Agenda for a Meeting of the AWP NHS Trust Boards3.amazonaws.com/zanran_storage/ · Agenda for a...

Agenda for a Meeting of the AWP NHS Trust Board To be held on Wednesday 30 November 2011

Meeting Location: Jenner House. Chippenham, Conference Meeting Room

This Agenda is for Information in the Part One of the Board

This Agenda is Sponsored by the Chair of the Trust Board of Directors

Part One Session

Members of the public wishing to provide questions, comments or feedback for the Board are invited to provide these to the Company Secretary prior to the start of the meeting

using the form provided. The Chair may limit the length of time allocated to each question, comment or feedback, according to the Agenda. Remaining questions will be

answered within 10 days of the Board meeting.

Pre Board Quality Presentation

Lynda Hughes – Forget Me Not Centre Manager / Occupational Therapy Manager, Victoria Centre

Item Title Sponsor Action Serial

Administration

1. Apologies Chair Note 11.0701

2. Declarations of Members’ Interests In accordance with AWP Standing Orders (s7.1), all members present are required to declare any conflicts of interest with items on this agenda

Chair Declare 11.0702

3. Minutes of the previous Meeting of the Board

Chair Approve 11.0703

4. Matters Arising from Previous Meetings Chair Review 11.0704

Chair’s and Chief Executive’s Reports

5. Chair’s and Chief Executive’s Actions Chair Note 11.0705

6. Chair’s Report - verbal Chair Note 11.0706

Agenda for a Meeting of the AWP NHS Trust Board, 30 November at 10:00

Sponsor: Chair Serial: 11.0701 Page 2 of 4


7. Chief Executive’s Report Chief Executive Note 11.0707

Quality, Safety, Standards and Compliance

8. Monitor Compliance Dashboard Appendix: The Monitor Compliance Dashboard

Chief Executive Note 11.0708

Executive Reports

9. Finance Report Appendices: Appendix 1 – Statement of Comprehensive Income Appendix 2 – Cash funding statement Appendix 3 – Statement of Financial Performance Appendix 4 – Capital Appendix 5 – Monitor metrics Appendix 6 – Monitor potential financial risk indicators Appendix 7 – Statutory duties Appendix 8 – Cash Flow

DoF Approve 11.0709

10. Medical and Strategy Status Report Appendix: Appendix A – Appraisal Policy on Medical Staff

Exec Dir M&S Note 11.0710

11. Nursing, Compliance, Assurance and Standards Status Report Appendix: Appendix A – NCAS Work Programme 2011/12

Exec Dir NCAS Note 11.0711




Special Interest Reports, Strategy, Business Planning, Risk, Communications and Any Other Business

12. FT Programme Report Appendices: Appendix 1 – Monthly Membership Target and breakdown on representation Appendix 2 – Monthly Membership Activity and constituency targets 2011/12 Appendix 3 – Tri-Partite Formal Agreement, September 2012

Chief Executive Note 11.0712

13. Communications Report

Chief Executive Decision 11.0713

14. Committee Minutes: Mental Health Legislation Committee– 8 September 2011 Quality and Healthcare Governance Committee - 4 October 2011

Committee Chair

Note 11.0714

15. Any Other Business. Date of the Next Meeting – 21 December 2011, Jenner House, Chippenham

Chair Note 11.0715


Key to Abbreviations

Abbreviation For

DoF Executive Director of Finance and Commerce, and Deputy Chief Executive

Exec Dir People Executive Director for People

Exec Dir M&S Executive Medical Director and Director of Strategy and Business Development

Exec Dir NCAS Executive Director of Nursing, Compliance, Assurance and Standards

Exec Dir Ops Executive Director of Operations

Dir FTP Foundation Trust Programme Director

CoSec Company Secretary

ACoSec Assistant to Company Secretary

(L) Items marked (L) are those for which papers have an exemption to be circulated in the second agenda pack.


Minutes of a Meeting of the AWP NHS Trust Board of Directors

Held on 26 October 2011 at 10:00 in Chippenham, Jenner House, Conference Meeting Room

These Minutes are presented for Information in the Part 1 session of the Board

Sponsor: Chair

Board Members Present

• Felicity Longshaw - Chair • Lee O’Bryan – Non-executive Director • Alison Paine – Non-executive Director • Susan Thompson – Non-executive Director• Peter Greensmith – Non-executive Director• Jim McAuliffe - Non-Executive Director

• Laura McMurtrie – Chief Executive • Paul Miller – Executive Director of Finance

and Commerce, and Deputy Chief Executive

• Julie Thomas – Executive Director for People

• Hazel Watson - Executive Director of Nursing, Compliance, Assurance and Standards

• Andy Sylvester - Director of Operations • Arden Tomison -Executive Medical

Director, and Director of Strategy and Business Development

In Attendance

• Jennifer Lock – Assistant to Company

Secretary • Mike Relph – Assistant Chief Executive

• Jill Thompkins – LINKs

• Sharon Weaver – PA to the Chair

• Alan Metheral – Deputy Director of Nursing, Compliance, Assurance and Standards

Item Action

1. Apologies 1.1. Apologies were received from Tony Gallagher (Non-executive Director),

Emma Roberts (Company Secretary) and Jane Britton (FT Programme Director).

1.2. Felicity Longshaw welcomed Lee O’Bryan to his first Board meeting as Non-Executive Director. He had attended the previous two Board meetings as an Associate Director. Andy Sylvester was also welcomed to the Board meeting in his new role as Director of Operations. Lindsey Scott’s last day as Executive Director of

Board Meeting Minutes – Public Session – 26 October 2011

Minutes Prepared for the AWP NHS Trust Board dated 26 October 2011

In the Public session, sponsored by the Chair

Agenda Item: 003 Serial: 11.0303 Page 2 of 9

Item Action

Operations was noted as the 25 October 2011.

2. Declarations of Members’ Interests 2.1. In accordance with AWP Standing Orders (s7.1), all members present are

required to declare any conflicts of interest with items on the Board Meeting Agenda.

2.2. There were no conflicts of interest declared.

3. To approve the Minutes of the Meeting held on 28 September 2011 3.1. The Board considered the minutes of the previous meeting and

resolved to approve them as an accurate record of the business transacted at the meeting, subject to the following amendments which would be made by the Assistant to the Company Secretary:

In relation to minute 9.3 – Alison Paine is no longer on the Board of Brunel Care. Also, Susan Thompson’s title as Chair needs to be amended to Chair of the Law Society’s Mental Health and Disability Committee.

ACoSec

4. Matters Arising from Previous Meetings 4.1. The Board resolved that all matters arising be recorded as complete as

shown in the matters arising log.

5. Chair’s and Chief Executive’s Actions 5.1. The Board resolved to note that there were no actions taken by the Chair

and Chief Executive on behalf of the Board, up to and until 26 October 2011.

6. Chair’s Report 6.1. The Board received and considered an oral Report 11.0606 by Felicity

Longshaw and noted that:

• Felicity and Julie Thomas attended the Staff Awards, to present the awards to staff. The event was an excellent experience and was hugely enjoyed by all who attended.

• AWP is now part of the Southern SHA “Cluster”. The cluster now has its Executive Team in place. The Chair of the cluster is Jeff Harris. Boards within the cluster have been advised that they need to take a broad perspective in relation to success of their whole health economies not simply focus on their individual organisations.

• Felicity attended the Mental Health Network Board this month. Further information on this would be provided in Part 2 of the meeting due to its confidential nature.

6.2. The Board resolved to note the report.





Item Action

7. Chief Executive’s Report 7.1. The Board received and considered Report 11.0607 presented by the

Chief Executive. 7.2. The purpose of the report was to highlight key strategic issues associated

with quality, safety, financial sustainability and modernisation relevant to the Trust.

7.3. From the written report, Laura McMurtrie highlighted the following areas:

• The Finance and Performance Recovery Board continues to meet weekly.

• There are still stubborn areas of performance in particular SBUs. There is good improvement in other areas.

• Patient Safety Walkabouts – There were recently two very successful patient safety walkabouts.

• A report on the Improvement and Modernisation Programme Board would be provided in Part 2 of the Board meeting.

• Laura explained that discussions continue with Commissioners through the Directors of Commissioning group and the through the six local modernisation boards in respect of our service redesign plans, with strong positive responses in respect of the proposals for primary care liaison.

• Laura had a very positive meeting with the Chief Executive of the Bristol Cluster. Further details would be discussed in Part 2.

• The organisation is still awaiting the publication of the serious untoward incident homicide reports. All other work in relation to the FT journey continues.

• Laura highlighted the corporate governance headlines detailed in the report. 7.4. Laura gave the Board the following updates which had arisen since the

report was written:

• Director of Psychology (Bill Jerrom) has retired. He made a significant contribution to AWP during his career. An event took place to mark his retirement the previous week at Callington Road.

• Lindsey Scott’s last working day was Tuesday 25 October 2011. Laura welcomed Andy Sylvester into the role of Director of Operations.

• Laura remarked on how well received the Staff Awards Event was. Many positive comments were made by the staff who attended.

• The launch of the South West Veteran Project has taken place. The project is an excellent example of partnership working for AWP. It was noted that other partnership agreements were to be





Item Action

considered in Part 2. 7.5. Susan Thompson asked for information about the Commission Coalition

conference taking place in December. It was agreed that AWP would ask for the meeting papers, and only send an attendee if it was felt necessary.


8. Monitor Compliance Dashboard 8.1. The Board received and considered Report 11.0608 sponsored by the

Chief Executive. 8.2. The report provides a strategic level insight into key areas of performance

in the “Monitor Compliance Dashboard” to the Board for confirmation. 8.3. The Board noted that the dashboard is fully Green and therefore the risk

rating is 0 for Monitor Compliance at this time, which demonstrates excellent progress.


9. Integrated Patient Experience Report 9.1. The Board received and considered Report 11.0609 presented by the

Executive Director of Nursing, Compliance, Assurance and Standards. 9.2. The purpose of the Integrated Patient Experience report is to provide the

Board with clear information and evidence relating to the patient experience across the Trust.

9.3. Hazel brought the Board’s attention to the real time surveys. The report gives examples of how SBUs are responding to the feedback of the surveys.

9.4. The report appendices illustrate the amount of patient experience work taking place within the organisation.

9.5. It was agreed that Hazel Watson would report a summary of the carer surveys in her next report to the Board.

9.6. Felicity Longshaw explained that the organisation now needs to focus on what actions are being taken as a result of the trends found. Hazel Watson agreed to take this area of work forward.

9.7. It was suggested that the CQC Quality and Risk profile would be included in the next Integrated Patient Experience Report.

9.8. Alison Paine suggested that it would be a good idea to balance the amount of qualitative examples of praise, with some qualitative examples of complaints. Hazel to action this change in the next report.


Exec Dir NCAS

Exec Dir NCAS

Exec Dir NCAS





Item Action

10. Charitable Funds Annual Report and Accounts 10.1. The Board received and considered Report 11.0610 presented by the

Executive Director of Finance and Commerce, and Deputy Chief Executive.

10.2. The purpose of the report was to present to the Board the Annual Report for AWP Charitable Funds for approval.

10.3. One aim of the committee is to encourage the use of the funds. Paul Miller explained the current charitable funds balance is £306,000. Only £126,000 of this is unrestricted funds. The Committee needs to continue to focus on income generation.

10.4. The Board approved the Annual Report, the statement of Financial Accounts and Letter of Representation. The Board resolved to delegate authority to the Chief Executive and Chair to sign the accounts before submission to the Charity Commission.

Chair and Chief Exec

11. Finance Report 11.1. The Board received and considered Report 11.0611 (and 8

appendices) presented by the Executive Director of Finance and Commerce, and Deputy Chief Executive.

11.2. The report provided an update on the Trust’s financial position as at 30th September 2011. The report also clarified main themes impacting on the Month 6 financial position.

11.3. Paul Miller asked the Board to note the following issues:

• Month 6 surplus of £118k against planned FIMs surplus of £100k

• The cumulative position is an actual surplus of £558k against a planned FIMs surplus of £735k

• Pay expenditure is the largest area of spend within the organisation and there is an in month overspend of £236k on a budget of £11,465k. The main reason for the over spend is that the implementation of the service redesign has not happened yet as planned and some of the associated savings have not been realised

• Temporary staff costs have seen a large increase of £220k between Month 5 and Month 6

• Adverse variance on non pay expenditure of £147k

• Cash Balance of £6,868k 11.4. The Board resolved to note the report, and approve the capital

scheme for the service redesign at Bybrook lodge and the capital scheme for the Blackberry centre dispensary.





Item Action

12. Operations Directorate Status Report 12.1. The Board received and considered Report 11.0612 sponsored and

presented by the Director of Operations, Andy Sylvester. 12.2. The report briefed the Board on operational activity in the past quarter

and the key issues for the coming quarter. It also reported on Estates and Facilities key performance indicators, and provided an update on the Operational Annual Plan.

12.3. From the written report Andy Sylvester highlighted that:

• Kristin Dominy has been appointed as the SDAS Service Director.

• The 24-hour switchboard is now up and running. It is proving to be very successful.

• Susan Thompson commented that the report’s new format is a great improvement.


13. People – Status Report 13.1. The Board received and considered Report 11.0613 sponsored by the

Executive Director of People. 13.2. The report briefed the Board on activity in the last quarter within the

People Directorate as well as future strategic planning. 13.3. Julie Thomas gave an overview of the report and asked the Board if

they had any questions. 13.4. Jim McAuliffe expressed his concern that 386 AWP staff are being

managed for sickness absence. He explained that this is a high figure, as it represents approximately 10% of our workforce. Julie Thomas said that this is probably partly due to a moral issue due the uncertainty associated with redesign. Lee O’Bryan suggested that this figure could be broken down to show the formal and informal levels of sickness management within this figure. Julie to report back on this as a Matters Arising at the November Board meeting.


Exec Dir People

14. Accountability Framework 14.1. The Board received and considered Report 11.0614 sponsored by the

Chief Executive. 14.2. The purpose of the report was to brief the Board on the annual review

and updating of the Organisational Accountability Framework. 14.3. The Board reviewed the framework and agreed to approve it, based

the following amendments being made:





Item Action

• Add a reference to Board committees in the framework.

• The section on service users and carers needs to be expanded to provide a better description of how AWP is accountable to them.

• Add a note to say that the framework will be refreshed when AWP becomes a Foundation Trust.

• Each SBU section needs to state the importance of functioning within their budget.

• Alter the Directorate accountability statements so they are aligned in relation to their accountability. State what all Directorates are accountable for and then distinguish individual Directorate accountabilities.

• The above amendments needed to be made within the next two weeks. 14.4. The Board resolved to approve the framework.

Arden Tominson and Ann Tweedale

15. FT Programme Report 15.1. The Board received and considered Report 11.0615 sponsored by the

Chief Executive. 15.2. The report updated the Board on progress in key areas of the

Foundation Trust work programme in the last month. 15.3. Laura McMurtrie gave an overview of the report, highlighting key

points. 15.4. Laura highlighted the excellent work taking place to engage members.

The first members’ event is taking place on 25 November, at Callington Road. Felicity Longshaw invited Non-Executive colleagues to attend the event.

15.5. Susan Thompson highlighted the issue of under representation for the male groups and the over 65 group. She stressed that effort needs to continue to increase representation in these groups. An update on this would be provided in the next FT report. Hazel Watson to work with Jane Britton and Nicolette Vos to make sure this is included in the next report.

15.6. It was noted that the report needed to be amended to ensure the correct spelling of Lee O’Bryan.


NEDs Hazel Watson/Jane Britton

16. Communications Report 16.1. The Board received and considered Report 11.0616 sponsored by

the Chief Executive, and presented by the Assistant Chief Executive. 16.2. The following items were agreed as Board messages to be

communicated through the Team Brief:

Assistant

Chief Exec





Item Action

• Patient Safety briefing

• Aims Accreditation

• Monitor Compliance Dashboard 16.3. The Board agreed the items for inclusion in the October 2011 team

brief and resolved to note the Communications report.

17. Committee Minutes: 17.1. The Audit Committee minutes for the meeting that took place on 6

June, and the minutes for Quality and Healthcare Governance Committee that took place on 5 July 2011 were both noted by the Board.

18. Committee Chair Reports – Exception reporting 18.1. There was no Committee Chair exception reporting for October 2011.

19. Any Other Business 19.1. There was no other business to report.

20. Next Meeting 20.1. The date of the Next Meeting was confirmed as Wednesday 30

November 2011, Jenner House, Chippenham, Conference Meeting Room.





Key to Abbreviations Used

Abbreviation For

Chief Exec Chief Executive

DoF Executive Director of Finance & Commerce, and Deputy Chief Executive

Exec Dir People Executive Director for People

Exec Dir M&S Executive Medical Director and Director of Strategy and Business D l

Exec Dir NCAS Executive Director of Nursing, Compliance, Assurance & Standards

Exec Dir Ops Executive Director of Operations

Dir FTP Foundation Trust Programme Director

CoSec Company Secretary

ACoSec Assistant to the Company Secretary

EMT Executive Management Team

SBU Strategic Business Unit

NED Non-executive Director

AWP Board Schedule of Matters Arising Public Session As at: 29/11/2011 05:42 PM

Boa

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Boa

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Doc

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t Se

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Age

nda

Item Topic Action Required

Ass

igne

d To

Dat

e D

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Not

ed

Com

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e/C

arrie

d Fo

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/F)

Com

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26-Oct-2011 11.0609 9 Integrated Patient Experience Report Hazel Watson to report a summary of the carers survey in her next report to the Board Exec Dir NCAS Next NCAS Status Report

Still to be completed

26-Oct-2011 11.0609 9 Integrated Patient Experience Report It was agreed that the CQC Quality and Risk profile would be included in the next Integrated Patient Experience Report.

Exec Dir NCAS Next Integrated Patient Exp Report

Carried Forward to next Integrated Patient Experience Report

26-Oct-2011 11.0610 10 Charitable Funds Annual Report and Accounts The Board approved the Annual Report, the statement of Financial Accounts and Letter of Representation. The Board approved that the Chief Executive and the Chair would sign these documents on behalf of the Board.

Chair and CEO ASAP Completed on 2nd November 2011

Complete

26-Oct-2011 11.0613 13 People Status Report Figures of management of sickness absence to be broken down into formal and informal figures. Julie to report under Matters Arising at the November Board meeting.

Exec Dir People November Board

Julie to report information at November Board meeting

26-Oct-2011 11.0614 14 Accountability Framework Amendments agreed by the Board to be made to the Accountability Framework. Exec Dir M&S Within next two weeks

Complete Complete

26-Oct-2011 11.0615 15 FT Programme Report Susan Thompson highlighted the issue of under representation for the male groups and the over 65 group. She stressed that effort needs to continue to increase representation in these groups. An update on this would be provided in the next FT report. Hazel Watson to work with Nicolette Vos to make sure this is included in the next report.

Exec Dir NCAS/Dir FT November Board

Due to be reported at November Board meeting

26-Oct-2011 11.0616 16 Communications Report The following items were agreed as Board messages to be communicated through the Team Brief:• Patient Safety briefing• Aims Accreditation • Monitor Compliance Dashboard

Assistant Chief Executive Team Brief Complete Complete

Chief Executive’s Report Report for the AWP NHS Trust Board

Meeting Date: 30-11-2011

Meeting Time: 10:00

Agenda Item: 07

Serial: 11.0707

This Report is presented by the Chief Executive for Noting in Part One of the Board

Report sponsor – Chief Executive

Report Summary

Purpose of this Report: This is the monthly report of the Chief Executive. The report highlights key strategic issues associated with quality, safety, financial sustainability and modernisation relevant to the Trust. The report also updates on the work of the Chief Executive’s Office, and her own contribution to the national, regional and local agendas in the context of leading the organisation.

Board Decisions Recommended: The Board is recommended to note the report.

Actions Arising from the Report: None specific

Quality and Safety Implications of the Report: Quality and Safety best practice is shared via the dissemination of information in the Chief Executive’s briefing.

Report Links

ALE All

CQC All

IG Toolkit All

Corporate Risk Register All

Chief Executive’s Report

Report for the AWP NHS Trust Board

In the Public session, sponsored by the Chief Executive

Agenda Item: 11.0707 Item: 07 Page 2 of 8

1. Overview of the month

1.1. Work continues to ensure that the Trust maintains and improves its quality arrangements and meets its financial control total, and colleagues are working incredibly hard to achieve this in the challenging financial climate.

1.2. In respect of the Trust’s financial position, there are reports elsewhere on the agenda detailing our progress in reaching our year end control total. We remain committed to ensuring that this is achieved and have the commitment and focus of the whole of the Extended Management Team to do so.

1.3. In respect of the overall quality of our services, we continue to make progress to achieve improvements in a number of quality targets and indicators.

1.4. On Thursday 3 November the Chief Executive opened the Trust’s annual Nursing Conference prior to going on two weeks leave.

1.5. An Expression of Interest under the Department of Health’s Right to Provide initiative has been received and will be considered following national guidance.

2. Quality and Safety highlights

2.1. At the time of the Board Meeting, there should have been one Executive Patient Safety Visit since the last Board Meeting; to Juniper Ward in Weston-super-Mare, led by Andy Sylvester. An internal audit, focusing on actions arising from the visits, is planned for January 2012. There are currently no issues of concern to report to the Trust Board.

3. Improvement and Modernisation Programme

3.1. Work in the Trust's Improvement and Modernisation Programme this month has focused on two main areas; maintaining momentum for the delivery of imminent service changes, and commencing longer term service and efficiency planning with a main focus on 2012/15.

3.2. In terms of service change in year, plans remain on track for the launch of the new Primary Care Liaison Services in each local area in the new year, closely linked to Intensive Services to ensure a 24/7 response to local mental health needs.

3.3. For the longer term, a detailed review has commenced, across all Directorates and Strategic Business Units, of plans to deliver the service and financial targets of the Integrated Business Plan over the entire five year life of the Plan, with the most detailed plans being looked at for the next few years, and 2012-13 plans being aligned to the annual business planning cycle.





4. Discussion with Commissioners

4.1. Ongoing discussions with Commissioners through the Directors of Commissioning group and the through the six local modernisation boards continue in respect of our service redesign plans, with strong positive responses in respect of the proposals for primary care liaison.

5. External Engagement

5.1. On Monday 21 November the Chief Executive attended a BRIG-H leadership away day; the event was for the chief executives of the six partner organisations to agree the strategic development of the proposed Bristol Academic Health Science Cluster (which was briefed by Arden Tomison at our recent seminar) and to draft a collaboration agreement, a constitution and outline job descriptions for its board and management team. An update on the progress made will be given orally at Board.

5.2. The Chief Executive attended the NHS Chief Executives’ Meeting on 24 November, where David Flory and David Nicholson spoke about the detail behind the NHS’ priorities and operating framework for the coming year. A verbal update will be provided during the meeting.

5.3. Laura McMurtrie met with Penny Brown (CE North Somerset Community Partnership) and Janet Rowse (CE Sirona Care and Health Social Enterprise, Bath and North East Somerset) on 25 November 2011. On 28 November she met with Jan Stubbings, CE NHS Swindon and Gloucestershire. She also addressed the General Adult Psychology Academic Programme Lunch at Southmead Hospital on 29 November.

6. The Chief Executive’s Office

6.1. The Chief Executive’s Office comprises the FT Programme team, Company Secretariat, the Communications Team and the Assistant Chief Executive and there are some key issues of note in the following section.

6.2. Assistant Chief Executive

6.2.1. Mike Relph met with Jack Lopresti, the Conservative MP for Filton and Bradley Stoke, Friday 18 November 2011. This was a positive meeting where there was an opportunity to brief Jack on the Trust’s plans to improve services and the challenges faced by front line staff.

6.2.2. On 2 November, Mike Relph represented the Trust at a meeting with the DH, the SHA, the MoD and the RNHRD at Hasler Company, Devonport, to agree the scope and extent of the new Veterans’ Prosthetics Project (triggered by Dr Andrew Murrison’s latest report – ‘A better deal for military amputees’). In parallel, it was agreed that AWP would manage the project, working to CE RNHRD. Dr William Bruce-Jones and Andrew Lauder will be





providing clinical mental health input to this important piece of work. The Assistant Chief Executive also attended the South West Armed Forces Forum on 3 November.

6.2.3. The Assistant Chief Executive and the Emergency Planning Team led a live command post exercise on 11 November 2011. A statutory requirement, the event usefully surfaced a number of lessons which will lead to improved emergency planning and business continuity processes and procedures.

6.2.4. Elsewhere, Mike Relph attended the NHS South West Top Leaders Alumini Conference, which celebrated the achievements of the 126 clinical and non-clinical development programme participants from across the region. Guest speakers included Dame Janet Trotter, Dr Sarah Wollaston MP for Totnes, Jan Sobleraj the interim Director of General Workforce at the DH and Tony Laverton from Vodaphone.

6.3. FT Programme Director

6.3.1. Work continues in respect of organisational delivery of fitness for purpose as a competitive, quality NHS provider that supports Foundation Trust status. It is reported elsewhere on this agenda.

6.3.2. In this regard FT Director input has particularly focused on liaison with the SHA in preparation for the DH assessment, the HDD review and has attended several Foundation Trust network events including a south west regional leads meeting for aspirant FTs.

6.3.3. The FT Director represented the Trust at the Foundation Trust Network Chair and Chief Executives Network on 8th November – the time of the November Board seminar.

6.3.4. Key highlights from the key note speakers from Monitor (Stephen Hay, Chief Operating Office and Sonia Brown, Chief Economist) include clarification that Monitor:

• anticipates adopting a more evidence based approach;

• will be seeking input in the next month on its plans to develop new licence conditions prior to statutory consultation;

• will work with the Commissioning Board to establish pricing frameworks. Monitor will set the methodology for pricing and efficiency expectations of the sector - and the NCB will identify what is to be priced e.g. by pathway, product or bundles of care;

• is working on integration by facilitating this for patient benefit rather than ‘integrated’ providers who deliver health and social care - eg though pricing and requirements to share information.





6.3.5. Work continues to develop SBU Business Development Plans for 2012/13, building on their first Business Plans submitted earlier this year. The FT Director chaired a meeting to identify learning from the first round/pilot and build on this.

6.3.6. As a result 2012/13 SBU Business Plans aim to be shorter, focused on business development and reference or attach other supporting documents (for example the SBU Quality Improvement Plan, Scorecard and Risk Register). They will continue to reflect and read across to the IBP and Trust Operating (Annual) Plan - and build on SBU actions to deliver Trust strategic and principal objectives.

6.3.7. In the context of the increasingly embedded annual business planning cycle, and development of a Trust Finance and Commerce strategy, the FT Director has concluded the review of business management activity (including the roll out across the Trust of project management methodology). Within this the FT office undertook a stock take of current activity that highlights the scale of activity and use of resources within that. With the support of key Executive Directors and the Company Secretary the FT Director is now taking forward:

at the strategic level:

• an overarching governance framework that clarifies who commissions projects and business cases, accountability including statutory Board reporting requirements and outlines what tools to use and where to find them;

• an updated and simplified framework for assessing strategic business opportunities that takes into account the Trust business planning cycle and Innovations strategy thereby updating the one agreed by the Board in September 2007;

• clarification of boundaries and scaling ie when something is a dedicated programme of activity, a business case, a project - or is business as usual;

• structured capacity building in mainstream training programmes (eg Managers Tool Kit) plus short, targeted facilitative support to designated project managers via existing dedicated Project Managers and the Service Improvement Manager;

and at the operational level:

• extending the role of the Investment Planning Group (IPG) to address business cases for revenue spend, and change of use of existing resources (with standard documentation) and confirming the Board reporting requirements;





• update and review existing standard documentation; develop ‘light touch’ suite of project management docs and consistent suite of business cases templates;

• provision and updating of guidance that is easy to access alongside standard documents and tools;

• develop the existing Our Space site to share standard documentation, guidance and establish and share a register of projects and business cases;

• wider use and roll out of MS Project.

6.3.8. The FT Director has written and distributed a discussion paper on earned autonomy to XEMT and, with the Chief Executive, is leading a discussion there on 23 November to progress this.

6.3.9. The 3 month period where the FT Director provided additional leadership and advice to the IMP programme concluded in October.

6.3.10. As the FT Director, Jane will continue to be involved in IMP validation and revalidation meetings with project leads regard to planning and delivery of efficiency, enabling and redesign projects. She will also review and scrutinise the audit trails at management and Board level to ensure they will effectively support and evidence Trust fitness for purpose for HDD, Board, DH and Monitor assessment and assurance requirements.

6.4. Company Secretariat and Corporate Governance Headlines

The Health and Social Care Bill and NHS reforms

6.4.1. At the time of writing, the Bill continues towards being passed into Law. The Committee stage of the Lords continues, with over 300 amendments is to be considered over the forthcoming 10 weeks. It is anticipated that the amendments relating to members and the role of Monitor will be debated towards the end of the month.

6.4.2. On 31 October, the NHS Commissioning Board was established in shadow form, with Sir Malcolm Grant nominated as its Chair.

6.4.3. Monitor has published an information sheet summarising how it would exercise its functions under the Health and Social Care Bill as currently anticipated. The key roles are summarised as follows: Preventing anti-competitive behaviour. The Bill initially proposed that Monitor should have a positive role in promoting competition, this has now become a duty to ensure that competition is fair and operates in the best interests of patients. It includes a power to impose license conditions to prevent anti-competitive





behaviour. In addition Monitor would have a key role in ensuring the protection of patients’ ability to have choices about their healthcare. Licensing providers. Under the provisions of the Bill, those wishing to provide NHS-funded services would have to be jointly licensed by Monitor and the Care Quality Commission. The information sheet stresses that the Bill is clear that in exercising its licensing functions Monitor must not favour either public or voluntary providers. Price regulation. From 2013/2014 price setting would be the joint responsibility of Monitor and the NHS Commissioning Board. Integrated care. Monitor’s role as sector regulator would be to work with others, particularly commissioners, to remove barriers to integrated care and in particular to consider how it can facilitate better integrated care for those patients such as the elderly or chronically ill who need to be in contact with a range of health and social care providers. Continuity of service. Monitor would also take a role in supporting commissioners to ensure that in the event of financial failure, a healthcare provider’s patients will continue to access the care they need. Monitor would have a duty of care to come up with a source of finance to draw upon to help providers tackle their financial problems. The mechanism for this is likely to be a “risk pool “, a fund which would be maintained by a levy on providers and commissioners. Accountability. Monitor would remain an independent, non-departmental public body, and would continue to be accountable to Parliament and subject to parliamentary scrutiny; as part of this, the Secretary of State would appoint the chair and non-executive members of Monitor’s board and would have a veto over the proposed chief executive.

Patient Choice

6.4.4. NHS patients in England will have the freedom to choose, not only where, but who provides their hospital care from April 2012, as announced in mid October as part of the ongoing reform programme.

6.4.5. The DH has published guidance in advance of the implementation of patient choice for a named consultant-led team by April next year.

6.4.6. Key points include:

• NHS providers have requirements to accept all clinically appropriate referrals; and





• provide lists of named consultant teams for all services on choose and book and publish information to facilitate choice;

• commissioners are expected to promote choose and book, enable all referrers to have access to that system and ensure all patients have sufficient information; and

• the Government has committed to evaluating and potentially revising the list of services excluded from choice as further initiatives are introduced; services currently excluded from choice of consultant-led team are:

o accident and emergency services; o cancer services, which are subject to the two week maximum waiting time; o maternity services; o mental health services; and o any other services where it is necessary to provide urgent care.

Duty of Candour

6.4.7 The Department of Health is currently consulting on further transparency provisions, requiring NHS providers to be open with patients when things go wrong with their healthcare.

6.4.8 The duty aims to build upon existing professional duties and obligations; it also proposes an enforceable contractual obligation on all organisations providing NHS funded care.

6.4.9 The aim of the proposed contractual “Duty of Candour” is to ensure providers are open and honest with patients, or their families, and that they give them information about any investigations that have taken place or any lessons learned. NCAS is currently collating responses on the consultation and will feed these into the Department.

7. Recommendation

7.1. The Board is recommended to note this report.

Monitor Compliance Dashboard Report for the AWP NHS Trust Board


Meeting Time: 10:00

Agenda Item: 08

Serial: 11.0708

This Report is presented by the Chief Executive for Noting in the Part 1 session of the Board.

Report Sponsor: Chief Executive

Report Summary

Purpose of this Report: To provide a strategic level insight into key areas of performance in the “Monitor Compliance Dashboard” to the Board for confirmation.

Board Decisions Recommended: The Board is recommended to note the current risk rating of 1.

Actions Arising from the Report: None specified.

Quality and Safety Implications of the Report: None specified.

Report Links

ALE All

CQC All

IG Toolkit All


List of Appendices

• Appendix A – Monitor Compliance Dashboard 2010-11

MONITOR COMPLIANCE DASHBOARD - 2011/12 (Appendix A)

Q4 - 2010-11 2011-12

1 Mandatory Services (delivered to contract standard/volume) Target Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Risk rating (current month)

Forecast to Next Quarter

Forecast to Year End

1.1 AOWA SBU (Risk = 4.0) GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0.0

1.2 OP SBU (Risk = 4.0) GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0.0

1.3 Secure & Specialised SBU (Risk = 4.0) GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0.0

Q4 - 2010-11 2011-12

2 Performance Risk Target Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Risk rating (current month)



2.1a Follow up within 7 days of discharge - number of areas at locally agreed standard(Risk = 1.0 - composite with 2.1b) 6 GREEN GREEN GREEN 4 6 6 5 6 6 6

1.02.1b Service users receiving a review (those on CPA for 12 months or more only)

(Risk = 1.0 - composite with 2.1a) 95% * 98% 97% 95% 94% 94% 96% 94%

2.2 Delayed Transfers of Care (Adults and Older People) kept to a minimum (Risk = 1.0) < 7.5% 0.3% 1.9% 2.7% 2.2% 1.7% 1.5% 1.0% 2.1% 2.7% 3.5% 0.0

2.3 % of Admissions (18-64 years) gate-kept by Crisis Resolution & Home Treatment teams (Risk = 1.0) 90% 95% 95% 93% 79% 76% 81% 86% 95% 97.7% 99.3% 0.0

2.4 No. of new cases of psychosis in Early Intervention Services (cumulative) - number of areas at locally agreed standard (Risk = 0.5) 6 GREEN GREEN GREEN 4 4 6 6 6 6 6 0.0

2.5a Data Quality (Monitor): completeness of identifier fields (Risk = 0.5) 99% 98.5% 97.2% 97.4% 99% 99% 99% 99% 99% 99% 99% 0.0

2.5b Data Quality (Monitor): completeness of outcome fields (Risk = 0.5) 50% 71% 77% 84% 85% 87% 89% 89% 91% 91% 91% 0.0

2.6 Access to Healthcare for People with Learning Disabilities (Risk = 0.5) Fully met GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0.0

NB: No rounding allowed; 3 successive quarters breaches on any indicator weighted 1.0 will automatically increase risk score to 4.0; overall risk score of < 1.0 is GREEN. Q4 - 2010-11 2011-12

3 Governance Risk Target Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Risk rating (current month)



3.1 Infection Control: Registration Standards & Vital Signs Targets (Risk = 1.0) GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0.0

3.2 Regulatory Reports: all actions delivered to time and standard Fully Met GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0

3.3 Membership Plan: delivered to trajectory and profile 5% tolerance GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0

3.4 Risk Registration & Mitigation: in place and evidenced Fully operational GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0

3.5 Information Governance Compliance - no significant in-year breaches TBC GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0

3.6 Disposal of assets To plan GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0

3.7 CQC Registration Compliance: Level of concern (Risk = 1.0 (Moderate) or 2.0 (Major) GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN GREEN 0.0

Q4 - 2010-11 2011-12

4 Financial Risk Target Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Risk rating (current month)



4.1 EBITDA Margin ≥ 3 3 3 3 4 4 4 4 4 4

4.2 EBITDA % Achieved ≥ 3 5 5 5 4 4 4 4 4 4

4.3 Return on Assets Excl Dividend (%) ≥ 3 4 4 4 5 4 4 5 5 5

4.4 I&E Surplus Margin net of Dividend (%) ≥ 3 3 3 3 3 3 3 3 3 3

4.5 Liquidity Ratio including WCF of £15.0M (days) ≥ 3 2 2 2 3 3 3 3 3 3

4.6 Overall Weighted Score for Finance ≥ 3 3 3 3 4 4 4 4 4 4

Q4 - 20010-11 2011-12

Target Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Risk rating (current month)

Score for Governance Risk Rating 2.5 1.5 1.0 2.0 1.0 0.0 1.0 1.0* Target presented here is the Monitor Compliance Framework target, which differs from the target in the PCT Contract

Finance Report Report for the AWP NHS Trust Board


Meeting Time: 10:00

Agenda Item: 09

Serial: 11.0709

This Report is presented by the Executive Director of Finance and Commerce, and Deputy Chief Executive for Approval in the Part 1 session of the Board.

Report Sponsor: Executive Director of Finance and Commerce, and Deputy Chief Executive

Report Summary

Purpose of this Report: o To provide an update on the Trust’s financial position as at 31st October 2011

(Month 7). o To clarify the main themes impacting on the Month 7 financial position.

Board Decisions Recommended:

Capital Programme (as set out in Section 5 of the report)

The Board are asked to authorise and agree:

o In-House Bank (Hillview lodge) (£50k)

o Carbon reduction (£110k)

o Interim data centre (£30k)

o N.Somerset feasibility (£8k)

Actions Arising from the Report: None

List of Appendices

Appendix 1 - Statement of Comprehensive Income

Appendix 2 - Cash funding statement

Appendix 3 - Statement of Financial Performance

Appendix 4 - Capital

Appendix 5 - Monitor metrics

Appendix 6 - Monitor potential financial risk indicators

Finance Report

In the Part 1session, sponsored by Executive Director of Finance and Commerce, and the Deputy Chief Executive

Item: 09 Serial: 11.0709 Page 2 of 18

Appendix 7 - Statutory duties

Appendix 8 - Cash Flow

Finance Report

1. Purpose

1.1. The purpose of this paper is as follows:

1.1.1. To provide an update on the Trust’s financial position as at 31st October 2011 (Month 7).

1.1.2. To clarify the main themes impacting on the Month 7 financial position.

2. Trust wide financial overview

2.1. The Trust financial position as at 31st October 2011 (Month 7) is summarised in the table below.

2.2. The budget position is the detailed budget developed from the high level budget approved by the Board at its meeting on 30th March 2011.

2.3. The Financial Information Monitoring System (FIMS) Surplus/ (Deficit) relates to the Trust plan as submitted to the Strategic Health Authority (SHA) on 22nd March 2011.

2.4. The projected financial surplus (after impairments) has increased from £1,600k to £2,969k, a favourable variance of £1,369k, due to a reduction in forecast impairments. However, as impairments are a technical, non-cash, accounting adjustment, this change does not benefit the Trust in achieving the DH (FIMS) control total.

Full Year Budget

Full Year Forecast

Full Year Variance

£,000 £,000 £,000Operating Surplus / (Deficit) 3,504 3,504 0

Impairments - capital programme (1,552) (1,890) (338)

Impairments - revaluation reversals 0 1,707 1,707

Total Impairments (1,552) (183) 1,369

IFRIC 12 * (352) (352) 0

Financial Surplus / (Deficit) 1,600 2,969 1,369

Trust wide position

2.5. The Trust summary position is shown in the following table over , amended from previous months to show this change:



Finance Report

Budget Month

Actual Month

Variance Month

Budget YTD

Actual YTD

Variance YTD

Full Year Budget

Full Year Forecast

Full Year Variance

2010/11 Full Year Variance

£,000 £,000 £,000 £,000 £,000 £,000 £,000 £,000 £,000 £,000

Direct Income 15,931 16,046 115 111,215 111,494 278 190,592 190,484 (108) 79

Total Operating Income 15,931 16,046 115 111,215 111,494 278 190,592 190,484 (108) 79

Pay costs (11,453) (11,387) 67 (80,539) (80,832) (293) (136,958) (135,174) 1,784 1,508

Non pay costs (2,973) (3,206) (233) (20,360) (20,588) (228) (35,601) (37,894) (2,293) (1,651)

Total Operating Expenditure (14,426) (14,593) (167) (100,899) (101,420) (521) (172,559) (173,068) (509) (143)

EBITDA 1,505 1,454 (51) 10,316 10,073 (243) 18,033 17,416 (617) (65)

Depreciation (494) (479) 15 (3,463) (3,285) 178 (5,934) (5,743) 191 (26)Amortisation 0 0 0 0 0 0 0 0 0Interest Receivable 4 2 (2) 30 14 (16) 52 25 (27) (9)Interest Payable (7) 0 7 (10) (12) (2) (44) (24) 20 (30)(Profit) / Loss on disposal of assets 0 0 0 0 (3) (3) 0 434 434 1Interest element of PFI Unitary Charge (422) (423) (0) (2,955) (2,956) (1) (5,065) (5,066) (2) 0PDC Dividends payable (295) (295) (0) (2,064) (2,064) (0) (3,538) (3,538) (0) 148

Trust Operating Surplus / (Deficit) 291 259 (32) 1,855 1,769 (86) 3,504 3,504 (0) 18

Impairments (129) 934 1,063 (905) 158 1,063 (1,552) (183) 1,369 3IFRIC 12 * (29) (29) 0 (205) (205) 0 (352) (352) 0 0

Financial Surplus / (Deficit) 132 1,164 1,032 744 1,722 977 1,600 2,969 1,369 21

FIMS Operating Surplus / (Deficit) 264 259 (5) 1,951 1,769 (182) 3,504 3,504 (0) 18

Impairments (129) 934 1,063 (905) 158 1,063 (1,552) (183) 1,369 3IFRIC 12 * (29) (29) 0 (205) (205) 0 (352) (352) 0 0

FIMS Retained Surplus / (Deficit) 106 1,164 1,058 841 1,722 881 1,600 2,969 1,369 21

* - Value of net change from UK GAAP / ESA95 to IFRS for IFRIC12 schemes included in Plan (excluding impairments)

Trust wide position

0

2.6. Statement of Comprehensive Income (SoCI) position

2.6.1. To enable the Trust to monitor its operating performance more easily the table above is now showing the impairment and IFRIC12 charges separately. This creates a new sub-total referred to as the Operating Surplus and equates exactly to the surplus that the Trust is performance managed to by the SHA.

2.6.2. The in-month position shows an actual of £259k compared with a budget of £291k, which is a difference of £32k. The cumulative position shows an adverse variance of £86k with budget and is £182k behind the FIMS.

2.6.3. The projected Financial surplus shows a favourable variance of £1,369k all due to changes in impairment charges.

2.7. Key financial risks

2.7.1. 5 key financial risks identified in 2011/12 are:



Finance Report

2.7.1.1. CQUIN

2.7.1.2. Contract penalties and performance

2.7.1.3. CRES

2.7.1.4. Cost Pressures including Medical staffing, Transport and Drugs

2.7.1.5. Cash

2.7.2. The financial implications of these issues are analysed in detail in the Part 2 session paper.

2.8. Monitor Financial Risk Ratings

2.8.1. The financial position reported above has generated the following scores for the Monitor Financial Risk Ratings:

Weighting Current Forecast Current Score

Forecast Score

EBITDA Margin 25% 9.0% 9.1% 4 4EBITDA % Achieved 10% 97.6% 96.6% 4 4 Return on Assets Excl Dividend (%) 20% 5.9% 6.4% 4 5 I&E Surplus Margin net of Dividend (%) 20% 1.4% 1.7% 3 3 Liquidity Ratio including WCF of £15.0M (days) 25% 18 18 3 3

4 4

4 4Capped Total Score

Monitor Metrics

EBITDA

Financial Efficiency

Weighted Total Score

2.8.2. The table above shows the calculations of the five financial metrics that Monitor require reporting on. Each metric is awarded a score (1-5) based on a scoring system defined by Monitor. Once the Trust becomes a Foundation Trust these metrics become a key compliance target with a minimum score of 3 required.

2.9. Trust performance against plan

2.9.1. Monthly progress relating to the achievement of the Budget and FIMS Plan surplus targets is represented graphically over. The chart also shows how the profiling of the CRES schemes has produced a back loaded phasing, although not as marked as in 2010/11 and a different profiling from the original FIMS Plan, which has been phased mainly in twelfths.

2.9.2. It is important to note that the Chart is now based on the Operating Surplus and equivalent FIMS figures for the purpose of this analysis.



Finance Report

Variance against Budget and FIMS plan

(500)

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

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

£ 00

0

FIMS plan cumulative Budget cumulative Actual cumulative Variance against Budget

2.10. Income

2.10.1. Income as at Month 7 has been cumulatively over-recovered by £278k against a budget of £111,215k (0.25%)

2.10.2. There has been lower than planned occupancy levels in the low secure and learning disabilities services, which are funded on a cost per case basis, but this has been offset by additional Education & Training income and other non clinical income.

2.10.3. There will be minor changes to the income budgets as we finalise recharge arrangements with Local Authorities. Work is ongoing to ensure these arrangements are sustainable.

2.10.4. The principal sources of income planned to be earned by the Trust in 2011/12 (£190,592k) are shown in the chart over:



Finance Report

Analysis of Trust income sources 2011/12 per approved budget

89%

6% 3% 0% 2%

PCTs Local Authorities Education, training and research NHS Trusts Other Revenue

2.10.5. Income from the Swindon PCT block contract, which is paid to the Trust via the Local Authority, has been included in PCT income.

2.11. Pay expenditure

2.11.1. This is the largest area of spend within the organisation and there is an in month under-spend of £67k on a budget of £11,387k (0.59%). Cumulatively there is an over spend of £293k on a budget of £80,832k (0.36%). These figures include all agency, bank and locum spend, and the effect of staff turnover and recruitment slippage.

2.11.2. The principal reason for the cumulative over spend is that the planned implementation of service redesign has not happened per the expected timeline and some of the associated savings have not yet been realised.

2.11.3. However, the spike in temporary staff costs observed in month 6 has now reversed, and this is the principal reason for the in month under-spend observed during Month 7. The temporary staff position is explained more fully in the Part 2 session paper.



Finance Report



2.11.4. Temporary staff costs reduced for 8 successive months from August 2010 to April 2011 and stabilised at this level in May 2011. However, since Month 3 the trend has been largely back upwards and there was a large increase of £220k between Month 5 and Month 6 as previously reported. However the spend has fallen in Month 7 by £140k from the previous month. The Executive Team may still look to consider more stringent arrangements for the authorisation of spend on temporary staff where appropriate.

2.11.5. The trajectory since August 2010 is shown in the following table:

Temporary staff costs - Month on Month trend from August 2010

Month In month cost Reduction on

previous month

Cumulative reduction from August 2010

% Cumulative reduction from August 2010

Aug 2010 1247

Sep 2010 1226 21 21 1.7%

Oct 2010 1168 58 79 6.3%

Nov 2010 1110 58 137 11.0%

Dec 2010 1051 59 196 15.7%

Jan 2011 988 63 259 20.8%

Feb 2011 966 22 281 22.5%

Mar 2011 881 85 366 29.4%

Apr 2011 841 40 406 32.6%

May 2011 842 (1) 405 32.5%

Jun 2011 950 (108) 297 23.8%

Jul 2011 993 (43) 254 20.4%

Aug 2011 966 27 281 22.5%

Sep 2011 1,186 (220) 61 4.9%

Oct 2011 1,046 140 201 16.1%

2.11.6. The table over identifies that pay costs are now 16.1% lower than in August 2010, despite increases in the pay bill in March, May, June and particularly September 2011. The performance in October reverses an upward trend during the summer months, but will need to remain under close review by the Executive Team until the downward trajectory is firmly established.

Finance Report



Total staff costs - Month on Month trend from August 2010

Month In month cost Reduction on

previous month Cumulative reduction

from August 2010

% Cumulative reduction from

August 2010

Aug 2010 12,315

Sep 2010 11,971 344 344 2.8%

Oct 2010 12,005 (34) 310 2.5%

Nov 2010 11,995 10 320 2.6%

Dec 2010 11,455 540 860 7.0%

Jan 2011 11,885 (430) 430 3.5%

Feb 2011 11,308 577 1,007 8.2%

Mar 2011 11,445 (137) 870 7.1%

Apr 2011 11,448 (3) 867 7.0%

May 2011 11,571 (123) 744 6.0%

Jun 2011 11,643 (72) 672 5.5%

Jul 2011 11,631 12 684 5.6%

Aug 2011 11,413 218 902 7.3%

Sep 2011 11,701 (288) 614 5.0%

Oct 2011 11,387 314 928 7.5%

2.12. Non pay expenditure

2.12.1. There is an adverse variance on non pay expenditure for the month of £233k against a budget of £2,973k (7.84%).

2.12.2. There is a YTD unfavourable variance of £228k against a budget of £20,360k (1.12%). Following one off benefits which were banked in Month 2, non pay costs are now expected to remain above budgeted levels. There are YTD overspends on Drugs (£894k) and Transport (£373k) which are explained in more detail in the Part 2 session report.

2.12.3. Please note these figures include actual contract penalties for Months 1 - 6 and estimated contract penalties for Month 7 that will be confirmed shortly.

Finance Report

2.12.4. A rolling month by month summary of the principal expenditure categories is shown on the chart below:

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

£ 000

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

Expenditure analysis October 2010 to October 2011

Permanent staff costs Temporary staff costs Non pay expenditure

3. Statement of Financial Position (SoFP)

3.1. The following highlights some of the key elements in the SoFP reporting as at 31st October 2011 that are shown in Appendix 3 to this report.

3.2. Modern Equivalent Asset (MEA) & Impairments

3.2.1. The impairments during 2011/12 had previously been estimated to be £1,552k for the full year based on current indexation forecasts and value added of the 2011/12 planned capital programme under MEA valuation methodology. This was included in the FIMS plan in achieving the retained surplus for the year of £1,600k.

3.2.2. Indexation of fixed assets remained at an index of 215 for buildings for quarter 2 of 2011/12 but a rise in indexation has been reported and accounted for at the start of Q3 and is expected to increase further in Q4. This has inevitably led to a significant reversal of previously impaired assets that were impaired under the MEA valuation exercise in 2009. The Trust has therefore accounted for impairments on its 2011/12 capital programme as in previous months but has also accounted for the reversal impacts as a result



Finance Report



of this indexation rise. The control total surplus that the Trust is performance monitored against is before impairments and IFRIC12 adjustments, and therefore any change in these has no impact on the surplus monitored by the SHA.

3.2.3. The charge for capital programme impairments in Month 7 has resulted in the variance of £1,063k that is shown in the Trust summary Income and Expenditure position.

3.2.4. The year to date impact of the impairment charge and the full year forecast can be seen in the table below:

YTD

£000

Full Year

£000

Impairment Capital Works

(1,102)

(1,890)

Reversals of MEA Impairments

1,260

1,707

Impairment Control Total

158

(183)

Finance Report



3.2.5. The reversal impact is expected to be £1,707k at this stage and the overall impact expected for the year is therefore:

Budget

£000

Actual

£000

SHA set control total/Operating Surplus/(Deficit)

3,504 3,504

Impairments – capital programme

(1,552) (1,890)

Impairments – revaluation reversals

0

1,707

Total Impairments

(1,552) (183)

Surplus after impairments

1,952 3,321

IFRIC 12

(352) (352)

Financial Surplus/(Deficit)

1,600 2,969

3.2.6. The Trust will continue to receive guidance from its valuation office to apply indexation treatment and the forecast position as we move into Q4 of the financial year.

3.3. Inventories

3.3.1. It remains the case that the Trust is expected to realise benefits of a further £70k in identifying and verifying increased levels of inventory. This is an assessment that is continually being worked on to organise counts and therefore the Trust has again accrued the expected benefit in its Month 7 position.

3.4. Accruals

3.4.1. The annual leave accrual remains unchanged from previous months. This £97k annual leave accrual is included within Accruals on Appendix 3 and it is currently forecast that this will remain the same throughout the financial year.

Finance Report



4. External Financing Limit (EFL) & Cash Position

4.1. The EFL position represents the increase in cash flow financing as demonstrated in Appendix 2.

4.2. The Trust has had its EFL set for the year in the 2011/12 operating plan and is permitted to undershoot but not overshoot this target. The plan is shown in the table below:

£000

Cash Flow Financing forecast at 31st March 2012

3,028

EFL set

(3,028)

Planned Under/(Over)shoot of EFL

0

4.3. The Trust has submitted a request to amend the EFL to a lower year end cash balance required. This will reduce the required balance from £6,969k to circa £5,500k at the end of the financial year at 31st March 2012. This request has been given support by the SHA and is expected to be successful resulting in a change to the Trust’s limits in the coming months.

4.4. The cash balance as at 31st October 2011 is £6,094k. This figure is a decrease in cash in month of £774k as the Trust has received less invoice income than in the previous month with this expected to increase in November as shown in Appendix 8 to this report. The Trust continues to ensure that it aims to achieve the Monitor supplementary cash balance of 10 working days liquidity i.e. minimum of £4,800k throughout 2011/12 financial year. The liquidity rating therefore remains at a score of 3 as shown in Appendix 5 to the report.

4.5. There are disposal plans in place to realise cash proceeds and more details are contained on these in the Part 2 session report.

4.6. The details of all cash movement in month can be seen in Appendix 8 to this report.

Finance Report

5. Capital Programme

5.1. Details of the Trust’s Capital Resource Limit (CRL) and the status of the capital projects developed to achieve the CRL are shown in the table below:

Capital resource limit (CRL) 5,825Reduction in Capital envelope -1,000

-175-173

-348

-1,000

Revised Capital envelope 4,825

Schemes already authorised by the Board 4,603Changes to previously authorised schemesService Redesign (Avebury)Mobile working pilotRevised outturn of approved schemes

Schemes requiring authorisation from EMT and then BoardIn-House Bank (Hillview lodge) 50Carbon Reduction 110Interim Data centre 30N.Somerset Feasbility 8Total schemes awaiting approval 198

Remaining schemes in authorised capital envelope, yet to be authorisedService Redesign (Other) remaining balance 100Capital Feasibility Fees 17Contingency for PFI related bids 50Remaining funding available 205Total funding envelope awaiting to be authorised 372

Total target envelope for the capital programme 4,825

Position against CRL

Capital Programme 2011/12 £’000 £’000

5.2. The Table above shows:

5.2.1. CRL £5,825k

5.2.2. Revised capital envelope £4,825k

5.2.3. Schemes awaiting approval £198k

5.3. Schemes authorised by the Board



Finance Report



5.3.1. At the Month 7 stage, the service redesign (Avebury) will be reduced further by £175k, and will now be allocated fully into the 2012/13 capital programme. Furthermore the full allocation of £173k for the Mobile working pilot will also slip into next year. This results in a total reduction of £348k, bringing the capital envelope to £4,255k and providing £570k for further schemes in the current year 2011/12.

5.4. Capital schemes awaiting approval

5.4.1. In-House Bank (Hillview lodge) (£50k)

5.4.1.1. To undertake refurbishment works and IM&T infrastructure required for Cedar Ward, Hillview Lodge to provide accommodation for a new team of 10 non clinical staff who will provide an in-house temporary staff service replacing the current NHSP service.

5.4.2. Carbon reduction (£110k)

5.4.2.1. To ensure sufficient investment in the estate, to enable the Trust to meet its 5-year Carbon Reduction commitment.

5.4.3. Interim data centre (£30k)

5.4.3.1. To provide an interim overflow server space for limited additional capacity, in addition to the two data centres at Bath NHS House and Callington, until the future data centre provision can rapidly be addressed.

5.4.4. N.Somerset Space utilisation Feasibility (£8k)

5.4.4.1. To undertake feasibility works to enable the services in North Somerset to work up a business case and implement their plans. This project will span AOWA community services, L&LL community services, Positive Steps in addition to some in patient management functions.

5.5. Remaining schemes in authorised capital envelope

5.5.1. At the Month 7 stage, £372k remains in the capital envelope after taking into consideration the schemes awaiting approval. The remaining envelope is as follows:

5.5.1.1. £100k for service redesign, increasing from £60k as a result of further bids expected in due course. The bids are in relation to the North Somerset feasibility works (above) and service redesign plans in Bristol.

Finance Report



5.5.1.2. £17k for capital feasibility, to take account of two further feasibility schemes anticipated to be for LD services and an automated pharmacy.

5.5.1.3. £50k for PFI contingency, whilst waiting on final confirmation on outstanding disputes which may require capital.

5.5.1.4. £205k is a remaining balance, due to the slippage from approved schemes. This can be managed within the remainder of the year to achieve an acceptable position against the CRL.

5.6. Expenditure and Cashflow forecast

5.6.1. Appendix 4 to this report shows that the capital expenditure to date is £1,615k, and is in line with forecasts provided at month 7. Cashflow has steadily increased as the rolling programme from 2010/11 is almost complete. From the revised £4,825k capital programme, an amended authorised capital programme stands at £4,255k of which £3,561k is contractually committed. To date additional bids totalling £372k are awaiting approval, including an unallocated remaining balance of £205k which will be managed through additional appropriate schemes, in order to meet an acceptable position against the CRL target.

5.7. Capital Programme

5.7.1. The Board are asked to authorise and agree:

5.7.1.1. In-House Bank (Hillview lodge) (£50k)

5.7.1.2. Carbon reduction (£110k)

5.7.1.3. Interim data centre (£30k)

5.7.1.4. N.Somerset feasibility (£8k)

6. Statutory duties

6.1. The Trust has a number of financial duties that it is required to meet. The performance against these duties as at 31 October 2011 is as follows over:

Finance Report

Financial Duty Tolerance Target Current Forecast

£’000 £’000 £’000

None 2,969 1,722 2,969

No overshoot (3,028) (3,028) (3,028)

No overspend 5,825 5,825 5,825

Forecast undershoot (1,000)

+/- 0.5% 3.50% 3.50% 3.50%

NHS 95% 97% 95% +

Non-NHS 95% 95% 95% +

NHS 95% 99% 95% +

Non-NHS 95% 95% 95% +

Capital Resource Limit (CRL)

Capital Cost Absorption Rate

Income and Expenditure - Surplus

External Financing Limit (EFL)

Better Payment Practice Code (Value) -

Better Payment Practice Code (Number) -

7. Conclusion

7.1. In Month 7 the in-month position is an actual surplus of £1,164k. Excluding impairments and the IFRIC 12 charge this gives an underlying surplus of £259k which is £32k behind budget and £5k behind the FIMS.

7.2. The cumulative position is an actual surplus of £1,722k. The equivalent underlying surplus in M7 is £659k, against a budgeted surplus of £745k and a FIMS plan surplus of £841k. The Trust is therefore £86k behind budget and £182k behind the FIMS plan at Month 7.

7.3. The forecast outturn retained surplus is now £2,969k after impairments and IFRIC 12. This has changed from the original planned surplus of £1,600k due to the revised impairment charge.

7.4. However, there are still a number of significant risks that need to be managed if the planned surplus is to be achieved. Pay expenditure is £67k under spent in month but pay costs are still cumulatively overspent at £293k. In month 7 it is realised that temporary staff costs have fallen and also there is still a linkage to the pay savings from the service design implementation not yet being realised. Non pay expenditure is £228k overspent cumulatively after accounting for contract penalties. These are discussed in detail in the Part 2 Session report.

7.5. Finally the cash balance as at 31st October 2011 is £6,094k and the Trust continues to review its monthly cash flow forecast taking into account all identified issues such as timing of disposals and the EFL target position.



Finance Report



8. Board Decisions requested

8.1. Capital Programme Decisions are requested as in Section 5 above

9. Appendices

9.1. Appendix 1 - Statement of Comprehensive Income

9.2. Appendix 2 - Cash funding statement

9.3. Appendix 3 - Statement of Financial Performance

9.4. Appendix 4 - Capital

9.5. Appendix 5 - Monitor metrics

9.6. Appendix 6 - Monitor potential financial risk indicators

9.7. Appendix 7 - Statutory duties

9.8. Appendix 8 - Cash Flow

Appendix 1

IN MONTH IN MONTH IN MONTH YTD YTD YTD ANNUAL FORECAST FORECASTBUDGET ACTUAL VARIANCE BUDGET ACTUAL VARIANCE BUDGET FULL YEAR VARIANCE

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

CLINICAL REVENUE

Block Contract Income 13,558 13,280 (277) 92,861 92,711 (150) 159,190 158,358 (832) Clinical Partnerships 1,212 1,172 (40) 8,483 8,389 (95) 14,543 14,242 (301) Other Cost & Volume Revenue 738 1,173 436 5,742 6,231 488 9,844 10,878 1,034 Other Revenue from Mandatory Services 43 15 (28) 311 144 (167) 528 227 (301)

OTHER REVENUE

Education & training 297 258 (39) 2,082 2,150 69 3,568 3,671 103 Research & Development 194 180 (14) 1,356 1,283 (73) 2,268 2,252 (15) Other Income (111) (33) 78 380 586 206 652 856 205

Total Operating Income 15,931 16,046 115 111,215 111,494 278 190,592 190,484 (108)

OPERATING COSTS

Staff Costs (11,453) (11,387) 67 (80,539) (80,832) (293) (136,958) (135,174) 1,784 Drug Costs (312) (436) (123) (2,225) (3,120) (894) (3,774) (5,200) (1,426) Clinical Supplies & Services (83) (136) (54) (578) (818) (240) (990) (1,393) (403) Non Cash Expenditure (Bad debts, etc) - - - - (8) (8) - (8) (8) PFI - Operating Costs (106) (106) (0) (740) (741) (1) (1,269) (1,270) (2) General Supplies and Services (262) (262) 0 (1,834) (1,640) 194 (3,143) (2,864) 280 Establishment & transport (613) (650) (37) (4,324) (4,343) (19) (7,382) (7,525) (143) Premises (772) (504) 267 (4,988) (3,454) 1,534 (8,846) (6,951) 1,895 Other Costs (826) (1,112) (286) (5,671) (6,463) (792) (10,197) (12,683) (2,486)

Total Operating Expenses (14,426) (14,593) (167) (100,899) (101,420) (521) (172,559) (173,068) (509)

EBITDA 1,505 1,454 (51) 10,316 10,073 (243) 18,033 17,416 (617)

NON OPERATING REVENUE & COSTS

Profit / loss on asset disposals - - - - (3) (3) - 434 434 Total Depreciation & Amortisation (494) (479) 15 (3,463) (3,285) 178 (5,934) (5,743) 191

(494) (479) 15 (3,463) (3,287) 176 (5,934) (5,309) 625

Total interest receivable/ (payable) 4 2 (2) 30 14 (16) 52 25 (27) Total interest payable on Loans and leases (7) - 7 (10) (12) (2) (44) (24) 20 Interest element of PFI Unitary Charge (422) (423) (0) (2,955) (2,956) (1) (5,065) (5,066) (2) PDC Dividend (295) (295) (0) (2,064) (2,064) (0) (3,538) (3,538) (0)

Total Non Operating Revenue & Costs (1,214) (1,194) 20 (8,461) (8,305) 157 (14,529) (13,913) 616

SHA Target - Monitored Surplus 291 259 (32) 1,855 1,769 (86) 3,504 3,504 (0) Fixed Asset impairments (129) 934 1,063 (905) 158 1,063 (1,552) (183) 1,369

IFRIC 12 (29) (29) - (205) (205) - (352) (352) -

RETAINED SURPLUS/(DEFICIT) FOR THE PERIOD 133 1,164 1,032 745 1,722 977 1,600 2,969 1,369

AVON AND WILTSHIRE MENTAL HEALTH PARTNERSHIP NHS TRUST

STATEMENT OF COMPREHENSIVE INCOME as at 31st October 2011

TRUSTWIDE TOTAL

Page 2

APPENDIX 2

PLAN* FORECAST

£000 £000 £000 £000

Forecast Operating Surplus 10,277 11,490

Plus: Non cash items - Depreciation 6,001 5,743Plus: Non cash items - Impairments 1,552 183Plus: Other gains and losses 0 0Plus: Transfer from the Donated Asset Reserve 0 0Plus: Interest paid (5,368) (5,418)Plus: PDC dividend paid (3,360) (3,630)Plus: Movement in Working Capital balances (155) (5,146)Plus: Movement in Provisions (144) (477)

Net Cash inflow/(outflow) from Operating Activities 8,803 2,744

Cash flow from investing ActivitiesPlus: Interest received 50 25Less: Capital Payments (5,825) (4,300)Plus: Capital Receipts (disposals) 0 2,718Plus: Movement in Capital Accruals and Transfers 0 (151)Plus: Revenue Rental Income 0 0Internally Generated Cash (EFL) 3,028 1,037

Cash flow from Financing ActivitiesLess: Capital element of PFI (1,305) (795)

Total Increase in Cash in 2011/12 1,723 241

Plus: Cash b/fwd 5,246 5,259

Forecast cash at 31st March 2012 6,969 5,500

* NOTE - the plan figures are based on the Medium Term Financial Plan as submitted to the SHA in March 2011


STATEMENT OF CASH FLOWS 2011/12

Page 3

APPENDIX 3

BUDGET OUT TURN VARIANCE OPENING As at31.03.12 31.03.12 FAV/(ADV) 01.04.11 31.10.11

£,000 £,000 £'000 £'000 £'000

NON CURRENT ASSETS (FIXED ASSETS) 161,017 159,885 (1,132) 161,189 160,124

CURRENT ASSETS

Assets Held for Sale - - - - 2,280 Inventories (Stock) 189 259 70 189 259 NHS Receivables (Debtors): Other 6,004 3,844 (2,160) 4,888 5,361 Non-NHS Receivables (Debtors) 2,704 2,629 (75) 2,202 3,067 Prepayments and Accrued Income 2,832 3,514 682 2,306 3,294 Cash and Cash Equivalents 6,969 5,500 (1,469) 5,259 4,094 Cash and Cash Equivalents on deposit - - - - 2,000 Total current assets 18,698 15,746 (2,952) 14,844 20,355

TOTAL ASSETS 179,715 175,631 (4,084) 176,033 180,479

TAXPAYERS EQUITY

Public Dividend Capital 99,552 99,552 - 99,552 99,552 Revaluation Reserve 24,383 26,528 2,145 24,383 26,528 Retained Earnings (16,859) (16,584) 275 (17,089) (16,582) IFRIC 12 Reserve (1,109) (1,109) - (1,109) (1,109) Surplus for 2011/12 1,600 2,969 1,369 - 1,722 Donation Reserve - - - 229 - LGPS Reserve - - - 34 - Total Taxpayers Equity 107,567 111,356 3,789 106,000 110,111

NON CURRENT LIABILITIES

PFI Borrowings due after 1 Yr 47,368 47,368 - 48,148 47,693 Provisions payable after 1 yr 1,520 1,228 (292) 1,289 1,233 Total Non Current Liabilities 48,888 48,596 (292) 49,437 48,926

CURRENT LIABILITIES < 1 YEAR

NHS Payables (Creditors) 4,744 3,071 (1,673) 4,186 3,453 Non-NHS Payables (Creditors) 8,410 561 (7,849) 6,960 5,658 Accruals 8,292 8,907 615 7,395 8,894 Deferred income 660 2,018 1,358 503 2,018 PFI Borrowings due within 1 year 781 781 - 797 787 Provisions payable within 1 year 373 341 (32) 755 632 Total Current Liabilities 23,260 15,679 (7,581) 20,596 21,442

TOTAL EQUITY & LIABILITIES 179,715 175,631 (4,084) 176,033 180,479

STATEMENT OF FINANCIAL POSITION as at 31st October 2011


Page 4

Appendix 4

AVON & WILTSHIRE MENTAL HEALTH PARTNERSHIP NHS TRUSTCAPITAL EXPENDITURE AS AT 31st October 2011

Schemes Approved by the Board StatusBoard date

Approved & Minute Number

FIMS Capital Programme Authorised Expenditure

£'000 1

Capital Programme Authorised

Expenditure £'000

Actual 2011/12 £'000

Forecast for Capital Expenditure

£'000Risk Code Note to the Board

Acer Permanent Move C May Board 845 803 601 803 Rolling Programme

ECH Permanent Move C May Board 131 173 159 173 Rolling Programme

24 hours Switchboard C Oct Board 91 72 60 72 Rolling Programme

N3 Coin C June Board 270 370 0 370 Rolling Programme

Essential IT RiO C Sept Board 0 0 0 0 Rolling Programme

Systems Management C June Board 32 32 32 32 Rolling Programme

HR Case Management C Oct Board 13 19 6 19 Rolling Programme

BBH Building works C Oct Board 392 392 330 392 Rolling Programme

Service Redesign (Applewood) C Apr Board 300 390 38 390 Board approved envelope, now BC seen by IPG/EMT

Service Redesign (Colston Fort) C Apr Board 5 0 0 0 Board approved envelope, now BC seen by IPG/EMT

Service Redesign (Vacation of the Mall) C Apr Board 400 450 11 450 Board approved envelope, now BC seen by IPG/EMT

Service Redesign (Avebury) C Apr Board 300 15 13 15 Board approved envelope, now BC seen by IPG/EMT

Bath NHS Server Infrastructure C Apr Board 91 91 3 91 Board approved envelope, now BC seen by IPG/EMT

Core infrastructure replacement C Apr Board 243 100 74 100 Board approved envelope, now BC seen by IPG/EMT

Mobile working pilot C Apr Board 173 0 0 0 Board approved envelope, now BC seen by IPG/EMT

Next generation working CORE C Apr Board 377 0 0 0 Board approved envelope, now BC seen by IPG/EMT

Lifecycle Phase 3 C Apr Board 10 0 0 0 Board approved envelope, now BC seen by IPG/EMT

Non-Clinical operations C Apr Board 25 15 0 15 Board approved envelope, now BC seen by IPG/EMT

IT infrastructure feasibility C Apr Board 25 25 0 25 Board approved envelope, now BC seen by IPG/EMT

PC/Laptop replacement C May Board 250 150 73 150 Board approved envelope, now BC seen by IPG/EMT

Telecoms replacement C May Board 175 395 209 395

Capital Feasibility Fees (Carbon reduction) C May Board 0 15 6 15

Feasibility for Windswept C June Board 0 9 0 9

Finance system C Aug Board 300 30 0 30

PFI Furniture C Aug Board 0 23 0 23

Capital Feasisbiltiy relocation eating disorders C Sept Board 0 9 0 9

PFI Works (Wickham unit) C Sept Board 0 22 0 22

Combe park relocation project C Sept Board 0 47 0 47

Lifecyle investment C Sept Board 0 189 0 189

Fountain way enhancements C Sept Board 0 159 0 159

Website C Sept Board 0 50 0 50

Rosterpro upgrade & e-incident C Sept Board 0 32 0 32

Secondary clinical record viewer C Sept Board 0 25 0 25

Care plan library builder & knowledge centre C Sept Board 0 43 0 43

Service Redesign Bybrook lodge (Draw down) C Oct Board 0 30 0 30

Blackberry centre dispensary C Oct Board 0 80 0 80

Sub total of bids approved by Board 4,448 4,255 1,615 4,255

Grand Total of Schemes 4,448 4,255 1,615 4,255Remaining Funding Available 1,377 570 3,210 570Total Funding available 5,825 4,825 4,825 4,825

Business cases seen by EMT StatusBoard date

Approved & Minute Number

FIMS Capital Programme Authorised

£'000 1

Capital Bids

Received £'000 2Actual 2011/12

£'000

Bids Awaiting Approval

£'000 3Type Note to the Board

In-House Bank (Hillview lodge) WA 0 50 50 SBU/Estates Business cases recommended by IPG/EMT

Carbon Reduction WA 250 110 110 SBU/Estates Business cases recommended by IPG/EMT

Interim Data centre WA 0 30 30 IT Business cases recommended by IPG/EMT

N.Somerset space utilisation Feasbility WA 0 8 8 SBU/Estates Business cases recommended by IPG/EMTBids awaiting approval in November 4

Capital Feasisbiltiy Fees WA 50 17 17 Business cases not yet recommended by IPG/EMT

Contingency for PFI related bids WA 32 50 50 SBU/Estates Business cases not yet recommended by IPG/EMT

Service Redesign (Other) WA 500 100 100 SBU/Estates Business cases not yet recommended by IPG/EMT

Next generation working (wifi 2 sites) WA 45 0 0 IT Business cases not yet recommended by IPG/EMT

Local access provision WA 500 0 0 IT Business cases not yet recommended by IPG/EMT

IT Microsoft Licences WA 0 0 0 IT Business cases not yet recommended by IPG/EMT

Sub total of bids received by IPG/EMT 1,377 365 0 365

Grand Total of Schemes including 5,825 4,620 1,615 4,620 Remaining Funding Available 0 205 205 4.25% under commitmentTotal Funding available 5,825 4,825 4,825

STATUS KEY Key Narrative

Committed C 1. FIMS capital programme of £5,825k identified at the start of the year

Awaiting Approval WA 2. Capital bids received by IPG

3. Bids identified from IPG/EMT for future approval

4. Bids recommended by IPG/EMT for board approval

Page 6

APPENDIX 7

STATUTORY DUTY ORIGINALTARGET

Breakeven Duty - the Trust is required to breakeven over a three year period. In agreement with the SHA this has been extended to seven years. The Trust must end the financial year with a surplus of £2.113m in order to meet this requirement.

£1,600 m £2,969 k

£5,825 m £5,825 k

Undershoot YTD (£4,210) k

Forecast Undershoot (£1,000) k

£3,015 m £3,015 k

Adjusted EFL expected £551 k

Forecast Undershoot £486 k

Capital Cost Absorption duty - The Trust is required to meet a 3.5% return on its average net assets employed in year. This represents a payment to the Department of Health in the form of PDC Dividends.

3.5% 3.5%

Better Payment Practice Code. Compliance requires 95% of all invoices by volume and value to be paid within 30 days or other agreed terms. Volume/(Value)

NHS - 95% (95%)Non NHS - 95% (95%)

NHS - 97% (99%)Non NHS - 95% (97%)

External Financing Limit - is a control placed on Trusts to manage cash. It was designed to encompass all sources of financing available to a Trust, be they internal, external or from DH. This initial limit is set based on the Trusts plans to manage its cash from internal financing and adjustments are made to this figure as unpredicted in year changes occur. A negative EFL is equal to an increase in cashflow financing, an undershoot against this is also an increase in cashflow financing than predicted.

Capital Resource Limit - the Trust is allocated a limit that can be spent on capital schemes. This limit plus the net book value of disposals is the maximum the Trust can spend on capital in the financial year. The Trust however can underspend against this limit.


STATUTORY DUTIES as at 31st October 2011

Year to dateACTUAL

Page 10

AVON WILTSHIRE MENTAL HEALTH PARTNERSHIP NHS TRUSTCASH FLOW FORECAST 2011/2012

Appendix 8

Actual Actual Actual Actual Actual Actual Actual Forecast Forecast Forecast Forecast Forecast 2011/12 2010/11 2009/10

April May June July August Sept Oct Nov Dec Jan Feb Mar TOTAL TOTAL TOTAL

Opening Balance 6,348 3,125 2,854 5,066 1,764 1,964 6,871 4,075 7,872 7,390 8,742 10,508 6,348 7,592 2,628

RevenueNHS Block Total 10,477 10,796 11,460 11,593 11,344 11,936 11,470 11,653 11,555 11,555 11,555 12,719 138,113 146,587 145,089Local Authority Block Total 384 105 248 142 401 245 126 176 310 176 176 274 2,762 2,346 1,567MPET & R&D Total 474 399 624 533 405 531 369 296 621 470 296 723 5,741 5,790 6,483Invoiced Income Total 4,010 2,416 4,738 3,758 4,559 3,972 2,331 5,026 2,491 2,633 4,723 3,210 43,867 38,706 50,368Other Income Total 619 591 570 450 544 441 604 234 234 234 234 236 4,992 5,595 4,329

Total 15,965 14,307 17,640 16,476 17,252 17,125 14,900 17,386 15,211 15,067 16,984 17,162 195,476 199,025 207,836

ExpenditureSalaries & Wages -6,502 -6,496 -6,552 -6,429 -6,422 -6,407 -6,426 -6,040 -6,040 -5,871 -5,857 -5,853 -74,894 -79,175 -79,563TAX & NI -2,683 -2,706 -2,692 -2,749 -2,652 -2,615 -2,639 -2,599 -2,662 -2,662 -2,587 -2,581 -31,825 -33,083 -32,470Pensions -1,656 -1,659 -1,653 -1,675 -1,631 -1,633 -1,625 -1,616 -1,536 -1,536 -1,493 -1,489 -19,201 -20,094 -19,788Non Pay Expenditure -7,479 -2,757 -3,614 -4,004 -3,438 -4,784 -4,095 -5,085 -4,539 -4,693 -4,365 -9,560 -58,412 -53,430 -59,164Miscellaneous Expenditure -57 -164 -120 -107 -106 -117 -138 -203 -116 -116 -116 -116 -1,473 -1,049 -910

Total -18,378 -13,781 -14,632 -14,963 -14,249 -15,555 -14,922 -15,543 -14,891 -14,877 -14,418 -19,599 -185,807 -186,832 -191,895

Net Cash Flow before Financing -2,413 526 3,008 1,513 3,003 1,570 -22 1,843 320 190 2,567 -2,437 9,669 12,193 15,941

FinancingFunds on Deposit 0 0 0 -4,000 -2,000 6,000 -2,000 2,000 0 0 0 0 0 0 0Fixed Asset Disposals 0 0 0 0 0 0 0 755 0 1,963 0 0 2,718 0 2,075PDC Repaid 0 0 0 0 0 0 0 0 0 0 0 0 0 136 655PDC Paid 0 0 0 0 0 -1,861 0 0 0 0 0 -1,769 -3,630 -3,347 -4,123PFI Charges -762 -801 -801 -802 -802 -803 -774 -801 -801 -801 -801 -801 -9,552 -8,170 -8,434Loans Repaid including Interest 0 0 0 0 0 0 0 0 0 0 0 0 0 -2,055 -1,150

Total Financing -762 -801 -801 -4,802 -2,802 3,336 -2,774 1,954 -801 1,162 -801 -2,570 -10,464 -13,436 -10,977

Comercial Cash at Bank and in hand -48 -44 -38 -52 -53 -53 -53 -53 -53 -53 -53 -53 -53 -58 -30

Closing Balance 3,125 2,854 5,066 1,764 1,964 6,871 4,075 7,872 7,390 8,742 10,508 5,500 5,500 6,291 7,562

FIMS PLAN* 6,031 6,125 6,423 6,540 6,972 5,561 6,096 6,864 7,102 7,434 7,897 6,969 6,969Variance to plan (ahead)/behind 2,905 3,271 1,356 4,775 5,008 -1,310 2,021 -1,007 -288 -1,308 -2,610 1,469 1,469

Reconciliation to ledger 3,139 2,239 5,075 5,764 7,310 6,868 6,094 0 6,291 7,562Final BACS payment 0 610 0 0 653 0 0 0 -1,035 -1,520Uncleared (Cheques)/Receipts -14 5 8 0 1 3 -20 0 3 54Bank balance 3,125 2,854 5,066 5,764 7,964 6,871 6,075 0 5,259 6,095

Page 11

Medical and Strategy Status Report Report for the AWP NHS Trust Board


Meeting Time: 10:00

Agenda Item: 10

Serial: 11.0710

This Report is presented by the Executive Medical Director and Director of Strategy and Business Development for Noting in the Part 1 session of the Board.

Report Sponsor: Executive Medical Director and Director of Strategy and Business Development

Report Summary

Purpose of this Report: To report to the Board on the work of the Medical, Strategy & Business Development Directorate to date in realising its annual plan.


Actions Arising from the Report: None specified.


Report Links

CQC All

IG Toolkit All


List of Appendices

Appendix A - Appraisal Policy for Medical Staff

Medical and Strategy Status Report

In the Part 1session, sponsored by Executive Medical Director and Director of Strategy and Business Development


1. Introduction

1.1. The Directorate Annual Plan for 2011/12 was approved in outline as part of the Directorate business plan at the Board meeting in March. This annual plan is now being refreshed for production later in the year to bring it in line with the annual planning cycle and will be reported again at the next Directorate status report.

1.2. The Directorate meets monthly to scrutinise its Risk Register and Balanced Scorecard.

1.3. The progress within each of the Directorate portfolios is described below.

1.4. Performance Management is subject to regular monthly reporting in detail and is not replicated in this report.

1.5. R&D Activity is separately reported to the Trust Board annually. The refreshed R&D Strategy will be presented to the Board in January in the light of recent discussion at the Quality & Healthcare Governance Committee and at Seminar.

2. Discussion

2.1. Directorate

2.1.1. The Directorate is required to ensure that performance reporting targets are met, it delivers its agreed CRES targets and ensures compliance with all statutory requirements namely (for this Directorate),performance reporting standards (Deputy Director for Strategy, Performance & Business development) medical revalidation (Medical Director and Deputy Medical Director) and controlled drugs (Chief Pharmacist). The Directorate is fully compliant with its statutory responsibilities.

2.1.2. The Directorate continues to play a lead role in coordinating the Trust’s response to the QIPP Programme. This work is being conducted in collaboration with our PCTs. It also sponsors the implementation of Payment by Results and Care Clusters, and projects on Improving Access to Mental Health Care (formerly the Easy Access Point Project) and Medical Staffing Redesign. In addition it contributes to a range of efficiency projects as part of re-design mainly to do with medicines management.

2.1.3. In response to various discussions in respect of strategic matters the Directorate plans to refresh its approach to its work with a view to enhancing its co-ordinating functions for innovations work,




outcomes evaluation and the wider quality & business development agendas at it’s planned meeting on 9th December.

2.1.4. Specifically, this will include rethinking how to fully embed innovations work in the business of the Trust, strongly linking it to both the care quality agenda and the business development agenda.

2.2. Medical

2.1.1. The new appraisal policy for medical staff (attached at Appx A) was formally approved by the General Negotiating Group in October and is now being rolled out into normal operations.

2.1.2. Responsible Officer training is underway; the ORSA assurance report was completed for the SHA and a Trust action plan completed and being progressed. We still anticipate the introduction of medical revalidation late in 2012.

2.1.3. The first development programme for medical leads has completed with encouraging feedback . Further training is now being procured. Medical leads in Adult SBUs are now substantive rather than interim as redesign of the services has progressed sufficiently to reorganise posts.

2.1.4 Work on the Medical Strategy has now commenced in collaboration with the Trust-wide Medical Advisory Group

2.1.5 The trainees rotas have been re-designed to ensure a better training experience and more resilience in respect of the working time directive and the national contract.

2.3 Performance and Business development

2.3.1 The quality and performance improvement project is now in it’s second month. Key achievements are:

2.3.2 19 improvement areas have been negotiated with the Commissioners. Team level analysis enables teams at variance to these standards to set trajectories to year end. These too have been completed and agreed with Commissioners. Consequently, a formal improvement notice has been deferred by the BNSSG Cluster Board, pending delivery at Q3, when Commissioners will re-assess the situation.

2.3.4 Review and alignment of key service policies has commenced and will conclude by Q3 end. Work will then begin to identify and problem-solve any issues associated with RiO that are thought to not support efficient and logical clinical practice, after which training




and guidance will be aligned to ensure a ‘single version of the truth’.

2.3.5 Team Level ‘on demand’ scorecards were made available in September through ReportZone. These are in addition to the suite of other performance and activity information made available to support delivery and management of care ‘right first time’. These have been very positively received by Teams.

2.3.6 The Programme Director is co-ordinating the production of Clinical Care Pathway documents for all core services. The first of these (PCLS) is ready in draft form. These will be reviewed during November by the Executive and signed off, and will subsequently be used as the basis for discussion at the December 8th Board Seminar looking at service models, patient flows and the implications for our PBR and Care Clusters Strategy.

2.3.7 A framework for development of CQUINs for 2012/13 has been written to ensure full engagement across managerial and clinical groups and areas, and to ensure (as in previous years) they align with Quality Accounts and SBU Quality Improvement Plans.

2.3.8 The developmental audit work under the project continues apace. It will have concluded prior to Christmas with an output report to EMT in January. Its value is self-evident in terms of the issues it has highlighted in some teams and areas, the positive light in which its been received, and the changes to practice and approach that are already being agreed as a result.

2.4 Innovations

2.4.1 Implementation of the Innovation Strategy is ongoing and performance against key measures is positive. Between January and October approximately 600 people participated in an innovation activity (e.g. innovation survey, workshop, competition) and there is a steady stream of requests from SBUs and professional groups for support to think creatively about improving the services provided.

2.4.2 The innovation portfolio includes 34 projects ranging from Trustwide

initiatives down to clinician-led projects. The innovation portfolio has been categorised into 4 domains: 1. Improving mental wellbeing 2. Improving access to services and choice 3. Innovative services and technologies 4. Promoting recovery

2.4.3 Projects are published on Innovations pages of

OurSpace. Drawing attention to one particular project, a strategic partnership has been forged with the West of England Sports




Partnership (Wesport) with the aim of addressing sustainability of the Bristol Active Life Programme and extending the Active Life Programme across the AWP geography. Bids worth £500,000 have been submitted to develop the Active Life Programme across the Trust. Funding outcomes will be known in the New Year.

2.4.4 The ‘Making a Difference Hall of Fame’ will be launched at the end of November. This initiative will see positive service developments led by individuals and teams summarised in case study format with the aim of recognising excellence in our staff, disseminating information across the organisation to encourage the uptake of ideas, as well as sharing best practice outside of the organisation and enhance reputation. This Hall of Fame will be located on the innovations page of Ourspace.

2.5 Medical Education

2.5.1 AWP achieved the highest proportion in the SW of educational supervisors with all 7 GMC standards for trainers: 98% now meet standards for 2012.

2.5.2 The medical education manager Rebecca Braithwaite has greatly

improved the quality of information and accuracy of training statistics across all groups. For trainees, all 5 trust indicators for statutory and mandatory training are now above target.

2.5.3 Improved induction for trainees at trust and local levels, plus electronic package. 95% compliance among trainees.

2.5.4 Monitoring of 8 local academic programmes (attendance, contents and quality) is now centralised. The number & quality of returns is increasing. Aim: to provide feedback to Specialty Tutors to enable continuous enhancement of programmes.

2.5.5 Business Internship Programme (BIPS) in place. 3 senior trainees are undertaking projects and two planned to start. The BIP, together with new, direct links through medical education to the University of Bristol and the Mental Health Research Network, has improved access for senior trainees to research, management and education leadership experience. This is reflected in improved feedback in the GMC survey 2011.

2.5.6 4 GP VTS placements in Bristol and Swindon graded ‘A’.

2.5.7 A comparison of the results from GMC survey s in 2010 and 2011 shows improvements in 15 domains out of a possible 21.




2.5.8 Our higher training scheme for the psychiatry of old age was rated the best in the country in the GMC survey.

Action Plan

1. Monitor service redesign through its implementation, ensuring training deployment and standards are maintained throughout the process.

2. Appoint second teaching fellow (non-clinical).Tasks will include improving

evaluation and feedback at all levels, overseeing BIPS, and training and education innovation.

3. Encourage senior trainees to address issues arising from GMC survey, e.g.

“handover”. Encourage trainees undertaking BIP projects to address CQINS and other trust targets.

4. Need to review the feedback system to alert DME of serious and untoward

incidents which involve trainees. The current system includes analysis of all SUI so that themes are identified. ‘Red Top Alerts’ are cascaded to all staff. At present the DME cannot extract data on SUIs which involve trainees.

5. Some trainees remain dissatisfied with internet access: issues may be resolved

through proposed trustwide IT developments.

“Outlier” results in the GMC trainee survey 2010

Trust Outlier above or

below

Area identified

AWP 2010 Below Handover (All) AWP 2010 Below Undermining by the Consultant (1 Foundation

Trainee) AWP 2010 Below Hours of Education per week (General Psychiatry) AWP 2010 Above Responsibility for Clinical Supervision AWP 2010 Above Compliance with European Working Time

Regulation AWP 2010 Above Access to Educational Resources AWP 2010 Above Work Load AWP 2010 Above Induction




AWP 2010 Above Other Learning Opportunities

Outliers in the GMC trainee survey 2011

Trust Outlier

above or below

Area identified

AWP 2011 Above Psychotherapy – Overall Satisfaction AWP 2011 Above LD – Workload AWP 2011 Above Psychotherapy –Access to Educational Resources AWP 2011 Above GP Programme – Responsibility for Clinical

Supervision AWP 2011 Above Foundation and Core – Access to Educational

Resources AWP 2011 Below Psychotherapy - Handover AWP 2011 Below GP Programme - Handover AWP 2011 Below Foundation and Core - Handover

2.6 Pharmacy 2.6.1 Completion of a major programme to switch to a new supplier for

Clozapine. The new process reduces the costs, as well as improving the quality of the service.

2.6.2 In the next month, pharmacy will be launching MI Databank. The

launch on MI Databank will allow AWP pharmacists to provide information on the use of medicines for individual service users around drug interactions, compatibility of different drug regimens etc, and as this service becomes more established, it will also be available to GPs and eventually, to service users and carers as a helpline for information on medicines.

2.6.3 Recruitment of pharmacy staff remains a challenge, but despite

this, the team is working hard to achieve key objectives such as medicine reconciliation, and maintain standards for medicine management.

2.6.4 Moving forward, the key challenges will be implementing a new

pharmacy service provision for Bristol, getting E-prescribing in place, and achieving the shared care protocols.

2.7 Research & Development




2.7.1 In R&D over the summer, we have recruited to 10 vacancies across the networks and R&D office due to staff leaving and maternity leave. We will be fully staffed from early December 2012, this has in part been made possible by a successful bid for additional funding from the Western Comprehensive Local Research Network.

2.7.2 The DeNDRoN coordinating centre visit in October 2011 was

positive in terms of feedback, but we still need to work on improving DeNDRoN performance in AWP, particularly in relation to recruitment of people with Dementia to network studies. DeNDRoN staffing and collaboration with Liaison and Later Life Services are amongst the initiatives in relation to this objective.

2.7.3 Recruitment of participants to Mental Health Research Network

NIHR portfolio studies is currently very good, exceeds our targets and our position this time last year. Our final figure for recruitment last year was over 700; over 250 of these were staff members who were recruited into research studies. This progress will be protected and further improved by the staffing increase described above.

2.7.4 Over the next 4-6 months we are planning to focus on increasing

the profile of R&D and networks within the Trust to ensure increasing adoption of studies and thus recruitment over the medium term.

2.7.5 We will be redrafting the Trust Research Strategy during December

2011 in response to ideas raised by Board and Executive members; we will also review the context of the strategy and its position with respect to related strategies in the Trust.

3. Conclusion

3.1. The Directorate will continue to work to meet its annual planning targets.

4. Recommendation

4.1. The Board is invited to note the progress to date.

5. Additional Report Contributors

5.1. Harvey Rees, Deputy Medical Director

5.2. Glen Monks, Deputy Director of Performance, Strategy and Business Development




5.3. Rachel Clark, Head of innovations

5.4. Hayley Richards, Director for Medical Education

5.5. Bina Mistry, Chief Pharmacist

5.6. Julian Walker, Director of Research and Development

11.0710.01

Appraisal for Consultants and SAS Doctors

Document Information

Board Library Reference

Document Type

Document Subject

Original Document Author

Assured By Review Cycle

Appendix; Procedure

Medical Appraisal

Harvey Rees Arden Tomison

Version Tracking

Version Date Revision Description Editor Approval Status

1.0 14/10/2010 Initial Draft CT Draft

2.0 10/11/2010 Amended Draft CT Draft

3.0 16/11/2010 Final Draft CT/HR Draft

4.0 17/06/2011 In response to ORSA HR Draft

Draft Appraisal Policy For Consultant and SAS Doctors

Location: Version: Status: Date: Page:

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1. Introduction 2. Definitions 3. Scope 4. Related policies, guidelines and other trust documents 5. What will appraisal cover 6. How Appraisal links to Job Planning 7. Roles and Responsibilities

7.1 The Trust Board 7.2 The Chief Executive 7.3 The Responsible Officer 7.4 The Director of Medical Education 7.5 Human Resources 7.6 The Appraiser 7.7 The Appraisee

8. Appraiser Selection, Skills and Training 8.1 Selection of Appraisers 8.2 Skills 8.3 Training

9. Appraisal Process 9.1 Preparation for appraisal 9.2 The appraisal meeting 9.3 Outcomes of appraisal 9.4 When difficulties arise 9.5 Conflicts of Interest 9.6 After the appraisal meeting

10. Confidentiality 11. Quality Assurance 12. Public Involvement 13. References 14. Glossary 15. Appendices

a. Flowchart outlining the Appraisal Process in AWP b. Framework of Supporting Information for Psychiatrists c. The Appraiser’s “Four Statements” d. Job Description for and Person Specification for an

Appraiser e. Self-Assessment checklist of Appraiser Competencies f. Questionnaire about the Appraisal Process



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1. Introduction 1.1 Annual appraisal is a requirement for all doctors under the General

Medical Council and forms the basis for providing the evidence for revalidation. Satisfactory participation in appraisal will be a requirement as part of the individual’s doctor’s revalidation with the General Medical Council.

1.2 The appraisal process has been revised since its introduction for

General Practioners and Consultants in 2001 in part because of a number of high profile inquiries about doctor’s poor performance and the variation in the quality of appraisal across the UK.

1.3 Revalidation is the process by which licensed doctors will have to

demonstrate to the General Medical Council that they are up to date and fit to practise and that they are complying with the relevant professional standards. The Royal College of Psychiatrists have set out how psychiatrists demonstrate that they meet the standards of Good Medical Practice and Good Psychiatric Practice. In the future, all licensed doctors will need to revalidate regularly, if they wish to keep their licence to practise. For most doctors, revalidation will take place every five years.

1.4 This document outlines the process for appraisal for career grade

Doctors employed by Avon and Wiltshire Mental Health Partnership NHS Trust (AWP). The aim of this document is to assist medical staff and the Trust in the implementation and delivery of a robust, quality assured system of appraisal, in support of revalidation, that is fully integrated with local clinical governance systems.

2. Definitions AQMAR Assuring the Quality of Medical Appraisal for Revalidation.

The revalidation support team for the NHS has produced descriptors of good practice in medical appraisal and has provided a manageable developmental framework for organisations interested in improving their appraisal system.

ORSA Organisational Readiness Self Assessment (Tool); replaced the AQMAR in 2011

Appraisal “A professional process of constructive dialogue, in which the doctor being appraised has a formal structured opportunity to reflect on his or her work and to consider how his or her effectiveness might be, approved “(DH, 2002)

Assessment Measurement of skills and performance against set criteria.



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Responsible Officer(RO)

The Responsible Officer is a role created under the provisions of the Health and Social Care Act 2008. The RO will have specific responsibilities relating to the evaluation of the fitness to practice of doctors. One of their key roles will be to recommend to the GMC whether or not a doctor should be revalidated.

Revalidation The process by which doctors will have to demonstrate to the General Medical Council that they are up to date and fit to practise and that they are complying with the relevant professional standards.

Recertification and Relicensing

When the Government published its proposals for revalidation in 2007, it divided revalidation into two elements – relicensing (standards specific to a medical speciality set by the medical royal colleges and facilities) and recertification (generic standards of practice set by the GMC) A single system of revalidation is now planned.

The Appraisal Team

This comprises; The Responsible Officer (RO), The Director of Medical Education (DME), The Medical Education Manager, The Medical Education Administrator.

Job planning Is a systematic activity designed to produce clarity of expectation for employer and employee about the use of time and resources to meet individual and service objectives. It is prospective in nature.

3. Scope 3.1 This policy applies to all career grade medical doctors on substantive

contracts, i.e. - Consultants, Associate Specialists, Speciality Doctors and Staff Grades employed by Avon and Wiltshire Mental Health Trust (AWP).

3.2 NHS locum doctors or temporary doctors will be offered Trust Appraisal

only if they are employed by, or seconded to the Trust for more than 6 months. Consideration to offering Trust Appraisal will be given to doctors who do a series of shorter NHS locums for the Trust over a sustained period.

3.3 For doctors who are employed by more that one employer, only one

appraisal should be carried out, normally by the lead employer. Doctors who are apprised elsewhere are responsible for submitting copies of the relevant forms to the Director of Medical Education.



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3.4 Doctors may request that an appraisal is deferred if they have breaks in clinical practice due to sickness or maternity leave or due to absence abroad or a sabbatical. As a general rule it is advised that doctors having a career break: • In excess of 6 months should try to be appraised within 6 months of

returning to work. • Less than 6 months should try to be appraised no more than 18

months after the previous appraisal and wherever possible so that an appraisal year is not missed altogether.

Each case should be dealt with on its merits and the Trust is mindful that no doctor must be disadvantaged or unfairly penalised as a result of pregnancy, sickness or disability. Doctors are likely to have to produce the required total amount of CPD credits stipulated for the five year revalidation cycle, even if they have had some periods of leave during these five years.

3.5 Doctors in approved training posts will participate in appraisal in the

format prescribed by the Severn Deanery. The Responsible Officer for trainees will be appointed by the Deanery. The Annual Review of Competence Progression (ARCP) process suitably enhanced should provide the vehicle through which trainees revalidate. Trainees first revalidation will either be at the point they are awarded their Certificate of Completion of Training (CCT) or five years from the date they are granted full registration, whichever is the sooner.

4. How Appraisal Links to Job Planning 4.1 Job Planning is a systematic activity designed to produce clarity of

expectation for employer and employee about the use of time and resources to meet individual and service objectives. It is prospective in nature. Appraisal on the other hand is a systematic approach to review a consultant’s achievements, consider their continuing progress and to identify developmental needs, therefore usually retrospective.

4.2 Job Planning and Appraisal are best seen as a continuous cycle, one

feeding into the other. A sensible start point is the phase of AWP’s business cycle which follows the financial year beginning in April. In order to coordinate and ensure completion of a large number of appraisals required across the Trust it is necessary to divide appraisals across the year. Any time frame will be set by the Direction of Medical Education and the Responsible Officer.

5. Related policies, guidelines and other trust documents Associated Trust policies and documents, which should be read in conjunction with this policy include: the Individual Performance Improvement and Capability Policy ; Conduct and Capability Policy and Procedure for Medical Staff; Appraisal Policy ; Grievance and Disputes Policy and Procedure ;Consultant Job Planning in AWP NHS Trust ;Induction Policy.

http://ourspace/Trust/Policies/Documents/HR_GOV_07.doc






http://ourspace/Trust/MSBD/Documents/Job%20Plan%20-%20Guidance.doc




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6. What Will Appraisal Cover The content of appraisal is based on the General Medical Council Frame work. The GMC has grouped the standards of Good Medical Practice into four domains, each with three attributes. The standards of Good Psychiatric Practice can also be considered in these twelve headings. The four domains and twelve attributes are: Domain 1 Knowledge, skills and performance: Attribute 1 Maintain your professional performance Attribute 2 Apply knowledge and experience to practice Attribute 3 Keep clear, accurate and legible records Domain 2 Safety and quality: Attribute 4 Put into effect systems to protect patients and improve care Attribute 5 Respond to risks to safety Attribute 6 protect patients and colleagues from any risk posed by your health Domain 3 Communication, partnership and teamwork: Attribute 7 Communicate effectively Attribute 8 Work constructively with colleagues and delegate effectively Attribute 9 Establish and maintain partnerships with patients Domain 4 Maintaining trust: Attribute 10 Show respect to patients Attribute 11 Treat patients and colleagues fairly and without discrimination Attribute 12 Act with honesty and integrity 7. Roles and Responsibilities 7.1 The Trust Board The Board of Directors of AWP is ultimately responsible for ensuring that appropriate governance systems, including appraisal for doctors are in place and are implemented. The Board delegates responsibility for appraisal of doctors as follows: 7.2 The Chief Executive Is accountable to the Board for: a) Ensuring there is a robust appraisal system in place which complies

with regional and national guidelines. b) Ensuring that the necessary links exist between the appraisal process

and other Trust processes concerned with clinical governance, quality and risk management and the achievement of service priorities.

c) Ensuring that an annual report on appraisal is made to the Trust Board.

d) Confirming to the Board that any issues arising out of the appraisals are being properly dealt with.



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e) Ensuring that there are adequate resources available to support the process.

7.3 The Responsible Officer The Responsible Officer will have a statutory responsibility for evaluating the fitness to practise of doctors in the trust. In AWP the role has been delegated to the Deputy Medical Director. The roles include to: a) Be responsible for the process to the Chief Executive. b) Oversee the appraisal process and ensure that annual appraisal and

job planning occurs. c) Arrange and consult on the appointment of appraisers and ensure

that appraisers have adequate time allocated in their SPA’s. d) Monitor and review progress on the numbers and quality of

appraisals during the appraisal year. e) Develop a system so that relevant information with regard to clinical

activity and issues round clinical governance such as complaints, litigation etc are supplied to Appraisees and Appraisers.

f) Deal with any agreements and serious concerns informally if possible or through trust investigation and disciplinary procedures if appropriate.

g) Ensure a sign off unless disciplinary procedures are continuing. h) Identify any Consultant not engaging in the process appropriately and

ensure compliance. i) Inform the Chief Executive of serious issues arising from individual

appraisal. j) Present the annual appraisal report to the Trust Board. k) Ensure adequate funds for appraisal training and CPD are available. 7.4 The Director of Medical Education(DME) Is responsible for ensuring that: a) Appropriate Appraisers are selected and assigned to Appraisees. b) Training is publicised and Appraisers and Appraisees are facilitated

to attend. c) Arrangements are in place for all medical practitioners to have an

annual appraisal. d) Appraisal is tracked and an up to date register/data base for all

appraisals undertaken is maintained. e) Appraisers understand the documentation and information they need

prior to the appraisal taking place. f) Records of appraisal are retained in a secure manner and access is

restricted to the appraisal team overseen by the DME. g) The appraisal process is subject to a quality assurance approved by

the Trust. Including o Evaluating newly appointed appraisers and ensuring

appraisers attended refresher training every 3 years o Auditing a sample of portfolios and Form 4’s. o Collating information from the appraisal questionnaires.



Draft Page 8 of 26

h) An Annual Report is prepared on appraisal summarising and highlighting any issues raised and/or emerging themes.

i) Overseeing the budgets for CPD and Training. j) Review the training needs identified from the appraisal and report to

the Medical Director on how the Trust is and can meet these needs effectively and efficiently.

7.5 Human Resources The Director of Human Resources is responsible for ensuring that: a) All new medical practitioners, receive a copy of the Appraisal Policy

at induction. b) Information is requested from all new substantive medical appointees

regarding previous appraisals and copies of Forms 1, 2, 3 and 4 from all appraisals since they were last revalidated are forwarded to the DME.

c) Provide appropriate advice to doctors on disciplinary issues. 7.6 The Appraiser The Appraiser is responsible for ensuring that they: a) Are up to date with their Trust Statutory and Mandatory training and

that they attend initial appraiser and refresher training as specified in section 7.3.

b) Complete up to 10 appraisals annually, the number to be agreed through job planning, in a manner consistent with the guidance issued by the Trust, RCPsych and GMC. In order to retain sufficient skills, appraisers will be expected to complete a minimum of 3 annual appraisals

c) Record the appraisal interview on the appropriate forms and send copies of the signed forms 1-4 to the DME.

d) Promptly raise any concerns about individuals with the DME and/or the Responsible Officer.

e) Collaborates with the DME in preparing an Appraisal Report. f) Collaborate in the audit process as part of quality assurance. g) Attend periodic peer group meetings and training organised by the

DME. h) AWP will indemnify the appraisers in respect of any loss suffered by

them arising from the proper performance of their duties as defined in this policy.

7.7 The Appraisee Is required to: a) Participate annually in appraisal as part of their contractual

obligations. b) Attend basic training in appraisal to ensure they understand the

Appraisal Process. c) Inform Medical Education Administration when they are planning an

appraisal and confirm whom the appraiser will be. d) Approach their identified/allocated appraiser and make an

appointment for the annual appraisal.



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e) Prepare a Personal Development Plan and draft of forms 1-6 of NHS appraisal system and forward these two weeks in advance of appraisal meeting to Appraiser.

f) Forward completed Form 4 and PDP to Director of Medical Education g) Undertake the agreed Personal Development Plan h) Establish and maintain their appraisal folder and include all relevant

reports developed by AWP in relation to their activity and performance, including previous personal development plans and CPD activity in accordance to RCPsych Guidelines. The Appraisee is obliged to include within their folder all information supplied by the Trust to them over the appraisal year, to ensure this is appraised and discussed. This key information includes specified complaints, SUIs/significant events, performance & clinical outcomes information personalised for individual or relevant team.

i) Retain appraisal information and original copies of relevant documentation in accordance with regional or national guidance (or in the absence of guidance retain information for at least one completed revalidation cycle).

j) As part of the Quality Assurance process the Appraisee will be o Expected to participate in the audit process of appraisal o Requested to complete and return an anonymised questionnaire

about the process and outcome of appraisal to the Director of Medical Education.

8. Appraiser Selection Skills and Training 8.1 Selection of Appraisers. a) All Consultants and SAS doctors are encouraged to become

appraisers if they have the relevant qualities as outlined in the person specification (see appendix d). Applications should be in writing to the DME with a copy of CV attached.

b) Appraisers are recruited based on a job description and person specification (see appendix d).

c) Appraisers will be formally selected by a panel chaired by the Director of Medical Education.

d) Appointment will be for 5 years, renewable subject to meeting competencies and attending training.

8.2 Skills a) The skills involved in are highlighted in the job description (see

appendix d). b) The appraiser skills will be reviewed and developed. Appraisers will

be supported with ongoing training and opportunities for peer support. c) The appraiser is expected in reflect upon their appraiser skills in their

own appraisal. 8.3 Training a) All Appraisers must participate in an initial training programme which

covers the core content prior to performing appraisals.



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b) The DME will evaluate the training provided by the chosen company to ensure it addresses the needs of the appraisers.

c) The appraiser should take part in update training every 3 years or when there have been significant changes in policy or guidance.

9. Appraisal Process The appraisal process is cyclical in nature and requires appraisers to select an appraiser for the coming year, arrange a date for this appraisal, prepare for and attend the appraisal meeting and submit documentation as evidence that the appraisal has been undertaken. A flowchart outlining the appraisal process in AWP is in the Appendix (a). 9.1 Preparation for appraisal a) Preparation will be part of a Consultants Supporting Professional

Activity planned activities. It is envisaged that between 2 – 4 hours a month will be sufficient to prepare for appraisal, including maintaining portfolio.

b) Supporting information. o The appraisee is required to gather supporting information, referring

to the standards in Good Medical Practice and Good Psychiatric Practice.

o The appraisee is expected to consider which out of the 12 attributes they wish to present supporting information for in the appraisal for each year. Final guidance is awaited but all supporting information must be mapped onto these attributes. All twelve attributes are to be covered in a 5 year appraisal cycle for revalidation.

o Some information will be presented each year; other information may only be required once in a five year cycle.

o See appendix for a framework of supporting information for psychiatrists.

c) Choice of Appraiser

o All Appraisers will be appointed through the AWP Process (See section 8). Employed doctors will be allocated an appraiser upon substantive appointment.

o Appraisals should be undertaken by a colleague with a good understanding of the work being undertaken by the appraisee.

o Each appraisee should be appraised no more than four times in succession by the same appraiser.

o In order to ensure continuity, however, appraisees should ensure that they do not frequently change their appraiser.

o Appraisees will be involved in a choice about their appraiser. In circumstances where concerns are being raised about practice agreement must be reached with the Director of Medical Education and/or the Responsible Officer.

o If the appraisee is concerned about the choice of appraiser they must approach the Director of Medical Education in the first instance. If where there is a recognised incompatibility between proposed appraiser and appraisee, the Director of Medical



Draft Page 11 of 26

Education, by delegated authority of the Responsible Officer and Chief Executive, will be responsible for nominating a suitable alternative.

d) Pre-meeting

o The appraisee and appraiser should make contact before the meeting to discuss the agenda and raise any particular points.

o The portfolio of supporting information should be delivered to the appraiser at least two weeks before the meeting.

o If any third party is to be present at another appraiser this must be agreed with the appraisee before the meeting

o The appraiser should come to an opinion early on about whether there is sufficient supporting information to enable the appraisal interview to go ahead as planned whether it should be adjourned or whether to a request for further information prior to the interview itself is necessary.

9.2 The appraisal meeting a) Practicalities

o Appraisal meetings are normally about 2 hours but this will vary depending upon the individual’s circumstances

o The meeting should be held somewhere private and free from interruptions. Access to a computer should be available especially as use of electronic portfolios is expected.

o The agenda and discussions should cover the following areas: o Introductions and clarification of the appraisal process, progress

so far and any particular issues to be considered. o A reflective and where appropriate challenging discussion about

practice based upon the 4 domains and 12 attributes and during which the supporting evidence can be considered.

o The PDP from the previous year should be reviewed and where elements are not completed reasons for these are understood.

o A personal development plan for the following year should be agreed.

o Formative aspects may include career advice and support. b) Others at the appraisal meeting

o The majority of appraisal will consist of a meeting of two doctors. It may be helpful to consider bringing in a third party into one or more of the appraisal discussions over a 5 year period , for example a sub specialty colleague for individual’s who practise in a very specialised area or have a split post such as education and management or a trained appraiser to quality assure the appraiser.

9.3 Outcomes of appraisal It is unlikely that concerns about a doctors practice will be arise for the first time during the appraisal interview.



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A crucial aspect of appraisal is the judgement of the appraiser with regard to the quality of supporting information and performance. The outcome of the appraisal should fall into one of the following 4 scenarios. a) Satisfactory appraisal This is the judgement that is made when

good supporting information is presented and no concerns are raised throughout the appraisal meeting. This is likely to be the majority of psychiatrists.

b) Satisfactory appraisal process but significant performance issues. This is when the psychiatrist has provided good supporting information but the information reveals concerns. The PDP must reflect this and have clear e.g. SMART (Specific, Measurable, Achievable, Realist, Timed) objectives that set out how and when the performance will improve. The appraiser may refer to the Medical manager, responsible Officer, the National Clinical Assessment Service and also the GMC .

c) Unsatisfactory appraisal- Poor Quality Information. The psychiatrist has not provided enough supporting information to satisfy the appraiser that the GMP and GPP standards have been met. There may be no performance concerns but the appraisal is adjourned for no longer than 3 months to ensure that the required information is provided.

d) Unsatisfactory appraisal and significant performance issues. The psychiatrist has not provided sufficient supporting information and there are concerns about performance. The appraisal is adjourned and the Medical manager, Responsible Officer, NCAS or GMC may be notified. The appraiser may need to seek advice before rescheduling a further appointment.

All appraisal meetings should end with the following four agreed statements:

1. Presence or absence of immediate concerns about the doctor’s fitness to practise. If concerns exist the statement will specify in which attribute(s) the concern exists.

2. Whether there is sufficient supporting information recorded to demonstrate the doctor is making satisfactory progress towards revalidation.

3. Whether there has been satisfactory progress with key elements in the previous year’s Personal Development Plan.

4. Agreement with the Personal Development Plan that derives from the current year’s appraisal discussion to demonstrate the doctor is making satisfactory progress towards revalidation and that key priorities for development have been included in the plan.

If these cannot be agreed, the appraisal is unsatisfactory and the process suggested in c and d above should be followed. 9.4 When difficulties arise.



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a) Where there is a disagreement that cannot be resolved at the appraisal meeting, this should be recorded and advice should be sought from the Director of Medical Education/Responsible Officer. Soundings on the issue may be taken from a number of appraisers and an opinion on the merits of the case will be conveyed to the appraisee and the appraiser by the Medical Director. Where the doctor continues to disagree with the content of the appraisal or the process that has been followed and satisfactory completion of appraisal cannot be confirmed then the doctor will be advised of his/her right to raise their concern formally in accordance with the Trust Grievance Procedure.

b) When it becomes apparent during the appraisal process that there is

a potentially serious performance, conduct, or health issue that requires further discussion or examination, the Appraiser must take action in accordance with Trust Policies and procedures appropriate to the seriousness of the situation, which may include informing the Medical Director and Chief Executive. If the situation is then remedied the appraisal process can continue. Nothing in the operation of the appraisal process can over-ride the basic professional obligation to protect patients

c) Where an appraisee’s performance gives rise to concerns which are

not serious enough to warrant immediate termination of the appraisal interview the following course of action will be undertaken. The appraiser will inform the appraisee that they will need to seek advice from the appraisal lead on a named basis, regarding these concerns All documentation written in addition to the Form 4 must be shared with appraisee. The following list provides examples of potential areas for concern o Significant negative 360 or patient feedback o Several significant complaints or serious untoward events or

refusal to discuss these. o Lack of reflection e.g. no weaknesses at all identified or poor

quality evidence or evidence that is not adequately personalised o Serial under-achievement in successive PDP’s or minimalist

PDP’s 9.5 Conflicts of Interest a) It is important that the evaluation of a doctor’s fitness to practise is

fair, honest and evidence based if it is to provide the assurances that patients and doctors require from the system. In some circumstances, doctors will find they have a conflict of interest with their appraiser or responsible officer.

b) If a conflict of interest is identified between appraisee and appraiser,

the responsible officer should be informed in writing, explaining the conflict and providing as much background information as is necessary and relevant. It may also be appropriate to request another appraiser is assigned. The responsible officer will consider




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the claimed conflict and may assign another appraiser. If a conflict exists between the doctor and the responsible officer, the designated organisation should be informed in writing giving as much information as possible. It is important that every attempt is made to resolve the issue using the existing mediation procedures. If, after all processes are exhausted, a satisfactory resolution is not possible the evaluation of fitness to practise may be overseen by another responsible officer.

c) In the same way that conflicts of interest must not be allowed to affect

a doctor’s career they should not be a route that allows a doctor to undergo a less rigorous assessment of his or her fitness to practise.

9.6 After The Appraisal Meeting a) A satisfactory appraisal will need to be confirmed in writing by the

appraiser to the appraisee within two weeks of the meeting with a summary of which attributes were satisfied and what actions were agreed in the PDP.

b) In cases of unsatisfactory appraisal there is need to establish whether simply more time is required to allow the appraisee to collect supporting information (scenario c) or should this appraisal be put on hold to allow performance management. The appraiser will notify the RO as well as the appraisee as soon as reasonably practicable.

c) A psychiatrist in scenario d will be in need of performance management and/ or remediation. And whilst appraisal should be completed in good time e.g. 3 months it may run parallel to a performance investigation, either internal or external.

10. Confidentiality 10.1 The detail of discussions during the appraisal interview is confidential

to Appraisee and Appraiser, apart from the sharing documentation as mentioned below or where concerns about performance arise.

10.2 AWP will keep all aspects of the appraisal process confidential in line

with the Data Protection Act (1998). Appraisal documentation will only be read by designated members of the appraisal team and for the purpose of job planning will be available to relevant Medical Lead.

a) In circumstances where access to this information is required by

other individuals, the doctor concerned will be informed and permission received before access is granted.

b) In exceptional circumstances, information may come to light during an appraisal, which in the interests of the welfare of the doctor or patient safety overrides the right to personal confidentiality. Should such an occurrence arise this will be referred to the Responsible Officer. Where there is performance concerns, reasonable effort should be used to seek consent from the person involved before breaking confidentiality.



Draft Page 15 of 26

10.3 Data stored relating to appraisals will be held securely. Access and use of data will adhere to the requirements of the Data Protection Act (1998). Under the Freedom of Information Act (2000), Form 4’s and PDPs are classed as data of a personal or confidential nature and as Human Resource files are not accessible under the Act. Access is limited to Director of Medical Education, Medical Director & Responsible Officer for specified purposes - these include appraisal, revalidation, and internal/external quality assurance by the GMC or Royal College. This restriction will remain in force until such time as the information has been anonymised.

11. Quality Assurance 11.1 Quality Assurance of the Appraisal process is a key component of the

Trusts Quality Assurance Framework. The GMC and the RCPsych highlight the need for quality assurance of the Appraisal Process.

11.2 The components of this framework include: a) Audit to assess compliance with Trust Policy on appraisal for medical

practitioners RCPsych and GMC Guidance. b) Monitoring participation in appraisal process and documentation

completion. c) An annual objective self assessment using ORSA Framework with

standard core content will be performed. d) An audit of anonymised Form 4s to ensure completion is in line with

guidance. e) Production of Annual Appraisal Reports and monitoring

implementation of agreed action plans f) External review of the appraisal system is still to be developed

possibly looking at Mental Health Trusts in the South West. 12. Public Involvement 12.1 The Trust wishes to encourage Public Involvement through lay

membership of The Regulation and Quality Improvement Authority and having the public directly commenting on the Annual Medical Appraisal Report and Trust Board’s Annual Report.

12.2 Service users view about individual doctors will be obtained through participation in 360° feedback.

13. Glossary GMC General Medical Council RO Responsible Officer AWP Avon and Wiltshire Mental Health Partnership NHS Trust DHSSPS The Department of Health, Social Services and Public Safety DME Director of Medical Education GMP Good Medical Practice



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GPP Good Psychiatric Practice PDP Personal Development Plan GMC General Medical Council



Draft Page 17 of 26

14. References Department of Health (2002) Appraisal for General Practitioners Working in the NHS. London: Department of Health. http://www.dh.gov.uk/assetRoot/04/03/47/23/04034723.pdf GMC Good Medical Practice (2006)http://www.gmcuk.org/guidance/good_medical_practice/index.asp GMCFramework ttp://www.gmc�uk.org/Framework_4_3.pdf_snapshot.pdf Good Psychiatric Practice, RCPsych, 3rd Edition (Feb 2009) RCPsych Good Practice Guidelines for Appraisal Dr Laurence Mynors- Wallis, Dr David Fearnley (Feb 2010) RCPsych (Feb 2009) Revalidation Guidance for Psychiatrists, Dr Laurence Mynors- Wallis NHS Revalidation Support Team (January2010).Strengthened Training of Appraisers for Revalidation – Draft. NHS Revalidation Support Team. (May 2009) Assuring the Quality of Medical Appraisal for Revalidation Dr Martin Shelly, Dr Keith Judkins.

http://www.dh.gov.uk/assetRoot/04/03/47/23/04034723.pdf

Draft Appraisal Policy For Consultant and SAS Doctors 15. Appendices a. Flowchart outlining the Appraisal Process in AWP

APPRAISAL PROCESS FLOWCHART

Appraisee chooses an Appraiser from a list of approved Appraisers.

Appraiser agrees an Appraisal date with the

Appraisee.

Appraisee collates supporting information for

their portfolio in line with revalidation requirements and fills in forms 1-3. Appraisee submits their portfolio to Appraiser at least two weeks prior to the Appraisal.

Appraiser reviews the portfolio and assesses

if sufficient supporting information is available. If the appraiser is not happy to proceed based on

the portfolio they should inform the appraisee and postpone the appraisal.

Pre-

App

rais

al

Appraisal interview takes place. Satisfactory appraisal good supporting information and no concerns

Unsatisfactory appraisal Poor Quality Information.

Satisfactory appraisal process but significant performance issues

Unsatisfactory appraisal and significant performance issues.

Appraiser and Appraisee agree a PDP

The appraisal is adjourned for no longer than 3 months

The PDP must have clear objectives that set out how and when the performance will improve

The appraisal is adjourned

Appraiser completes the

four statements for revalidation and forwards it to the Appraisal Team.

The appraiser may refer to the Director of Medical Education, Responsible Officer, the National Clinical Assessment Service and also the GMC.

Appraiser prepares the form 4 and completes the four statements for revalidation ( See Appendix c)

. Appraiser completes the four statements for revalidation and forwards it to the Appraisal Team.

Form 4 typed and signed off by

Appraisee and Appraiser Appraiser sends Form 1-4 for first

appraisal & thereafter form 4 to the Appraisal Team

Every 5 years the Responsible Officer will recommend to the GMC whether or not a doctor should be revalidated.

Appraisee completes an anonymised questionnaire about the appraisal process and returns it to the Appraisal

Team The Appraisal Team updates the database, collates common issues from the form 4’s and questionnaires. An

audit of anonymised form 4’s is done.

Afte

r App

rais

al

The Director of Medical Education prepares an annual report to be take to board by Responsible Officer The Appraisal Team consists of the Director of Medical Education, Responsible Officer, Medical Education Manager and Administrator. The team is currently based in Woodland View Brentry Bristol.


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b. Framework of Supporting Information for Psychiatrists Type of information Minimum

Required in 5 Years

Comment

1 Case based discussion 10 Minimum 2 per year Incorporate identified action points In a personal development plan

2 Review of and reflection on complaints and serious untoward incidents

All

3 Audit Complete 2 audits of significant clinical areas of practice over a 5-year cycle. Undertake at least 1 audit of record keeping in each 5 year cycle

4 Patient feedback survey (using GMC approved tool) and review

1 To be presented no later than year 3.

5 Colleague feedback survey (using GMC approved tool) and review

1 To be presented no later than year 3.

6 New PDP and review of previous year’s PDP

5 Annually

7 Meeting College CPD requirements

5 Annually

8 Clinical governance and other information (including outcomes) produced by the organisation and doctor

5 Annually

9 Information supporting non-clinical work e.g. teaching research, management and expert advise activities.

5 Annually if part of role

Draft Appraisal Policy For Consultant and SAS Doctors c. The Appraiser’s “Four Statements” Provisional Form The Appraiser’s “Four Statements” Date of Appraisal ………………………………………………. Appraisee ……………………………………………………. Appraiser ……………………………………………………. The Appraisee’s Fitness to Practise The doctor has provided sufficient information and this demonstrates good practice. There are no concerns for patient safety.

The doctor has provided information that raises some concerns. Further investigation or action is required. There may be an issue that affects patient safety or quality of care.

There is insufficient information for an assessment to be made. The Appraisee’s Progress in collecting Information for Revalidation The doctor has provided sufficient information in all attributes of Good Medical Practice.

The doctor has provided sufficient information and the doctor is making satisfactory progress towards revalidation.

The doctor has provided some information but this is insufficient and raises concerns about the doctor’s progress towards revalidation. Further action, support or investigation is required.

There is insufficient information for an assessment to be made. The Appraisee’s Progress with previous years’ Personal Development Plans The doctor has engaged with and exceeded the aims of the previous year’s developmental plan.

The doctor has engaged with and made progress with key elements in the previous year’s development plans.

The doctor has not engaged with or made progress with previous year’s development plans. Further action, support or investigation is required.

There is insufficient information for an assessment to be made. Agreement that the Personal Development Plan from this Appraisal derives from the current year’s Appraisal discussion Important developmental areas have been incorporated into this year’s Personal Developmental Plan and the doctor is making progress towards revalidation.

Important developmental areas are not incorporated in this year’s Personal Developmental Plan. Further action, support or investigation is required.

There is insufficient information for an assessment to be made.


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d. Job Description and Person Specification for Appraiser JOB DESCRIPTION Appraiser for Employed doctors in AWP (Consultants and SAS Grades) November 2010 INTRODUCTION AWP advocates and is committed to fully support the process of Medical Revalidation. Integral to this process is strengthened appraisal which all employed doctors must participate in annually. The Trust facilitates appraisal processes including provision of high quality training for appraisers. The Trust also promotes the opportunity for all eligible doctors to become appraisers. This job description and person specification should be read in conjunction with the AWP policy for Appraisal for employed Doctors. NHS appraisal has been a statutory requirement for medical practitioners since 2001. The quality and consistency of appraisal relies heavily on the skills and the professionalism of the appraiser. An appraiser must develop the experience to benchmark a portfolio and assess the evidence within the context of the stage of the revalidation cycle and the circumstances of the appraisee. Appraisers are employed and supported within the organisation and so decisions relating to recruitment and training lie with the Responsible Officer and Director of Medical Education.



Draft Page 22 of 26

Person Specification of Medical Appraiser

CRITERIA Essential Desirable Qualifications Medical Degree Entry on GMC Specialist Register (for Consultants) and current License to Practice

In good standing with RCPsych for CPD Completion of Appraisal training (not requirement of appointment but to be completed before appraisals performed)

Experience 2 years since substantive appointment at Consultant/SAS grade

Experience of managing own time to ensure deadlines are met

Experience of applying principles of quality improvement

Experience of acting as Educational supervisor

Knowledge

Understanding the appraisal and revalidation process and its links to revalidation

Knowledge of the role of appraiser

Knowledge of responsibilities of doctors as set out in GMP

Understanding of equality and diversity, and data protection and confidentiality legislation and guidance

Knowledge of relevant Royal College speciality standards and CPD guidance

Knowledge of EBM and clinical effectiveness

Expertise, Skills and Aptitudes Excellent interpersonal and written communication skills,

Objective evaluation skills Commitment to ongoing personal education and development

Good working relationships with professional colleagues

Motivating, influencing and negotiating skills

Training: AWP offers appraisal training and the aim is to demonstrate an understanding of the purpose of appraisal and its relation with the appraisal process and the wider context of clinical governance and quality improvement with the NHS.



Draft Page 23 of 26

Appraiser Support, Development and Performance Review The quality and consistency of appraisal relies on the skills and the professionalism of the appraiser. The appraiser needs to understand the purpose of appraisal and revalidation and to appreciate his or her responsibilities within those structures. AWP has clear arrangements to support appraisers with structured ongoing training and opportunities for peer support, and their development needs in the role of appraiser should be reflected in their Personal Development Plans (PDPs). AWP intends to encourage Appraiser Support Groups to meet the above needs to be led by a suitably skilled Appraisal Lead or support group convenor. These will be a combination of internal (addressing needs in the context of the organisation) and external (bringing new perspectives and expertise from outside the organisation) supervision groups. Participation in an annual performance review is a requirement of working as an appraiser and includes participation in CPD activities, having a personal development plan, receiving feedback on role as an appraiser. There will be a review of the appraiser’s handling of difficult areas of appraisal including how to handle insufficient supporting information and performance concerns arising within the appraisal meeting. Appraiser training will be available on a regular basis to maintain skills. Accountability: The appraiser responsibility is outlined in the AWP policy on appraisal and revalidation. The appointment as an appraiser will initially be for a period of up to five years which is renewable subject to satisfactory performance. There are clear indemnity arrangements for the role as an appraiser as outlined in the policy.

Draft Appraisal Policy For Consultant and SAS Doctors e. Appraisee Feedback Questionnaire Appraisee Feedback Questionnaire

Date of your appraisal ……………… Appraiser …………………………….. Appraisee (Optional)…………………

The appraisal interview 1Very poor Strongly Disagree

2 Poor/ Disagree

3 Average Neutral

4 Good Agree

5Very good Strongly

Agree

The appraiser reviewed progress against last year’s development plan

How challenging was the appraisal in making me think about my practice

Usefulness of the appraisal in my professional development

The development plan reflects my main priorities for development

The appraisal helped me prepare for revalidation

My appraiser’s skills 1 Very poor Strongly

Disagree

2 Poor Disagree

3 Average Neutral

4 Good/ Agree

5Very good Strongly

Agree

The appraiser’s preparation for the appraisal

The appraiser’s skill in conducting my appraisal

The appraiser’s ability to listen to me and show interest in my comments and opinions

The appraiser was supportive

The appraiser’s feedback was constructive and helpful

The appraiser made me think about new ideas and areas for development

Overall rating of my appraiser in their role as an appraiser

The administration of appraisal 1 Very poor Strongly Disagree

2 Poor/ Disagree

3 Average/

Neutral

4 Good/ Agree

5Very good Strongly

Agree

I was given adequate notice of my appraisal

I had access to the necessary supporting information

My satisfaction with the process for allocation of appraiser

My confidence in the confidentiality of the appraisal

Overall rating of the administration supporting appraisal in the Organisation


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How long did the appraisal meeting take? Did you have sufficient protected time for the appraisal meeting? Yes No If not what was the reason for this?


Draft Page 25 of 26

Please describe what you felt went well during your appraisal

Did you write construct your PDP yourself? Yes No Did your appraiser help? Yes No Did your appraiser construct your PDP? Yes No Comments

Was the content of the form 4 agreed during the appraisal? Yes No Was the form 4 completed during your appraisal? Yes No Comments How could the administration of Appraisal in AWP be improved? How could the support for Appraisal in AWP be improved?


Comments to help your appraiser improve their skills How could you or your appraiser have made the appraisal interview more productive? Any other comments?

Are you interested in becoming an appraiser ? Yes No


Draft Page 26 of 26

Nursing, Compliance, Assurance and Standards Status Report Report for the AWP NHS Trust Board


Meeting Time: 10:00

Agenda Item: 11

Serial: 11.0711

This Report is presented by the Executive Director of Nursing, Compliance, Assurance and Standards for Noting in the Part 1 session of the Board.

Report Sponsor: Executive Director of Nursing, Compliance, Assurance and Standards

Report Summary

Purpose of this Report: To brief the Board on the work of the Nursing, Compliance, Assurance, and Standards (NCAS) Directorate.


Actions Arising from the Report: As detailed in the Action Plan.


Report Links

ALE Not applicable.

CQC All CQC outcomes.

IG Toolkit None.

Corporate Risk Register

Risk of non-compliance with regulatory framework on Corporate Risk Register.

List of Appendices

• Appendix A – NCAS Work Programme 2011/12

NCAS Status Report

In the Part 1session, sponsored by Executive Director of Nursing, Compliance, Assurance and Standards


1. Overview

The Directorate continues to deliver against the Action Plan agreed by the Board at the beginning of the year 2011/12.

Since the previous report in May 2011 NCAS has focussed on the following areas of the work programme;

• Supporting the organisational preparation for CQC inspections at Callington Rd, the Victoria Centre, Juniper, and Lansdown. Coordinating and supporting the delivery of Action Plans from these inspections. CQC Inspections are now always unannounced so the directorate works to ensure organisational readiness.

• Completing the review of the Mental Health Act administration team to improve quality and consistency of service. We have this month agreed 2 Service Level Agreements for the management of Mental Health Act administration processes for NBT and Glenside Hospital.

• Completing the Quality Governance work for the SHA submission and in preparation for Monitor. This has warranted a complete refresh and update of the previous submission. The assessment shows the Trust to be very strong in the area of Quality Governance. Details of the submission are reported separately.

2. Other directorate work

2.1. Nursing Conference 2011

On 3rd November 2011, the Senior Nursing Team hosted the annual Nursing Conference. With an emphasis on presenting and sharing best practice in nursing, colleagues heard presentations and saw poster displays detailing good practice in a wide variety of services. The award for the best practice presentation went to Lime Ward for their work on improving the quality of handovers. The Senior Nursing Team will work with the team on Lime to take their work forward across the Trust and to share the practice nationally if possible.

2.2. Safeguarding Adults and Children

We have met several times with Local Authority Safeguarding Leads and chairs of Safeguarding Boards to agree a common approach. The quality of Safeguarding by AWP is agreed by the Local Authorities to be good, but the meetings have resulted in a much better understanding of the various processes, and have highlighted some areas of process improvement. BANES have indicated that they wish to revert to managing some parts of the process to make the AWP relationship consistent with other provider relationships, and it is likely that other Local Authorities will want to do the

NCAS Status Report



same. AWP would agree with this approach as it clarifies governance processes.

2.3. Mental Capacity Act

We have been working with Local Authorities to agree a common understanding of the application of Deprivation of Liberty safeguards. This remains work in progress as different Local Authorities have different interpretations of the legislation. This is being managed through the Mental Health Legislation Committee to ensure that the Trust is acting lawfully at all times.

2.4. Quality Impact Assessments (QIAs)

We have been working closely with the Improvement and Modernisation programme to revise the guidance relating to QIAs.

The Directorate supported the Liaison and Later Life SBU to work with NHS BANES to complete a multi-stakeholder QIA to support the reduction of inpatient episodes at St Martins. More work is needed to support the proposed changes in the High Dependency Unit model at Hillview Lodge.

2.5. Homicide reports and publications

The Directorate continues to manage AWP’s input into the process of reports and publications, liaising between the SHA, AWP staff, service users and families, and the Inquiry teams. Outstanding reports are:

2 publications (TC, MH)

3 further publications (MP, RS, DN)

3 desk-top reviews. (JA, JB, LC)

As publication dates are announced, the Directorate works alongside operational colleagues to support staff, service users and families.

2.6 Patient Safety Visits

The Directorate supports the Executive Patient Safety visit programme. The programme is running well (details were reported in Integrated Patient Experience Report October 2011) and feedback from the visits is that they are appreciated and helpful. More work is needed to ensure that actions are completed and the Directorate will be focussing on this.

2.7 Caldicott Guardian

The Director holds Caldicott Guardian responsibility for the Trust. The function is supported by the Head of Safeguarding and the Head of Information Governance. Formal and informal inquiries are received from

NCAS Status Report



internal and external sources and are dealt with. More formal structures for logging inquiries and responses are currently under development.

2.8 RIO

Responsibility for the implementation of RIO has moved to NCAS. This shift indicates the completion of the system implementation and a move to ensure that the delivery of high quality care is supported by an effective Electronic Clinical Records system.

3. Conclusion

3.1. The Directorate continues to work hard to ensure that AWP services are delivered to a high standard, and that the organisation remains compliant with all regulatory requirements.

Nursing, Compliance, Assurance, and Standards Directorate Annual Plan

Detailed plan 2011/12

Update November 2011

Function Priorities

2011/12 objectives Responsible Lead

Timescale Progress

Strategic Objective - Person Centred Services Supporting Best practice in Service Delivery

• Deliver professional accountability

structure for Social Care.

• Deliver ‘Team to Board’ Management Information system to enable Quality and Safety outcomes to be measured and improved at local level.

• Participate in the national programme for improving safety in mental health services, sharing learning and changing practice in the Trust as required.

• Delivery of ‘Getting it Right’ Mencap Charter (CQUIN)

HW HW/HL HW/JH HW/AM

September 2011 March 2012 January 2011 for 3 years. Milestones as agreed with commissioners, full implementation March 2012.

Arrangements with Social Care are changing. Meetings in diary for Nov to talk to each of the 6 Las about strategic intentions for future working. Propose change date to March 2012 Remains in IT work plan Good participation from AWP. HW and JH part of Faculty. Programme currently supporting learning around AWOLs, Falls, and Medicines Reconciliation on admission. Launch event successful. Implementation plan being delivered to timetable. Good progress being made.

Function Priorities


Timescale Progress

Engagement with Service Users and Carers. (QIS target)

• Review of Service User Engagement

process in partnership with national partner (NSUN) and implementation of recommendations.

• Lead delivery of Carers Feedback questionnaires and resulting actions (CQUIN target)

HW/HL HW/HL

Review July 2011 As agreed with commissioners.

Partner (NSUN) commissioned. Final report yet to be received as NSUN have yet to meet with all groups First questionnaire completed. Results reported to Board through IPE report. Update questionnaire currently being undertaken. All progress reported to MHDoCs. Good progress made.

Quality Agenda

• Lead programme of work to ensure

development, coordination, and alignment of Quality Agenda.

• Deliver Quality Governance

Memorandum for Board sign-off consistent with Monitor standards and best practice.

• Strengthen management support for

assurance processes associated with homicide action plans to ensure delivery of full assurance to internal and external stakeholders.

HW/HL HW/HL HW/HL

In line with planning timetable In line with FT timetable June 2011

Underway. Quality Account targets for 2012/13 need to be agreed to align with QIS Submission to SHA completed. Board approval to be sought in line with Monitor timetable Complete. Senior Nurse in post to provide dedicated support.

Function

o2011/12 objectives Responsible

Lead Timescale Progress

Pri rities

• Strategic Objective - Sustain Financial Viability Efficient and cost-effective Directorate

• Implement Service Delivery model

within Directorate consistent with efficiency and cost-effectiveness, and in line with organisational approach to corporate services

HW//AM/HL

October 2011 and in line with any staff-side requirements

Ongoing. MHA admin team model complete. Work underway with Ops regarding arrangements for Safeguarding work. Work underway with PCTs re arrangements for Service User Involvement work.

Delivery of Cost Improvement Plans

• Support delivery of CIPs across the

Trust to ensure consistency with best practice.

HW/AM/HL

As CIP timescale As CIP timescale.

Ongoing

• Strategic Objective – NHS Foundation Trust Organisation compliant with standards

• Support continued delivery of Quality

and Safety Outcomes to remain compliant with Care Quality Commission Registration Criteria.

• Support the Trust to meet the contract requirement to act on any improvement requirements from the CQC within dictated timescales.

HW/HL/AM HW/HL/AM

Ongoing

2011/12 support for 4 CQC visits – Sandalwood, Victoria Centre, Callington Rd, Juniper. Lansdown also visited on 9/10th Nov as part of national inspection process. No compliance issues to date, reports awaited for Juniper and Lansdown No compliance notices received. All improvement actions delivered to timescale.

Function Priorities


Timescale Progress

Well governed organisation

• Review governance structures to

ensure ‘fitness for purpose’ with Monitor’s requirements.

• Ensure delivery of policies,

procedures, and associated structures to deliver against CNST level 2 requirements.

HW/HL HW/HL

Summer 2011 In line with timetable agreed between AWP/CNST

Reviewed against Compliance Framework. No changes required. Timetable and implementation plan agreed by EMT.

Membership Organisation

• To continue to deliver against the

Membership Recruitment Strategy to ensure a comprehensive and representative membership.

• To lead the delivery of governor elections.

HW/HL/AM HW/HL

As detailed in Membership Recruitment Strategy. In line with FT application timetable.

Continuing. Reported through FT report.

FT Programme Report Report for the AWP NHS Trust Board


Meeting Time: 10:00

Agenda Item: 12

Serial: 11.0712

This Report is presented by the Chief Executive for Noting in the Part 1 session of the Board.


Report Summary

Purpose of this Report: To update on progress in key areas of the FT work programme in the last month.


Actions Arising from the Report: For the FT Director to take forward the FT work programme with relevant Executive Directors.

Quality and Safety Implications of the Report: The report includes the Trust self-assessment of compliance with Monitor Quality Governance criteria and SHA Quality Review that whilst highlighting areas which can be further strengthened also provide assurance to the Board that control systems on quality and safety are in place.

Report Links

ALE 2.1, 5.1

Corporate Risk Register STR 10

List of Appendices

• Appendix 1 - Monthly Membership Target and breakdown on representation

• Appendix 2 - Monthly Membership Activity and constituency targets 2011/12

• Appendix 3 - Tri-Partite Formal Agreement, September 2012

FT Programme Report

In the Part 1 session, sponsored by the Chief Executive


1. Overview

1.1. This paper updates the Trust on progress on the FT programme and application since the October FT Board report. It does this primarily through the Monitor domains of assurance of FT readiness (sections 4 -12).

2. Department of Health phase and FT timeline.

2.1. In line with the Trust TFA, and to support the pending assessment of the Trust FT application in the Department of Health from 1st December the Trust has, submitted to the SHA this month :-

• 2 self assessments relating to Quality, and the Trust CQC Intelligence Framework - see section 11

• IBP v10.1, the October 2011 commissioner convergence letter and draft November 30th 2011 Board report on proposed supplementary minor additions or changes to the IBP in response to commissioner feedback

2.2. Commissioning the HDD (Historical Due Diligence) I and II review has been pending SHA confirmation of their publication date for 2 Independent Inquiry reports. A publication date has now been confirmed and consequently HDD has been commissioned using auditors - Alvarez and Marcel.

2.3. The HDD exercise commences on 5th December 2011 and is expected to conclude that month. It involves

• submission of evidence on financial plans and strategy

• interviews with the Chair, CEO, Executive Directors, FT Director and key members of the finance team

• a draft report for comment and factual accuracy, and final report to the Trust (RAG ratings of key assurance criteria). This is forwarded to the SHA and DH as part of the Trusts FT application process.

• an action plan as required - which may be forwarded to the SHA and DH

2.4. The FT office is managing a formal work plan to deliver HDD. Discussion of the findings is scheduled for the January or February 2011 Board seminar.

2.5. The Trust Tripartite Formal Agreement (TFA) is attached as Appendix 3 which publishes this formally. It was signed by all relevant parties (AWP, SHA, DH, lead commissioner) between March and late September 2011. It identifies the 1st December 2011 as the start date of the DH assessment process - pending SHA publication of the two independent Inquiries.

FT Programme Report



3. Monitor Phase

3.1. In future the role of Monitor will change. Whilst it will continue to authorise NHS FTs through to 2013/14 it will also become the sector regulator licensing a range of providers of NHS funded services by exercising the following functions: • regulating prices • licensing providers of NHS funded services in England • enabling integration and protecting against anti-competitive behaviour • supporting service continuity ie developing distress and failure regimes Monitor’s recent document on its evolving role can be downloaded from http://www.monitornhsft.gov.uk/sites/default/files/The%20Health%20and%20Social%20Care%20Bill%20-

3.2. In mid November Monitor launched ‘Developing the new NHS Provider License - A Framework Document’ on its role in licensing providers. They will introduce this following royal assent of the Health and Social Care Bill in 2012 and following a more formal consultation at that time. Responses are sought by 12th December 2011 and the FT Director is reviewing the document to support and co-ordinate a Trust response to it. It can be downloaded from http://www.monitornhsft.gov.uk/sites/default/files/Developing%20the%20new%20NHS%20provider%20licence%20a%20framework%20document_final151111.pdf

3.3. It outlines Monitors current thinking on licensing in four key areas :

• Pricing conditions - with a license based on the publication of a national tariff which those licensed by Monitor must evidence compliance with. This would be built on high quality, complete and relevant information on activity levels, costing and performance from those providers.

• Competition oversight and integrated care conditions - having concurrent powers with the Office for Fair Trading (OFT) to ensure that the existing rules in the PRCC (Principles and Rules for Competition and Co-operation) are applied by a regulator with health expertise. License conditions will focus on a number of areas from the PRCC - obligations on commissioners; co- operation and agreements between commissioners and providers; the conduct of individual organisations and mergers/vertical integration where mergers between FTs, and with other enterprises, are reviewed by the OFT.

• Continuity of service conditions - where a license requires robust financial record taking and reporting in order to protect those services that commissioners identify as essential from financial insolvency or instability. License conditions will be based on financial risk ratings, incentives for robust financial management and triggers for distress, insolvency and - if necessary as a last resort- restructuring interventions.

• Special conditions - on a license for a specific provider, for example where existing restrictions are in place on a FTs terms of authorisation and need to be carried forward.

http://www.monitornhsft.gov.uk/sites/default/files/The%20Health%20and%20Social%20Care%20Bill%20-

http://www.monitornhsft.gov.uk/sites/default/files/The%20Health%20and%20Social%20Care%20Bill%20-

http://www.monitornhsft.gov.uk/sites/default/files/Developing%20the%20new%20NHS%20provider%20licence%20a%20framework%20document_final151111.pdf

http://www.monitornhsft.gov.uk/sites/default/files/Developing%20the%20new%20NHS%20provider%20licence%20a%20framework%20document_final151111.pdf

FT Programme Report



4. Progress: the Trust is legally constituted

4.1. The Heath and Social Care Bill propose longer term changes that strengthen the role of Governors in recognition of Monitors primary role as a regulator.

4.2. Currently this is not expected to take force until 2016, after introduction of significantly strengthened systems to induct, train and support Governors.

4.3. The Trust constitution is fully compliant with legislation and Monitor guidance today ready for the impending FT assessment process.

5. Progress: The Trust has a representative membership

5.1. Membership figures at the 30th November 2011 have increased from 16,144 in October to 16,211. There are 11,182 public members and 1,552 patient members (service users and carers) - of which 606 are carers. The remaining 3,477 members are staff members. Appendix 1 shows more detail and no significant change on representation from previous recent reports.

5.2. NCAS has taken action to target recruitment of older people and more generally men with regards to representation, however this is proving challenging with significant number needed to impact upon percentage figures. The FT Director has put in place a formal review meeting in the coming weeks to review the strategy in use alongside delivery of the target of 16,500 members by year end.

5.3. Membership Recruitment: Ongoing recruitment continues with the NCAS Membership Team recruiting this month at events including the Tidworth Health and Social Care event, a Black and minority ethnic event held by Bristol County Council, Lackham College Freshers Fair and a World Mental Health Day celebration in Bath.

5.4. Membership Engagement: The November 25th members event has been planned and promoted. It has proved to be popular with all 150 places booked.

5.5. Membership Governance: EMT has this month received its first progress report from the Membership Governance Project Board. This was established in July 2011 to lead and co-ordinate all work related to members and governors across directorates, the Chair and CEOs office, in a resource effective way that proactively develops an integrated approach within mainstream business. The project is led by the FT Director on behalf of the CEO and the Project Board is chaired by NCAS.

5.6. Key areas of progress reported through July - mid October are outlined below.

Action Progress

Efficient and effective working

• Action Plan, Project Initiation Document, Risk Register, Issue and Learning Log in place

• Membership Governance Our Space work group

FT Programme Report



established. Underpins electronic administration, shared internal and external resources.

• Promote use of FTN Tool Kits (eg on Governor elections); links to key Monitor reports eg on Members and Governors.

Roles, Responsibilities and Resources

2012 - 2016

• First outline of Business Case developed on costs and ways of working as an NHS FT - for a December EMT

• Business Case brief extended to 4 years to cover transition year 2012/13 - and following three years as an NHS FT

Legally compliant and delivery against statutory responsibilities

• Statutory and legal responsibilities scoped and embedded in to all aspects of project work

• NHS FT Constitution reviewed and updated

• Updates on implications of Health and Social Care Bill

Governors • 40 day Governors election plan in place, independent electoral agency commissioned and ready to go. Mid year governor turnover/churn and costs scoped.

• Action plan to increase contested Governor seats in place and being delivered. Delivered to target in all sub constituencies except older people (service users); social care and managerial staff.

• 3 Day Governor Induction Programme planned. Chair will meet each new Governor for a 1-1 once elected, where Code of Conduct will be discussed and signature secured.

• Scope responsibilities and functions for each of proposed Council of Governors work groups

Learning Disabilities Governor

• Plain English, symbol format version of Governors Code of Conduct commissioned, available and in use.

• Actions to deliver contested seats for LD Governor identified, acted and delivered outcome required

• Advice sought and costs understood of systems to provide appropriate support and access for Governors with Learning Disabilities - as per other public sector standards.

Membership Engagement

• FT Membership Engagement Survey undertaken July 2011 with public members to inform future action

FT Programme Report



• Annual Membership Engagement Plan 2011/12 developed

• Members event - planned for 25th November 2011

• Quarterly membership newsletter

Membership recruitment and retention

• Membership Annual Plan in place with targets as per Monitor requirement for 2011/12

• Process and outcome embedded in annual planning cycle of Trust and Operating (Annual) Plans in support of FT status.

6. Progress: The Trust has a 5 year Business Strategy

6.1. The November Board will receive proposals for change to IBP v10.1 relating to commissioner feedback that further strengthen the IBP.

6.2. As per the annual business planning cycle, the October Planning Conference was attended by over 100 clinicians and senior staff. It focused on the local, national and economic context, NHS landscape, Bristol tender and future direction of SBU activity and business development. Building on this and Board seminars in October and December 2011 SBU Business Development Plans for 2012/13 are now being planned.

7. Progress: The Trust is Financially Viable

7.1. Work commenced this month with an XEMT workshop to ensure understanding of the IBP financial framework, and add to and consolidate efficiency plans and projects to deliver the IBP targets from 2012/13.

7.2. The Finance and Performance Recovery Board, chaired by the CEO, continues to meet weekly to monitor and ensure delivery of the 2011/12 control total. Progress on this is reported elsewhere at the Board.

7.3. Supported by the FT office the Finance Directorate has collated a bank of evidence to support the Monitor assessment, and HDD - and continues to update the LTFM as required.

8. Progress: The Trust has appropriate Board capability and capacity

8.1. Best practice in governance identifies a regular independent assessment of Board capability as key to success. Monitor expects this to be undertaken in the year running up to FT authorisation. The Board agreed a Board evaluation framework in April 2011 that included provision for independent evaluation.

FT Programme Report



8.2. This principle has been taken forward by the Chair with an independent Board evaluation proposed between December and February 2012. It will be based on the framework outlined in the recently published joint FTN and Beachcroft “The Foundations of Good Governance – A Compendium of Best Practice”. The Company Secretary is commissioning this, supported by the FT Director.

8.3. The November Board seminar reviewed progress on implementing the Research and Development and Innovations strategy of the Trust along with the partnership collaboration of BRIG-H and the proposal for an Academic Health Science Collaboration. It also received the Trust CQC Quality and Risk profile and feedback from the Trust Planning Conference.

9. Progress: The Trust has appropriate governance arrangements in place

9.1. Trust governance arrangements continue to develop. The recently commissioned HDD exercise will provide the Board with an up to date independent view on effectiveness in the new year.

9.2. In response to quality related self assessments an audit of exception reporting from the 8 Trust management groups to Performance EMT will be undertaken to monitor, review and evidence the efficacy of exception reporting in the Trust. These management groups cover Patient Safety, Clinical Effectiveness, Patient Experience, Modernisation and Workforce, Mental Health Legislation and Safeguarding, Finance, Information Governance and Critical Incidents.

10. Progress: Service Performance

10.1. Work continues with some success to drive improved performance against Monitor and contractual targets, with a fully compliant green Monitor dashboard from October 2011.

10.2. At the time of writing it is expected that the Trust will sustain this Monitor dashboard position, with a governance risk rating of 0.0.

11. Progress: Quality Governance

11.1. The Trust has submitted its SHA Quality Review self assessment along side physical submission of the evidence base (5 lever arch files) for consideration by 3 assessment teams at the SHA. SHA feedback is pending.

11.2. Headline feedback is that of 56 assessment areas 53 are rated Green, 2 are Amber and 1 is rated Red. The SHA is clear that the Never Event of March 2010 puts a red indicator into the system. This was also red in the first Quality Review. This position represents a significant improvement on the self assessment dated September 2010 with 10 amber rated areas and the one red rated area.

11.3. The two amber rated areas in the November 2011 submission relate to:

FT Programme Report



• Patient Experience - the requirement for all job descriptions in the Trust to contain a commitment to improving the patient experience. The self assessment makes clear that action on this will be taken by the Executive Director who will insert an agreed patient experience statement into generic job descriptions, and into Trust staff handbook currently being developed.

• MaPSaff - having a clear rollout and implementation plan for the MaPSaff patient safety initiative which is viewed by many regulators as a national standard in patient safety work. The Trust piloted this approach successfully in 2010 with 4 teams and the Executive Director of NCAS has undertaken to bring forward the implementation plan for agreement at EMT in the coming weeks.

11.4. In addition, the Trust has submitted its Monitor Quality Governance Self-Assessment structured around the 10 questions against which Monitor judge fitness for purpose in the FT authorisation process. The detail of the self assessment was agreed by EMT on 1st November and is available to Board members for review from the FT office. It will form the basis of the Board Quality Governance Memorandum.

11.5. Headline feedback is that of 68 assessment areas, 60 are Green, 7 are Amber-Green and 1 is Amber-Red. An Improvement Plan is being developed by the FT Director which will further strengthen the evidence base for some green areas and address amber-green and amber-red assessments.

11.6. A summary of RAG ratings and issues emerging is as follows: Quality Governance RAG ratings Comment 1A Does quality drive the Trust’s strategy?

4 Green 1 Amber/Green (line 5)

MaPSaff roll out plan to be submitted and approved to EMT – due end Nov 2011

1B Is the Board sufficiently aware of potential risks to quality?


Work to embed Quality Impact Assessments in mainstream work; QIA framework annual review Dec 2011.

2A Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda?


Update Board training on quality governance. Documentary evidence for Chairs appraisals needed, and evidence of Trust succession planning

2B Does the Board promote a quality focused culture in the Trust?

5 Green No issues

3A Are there clear roles and accountabilities in relation to quality governance?


Action pending to place patient experience statement in all job descriptions - now planned

3B Are there clearly defined, well understood processes for escalating and resolving issues and managing


Need update of Performance Management Strategy for 2011/12 - due December 2011

FT Programme Report



quality performance? Q&HC Governance Committee. It is an IBP Enabling strategy.

3C Does the Board actively engage patients, staff and other key stakeholders on quality?

13 Green 1 Amber/Green (line 52) 1 Amber/Red (line 50)

- need to strengthen evidence and activity in securing user views in redesign work - Board position on user and carers voices at Board to be reviewed and strengthened - scheduled for January 2012 Board seminar and Trust Board. (JB/Peter Greensmith).

4A Is appropriate quality information being analysed and challenged?


Need update of Performance Management Strategy for 2011/12. Due December 2011 Q&HC Governance Committee

4B Is the Board assured of the robustness of the quality information?

5 Green

No issues

4C Is quality information used effectively?

3 Green No issues

Total 68 RAG ratings - 60 Green, 7 Amber/Green, 1 Amber/Red

11.7. In additon EMT has agreed a CQC Intelligence Framework developed by NCAS. This is a new DH requirement and demonstrates how CQC intelligence is managed by the Trust. It reflects Trust action relating to

• Planned and Responsiveness Review visits and reports

• the monthly Trust Quality and Risk Profile

• Mental Health Act Commissioner visits and reports

11.8. This document will form part of the Trust Clinical Governance Framework.

12. Progress: Local Health Economy issues and external relationships

12.1. The FT Director and Trust Memerbship Manager has attended a South West regional meeting of aspirant FTs that focused on Membership and Governors. It has confirmed that the Trust benchmarks well on number of issues eg numbers of staff opt outs; recruitment methodology, preparation for Governors.

13. Recommendations

13.1. The Board is asked to note the report.

14. Report Author Jane Britton - Foundation Trust Programme Director Additional Report Contributors Nicolette Vos - Membership Manager, NCAS.

Appendix 1 Membership Targets 2011/12 All data reflects position at: 30/10/2011

Monitor Membership Report Total Public: 11,182

date: 30/10/2011 Total Patient: 1,582

Total Carers: 606

Total Staff: 3,447

TOTAL members: 16,211

Public constituency¹

Age (years)4 5%

16 26 0.2% 19,452 1.5% -1.3 %pts

17 - 21 1366 12.7% 98,793 7.7% 5.0 %pts over

22-64 7,456 69.5% 910,789 70.9% -1.5 %pts

65+ 1,886 17.6% 255,227 19.9% -2.3 %pts

Not Stated 446

Ethnicity

White 10,237 94.2% 1,542,306 96.3% -2.1 %pts

Mixed 144 1.3% 17,450 1.1% 0.2 %pts

Asian or Asian British 195 1.8% 19,539 1.2% 0.6 %pts

Black or Black British 214 2.0% 13,210 0.8% 1.1 %pts

Other 83 0.8% 9,847 0.6% 0.1 %pts

Not Stated 309

Socio-economic sub-grouping²

ABC1 8,186 75.5% 692,407 55.4% 20.1 %pts over

C2 1,574 14.5% 188,089 15.0% -0.5 %pts

D 460 4.2% 197,235 15.8% -11.5 %pts under

E 624 5.8% 172,941 13.8% -8.1 %pts under

Not Stated 338

Gender

Male 4,486 40.4% 815,684 50.9% -10.5 %pts under

Female 6,603 59.6% 786,668 49.1% 10.5 %pts over

Not Stated 27

Patient constituency³ Over or under Over Age (years)

16 1 0.1% 206 0.6% -0.5 %pts

17-21 78 5.1% 1,935 5.5% -0.4 %pts

22-64 1,186 78.2% 19,895 56.8% 21.3 %pts over

65+ 252 16.6% 12,962 37.0% -20.4 %pts under

Not Stated 65

¹Data sourced from the Office for National Statistics. Data represents the 2001 census.

²Socio-economic sub-grouping only included data for those aged 16 and over in households.

AB: Higher and intermediate managerial / administrative / professional

C1: Supervisory, clerical, junior managerial / administrative / professional

C2: Skilled manual workers

D: Semi-skilled and unskilled manual workers

E: On state benefit, unemployed, lowest grade workers

³Data sourced from internal staff systems for 2008-09.4ONC data for 0-15 age bands excluded from totals.

Note: Tolerance level for highlighting representation: +/- 5 %pts

Data is based on Public, Service User & Carer constituencies and does not include staff membership.

Number of Eligible Over or under

Number of Eligible

Total membership by month 2011-2012

15900

15950

16000

16050

16100

16150

16200

16250

16300

16350

16400

16450

16500

16550

16600

April

May

June Ju

ly

Augus

t

Septe

mbe

r

Octob

er

Nov

embe

r

Dec

embe

r

Janu

ary

Febru

ary

Mar

ch

Nu

mb

er

of

mem

bers

Members Target for 2011/12 =16,500 Target for 2010/11 = 16,000

Appendix 2 Constituency Target Performance 2011/12 All data reflect position at: 30/10/2011

Constituency

Male Female Male Female Male Female Male Female Male FemaleService users

and carers 18 12 9 17 9 -5 3 2 12 -3

18 12 7 20 11 -8 2 13 13 5

6 4 6 8 -4 2 1 2 -3

6 4 3 3 3 1 3 4 6 5

6 4 2 6 2 6 2

6 4 4 7 2 -3 2 -3

7 4 2 2 5 2 5 2

67 44 31 59 36 -15 10 20 46 5

Public 50 34 17 19 33 15 5 7 38 22

57 38 21 34 36 4 8 20 44 24

56 38 6 4 50 34 7 14 57 48

18 12 14 48 4 -36 11 15 15 -21

13 8 8 48 5 -40 7 9 12 -31

29 19 31 51 -2 -32 19 37 17 5

11 8 5 18 6 -10 15 28 21 18

235 156 102 222 133 -66 72 130 205 64

Ex-Members ReportYear Ex-members Year Year

2011-2012 254 2010-2011 701 2009-2010 242 Total to date 1197

7.46%

Month Public Patients Staff Total

April 35 5 3 43 16013

May 9 2 1 12 16035

June 6 1 12 19 16112

July 56 6 2 64 16099

August 50 7 57 16050

September 3 1 4 16144

October 43 8 4 55 16211

November

December

January

February

March

Ex-members 254 1.58% ex-members in 2011 todate

To recruitEx membersTarget Recruited Variance

to achieve target

target

2011/12

Patient Environment & Trust Wide Services

Specialised & Secure Services

Specialist Drug & Alcohol Services

Total Service users and carers

Adults of working age

Carer

Learning Disabilities

Older People Services

Date: 30/10/2011

Total Public

South Gloucestershire

Swindon

Wiltshire

Out of area

Total members at end of month

Ex-members

to date

Ex-members

Sub constituency / catchment area

Bath and North East Somerset

Bristol

North Somerset

Service users & carers recruitment target vs actuals by sub-constituency

0

5

10

15

20

25

Ad

ults o

f

wo

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Sp

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list

Dru

g &

Alc

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es

Ta

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ts

Target Male Target Female Recruited Male Recruited Female

Service users & carers recruitment target vs actuals by sub-constituency

0

10

20

30

40

50

60

Ba

th a

nd

No

rth

Ea

st

So

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Bristo

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No

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So

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Glo

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Sw

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Target Male Target Female Recruited Male Recruited Female

TFA document

Supporting all NHS Trusts to achieve NHS Foundation Trust

status by April 2014

Tripartite Formal Agreement between:

− Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)

− NHS South West − Department of Health

Introduction This Tripartite Formal Agreement confirms the commitments being made by the NHS Trust, their Strategic Health Authority and the Department of Health that will enable achievement of NHS Foundation Trust status before 1 April 2014. Tripartite Formal Agreements are made up of nine parts, each of which is introduced below. Part 1

Part 1 confirms the date when the NHS Trust will submit its ‘NHS Foundation Trust ready’ application to the Department of Health to begin their formal assessment towards achievement of NHS Foundation Trust status. Part 2

The organisations signing up to this agreement are confirming their commitment to the actions required by signing in part 2a. The signatories for each organisation are as follows: • NHS Trust – Chief Executive; • Strategic Health Authority – Chief Executive; • Department of Health – Ian Dalton, Managing Director of Provider

Development

Prior to signing, NHS Trust Chief Executive Officers should have discussed the proposed application date with their Board to confirm support. In addition the lead commissioner for the NHS Trust will sign in part 2b to agree support of the process and timescales set out in the agreement. The information provided in this agreement does not replace the SHA assurance processes that underpin the development of FT applicants. The agreed actions of all SHAs will be taken over by the National Health Service Trust Development Authority (NTDA) NTDA previously known as the Provider Development Authority – the name change is proposed to better reflect their role with NHS Trusts only when they take over the SHA provider development functions. Part 3

Part 3 sets out the services provided by the NHS Trust, its commissioners, the financial context and key quality and performance issues.

Part 4

Part 4 sets out the key strategic and operational issues facing each NHS Trust.

Part 5

Part 5 sets out the key actions to be taken by the NHS Trust to address the key strategic and operational issues facing the NHS Trust.

Part 6

Part 6 sets out the key actions to be taken by the Strategic Health Authority to address the key strategic and operational issues facing the NHS Trust.

Part 7

Part 7 sets out the key actions to be taken by the Department of Health to address the key strategic and operational issues facing the NHS Trust.

Part 8 Part 8 of the agreement sets out the key milestones that will need to be achieved to enable the NHS Foundation Trust application to be submitted to the date in part 1 of the agreement. Part 9 Part 9 sets out the key risks to delivery of the NHS Foundation Trust application to the date set out in part 1 of the agreement. The guidance provided by the Department of Health for the preparation of Tripartite Formal Agreements is set out in Appendix 1.

Standards required to achieve NHS Foundation Trust status The establishment of a Tripartite Formal Agreement for each NHS Trust does not change, or reduce in any way, the requirements needed to achieve NHS Foundation Trust status. That is, the same exacting standards around quality of services, governance and finance will continue to need to be met, at all stages of the process, to achieve NHS Foundation Trust status. The purpose of the Tripartite Formal Agreement for each NHS Trust is to provide clarity and focus on the issues to be addressed to meet the standards required to achieve NHS Foundation Trust status. The Tripartite Formal Agreement should align with the local quality and productivity agenda. Alongside development activities being undertaken to take forward each NHS Trust to NHS Foundation Trust status by 1 April 2014, the quality of services will be further strengthened. Achieving NHS Foundation Trust status and delivering quality services are mutually supportive. The Department of Health is improving its assessment of quality. Monitor has also been reviewing its measurement of quality in their assessment and governance risk ratings. To remove any focus from quality healthcare provision in this interim period would completely undermine the wider objectives of all NHS Trusts achieving NHS Foundation Trust status, to establish autonomous and sustainable providers best equipped and enabled to provide the best quality services for patients.

Part 1 - Date when NHS foundation trust application will be submitted to Department of Health

1 December 2011

Part 2a - Signatories to agreements By signing this agreement the following signatories are formally confirming:

− their agreement with the issues identified;

− their agreement with the actions and milestones detailed to support achievement of the date identified in part 1;

− their agreement with the obligations they, and the other signatories, are committing to; as covered in this agreement.

Laura McMurtrie, CE of Avon and Wiltshire Mental Health Partnership Trust

Date: 4 April 2011

Sir Ian Carruthers OBE, CE of NHS South West

Date: 4.4.11

Ian Dalton, Director of Provider Development, Department of Health

Signature

Date: 29.9.11

Part 2b – Commissioner agreement In signing, the lead commissioner for the Trust is agreeing to support the process and timescales set out in the agreement.

Penny Harris, Chief Executive of NHS South Gloucestershire

Date: 1.4.2011

Part 3 – NHS Trust summary

Short summary of services provided, geographical/demographical information, main commissioners and organisation history.

Avon and Wiltshire Mental Health Partnership NHS Trust is a significant provider of mental health services with a turnover of £196m in 2010/11. The NHS Trust provides high quality mental health and social care services to 1.6m people across the geographical area covering Bath and North East Somerset (BaNES), Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire. The NHS Trust also provides specialist services for a wider catchment extending throughout the south west of England. Avon and Wiltshire Mental Health Partnership NHS Trust employs approximately 3,332 (WTE) staff from a variety of professional backgrounds, including psychiatrists, psychologists, mental health nurses, allied health professionals, and will shortly have Section 75 agreements in place with the six local authorities for the provision of social work services. The NHS Trust has broken even for the last five years and cleared its historic debt. Financial data

2009/10 2010/11

Total income 198,753 195,955

EBITDA 14,440 16,617

Operating surplus/deficit (22,178) 1,619

Retained surplus/deficit 1,113 3,219

CIP target 6,631 6,254

CIP achieved recurrent 6,023 5,620

CIP achieved non-recurrent 608 634

The Trust has 6 primary commissioners, Bristol PCT, Bath and North East Somerset PCT, North Somerset PCT, South Gloucestershire PCT, Wiltshire PCT and Swindon PCT. The Trust has recently signed the Department of Health (DH) Mental Health Contract with its six PCTs. The contract is for three years with annual ‘break’ clauses. The contracts are predominately in the form of block contracts/activity based contracts on a service level agreement (SLA) basis.

Summary of contractual relationships – percentage of total income by commissioner

Commissioner Type of service 2010/11

£'000 %

Regional Specialist Commissioning Group Secure 22,822 12%

Bristol PCT Adult & older 46,556 24%

Wiltshire PCT Adult & older 31,945 16%

Bath & NE Somerset PCT Adult & older 14,412 7%

North Somerset PCT Adult & older 14,451 7%

South Gloucestershire PCT Adult & older 17,655 9%

Swindon PCT Adult & older 16,531 8%

Other commissioners Adult & older 1,460 1%

Swindon, N Somerset, Wiltshire PCTs IAPT 2,781 1%

Former Avon commissioners Learning disability 3,853 2%

Six local authorities Clinical partnerships 3,240 2%

All six main commissioners Specialist drugs 10,829 6%

Other clinical income Adult & older 606 0%

All six main commissioners CQUIN 1,075 1%

Total clinical income 188,216

Non clinical income 7,738 4%

Total forecasted income in 2010/11 195,954

Between 2003/04 and 2007/08 the Trust delivered a £69m PFI scheme which significantly enhanced the quality of the estate in the Bristol, North Somerset and South Gloucestershire areas. This was part of the wider Avon modernisation project which also included £31m of publicly funded schemes, all designed to extend the provision of safe, pleasant, fit for purpose environments for service users and staff. Of the £69m, £19m provided a new and modern Medium Secure Unit (Fromeside) and the remainder delivered a new, modern inpatient unit in Bristol (Callington Road) and a number of smaller units across the three areas. Callington Road and the smaller units provide services for adults and older people, specialist addictions beds and specialist low secure beds. It is registered without conditions with the CQC. The NHS Trust’s lead commissioner is NHS South Gloucestershire.

Part 4 – Key issues to be addressed by NHS trust Key issues affecting NHS Trust achieving FT

Strategic and local health economy issues

Service reconfigurations Site reconfigurations and closures Integration of community services

Not clinically or financially viable in current form Local health economy sustainability issues

Contracting arrangements

Financial Current financial Position

Level of efficiencies PFI plans and affordability

Other Capital Plans and Estate issues Loan Debt

Working Capital and Liquidity

Quality and Performance QIPP

Quality and clinical governance issues Service performance issues

Governance and Leadership

Board capacity and capability, and non-executive support

None Outstanding - Already with DH

Please provide any further relevant local information in relation to the key issues to be addressed by the NHS Trust: Avon and Wiltshire Mental Health Partnership NHS Trust is currently in the Department of Health assessment process having made an original application on 1 November 2010. The Trust’s referral to the Foundation Trust Application Committee is pending and is subject to South West Strategic Health Authority sign off of the publication of two independent mental health homicide investigation reports expected in June 2011. South Gloucestershire PCT on behalf of associate PCTs is working closely with AWP through existing governance processes, to address any ongoing areas for improvement through associated action plans. NHS South Gloucestershire as Lead Commissioner is supportive in principle of AWPs FT Application, overall vision and strategic direction. However, it should be noted that NHS Bristol has decided to re-tender inpatient and community mental health services in Bristol. The process is expected to be completed by March 2013. This risk is identified within the IBP and already modelled in its downside scenarios but the full impact and associated risks will be further assessed by the Trust.

Part 5 – NHS Trust actions required

Key actions to be taken by NHS Trust to support delivery of date in part 1 of agreement

Strategic and local health economy issues Integration of community services

Financial

Current financial position

CIPs

Other capital and estate Plans

Quality and Performance Local / regional QIPP

Service Performance

Quality and clinical governance


Board Development

Other key actions to be taken (please provide detail below)

Describe what actions the Board is taking to assure themselves that they are

maintaining and improving quality of care for patients.

• Regular Board reports and monthly performance monitoring

• Monthly Quality and Healthcare Governance Board Committee annual work

programme to assure standards, quality and compliance including patient

experience, patient safety and clinical effectiveness

• Self assessment against Monitor Quality Governance criteria

• Memorandum of Quality Governance due at April 2011 Board

• SHA Quality Review

Please provide any further relevant local information in relation to the key actions

to be taken by the NHS Trust with an identified lead and delivery dates: Avon and Wiltshire Mental Health Partnership NHS Trust will work in partnership with South West Strategic Health Authority, to ensure its publication of the independent mental health homicide investigation reports are handled sensitively and appropriately for all. The Trust accepts in full the draft report it has received, and its recommendations. An AWP Action Plan was put in place and implemented at the time of the incidents, and where appropriate a further multi-agency action plan developed. The implementations of the action plans in AWP are subject to quarterly scrutiny and assessment by the Strategic Health Authority and the Trust’s lead commissioner (NHS South Gloucestershire).

Part 6 – SHA actions required

Key actions to be taken by SHA to support delivery of date in part 1 of agreement

Strategic and local health economy issues Local health economy sustainability issues

(including reconfigurations)

Contracting arrangements

Transforming Community Services

Financial CIPs\efficiency

Quality and Performance Regional and local QIPP

Quality and clinical governance

Service Performance

Governance and Leadership Board development activities

Other key actions to be taken (please provide

detail below)


to be taken by the SHA with an identified lead and delivery dates.

NHS South West is working with the NHS Trust and the Lead Commissioner to

ensure actions from the independent mental health homicide investigation reports are taken forward.

Part 7 – Supporting activities led by DH

Actions led by DH to support delivery of date in part 1 of agreement

Strategic and local health economy issues Alternative organisational form options

Financial

NHS Trusts with debt

Short/medium term liquidity issues

Current/future PFI schemes

National QIPP workstreams


Board development activities

Other key actions to be taken (please

provide detail below


to be taken by DH with an identified lead and delivery dates:

Part 8 – Key milestones to achieve actions identified in parts 5 and 6 to achieve date agreed in part 1 Date Milestone

20 November 2008 First draft IBP and LTFM in AWP

August 2009 Historical Due Diligence part one undertaken - action plan delivered

1 September 2009 12 week consultation begins; Board decisions January 2010

December 2010 Final IBP (V 10 ) and LTFM

April 2010 Historical Due Diligence part two begins - action plan delivered

June 2010 SHA Quality review begins - completed September 2010

October 2010 Second Commissioner convergence letter received - also one in June 2010

22 October 2010 SHA Board to Board

1 November 2010 Entry to DH - through national SHA Medical Network scrutiny and DH Technical Committee. Application pending assessment at Applications Committee is dependent on the publication of the independent mental health homicide investigation reports.

September 2011 Publication of homicide investigations

1 December 2011 Application to Department of Health

March 2013 NHS Bristol retendering complete

Provide detail of what the milestones will achieve\solve where this is not immediately obvious. For example, Resolves underlying financial problems – explain what the issue is, the proposed solution and persons\organisations responsible for delivery. Describe what actions\sanctions the SHA will take where a milestone is likely to be, or has been missed. All milestones within the South West Strategic Health Authority assurance process achieved and the NHS Trust was approved to be passed to the Department of Health on 1 November 2010 following a Board to Board with the South West Strategic Health Authority on 22 October 2010 The Avon and Wiltshire Partnership NHS Trust application has successfully progressed through the national SHA Medical Directors Network quality checks and DH technical Committee in December 2010. Through December to February 2011 a range of information was required and supplied to support the NHS Trust application to the DH Application Committee which is currently planned for after the publication of the independent mental health homicide investigation reports.

Key milestones will be reviewed every quarter, so ideally milestones may be timed to quarter ends. The milestones agreed in the above table will be monitored by senior Department of Health and Strategic Health Authority leaders until the NHS Trust Development Authority takes over formal responsibility for this delivery. Progress against the milestones agreed will be monitored and managed at least quarterly, and more frequent where necessary as determined by the Strategic Health Authority (or NHS Trust Development Authority subsequently). Where milestones are not achieved, the existing SHA escalation processes will be used to performance manage the agreement. (This responsibility will transfer to the NHS Trust Development Authority once it formally has the authority).

Part 9 – Key risks to delivery Risk Mitigation including named lead

All milestones delivered as above

On going mitigations as normal through IBP, Corporate and FT Risk Registers

Communications Report Report for the AWP NHS Trust Board


Meeting Time: 10:00

Agenda Item: 13

Serial: 11.0713

This Report is presented by the Chief Executive for noting in the Part 1 session of the Board.


Report Summary

Purpose of this Report: To brief the Board on Trust communications activity, agree the monthly Board briefing messages and provide the Board with recommendations on the management of any potential risks to the Trust’s reputation.

Board Decisions Recommended: The Board is recommended to consider the briefing in the context of reputational risk, and to select appropriate team brief messages.

Actions Arising from the Report: Team brief and reputation management as specified by the Board

Report Links

ALE 5.2.1, 5.2.4 and 5.2.7

Communications Report

1. Overview

1.1. To provide the Board with information on communications activity and reputation management as summarised below:

1.1.1. Management information: trends and statistics reflecting the Trust’s media profile over the past 12 months

1.1.2. Media profile: summary for October

1.1.3. Horizon scanning: forthcoming major events/activities

1.1.4. FOI: summary of requests, October

1.1.5. Team brief: summary of messages over the past 12 months

1.1.6. Other communication activity.

1.2. The Board’s potential briefing messages for December 2011 will be discussed and agreed during the meeting.

2. Media coverage during the last 12 months, broken down by month:

Month Media releases issued

Media statementsprovided

Positive coverage

Negative coverage (factually

inaccurate)

Neutral/ balanced coverage

October 11 1 1 10 4 1 September 8 1 2 2 1 7 August 8 1 5 4 0 5 July8 0 4 2 4 3 June 0 3 5 3 4 May 1 0 3 0 3 April 2 2 7 2 48 March 2 0 8 2 1 February 2 0 6 0 0 January 0 1 2 1 1 December 0 2 1 27 2 November 1 1 4 107 0

Notes:

7 Not all homicide investigation coverage included in above figures

8 Coverage re high profile service user detained at Fromeside excluded from above figures

3. Media coverage – October 2011

3.1. Positive coverage related to the launch of the SW Veterans Mental Health Partnership Service, world mental health day and wellbeing.

In the Part 1session, sponsored by Chief Executive



3.2. Negative coverage related to inquests and interviews with a relative in relation to a 2007 homicide.

3.3. Neutral coverage related to the disciplinary hearing by a professional body of a former employee.

4. Horizon Scan

November Date Subject Lead Details 21 Carers Drop In

Session Adult Acute Community

Gloucester House, Southmead

24 Lunch with Paul Chief Executive Conference room, Fromeside

25 Wiltshire domestic abuse conference

Wiltshire music centre, Bradford on Avon

25 Sexuality & Intimacy in Dementia

Nursing, Compliance, Assurance and Standards

Jenner House uk)

25 FT Members Event FT Callington Road Hospital

28 Carers Drop In Session

Adult Acute Community

Woodside, Calington Road Hospital

30 Trust Board Chief Executive Jenner House, Chippenham

December Date Subject Lead Details 2 Carers Rights Day Carers UK National

3 NHS Carol Concert Strategic Health Authority

Salisbury Cathedral

5 Fit4Life clinic People Southmead Hospital, Bristol 5 Carers Drop In

Session Adult Acute Community

Gloucester House

6 Making it Happen: Achieving Transgender Equality in the NHS

Strategic Health Authority

2 Rivergate, Bristol

6 Video Team Brief Chief Executive Video conferences across the Trust




7 Fit 4 Life clinic People Southmead, Bristol

7 Trust Long Service Awards

Chief Executive/People

Neeld Hall, Chippenham

8 Recovery in Action Workshop

Acute adult community

Bristol City Council, The Council House



Woodside, Callington Road Hospital

13 Fit4Life clinic People Green Lane Hospital, Devizes

14 Fit4Life clinic People Hillview Lodge, Bath

14 Wiltshire’s fourth annual Health Improvement Partnership Awards

Close of nominations

15 Making it Happen: Achieving Transgender Equality in the NHS

Strategic Health Authority

South West House, Taunton



Gloucester House, Southmead Hospital

22 Lunch with Laura Chief Executive Conference room, Jenner House

5. Freedom of Information

The Trust received eight requests in October 2011 which were addressed under the provisions of the Freedom of Information Act and are processed centrally in accordance with the Trust’s Freedom of Information Policy:

Origin of Request October 2011

Private individual 5

Company 1

Media 2

Total 8

These requests covered a range of topics including the disclosure of MAPPA minutes, ICT information, Data Protection Act breaches, Trust waiting times and various Trust Policies, complaints and whistle blowing in the Trust.






6. Video team brief messages

The following table summarises team brief messages for the past 12 months.

Month Board messages Executive message

November 2011

AIMS project Performance recovery

Planning conference Fire training

October Improving action on violence and aggression Carer survey outcome Quality rising

NHS national staff survey underway Book a flu jab today

September Service Redesign Update Alcohol Related Violence Programme Contract in HMP Erlestoke

Liaison and Later Life Strategic Business Unit Health and Safety

August None None

July Service redesign update Modernising mental health services in Bristol

Quality improvement strategy

June Maintaining the safety of service users RiO implementation almost complete

Foundation Trust update

Update on adult changes

May End of year message of thanks

Quality and targets – two sides of the same coin

Use the latest research to help provide a better service (BEST) Book a place at the Suicide Prevention conference Changes to Jobs First

April Improvements in service quality Mental Health Contract negotiations 2011/12 – update Innovation and 'Dragons’ Den'

Operational message from Lindsey Scott Patient safety

March Mental Health Contract negotiations 2011/12 Improving care and support for military veterans

Patient experience Savings update




February End of year performance Jobs Choice Ministerial visit

Working together to deliver safer services Snapshot staff survey Information governance matters

January 2011

Report of the Board’s discussion of the action plan relating to the ‘Report of the independent investigation into the care and treatment of Mr SN’

December FT Update CQC Compliance Review

Winter resilience 10:10 Campaign

7. Other communications activity

7.1. Quality and safety: In addition to the monthly safety alerts, NICE advice, statutory risk assessments and policy updates, we promoted training courses relating to stress, nutrition and diet as well as security around Smart cards and fire training.

7.2. In addition to the ongoing work of the team (media relations, design, Ourspace, internal and external communications, supporting staff in dealing with a range of issues and enquiries), major activity included the staff awards in conjunction with learning & development, promotion of world mental health day, the launch of the veterans’ service, the appointment of area managers in adults and a new nurse consultant together with a range of initiatives relating flu vaccinations, reclaiming expenses, AWP bank development. The specification for the web project was finalised and preparation for tendering completed.

8. Additional report contributors

• Ray Chalmers, Head of Communications

• Simon Gerard, Senior Communications Officer

• Nicola Bliss, Communications Officer

• Julie Benfell, Information Governance Manager

Minutes of the Quality and Healthcare Governance Committee held on 4th October 2011 at 1pm in the Conference Room, Jenner House, Chippenham

These draft minutes are presented for agreement

Present

Quality & Healthcare Governance Committee Members Members Felicity Longshaw Susan Thompson Tony Gallagher Laura McMurtrie Julie Thomas In Attendance Howard Lawes Arden Tomison Emma Roberts Ian Dickinson Jayne Hayes Julie Hankin Andy Johnston Roger Bullock Bina Mistry Rebecca Peterson

Chair NED member NED member Chief Executive Director for People Deputy Director of Quality and Healthcare Governance Medical Director Company Secretary Clinical Director, SDAS SBU Clinical Director, Specialised & Secure SBU Clinical Director, Service Redesign Clinical Director, AOWA SBU Clinical Director, Liaison and Older People SBU Chief Pharmacist Minuting

In attendance for part of the meeting

Paul Daniels Richard Edwards Carol Bowes Jean Kirk Alison Griffin Chris Stancliffe Chris Williams

Head of Health and Safety Nurse Consultant, Dual Diagnosis Operational Services Manager, Specialised and Secure Services PA to Finance Head of Engagement and Responsiveness Human Resources Operational and Policy Manager Interim Emergency Planning Officer

Apologies Hazel Watson Justine Faulkner Katherine Godfrey

Director of Nursing, Compliance, Assurance and Standards Interim Clinical Director, Acute Adult Community Services Trust Lead Occupational Therapist (Chair of Professional Council)

Draft Minutes of the 4th October 2011 Quality and Healthcare Governance Committee

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To approve the minutes of the meeting on 5th July 2011 The minutes were approved as an accurate record.

4 Assurance Report – CQC Quality & Safety Outcome 14 (Regulation 23) – Supporting Workers.

The Committee received and considered this paper presented by Julie Thomas, Director of People. Outcome 14 relates to the essential standard of Supporting Workers. The Trust is compliant with this outcome. However, 14d is rated yellow. This will be addressed through the review of the Dignity at Work Policy, which is on today’s agenda. This outcome predominately relates to training of staff and comes under the ownership of the Modernisation and Workforce Management Group. Significant evidence is included under each section.

• Susan Thompson commented on the section of risks identified on page 2, which highlights the importance of staff attending key mandatory and voluntary training events. She highlighted that it states in the paper that there has been an increase in capacity for staff to attend Dual Diagnosis training but the intake has reduced. Susan felt there was an issue that staff did not always take advantage of the training opportunities.

• Julie Thomas highlighted that e-learning is a partial solution as it does not always require staff to be away from the workplace. She confirmed that one of the issues around some of our training packages relates to IT particularly around the Dual Diagnosis training package. Once network upgrade is completed in January 2011, we should be able push this training more significantly.

• Julie Thomas confirmed that attendance at training is monitored monthly at EMT, Performance EMT and at the SBU IG meetings every six weeks.

RESOLVED That the report was approved.

5 Assurance Report CQC Quality and Safety Outcome 4 (Regulation 9) – Care and Welfare of people who use the services.

The Committee received and considered this report presented by Carol Bowes, Operational Services Manager, Specialised and Secure. Outcome 4 relates to the essential standard of Care and Welfare of people who use the services and that they receive effective and appropriate care and treatment and support that meets their needs and protects there rights.

• It is a detailed report with evidence in every section. • The Trust has had 3 separate inspections on compliance by the CQC in the

period covered by this report. The CQC assessed the sites inspected as being full compliant with this Outcome.


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• The assurance report went to the Quality and Effectiveness Management Group meeting. The group identified areas that we can strengthen, some of the elements of evidence which are in relation to rapid tranquilisation, diagnostic tests in community teams, and internal Trust safety alerts and out of hours incidents and issues relating to services users on CPA.

• There is some work to be done with Linda Hutchings, Lisa Marrett and the SBUs about how to take some of these issues forward and to look at how these actions can be progressed.

• Susan Thompson felt it was an excellent report and confirmed that the Mental Health Legislation committee is looking at rapid tranquilisation.

RESOLVED That the report was approved.

6 Dual Diagnosis Assurance Report The Committee received and considered this paper presented by Richard

Edwards, Consultant Nurse, Dual Diagnosis. This report discusses the effectiveness of the previous Dual Diagnosis Strategy and Action Plan (2008-2010) and considers the recently revised 2011-2013 update.

• This is an update of the report that came to the committee in March 2011. There are 5 areas that were highlighted as potential areas of risk. One was around the recording of prevalence. A new system is now in place to record this as we have now changed over to RIO. This ensures that it is easy to record and our first data will be available at the end of Quarter 3.

• There is an ongoing issue around e-learning and capacity to release staff. Richard highlighted that Dual Diagnosis training is essential but not mandatory. It is an ongoing issue that some staff are not able to access the opportunities available.

• Richard highlighted a risk relating to the change in the SHA`s training content from UWE to Tribal/Capita. An initial review of the new training package indicates a change from an 8 day accredited module to 30-60 minute training slots. Richard confirmed that there is some ongoing work looking at this to see what this reduced training time could mean.

• Medical Training rates have now improved significantly with 30 medical staff attending training this week.

• There had been an issue regarding quality feedback from service users about their experiences. However, data coming back from service users stated that between 75% and 80% of them had been asked about drug and alcohol use and 80% to 90% felt that they were offered appropriate help and support.

• The link worker model has continued and there are over 100 across the Trust. There has been some recognition of this nationally. The framework is quite robust but over the last 6-9 months the capacity for staff to deliver this over and above their day job has been restricted with the delays in service redesign and some services having to hold back on appointing full time staff.

• The Chair asked why there was a need for extra staff. Richard confirmed that the link worker model at the moment is for staff not to take on the responsibility of Dual Diagnosis but it is to raise awareness amongst teams and to do training. Richard confirmed that most of the link workers are


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permanent staff within their teams but the capacity within the teams to allow them extra time to that additional work is limited.

• Richard confirmed that the revised strategy had been rewritten with the involvement of Directors and is awaiting sign off by EMT.

• The Chair queried the section on the observation about guidelines not covering people with personality disorders on page 6, 4.3. Richard confirmed that this comes from the NICE guidelines and not the Trust`s,

• The Chair highlighted point 4.12 relating to homicide reviews which states that it would be helpful to collate Dual Diagnosis recommendations from the Homicide Reviews over a period of time. Laura confirmed that this could be done and it would go to EMT along with the strategy.

• The Chair was concerned about the reduction in training in the new contract. Julie Thomas advised that the Board had agreed the use of contingency funds to cover the gap between the end of the UWE contract and the start of the new contract. The Trust will continue to influence curriculum development of the new training. Susan Thompson said that the level and quality of this training should be monitored. Julie confirmed that she would include this in her quarterly Board report.

RESOLVED: That the report was approved.

RE

7 Assurance Report against Patient Experience Strategies/Action Plans

The Committee received and considered this report presented by Alison Griffin, Head of Engagement and Responsiveness. This report covers the period 1st August 2010 – 31st July 2011. The purpose of the report is to assure the committee that our legal requirements and obligations on implementing the patient experience strategies and progress on the action plans are being met.

• The report is broken down against our performance on meeting our statutory requirements, our performance against the standards, and updating the committee on the implementation of recommendations from Ombudsman reviews.

• The report covers the standards against PALS, patient information, real time surveys and the carer’s strategic framework.

• The NSUN review of patient and carer engagement is ongoing with a report expected later on this year.

• Susan Thompson brought the committees attention to the section 4.22 that highlights how people access information, and how people share learning. She asked if there was an area for this on the Intranet. Alison confirmed that there are guidelines available for staff on Ourspace, this includes a page for service users and carers, PALS, complaints and volunteering that is available to all staff. The SBUs explore the learning and how that information is shared as part of their IG meetings and then that information is cascaded out. Alison agreed that it would be useful to centralise this information. This could be incorporated into the development of the AWP intranet.

• The Chair highlighted that the report describes a lot of activity and processing but it does not identify the key messages. She felt we need to make sure that we are getting really consistent messages from our service


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users about any issues that they have. • Howard Lawes reported the themes around messages emerging from IPE

reporting needed to be effectively incorporated into the SBU quality improvement planning process. We will be discussing this with Clinical Directors and Corporate Leads as part of the move to a 2-3 year quality improvement planning.

• Julie Hankin highlighted that in point 4.9.3 it states that the system for covering doctor’s sickness was reviewed and a record will be kept on the care cluster tool of people who are receiving a prescription should their work need to covered. Julie confirmed that this cannot be done using the care cluster tool. Alison to look into this and change the wording.

• Susan Thompson highlighted point 4.17.11 relating to the Patient Opinion website that gives service users the opportunity to have their say about NHS services. Susan asked what this was and was it something that our service users were aware of. Ian Dickinson confirmed that this is an independent website and AWP has its own presence within the site and we promote the patient opinion site in our surveys. Alison Griffin confirmed that the funding that the Department of Health funding for membership has just ended and the Trust needs to make a decision as to whether we want to subscribe to it in the future. Laura felt that this should be discussed at EMT and then report back the outcome to the committee.

• Bina Mistry highlighted the section in point 4.9.11, page 11 that states that the central pharmacy will explore ways to avoid delays in the delivery of medication to be issued to service users on their discharge. Bina also highlighted that the report states we do thematic reviews of complaints and asked that if there were any issues around medication could these go through to the Medicines Management group. Alison confirmed she would take these forward to the group.

• Susan Thompson highlighted how pleased she was to see the significant number of volunteers we now have.

• RESOLVED:

That the report was approved.

AG AG

8 Complaints Assurance Report The Committee received and considered this report presented by Alison Griffin,

Head of Engagement and Responsiveness. This paper was requested by the Board following the Quarter 3 and 4 Improving the Patient Experience Report which identified that there was a large number of PALS and complaints cases relating to Information, Advice and Choice.

• Alison confirmed that the number of complaints and queries in this category was similar to other Mental Health Trusts.

• The Chair said that the report was helpful and she felt more informed about the issue. She asked if it was the intention that PALS be the main source of information for service users or if the large number of calls they received indicated that people were not obtaining information directly from wards and teams. The report does not show whether our information services are working appropriately through the SBUs or whether PALS is being used to provide information which could be sourced through other areas such as their teams or inpatient services. Alison agreed to do some research into


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this and when requests come in over the next quarter she will ensure that they are asked if PALS have been their first point of call or if they have been anywhere else. Alison to bring a report back to the January 2011 committee meeting.

• Andy Johnston confirmed that PALS have made a significant contribution to his SBU.


AG

9 Report on Overview of Internal Audit The Committee received and considered this report presented by Jean Kirk, PA

to Finance Department. The purpose of this report is to report on outstanding internal audit recommendations. These would have been reported at the September 2011 committee which was cancelled so this report is therefore a month out of date.

• Operations Directorate – Review of RIO Implementation 2009/2010. There is an overall review taking place. John Riddler is meeting Andy Sylvester on the 10th October 2011 to discuss this.

• Board – 02.10/11 Communications para 1.3. – A target extension date will be requested.

• Finance & Performance Directorate – Provider Service Level Agreements para 1.1. A revised target paper was issued to EMT in August 2011. The project close date has now been extended to March 2012. An extension will be requested.

• Operations Directorate – Carbon Management (Sustainability) para 3.2.2a. It was agreed that Laurie Stroud will take on these responsibilities within his job role. The responsibilities will be documented in a revised job description and we are awaiting feedback from Andy Sylvester on this.

• Operations Directorate – Carbon Management (Sustainability) para 3.2.1c. This is on target.

• Strategy & Business Development – Follow up, Para 3.12.1. An update was received at the PbR Project Board at its meeting on the 2nd September 2011. This recommendation has now been closed.


10 Acute Adult Community Services Quality Improvement Plan The Committee received and considered the report presented by Howard Lawes,

Deputy Director of Quality on behalf of Justine Faulkner. This paper outlines the proposed framework for the Adult Acute Community SBU to bridge the period 2011-2012.

• The paper outlines a proposed Quality Improvement Framework for the SBU. The aim is to test it with practitioners and clinicians to ensure it is effective and appropriate. It will structure the quality improvement process in the SBU and inform the 2012-13 quality improvement plan.

• It outlines 5 key aims: The delivery around marked improvements in the user/carer experience; energising and engaging staff; on the recovery ethos; being very solutions focused: being outcomes focused.


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• The framework has four domains: effectiveness; safety; patient experience; performance.

• Bina Mistry noted that the section on measurement of success did not include audits and other potential measurements.

• Roger Bullock, in relation to references to the recovery model, noted that AWP was only one part of the recovery journey and that the Trust should be clear about its role. Arden Tomison noted that the service specification used the national definitions of recovery. Laura McMurtrie recognised the importance of this point and its significance for market differentiation.

• It was agreed that there should be a timetable for implementing the framework. In addition Laura McMurtrie confirmed that she expected the SBU to rapidly catch up with the other SBUs improvement planning process.

• Susan Thompson expressed concern that the paper stated that users and carers were not involved in the work the report relates to. She also noted that there was no reference to the Board Strategy for Quality Improvement or the Quality Accounts. She further noted that there was no link in the framework for the other SBU quality plans. It was pointed out that the Board Strategy was the focus and link for all SBU Quality Improvement plans.


JF JF

10 Acute Adult Inpatient Services Improvement Quality Plan The Committee received and considered this report presented by Andy Johnston,

Clinical Director, AAI SBU. The Trust Quality Improvement Strategy was approved by the Board in March 2010. This paper outlines the proposed framework for the Acute Adult Inpatient SBU for 2011/12.

• This is a draft report outlining how the new SBU will approach quality improvement. The paper outlines work on developing a clinical governance structure through engagement with staff and service users. This was launched in July at a meeting attended by 75 clinicians.

• A new clinical management structure is in place and the SBU has identified the areas where it wants to make significant improvements to patient experience.

• Susan Thompson felt it was a very good report and identified very clearly where improvements are needed. She felt it would be helpful to cross reference across the SBUs and include Quality Accounts. She asked if we should be reflecting the contract requirements in the success criteria. Andy confirmed that he had used the KPIs to word the success criteria in a way that would make sense to the clinicians.

• Susan noted the reference to the quality of face-to-face contact at 5.22 in the report. As some of this is measurable it would be helpful to include some measures. Andy confirmed that the SBU was using real time surveys for this measure.

• The Chair queried the sentence on page 3 that talks about an organisational and learning mechanism. She felt it was very focused on information and felt there needed to be methodologies to complete the cycle.


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That the report was approved

11 Procedural Documents Recommended for Approval.

(i)Appraisal Policy for Consultants and Speciality and Associate Specialist Doctors The Committee received and considered this policy presented by Julie Thomas, Executive Director for People. This is a new policy that has been developed to meet the requirements set by the GMC for revalidation of career grade doctors.

• It has been reviewed by the usual negotiating groups and has been to the Modernisation and Workforce group.

• The policy has come to the committee with a proposed 12 months review period.

• Howard Lawes queried section 3.2 which states that consideration will be given to offer locum doctors an appraisal. Howard asked if there will be any guidance to support this. Arden Tomison confirmed that this would be based on individual cases about whether we would undertake an appraisal ourselves or whether the agency that the locum works for would undertake the appraisal.

• Susan Thompson queried point 10.4 that refers to service user’s feedback and asked if that happens now. Arden confirmed that it does.

RESOLVED: That the policy was approved. (ii) Dignity at Work Policy The Committee received and considered this policy presented by Julie Thomas, Executive Director for People. The purpose of this policy is to confirm the Trust`s expectation that all staff should be treated with respect and dignity at work. The policy provides guidance for staff on how to address and raise concerns about unacceptable behaviour and harassment.

• This is a review of an existing policy and has come to the committee with a proposed review period of 12 months.

• Susan Thompson asked if the policy links into the Equality Act. Julie confirmed that it does and that it has been reviewed by the Trust Dignity and Equality Advisor. Susan highlighted that she could not see any reference to this in the version tracking. Julie confirmed that an equality impact assessment has been carried out and the Act is referenced on page 6. Julie to add this to the tracking to highlight this and to add the date that it was looked at in the context of the Equality Act.

RESOLVED:

JT


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That this policy is approved subject to inserting a reference to the Equality Act. (iii)Policy for Managing Poor Performance (to replace the Individual Performance Improvement and Capability Policy) The Committee received and considered this policy presented by Julie Thomas, Executive Director for People. This policy is to replace the existing Individual Improvement and Capability Policy. The new title gives a much clearer indication of the purpose of the policy.

• The purpose of this policy is to establish a process for managers to address matters of poor staff performance when this is due to a lack of ability, skill, aptitude or knowledge to carry out the work that is required by the Trust.

• The policy has come to the committee with a proposed review period of 12 months.

• Jayne Hayes noted that it would be helpful if the suite of policies ensured clarify about the process for referrals to the Independent Safeguarding Authority. Julie Thomas confirmed that in relation to the ISA, there has been so much change in the national position and who will ensure that there is some clear guidance in any other related HR policies.

RESOLVED: That the policy was approved. (iv) Administrative amendments to People Directorate Policies (Appraisal Policy, Workforce Diversity and Equal Opportunities Policy and Practitioner Registration Policy) The Committee received and considered this policy presented by Julie Thomas, Director for People.

• Julie Thomas asked the committee to note some administrative amendments that have come out of the policy going through the Modernisation and Workforce committee.

RESOLVED The committee noted the administrative amendments. (v)Supervision Policy The Committee received and considered this policy request represented by Julie Thomas, Director for People. The purpose of this policy is to provide a framework for the delivery of comprehensive, consistent and good quality supervision for all our staff. The policy deals with the three elements of a comprehensive supervision structure, managerial supervision, caseload supervision and clinical supervision.

• The policy has been reviewed by the general negotiating group but it has not yet been to the Modernisation and Workforce group meeting. It has

JT


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been brought to the committee today because there have been some amendments made to the policy as a result of recommendations from a serious case review in South Gloucestershire and the Head of Safeguarding requested these changes come to the committee as soon as possible.

• The changes are highlighted on the cover sheet of the policy. • It was agreed that committee would approve the policy subject to its review

at the Modernisation and Workforce group next week. The committee delegated authority to the Chair and Chief Executive to approve any final amendments and to provide assurance of these changes back to the committee.

• Jayne Hayes highlighted that one of the reasons for the change to the policy was to ensure that the clinical supervision policy was addressing the safeguarding issue There appeared to be confusion in practice between clinical and people policies.

RESOLVED: It was agreed that committee would approve the policy subject to its review by the Modernisation and Workforce group to delegate authority to the Chair and Chief Executive to approve any final amendments and to provide assurance of these changes back to the committee. (vi) The Policy for Standards of Dress on Trust Business The Committee received and considered this policy presented by Paul Daniels, Head of Health and Safety. This is a new policy incorporating guidance from various sources such as Food Hygiene, Infection Control, HR guidance and health and safety guidelines as well as the Department of Health.

• The purpose of the policy is to bring together the various strands of safety, infection control, food hygiene and professionalism into one coherent policy and set of standards. This would remove inconsistency of approach and allow managers to manage the issue of inappropriate.

• The policy has been through an extensive consultation exercise via GNG, JUC, Diversity and Workforce, Health and Safety, Modernisation and Workforce, Infection Control as well as input from Professional and Operational representatives.

• Susan Thompson queried the section on page 12 that states that hidden necklaces are accepted and asked if this related to religious or cultural issues. Paul confirmed that the statement was based around infection control and violence and aggression and that any necklaces were permitted as long as they were hidden and tucked into clothing so would not be a risk to the member of staff or patient.

RESOLVED: That this is approved.

JT JT/MD PD


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(vii) Health and Safety Policy The Committee received and considered this policy presented Paul Daniels, Head of Health and Safety. This is a revised policy, the previous version being approved in June this year. This policy is reviewed on an annual basis.

• The revisions made to this policy are solely to section 6.7 starting on page 15 concerning vulnerable persons. The Trust has been operating to an unwritten custom and practise regarding young persons, particularly those engaged on work experience and it has not allowed them to work on wards and within CMHTs. This has now been incorporated into the policy together with links to the Policy for the Protection of New and Expectant Mothers.

• The section on young people has been taken largely from the Approved Code of Practice “Management Regulations”.

• Ian Dickinson queried the wording of the first paragraph in page 16 and the section about how exemptions to the general exclusions allow young persons to work. The principles do not sit well in that they suggest that young persons could be exposed to risk under the circumstances listed. The committee agreed that this could be better worded and asked Paul to refer back to the approved code of practice and amend this sentence.

• Paul to amend section 6.7.1 and bring the policy back to the committee next month.

• In principle the committee agreed to the paragraph excluding under 18`s from wards and CMHT`s etc where patient contact was possible.

RESOLVED: That this policy is not approved and will come back to the next committee with the above amendments.

PD

12 HSE Inspection Report

The Committee received and considered this paper presented by Paul Daniels, Head of Health and Safety. This report details the findings and feedback from the Health and Safety Executive following their inspections of Trust teams on 7th March 2011 and 2nd June 2011.

• The HSE has not issued a formal report on the inspections and there has been no statutory enforcement action. The inspector sent out an email summary of the inspection findings.

• A number of minor issues were highlighted by the HSE. These items were added to the Improvement Plan produced in 2010 which has been reviewed. The Improvement Plan will be taken to EMT on the 15th November 2011 and will come back to the December 2011 committee as matters arising.

RESOLVED: That the report was approved

Draft Minutes of the 4 October 2011 Quality and Healthcare Governance Committee

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13 Annual Emergency Planning Assurance Report The Committee received and considered this report by Chris Williams, Interim

Emergency Planning Officer. This report provides an update of progress in emergency preparedness, business continuity and pandemic flu planning and assures the Board of continued compliance with relevant national standards and Acts of Law, and the NHS Operating Framework.

• There have been some very minor changes since last year. It was noted that the SHA demonstrated that we are the strongest performing Trust in emergency preparedness and resilience.

• The SHA recently undertook an audit of our capabilities. There were no negative findings and no recommendations for improvement.

• We have a high level of participation in local and national exercises and recently participated in a mass casualty event, We will continue to participate as and when exercises arrive.

• The report also mentions notes that our vaccination uptake was highest in the South West for seasonal flu and the fifth highest in the country last year.

• On page 10, 5.6 it states MTAS (the mobile telecommunications access scheme) is still ongoing. Chris confirmed that this has now been completed. The executives on calls all have MTAS access on their mobile phones.

• Susan Thompson referred to the section that states that all staff are being offered a flu vaccination and asked if this is being advertised to staff. Chris confirmed that the campaign began yesterday.

RESOLVED That the report was approved

14 Annual Winter Plan The Committee received and considered this plan presented by Chris Willliams,

Head of Emergency Planning. This plan sets out how AWP will continue to work in partnership with other organisations as part of the Local Health Authority through the winter period, and how specific risks for winter have been assessed and mitigated.

• There have been very minor changes since last years plan. • The Department of Health has not produced any updated guidance. The

Primary Care Trust`s support the plan. It was noted that the winter plan has been effectively applied over the last two years.

RESOLVED That the report was approved

15 Any Other Business: 16 Date of the next meeting:

1st November 2011 - Conference Room, Jenner House.

Dates of future meetings

Time Venue Committee papers to be received by Rebecca Peterson for distribution

Please not there will be no Committee meeting in August 2011

6th Sept 2011

1-4pm Conference Room, Jenner House

19th August 2011

4th October 2011 1-4pm Seminar Room 4, Jenner House

16th September 2011

1st Nov 2011

1-4pm Conference Room, Jenner House

14th October 2011

13th Dec 2011 1-4pm Conference Room, Jenner House

19th November 2011

10th Jan 2012 1-4pm Conference Room, Jenner House

23rd December 2011

7th Feb 2012 1-4pm Conference Room, Jenner House

20th January 2012

6th March 2012 1-4pm Conference Room, Jenner House

24th February 2012

3rd April 2012 1-4pm Conference Room, Jenner House

2nd March 2012

8th May 2012 1-4pm Conference Room, Jenner House

20th April 2012

5th June 2012 1-4pm Conference Room, Jenner House

18th May 2012

3rd July 2012 1-4pm Conference Room, Jenner House

22nd June 2012

7th August 2012 1-4pm Conference Room, Jenner House

20th July 2012

4th Sep 2012 1-4pm Conference Room, Jenner House

24th August 2012

2nd Oct 2012 1-4pm Conference Room, Jenner House

21st September 2012

6th Nov 2012 1-4pm Conference Room, Jenner House

19th October 2012

4th Dec 2012 1-4pm Conference Room, Jenner House

23rd November 2012


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