m e ly in re la tion p rocesses a round the sa fe ope ra tion o f the T rus ts 136 su ites

E x is ting R epo r ting S y s t e m s

15 /10 /2015


Rosie Musson, Hassan Omar, Anne-Marie Carey

4 4 R ed

16 A n in itia l ve rs ion o f the po licy has been d ra fted and is cu rren tly be ing consu lted upon .. It is the in ten tion tha t on ly 1 doc to r and an A M HP w ill be requ ired fo r a S ec tion 12 and an A M H P . P a rtne rsh ip G roup had s igned o ff the 136 po licy in the m a in

4 4 R ed

16 R ev ie w ing N a tiona l S tanda rds fo r 136 su ites to de te rm ine env iron m en ta l requ ire m en ts (Ju ly 2017 )

T o unde rtake a rev ie w o f the 136 su ite aga ins t requ ire m en ts (Ju ly 2017 )

T o m ake a lte ra tions to env iron m en t to ensu re su ite m ee ts the needs o f the requ ire m en ts (Ju ly 2017 )

T o unde rtake spo t checks o f env iron m en t on an on -go ing bas is (Ju ly 2017 )

It is no ted tha t a lthough the P a rtne rsh ip G roup had s igned o ff the 136 po licy in the m a in the re w e re s till so m e re m a in ing issued to be w o rked th rough .

D irec to r o f O pe ra tions and N u rs ing to p rov ide inpu t in to the po licy

4 1 G reen

4 P a rtne rsh ip G roup M ins

26 /05 /2017

F o llo w ing d iscuss ion a t the T rus ts M H A S C in ligh t o f the find ings o f the N ove m be r 2016 C Q C v is it it w as no ted tha t th is risk shou ld be escala ted to the s ta tus o f a red risk .

It is acknow ledged tha t the con tro ls w ill requ ire a lign ing w ith the T rus ts C Q C ac tion p lan


R isk N o .



D a te Iden tified



In itia l S co re

S L

C o n t r o l s

C u r r e n t

S c o r e

S L


R e s id u a l

S c o r e

S L


D a te o f R ev ie


379 S ho rtage o f N a tiona l Jun io r psychia tric tra inees fro m A ugus t's ro ta tion m ay im pac t on pa tien t ca re due to reduced w o rk fo rce c a p a c i t y

W o r k f o r c e S t a t is t ic s

06 /06 /2017

A sh i W il l ia m s

Dr Mark Weaver

Dr Kate Gingell

4 4 R ed

16 4 4 R ed

16 R ev ie w o f on ca ll a rrange m en ts

U se o f agency/locu m s

4 2 A m be r

8 W o r k f o r c e c o m m i tt e e

06 /06 /2017

R isk added as a red risk fo llo w ing d iscuss ion a t T rus t B oa rd , w he reby it w as sugges ted tha t th is risk w ou ld be added to the risk reg is te r as it w ou ld need be c lose ly m on ito red and it m ay be necessary t rev ie w the on ca ll a rrange m en ts if the sho rtfa ll w as no t add ressed.

A dd itiona lly sou rc ing su itab le agency locu m cove r re m a ined cha lleng ing fo llo w ing the agency cap and o the r changes in locu m sho rt te rm e m p loy m en t a rran g e m e n ts .

o



Agenda Item number: 10.1 Enclosure: 29

Report Title:

MExT Committee Chair’s Report

Committee:

MExT meeting held on 27 June 2017


Mark Axcell, Chief Executive Paul Lewis-Grundy Company Secretary


Decision / Approval

Gain assurance

Discussion

Information

Key issues and Risks MExT received a presentation on MERIT from a representative from Coventry and Warwick Partnership Trust. MExT received the following items:

• Chief Executive’s Update • Heatwave Planning Update • Service Line Reviews • Verbal updates from the Joint Medical Directors, the Nursing Director, the Operations

Director and the HR Director • Director of Finance Report (Month 2 Financial position) • Cash Releasing Efficiency Savings Planning Process 2018/19 • CIP Report • Service Developments / Changes • Social Inclusion and Section 75 update • Communications update • Review of MExT Terms of Reference • OA Inpatient Wards (DPH) Update

MExT received the following business cases/service proposals

• Caseload Management Tool Implementation Plan which was agreed as a pilot • Physical Health CQUIN Strategy • TCT integration Support HR Support Business Case • Mental Health First Aid

Enc 29 MExT Chair's Report (Final) Page 1 of 2

Interfaces with other Committees The business that was discussed by MExT interfaces with the following Committees/Groups:

• Audit Committee • Quality & Safety Committee • Finance & Performance Committee • Workforce Committee • Trust Board

Recommendations and requests for direction The Board is asked to receive this report from MExT for information and assurance.

Enc 29 MExT Chair's Report (Final) Page 2 of 2