PUBLIC MEETING OF THE TRUST BOARD 1.00pm, Thursday, 4 th May 2017 The Board Room, Canalside, Bloxwich AGENDA Culture and Conduct Protocol We are a values-led Board. We place quality of care and safeguarding the needs of our patients at the heart of everything we do. We work consciously as a team to support and constructively challenge each other in the best interests of service users, their carers and families. We champion the interests of staff and acknowledge that they are working well in challenging times. We seek to ensure value for money at all times through efficient use of our resources in the delivery of services and achievement of standards. We welcome the rigour of debate with fellow Board members, drawing upon a range of different experiences and perspectives and applying the Nolan principles of Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership. ITEM Purpose Board Lead Format Timings 1. Apologies Mr Reid Oral 1.00pm 2. Declarations of Interest For Board members to declare any relevant interests in items on the agenda Mr Reid Oral 3. Minutes of the Previous Meeting To approve the minutes of the Extraordinary Board meeting held on 30 th March 2017 and the Board meeting held on 6 th April 2017 Approval Mr Reid Enc 1 Enc 1A 4. Matters Arising/Action Schedule Continuity Mr Reid Enc 2 5. Summary Report of Confidential session of Trust Board held on 6 th April 2017 Information Mr Reid Enc 3 6. Chief Executive Officer’s Overview (including written summary of strategic publications and headlines) Information Mr Axcell Enc 4 1.05pm 7. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS 7.1 Trust Integrated Performance Dashboard (Month 12) including the Performance Dashboard and Contract Performance Report Dashboard Assurance Mr Davies Enc 5 1.10pm 7.1.1 a b c Quality Quality and Safety Committee Chairs Report Quality & Safety Committee Minutes from meeting held on 8 th March 2017 Quality Report Assurance Assurance Assurance Dr Murphy Dr Murphy Ms Musson Enc 6 Enc 7 Enc 8 1.15pm
Transcript
PUBLIC MEETING OF THE TRUST BOARD
1.00pm, Thursday, 4th May 2017
The Board Room, Canalside, Bloxwich AGENDA
Culture and Conduct Protocol
We are a values-led Board. We place quality of care and safeguarding the needs of our patients at the heart of everything we do. We work consciously as a team to support and constructively challenge each other in the best
interests of service users, their carers and families. We champion the interests of staff and acknowledge that they are working well in challenging times. We seek to ensure value for money at all times through efficient use of our
resources in the delivery of services and achievement of standards. We welcome the rigour of debate with fellow Board members, drawing upon a range of different experiences and perspectives and applying the Nolan principles of
Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership.
ITEM Purpose Board Lead Format Timings
1. Apologies Mr Reid Oral 1.00pm
2. Declarations of Interest For Board members to declare any relevant interests in items on the agenda
Mr Reid Oral
3.
Minutes of the Previous Meeting To approve the minutes of the Extraordinary Board meeting held on 30th March 2017 and the Board meeting held on 6th April 2017
9.1 Communications and Engagement Report – 2016/17 Quarter 4
Assurance Mr Axcell Enc 24 3.00pm
10. FOR ASSURANCE
10.1 a b
MERIT Vanguard NED Assurance Group Report Quarterly Overview Report
Assurance
Assurance
Mr Turner Mr Axcell
Enc 25 Enc 26
3.05pm
10.2 MExT Chair’s Report from April 2017 Assurance Mr Axcell Enc 27 3.15pm
11. ANY OTHER BUSINESS
ITEM Purpose Board Lead Format Timings
12. QUESTIONS FROM MEMBERS OF THE PUBLIC
Questions from members of the public pertaining to agenda items.
Oral
3.20pm
13. DATE AND TIME OF THE NEXT MEETING
1.00pm on Thursday 1st June 2017, Conference Room 1, Trafalgar House, Dudley
Enc 1 MINUTES OF THE EXTRAORDINARY TRUST BOARD MEETING OF
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST
Held at 3.30pm on Thursday, 30 March 2017 The Board Room, Canalside, Bloxwich
PUBLIC SESSION Present Mr B Reid Chair Mr M Axcell Chief Executive Officer Mr R Davies Interim Director of Finance, Performance and IM&T Dr K Gingell Joint Medical Director Ms M Ingram Acting Director of Operations Mr J Lancaster Non-Executive Director Dr M Weaver Joint Medical Director Mrs A Williams Acting Director of People In Attendance Mr P Lewis-Grundy Company Secretary Mrs L Wix Corporate Governance Support Officer (minutes) ITEM ACTION 223. APOLOGIES
Apologies had been received from Mrs G Cooper, Non-Executive Director, Ms O Clymer, Non-Executive Director, Dr S Murphy, Ms R Musson, Acting Director of Nursing, Mr H Turner, Associate Non-Executive Director and Mr P Rana, Non-Executive Director and Dr M Weaver, Joint Medical Director.
224. DECLARATIONS OF INTEREST
Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. No interests were declared in addition to those already recorded on the Register of Interests.
225.1 Income and Expenditure and Capital Budget Plan for 2017/18
Mr Davies gave a presentation on the proposed income and expenditure and capital budgets for the Trust for the full year 2017/18 and advised that the income and expenditure budget was based upon a planned turnover of £63.7m, and a surplus of £1.8m (ie, including £0.5m STF funding). He stated that crucial to the delivery of the budget was the securing of some £3.8m of savings – for CIP and QIPP purposes. It should be noted that £1.9m of this requirement had been carried forward from 2016/17. A detailed saving programme schedule was included in the presentation which identified the required value of savings profiled over the financial year. Delivery of the overall programme represented a significant risk to the delivery of the plan. The plan included application of some £0.5m of budget reserves recurrently. The capital plan was predicated upon an allocation of £3.8m. This had been submitted to NHSI but the Trust is awaiting final confirmation that it would be allowed to spend the full allocation. Based on recent history the Trust expects to be given the authority to spend up to the £3.8m. The capital plan excluded the developing Bloxwich wards replacement project which would require the support of NHSI and the STP. At this stage it is not envisaged that external funding would be required as the project would be sourced from the Trust’s existing cash balances. The Interim Director of Finance highlighted the risks around the income budgets. He suggested that, based upon 2016/17 experience, there could be risks around losing an element of CQUIN funding and potential contractual penalties in relation to the two main NHS contracts. He further highlighted the need to ensure that the Trust secures the full income target in respect of its recent development of the Neuropsychiatry service. Overall, the Interim Director of Finance believed that the total income risk could be in the region of £400k. The proposed budget required a total cost improvement (ie, including QIPP) savings of £3.7m. This was a significant level of savings and represented some six per cent of the Trust’s cost base. This figure includes some £1.9m of unachieved cost improvements/QIPPs brought forward from 2016/17.
A CIP/QIPP schedule was presented as part of the budget proposals setting down the cost saving schemes for 2017/18. This schedule profiled savings on a monthly basis and broadly indicated a 40:60 split of cost savings between the first and second halves of the year. It was noted that there was a range of schemes for which savings were secure from the beginning of the financial year. Reconciliation between the forecast 2016/17 pay outturn and the start 2017/18 pay budget focused discussion upon the robustness of the pay budget and the importance of delivering the CIP, particularly the pay element. The Interim Director of Finance explained that the risk was that the pay cost improvements were not delivered while agency costs continued at a rate similar to the 2016/17. The Chief Executive Officer made the point that given the Trust’s current level of vacancies it would commence 2017/18 with a financial benefit. Therefore, the key to successful delivery of the financial plan was the embedding of the individual savings schemes into the Trust whilst taking benefit from the current vacancy levels. The Board further considered the capital budget for 2017/18. It was proposed to set a capital budget for the year of some £3.8m, with significant sums allocated to the electronic patient record project (£2.4m) and the Bushey Fields refurbishment (£800k). This was to be funded entirely from internal resources, subject to NHSI agreeing to authorisation of £800k additional CRL requested in excess of expected depreciation (£2.0m) and agreed slippage of capital expenditure from 2016/17 (£1.0m). The Board considered both the income and expenditure and capital budgets and agreed them as forming the basis of the 2017/18 financial plan. RESOLVED: That the Board approved the Income and Expenditure and Capital Budget for 2017/18.
226. ANY OTHER BUSINESS
There were no items of any other business.
227. DATE AND TIME OF NEXT MEETING
The next Trust Board meeting would take place at 1.00pm on Thursday, 6th April in Conference Room 1, Trafalgar House, King Street, Dudley
Meeting closed at 3.45pm Enc 1 Extraordinary PublicTrust Board Minutes 30.3.17 (Final) Page 3 of 4
Signature……………………………………………………….. Date……………. Mr B Reid, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST
Held at 1.00pm on Thursday, 6th April 2017 Conference Room 1, Trafalgar House, King Street, Dudley
PUBLIC SESSION Present Mr B Reid Chair Mr M Axcell Chief Executive Officer Ms O Clymer Non-Executive Director Mrs G Cooper Non-Executive Director Dr K Gingell Joint Medical Director Ms M Ingram Acting Director of Operations Mr J Lancaster Non-Executive Director Dr S Murphy Non-Executive Director Ms R Musson Acting Director of Nursing Mr H Turner Associate Non-Executive Director Dr M Weaver Joint Medical Director Mrs A Williams Acting Director of People In Attendance Mr M Banks Deputy Director of Finance Mr P Lewis-Grundy Company Secretary Mrs L Wix Corporate Governance Support Officer (minutes) ITEM ACTION 1. APOLOGIES & WELCOME
Apologies had been received from Mr R Davies, Interim Director of Finance, Performance and IM&T and Mr P Rana, Non-Executive Director
2. DECLARATIONS OF INTEREST
Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. Dr Murphy reminded members that he had been appointed as a Non-Executive Director at Birmingham Community Healthcare NHS Foundation Trust with a start date to be confirmed and Ms Ingram advised that she had recently been seconded to Birmingham Community Healthcare NHS
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Foundation Trust in the role of Integration Director. No other interests were declared in addition to those already recorded on the Register of Interests.
3. MINUTES OF THE PREVIOUS MEETING 3.1 3.2
To approve the minutes of the meeting held on 2nd March 2017. Two amendments were proposed: Minute 210.3 Mental Health Act Scrutiny Committee Chair’s Report Add the time of Dr Murphy’s arrival at the beginning of the minutes. 210.8 Finance Report Dr Murphy asked that the data provided in paragraph 2 be verified by the Interim Director of Finance. RESOLVED: That the minutes of the meeting held on 2nd February 2017 be approved and signed by the Chair, subject to the amendments above being made.
4. MATTERS ARISING/ACTION SCHEDULE
All items were either complete or had future completion dates. RESOLVED: That the matters arising and the assurance given where those actions have been completed be noted.
5. SUMMARY REPORT OF THE CONFIDENTIAL SESSION OF TRUST BOARD HELD ON 2nd March 2017.
Members noted the content of the confidential summary of the meeting held on 2nd March 2017. RESOLVED: That the Board received the report for information.
6. CHIEF EXECUTIVE OFFICER’S OVERVIEW
Mr Axcell presented his report which provided an update on the following:
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Publication of the CQC Inspection Report on the Trust The CQC published its inspection report on the Trust on 28 March 2017. The Trust had overall been rated “Good” and Good in all of the individual domains with the exception of Effectiveness which remained “Requires Improvement” The Trust was reviewing the report in detail to understand any learning and to prepare an action plan to address the reports’ recommendations. Mr Axcell, together with all Board members, wished to express their thanks and appreciation to colleagues across the organisation who had been instrumental in delivering the improvements required which resulted in the improved rating from the CQC. Dr Murphy stated that the Trust should now be reviewing actions to be taken to achieve the Trust’s aspiration to become “outstanding” and that action plan would be overseen by the Quality & Safety Committee. Transforming Care Together TCT had moved into a phase of integration and a Full Business Case and Integration plan was being prepared and would be presented to the Board in June. A number of Trust staff were leading either Mental Health specific work streams or leading the development of the TCT partnership across the three Trusts. MERIT and Dudley CCG Vanguard The Trust continues to be an active part of the MERIT development. Discussions had taken place between partners on the 2017/18 priorities with a number of shared priorities being agreed.
Sam Jones (National Clinical Director for New Models of Care) had visited Dudley CCG vanguard in the month which was attended by a number of the Trust’s clinicians
Walsall CCG Healthy Walsall Partnership Board Work continued to progress on partnership across the Walsall Health Economy
Five Year Forward View for Mental Health One Year On –
Formed in March 2015, the independent Mental Health Taskforce brought together health and care leaders, people who use services and experts in the field to create a Five Year Forward View for Mental Health for the NHS in England. This national strategy, which covers care and support for all
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ages, was published in February 2016 and signified the first time there has been a strategic approach to improving mental health outcomes across the health and care system, in partnership with the health arm’s length bodies. In July 2016, NHS England published an Implementation Plan to set out the actions required to deliver the Five Year Forward View for Mental Health and the report marked the anniversary of the publication of the Five Year Forward View for Mental Health. Mr Axcell confirmed that the four Black Country CCGs had put forward proposals on integrated working between organisations, to include joint committee membership, and discussions on the way in which services would be jointly commissioned in the future across a wider black country footprint.
Mr Axcell finally referred to the success of the Mental Health Forum that had been well attended.
RESOLVED: That the Board noted the report for information and the actions contained therein.
Mr Banks summarised the main points advising that the finance, performance and workforce reports included greater detail on the items referred to, although he highlighted the improving position with appraisals and mandatory training.
The Chair commended the improved RAG rating of a significant number of items across the domains.
RESOLVED:
That the Board noted the content of the report.
7.2 Quality & Safety Committee Chair’s Report
In presenting the report, Dr Murphy advised that the Committee had received an update report from the Head of Service relating to IAPT activity. Since the briefing in October 2016 there had been sustained efforts to support achieving targets and KPIs. The Committee received assurance that a number of actions and recommendations had been implemented by the service, although it was acknowledged, largely due to the level of demand, that the targets were
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difficult to achieve at both a local and national level.
Mrs Cooper queried whether any further action could be taken to improve achievement against the IAPT targets given that the service delivery in Dudley differed to that in Walsall. Ms Ingram advised that whilst Dudley had always struggled to achieve target there was now a worsening position in Walsall. She would be recommending short term external support to understand the IAPT services, although she believed that everything possible was being done to increase demand. Dr Murphy advised that the Quality & Safety Committee had concluded that there were insufficient numbers of service users who required referral to the service and despite a number of communications initiatives the numbers had not increased and this was due to unrealistic target setting. Dr Weaver advised that it was anticipated that the number of IAPT appointments would increase to 26000 by 2018/19, although he could not envisage how this would be achieved given that patients in recovery from mild to moderate depression did not usually wish to continue treatment from IAPT. Mr Axcell advised that an approach had been made to a Trust that had been put into special measures for IAPT services by their CCG and the service was now delivered by the private sector to identify any learning.
The Committee received a Fire Safety Action Plan update which outlined the work of the Fire Safety Group and provided assurance that actions were being taken in line with the Action Plan. A further update would be provided to the Committee in May 2017. The outcome of the review of the Trust’s Serious Incident and Mortality Review processes had been presented to the Committee and this was also a Board agenda item. Dr Murphy confirmed that the Policy and Procedures Focus Group had agreed to re-ratify a number of policies outlined in the report. Additionally, the Committee had ratified three policies:
• Food Safety Policy • Information Governance, Serious Incidents Requiring
Investigation (SIRI) Policy • Research Governance Policy
Dr Murphy advised that the short listed Quality Improvement Priorities for 2017/18 had been received as follows:
• Person Centred Care / Care Planning • Improving the quality of record keeping • Ensure organisational learning is embedded and
sustained
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• Smoke Free (continuing from 2016-17) • Refocus Recovery Model
The Committee discussed the priorities based on feedback following consultation and consideration given following initial feedback from the CQC and recommended them to the Board for adoption. In response to the Chair’s enquiry as to which of the priorities, leaving record keeping aside, would have the greatest impact on the Trust Dr Murphy advised that the Smoke Free priority would have a significant impact. Ms Musson added, with regard to the stated priority to embed and sustain organisational learning that changes made following the CQC inspection were empowering services to make changes to realise improvements within their service area through the embedding lessons group.
RESOLVED:
That the Board: • accepted the report for assurance about the
exercise of delegated authority by the Quality and Safety Committee.
• approved the 5 Quality Improvement Priorities for 2017/18 as recommended by the Committee.
7.3 Quality & Safety Committee Minutes from the meeting held on 8th February 2017.
RESOLVED:
That the Board received the minutes for information and assurance.
7.4 Quality Report
Mrs Musson presented the Quality report for month 11 which made reference to:
• A summary of incidents • Operational Service Line Reports • Safety Alert Broadcasts (SABs) • Safeguarding Performance Framework
RESOLVED:
That the Board received the report for information and assurance.
7.5 Audit Committee Chair’s Report
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Mr Lancaster presented the report and advised that the Committee had sought to ensure that the risks associated with integration under the TCT partnership would be considered for inclusion and monitoring within the operational risk register. It was anticipated by the Committee that any plans being presented for consideration for the next financial year may need to be amended/revised at a later date to support the TCT initiative. Mr Turner advised that the Integration Board had a Risk Register and Mr Axcell confirmed that this would be received by the Board as a standing agenda item going forward. Mr Turner suggested that the Board’s rik appetite needed to be considered in developing the risks on the risk register, Mr Lewis-Grundy confirmed that the Board at a Board Development Session on 30 March had reviewed the strategic risks in the BAF and agreed the additional of a further strategic risk of the TCT partnership in 2017/18 which Mr Lewis-Grundy confirmed would be prepared and monitored in the context of the TCT partnership risks on the operational risk register. Mr Lancaster advised that the Committee had received a report on the implications for the Trust of the implementation of the IR35 rule. The Trust was identifying all those engaged by the Trust that were effected and were seeking assurance from the Agencies that the Trust worked with that they had identified those that were subject to the IR35 regulations. Dr Weaver stated that the Trust had not engaged many locums on a personal company basis and assurance was given that the regulations wouldn’t have a significant impact on the Trust. Mr Lancaster advised that the external auditors were of the opinion that TCT would not impact on this year’s final accounts and confirmed that the external auditors had undertaken a Value for Money Audit as required by the National Audit Office to be included in final accounts. RESOLVED:
That the Board received the report for information and assurance.
7.6 Audit Committee Minutes from the meeting held on 20th March 2017
RESOLVED:
That the Board received the minutes for information and assurance.
In the absence of Mr Rana, Mr Banks presented his report and made reference to the key items discussed:
KPIs Under the contracts with its two main commissioners eight new KPI’s had been agreed for 2017/18 and the the Trust had discussed the phasing of delivery against these targets across the year with its commissioners. Service Development Income Opportunities The committee reviewed the report produced by Deloitte and particularly focused on the service development opportunities of which there were seven identified. It was noted that whilst some of the areas had indeed shown growth potential, the level of growth achieved overall would not support a strategy of ‘growing ourselves out of financial difficulty’. Members discussed the over activity of 6.5% above contract and the Chair sought assurance that the Trust could continue to provide the current levels of service with the funding available. In response Mr Banks agreed to share the outturn activity and funding detail with Board members following the meeting. ACTION: Share the outturn activity and funding detail with Board members following the meeting. Mr Axcell advised that it was unclear whether the CCG would issue financial penalties against non-performance of KPIs whilst the Trust was achieving its stretch target and STP this would be discussed with NHSI. Mr Lancaster commented on the volume of data that the Committee received through the performance report rather than the aggregation and analysis of the data to inform committee of the key issues and support debate at the meeting Mr Axcell advised that CIPs of £5.7m for 2017/18 would be phased over the year and CIPs for the first quarter were RAG rated green although there was a risk of under-delivery of between £500,000-£750,000 over the financial year and an update would be provided to the Board at the meeting in May. Mrs Cooper stated that there was a need to identify alternative CIPs for those schemes at risk of delivering the required savings.
Mr Banks
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ACTION: Provide an update on CIPs at risk to the Board in May. RESOLVED: That the Board received the report for assurance and information and noted the content.
Mr Davies
7.8 Finance & Performance Committee Minutes from the meeting held on 20th February 2017.
RESOLVED:
That the Board received the minutes for information and assurance.
7.9 Finance Report
Mr Banks advised that the Trust had delivered a Month 11 surplus of £1,566k which represented a favourable variance against plan of £8k year to date (YTD) (based on a planned surplus for the year of £1.7m).
Pay expenditure was £1,020k in surplus against budget YTD, which was being driven by surpluses within Community and Corporate Operations. Bank and Agency spend equated to £583k in month (split £456k for Agency and £127k for Bank), which had increased since Month 10 spend of £539k. Agency spend was behind plan by £610k in relation to the overall £4.05m Agency target for the year (actual spend of £4,379k against £3,769k plan to date). There was a high risk that the Agency Cap Target would be exceeded by year end in the region of circa £750k. The latter had increased in month although this was due to one off projects and linked to the water management issues in the Trust and without these projects the Trust would be operating within the cap. Dr Murphy advised that the work undertaken in relation to the Fire Safety Action Plan may also have cost implications. Dr Gingell advised that two substantive clinical posts had been filled and this would impact positively on the agency spend. Mr Lancaster advised that agency usage enabled the Trust to achieve financial targets. The Chair requested an update on agency spend at the May meeting, highlighting required actions to achieve the agency cap in year.
ACTION. Provide an update on agency spend at the May meeting, highlighting required actions to achieve the agency cap in year.
Mr Axcell advised that a separate target for medical locums had been announced 6 weeks ago and Mr Banks confirmed that he had disseminated best practice information to
Mr Davies Mr Davies
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relevant individuals.
Dr Murphy queried whether other organisations had operated within the agency spend cap, in response Mr Banks advised that the Workforce Committee had reviewed a report of the performance of 70 Trusts across the region and this had prompted a benchmarking review alongside our TCT partner Black Country Partnership FT. The Chair requested that the information be shared with members to facilitate informed discussions on the agency cap at the meeting in May. ACTION: Share information on BCP benchmarking exercise with members. In response to a query from the Chair related to the run rate for pay and agency, Mr Banks confirmed that he would need to undertake further investigation.
ACTION: Provide a high level summary of the run rate for pay and agency to Board members following the meeting.
Non-Pay expenditure was £338k in deficit against budget YTD (which included the impact of Reserves, Depreciation and PDC). Reserves were over committed by £635k reflecting the impact of un-devolved CIP yet to be allocated to service lines, non pay items such as water testing and IT expenditure as well as provisions made against NHS Property Company charges and CQUIN under-delivery clawback.
The Trust wide activity position at Month 11 reflected an under-performance of £632k. The net position was an over-performance of £12k, however, after taking account of the impact of the CIP target that has been applied to activity, being £644k , overall performance was £632k behind plan.
The Trust’s Cost Improvement Target for the year was £2,500k and schemes had been developed for the year equating to £2,587k. To date delivery of schemes equated to £2,471k (both on a recurrent and a non-recurrent basis). At Month 11 there was £986k worth of schemes that posed a recurrent pressure in terms of delivery going forward. Of these schemes the two Income CIPs of £703k (relating to Acute Wrekin beds and OA Dementia beds) were being covered on a non-recurrent basis through activity over-performance, which included an element relating to NCA’s.
The Capital Programme had been agreed at £2,748k for the year. The Trust had received agreement from NHSI to carry forward funding for several of the schemes into 2017/18 as part of a revised plan – thus in year the plan had been
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revised down to £1,639k.
RESOLVED: That the Board received the report for assurance and noted the content.
7.10 CIP PMO Report
Mr Banks advised that the majority of CIP targets were devolved to team budgets with any slippage managed at team level. There were 28 projects for the current year. 2 had been closed and 18 had delivered. A further 3 schemes have been reviewed for closure as they had not delivered as anticipated, and these were:
Referring to Mandatory Training Ms Clymer highlighted that as of 21st March 2017 Mandatory Training compliance had increased to 89.2%. Compliance against the national target for annual IG training had increased to 96.1% against the national target of 95%. The Essential Training at Month 11 demonstrated a
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compliance rate of 66.1% which was significantly below the target rate of 90%. The Committee noted the actions being taken to increase the take up of e-learning and the potential to use the Trust’s Capability Policy for staff who consistently fail to undertake Statutory and Mandatory and Essential training. Ms Clymer added that the Staff Health & Wellbeing plan had been developed and that the Cultural Ambassadors Programme was being reviewed to identify whether staff at Band 7 and below could be included. RESOLVED: That the Board received the report for assurance and information and noted the content.
7.12 Workforce Committee Minutes from the meeting held on 24 January 2017.
RESOLVED:
That the Board received the minutes for information and assurance.
7.13 Workforce Performance Report
Ms Williams presented the report and referring to the key messages she advised that there were currently 158 Full Time Equivalent (FTE) contracted vacancies across the Trust decreasing the vacancy rate to 13.8% during Month 11. The TRAC recruitment system was being utilised giving increased control and oversight of the recruitment process to recruiting managers. The 12 Month Turnover rate had decreased to 10.33%.
She referred to the rolling 12 month sickness rate which had decreased in Month 11 to 4.39% for the fourth consecutive month and the in-month sickness had decreased to 4.59% in Month 11.
Ms Williams asked the Board to note that appraisal compliance had increased from 79.4% to 86.0%, which was above the Trust’s target of 85%, the first time this had been achieved in the last 12 months, although there were remained 121 employees in the Trust that had not had an appraisal recorded in the last 12 months. Weekly reports were being produced in order to support managers and highlighting areas of low compliance.
She reported that Mandatory Training compliance remained static at 88.9% for Month 11 and this was just below the target of 90% agreed at MEXT for all mandatory training.
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Compliance against the national target for annual IG training for Month 11 was 96.0% which was above the 95% target and new reports were being distributed to Service leads to assist with what training individuals need to undertake over the remainder of 2016/17 in order to remain compliant. Mrs Cooper advised that the Associate Lay Managers employed under the Mental Health Act would also undertake mandatory training.
RESOLVED: That the Board noted the updates on key current workforce agenda items
8. Medical Directors’ Report In presenting the Medical Directors report, Dr Weaver
referred to the sixth report of the 2016/17 session of the House of Commons Health Committee on Suicide Prevention advising that 95% of people who took their own live had had a GP appointment in the month prior to death. For secondary mental health services, whilst the Committee recommended that all patients discharged from inpatient care should receive follow up within three days the Trust would be adhering to the previous recommendation for a follow up within seven days due to workforce issues. The suicide rate of the Trust’s patient’s was low compared with national statistics and he felt this was due to good continuity of care and the very low numbers of patient’s referred out of the area, recommending that current practices continued as the TCT partnership progressed. Mr Axcell queried how the positive outcomes for patients due to good continuity of care could be evidenced and Dr Weaver advised that the low suicide rates were due to patients remaining in secondary care for longer periods. Dr Gingell advised that the Trust was one of six Trusts across the country reviewing the continuity model in comparison to the functional model and the evidence collated would identify the preferred model at the end of the project. Dr Weaver stated that high calibre locum staff were being encouraged to join other organisations for better terms and conditions and this was having an impact on existing staff who were providing temporary cover or undertaking work via the Trust Bank. He provided assurance that he would alert Board to any service at risk due to staff shortages.
In response to a query from Mr Lancaster, Dr Weaver advised that there was a shortage of 6 medical locums, and some areas within the Trust were particularly difficult to recruit to.
Mr Turner referred to the two unexpected deaths and
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queried whether a benchmarking exercise had been undertaken. Dr Weaver advised that 2 deaths in month were slightly above the norm and the Trust average 1.5 deaths and the Trust was not an outlier in this regard.
RESOLVED: That the Board received the report for assurance and information and noted the content.
9. Serious Incident Investigations and Mortality Process Review
Serious Incident Investigations Ms Musson gave a presentation on the Serious Incident Investigation process, highlighting the review that had been undertaken and assuring Board that the process was robust with the inclusion of best practice although there were opportunities to improve. The Chair queried whether lessons learnt from the Root Cause Analysis (RCA) and any further investigations would be embedded by clinicians or nursing staff and Ms Musson stated that this was dependent on the recommendations within the report, although a change of policy would be taken forward by heads of service. Dr Weaver advised that Commissioners were against recording a person’s mental health as the cause of death which had a negative impact on the root cause analysis process. Mr Axcell agreed to raise this issue at a future meeting with Dudley & Walsall CCG management teams. Mortality Review presentation Dr Gingell advised that since preparing the presentation a “Learning from death in the NHS” event had been held on 21st March in Westminster and a number of outcomes from that event would be brought to the Board. The event had highlighted the airline aircraft industry’s “near miss” learning process which promoted a no blame and the Trust would culture develop a policy spelling out how carers and families of patients can become involved in the mortality review process. Both NHS Improvement and NHS England had advised that any statistical information related to mortality reviews would not be used for comparison purposes and would be utilised to facilitate the learning process. Dr Murphy confirmed that the Quality & Safety Committee would be reviewing and contributing to the policy and he anticipated that it would have followed due process with
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implementation in September 2017. Whilst Mr Turner concurred with the “no blame” culture he stated that individuals should be held to account should an investigation highlight any specific issues. Dr Gingell advised that in the majority of cases the investigation highlighted a combination of failures with a focus on support and retraining for some individuals. Ms Clymer advised that other organisations held “dare to share” events where outcomes of investigations into SUIs were shared with staff and that such events demonstrated openness and transparency within the organisation. The Chair commended the presentations, advising that he would be taking on the role of designated Non-Executive Director Lead for mortality within the Trust.
RESOLVED: That the Board:
• Agreed that the Trust had a robust process in line with National Requirements and Duty of Candour was fully embedded across Trust and acknowledged that there were opportunities for improvements.
• Agreed to appoint Mr Reid as the designated NED lead for Mortality
• Agreed to develop a framework / dashboard for the publication of mortality data on a quarterly basis and produce and publish a policy for undertaking case record reviews in relation to mortality, following further guidance issued via NHS Improvement
10. Director of Nursing Report
Mrs Musson referred to the following:
• Safe, sustainable and productive staffing • Bank and Band 5 Recruitment • Nursing and Midwifery Regulatory Advisors • Nurse Revalidation • Follow up actions from the Patient Story
Referring to Band 5 Nurse recruitment, the Chair queried how many trained mental health nurses would qualify from Wolverhampton University. Ms Musson advised that there were usually around 18-20 individuals who would qualify with approximately 4 or 5 of those accepting posts within the Trust as well as students from the MSE programme.
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The Chair commended the actions to realise improvements to the recruitment process, including rolling advertisements and the inclusion of managers in the process. Ms Musson confirmed in response to Ms Clymer’s query that there was a delay in payment being taken for NMC registration for revalidation from individual’s bank accounts fo and this impacted on their ability to work in a clinical role, although those affected were working at a lower band until payment was authorised and in some cases this could take up to eight weeks. Ms Williams confirmed to the Chair that the Trust Bank pay was comparable to that of MERIT partners, although some Trusts paid bank staff on a weekly basis rather than monthly. Ms Williams advised that around 100 people from within the Trust had recently expressed an interest in undertaking HCA duties on the bank as well as eight RMNs. The Chair stated he was aware that Bank staff in some Trust’s who were also substantive members of staff were paid at their substantive pay rate when they did shifts through the bank which encouraged substantive staff to register on the bank. Mr Banks advised that the Trust had 30% bank usage and 70% agency, compared bank with the Black Country Partnership who had 50% bank and 50% agency usage and their processes were being reviewed to identify best practice that could be adopted by the Trust. Mr Axcell advised that Mr Sean Russell, Chief Inspector of the West Midlands police had attended a recent Board Development session and had offered to provide guidance and support for incidences of violence towards staff. There was also concern that changes to the Section 136 regulations could potentially mean that more dangerous individuals may be taken to a 136 Suite (Place of Safety) Dr Murphy stated that a policy should be compiled and reviewed by the Quality & Safety Committee as a priority. RESOLVED: That the Board received the report for assurance and information and noted the content.
In presenting the report, Mrs Musson advised that across the inpatient areas the overall fill rates were 99.89%, with 98.8% for registered staff and 100.54% for care staff which indicated that the Trust was meeting the optimum level of fill rates and where care staff rates exceeded 100%, this is due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix.
Page 16 of 19
Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity. Concerns about safe staffing levels were reported through the Trusts incident reporting processes. Two were reported and investigated in February. The investigations concluded that the appropriate risk mitigation took place to ensure patient care was not compromised. Ms Musson advised that from April the information would be collated electronically via the Trusts ERostering system providing greater transparency and enable increased triangulation of data to ensure resources are being used efficiently and effectively. RESOLVED:
The Board noted: • the monthly data return submitted, providing
details of planned and actual staffing at ward level. Data represents February 2017 and a 12 month trend analysis.
• the work underway to enable to most efficient safe and effective use of nurse staffing in inpatient service.
12. Director of Operations Report
Mrs Ingram presented her report and referred to the revised service line structure advising that the management information and financial systems were being re-aligned to support the new configuration of services with effect from April 2017.
She advised that negotiations with the two Local Authorities regarding the future of the ‘Section 75’ integration arrangements continued and were especially challenging given the financial pressures being faced by both Local Authorities. Walsall Local Authority had commissioned a piece of work to scope the impact and consequences of proposals to re-align mental health social care resources with locality teams in primary care and the Trust was participating fully in this review. She confirmed that the Trust was in receipt of a performance notice from the CCG related to IAPT and the service would be moving to Sandringham Ward which would improve access to psychological therapies. RESOLVED: That the Board received the report for assurance and information and noted the content.
13. STRATEGIC DEVELOPMENT & DIRECTION
Page 17 of 19
13.1 Annual Plan Priorities 2017/18
Mr Axcell presented the report and advised that each year a review of the existing priorities was undertaken with areas of focus agreed for the forthcoming year and this underpins the formal operational planning process governed by NHS Improvement. The Board was asked to approve the priorities for 2017/18 and the publication of the summary plan. RESOLVED: That the Board approved the priorities for 2017/18 and the publication of the summary plan.
13.2 High Level Operational Risk Register
Ms Ingram introduced the report advising that there were nine red rating risks highlighted to Board and confirmed that the risks had been considered by the appropriate committees and the Register had been updated to reflect issues raised in the final CQC report. Referring to the mitigations under EF002 Fire Safety management, Ms Ingram advised that the Trust had the recommended number of trained fire marshals on all inpatient sites and commended colleagues for this achievement. RESOLVED: That the Board approved the risks included within the report and noted the action taken to date in managing these.
14. LEADERSHIP & CULTURE
14.1 Annual Staff Survey 2016
Mrs Williams presented the report and reminded Board that the results had been reviewed in detail at a recent Board Development session highlighting that the results were very positive overall. The response rate for the survey was 52% against a mental health sector average of 49%. Compared to the rest of the sector virtually all scores were around or above average and none were lower than the sector average by a statistically significant margin. The Trust’s Overall Staff Engagement score was 3.82 out of 5 against the sector average of 3.80.
The results had been communicated to staff in Team Brief and Wednesday Wire and there had been articles in the local
Page 18 of 19
press and positive feedback from stakeholders.
RESOLVED: That the Board received the Annual Staff Survey 2016 outcomes and approved the proposed actions and next steps outlined in the report.
15. FOR ASSURANCE
15.1 MExT Chair’s report from 28th March 2017
Mr Axcell referred to the items discussed at MExT, advising that the Chair’s Report had included an updated Service Line Governance Report. The Committee received a number of business cases for consideration and verbal updates on key operational issues, Quality Improvement priorities and CQUINs, and a briefing from the Acting Director of Nursing. Additionally reports were received Freedom of Information compliance, the Bi-Annual Food Hydration and catering report and an IAPT update.
RESOLVED: That the Board noted the content of the report for information and assurance.
16. ANY OTHER BUSINESS
16.1 Ms Ingram
Mr Axcell advised Board that this would be the last meeting of Board that Ms Ingram would attend prior to her secondment to BCHC as Integration Director.
Ms Ingram had made a significant contribution to the Trust and he offered a vote of thanks for the support she had given in her role as Deputy Chief Executive, wishing her well for the future.
17. DATE AND TIME OF NEXT MEETING
The next Trust Board meeting would take place at 1.00pm on Thursday, 4th May 2017, The Board Room, Canalside, Bloxwich
Meeting closed at 3.30pm Signature……………………………………………………….. Date……………. Mr B Reid, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board
Page 19 of 19
Enc 2 MATTERS ARISING FROM PUBLIC MEETINGS
RAG Actoin Outstanding Completion date in the future Action Completed
Item No. Date Added Action Responsibility Due Date Update
179.10 5 January 2017 & 2 March 2017
Contract Performance Report Assure the Board that actions taken have improved the Trust compliance of performance against KPI 16.
Dr Weaver
May 2017
Dr Gingell advised that it was a system issue and it was unlikely that the position could be improved without a system change. Dr Weaver and Dr Gingell to undertake a review of the process and report back to the Board in May.
7.7 6 April 2017
Finance & Performance Committee Chair’s Report Share via Email the outturn activity and funding information Provide an update on CIPs at risk to the Board in May.
Mr Banks Mr Davies
May 2017
The 6.8% activity growth is an average. The Trust secured an additional £700k for activity growth (full cost) relating to the Walsall CCG contract. There was also some contract increase in respect of minor commissioners. However, the Dudley CCG contract activity flat-lined in 16/17 and therefore there was no net growth in the value of the Dudley CCG contract.
Mr Davies will update the Board verbally on CIP risks, following his presentation to F&P 21st April.
7.9 6 April 2017
Finance Report Provide an update on agency spend at the May meeting, highlighting required actions to achieve the agency cap in
Mr Davies
May 2017
Mr Davies will provide a verbal update on the
1
Item No. Date Added Action Responsibility Due Date Update
year.
proposals to manage the 17/18 agency cap.
7.7 6 April 2017 Finance Report Provide a high level report on the running rate for pay and agency.
Mr Banks
May 2017
Information shared via Email on 12.4.17. Completed. Closed.
63.1 184.1 & 4.9TB
1 July 2015 2 March 2016 6 April 2016
Quality Implications should be included more prominently on Board and Committee reports and that quality impact assessments should have greater visibility within the report.
Mr Lewis-Grundy
June 2017
The new template has been shared with the Exec team and positive feedback has been received. The new style report will be utilised from June onwards. Completed. Closed.
7.9 6 April 2017 Finance Report Share information on BCP benchmarking exercise with members.
Mr Banks May
2017
Information shared via Email on 27.4.2017. Completed. Closed.
2
Board meeting date: 4 May 2017
Agenda Item number: 5 Enclosure: 3
Report Title:
Summary Report of Confidential Session of Trust Board held on 6 April 2017
Accountable Director:
Ben Reid, Chair
Author (name & title):
Paul Lewis-Grundy, Company Secretary
Purpose of the report: Best practice in corporate governance requires that business considered in private session is reported into the public session as soon as possible. Given the arrangement of the Board meetings, the earliest opportunity is at the public session of the following month. This report outlines the business considered in private at the meeting of the Board held on 6th April 2017
Action required from the Board Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: None
Date reviewed: N/A
Key points or recommendations from Committee:
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
Best practice in corporate governance requires that business considered in private session is reported into the public session. Responsive
Effective Well-led Safe Enc 3 confidential session 6 April 2017 (Final)Page 1 of 2
Title Summary Report of Confidential Session of Trust Board
held on 6 April 2017 Introduction This report outlines the business considered at the meeting of the Board held in private on 6th April 2017. Summary of key points, issues and risks The Board received the following reports:
The review had been conducted in the context of NHS Improvement’s Single Oversight Framework, dashboard’s of neighbouring Trusts and of an outstanding mental health Trust and the agreed amendments would be incorporated in future reports to Board.
• Ratified minutes of the MExT meeting held on 28th February 2017
Recommendation
The Board is invited to note the business transacted in the private session held on 6th April 2017.
Board action required The Board is asked to receive this report for information.
Enc 3 confidential session 6 April 2017 (Final)Page 2 of 2
Board meeting date: 4 May 2017
Agenda Item number: 6 Enclosure: 4
Report Title: Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)
Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary Purpose of the report: This report summarises recent reports, publications and
information, which are of relevance or interest to the Trust. It sets out the key points of each item and identifies the officer accountable for any action required and appraising the Board where appropriate.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: None
Date reviewed: N/A Key points or recommendations from Committee:
N/A
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Accountable workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring The report provides information regarding latest news and relevant strategic developments that may impact all 5 CREWS domains. Responsive
Effective
Well-led
Safe
Enc 4 CEO StrategicBrief-May2017-(Final) Page 1 of 5
Report Title: Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)
Introduction This report provides a summary of internal news from the Chief Executive and recently announced legislation, publications and information that is of interest and relevance to the Board. It identifies the Trust officer accountable for any action the Trust may be required to take and for appraising the Board where appropriate.
Summary of key points, issues and risks CHIEF EXECUTIVE UPDATE Pre-Election Period Guidance has been published regarding the pre-election period before the general election on 8 June, which has been circulated to all Board members. The general election pre-election period, known at purdah began at midnight on 22 April 2017 and ends on 9 June 2017, if a government can be formed after the election results have been announced. During this period the Trust should not be engaging in activity that could be considered politically controversial or influential, which could compete for public attention or which could be identified with a political party, candidate or campaign group. The Agenda’s for Board meetings during this period should be confined to those matters that need a Board decision or require Board oversight. Matters of future strategy or the future deployment of resources may be construed as favouring one party over another and should be avoided. Action: To Note Transforming Care Together – Clinical and Non Clinical meetings continue to take place across all the TCT partners to develop the potential for our partnership. In addition both myself and the Chief Executive of Black Country Partnership NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust continue to hold listening events across the 3 organisations which have been well attended. Action: To Note Vanguard Development – The Trust continues to actively participate on both the MERIT and Dudley CCG vanguard development. An update on the progress of the MERIT Vanguard is included in the agenda today. Action: To Note Enc 4 CEO StrategicBrief-May2017-(Final) Page 2 of 5
NATIONAL POLICIES & STRATEGIES The following national strategies and policies have recently been issued. They are potentially relevant to the future strategic, planning and operational management of the Trust and the implications should be taken into account. Each document has been considered with the respective executive directors. This summary is not intended to incorporate all national publications, for instance those issued by National Patient Safety Agency, National Institute for Clinical Excellence or every operational directive issued by Department of Health which should be considered within the Trust by the appropriate department and necessary action taken. 1. Mental Health of Adults in contact with the criminal justice system
Published by: NICE Date Published: March 2017
This guideline covers assessing, diagnosing and managing mental health problems in adults (aged 18 and over) who are in contact with the criminal justice system. It recommends that people who are diagnosed with a mental health problem within the criminal justice system should receive annual checks and staff should be trained to spot the warning signs. It aims to improve mental health and wellbeing in this population by establishing principles for assessment and management, and promoting more coordinated care planning and service organisation across the criminal justice system. This guideline includes recommendations on: • assessing and managing a person’s mental health problems, including assessing risk to themselves
and others • planning their care • psychological and pharmacological interventions • how services should be organised • staff training Action: To note the guideline and review the recommendations. Web-link https://www.nice.org.uk/guidance/ng66 Executive Director: Medical Director Board Committee: Mental Health Act Scrutiny Committee 2. NHS Workforce Race Equality Standard (WRES): technical guidance refresh
Published by: NHS England Date Published: March 2017
NHS England has published updated WRES technical guidance 2017. The refresh includes changes made in the NHS Standard Contract (2017/18 to 2018/19) and definitions of terminology used in the WRES indicator descriptions. The WRES technical guidance is a resource to support healthcare organisations implement the WRES, and in doing so, to make measurable and continuous improvements in workforce race equality. A second annual report into race equality across the NHS was also published by NHS England on 19 April 2017.
The Workforce Race Equality Standard (WRES) report publishes data from providers of NHS-funded care, including the voluntary and private sector, to demonstrate how they are addressing equality issues.
Enc 4 CEO StrategicBrief-May2017-(Final) Page 3 of 5
This year’s report includes nine WRES indicators including four relating to the workplace covering recruitment, promotion, career progression and staff development alongside BME board representation. The remaining four indicators are based on data from the NHS staff survey 2016, covering harassment, bullying or abuse from patients, relatives or the public.
It shows a positive change in a range of areas including the number of nurses and midwives who have progressed from lower grades into senior positions (band 5 entry level into bands 6 – 9); in BME representation at very senior management (VSM) and executive board level; and a slight reduction in the reported experience of discrimination of BME staff from colleagues and managers. Action: The Trust has reviewed its WRES Action Plan and this is being considered through the Equality and Diversity Steering Group and Workforce Committee. Web-link https://www.england.nhs.uk/about/equality/equality-hub/equality-standard/resources/ Executive Director: Acting Director of People Board Committee: Workforce Committee 3. Adapting for the future: a plan for improving the flexibility of UK postgraduate medical
training Published by: GMC Date Published: 3 April 2017
The General Medical Council (GMC) has today unveiled a new plan that aims to improve education paths for doctors by moving away from rigid training and allowing trainees more flexibility while they learn. There were five key barriers to improving training flexibility identified in the report, including doctors having to start training from scratch if they decided to transfer between specialties, whilst training in alternative ways such as overseas and through experience in non-training grade posts not being recognised. The recommendations outlined in this report cover the organisation of specialities curriculums, focusing on outcomes rather than time spent in training and reducing the burden of the GMC's approval system and UK legislation to enable a more agile training system. It was also recommended that extra career support was put in place for juniors doctors Action: To note the content of the report in conjunction with the post graduate department and the Black Country Training Scheme Web-link http://www.gmc-uk.org/Adapting_for_the_future___a_plan_for_improving_the_flexibility_of_UK_postgraduate_medical_training_FINAL.pdf_69842348.pdf Executive Director: Medical Director Board Committee: Workforce Committee 4. Updated revalidation standards and guidance
Published by: NMC Date Published: 4 April 2017
The Nursing and Midwifery Council (NMC) has updated its revalidation standards and guidance in line with a planned review and stakeholder feedback. All documents except the Code have been revised. The standards and guidance includes, new examples of circumstances which would not count towards practice hours, changes in how to revalidate and the
Enc 4 CEO StrategicBrief-May2017-(Final) Page 4 of 5
guidance sheet, Changes to the continuing professional development (CPD) examples, Amendments to the alternative support arrangements guidance sheet, clarification what will happen applicants declare they are not able to meet the revalidation requirements due to health reasons Action: To note. The Revalidation Standards and Guidance are discussed in more detail in the Director of Nursing’s report. Web-link http://revalidation.nmc.org.uk/download-resources/guidance-and-information Executive Director: Acting Director of Nursing Board Committee: Quality and Safety Committee 5. The long-term sustainability of the NHS and adult social care
Published by: House of Lords Date Published: 5 April 2017
This report argues that a new political consensus on the future of the health and care system is needed and that this should emerge as a result of government-initiated cross-party talks. It also recommends that budgetary responsibility should be held at a national level by the Department of Health and that the recommendations of the Dilnot Commission should be implemented. Action: To note. Web-link https://www.publications.parliament.uk/pa/ld201617/ldselect/ldnhssus/151/151.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=8167388_NEWSL_HMP%202017-04-07&dm_i=21A8,4V1ZW,M5T16P,IEB0M,1 Executive Director: Chief Executive Board Committee: Board Recommendation It is recommended that the Board: • Considers and discuss the information contained within this report, and note for assurance the
actions identified throughout the report. Board action required The Board is asked to:
• Note the information and actions contained within the report. • Identify any further specific action required and agreed timeframe for completion.
Enc 4 CEO StrategicBrief-May2017-(Final) Page 5 of 5
Title Trust Integrated Performance Dashboard Month 12 including the Performance Dashboard and Contract Performance Report Dashboard
Introduction
• This paper presents the Trust’s performance at the end of month twelve 2016/17
financial year. • The 2016/17 Integrated Dashboard allows comparison and triangulation across Quality
and Safety, Service User Experience, Efficiency, and Resources to give a comprehensive picture of the performance of the Trust.
• The 2016/17 Integrated Dashboard also includes performance, and exception commentary, by service line, so that the Board is better able to see achievements as well as any adverse performance within the overall aggregate level.
Summary of key points, issues and risks
Quality and Safety Domain • In March, the Trust reported 392 incidents of which 253 were Patient Safety Incidents.
This represents an increase of 14% (337) compared to February 2017. Of the 3 cases considered under the Duty of Candour only 1 met the criteria.
• The Trust reported one Serious Incident during March under the Acute service line. A position statement in relation to all of the open Serious Incidents is also included in the quality report.
• CPA Performance at Month 12: The Trust has remained above target for Copies of Care Plan at 96.50%; CPA Formal Reviews performance is at 96.90%.
• There were 2 Safety Alert Broadcasts received by the organisation via the Central Alerts System. Both alerts required no action taking.
• The benchmarking data in the quality report is taken from the submission of patient safety related incidents made to the NRLS during the period of 1st April 2016 to 30th September 2016. The same report for Black Country Partnership NHS Foundation Trust is included as a direct comparison and the report for Birmingham Community Healthcare NHS Foundation Trust is included for information.
Efficiency Domain • Activity against contract (NHS Activity) – NHS contracted activity remains above the
target as at month twelve. In March, the Trust is reporting 349,599 units of activity against a target of 327,040. Activity against contract is above target for all service lines.
• The Trust’s Cost Improvement Target for the year is £2,500k and schemes have been developed for the year equating to £2,663k. A recent review of schemes has reduced the total down to £2,577k, which is still more than the required target for the year.
• At month twelve £1,767.8k worth of CIP schemes have been transacted and delivered however there are several schemes (OA Day Hospital and OA Establishment Review for example), totalling £94.2k that have not been devolved down to service lines.
• Income budgets also reflect £703k of CIP targets in relation Acute Wrekin beds and OA Dementia beds and this is non-recurrently being supported year to date by over-performance on both the Walsall contract and within NCA’s.
• Based on the ‘Agency Cap’ ceiling of £4.05m for the financial year and the anticipated spend of Bank staff this equates to an overall target of 11.5% of the Trust’s annual pay costs. Current position to date is reflecting an adverse position to plan of 14.17%.
• Vacancies – There are currently 157 FTE contracted vacancies across the Trust decreasing the vacancy rate slightly from 13.8% in Month 11 to 13.7% during Month 12.
• The TRAC recruitment system is currently being used within the Trust giving increased control and oversight to recruiting managers and allows the Trust to performance manage against recruitment KPIs.
• Turnover – The 12 Month Turnover rate has increased from 10.33% to 10.53%. When comparing the Turnover (exc Jr Medics) rate of the Trust against other Mental Health organisations in the NHS, it was found that the Trust can be considered average in terms of % Turnover.
• Sickness Absence – The rolling 12 month sickness rate has decreased in Month 12 to 4.31% from 4.39% in Month 11, this is within the Trusts target and the fifth consecutive month of being so.
• In month sickness has decreased from 4.59% in Month 11 to 3.33% in Month 12. A probable reason for this change is the increase of annual leave absence during March.
• Appraisal – Compliance has increased from 86.0% to 86.97%, this is above Trust target of 85% being the second time this has been achieved in the last 12 months, it also indicates the continuation of the positive trend of recent months. There are 114 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 223 reported in Month 6. Weekly/Bi Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements.
• Mandatory Training - Mandatory Training compliance increased to 89.82% in Month 12 from 88.95% in Month 11 and remains just below the target of 90% agreed at MEXT for all mandatory training. IG compliance remains at 96%.
• The overall Continuity of Service risk rating for the month remains green. • The overall Financial Sustainability risk rating for the month remains green. • Our overall Governance risk rating for the month is green with a score of 0.
Further detail Please see enclosed Integrated Performance Dashboard and underpinning reports for finance, contractual performance, quality and workforce. Recommendation
It is recommended that the Board note the performance of the Trust as at month twelve and debate accordingly. Board action required Debate the content of the reports accordingly. Enc 5 Cover Sheet 16_17 Integrated Dashboard Month 12 Page 4 of 4
Service Line Summary • This service line has overspent by £147k to month twelve. Ward
staffing is £251k overspent at year end, but is offset to a large extent by various non-ward vacancy savings (psychology and management posts), and non pay savings.
• Acute Services sickness – there has been an decrease in sickness levels in month twelve to 2.47% (3.92% in month eleven). 12 month sickness has decreased to 3.90% in month twelve from 4.06% in month eleven.
• Appraisal performance has increased from 82.74% in month eleven to 83.53% in month twelve and the service remains below the 85% target. New reports are in development which will be sent to managers to facilitate planning of appraisals during 2016/17.
• Performance for Mandatory Training has increased from 88.49% in month eleven to 89.50% in month twelve and is slightly below the 90% Target.
3
Indicator Period Target Actual RAG Trend Indicator Period Target Actual RAG Trend
CQC Compliance YTD 0 0 G Activity Against Contract (NHS Activity) YTD 74,608 82,795 G
7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 96.50% G
CPA - Review in 12 months YTD 95% 96.80% G
CPA – Copies of Care Plans YTD 95% 97.30% G Indicator Period Target Actual RAG Trend
Never Events YTD 0 0 G Income Against Plan (£000) YTD £9,910 £9,615 A
Incidents Monthly N/A 10 N/A Performance against Budget (£000) YTD B/Even £133k G
Serious IncidentsMonthly N/A 0 N/A
Cumulative Agency Spend as a % of Total Employee Benefits
YTD 11.50% N/A
Falls Resulting in Severe Injury/Death Monthly 0 0 G Turnover - Rolling 12 Month Apr 16 - Mar 17 8-14% 6.29% A
Grade 3 or 4 Pressure Ulcers (whilst in our care) Monthly 0 0 G Sickness - in Month Monthly 4.68% 2.59% G
MRSA Bacteraemia Monthly 0 0 G Sickness - Rolling 12 Month Apr 16 - Mar 17 4.68% 4.78% A
Appraisals Monthly 85% 90.60% G
Mandatory Training (Aggregated) Monthly 90% 86.61% A
Indicator Period Target Actual RAG Trend
Friends and Family Test - % of Promoters (CQUIN) Monthly N/A 74.75% N/A
New Complaints Monthly N/A 4 N/A
New Concerns Monthly N/A 7 N/A
% Complaints/Concerns regarding Care/Treatment Monthly <80% 54.50% G
Complaints Upheld/Partially Upheld YTD <75% 100.00% A
Compliments (Month) Monthly N/A 5 N/A
Response Breaches YTD <30% 54.17% N/A
Efficiency
Community & Recovery Performance Dashboard 2016/17 Month 12
Quality and Safety
Resources
Service User Experience
Service Line Summary • Community & Recovery Services position at month twelve is
£133k underspent (an improvement of £11k in the month). This is driven by agency backfill in Walsall CRS, the formation of the Community Rehab team and draw down of monies aligned with Employment Support. This is offset by continued vacancy slippage across the CRS Teams and Criminal Justice MH Team.
• Sickness – this service has seen an decrease in month twelve to 2.59%, 4.69% reported in month eleven.
• Appraisals – this service has increased in performance to 90.60% in month twelve (87.07% reported in February). New reports are in development which will be sent to managers to facilitate planning of appraisals during 2016/17.
• Mandatory training performance remains consistent at 86.61% in March.
4
Service Line Summary • IAPT Project team is in place to review and take action on the needs of delivering an IAPT service, where the Trust needed to increase the target
for IAPT KPI’s during the year in order to meet the end of year target that now only applies to IAPT and can only be met by IAPT recognised staff and IAPT therapies for depression and anxiety only. The thresholds are extremely difficult for an element of the service to meet compared with the previous position where the service met their KPI’s and also measured against the prevalence for depression and anxiety in the local communities. There is a robust communication campaign on going to encourage more people to access the service.
• The Early Intervention service line is underspent by £392k at month twelve (an improvement of £122k in the month). The driver in month for the improvement is from the formation of the Dudley Health and Wellbeing Team which will have significant slippage within 16/17. Additional monies have come from our main CCGs for Waiting List Initiatives for CAMHS which is showing increased levels of agency to support this process. This may spill into 2017/18.
• Early Intervention sickness has seen a decrease to 2.40% in month twelve (2.78% in month eleven). There has been a decrease in the 12 month sickness and this service is still performing in line with the 4.68% threshold reporting at 3.92%. Performance for appraisals has increased at 88.69% in month twelve (87.88% reported in month eleven). Performance for Mandatory training has increased to 91.14% in month twelve (90.40% in February).
Indicator Period Target Actual RAG Trend Indicator Period Target Actual RAG Trend
CQC Compliance YTD 0 0 G Activity Against Contract (NHS Activity) YTD 103,369 109,422 G
7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 96.50% G IAPT - people receiving Psychological Therapies Monthly 787 711 A
CPA - Review in 12 months YTD 95% 97.70% G IAPT - people who have successfully completed treatment (Dudley) Monthly 50% 62.50% G
CPA – Copies of Care Plans YTD 95% 96.10% G IAPT - people who have successfully completed treatment (Walsall) Monthly 50% 59.26% G
Never Events YTD 0 0 G
Incidents Monthly N/A 57 N/A
Serious Incidents Monthly N/A 0 N/A Indicator Period Target Actual RAG Trend
Falls Resulting in Severe Injury/Death Monthly 0 0 G Income Against Plan (£000) YTD £16,383 £16,254 A
Grade 3 or 4 Pressure Ulcers (whilst in our care) Monthly 0 0 G Performance against Budget (£000) YTD B/Even £392k G
MRSA BacteraemiaMonthly 0 0 G
Cumulative Agency Spend as a % of Total Employee Benefits
YTD 11.50% N/A
Turnover - Rolling 12 Month Apr 16 - Mar 17 8-14% 6.94% A
Sickness - in Month Monthly 4.68% 2.40% G
Indicator Period Target Actual RAG Trend Sickness - Rolling 12 Month Apr 16 - Mar 17 4.68% 3.92% G
Friends and Family Test - % of Promoters (CQUIN) Monthly N/A 81.82% N/A Appraisals Monthly 85% 88.69% G
New Complaints Monthly N/A 3 N/A Mandatory Training (Aggregated) Monthly 90% 91.14% G
New Concerns Monthly N/A 15 N/A
% Complaints/Concerns regarding Care/Treatment Monthly <80% 44.40% G
Complaints Upheld/Partially Upheld YTD <75% 100.00% A
Compliments (Month) Monthly N/A 1 N/A
Response Breaches YTD <30% 61.11% N/A
Early Intervention Performance Dashboard 2016/17 Month 12
Quality and Safety Efficiency
Service User Experience
Resources
5
Service Line Summary • Copies of Care Plan remains below the 95% threshold and the month
twelve performance is 94.00%. Head of Service and Team Managers are reviewing the reported exceptions with the clinical teams.
• This service line has overspent by £147k to month twelve. Ward staffing is £321k overspent year-to-date, but is offset to some extent by various non-ward vacancy savings (psychology and community posts).
• Older Adults sickness has decreased from 6.79% in month eleven to 4.48% in month twelve. The 12 month sickness has decreased from 4.80% in month eleven to 4.68% in month twelve.
• Performance in appraisals has increased from 77.27% in month eleven to 82.47% in month twelve and the service remains below the 85% target.
• Mandatory training has seen an increase in performance to 86.24% in month twelve and remain below the 90% target (85.10% reported in month eleven).
Part 1 – Contractual Quality Requirements – Trust and CCGs (In month performance and monthly trends)
KPI No KPI Detail and Target Trust Dudley CCG Walsall CCGTrust Monthly
TrendDudley CCG
TrendWalsall CCG
Trend
1Percentage of Service Users on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from Referral. (Target: Above 92%)
100.00% 100.00% 100.00%
2Care Programme Approach (CPA): The percentage of Service Users under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care. (Target: Above 95%)
95.60% 94.90% 97.90%
3Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS (Target: Above 99%)
99.85% 100.00% 100.00%
4Completion of Mental Health Minimum Data Set ethnicity coding for all detained and informal Service Users. (Target: Above 90%)
91.15% 91.25% 91.87%
5Completion of IAPT Minimum Data Set outcome data for all appropriate Service Users. (Target: Above 90%)
99.20% 100.00%
6 Delayed Transfer of Care (All Reasons). (Target: Below 7.5%) 4.20% 4.90% 2.30%
7aIAPT - Proportion of people who complete treatment who are moving to recovery. (Target Dudley: Above 50%)
62.50%
7bIAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50%)
59.26%
8aIAPT - number of people who receive psychological therapies. (Target Dudley: 5108 pa; 426 per month)
369
8bIAPT - number of people who receive psychological therapies. (Target Walsall: 4328 pa; 361 per month)
342
9 Percentage of patients who are provided a copy of their care plan. Target: Above 95%) 96.50% 96.40% 96.50%
10 Number of home treatment episodes by crisis teams. (Target Walsall only: 608 pa; 51 per month) 54
11Percentage of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. (Target: Above 50%)
85.71% 100.00% 50.00%
3
Part 1 – Contractual Quality Requirements – Trust and CCGs (In month performance and monthly trends)
KPI No KPI Detail and Target Trust Dudley CCG Walsall CCGTrust Monthly
TrendDudley CCG
TrendWalsall CCG
Trend
12The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 75%)
93.01% 86.96% 100.00%
13The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 95%)
99.73% 99.71% 100.00%
14The proportion of users on CPA who have had a review within the last 12 months. (Target: Above 95%)
96.90% 97.20% 96.70%
15The proportion of users on CPA with a crisis plan in place. (Target: Walsall Only: Q1 - no target; Q2 - 75%; Q3 - 85%; Q4 - 95%)
96.70%
16The proportion of users with a valid ICD10 diagnosis code recorded. (Target: (Dudley: M1 - 75%; M2 - 80%; M3 - 85%; Q2 and Q3 - 90%; Q4 - 95%);(Walsall - TBC))
92.11% 76.56%
17 Proportion of in-scope patients assigned to a cluster. (Target: Above 95%) 96.87% 97.25% 97.30%
21 Zero tolerance RTT waits over 52 weeks for incomplete pathways 0 0 0
22 IAPT DNA Rate (Target Walsall Only: Below 13.1%) 6.84%
23Memory Assessment Service - Face to face initial assessment to be made within 20 days (Target Walsall Only: Above 95%)
66.67%
24Dudley and Walsall Recovery Outcome Measure - Number of CPA patients assessed using DWROM (Target Dudley Only: Q1 - 65%; Q2 - 75%; M7 - 78% ; Q3 - 85%; M10 - 88%, M11 - 91%, M12 - 95%)
92.45%
Board meeting date: 4 May 2017
Agenda Item number: 7.1.1a
Enclosure: 6
Report Title:
Quality and Safety Committee Chair’s Report
Committee:
Quality and Safety Committee
Author:
Simon Murphy – Non Executive Director Rosie Musson – Acting Director of Nursing
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
Introduction The Quality and Safety Committee met on the 12th April 2017. Summary of key points, issues and risks Risk Deep Dive Community Service The Committee undertook a deep dive into the Community Line Risk register. The Committee received assurance that the risks were being managed and mitigations in place. The Committee discussed the risk relating to the impact of the Section 75 agreement. It was agreed this would be subject to a spotlight session at the Committee in June 2017. Quality report The Quality and Safety Report was presented to the Committee for information and assurance. The Committee noted the NRLS Patient Safety Incidents Benchmarking data contained in the report. Quality and Safety High Level Risks The Committee was advised that there are currently 9 operational red risks.
• Risk Ref EF002 had been updated by the Fire Safety Group and had seen good progress against the actions outlined within the Fire Safety Group’s Action Plan
• Risk Ref 320 – Use of Personal Alarms and Lone Working risk to be updated actions to reflect current position.
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Interim Director of Nursing/Joint Medical Directors Update Dr Gingell and the Chair attended a NHSI Avoidable Deaths Conference on 21st March. The actions for Trust from the Conference were:
a) Mental Health Care in Acute Trusts – the Trust needs to build links to investigate
deaths that occur in Acute Trusts. b) Investigate and scrutinise the bereavement and support we give to families and
carers. c) Develop a Policy on our Mortality Review Processes by September. d) Develop how we communicate to frontline staff the outcomes of our Mortality Review
Group and other relevant information. e) Investigate whether the Strategic Judgement Review, which is Acute focussed, is
relevant for Mental Health or wait for the document for Mental Health which is likely to be published at the end of the year.
f) Obtain feedback on the Mortality Tool which the Trust has developed. The tool is used on patients who have died from physical causes but in a way that is premature in Dudley/Walsall.
g) Invite EBE, Public Health and CCG representations to the MortalitStrategic Review Group. It was noted that the Public Health Consultant in Dudley had accepted the invitation.
h) Consider how case reviews are undertaken. i) Investigate, using the national early warning tool – this should focus on deteriorating
patients on the wards Dr Gingell explained that the actions from the Conference will form Agenda Items for the next Mortality Review Group and an action plan will be developed. Mrs Musson provided the following update: • The next round of PLACE assessments will be undertaken in April. • Mrs Musson highlighted that she had asked for assurance on the frequency of the
number of qualified staff falling below the Trust’s locally agreed standard on two qualified staff being on duty per shift. It was reported that this was occurring on night shifts, when it was being planned to have one qualified on duty, supported by experienced HCAs rather than using temporary staff. Update to be provided in the Safer Staffing report to Workforce Committee and Trust Board.
Board Assurance Framework – Qtr 4 Update The Q4 BAF update was presented to the Committee. Strategic Risk 3 – Failure to achieve quality of care and Strategic Risk 5 – Management, Maintenance and Strategy for the Estates had been reviewed and revised through discussion with the Executive Team. Positive progress had been made in relation to Strategic Risk 3 and assurance levels had improved. The Committee was advised that this was reflected in the published CQC Inspection Report which gave the Trust an overall rating of Good. The Quality
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and Safety Committee is assured that Strategic Risks 3 and 5 are being managed appropriately. The Committee recommended that a short term TCT Partnership quality and safety risk register to be developed. A discussion took place relating to the strength of the On-Board Walkabouts as a control mechanism to mitigate against the risk in maintaining quality care particularly the need to strengthen the governance process around onBoard Visits The Committee were assured that there is a process in place for Freedom to Speak Up and Whistleblowing. The strength of this as a control mechanism reflected the infancy of the process. The Freedom to Speak-Up Guardian would be reporting to the Board on a quarterly basis and assurance around the process would be gained from this. Fire Safety Action Plan Update The Committee received assurance that good progress had been made against the Fire Safety Improvement plan and noted there is a significant reduction made on the Fire Safety Risk. The Committee recommends that the Estates and Capital Committee provide assurance around the implementation of the NHS Estates Toolkit to the Finance and Performance Committee and then to Board. It was agreed, subject to the audits not showing anything significant, the Committee should look to invite the relevant West Midlands Fire Safety Officer to Committee in July 2017. Survey Monkey Results – Effectiveness of Q&S Committee The Committee reviewed the results from the annual survey conducted to assess the effectiveness of the Committee. Key headlines
• Spotlight sessions are valued by members • Meetings are chaired effectively • There is clarity of purpose • Closing off agenda items could be improved • Use of benchmarking could be enhanced
The Committee agreed that the Board should be informed that the Quality & Safety Committee is effective and that the results should be shared with the Audit Committee. Policy and Procedures Group The Committee were informed that the Policy and Procedures Focus Group agreed to re-ratify the following policies which had minor amendments: • Control of Substance Hazardous to Health (CoSHH) Policy • Display Screen Equipment (DSE) Policy • The Electronic Data Disposal Policy • Corporate Records Policy Enc 6 QS Committee Chair's Report to BoardPage 3 of 4
• Procedure for the Transfer of Confidential Information as part of Office Moves • Overarching Information Governance Policy The Quality and Safety Committee agreed to ratify the following policy as recommended by Policy and Procedures Group. • Data Encryption Policy Recommendation The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Quality and Safety Committee . Board Action Required As recommended.
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Board meeting date: 4 May 2017
Agenda Item number: 7.1.1b
Enclosure: 7
QUALITY AND SAFETY COMMITTEE MINUTES OF MEETING HELD ON 8 MARCH 2017 BOARD ROOM, CANALSIDE HOUSE START TIME 9:00 AM Members Present Dr Simon Murphy Non-Executive Director (Chair) Mr Mark Axcell Chief Executive Dr Kate Gingell Joint Medical Director Mrs Rosie Musson Interim Director of Nursing Dr Mark Weaver Joint Medical Director In Attendance Mrs Julie Adams Service Experience Lead Dr Andrew Campbell Chief Pharmacist Mrs Anne Marie Carey Head of Service (item 10) Mr Rupert Davies Deputy Director of Finance (Item 16 & 19) Ms Margaret Barnsley Serious Incident Co-ordinator Mrs Debbie Cooper Vulnerable Adults and Children’s Lead Mr Tom Jinks Patient Safety and Compliance Manager Mr James Maimba Third Year Student Nurse Mrs Rebecca Temple-Purcell Senior Workforce Development Manager Mr Neil Tong Patient Safety Facilitator Mr David Stocks Expert by Experience (Item 17) Mr Graeme Welsh Patient Safety Analyst) Mrs Amanda Rose Directorate Admin Lead (Note Taker) Mrs Winsome Tyrell-Haye Senior Administrator Apologies Dr Ananta Dave Consultant Child Psychiatrist Mrs Olive Hewitt Clinical Quality Improvement Manager Ms Marsha Ingram Acting Director of Operations Mr Harry Turner Non-Executive Director Mrs Ashi Williams Associate Director of People Mr Liam Dolan Associate Director of Operations Ms Wendy Pugh Director of Nursing, Operations and Estates
306 WELCOME AND APOLOGIES
Mr James Maimba, Student Nurse attended the meeting as an observer and was welcomed by the Committee. Apologies for absence were noted as above.
307
ADDITIONAL ITEMS The Chair informed the Committee that there were two additional items to be
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discussed and these were taken as follows:
307.1 CQC Update
Mr Axcell explained that the draft CQC report had been received following the CQC visit to the Trust in February. A process to review factual accuracy was undertaken. A submission has been made to the CQC and the Trust is awaiting a response.
307.2 Timing of the Quality and Safety Committee
The Chair highlighted to the Committee the issue of reports being received after the agreed timescale. There was discussion regarding whether the date of the Committee should be moved to later in the month to resolve this and also the impact that this would have on the reports required for Board. The Committee agreed that Mrs Musson and Mr Jinks should look at the suggestion of moving the date of the Committee to the third Wednesday of the month with effect from May and inform the Chair if there are any issues. Action: Mrs Musson and Mr Jinks to look at the suggestion of moving the date of the Q&S Committee to the third Wednesday of the month with effect from May.
308 DECLARATION OF INTERESTS
Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. Dr Murphy informed the Committee that he had been appointed to the position of Non- Executive Director on the Board of Birmingham Community Health Care Foundation Trust and that he would discuss his Declaration of Interest with the Company Secretary. No further declaration of interests was declared at the time of the meeting.
309 MINUTES OF THE PREVIOUS MEETING
The Minutes of the meeting held on 8 February 2017 were agreed as an accurate record.
310
MATTERS ARISING ACTION SHEET
The Chair asked whether there were any actions from the Minutes which were not included in the Matters Arising schedule. No further actions were raised.
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Action updates were noted as follows:
311 Item 128 – Patient Story – Mrs Musson reported that she attended a meeting with Dr Weaver and the service user and agreed to address the actions raised.
312 Item 252 – Mrs Musson explained that the Therapeutic Day Project meeting had been rescheduled. Mrs Temple-Purcell informed the group that interested staff have been identified and Workforce Development colleagues have found training to enable our staff to be up-skilled to support gym sessions however alternative options for addressing this need are being considered. Our TCT partners have advertised for Gym Instructors at Hallam Street Hospital and Mrs Temple-Purcell intends to liaise with the relevant leads to see if there is an opportunity to learn from their existing practice around therapeutic use of gyms and to see if it is possible to share expertise.
313 The Committee agreed that the actions completed could be removed from the action log.
314 FEEDBACK FROM BOARD / Q&S COMMITTEE REPORT FROM PREVIOUS MEETING
The Chair gave an oral update as follows: • Patient story was presented to the Board and this included an audio
clip. The carer gave positive feedback in terms of how the organisation helped but concerns were raised around the access to the Crisis Team. Whilst it is simple to register a call for the team to call back the responsiveness of the Crisis Team was lacking.
• The Board discussed the Mortality Review Group. • The Board discussed Embedding Lessons and how we are able to
notice changes and what impact they have. • The Board discussed the Safer Staffing Report. • The Board recognised the enormity of the work required in terms of
Smoking Cessation and that it was important that the Trust works with its partners to implement the action plan and achieve the agreed outcomes.
• The Board received the SED report. • The Annual Safeguarding Report has been adopted for publication. • The Board added new risks to the Risk Register in terms of TCT and
MCP, these are based on the new climate in which we will need to work closely with other organisations. Mr Jinks added that this will include risks associated with patient experience, finance and other organisational risks. The Chair expressed the need for the Committee to think about the impact that this could have on quality issues and on the patient. The Board Development session prior to May Trust Board will also consider associated risk.
• The Chair said that he has informed the Board of his meeting with the Freedom to Speak Up Guardian. The importance of the role was
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discussed along with the need to support both the role and the Freedom to Speak Up Guardian, Mr Hirons. It is very important to open to both positive and negative stories.
Mr Axcell informed the Committee that the patient story was from the perspective of the Carer. They were very happy with the care given and their experience of our services, however, they did have concerns with how Crisis responds to service user needs.
BI – MONTHLY SPOTLIGHT ON RISK
315 Red Risk 319
The Committee were informed that this risk had also been discussed at the Mental Health Act Scrutiny Committee. Mr Tong took the Committee through the presentation. The Chair asked if any changes had been noted. Mr Tong explained that there had been a reduction in the use of blanket restrictions however some wards were still interpreting the Trust’s search policy in different way. The Chair asked if the actions required were achievable against the current available resources. Mr Tong explained that this work is now considered as part of the day to day business and that monitoring of this would be included in the CQC supportive visits and other CQC work. The Committee were informed that CW Audit had conducted an audit which highlighted that there were still challenges in the application of the search policy. It was noted that a follow up audit which looks at the impact of the work being undertaken would be carried out in October 2017. The Chair asked if the Committee needed to support the team and Mr Jinks confirmed that the work was embedded within ongoing processes. Action: Mrs Musson to update the Committee in November.
QUALITY AND SAFETY
316 Quality Report
The Chair acknowledged the new format had made the report easier to follow. Mr Welsh presented the report to the Committee and the following were highlighted:
• There was a decrease in incidents during the month, 191 were reported. Following release of the NRLS figures a bench marking exercise will be completed to show the Trusts position against other organisations.
• 7 cases considered for Duty of Candour.
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• 4 serious incidents were reported • 6 Safety Alert Broadcasts had been received.
Acute and Access Service – Incidents numbers remained the same in comparison to previous months. Discussions took place regarding the disruptive / aggressive behaviour incidents and it was noted that this was attributable to a small number of service users. The Committee discussed what further actions could be taken to minimise the number of incidents. Mrs Cooper assured the Committee that feedback from incidents is shared with the clinical teams in relation to what action is taken. Older Adults Service – there was a decrease in the number of incidents when compared to previous months. Disruptive / Aggressive Behaviour was the highest category and it was noted that 1 patient was responsible for 10 incidents. Early Intervention Service – there was a increase in the number of incidents when compared to the previous month. Community & Recovery Service –there was a decrease in the number of incidents when compared to the previous month. Serious Incidents - There were 4 serious incidents and investigations are on going. The Committee noted that the detailed summary of all the active serious incidents cases and their current status which was included in the report. Mrs Cooper updated the Committee on one of the incident which has been upgraded to a Serious Case Review by the Police. Mr Tong reported that there were 6 Safety Alert Broadcasts issued and all 6 alerts required no action be taken by the Trust. Mr Welsh updated the Committee on the Safety Thermometer Report and it was noted that a nil return in regard to pressure ulcers and 5 patients falls were reported for the period December 2016 to February 2017. Safeguarding – Mrs Cooper reported that there had been some challenges around Level 3 Adult and Children Safeguarding training and this has now been addressed. It was agreed that the Safeguarding information would be circulated to the Committee outside of the meeting. Action: Mrs Cooper to circulate the Safeguarding Training Data to the Committee members. The Committee noted the data for DOLs and Domestic Abuse, Safeguarding Children and Vulnerable Adults. Mr Axcell reported that he had requested benchmarking information for other Trusts be included in the report. Mr Welsh advised that there were issues
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with obtaining benchmarking data and comparing like for like but that the NPSA data would be included in the next report. Mr Axcell agreed to raise this issue with our MERIT colleagues. In response to a query from Mr Axcell regarding the snap shot given for the Serious Incidents Report, Mr Welsh confirmed that the Committee receives a quarterly report on all completed serious incidents which gives details of progress made. The Committee noted that an assurance column would be added to the report. The Committee took the report for information and assurance.
317 Quality and Safety High Level Risks
Mr Tong took the Committee through the report advising that there were currently 9 operational red risks applicable to the remit of the Committee. Mr Tong explained that Risk Ref EF002 had been updated by the Fire Safety Group and had seen good progress against the actions outlined within the Fire Safety Group’s Action Plan. The Chair advised that Risk Ref 314 is an ongoing issue and matters are in hand and that this matter had recently been discussed at Trust Board.
318 Interim Director of Nursing/Joint Medical Directors Update
Dr Gingell gave an update as follows: • A meeting is being arranged with Black Country Partnership to discuss
proposals for an integrated Research and Development Department. with our partners.
• At a recent Vanguard meeting the Trust presented the work currently
being undertaken in regards to integrating primary and secondary care with visits to GP surgeries by consultants psychiatrists to increase the quality of services available to patients in Dudley.
• Consultants Away Day would take place on Friday 10 March
discussions will take place regarding how we deliver good quality and safe services.
• The Committee to be updated on the outcome of discussions via the
Medical Directors Update in April. Action: Medical Directors update to be given on outcome of discussion at the Consultants away day regarding delivery of good quality and safe services. Dr Weaver gave an update as follows: • The Trust has received its annual NCI score card, which compares
and Response Rate. This shows that in some areas we are above the national average, however Staff Turnover was below the national average.
• Work is continuing in terms of “Response to Crisis”. The Committee noted that the Samaritans are members of the Suicide Prevention Group. The Chair asked if there were any figures available to support the activity of the Crisis Team. Dr Weaver explained that this would be available as part of the Suicide Prevention feedback.
• The Outpatient Group continues to monitor the needs of our service
users, making sure that they are seen by the right people in the right place.
• In response to a query from Mrs Temple-Purcell regarding the data, Dr
Weaver confirmed that the data for the NCI was submitted by the Trust.
Mrs Musson provided the following update: • The NHSI local Quality Leads will be providing links to Trusts who
have looked at how observations are delivered, this includes from a therapeutic and staffing perspective. Falls Prevention and pressure care will remain high on the forth coming agenda.
• Following presentation of a Patient Story to Board, a meeting took
place with the service user to discuss their concerns. Actions are being taken to address the concerns.
• The Trust will be presenting Triangle of Care to the Regional Group later in the month. The initial feedback from assessors has been positive.
319 UPDATED IAPT REPORT
Mrs Carey joined the meeting.
Mrs Carey updated the Committee on the progress made of the IAPT activity, it was noted that since the updated given in November 2016 there had been sustained efforts to support achieving targets and KPIs. Mrs Carey gave assurance that a number of actions and recommendations have been implemented by the IAPT project and these have included:-
• The services are now receiving self referrals. • In Dudley, Primary Care Mental Health is well established in the GP
surgery, MDT meetings and are accepting referrals from the various agencies attending under the auspices of the GP surgery.
• IMT and the clinical teams are working closely together to ensure timely and accurate reporting.
• There has been a communications drive and support from the Communications Team to promote the Services.
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Mrs Adams informed the team of issues with service users being unable to contact the team over the phone. Mrs Carey acknowledged that there had been issues whilst the team had been relocated to another area but this has been addressed by the Head of Information and Technology with Dudley IT Services. There was discussion regarding the national target and whether a new system would enable the targets to be met. Mr Axcell informed the Committee that the CCGs have a new understanding of the national definition and this has resulted in a drop in activity. The CCG are aware of this and are supportive of our plans to rectify this. It was suggested that additional methods of delivery of care should be reviewed. The Committee received the report for information and assurance. Mrs Carey left the meeting.
320 QUARTERLY PLACE REPORT
Mrs Musson updated the Committee on the quarterly report for PLACE and explained that progress had been made in the key arrears and there are stronger links into how we link this into Estates, Capital Planning and Governance systems. The Committee noted that feedback from service user has been taken on board and an example of this is that the issue regarding hot food on the wards has been investigated and been addressed. Mr Jinks informed the Committee that the Trust will face challenges. Mr Jinks explained that there is a need to link PLACE with the CQC work and Supportive Visits, there is also a need to review how this links in with Estates. Mrs Musson informed the group that PLACE was part of the Quality agenda. Mr Axcell asked are the Ward Managers empowered to address issues and escalate as necessary, assurance was given around this. The Committee were informed of the on-going work to ensure that our environments are compliant with the Dementia Friendly standards where appropriate; all wards are included in this work. The Committee noted that the PLACE results are expected at November’s Committee.
321 CORRELATION OF INCIDENTS FROM LONG STAY SERVICE USERS
This item was not discussed at the meeting and will be carried forward to the next Committee.
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322 REVIEW OF SERIOUS INCIDENTS PROCESS
The Committee agreed to include the review of mortality review as part of this agenda item, as it would be presented to Trust Board as one paper, part A being the review of serious incident process and part B being the Mortality Review Process. Mr Jinks took the Committee through the Review of Serious Incident presentation, and provided an overview of our current processes. Mrs Musson updated the Committee on the review process and some of the challenges faced by the team and investigators, these include:-
• Understanding the levels of investigation; • Interface with other investigations i.e. Coroners, Complaints,
Safeguarding, MPs and other Trusts • Timescales • Strengthening sign off processes • Embedding lessons process • Clinical engagement
Dr Weaver informed the Committee that it was important that the process was updated and that learning from lessons needed to be shared across the Trust. The Committee noted that following the review there are opportunities to:-
• streamline processes • review / simplify processes; • improve decision making; • strengthen development of Terms of Reference; • Improve effectiveness of strategy meetings; • Increase expertise through training MERIT; • Enhance Commissioner understanding of mental health root causes; • Strengthen Executive sign off.
Mrs Musson explained that there are proposals for Executive Directors to be briefed prior to Exec Comms Meetings. Mrs Musson and Mr Jinks asked the Committee to endorse the proposed process and welcomed questions. Mr Axcell requested that the CQC be contacted to ascertain which organisation in this area so that we review their processes to ensure best practice. Mrs Cooper informed the Committee that the Terms of Reference are very important, equally so are the Lessons Learnt and how they are disseminated out and how we scrutinise this. Dr Weaver expressed concerns that Learning Lessons are seen as criticism
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by staff and the process needs to be supportive. The Chair asked that the agenda item be taken to Board. Mrs Musson confirmed that both the Serious Incident Process and Mortality Review Work are included on the agenda for Board. It was agreed this should be in form of a presentation.
322.1 MORTALITY REVIEW PROCESS
This was discussed after agenda item 17. Mr Tong took the Committee through the presentation and gave an overview of the process, the challenges, strengths and opportunities. The review looked at the topics highlighted in the Mazar’s Report into Southern Health. It is proposed that a new process will be put in to place and there will be feeds from the NHS Spine and further work to establish links with Embedding Lessons, Suicide Prevention Group and Physical Healthcare Group. It was noted that the Trust is invited to the CCGs Mortality and Suicide Prevention groups. Mr Tong reported that there is a conference taking place 21 May which Dr Gingell and the Chair will be attending. Discussions took place regarding the presentation and Dr Gingell explained that any unexpected deaths are reviewed by the Mortality Review Group that sit outside of the expected age of death. Mr Axcell highlighted that there is a West Midlands group being formed to look at how organisations can share learning in this area.
323 QUALITY IMPROVEMENT PRIORITIES 2017-18
This was discussed after agenda item 21.
Mrs Musson informed the Committee that the Quality Improvement Priorities had been circulated outside the Committee for comment and 5 priorities had been shortlisted and these were: • Person Centred Care/Care Planning • Improving the quality of record keeping • Ensure organisational learning is embedded and sustained • Smoke Free (continuing from 2016-17) • Refocus Recovery Model The Chair asked if the Trust had the resources to deliver on all 5 priorities and confirmation was received on this. The Committee recommend to the Board that the Quality Priorities for 2017-18 be adopted.
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Action: Committee’s Report to the Board to include recommendation for the Board to adopt the 2017-18 Quality Priorities. The Committee received the report discussion and approval.
324 FORWARD PLAN FOR QUALITY DEEP DIVES
Due to time constraints, the Committee agreed that this item should be carried forward to the next meeting.
325 FIRE SAFETY PLAN UPDATE
Mr Davies and Mr Clark were welcomed to the Committee. The Chair informed the Committee that discussions took place at Board regarding compartmentalisation on Clent Ward. Mr Clark gave assurance that there is compartmentalisation and discussion took place around this. Mr Davies reported that detailed discussions had taken place at the Fire Safety meeting regarding this. Mr Davies updated the group on the Trust Fire Safety action plan and the work of the Fire Safety Group. Mr Davies reported that the Trusts Fire Policy has been updated and has been circulated for consultation; the deadline for receipt of comments is 10 March. The policy was subject to minor changes and an appendix has been added to address the current management situation. Mr Davies highlighted that Fire Marshalls have been identified for each hospital site, and the total number of Fire Marshalls for the Trust has been confirmed. Training sessions are being held over the next month. It is proposed that from April 2017 all inpatient qualified nursing staff will be trained and there will be a rolling program of training in place. Fire Risk Assessments will be completed at all hospital sites and as a result of this a risk register will be developed. Currently the Trust is not able to evidence that identified risks have been escalated and necessary actions taken. Mrs Cooper acknowledged the progress being made but reminded the Committee of the need for Contractors to receive a complete induction to the ward environments in order to maintain safety for patients, staff and visitors. Mr Clarke advised the Committee that all contractors are subject to an induction to site. Mr Axcell noted the amount of work to be undertaken and asked whether the Committee would receive an updated action plan which includes the outcome of the risk assessments. The Committee discussed this and noted the caveat for the works to be completed. Mr Davies confirmed that he would aim to have this done by May 2017.
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Mr Davies explained to the Committee that the replacement of Fire Doors at Dorothy Pattison Hospital would need to take priority in terms of the Capital Program and the Committee noted this. Action: Mr Davies to bring update on Fire to the Committee in May.
326 EBE’s REPORT This item was discussed after item agenda 12.
Mr Stocks was welcomed to the Committee. The Chair acknowledged the EBE’s request for more time to be allocated to their standing agenda item. The Chair made a suggestion to meet with the EBEs outside of the Committee to go through some of the issues raised on a quarterly basis. The Committee took on board Mr Stocks suggestion to feedback on issues that they had been raised and any the outcomes. Mr Stocks highlighted an issue with Outpatient Project Team and in particular the number of DNAs. The EBEs had suggested the use of text message reminders as a way forward for reducing this. Another issue was to highlight the discharging of patients from secondary care back to primary care services. Mr Stocks asked for clarification around the rumours in regards to CRS South being moved to Dorothy Pattison Hospital, Mrs Musson confirmed that discussions have taken place but no decisions have been made and this is being looked at in line with Commissioner’s intentions. The Chair noted the ongoing issues with patients from Walsall being cared for in Dudley. Mr Stocks advised that he and another EBE colleague had been invited to attend Dorset NHS Trust. The Committee thanked Mr Stocks and his EBE colleagues for their valuable work. The Committee received the report for their information, discussion and assurance. Mr Stocks left the meeting. Action: The Chair agreed to meet with the EBEs on a quarterly basis.
REGULATION AND COMPLIANCE
327 CQC ACTION PLAN UPDATE
The Chair explained that due to the update provided by Mr Axcell at the start of the meeting, no further update was required on the CQC Action Plan.
Enc 7 Q&S Minutes - 08 03 17 v1.0 Page 12 of 14
328 INTEGRATED PERFORMANCE DASHBOARD MONTH 10
This item was discussed after Agenda Item 16. Mr Davies presented the report and made reference to the following:
• CPA Performance at month 10 showed copies of care plans were 94.9% which is below the 95% threshold.
• CPA formal reviews were 95.44%. • PDRs have increased from 77.61% to 79.42% and remain below the
Trusts target. Mr Jinks highlighted that discussions are taking place with Mr Singh regarding targets for serious incidents. The Committee thanked Mr Davies for his report. Mr Davies left the meeting.
SUB-GROUP EXCEPTION REPORTING / MINUTES
329 INFECTION PREVENTION AND CONTROL COMMITTEE
Mrs Musson explained that there were no exceptions to report from the Infection Prevention and Control Committee.
330 MEDICINES MANAGEMENT COMMITTEE This was discussed after agenda item 19.
Dr Campbell gave an oral update and highlighted the following: • Chief Pharmacist – Joint Working Proposal • Ongoing work on a unified prescribing formulary • Engagement with nurses to promote Medicines Management Link
Nurses.
331 POLICY AND PROCEDURES FOCUS GROUP
The Committee noted the exception points in the report. Mr Tong explained that at the Policy and Procedures Focus Group Meeting held on 2 March 2017, the Group agreed to re-ratify the following policies which had minor amendments: • Maternity, Paternity and Adoption Leave Policy • Agency and Locum Medical Workers Policy • Clostridium Difficile Prevention and Control Policy • Children Visiting within Mental Health Settings Policy • Infection Prevention and Control Isolation Policy • MRSA – Prevention and Control (including screening)
Enc 7 Q&S Minutes - 08 03 17 v1.0 Page 13 of 14
• Outbreaks of Infectious Disease (Mental Health Trust Premises) Management Policy
The Quality and Safety Committee agreed to ratify the following policies as recommended by Policy and Procedures Group. • Food Safety Policy • Information Governance Serious Incidents Requiring Investigation
(SIRI) Policy • Research Governance Policy Mr Tong informed the Committee that the Fire Safety Policy has been circulated for consultation until 10th March at which point a decision will be made to virtually ratify the Policy.
332 AGREEMENT OF NEXT QUALITY AND SAFETY AGENDA
The Chair explained that the next Agenda would include the monthly standing items and reports from the Matters Arising Schedule that are due for April.
333 ANY OTHER BUSINESS
Mrs Cooper informed the Committee that the Commissioners had a sum of money for further provision of MCA / DOLS training This is a positive step which will allow the Trust to work closely and build on our current relationship with the Commissioners.
334 AGREEMENT OF ITEMS FOR COMMITTEE’S REPORT TO THE BOARD
The Chair informed the Committee that the Report to Board would be put together from the discussions held in the meeting.
335 DATE AND TIME OF NEXT MEETING
Wednesday, 12 April 2017, 9.00 am – 12.30 pm, Conference Room 1, Trafalgar House, Dudley.
Enc 7 Q&S Minutes - 08 03 17 v1.0 Page 14 of 14
QUALITY REPORT (Month 12)
Board meeting date: 4 May 2017
Agenda Item number: 7.1.1c Enclosure: 8
1
Section 1 Summary of Trust Incidents and
Serious Incidents
2
Section 1
Quality & Safety Report for April 2017
Summary of Trust Incidents and Serious Incidents01 March - 31 March 2017
Cause Group No. Incidents
65.31% of incidents were Patient Safety Incidents (253 of 392 incidents)
Failure To Return From Agreed Sec 17 Leave 10 incidents
Absconded (Sectioned Patient) 7 incidents
392 Total IncidentsReported
* SI: Serious Incidents** SIRS: Security Incidents Reporting System
Of the 3 cases considered for Duty of Candour, only 1 of these has met the criteria and will be included in next months Serious Incident Section as this incident occured at the end of the March and will reported on next month.
3
Appendix 1 - Incidents and SeriousIncidents by Commissioning Locality
Quality and Safety Report April 2017
0
50
100
150
200
250
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016 2017
Dudley Walsall
01234567
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016 2017
Dudley Walsall
AP1 - Graph to show total Trust Incidents, broken down by service locality
AP2 - Graph to show total Trust Incidents, broken down by serviceline showing locality only.
AP3 - Graph to show total Serious Incidents, broken down by locality
Acute and Access Services 12 Monthly Average Mean + 2S.D.
Mean - 2S.D. Acute Bed Occupancy
Commentary • The monthly (mean) average for incidents relating to Acute & Access Services (calculated using data
from the last 12 months) is 171.50. • Chart 2.1.1 shows the incident numbers for Acute & Access Services have shown a slight increase in
comparison to the previous month and are now above the 12 month average. • Chart 2.1.1 also offers a comparison of the bed occupancy for acute inpatient services during this
period. • Table 2.1.1 shows the total number of incidents broken down by cause group, and highlights some of
the incident categories with most activity and provides a further break down to the incident causes. There has been an increase in the number of incidents relating to Disruptive / Aggressive Behaviour across the acute wards. The hotspots for the incidents are Clent Ward and Langdale Ward. However, the incidents for Langdale have decreased to 19 incidents in comparison to 29 from the previous month. • On review, a significant amount of the incidents relate to particular patients on Clent. Patient A was
responsible for 8 of the 33 incidents. Although there was no acute mental illness determined, the patient’s erratic behaviour is due to substance misuse. He was transferred to a PICU from Clent and then discharged to Langdale. However, the patient has now been sent back to the PICU. Patient B is responsible for 7 of the incidents and his behaviour is affected due to the medication changes as he was not compliant, this results in unprovoked attached on staff, his care plan is being reviewed regularly.
• On Langdale, there has been a sharp decrease in incidents and this is due to many patients being discharged for follow up in the community. However, Patient F is responsible for 10 out of the 19 incidents due to having suicidal thoughts. He is a recent admission and an MDT is due to take place todiscuss possible transfer to a personality disorder unit.
• There are noted trends on Ambleside in relation to the Serious Harming Behaviour category. Patient H is responsible for 6 of the 19 incidents, however, since the formulation of a new care plan as advised by the Senior Clinical Lead, there has been a decrease of self-harm incidents for this patient when compared to the previous month. Patient I and Patient J are involved in 8 of the 19 incidents. Both patients recently started self-harming due to changes in their personal lives, they are being closely monitored and appropriate care plans are in place.
Access, Admission, Transfer DischargeDocumentation & Electronic Records Manageme
Commentary
• The monthly (mean) average for incidents relating to Older Adults Services (calculated using data fromthe last 12 months) is 109.00.
• Chart 2.2.1 shows the number of incidents have increased since the previous month and is now abovethe 12 month average.
• Table 2.2.1 shows the total number of incidents broken down by cause group.
• The majority of the incidents have been reported for Linden. These incidents are mostly attributable to two particular patients. Patient K is responsible for 21 of the 34 incidents and patient L is responsible for 11 incidents. Both patients have care related incidents and therefore, clinical holds have to be utilised to address these issues, any holds used have been subject to independent scrutiny and their care plans are regularly updated accordingly.
• There has been a noticeable rise in incidents on Holyrood with 27 being reported compared to 11 in the previous month. However, this is due to two patients, Patient K is responsible for 9 of the incidents andPatient L has 8 incidents. Patient K was constantly mistaking Patient B for their partner which led to her attacking staff. Patient L has now been transferred to a nursing home and Patient K is settling well.
Table 2.2.1 - Total Older Adults incidents by Cause Group and showing a position on the previous months figures
2.2 Older Adults Service Line
Chart 2.2.1 - Total Older Adults incident numbers during the last 12 months
The monthly (mean) average for incidents relating to E.I. Services (calculated using data from the last 12 months) is 37.67 Chart 2.3.1 shows this month has seen an increase in the number of incidents for the Early Intervention Service line, with 57 incidents reported for the month. • Table 2.3.2 shows the total number of incidents broken down by Cause Group.
Exceptions/Trends The has been an increase in the number of incidents since December 16, this has been in relation to the ongoing activity of the iCAMHS team.
No further trends or significant incidents relating to this service.
2.3 Early Intervention Service line
Table 2.3.2 - Total Early Intervention incidents by Cause Group and showing a position on the previous months figures
8
Section 2 - Service Line Reports Quality and Safety Report April 2017
Incident Cause GroupCurrent Month
Last 12 months
Serious Harming Behaviour 0 3
Disruptive / Aggressive Behaviour 3 1
Clinical Care, Quality And Treatment 1 2
Equipment 0 0
Information Governance And Confidentiality 1 1
Health & Safety 1 1
Security / Cyber Security 0 0
Patient Accident 1 0
Access, Admission, Transfer Discharge 1 0
Medication 0 0
Fire 0 0
Documentation & Electronic Records Management 1 0
Infection Control 0 0
Skin Integrity 1 2
Grand Total 10 10
Previous month
Community & Recovery
Chart 2.4.1 - Total Community & Recovery incident numbers during the last 12 months
0
2
4
6
8
10
12
14
16
Community & Recovery Service 12 Monthly Average
Commentary The monthly (mean) average for incidents relating to Community & Recovery (calculated using data from the last 12 months, and as a combination of the previous individual Services) is 8.92 Chart 2.4.1 shows the incident figures which have remained the same when compared to the previous month. • Table 2.4.2 shows the total number of incidents broken down by cause group.
Exceptions/Trends
The have been no trends or significant incidents relating to this service.
2.4 Community & Recovery Service line
Table 2.4.2 - Total Community & Recovery incidents by Cause Group and showing a position on the previous months figures
9
Section 3 Serious Incidents
10
Section 3.1 - Serious Incidents Quality and Safety Report
April 2017
SI Number Date of Incident Service Line Incident DescriptionLevel of
Risk
DoC
applicableLevel of response
2017/7608 15/03/2017 Acute Behavioural - Aggressive Low No Consise
Chart 3.2 - Total number of Serious Incidents during the last 12 months
Serious Incidents Trust Average Mean + S.D. Mean - S.D.
Table 3.1 - List of Serious Incident raised during the month of March 2017
Commentary
• The monthly (mean) average for Serious Incidents across the Trust (calculated using data from the last 12 months) is 3.92.
• Table 3.1 Shows a list of the serious incident logged on STEIS during the previous month, this includes details of the service line and nature of the incident.
• There is one Serious Incident which has been reported during this month and is linked to the Acute Inpatient Services.
• Chart 3.2 shows that the number of Serious Incidents are currently below the 12 month average. • Chart 3.1 illustrates the types of the Serious Incidents that have been reported over the previous 12 months.
Incident Summary
2017/7608 - A Section 3 patient absconded from a ward by damaging an exit fire door. The ward was contacted by the Police to inform that the patient was under investigation for two charges of shop lifting, he was also reported to have been seen carrying a knife whilst wandering on the roadside. The patient later returned to the ward but was not allowed entry into the ward because of the risks posed to others due to the alleged possession of the knife.3070 –
See the Serious Incident Summary below for further information on all on-going Serious Incidents.
Chart 3.1 - Summary of the Serious Incident types during the last 12 months
49%
35%
5% 5%
2% 2% 2% Serious Harming Behaviour
Access, Admission, Transfer Discharge
Infection Control
Patient Accident
Fire
Clinical Care, Quality And Treatment
Disruptive / Aggressive Behaviour
0
2
4
6
8
10
12 Serious Incident Comparison with Partnership Trusts 12 month comparison
BCHC
BCP
BCHC - 12mth avg
BCP - 12mth avg
11
Section 4 National Guidance
Central Alerting System
12
Quality and Safety Report April 2017
Table 4.1 – Summary of Alerts received during March 2017
• During March 2017 there were 2 alerts issued via the Central Alerting System, of these 2 alerts:o Both required no action taking.
• The table below (3.1) outlines a summary of the alerts issues and any action taken.
Table 4.2 –Alerts issued during March via the Central Alerting System
Alert Number Alert Date Description of Alert Status Notes / action taken / assurance
MDA/2017/004 07-Mar-2017
Cardiosave Hybrid intra-aortic balloon pump (IABP) and Cardiosave Rescue IABP – damaged lithium ion batteries may give off smoke, a bad smell or produce sparks
Action not required
The Trust does not use these devices. As such no action was required in relation to this particular alert.
EL (17) A /05 29-Mar-2017
Drug alert class 2 (action within 48 hours); strides pharma trading as co-pharma; diclo-sr 75 tablets; pl 13606/0145
Action not required
This is not a product purchased by pharmacy services at Russells Hall Hospital / DGOH. As such, DWMH were unaffected by this alert
Section 4: CAS Alerts
13
Section 5 National Benchmarking
NRLS Patient Safety Incidents
NRLS (National Reporting and Learning System). This benchmarking data is taken from the submission of patient safety related incidents made to the NRLS during the period of 1st April 2016 to 30th September 2016.
We have also included the same report for Black Country Partnership NHS Foundation Trust as a direct comparison and we have included the report for Birmingham Community Healthcare NHS Foundation Trust for information
14
Organisation Patient Safety Incident ReportReported incidents between 01 April 2016 to 30 September 2016
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTOrganisation type: Mental health organisation
Are you actively encouraging reporting of incidents?
The comparative reporting rate summary shown below provides an overview of incidents reported by NHS organisations to the National Reporting and Learning System(NRLS) occurring between 01 April 2016 to 30 September 2016. Your organisation reported 1,043 incidents (rate of 36.82) during this period.
Figure 1: Comparative reporting rate, per 1,000 bed days, for 55 Mental health organisations.
The median reporting rate for this cluster is 42.45 incidents per 1,000 bed days.
Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are.
How regularly do you report?
Your organisation reported incidents to the National Reporting and Learning System (NRLS) in 6 out of the 6 months between 01 April 2016 to 30 September2016.
Report regularly: Incident reports should be submitted to the NRLS at least monthly.
Fifty per cent of all incidents were submitted to the NRLS more than 26 days after the incident occurred. In your organisation, 50% of incidents were submitted morethan 10 days after the incident occurred.
Report serious incidents quickly: It is vital that staff report serious safety risks promptly both locally and to the NRLS, so that lessons can be learned and action takento prevent harm to others.
Your Organisation's Reporting Rate Highest 25% of Reporters Middle 50% of Reporters Lowest 25% of Reporters
If your reporting profile looks different from similar organisations, this could reflect differences in reporting culture, the type of services provided or patients cared for. Itcould also be pointing you to high risk areas. The response system is more important than the reporting system.
Figure 3: Incidents reported by degree of harm for Mental health Organisations
All Mental health organisations Your Organisation
65.1%
28.5%
5.2%
0.3% 0.8%
53.2%
44.8%
1.6%0.1% 0.3%
0%
20%
40%
60%
80%
100%
10%
30%
50%
70%
90%
Per
cen
t of i
ncid
ents
occ
urrin
g
None Low Moderate Severe Death
Yourfigures:
Degree of harm
None Low Moderate Severe Death
555 467 17 1 3
Do you understand harm?
Nationally, 73 per cent of incidents are reported as no harm, andjust under 1 per cent as severe harm or death.
However, not all organisations apply the national coding of degreeof harm in a consistent way, which can make comparison of harmprofiles of organisations difficult.
Organisations should record actual harm to patients rather thanpotential degree of harm.
Recognising and reporting incidents resulting in severe harm ordeath is an important sign of an organisation's reporting culture. Ifthe numbers of incidents reported as severe harm or death are lowcompared with peers you should check that your reports reflect allincidents you are aware of through sources such as mortalityreview, inquests, litigation or complaints.
For further information on the reporting of serious incidents pleasesee NHS England's guidance
The NRLS helps the NHS to understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent futureharm to patients. Alerts and other learning resources can be found at: www.england.nhs.uk/ourwork/patientsafety/psa/ and national data can be found at:www.nrls.npsa.nhs.uk/patient-safety-data/.
Reviewing the results of the NHS staff survey relating to incident reporting alongside this report will provide an important indicator of your reporting culture.
Organisation Patient Safety Incident ReportReported incidents between 01 April 2016 to 30 September 2016
BLACK COUNTRY PARTNERSHIP NHS FOUNDATION TRUSTOrganisation type: Mental health organisation
Are you actively encouraging reporting of incidents?
The comparative reporting rate summary shown below provides an overview of incidents reported by NHS organisations to the National Reporting and Learning System(NRLS) occurring between 01 April 2016 to 30 September 2016. Your organisation reported 740 incidents (rate of 23.81) during this period.
Figure 1: Comparative reporting rate, per 1,000 bed days, for 55 Mental health organisations.
The median reporting rate for this cluster is 42.45 incidents per 1,000 bed days.
Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are.
How regularly do you report?
Your organisation reported incidents to the National Reporting and Learning System (NRLS) in 6 out of the 6 months between 01 April 2016 to 30 September2016.
Report regularly: Incident reports should be submitted to the NRLS at least monthly.
Fifty per cent of all incidents were submitted to the NRLS more than 26 days after the incident occurred. In your organisation, 50% of incidents were submitted morethan 7 days after the incident occurred.
Report serious incidents quickly: It is vital that staff report serious safety risks promptly both locally and to the NRLS, so that lessons can be learned and action takento prevent harm to others.
Your Organisation's Reporting Rate Highest 25% of Reporters Middle 50% of Reporters Lowest 25% of Reporters
If your reporting profile looks different from similar organisations, this could reflect differences in reporting culture, the type of services provided or patients cared for. Itcould also be pointing you to high risk areas. The response system is more important than the reporting system.
Figure 3: Incidents reported by degree of harm for Mental health Organisations
All Mental health organisations Your Organisation
65.1%
28.5%
5.2%
0.3% 0.8%
62.8%
33.1%
2.7%0.0% 1.4%
0%
20%
40%
60%
80%
100%
10%
30%
50%
70%
90%
Per
cen
t of i
ncid
ents
occ
urrin
g
None Low Moderate Severe Death
Yourfigures:
Degree of harm
None Low Moderate Severe Death
465 245 20 0 10
Do you understand harm?Nationally, 73 per cent of incidents are reported as no harm, andjust under 1 per cent as severe harm or death.
However, not all organisations apply the national coding of degreeof harm in a consistent way, which can make comparison of harmprofiles of organisations difficult.
Organisations should record actual harm to patients rather thanpotential degree of harm.
Recognising and reporting incidents resulting in severe harm ordeath is an important sign of an organisation's reporting culture. Ifthe numbers of incidents reported as severe harm or death are lowcompared with peers you should check that your reports reflect allincidents you are aware of through sources such as mortalityreview, inquests, litigation or complaints.
Learning from your incident reports
We know from international research studies that not all patientsafety incidents are recognised and reported, even in the mostsafety-aware organisations. NHS Improvement are keen thatnumbers of reported incidents to the NRLS are always framed interms of reporting patient safety incidents is good, not that highreporting equals an unsafe organisation.
An NHS trust where staff feel encouraged and supported to reportshould show a higher rate of incident reports, a higher proportion ofno harm reports, and staff survey responses about incidentreporting behaviour that are above average.
NHS organisations are encouraged to apply their local knowledgeand expertise – in addition to considering these other relatedsources of patient safety information (such as CQC reports, localserious incident information, ‘friends and family’ patient feedback,and local complaints data) alongside their NRLS data, in order tocheck that the messages from each data source are consistent andlearning is identified and acted upon.
For further information click here.
Further information
The NRLS helps the NHS to understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent future harm topatients. Alerts and other learning resources can be found at: https://improvement.nhs.uk/resources/patient-safety-alerts/ and national data can be found at:www.nrls.npsa.nhs.uk/patient-safety-data/.
For further information on the reporting of serious incidents please see NHS Improvement's guidancehttp://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety-incidents/
Implementation of care and ongoing monitoring / review
0% 20% 40% 60% 80% 100%Per cent of incidents
If your reporting profile looks different from similar organisations, this could reflect differences in reporting culture, the type of services provided or patients cared for. Itcould also be pointing you to high risk areas. The response system is more important than the reporting system.
Figure 2: Incidents reported by degree of harm for NHS Community Organisations
All NHS Community organisations Your Organisation
56.7%
35.3%
7.4%
0.5% 0.2%
66.9%
28.6%
4.4%
0.1% 0.0%
0%
20%
40%
60%
80%
100%
10%
30%
50%
70%
90%
Per
cen
t of i
ncid
ents
occ
urrin
g
None Low Moderate Severe Death
Yourfigures:
Degree of harm
None Low Moderate Severe Death
1,155 494 76 1 0
Do you understand harm?Nationally, 73 per cent of incidents are reported as no harm, andjust under 1 per cent as severe harm or death.
However, not all organisations apply the national coding of degreeof harm in a consistent way, which can make comparison of harmprofiles of organisations difficult.
Organisations should record actual harm to patients rather thanpotential degree of harm.
Recognising and reporting incidents resulting in severe harm ordeath is an important sign of an organisation's reporting culture. Ifthe numbers of incidents reported as severe harm or death are lowcompared with peers you should check that your reports reflect allincidents you are aware of through sources such as mortalityreview, inquests, litigation or complaints.
Learning from your incident reports
We know from international research studies that not all patientsafety incidents are recognised and reported, even in the mostsafety-aware organisations. NHS Improvement are keen thatnumbers of reported incidents to the NRLS are always framed interms of reporting patient safety incidents is good, not that highreporting equals an unsafe organisation.
An NHS trust where staff feel encouraged and supported to reportshould show a higher rate of incident reports, a higher proportion ofno harm reports, and staff survey responses about incidentreporting behaviour that are above average.
NHS organisations are encouraged to apply their local knowledgeand expertise – in addition to considering these other relatedsources of patient safety information (such as CQC reports, localserious incident information, ‘friends and family’ patient feedback,and local complaints data) alongside their NRLS data, in order tocheck that the messages from each data source are consistent andlearning is identified and acted upon.
Are you actively encouraging reporting of incidents?
There were 1,726 incidents reported by your organisation to the National Reporting and Learning System (NRLS) occurring between 01 April 2016 to 30 September2016.Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are.
How regularly do you report?
Your organisation reported incidents to the National Reporting and Learning System (NRLS) in 6 out of the 6 months between 01 April 2016 to 30 September2016.
Report regularly: Incident reports should be submitted to the NRLS at least monthly.
Fifty per cent of all incidents were submitted to the NRLS more than 26 days after the incident occurred. In your organisation, 50% of incidents were submitted morethan 20 days after the incident occurred.
Report serious incidents quickly: It is vital that staff report serious safety risks promptly both locally and to the NRLS, so that lessons can be learned and actiontaken to prevent harm to others.
Further information
The NRLS helps the NHS to understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent future harm topatients. Alerts and other learning resources can be found at: https://improvement.nhs.uk/resources/patient-safety-alerts/ and national data can be found at:www.nrls.npsa.nhs.uk/patient-safety-data/.
For further information on the reporting of serious incidents please see NHS Improvement's guidancehttp://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/about-reporting-patient-safety-incidents/
Changes to the Organisation Patient Safety incident reports for NHS Community Trusts
The NRLS cluster group for NHS Community trusts was formed following the formation of new NHS organisations as a result of the Transforming Community Servicesprogramme. Due to structural changes within these organisations, many no longer having inpatient services and the provision of diverse services between them meanthis cluster cannot be described as a homogenous group. A comparative reporting rate per 1,000 bed days is not appropriate within this cluster and comparingorganisations based on this rate will be misleading.
Therefore, no reporting rate will be calculated for this cluster and the comparative reporting rate chart generated by the Explorer tool in the PDF report has beenremoved until further notice.
20
DWMHT Safeguarding Performance Framework 2016/17
Section 1 • Safeguarding Training Compliance
Section 2 • Deprivation of Liberty (DoL’s)• Domestic Violence
Exceptions / Commentary This section shows the latest Training requirement and compliance levels as set out in the new Comissioner Contract, related to Safeguarding and Vulnerable Adults. Within the contract there are agreed trajectory requirements. Adult Safeguard Training - Childrens Safeguarding Training - Q1 - Scoping exercise to identify numbers and training levels required Compliance as detailed in the table above. Q2 - 80% Q2 - 80% Q3 - 85% Q3 - 85% Q4 - 90% Q4 - 90% Mental Capacity Act (MCA) and Deprivation Of Liberty (DOL’s) Prevent Domestic Abuse Q1 80% Q1 75% Q1 20% Q2 80% Q2 80% Q2 30% Q3 85% Q3 90% Q3 40% Q4 90% Q4 95% Q4 50%
22
NHS Dudley
NHS Walsall
0 100 2
13 0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 3 0
Mar-17Safeguarding Cases Internally reported as Domestic Abuse
Open To Mental Health
Referred into
MARAC
Open To Mental Health
MARAC
Referral
Dudley
Alert Only
Walsall
2068
Active DoL's
Total
104
13
Safeguarding Performance Framework for March 2017
Grand Total
3616
55
Linden CedarsHolyroodMalvern
Old
er
Section 2 - DoL's and Domestic Violence
2.2 Domestic Abuse
Total number of cases of Domestic Violence for the current month, these include cases reported within the Trust and Externally notified by MARAC (Multi-Agency Risk Assessment Conference)
2.1 Deprivation Of Liberties (DOL's) - This shows the total number of active cases of DOL's, broken down by Locality
Commentary Table 2.1 This table shows the activity in relation to cases of Deprivation Of Liberties (DOL's). This information is broken down by locality and shows the current number of Active cases, and activity for the last 12 months. There are currently 29 active cases of DoL's across the Trust
Further information relating to Older Adults, health related legal restrictions / provisions (Ward breakdown provided above).
• Dudley - 16 patients • Walsall - 13 patients
Table 2.2 Domestic abuse cases are reported as separate figures to display the prevalence within the service. Case figures are also shown for MARAC (multi agency risk assessment conference), these figures demonstrate how many cases are heard at MARAC where the victim, perpetrator or children are open cases to mental health. • The first table provides information on Cases reported Externally of the Trust which are then checked to see if
these Patients are open to Dudley and Walsall Mental Health. • The second table provides information on Domestic Abuse cases which have been reported internally into our
Child Safeguarding CasePatient considered High Risk Position of Trust InternalPosition of Trust ExternalUnder 18 AdmissionUnder 18 Death FGM
Grand Total
Dudley Walsall Grand TotalNumber of Looked after
ChildrenNumber of Looked after
ChildrenTotal 98 135
3.1 Safeguarding Children
Graph 3.1 - This graph provides information relating to the last 12 months and shows a breakdown of Safeguarding cases which are just for alert only and those which have been progressed to be continued under Safeguarding
Table 3.1 -This shows that the number of Safeguarding cases broken down by case type and showing the locality . This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency.
Table 3.1.1 This table provides information in relation to Looked after Children (LAC), who have been referred or in receipt of our services. Serious Case Reviews (SCR) - The Trust is currently involved in 3 Serious Case Reviews. In the Walsall Borough there is 1 case, which the Trust has provided input, The final report for this case is now out for review. In Dudley there are 2 cases . 1 case involves a child perpetrator and 2x child victims all of whom have been known to CAMHs. The other case is now complete and we are awaiting sight of the final report. The outcome requires the trust to produce evidence of action taken over the past 2 years to ensure systems are in place to flag and respond Safeguarding concerns effectively with the Police.
Graph 3.1 - Total number of Safeguarding Children incidents reported during the last 12 months
Table 3.1 Total number of Safeguarding Children cases for the current month
Table 3.1.1 Looked after Children (LAC) Total number of cases of Looked after Children 0
AdultPatient Considered High RiskPosition Of Trust InternalPosition Of Trust ExternalPrevent CaseSerious Case Review (Adult)
3.2 Vulnerable Adults
Graph 3.2 Total number of Vulnerable Adults incidents reported during the Last 12 Months
Graph 3.2 -This graph provides information relating to the last 12 months and shows a breakdown of Vulnerable Adults Cases which are just for alert only and those which have been progressed to be continued under Safeguarding.
Table 3.2 This shows that the number of Vulnerable Adults cases broken down by case type and showing the locality. This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency . There is 1 PREVENT case which has been reported by the Trust, this case is being overseen and monitored by the Safeguarding team along with Multi agency professionals. Serious Case Review - There is one SCR in walsall, this case is ongoing and both Victim and Perpetrator are previously know to the Trust. Domestic Homicide Review (DHR) - There is one case in Dudley which is ongoing
Table 3.2 - Total number of Vulnerable Adults incidents for the current month
020406080
100120140160
Apr
May Jun Jul
Aug
Sep
Oct
Nov De
c
Jan
Feb
Mar
2016 2017
Alerts
Referral
25
Board meeting date: 4 May 2017
Agenda Item number: 7.1.2a
Enclosure: 9
Report Title:
Finance and Performance Committee Chair Report
Committee:
Finance and Performance Committee (F&P)
Author (name & title):
Pawiter Rana – Non Executive Director
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
Key issues & risks The Finance and Performance committee met on the 21st April and considered the Finance, Performance information position for March (Month 12). The committee reviewed the following items of business: Performance The following areas were noted:
• Activity performance – seven percent above target across the Trust but 12 percent above target in respect of Walsall CCG
• KPIs – Against the 26 contractual KPIs the Trust continues to be non-compliant in a small area of indicators:-
Users with valid ICD diagnosis codes Patients reviewed within cluster review periods Numbers receiving IAPT treatment’.
• Two other areas of non-compliance noted – in respect of the Memory Assessment Service and the number of patients assessed using the Dudley and Walsall Recovery Outcome Measure (DWROM).
• Activity and contractual performance KPIs by service line – acute, community, early intervention, older adults, medical and ‘other’ – were reviewed and key issues highlighted. Debate took place as to the implications for the Walsall CCG contract of the very high levels of activity in respect of Walsall EAS and CRS services.
In-Patient Services Discussion took place around the key findings of this report. The report is presented on a quarterly basis. Some key trends were immediately apparent – for example, rising bed occupancy (and its relationship to home leave), rising re-admissions and the path of delayed transfers of care over the last four years (decline followed by increasing levels in last year).
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There was some discussion around the purpose of this report and refining it for future meetings. Finance Report & Income Report The finance report was presented. The financial position to the end of March 2017 showed a £1,703k surplus which was £3k ahead of the annual plan for 2016/17. On this basis and subject to audit the Trust has therefore delivered its revenue plan for the year. However, within this overall success there were significant variances. Pay was some £1.3m underspent, reflecting the level of vacancies across the Trust. This figure was despite the level of agency spend (£4.8m - £0.7m above the target set by NHSI). Non-pay over-spent by £0.8m, due to some non-delivery of non-pay CIP targets and the impact of potential liabilities in respect of leased properties. Income was some £0.5m under target – reflecting the under-delivery of income generation targets (part of the Trust’s overall cost improvement target, as well as the application of contract penalties by commissioners. In overall terms the CIP for the year (£2.5m) had been delivered but £0.9m was non-recurrent and therefore impacted adversely upon the establishment of the 2017/18 financial plan. Agency spend was discussed in light of the NHSI agency cap of £4,050k. The final position was a spend of £4,814k, being a net adverse impact against target of £764k. It was disappointing to move away from the target but agency spend was nevertheless a £1.4m reduction over the previous year. Capital spend was noted at £1.638m against a Capital Resource Limit (allocation) of £1.639m. The Trust therefore had delivered its capital plans within the authorized CRL. Income and Activity The report was noted by the Committee. Cost Improvement Programme The Interim Director of Finance undertook a presentation on the key risks around the 2017/18 CIP programme. He risk rated the 19 schemes as follows:- 6 schemes – high risk – red – value £723.5k 3 schemes – medium risk – amber – value £310.0k 10 schemes – low risk – green – value £2,731.6k Total value of all schemes - £3,764.8k.
The Director of Finance, Performance and IM&T agreed to update the analysis based upon the comments made. Review of Risk Register The report on the risk register was discussed. The Interim Director of Finance confirmed that the three key risks – CIP, S75 agreement, and the electronic patient record are the three risks
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he would identify in his role. The Interim Director of Finance further noted that he was aware that he had made the commitment to consider the inclusion of CQUIN targets on the register. Review of the Board Assurance Framework Strategic risk two, relating to financial sustainability, was discussed. Some further updates to the gaps in controls/assurance were agreed and are reported separately on the Agenda under the BAF Quarter 4 review. E&CPG Minutes The minutes from the Estates & Capital Planning Group were accepted. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:
Recommendations and requests for direction The Trust Board is asked to:- Accept this report for assurance about the exercise of delegated authority by the Finance and Performance Committee Endorse the decisions and recommendations made by the Finance and Performance Committee.
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Board meeting date: 4 May 2017
Agenda Item number: 7.1.2b
Enclosure: 10
FINANCE & PERFORMANCE COMMITTEE MEETING
Minutes of a Meeting Held on
24th March 2017
Board Room, Canalside House, Walsall
START TIME 14:00 HOURS
Present: Pawiter Rana Non Executive Director (Chair) John Lancaster Non Executive Director Dr Kate Gingell Joint Medical Director (part attendance) Rupert Davies Interim Director of Finance Marsha Ingram Acting Director of Operations In Attendance: Mark Banks Deputy Director of Finance (part attendance) Paul Chamberlain Head of Financial Planning James Parker Commissioner Liaison Manager Suren Vasia Information Systems and Data Warehouse Manager (part
attendance) Emma Jackson Note Taker Apologies: Mark Axcell Chief Executive Officer Dr Mark Weaver Joint Medical Director Wendy Pugh Director of Operations, Nursing & Estates Liam Dolan Associate Director of Operations Rosie Musson Acting Director of Nursing Ashi Williams Acting Director of People Dan Howard Head of Business Intelligence and IM&T Makhan Singh Principal Consultant, Information & Performance
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ACTION 105. Apologies For Absence
105.1 Apologies noted as above.
106. Declarations of Interest
106.1 No Declarations of Interest noted.
107. Minutes of Previous Meeting held on 20th February 2017
107.1 The minutes of the previous meeting held on 20th February 2017 were agreed as an accurate record with the following exception:- Page 5, item 99.3.1, final bullet point/action captured incorrectly. Mr Parker explained that a CAMHs scorecard was already in place. The action related to looking at where the Trust was at with regards to process and to discuss the CAMHs KPIs moving forward with Commissioners.
108. Matters Arising
108.1
The actions were discussed and an update was provided where appropriate: Action point 99.2.1 (a) – CPA Performance Update Ms Ingram advised that a lot of work was underway with regards to recruitment. The number of vacancies within the Walsall Older Adults CMHT team remained an outstanding issue. Interviews were being held next week with 12 out of 19 applicants shortlisted; this would be the 3rd round of interviews since December 16. As of this week, a significant improvement was noted with regards to CPA KPIs with only 11 outstanding breaches as of 23rd March. Mr Lancaster asked if the Trust had a clear position with regards to the number of Trust vacancies and whether the Trust was in control re; staff numbers. Ms Ingram advised that a working group had been established, namely the Vacancy Reduction Group that looked at how the Trust recruited and retained staff. In addition a lot of work was underway as part of the MERIT and TCT partnerships. Ms Ingram advised that the Trust needed to keep up to date with the reconciliation of systems i.e. what the workforce system was telling the Trust in terms of the number of vacancies and what the finance system was telling the Trust in terms of the number of vacancies. A discussion was raised around accountability where it was agreed that Ms Ingram would request the Workforce Committee to consider any additional actions to support resolution of the vacancy and staffing issues. Whilst some improvement was noted, the Committee noted that further work was required given the risk the performance issues
Ms Ingram
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108.2 108.3 108.4 108.5
posed to the Trust. Action point 99.3.1 – Data Quality Improvement Plan Mr Parker noted that the action point had been captured incorrectly, advising that a CAMHs scorecard was already in place. The action related to looking at where the Trust was at in relation to process and to discuss CAMHs KPIs moving forward with Commissioners. Mr Parker informed the Committee that a meeting had taken place with CAMHs and the informatics team to look at information flows and the establishment of data sets for:-
- CAMHs; - i-CAMHs and; - CAMHs Eating Disorders (the only indicator with targets)
A data set had been agreed that looked at discharges, referrals and waiting times, which would be submitted to Commissioners on a monthly basis. It was noted that the CAMHs Service provided the Trust with an opportunity for growth; this had been factored into the STP. Action point 99.4.1 (a) – PbR Update Mr Davies advised the Committee that he had liaised with Mr Byng with regards to the caseload data presented within the PbR report. My Byng acknowledged that there was an issue with the caseload data presented, which would be reviewed and reconciled for Month 12. Action point 101.1.1 (a) – Workforce Report Month 10 Headline vacancy/apprenticeship numbers required for Trust Board to be progressed via the Workforce Committee. Action point to be removed. Action point 98.2.1 – Data Systems and Clinical Review
Mr Lancaster referred to action point 98.2.1 colour coded “blue” – Data Systems and Clinical Review. Mr Lancaster questioned the timeline of June 17 given that work around a clinical system needed to be progressed. Mr Davies provided a position update, confirming that a meeting between relevant individuals had been held.
109. PERFORMANCE
109.1 Performance Report – Month 11
Mr Vasia talked through the key messages as reflected on page 5 of the report. The following points were raised and noted:-
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• Assurance was provided that the issue relating to bed
numbers had now been resolved. • In relation to the number of individuals receiving
Psychological Therapies, Walsall CCG was likely to revert back to a “red” rag rating. A lengthy discussion was held around the IAPT KPIs. Ms Ingram, as Accountable Director explained to the Committee the actions taken by the Trust in an attempt to increase demand, in addition to explaining the challenges resulting in the Trust not being able to achieve the IAPT KPI targets. Ms Ingram advised that the challenges faced by the Trust had been sent to Commissioners. It was agreed that Ms Ingram would share the response from Commissioners via the Committee and Trust Board, once received. Mr Lancaster acknowledged the importance of highlighting the actions being taken by the Trust to the Board. Mr Lancaster also acknowledged the importance of closely monitoring those KPIs with no financial impact but an impact on patient care.
• Mr Lancaster commented that the Performance Report included a significant amount of statistical data, making it difficult for the Committee to understand the “real” issues for the Trust. Mr Lancaster added that the Trust needed to be focusing on, and dealing with the “Must Do’s”.
• Ms Ingram referred to page 17 of the report, challenging the figures presented re; referral discharge outcomes going into secondary mental health services. Mr Parker confirmed that this data was incorrect due to some data quality issues.
The Committee discussed and noted the contents of the report. Mr Vasia left the meeting.
Ms Ingram
109.2 KPI Priority List
Mr Parker talked the Committee through the full list of 2017/18 Key Performance Indicators from the NHS contracts with Dudley and Walsall CCGs. Dr Gingell and Mr Banks joined the meeting. The following points were raised and noted:-
• IAPT Access Rate; Dudley were performing better than Walsall.
• Eating Disorders was a new service with a contact now in place for Dudley also. Rigorous and tested reporting processes were in place. No immediate financial impact. Active engagement noted from teams.
• KPI re; proportion of adult patients with a stay of 40 days
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or less related to Dudley patients only. Dr Gingell commented that the target was tight. Mr Parker confirmed that the Trust had not gone above 36 days in any given month over the last 12 month period. Against the KPIs where a Walsall target was not applicable, the Chair was of the view that the Trust should still be monitoring the performance of Walsall against these KPIs. Dr Gingell advised that the targets were set via Commissioners, whilst accepting that Dudley and Walsall Commissioners had very different requirements. Ms Ingram suggested that a system was implemented via Mr Parker to monitor Walsall performance, however, asked the Committee to be mindful that services and requirements were different across Dudley and Walsall borough’s and it was therefore likely that deviations would arise.
• KPI re; proportion of patients within cluster review periods, the Trust had already achieved the Qtr1 target of 80% compliance. However, the target increases throughout the year would be challenging for the Trust. Mr Parker advised that Qtr2 target was likely to pose an issue. Whilst Dr Gingell felt more satisfied with the position, Dr Gingell acknowledged there was further work to do. The Chair requested that the committee received assurance from Mr Parker re; robust plan to achieve 90% compliance in Qtr2.
The Committee discussed and noted the contents of the report.
Mr Parker
Mr Parker
110. PbR Update
110.1 Mr Davies talked through the key messages of the report as per page 13. Mr Davies commented that the loss of income was not notional. The position with regards to under delivery against target continued. It was disappointing to note that the Trust was achieving a lower level of clustering compared to last year. A discussed previously, the caseload position – page 8 of the report would be reviewed and reconciled for Month 12. Mr Lancaster requested clarity around what the data within the report told the Committee. Dr Gingell advised she would talk Mr Lancaster through the detail of the report, outside of the meeting if required. The Committee discussed and noted the contents of the report.
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111. FINANCE
111.1 Finance Report – Month 11
Mr Banks talked through the key messages as reflected on page 5 of the report, highlighting a Month 11 surplus of £1,566k and a favourable variance against plan of £8k year to date. The following points were raised and noted:-
• The Trust’s Expenditure – Pay position had not changed vastly over the last few months.
• The Trust-wide activity position at Month 11 was reflecting an under performance of £632k – mainly due to QUIPP and additional impact in Dudley during Month 11 due to IAPT financial penalty. It was confirmed that the Trust was likely to receive further financial penalties at £23k per month. It was requested that Mr Parker compiled a paper for Trust Board re; IAPT and implications. The Committee agreed that the Trust really needed to look at its strategic position with regards to IAPT; Mr Parker commented that the position was likely to worsen in 2018/19 given the introduction of outcome payments for delivery.
• The Trust was less than £50k away from achieving the cost improvement target for the year.
• Expenditure Capital – Trust expected to hit target by year end.
• Single Oversight Framework – current month position and forecast position for the Trust by year end was giving a maximum rating of 1.
• Discussion held around detox beds. Divergent reasons noted for not achieving target. It was agreed that Dr Gingell and Mr Parker would consider the opportunity to charge Dudley Public Health (income generation) for dual diagnosis patients where one diagnosis related to detox.
• NHSI Agency Expenditure Cap 16/17 – noted a move away from plan over the last few months. Mr Lancaster commented that the Trust appeared to be moving towards the same position at year end, to where the Trust started at Mth 1. Mr Banks explained that the Trust had needed to utilise agency to support one-off elements, either by Commissioners wanting to trial/pilot work-streams, funding waiting list initiatives or by other factors needing support such as projects like e-rostering. Mr Banks was requested to undertake a high level review of the agency costs to date, showing what elements of the total costs would or wouldn’t be within the Trust’s control.
• It was noted that Ms Ingram and Mrs Musson were working on a significant piece of work around bank recruitment.
Mr Parker Dr Gingell/Mr Parker Mr Banks
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• Re; TCT Partnership, a protocol around how vacancies would be managed would be discussed amongst the three Executive Teams on 3rd April.
The Committee discussed and noted the contents of the report.
111.2 Income and Activity Report – Month 11
The Committee received and noted the Income and Activity Report for Month 11. Report reviewed and presented via CARM.
111.3 Service Development Income Opportunities (Deloitte High Level Market Assessment)
Mr Davies referred the Committee to page 10 of the report – Summary of Findings which summarised Deloitte’s review of seven development income opportunities. The following points were raised and noted against the development income opportunities identified:-
• The Trust was looking to maximise its contribution and income.
• 1. Eating Disorders – a Black Country and PAN Trust CAMHs Eating Disorders Service was now being provided. Trust receiving overhead contribution.
• 2. PICU – No work undertaken to date. View was that PICU was no longer an opportunity for the Trust (any opportunity would need to be developed as a wider Black Country bed strategy).
• 3. ASD and ADHD – The Trust was moving in the right direction. Income budget set up for next year.
• 4. Peri-natal Mental Health – Meeting being held on 11th May 17. New investment being made available on STP basis.
• 5. Home Treatment – Home Treatment for Older Adults being established. However, not a significant income opportunity. In response to Mr Lancaster, Mr Chamberlain provided clarity re; recovery of set up costs.
• 6. CAMHs Tier 2 – Significant monies been made available to employ 7 Tier 2 nurses in Dudley.
• 7. Rehabilitation Services – No additional income generated. This area provided the Trust with a growth opportunity. A meeting had taken place with partners and a number of work-streams established.
The Committee discussed and noted the contents of the report.
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111.4 2017/18 Income and Expenditure Financial Plan including CIPs
Mr Davies talked the Committee through the proposed revenue and capital budgets 2017/18. The following points were raised and noted:-
• Budget setting cost pressures for 2017/18 were built into the pay and non pay budgets (not a risk in addition to £1m).
• Clee Ward would now be refurbished as opposed to Kinver Ward. Mr Davies explained the reasons for this change, noting some learning experiences from the Clent Ward refurbishment i.e. maximising the number of available beds. Dr Gingell requested to see the detail re; how the process would be managed i.e. moving staff from Clee ward.
• The Chair questioned if the Trust would be joining up with other Trusts in relation to the Enterprise Wide Agreement for Microsoft Windows. Mr Davies agreed to pick this up, noting this could be an STP wide solution. Mr Davies advised that the Trust’s Income and Expenditure for 2017/18 would be taken to the Trust Board on 30th March for approval. The Committee had a lengthy discussion around the Trust’s Income and Expenditure for 2017/18, with Mr Davies explaining how the pay value of £50,568k was made-up i.e. out-turn in pay/pay award/service developments. Ms Ingram acknowledged that the biggest risk given the strategic challenges was capacity and resource. Mr Lancaster commented that the Committee had not received anything to suggest the Trust would achieve its CIP targets. At this point, Mr Davies referred the Committee to Appendix 2 – CIP proposals. In response to Mr Lancaster, Mr Davies confirmed there were 3 schemes that would take out posts namely the Vacancy Review, Apprenticeship Levy and Casual Vacancy Deductions. Mr Lancaster asked if the Trust had control of its staff budgets. Mr Davies advised that should any team report an under-spend in any given month, the monies unspent would not be carried forward into the following month. It was questioned if any of the schemes required additional staffing (where the Trust could not recruit to) or required any up-front investment. Mr Davies advised there was only 1 scheme where this would apply; 4 step down beds from DGoH. Ms Ingram provided assurance that the Trust had very robust controls over its recruitment and vacancy processes.
The Committee discussed and approved the Income and Expenditure and Capital Budgets for 2017/18.
Mr Davies
Mr Davies
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112. WORKFORCE
112.1 Update on NHSI Review of Agency and Locum Costs
Mr Banks provided a verbal update advising the Committee that the Trust had met with NHSI where the reasons for the Trust being over spent were explained and challenged. Mr Banks advised that NHSI had questioned if the Trust had considered international recruitment and were keen to understand if the Trust was able to support the overall financial position any further. It was noted that the progress made by the Trust had been recognised by NHSI which was positive.
113. Risk Register
113.1 Mr Davies provided a summary as follows:-
• The same 3 risks remained on the risk register in relation to CIP, Section 75 funding and electronic paper clinical records.
• Mr Davies provided assurance that the risks relating to CIP and electronic paper records were discussed on a regular basis.
• In response to the Chair, Mr Davies confirmed that the CIP risk would remain red for 2017/18 until Managers started to deliver against CIP targets, following which Mr Davies would consider changing the rag rating to Amber or Green.
• In relation to Section 75 funding, it was noted that Walsall MBC had refused to pay the balance of the management charge hence Mr Davies had written a letter to them. A further risk noted was that Walsall MBC would be serving notice on the Section 75 agreement, withdrawing their staff from Mental Health/secondary services. Ms Ingram advised that an urgent piece of work needed to be undertaken to ascertain what work social care staff were offering to the care package, work of which Walsall MBC would need to take back with the individuals concerned. Ms Ingram added that an external Consultant was currently scoping “how it will work”. Ms Ingram advised that the Consultant had acknowledged that service users in secondary care should not be jeopardised as a result of Walsall MBC serving notice on the Section 75 agreement.
114. Any Other Business
114.1 No items of any other business noted.
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114.2 Minutes of the Estates and Capital Planning Group Meeting held on 26th January 2017 – for information
The minutes were enclosed for information. Mr Lancaster suggested the ECPG meetings being more structured moving forward and suggested another Executive Director being in attendance to ensure a balanced approach. It was requested that the service line report be circulated to Committee members and added to the Committee agenda in April.
Mr Banks/Ms Jackson
115. Date and Time of Next Meeting
115.1 Friday 21st April 2017 14:00 to 17:00 hours Conference Room 1, Trafalgar House, Dudley.
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Trust Board Meeting date: 4 May 2017
Agenda Item number: 7.1.2c Enclosure: 11
Finance Report
Finance Report Month 12 Page
• Key Messages: Current Performance 1
• Single Oversight Framework (NHS Improvement) 2
• Overall Summary and RAG Assessment 3-4
• Trust Summary Income & Expenditure Statement: Functional Analysis 5-8
• Cost Improvement Programme 9
• Agency Cap / Agency Spend by Staff Group / Reported Shift Breaches (weekly) 10-12
• Capital Programme 13
• Payables Performance & Aged Debt 14
• Cash Flow Statement 15
• Statement of Financial Position (Balance Sheet) 16
Key Messages : Current Performance
Financial Position £1,703k surplus at Y/E £3k Favourable variance
• The Trust has delivered a year end surplus of £1,703k.
• This represents a favourable variance of £3k against the planned surplus of £1.7m for the financial year.
• NHSI have indicated that additional STF funding will be available to those Trusts which have delivered their control total for the year – at this stage indications are suggesting this may well improve the finance position by a further £4k to a position of £1,707k (final details will not be known until 24th April when allocations are finalised).
Expenditure – Pay £1,326k Favourable variance
• Pay expenditure is £1,326k in surplus against budget at year end, which has been driven by surpluses within Community and Corporate Ops.
• Bank & Agency spend equates to £592k in month (split £434k for Agency and £158k for Bank), which is up on the Month 11 spend of £583k..
• Agency spend has finished the year behind plan by £764k in relation to the overall £4.05m Agency target for the year (actual spend of £4,814k against £4,050k plan).
Expenditure – Non Pay
£828k Adverse variance
• Non-Pay expenditure is £828k in deficit against budget for the year (which includes the impact of Reserves of £681k, offset by depreciation of £9k and PDC of £148k, giving a ‘pure’ NonPay overspend of £304k for the year).
• Reserves are over committed by £681k reflecting the impact of un-devolved CIP not allocated down to service lines, non pay items such as water testing and IT expenditure as well as provisions made against NHS Prop Co charges and CQUIN under-delivery clawback.
• The Trustwide Activity position at year end reflected an under-performance of £675k and is explained as:
• Dudley CCG is now on block but is reflecting a £173k adverse position due to a financial penalty imposed around IAPT access and failure to achieve actions agreed as part of the agreed RAP.
• Walsall CCG has over-performed against its ‘cap and collar by £500k but has been deflated by £432k in relation to the impact of QIPP funding being removed.
• Other smaller CCG contracts in total (such as Birmingham and Worcester) over-performed by £37k
• NCAs have over-performed against plan by £184k
• The activity in the Detox beds at Bushey Fields has under recovered by £88k
• The Net position is an over-performance of £28k, however, after taking account of the impact of the CIP target that has been applied to activity, being £703k , overall performance is £675k behind plan.
• Non-contracted Income such as SLA’s and Education Income are ahead of expected plan and are mitigating against the current under-performance in contracted income mentioned above, giving an overall adverse income position for the year of £496k (which includes Interest Receivable of £7k).
CIP plans delivered for 2016/17
Recurrent Under Delivery of £986k at Year End
• The Trust’s Cost Improvement Target for the year is £2,500k and schemes have been developed for the year equating to £2,587k. For the year delivery of schemes equates to £2,471k (both on a recurrent and a non-recurrent basis).
• At year end there are £986k worth of schemes that did not delivery on a recurrent basis and this shortfall will be carried over into the 17/18 CIP plans. Of these schemes the two Income CIPs of £703k (relating to Acute Wrekin beds and OA Dementia beds) have been covered in part during the year on a non-recurrent basis through activity over-performance and NCA’s.
Expenditure - Capital
£1,638k spend for the Year
• The Capital Programme had originally been agreed at £2,748k for the year.
• It has been agreed with NHSI that several of the schemes be carried over into 2017/18 as part of a revised plan – thus in year the plan has been revised down to £1,639k. The Trust spent to the revised plan level at year end.
1
Single Oversight Framework – Trust Performance
Commentary
• The Single Oversight Framework is designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’. The Framework doesn't give a performance assessment in its own right.
• The Framework will help NHSI identify NHS providers' potential support needs across five themes: - quality of care - finance and use of resources - operational performance - strategic change - leadership and improvement capability
• NHSI will segment individual trusts according to the level of support each trust needs. NHSI can then signpost, offer or
mandate tailored support as appropriate.
• Scoring a ‘4’ on any finance metric will mean the overall rating is at least a ‘3’, triggering a concern.
• Current month position and position for the Trust at year end is giving a maximum rating of 1.
2
M11 M12 Forecast Outturn subcode Plan Actual Plan Actual Plan Actual
Liquidity Ratio Days 373 57 69 57 69 57 69 Liquidity Ratio Metric 374 1 1 1 1 1 1
Revenue Position • The plan for the year currently reflects a planned surplus position
of £1.7m.
• At year end the Trust delivered a surplus of £1,703k, which was £3k ahead of plan.
• Total Income after taking account of the impact of the applied CIP (£703k FYE) is reflecting an under-performance of £675k, coupled with other SLA and Educational income giving a total under-recovery of £489k on income.
• Income is also currently reflecting the impact of Walsall CCG QIPP clawback and Dudley IAPT penalties.
CIP 2016/17 Delivery • The Trust has a declared plan of £2,500k for 16/17 and has
updated schemes in place totalling £2,587k.
• The Trust was unable to deliver £986k of the CIP plan on a recurrent basis but was able to deliver this in year through non-recurrent means
Budgetary Reserves • Trustwide Reserves are reflecting a balance of £494k for the
year, and are over-committed by £681k at year end – this is due primarily to un-devolved CIP schemes, commitments to support partnership working, one-off non-pay costs around water management and IT and provisions for NHS Property Company and CQUIN under-delivery clawback.
3
Statement of Comprehensive Income - Financial Position to 31st March 2017 Annual In Month Year To Date Plan Plan Actual Variance Plan Actual Variance
Trust Summary Income & Expenditure Statement Including Functional Analysis
Commentary
• The Trust is showing a £675kk under-performance position against contracted activity levels. This is due to reporting the potential impact of clawback of QIPP monies from Walsall commissioners which is offsetting the benefit of the £500k Full Year Effect (FYE) ‘cap and collar’ over-performance. Coupled with this we also have the impact of £703k relating to the CIP target for 2016/17.
• Corporate areas have finished the year in a surplus position which is due to surpluses within Governance, MCA DOLs and Liaison & Diversion.
• Central Reserves are reflecting the impact of CIP schemes that have not been devolved down to service lines, as well as one-off costs around water management and IT as well as NHS Property Company and CQUIN clawback provisions.
• Acute and Older Adult Services are £18k in surplus at year end, despite being impacted by overspends within Inpatient areas (including Bank and Agency).
• Community areas are also in surplus due to additional funding received during the year that was not fully utilised due to slippage on recruitment.
• The Trust has out turned the year at a surplus position of £3k ahead of the trajectory to deliver the £1.7m planned surplus at year end.
5
Annual Plan In Month Year to Date
2016/17 Plan Actual Var Plan Actual Var £'000 £'000 £'000 £'000 £'000 £'000 £'000
• The Trust is now operating on a block contract with Dudley CCG and Walsall CCG, with the exception of Cost & Volume for Inpatients, CRS and EAS in Walsall.
• Neighbouring CCGs remain on block contracts with the exception of Birmingham CCGs where there is a cost per case arrangement in place for Inpatient activity that exceeds the agreed plan.
• The position at the moment still reflects the potential claw-back aligned to QIPP from Walsall CCG.
• In terms of the impact on the year end forecast this QIPP element has been scaled back by 50%.
• Walsall activity is currently over-performing against Inpatients, CRS and EAS, however, the contract includes a ‘cap and collar’ arrangement of £500k pa which limits the impact of any over/under-performance to £43k per month. (true over-performance at year end is £2,240k).
• Dudley contract has under-performed at year end by £15k on the traditional currency method – this is due to under performance within CRHT, EI and Primary Care, offset by over-performance on CAMHs. Despite being on a block contract we are reflecting an adverse financial impact for the year due to penalty charges around non-delivery of IAPT.
• NCA’s reflect an over-performance of £184k to date.
• In patient detox service at Bushey Fields is currently £88k adrift against the annual target.
• CIP of £703k has also been applied to activity which means a required over-performance of £59k each month in order to deliver the target.
• Overall the Trust under-performed by £675k against its target for the year.
6
Annual Plan In Month Year to Date
2016/17 Plan Actual Var Plan Actual Var £'000 £'000 £'000 £'000 £'000 £'000 £'000
NCA - Other HC 0 0 0 0 0 (4) (4) Total Revenue from LAs 448 88 81 (7) 448 355 (93)
Total Revenue from Activies 62,480 5,370 5,327 (43) 62,480 61,805 (675)
Trust Income & Expenditure Statement - Corporate Functions
Commentary
• CEO – Vacancy slippage continues against the new Liaison and Diversion service and CSD department which continues to support the function which has overspends generated by CEO/PA/Non-Exec areas from current investigations.
• Corporate Affairs – Public Engagement and Legal fees in month 12 are the
drivers behind the in month change. Overall overspends generated by over establishments on SED and increased costs of Project Management on FT Project. These are partially offset by the benefit of reduced costs from maternity leave and vacancy slippage against Business Development.
• Corporate HR has deteriorated in month due to the impact of the new DBS
system and its implementation with temporary staffing. There is also an impact of the current temporary arrangements employed within the trust.
• Corporate Medical – One Clinical Director post still remains unfilled which is offsetting some non-recurrent impacts within Pharmacy and Admin from Agency.
• Corporate Estates – As expected the position within Estates has fallen back
in the month reflecting an increased level of activity in the last month of the year. Overall benefits from ISS recharges/Falcon House/Estates Maintenance are covered by the impact of the Water Maintenance regime this year.
continues to persist and supports a number of non-recurrent activities including additional Psychology duties, CQC remedial costs, Interpreting and in particular Psychology Trainee where additional PAYE benefits have had to be paid to previous trainees. It has also been agreed that temporary staffing being utilised in the E-rostering team will continue until longer term plans have been formulated. In month we have had the benefit of capitalisation of costs from CQC activities, R&D network income slippage and additional LDA income on trainees where they had been on LTS/Maternity leave.
• Corporate Finance – Various cost pressures remain including Finance
memberships, Asset revaluation and Quality accounts offset by non-committed budget and slippage against the Director of Finance post.
• Corporate IT/Performance – Saving on EPR due to postponement of the
system until next year. IT contract/Records Management continue to run below budgeted levels. In month change due to a contribution towards BCP for the EPR license arrangement. 7
Total Corporate Functions (12,309) (1,019) (1,091) (72) (12,309) (11,885) 424
Trust Income & Expenditure Statement - Operational Services
Commentary
• The Acute & Older Adult service Year To Date (YTD) position has improved by £8k in March, bringing the total 2016/17 variance to a total of £18k below budget. This is £70k better than expected, as Acute inpatient costs were significantly below average in March (due to lower observations than average on the female wards), and CRHT agency staff worked less shifts than planned in March.
• (In-month, there was an underspend of £8k on Acute inpatient staffing,
and an overspend of £36k on OA inpatient staffing, which was more than offset by various management and OA Community vacancy savings).
• The Medical Service YTD position has improved by £12k in March,
bringing the total 2016/17 variance to £201k below budget. This is in line with the forecast.
• Community Estates – Expected to be around break even on historic run rates. The NHS Property Company effect is being shielded from the position where we have outstanding debt of £1.5M which we are disputing due to the rates applied and the building space we occupy (now and in the past).
• Community Services & Recovery - results have improved by £12k in
month to £133k favourable. The driver for this is from non-recurrent income on Employment Support being kept in year and so realising the benefit. There is an expectation that this will need to be managed within the trust as activities are expected to continue.
• Community Management – HoS post still vacant. Monies currently covering cost pressure on Band 7 Nurse (0.46wte). Old year accruals have been moved here for vacated buildings have bene used to support the trust wide position.
• EI – The overall position has improved in month by £123k to £392k. The drivers for the improvement are from slippage from the Dudley CAMHS areas where a significant investment has been made in year. It is expected that with the additional monies coming into service in 1718 that there will be outcomes that will need to be managed by the trust given the level of slippage money which has been retained in 1617.
8
Annual Plan In Month Year to Date
2016/17 Plan Actual Var Plan Actual Var £'000 £'000 £'000 £'000 £'000 £'000 £'000
Total Community Services (15,003) (1,369) (1,234) 135 (15,003) (14,432) 571
Medical Services (11,855) (1,041) (1,029) 12 (11,855) (11,654) 201
Total Operating Services (45,424) (3,967) (3,812) 156 (45,424) (44,634) 790
Cost Improvement Programme
Commentary
• Target for 2016/17 = £2,500k.
• Trust had identified schemes for the year which could deliver £2,664k Full Year Effect (FYE), but three schemes have been re-assessed (CIP001, CIP005 and CIP009) and have been reduced by £10.0k, £69.6k and £7.2k respectively, thus giving a revised scheme values of £2,577k.
• As at month 12 £2,483k of the schemes had been devolved to appropriate budget areas and £94k were being managed centrally in reserves.
• Of those devolved schemes £1,768k have been transacted to date.
• At this stage there are several schemes still at risk of non-delivery on a recurrent basis. These have been highlighted in the table opposite under the ‘At Risk’ column and currently equate to £986k of risk.
• Of these, schemes CIP003 and CIP005 (relating to Income) are being covered non-recurrently through the over-performance within the Walsall Contract and NCA Income.
• CIP010 (Medics) has recurrently part achieved due to savings on the LDA training contract. Additional benefits have been scoped and now actioned, but there still remains a recurrent risk of full delivery
9
Annual Schemes Schemes Transacted to Date
(against original scheme)
Likely Achieveme
nt
Cost Improvement Programmes (by POD) Ref Plan Devolved Held
• For 2016/17 the Trust has been tasked with working within an overall agency expenditure cap of £4.05m for the year, which represents a circa. 35% reduction on the actual spend in 2015/16.
• The planned spend across the year has been profiled in line with the workforce plan based on increasing recruitment of substantive staff and the use of bank staff to offset the previously required use of agency staff. At year end the Trust finished at £764k behind plan in terms of anticipated agency spend (£4,814k spend against £4,050k plan).
• At year end the spending on Agency staffing equated to £4,814k, which when compared to the plan of the £4.05m target meant the Trust exceeded the plan by £764k.
• Previously we had seen a levelling out of spend during the last several months (circa £330k) but we have seen a peak of spending over the last five or so months of over £400k.
• Some of this extra spending has been the result of additional support needed to cover areas such as:
• 1-2-1 observations
• Support for one-off project works, such as E-rostering and Water Management
• Delivery of in year waiting list schemes funded non-recurrently by commissioners, for example, CAMHs.
• These additional costs have meant that the Trust has exceeded its target for the year.
11
In Mth (£000) Year End (£000) Plan Act Variance Plan Act Variance
note 1 note 2 note 3 Malvern £36.4 Estates £166.6 Walsall CAMHs £110.1 Wrekin £27.6 E-Rostering £121.8 Pharmacy £17.0 Clent £48.6 IM&T £87.1 Dudley CAMHs £136.0 Kinver £52.6 DPH / BF Med Secs £82.2 Dudley Primary Care £260.5 Langdale £102.7 HR £53.4 Walsall Primary Care £48.5 Cedars £77.6 PA's Exec Office £21.1 PT Hub £8.8 Linden £142.3 Various (incl. £131.0 OA Malvern / OT / £59.7 Ambleside £153.7 Primary Care / Mgmt / EAS Holyrood £133.2 CAMHs / SED) Adult In-Pats £16.0 Dudley Primary Care £11.1
£785.6 £663.2 £656.7
Agency – Reported Shift Breaches to NHSI (weekly)
Commentary
• The above graph represents the reported shift breaches, both in terms of agency staff who are not on an approved framework agreement and /or who are charging hourly prices above the mandated agency cap rates.
• Reporting is reflective of staff groups as per TFIMS headings – Medics do not appear on this analysis as they are covered under StaffFlow which ensures that agencies used and rates paid are in line with the mandated agency rules.
• Proposed Capital Funding for 2016/17 has been amended at Month 9 to reflect the delay in the purchase of the Trust’s Electronic Patient Record System.
• The Trust has fully spent against the revised capital programme for the year.
13
Payables Performance & Aged Debt
Commentary on Payables
Better Payment Practice Code • The Trust has achieved the required target for NHS invoices by number and by value in the current
month.
• In terms of YTD all areas still remain outside of the 95% threshold, albeit marginally for NHS.
• Performance earlier in the year was impacted by the decision to hold payments at the end of March to ensure the Trusts cash balance remained within External Financing Limits at the year end.
Commentary on Aged Debt
Aged Debt Profile by Value • 18.0% of debt was aged 90 days or older at the end of the year (this figure was 17.2% at the end
of the previous month).
• Debt between 91-120 days (totalling £13k) relates in the main to:
• Dudley MBC £5.2k re salary recharges
• Walsall CCG £8.1k re CAMHS Eating Disorder funding
• Debt over 120 days old (totalling £108k) relates in the main to:
Current 31-60 days 61-90 days 91-120 days 120+ days
Debt Profile and Value Current 31-60 days 61-90 days 91-120 days 121+ days Total £000 £000 £000 £000 £000 £000 £426 £30 £95 £13 £108 £672
Aged Debt Value % of Total
Agreed
Tolerances £000 Debt
Over 91 days >20% 10% - 20% <10% £121 18.0%
Over 120 days >10% 5% - 10% <5% £108 16.0%
Cash Flow Statement
Commentary
Cash Flow • The Trust has made an operating deficit of £13,373k in
2016/17 and received cash of £1,720k in respect of depreciation and amortisation
• The Trust has transacted £15,764k of net impairments in 2016/17 as a result of asset valuation and verification exercises
• Trade and Other Receivables have increased over the period (a negative impact on cash)
• Trade and Other Payables have increased over the period (a positive impact on cash)
• The Trust has received £33k of interest, and spent £1,436k on capital (£262k increase on capital payables has been recognised and offset against £1,638k on 2016/17 capital expenditure). Total capital expenditure in cash terms was less than the cash received for depreciation and amortisation (a positive impact on cash)
• The impact of all these movements was to increase the Trust’s cash balance Year to Date by £2,672k
15
Statement of Financial Position
16
Commentary
Non Current Assets • Amortisation and depreciation exceeds capital expenditure
for the year decreasing the value of the Trust’s Non-Current Assets in the year
• In addition, the impact of the MEA land and building asset impairment and year end valuation has decreased the value of the Trust’s Property, Plant and Equipment assets by a further £18,562k
• Final outturn against capital schemes is reviewed later in this report
Current Assets • Receivables have increased by £38k in 2016/17
• Cash is £2,672k higher than the balance at 31 March 2016
• An analysis of cash flows can be seen elsewhere in this report
Current Liabilities • Payables have increased by £957k in the financial year
• There has been a decrease in provisions in the year of £37k
Tax Payers’ Equity
• The Current Year I&E figure represents the net effect of the surplus for the year to date of £1,708k and non-current asset impairments of £15,764k
• This is £8k ahead of the revised plan for the year and £4k of this relates to STF pound for pound incentive expected
Rupert Davies, Interim Director of Finance, Performance, IM&T and Estates
Author (name & title):
Jacky O’Sullivan, Clinical Development Director/Acting Associate Director of Operations
Purpose of the report: To present to the Board a summary of the current status of the
Cost Improvement Programme for 2017/18.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: MExT and CIP Programme Board
Date reviewed: 18th April 2017 for both meetings
Key points or recommendations from Committee:
• Outstanding QIAs and workbooks to be completed by the 5th May
• Joint Medical Directors and Director of Nursing to review QIAs before the 16th May
• All QIAs to be presented to CIP Programme Board 16th May, Q&S 14th June and Board development 19th June.
Strategic Objective(s) to which this paper relates: High quality
services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
Plans use evidence based practice to ensure improvements in quality, outcomes and patient experience.
Responsive
Plans are developed to ensure responsiveness to service user needs.
Effective
Plans represent best value to ensure CIP plans are met through efficiency and effectiveness
Well-led
All transformational and service development plans have a project team approach to both development and implementation.
Safe
All plans are assessed for the need for a Quality Impact Assessment and where indicated a full assessment including risks and mitigations is undertaken and monitored.
Enc 12 Trust Board CIP report April v2 Page 1 of 12
CIP ideas brainstormed and scoped by Management Executive Team (MExT) and wider
Yes
Idea developed and presented to MExT MExT approve/reject
No Idea archived
Project Overview Document (POD) developed & submitted to MExT for approval & sign off –
including QIA, EIA, PIA & risks
Implementation Stage
Final QIA and risks presented to MExT for project closure
Summary of schemes including Quality Impact Assessment (QIA) & risks submitted to Trust Board
Review of all strategic themes by Trust Board to agree which proceed further within these
QIA & risks on delivered projects presented to MExT for sign off including Director of Nursing & Medical Directors
All projects – complete POD Completed PODs & QIA signed off by Director of Nursing and Medical Directors and MExT
Final QIA and risks presented to Trust Board for final sign off
Idea archived No
Enc 12 Trust Board CIP report April v2 Page 2 of 12
Title Cost Improvement Programme (CIP) Progress Report
Introduction The purpose of this report is to present to the Board a summary of the current status of the Cost Improvement Programme for 2017/18. Summary of key points, issues and risks 1.0 CIP 2016/17 4 schemes were carried over into 2017/18 (appendix 1), these are: Dudley Older Adult Service Early Intervention Service Line Developments Medical Services Establishment Review Payroll
Two schemes are expected to deliver in quarter 1. The Dudley Older Adult Service scheme is dependent on the implementation of the new service model. The schemes are being monitored by the CIP Board. 2.0 CIP 2017/18
£ • Target for 2017/18 3,780,000 • Projects in total (full year effect) 4,778,000 • Forecast year end position 3,737,300 • Variance 998,000
There are 19 schemes for 2017/18, of which 9 are subject to QIA approval by the Quality and Safety Committee and the Board prior to implementation. The QIAs were reviewed at MExT in March and it was agreed that more detail is required to understand the risks. These schemes are: Walsall QIPP Access Pathway (Urgent Care) Estates Review TCT Back Office Review Vacancy Review Apprenticeship Levy Walsall Carers Service Efficient Recovery Pathway Review Dudley Primary Care & IAPT Decommissioning Operational Budget Reserves
6 new schemes have been proposed, and the QIAs are being undertaken for these. The schemes are: Increase NCAs Corporate Operations Shift Pattern Review 4 Step Down Beds from DGoH Casual Vacancy Deductions (Non recurrent) Budgetary Reserves
Enc 12 Trust Board CIP report April v2 Page 3 of 12
A full list of projects can be found in appendix 2. The CIP Board will be monitoring and tracking the progress of these schemes to report risks, and mitigations to the Finance and Performance Committee and the Board. The RAG rating for the forecast year end position is as follows: - RED Will not achieve full target AMBER Will not deliver full target until 18/19 GREEN Will achieve FYE by March 18
3.0 CIP 2018/19 3 schemes have been identified to realise savings in 2018/19 (appendix 3). These schemes are: Walsall QIPP Rehab Savings Walsall QIPP Bloxwich Costs Productivity Growth in Dudley Locality
The QIAs are being completed for these schemes and will be presented to the Quality and Safety Committee and Trust Board for sign off. Further detail (if required) Appendix 1, 2 and 3 contain further details of the schemes. Recommendation Trust Board members are asked to note the contents of this report and receive it for information and assurance. Board action required As recommended.
Enc 12 Trust Board CIP report April v2 Page 4 of 12
Appendix 1 – 2016/17 CIP schemes
Division Type Ref. Project Title Exec Lead
FYE Value
(£)
Implementation Progress Report
Ove
rall
Proj
ect
Stat
us
Plan
Fina
nce
KPI
s
Ris
ks
QIA
Operations Transformational CIP007-16
Dudley Older Adult Service
WP 118,300 R A R N/A A A £61k to be delivered recurrently
Operations Transactional CIP009-16
Early Intervention Service Line
Developments
WP 172,480 R A R N/A A A £42,476 to be delivered recurrently. Scheme expected to meet the target in quarter 1.
Medical Transformational CIP010-16
Medical Services - Establishment
Review
MW / KG
350,000 R A A N/A R A £150k to be delivered recurrently
Corporate Transformational CIP017-16
Payroll MI 24,000 A A A N/A 6 A Scheme expected to meet the target in quarter 1.
Enc 12 Trust Board CIP report April v2 Page 5 of 12
Appendix 2 – 2017/18 CIP schemes
Operations Scheme Executive
Lead Links to
other projects
Value £
Overall Project Status Pl
an
Fina
nce
Ris
ks
QIA
EI
A
PIA
KPIs Implementation Month
Mon
th 1
RA
G
Mon
th 1
1 Fi
nanc
ial
Posi
tion
(FYE
) Fo
reca
st Y
ear
End
RA
G
Fore
cast
Yea
r En
d Po
sitio
n
Walsall QIPP Access Pathway (Urgent Care)
Remodeling of the urgent care pathway in Walsall as part of a QIPP will potentially deliver this scheme. The CCG will review the outcome of the recent pilot before any commissioning decisions are made.
Lesley Writtle
None 150,000 R R R
No
impa
ct
Yes
N/A
75,000
Estates Review Review the Trust's portfolio of properties across Dudley and Walsall with a view to minimising the use of leased properties and maximising the use of owned properties.
Rupert Davies
None 100,000 R A A
No
impa
ct
No
impa
ct N/A 50,000
Dudley Primary Care & IAPT Decommissioning
Reduce expenditure on service by £200K in line with CCG reductions.
Lesley Writtle
None 200,000 R R R
No
impa
ct
No
impa
ct N/A 172,500
Operational Budget Reserves
Removing an uncommitted reserves budget
Lesley Writtle
None 150,000 R
No
impa
ct
No
impa
ct N/A 150,000
Enc 12 Trust Board CIP report April v2 Page 6 of 12
Increase NCAs Income generation through non contracted activity. QIA to be completed.
Lesley Writtle / Rupert Davies
None 200,000
N/A 200,000
Corporate Operations
Savings to be realised from the Corporate Operations budget. Review to be undertaken and QIA to be completed.
Rosie Musson /
Lesley Writtle
None 300,000
N/A 170,000
Shift Pattern Review
Rostering review or changing work patterns to deliver savings. QIA to be completed.
Rosie Musson
None 250,000
N/A 125,000
4 Step Down Beds from DGoH
Income generation through the provision of step down beds. QIA to be completed.
Lesley Writtle
None 238,000
N/A 178,500
Enc 12 Trust Board CIP report April v2 Page 7 of 12
Medical Scheme Executive
Lead Links to
other projects
Value £
Overall Project Status Pl
an
Fina
nce
Ris
ks
QIA
EIA
PI
A KPIs Implementation
Month
Mon
th 1
RA
G
Mon
th 1
Fi
nanc
ial
Posi
tion
(FYE
)
Fore
cast
Yea
r En
d R
AG
Fo
reca
st Y
ear
End
Posi
tion
Efficient Recovery Pathway Review
Savings to be realised from reduction in activity and new service model
Mark Weaver
Urgent Care
Outpatient
Review
250,000 R A A
No
impa
ct
No
impa
ct N/A 125,000
Enc 12 Trust Board CIP report April v2 Page 8 of 12
Corporate Scheme Executive
Lead Links to
other projects
Value £
Overall Project Status Pl
an
Fina
nce
Ris
ks
QIA
EIA
PI
A KPIs Implementation
Month
Mon
th 1
RA
G
Mon
th 1
Fi
nanc
ial
Posi
tion
(FYE
) Fo
reca
st Y
ear
End
RA
G
Fore
cast
Yea
r En
d Po
sitio
n
MEA Revaluation of Fixed Assets
PDC savings and IT depreciation moving to 7 years
Rupert Davies
None 400,000 G G G 0
No
impa
ct
No
impa
ct
No
impa
ct N/A 400,000
Inflation Topslice Topslice of inflation dependent on budget setting
Rupert Davies
None 125,000 G G G 0
No
impa
ct
No
impa
ct
No
impa
ct N/A 125,000
Enc 12 Trust Board CIP report April v2 Page 9 of 12
Trust wide Scheme Executive
Lead Links to
other projects
Value £
Overall Project Status Pl
an
Fina
nce
Ris
ks
QIA
EIA
PI
A KPIs Implementation
Month
Mon
th 1
RA
G
Mon
th 1
Fi
nanc
ial
Posi
tion
(FYE
) Fo
reca
st Y
ear
End
RA
G
Fore
cast
Yea
r En
d Po
sitio
n
TCT Back Office Review
This project will reduce the requirement of redeployment/redundancy when the TCT Trusts merge in coming months/years. This will contribute to current and future cost saving schemes.
Rupert Davies /
Ashi Williams
None 100,000 R A A
No
impa
ct
Yes
N/A
50,000
Vacancy Review Long term vacant posts will be assessed for continued requirement and removal
Ashi Williams
ECT project
400,000 R A A
No
impa
ct
No
impa
ct N/A
200,000
Apprenticeship Levy
This project will look at current band 2 and band 3 vacancies to establish where there are opportunities to introduce apprenticeships with scope to generate non recurrent savings. The assessment of vacant posts will then be extended to all under band 7, and a succession planning framework developed to include apprenticeships into workforce establishments in the future.
Ashi Williams
TCT Back Office review
240,000 R A G N
o im
pact
No
impa
ct N/A
60,000
Walsall Carers Service
Decommissioning of the carers service by the CCG will deliver savings.
Lesley Writtle
None 75,000 R A A
No
impa
ct
Yes
N/A
56,300
Enc 12 Trust Board CIP report April v2 Page 10 of 12
Non Recurrent Savings
A non-recurring contribution to the recurring shortfall of the 2016/17 QIPP. This relates to end of year provisions which may not be required in 2017/18, and can therefore be used to offset slippage on the QIPP.
Rupert Davies
None 500,000 A G G A A
No
impa
ct
No
impa
ct N/A
500,000
Non Pay Review (Travel savings)
Deliver savings via a review of the travel expenditure
Rupert Davies
None 100,000 G G G G G
No
impa
ct
No
impa
ct N/A
100,000
Casual Vacancy Deductions
(Non recurrent)
Non recurrent savings from vacancies
Rupert Davies / Lesley Writtle
None 500,000
N/A
500,000
Budgetary Reserves
Savings from budgetary reserves
Rupert Davies
None 500,000 N/A
500,000
Key: QIA = Quality Impact Assessment EIA = Equality Impact Assessment PIA = Privacy Impact Assessment KPIs = Key Performance Indicators NR = Non Recurrent R = Recurrent
Enc 12 Trust Board CIP report April v2 Page 11 of 12
Enc 12 Trust Board CIP report April v2 Page 12 of 12
Board meeting date: 4 May 2017
Agenda Item number: 7.1.3a
Enclosure: 13
Report Title:
Workforce Committee Chair’s Report
Committee:
Workforce Committee
Author:
Harry Turner – Non Executive Director
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
Introduction The Workforce Committee met on the 25th April 2017 and considered and discussed key topics around the Trust’s Workforce The Workforce committee agenda is categorised under 4 main areas, i.e.
Summary of key points, issues and risks WORKFORCE PERFORMANCE Workforce Performance Report Key messages from the Workforce Performance Report were:
- There are currently 157 FTE contracted vacancies across the Trust decreasing the vacancy rate slightly from 13.8% in Month 11 to 13.7% during Month 12.
- The TRAC recruitment system is currently being used within the Trust giving increased control and oversight to recruiting managers. A report on performance against recruitment KPIs is expected July 2017 and refreshed service recruitment plans are also being developed via the Workforce Committee.
- The 12 Month Turnover rate has increased from 10.33% to 10.53%. When comparing the Turnover (exc Jr Medics) rate of the trust against other Mental Health organisations in the NHS, the trust can be considered average in terms of % Turnover.
Enc 13 WFC Chairs Report May 17 FINAL Page 1 of 5
- The rolling 12 month sickness rate has decreased in Month 12 to 4.31% from 4.39% in
Month 11. This is within the Trusts target for the fifth consecutive month. - In month sickness has decreased from 4.59% in Month 11 to 3.33% in Month 12. A
probable reason for this change is the increase of annual leave absence during March. - Appraisal compliance has increased from 86.0% to 87.0% in Month 12. This is above
the Trust target of 85% for the second consecutive month. There are 114 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 223 reported in Month 6. Weekly/Bi Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements.
- Mandatory Training compliance increased to 89.8% in Month 12 from 88.9% in Month 11 and remains just below the target of 90% agreed at MEXT for all mandatory training. IG compliance for Month 12 is 96.0% which is above the 95% target for that competence. As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake in order to remain compliant.
The committee noted evidence of a continuing trend of improvement against workforce indicators. The need for alignment between reported vacancies and cost improvement plans was discussed. Work to achieve this was agreed for the next committee. Essential Training compliance A paper to update the Workforce Committee on key areas of work undertaken to support achieving mandatory and essential training compliance was presented which included
- A summary of 16/17 utilisation of mandatory and essential training places noting a high rate of DNA (20%) and significant wastage of classroom places for both mandatory and essential training.
- A revised trust wide mandatory and essential training matrix in response to service line changes further review with medics.
- A plan for 17/18 delivery of mandatory and essential training, including revised plans for delivery of Trust Induction.
- A draft accountability framework to underpin managing non-compliance with mandatory and essential training.
The committee approved the following proposals and recommendations made by the paper:
- Approved a proposed target of 40% uptake of training through use of ELearning. - Supported a continued focus on levels of DNA training. - Approved a revised Mandatory and Essential Training Matrix. - Supported the presented plan for delivery of mandatory and essential training 2017/18. - Approved the proposed review of induction to reduce the time allowed for completion of
mandatory and essential training from 8 weeks to one month. - Approved the recommendation that new starters are excluded from mandatory and
essential training reports for one month from the date of their employment.
Enc 13 WFC Chairs Report May 17 FINAL Page 2 of 5
- Approved the proposed Accountability Framework
STAFF WELLBEING Health and Wellbeing Update and Work Plan A Health and Wellbeing plan for 2017-18, underpinned by the workplace wellbeing charter principles was presented. The committee agreed to the principles and aspirations of the plan but requested further work be done to prioritise and cost actions contained within it to enable a clearer understanding of commitment required to implement this. ORGANISATIONAL DEVELOPMENT Non-Medical Prescribing A verbal overview was given about the current status of Non-medical Prescribing (NMP) within the Trust. There are currently 3 active NMPs (EI and Memory Service), 2 awaiting final results (CRHT) and a further qualified NMP about to begin prescribing (Early Access camhs). Expressions of interest have been received from 6 other nurses from a range of service areas. It was noted that NMP is now appearing as a requirement within service specifications from commissioners. Required infrastructure to support successful progression of NMP within the organisation was noted. Further work to develop a Trust wide strategy tied into workforce planning was requested by the committee. Learning and Development Agreement 2016/17 A presentation providing a retrospective look at income associated with the Trusts 2016/17 Learning and Development Agreement (LDA) with Health Education England (HEE) was given to increase committee member’s awareness of funding streams to better understand future implications of education funding reforms. Key messages were:
- Staged reductions in non-medical tariff income will continue through 17/18 and arrangements beyond are uncertain
- Staged increases in medical tariff income continue as per transitional plan up to 2020 - Learning Beyond Registration funding is uncertain for 17/18 impacting on the Trusts
ability to support CPD for non-medical registered professionals - Widening Participation income will cease 17/18 with Trusts expected to rely on
apprenticeship levy funding instead WORKFORCE COMPLIANCE Workforce Risk Register The Committee received the workforce risk register and the Committee was assured that the risk was being appropriately managed. Enc 13 WFC Chairs Report May 17 FINAL Page 3 of 5
Risk 317 in relation to staff receiving a regular appraisal of performance in their role is to be reviewed ahead of the next committee given the reported improvement in compliance exceeding the board set target over the last 2 months. If a 3 month trend in compliance is evident the risk will be reviewed and removed from the register. Risk 369 in relation to the technical process of change management as a consequence of TCT is to be reviewed to make specific reference to TUPE. Risk 61 in relation to risk of potential redeployment and redundancy is to be reviewed as the recorded risk score looks to be higher after mitigations in place. Board Assurance Framework Strategic Risk 4 Ability to Recruit and Retain Staff was presented to the committee for discussion and review. The committee agreed that the risk remains amber with a score of 12. Safe Staffing Levels The safe staffing level report was presented. Overall fill rates match requirements however continued focus on attaining optimum skill mix is needed. Mitigations were reported to be in place. Further assurances to be sought at the next committee meeting to monitor this. A speedier process for existing staff to join the trust bank is being introduced along with a major recruitment campaign to attract external candidates to join the bank. A verbal update was provided in relation to a deep dive into Cedars and Linden temporary staffing use. Route causes were reported to be linked to higher than normal levels of patient dependency and an increase in funded establishment, currently covered by temporary staff. A paper detailing recommendations from the current In Patient Establishment Review was presented. Further work is required to cost the impacts of higher than normal levels of patient observations. The committee have requested that the final report be presented to Finance and Performance committee and that a Quality Impact Assessment is also undertaken. Proposed Safer Staffing Metrics were presented to the committee and comments sought from committee members. Dashboard reports will commence from the next committee meeting. Roster Exception Report A Roster Exception report was presented to report progress and exceptions in relation to implementing e rostering and the Temporary Staffing Hub. Good progress was noted by the committee. By the end of April 17 all of the trusts workforce with the exception of medics will be on the Health Roster system. Medics were not in the initial remit of the project however it is considered timely to explore how manual processes can be moved onto the electronic system. Options will be explored in May and recommendations made to the committee.
Enc 13 WFC Chairs Report May 17 FINAL Page 4 of 5
The system has highlighted issues around use of overtime as opposed to bank/agency and therefore a robust policy around the use of overtime and the reporting and accountability for this is required. Agency usage for community and corporate service areas, managed locally are not subject to central oversight or control having an impact on agency spend. Consideration should be given to working hours of the Temporary Staffing Hub (currently Mon-Fri 8 to 5) to ensure adequate control over bank and agency usage, as well as meeting customer service requirements. The Trust should consider a move to weekly pay for bank staff to be competitive in the local market place and to align with strategic partners. NHSI require confirmation of audit control relating to IR35 and the Temporary Staffing hub would be able to accommodate this if all agency business Trust-wide were to be managed by the centralised Hub. Currently the Temporary Staffing Hub is being managed through temporary roles which are due to end in June 2017. In view of the TCT integration schedule and position of the project, the Trust should consider an extension of these arrangements until October 2017. Further work to measure progress against benefits identified through the e rostering and Temporary Staffing Hub original business case and benefits realisation plan are to be undertaken. NHSI on Medical Locum Usage and Best Practice NHSI Best Practice Guidance was shared with the committee in relation to reducing reliance on medical locum usage. Notification has been received from NHSI requiring a further in year reduction in spending on medical locums to the value of £87K. Recommendation and requests for direction The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Workforce Committee
Enc 13 WFC Chairs Report May 17 FINAL Page 5 of 5
Board meeting date: 4 May 2017
Agenda Item number: 7.1.3b
Enclosure: 14
WORKFORCE COMMITTEE MEETING
Minutes of a Meeting Held on
27 March 2017
Board Room, Canalside House, Walsall
START TIME 11:00 HOURS
Present: Olivia Clymer Non Executive Director (Chair) Mark Axcell Chief Executive Officer Rupert Davies Interim Director of Finance Ashi Williams Acting Director of People Marsha Ingram Acting Director of Operations Jacky O’Sullivan Clinical Development Director/Acting Associate Director of
Operations In Attendance: Mark Banks Deputy Director of Finance James Parker Commissioner Liaison Manager Andrew Campbell Chief Pharmacist Anne Marie Carey Head of Urgent Care and Access and Early Intervention Services Paul Singh Equality and Diversity Manager Peter Hayward Consultant OT Hannah White Senior HR Business Partner Becky Temple-Purcell Senior Workforce Development Manager Catherine Needham Senior OT (observation purposes) Emma Jackson Note Taker Apologies: Harry Turner Associate Non Executive Director Dr Kate Gingell Joint Medical Director Dr Mark Weaver Joint Medical Director Rosie Musson Acting Director of Nursing Michael Hirons Staff Engagement Lead/FSUP Guardian Nick Stephens Head of Community Services Daniel Peniket ESR Systems Manager Rebecca Salari Interim Head of Communications Enc 14 WFC Minutes 270317 (PTB Version) Page 1 of 9
ACTION 24. Apologies For Absence
24.1 Apologies noted as above.
25. Declarations of Interest
25.1 No Declarations of Interest noted.
26. Minutes of Previous Meeting held on 21 February 2017
26.1 The minutes of the previous meeting held on 21 February 2017 were agreed as an accurate record. Mrs Williams expressed her thanks to Ms Dixon for taking the notes at the meeting in February.
27. Matters Arising
27.1 27.2 27.3 27.4
The matters arising were discussed and an update was provided on those actions where appropriate: Item 7 – WRES Meeting held between Mr Singh and Ms Salari. Noted that some communications would be sent to staff – looking at potential dates in May during Diversity week. Action to be brought forward to May. Item 6.2 – Older Adult Sickness Analysis Capacity an issue to undertake a full audit. Agreed to continue with the practical solutions including reports being sent to Managers when individuals had triggered the sickness absence policy and equitable application to policy. It was agreed that overall sickness compliance would be included as part of the Workforce Report moving forward, as a key metric. Item 8.2 – Midland and East Agency Report (1) Timescales remain unclear. NHSI agency webinar held last week where potential changes to submission requirements were discussed. Action to be picked up as part of the regular agency agenda item moving forward. Action to be removed. Item 8.2 – Midland and East Agency Report (2) Information from BCPFT now received. Committee referred to comparative data via attached power-point slides. Noted that there was more work to do with regards to shared working. It was acknowledged that BCPFT was a much larger Trust than DWMHPT and yet their medical staffing spend was only £300k higher. It was agreed that a piece of work would be undertaken to look at BCPFT working model to ascertain if their model was more efficient than that of DWMHPT in addition to a review of the number of substantive posts across BCPFT medical workforce compared to
Mrs Williams Mrs Temple/Purcell/Joint Medical Directors
DWMHPT. MERIT discussions still progressing with regards to a shared bank. Discussions were also taking place, as part of the TCT Partnership re; joining resources and shared resource in the bank. Item 21.1 – Workforce Risk Register Risk Register reviewed as part of agenda item 13. No reference made to inclusion of dates. Action to be brought forward to April. Item 22.1 – 2017/18 Committee Work Plan No update provided during the Committee. Action to be brought forward to April. Item 8 – HEE Action timeline of September was questioned given the concerning picture. Mrs Temple-Purcell provided her perspective of the current position. Noted that HEE were still not clear with regards to available funding as of 1st April 17. It was agreed that a presentation would be given to the Committee in April based on 2016/17 Learning & Development Agreement and how the Trust could mitigate the implications of the mandate on DWMHPT.
Mrs Temple-Purcell
28. WORKFORCE PERFORMANCE
28.1 Workforce Report
Mrs Williams welcomed Ms Needham to the Committee meeting. The Committee reviewed the Workforce Performance Report at Month 11. Key Messages:
- Vacancy rate had decreased to 13.8% during Month 11. - 12 month turnover rate had decreased from 10.72% to
10.33%. The Trust’s turnover rate was in line with that of other Mental Health partnering organisations.
- Rolling 12 month sickness rate decreased in Month 11 to 4.39% compared to 4.42% in Month 10.
- Appraisal compliance increased to 86% (87% live position). - Mandatory training compliance increased to 88.9% (89.2%
live position). It was important that compliance reports sent to Managers were actioned appropriately – reports were not being issued for information purposes. Committee to be mindful that essential training compliance target was still not being achieved and therefore needed to be monitored closely.
- IG training compliance was at 96% in Month 11. The Trust was likely to see a decrease in compliance from 1st April 17 unless individuals undertook their IG training refresher.
- TRAC: Implementation of the new recruitment system was going well. A rolling programme was now in place for
substantive band 5 nursing posts. Four adverts had recently been placed. Complete schedule in place until March 18. Committee acknowledged the good progress that had been made, expressing their thanks to the HR department. Suggestion made via Bright Ideas re; making contacting with individuals who failed to attend interview. It was noted that the TRAC system sent daily reminders to shortlisted candidates regarding their interview and therefore it was not necessary to make contact with individuals. In response to Mr Axcell, Mrs Carey commented that the new TRAC system was working really well “on the ground” which was positive. Mr Axcell questioned when the Committee would start to receive some KPI data. Mrs Williams advised that the HR department would be in a position to present some data to the Committee in July, following the 6 month system implementation period.
- It was questioned how the cost of sickness was calculated as the figures appeared slightly low. Mrs Williams noted that Mr Peniket was responsible for the calculations, however, understood that the calculation was based on the direct cost of sickness absence. Consideration also needed to be given to those individuals receiving no or half pay.
The Committee received and noted the contents of the report.
Mrs Williams
28.2 Vacancy Control Process (TCT)
Mrs Williams talked the Committee through the vacancy controls proposal. The following points were raised and noted:-
• The proposal was not to introduce a recruitment freeze (this would be detrimental) but to have a robust recruitment control process in place.
• Whilst the process was ambiguous at the current time given structures were not yet clear, the proposal outlined a framework to build upon.
Following discussion Mrs Williams to feedback Committee comments to TCT partners. Revised vacancy control proposal to be taken via the Executive Team or circulated via email for approval.
Mrs Williams
28.3 Service Recruitment Plans
Mrs Williams provided the context for developing service recruitment plans. The following points were raised and noted:-
• Those roles in the process of being recruited to would be
converted into the recruitment plan. • Consideration needed to be given to the future of those roles
RAG rated amber. • There were very good reasons as to why many of the
vacancies were on hold. • A review needed to be undertaken of medical and corporate
vacancies. Mr Haywood asked that OT and Psychology were involved in medical vacancy meetings.
• It was questioned why there was more clearly defined posts in Walsall compared to Dudley. It was noted that this potentially linked to pan Trust roles; posts that sat/were badged as Walsall but operated across the two Boroughs. Ms Clymer asked that this be reflected within the detail.
• Mr Axcell questioned if the Trust was looking at vacancies based on need or based on there being a budget for a post/s. Mr Axcell emphasised the importance of challenging the need.
• The Committee needed to be mindful of the impact of the CIP Programme on the service recruitment/vacancy plans.
• Plans to be brought back to the Committee in May.
Mrs Williams Mrs Williams
28.4 Mandatory Training Report
The mandatory training report was presented to the Committee. The following points were raised and noted:-
• The report reflected the most up to date compliance position, to that included within the Workforce report.
• Mandatory training compliance was currently at 89.2%. • Workforce Team had been looking at a couple of areas of
work including provision of training in 2016/17 and training provision plan for 2017/18. Report to be brought to the next Committee meeting.
• A training programme had been confirmed for the new financial year – available for staff to book onto.
• Looking to re instigate DNA process. • Overall review of induction underway – will form part of report
brought to the Committee in April. Induction policy suggests allowing individuals an 8 week period to undertake their mandatory training. Mrs Temple-Purcell was of the view that the Committee should review this timeline. Ms Ingram noted that lots of discussions had been held, including at the Staff Partnership Forum with regards to what action was being taken for persistent non-compliance. Mrs White confirmed that Staff Side were supportive of a performance management approach to persistent non-compliance, however, acknowledging that there would be exceptional circumstances and therefore cases of non-compliance should be reviewed on a case by case basis. Ms Clymer was keen to get convert these discussions into reality – what did the Trust need to do to start making this happen? It was agreed
that Mrs Temple-Purcell and Mrs Williams would meet to discuss with a progress update bring provided to the Committee in April as part of the mandatory training update report.
The Committee received and noted the contents of the report.
Mrs Temple-Purcell/Mrs Williams
28.5 MAPA & MHA Training Compliance
The MAPA & MHA training compliance report was presented to the Committee. An improvement was noted with regards to MAPA training compliance. However, there was still some way to go to achieve 90% compliance target. Less improvement made with regards to MHA training. The Committee received and noted the contents of the report.
28.6 Appraisal Report
A comprehensive report was provided to the Committee with regards to the level of appraisal activity undertaken across the workforce as of 20th March 2017. The following points were raised and noted:-
• The report reflected the most up to date compliance position, to that included within the Workforce report.
• Since the end of February, the Trust had moved from 86% to 87% compliance rate (now above compliance target).
• From an Executive Team perspective, work had been undertaken to look at appraisal plans. Mrs Williams gave apologies to the Committee for not being able to present the appraisal recovery plans. However, provided assurance to the Committee that work was underway “behind the scenes”.
• The Committee were satisfied that momentum was starting to be gained with regards to appraisal compliance, with Mr Axcell acknowledging some big success stories.
The Committee received and noted the contents of the report.
29. STAFF WELLBEING
29.1 Health & Wellbeing Update
Mrs Williams provided a verbal update as follows:-
• The Health & Wellbeing Group was now an operational group, reporting to the Workforce Committee.
• The Health & Wellbeing Group had recently met to look at 2017/18 priorities, utilising the wellbeing charter and its principles, which linked succinctly to the work being undertaken by the Trust.
• Public Health had undertaken an assessment of where the Trust was at; it was noted that the Trust could make improvements in a number of areas including:-
- Supporting staff re; Mental Health and wellbeing - Smoking cessation - Physical activity - Healthy eating
A work plan was being developed which would be brought to the Committee.
• Mr Axcell commented that all clinical areas should be undertaking first aid training.
• Referring back to the Health and Wellbeing events held, Mr Axcell questioned if the staff suggestions (what Health & Wellbeing initiatives staff would like to see) would form part of the work plan. Mrs Williams advised that the work plan would certainly include support mechanisms for staff. However any initiatives would need to be staff led.
Mrs Williams
30. ORGANISATIONAL DEVELOPMENT
30.1 Cultural Ambassador’s (CAs) Programme
Mr Singh briefed the Committee on the Cultural Ambassador’s Programme. The following points were raised and noted:-
• BCPFT had already signed up to programme and BCHC were looking to sign up to the programme.
• The CAs would be managed by Mr Singh and training would be provided.
• Whilst Mrs Williams supported the principles, it was Mrs Williams’ view that the issues outlined were not issues for the Trust and therefore would not want to support the programme as a single Trust, but would be happy to support as a Partnership.
• It was noted that disciplinary issues were not a significant issue for the Trust therefore questioning if the CAs programme was the most appropriate approach for the Trust.
• Ms Clymer expressed her view that the Trust should move forward with the programme, and to seek some volunteers. This was echoed by Mr Axcell. Mr Singh agreed to progress appropriately.
• The programme provided the Trust with an opportunity to be more progressive – it was important for the Trust not to become complacent.
Mrs Williams talked the Committee through the Workforce Risk Register. The following points were raised and noted:-
• Risk ID number 317 should read risk ID number 314. • Committee satisfied re; closing down risk 328. • It was questioned if risk 58 should now be changed to
“Green” given the improved position with regards to appraisal and mandatory training compliance rates. Mr Axcell advised he would be happy to turn the risk to “Green” once the improved position had been sustained for a three month period.
• Agreed additional risks to be added to the risk register:- - IR35 - Staffing levels across the organisation, particularly relating to
nursing staff - TCT – roles and responsibilities “technical aspects of change
management”.
Mrs Williams
31.2 Midlands and East Agency Report
Mr Banks referred to the Midlands and East – M10 Monthly Agency Performance Report which demonstrated where the Trust sat with regards to its agency performance, against all other Trusts (69 in total) within the Midlands and East region. It was noted that focus was being placed on the Midlands and East region at the current time. The report aligned with the previous discussion had re; BCPFT and DWMHPT comparative data. With regards to the letter received from NHSI re; Locum and Agency spend, Mr Banks highlighted the national target to reduce medical agency expenditure by £150m in 2017/18. There was no indication at the current time re; DWMHPT proportion. In response to Ms Ingram, it was confirmed that IR35/targets/high levels of scrutiny were not applied to other non NHS organisations. It was agreed that Mr Banks would raise this challenge with NHSI on behalf of the Chair. The Committee received and noted the contents of the report.
Ms Ingram talked the Committee through the Safe Staffing Progress update report. It was confirmed that a review of other staff i.e. therapists, OTs, Pharmacy would be progressed via the inpatient review. Ms Clymer requested that this be made explicit in the report to Trust Board. The Committee received and noted the contents of the report.
Vacancies – There are currently 157 Full Time Equivalent (FTE) contracted vacancies across the Trust decreasing the vacancy rate slightly from 13.8% in Month 11 to 13.7% during Month 12. The TRAC recruitment system is currently being used within the Trust giving increased control and oversight to recruiting managers and allows the Trust to performance manage against recruitment KPIs. Refreshed service recruitment plans are also being developed via the Workforce Committee. Turnover – The 12 Month Turnover rate has increased from 10.33% to 10.53%. The Trust’s turnover rate is average In comparison to the turnover rates excluding junior medics of other Mental Health organisations in the NHS.
3
Sickness Absence – The rolling 12 month sickness rate has decreased in Month 12 to 4.31% from 4.39% in Month 11, this is within the Trusts target and the fifth consecutive month of being so. In month sickness has decreased from 4.59% in Month 11 to 3.33% in Month 12. A probable reason for this change is the increase of annual leave absence during March. Appraisal – Compliance has increased from 86.0% to 87.0%, this is above Trust target of 85% being the second time this has been achieved in the last 12 months, it also indicates the continuation of the positive trend of recent months. There are 114 employees in the Trust that have not had an appraisal recorded in the last 12 months, an improvement of the 223 reported in Month 6. Weekly/Bi Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements. Mandatory Training - Mandatory Training compliance increased to 89.8% in Month 12 from 88.9% in Month 11 and remains just below the target of 90% agreed at MEXT for all mandatory training. IG compliance for Month 12 is 96.0% which is above the 95% target for that competence. As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake in order to remain compliant.
4
5
445 Dudley and Walsall Mental Health Partnership NHS Trust
The table above shows the number of adverts published on NHS jobs in February and the associated FTE by Staff Group. The nursing and midwifery posts are established under a single position number and advertised as such although more then 1 FTE can be appointed into the position.
The table above shows the breakdown by service and band where the 157 vacant FTE belong. It is worth noting the 12.3 FTE under Trainee Grade are recruited via the Deanery
ServiceApprentice Band 1 Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8A Band 8B Band 8C Band 8D Band 9 VSM
12 Month Turnover has increased slightly to 10.53% in Month 12. This is within the Trusts targeted range and could be considered a good indicator that the Trust in general retains its staff.
445 ACC Access Services Level 3 0.4 1.0 7.0%445 ACU Acute Services Level 3 4.0 2.0 11.1%445 AOMGT Acute & Older Adults Management Level 3 1.0 0.0 0.0%445 CAF Corporate Affairs Level 3 0.0 1.0 23.9%445 CDP Corporate Development and People Level 3 0.0 0.0 0.0%445 CHX Chief Executive Level 3 0.0 0.4 19.3%445 COM Community Services Level 3 0.0 4.0 6.3%445 EIN Early Intervention Level 3 3.0 0.0 6.9%445 FIN Finance Level 3 1.0 0.0 11.9%445 HR Human Resources Level 3 0.0 0.0 24.8%445 MED Medical Level 3 0.0 1.0 12.5%445 OAS Older Adults Level 3 0.0 0.0 11.0%445 OPS Operations Level 3 1.6 3.0 19.6%445 Dudley and Walsall Mental Health Partnership NHS Trust 11.0 12.4 10.5%
9
The rolling 12 month sickness rate has decreased slightly in Month 12 to 4.31% from 4.39% in Month 11. This within the trusts target 4.68%. In month sickness has decreased from 4.39% in Month 11 to 3.33% in Month 12.
445 CHX Chief Executive Level 3 10.33% 3.88% 8.36%445 CDP Corporate Development and People Level 3 1.79% 0.54% 1.94%
445 HR Human Resources Level 3 0.67% 0.93% 1.47%
445 COM Community Services Level 3 4.69% 2.59% 4.78%445 EIN Early Intervention Level 3445 FIN Finance Level 3
2.78%3.34%
2.40%3.57%
3.92%2.83%
445 Dudley and Walsall Mental Health Partnership NHS Trust 4.59% 3.33% 4.31%
445 MED Medical Level 3 5.47% 4.51% 4.22%445 OAS Older Adults Level 3 6.79% 4.48% 4.68%
5.43% 5.03% 5.50%445 OPS Operations Level 3
10
Long term sickness accounts for 63% of sickness for the rolling 12 month period to Mar-17. The number of open Long Term sickness cases is 21 in Month 12. The top 3 reasons for sickness based on FTE days lost for Month 12 were: 1. Anxiety/Stress – 362 2. Other musculoskeletal
problems - 133 3. Benign and malignant
tumours, cancers - 123
1.3%2.1% 2.0% 1.6% 1.3% 1.3%
2.2% 1.6%
3.12% 1.52% 2.11% 3.18%2.61% 2.96%
2.50%2.71%
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
445 CorporateLevel 2
445 ACC AccessServices Level 3
445 ACU AcuteServices Level 3
445 COMCommunity
Services Level 3
445 EIN EarlyIntervention
Level 3
445 MEDMedical Level 3
445 OAS OlderAdults Level 3
445 Dudley andWalsall Mental
HealthPartnership NHS
Trust
Short Term/Long Term Sickness % (Rolling 12 Months)
Appraisal compliance is tracking at 87.0% at the end of Mar-17. This is above the Trust target and a continuation of the recent positive trend. There are 114 employees in the Trust that haven't had an appraisal recorded in the last 12 months.
Purpose of the report: To update the Board on matters pertaining to the joint Medical
Directors’ portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: N/A
Date reviewed: N/A
Key points or recommendations from Committee:
N/A
Strategic Objective(s) to which this paper relates: High quality
services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring There is a potential impact across all the CQC domains Responsive
Effective Well-led Safe Enc 16 MD Board Briefing Paper Page 1 of 4
National and Regulatory guidance A report by the GMC highlights problems with the training of junior doctors that states currently the training is rigid training and adapts too slowly for current needs. The plan follows a review of training which the Secretary of State for Health asked the GMC to carry out during the contract dispute in 2016, an analysis which heard from trainees, trainers, patients and the medical colleges and faculties. The plan identifies five key barriers to improving training flexibility:
• Transferring between specialties is difficult without doctors going back to the start – often referred to as the ‘snakes and ladders’ effect. This is caused by the complex legal framework controlling UK postgraduate training
• Training in other ways is not recognised – work overseas and experience gained in non-training grade posts are not counted;
• More career support is needed to help doctors who want to refocus their training without starting from square one;
• Postgraduate training is slow to adapt to changes in patient demand • Rigid training structures can make rota gaps worse.
In Adapting for the future, the GMC proposes a seven-point plan geared to delivering more flexible training:
• Training will be organised by outcomes rather than time spent in training • Related specialties curricula, will share common outcomes and elements • The GMC will reduce the burden of its approval system so that medical colleges and
faculties can make changes to postgraduate curricula more quickly • The GMC will work with others to promote mechanisms which already exist to help
trainees change training programmes – such as the Academy of Medical Royal Colleges’ Accreditation of Transferable Competences Framework
• The GMC will ask the UK government to make the law less restrictive so that we can be more agile in approving training
• The GMC will support doctors with specific capabilities or needs • The GMC will encourage national education bodies to continue to improve the work-life
balance of trainees. Local Matters We are engaging with other leaders in the health economy such as CCG leads; acute hospital medical and nursing directors and the CSU to discuss clinical aspects of the Black Country STP as a way of improving care across a range of conditions, particularly where the pathways involve a number of providers. The first meeting was held last month and further meetings are to be arranged in the next two weeks. The Black Country STP is one of the few in the country with a chapter on mental health. It is also committed to trying to reduce the premature death from physical disease of people with long term mental health conditions and this work is a very positive step towards achieving this aim.
Title Medical Directors’ Report
Enc 16 MD Board Briefing Paper Page 2 of 4
Mortality Report Mortality Data for March 2017 There are 11 cases applicable for inclusion within this month’s figures which are outlined within the table below. Information in respect to these cases has been collected from the Safeguard Reporting system and the Informatics and Performance Department. The information from each electronic system complements the other and through cross referencing within other clinical information on OASIS, information from the coroner’s office and information from partner agencies, are aligned via the agreement of the Trusts mortality review group with one of the 4 following definitions: Natural death - one from a recognisably incurable condition. Expected death - one where prognostic features have been identified leading to a reasonable expectation of death within an identified timescale Unexpected death - one occurs at a time that is sooner than may reasonably have been predicted from a non-natural cause or where the cause in unknown Preventable death - one that should not have occurred given current medical knowledge and technology’ None of the 11 deaths falling under the scope of this report were identified as being a serious incident. There are 11 cases falling inside the scope of this report and can be summarised as follows:
Age Team Diagnosis Summary
Definition 83 CMHTOP
Dudley None Given Email notification from Social Services that DP had passed away. Patient was open to CMHTOP
Dudley. Case Notes state that patient died in hospital. Cause of death listed as: 1a) Aspiration pneumonia 1b) Impaired swallow 2) Advanced dementia
Natural death
62 CRHT Walsall
None Given Informed by CPN that patient has passed away. Patient was open to CRHT and had been suffering with cancer for some time Cause of death - terminal cancer. CoD:- 1a) Endrochondroma with extensive metastasis.
Expected Death
91 Memory service
Mild depressive episode
Whilst checking Fusion, Walsall Manor Hospital's patient records system, it was noted that patient had a date of death against her name. Referred for a memory assessment on 28.2.2017. Discharge summary states admitted to hospital 4.3.2017 and died 9.3.2017. Reason for admission generally unwell and reduced level of consciousness. CoD:- 1a) Bilateral pneumonia 1b) Non stemi leading to ccf 1c) Ischemic heart disease 2) Frailty, acute kidney injury.
Natural death
Enc 16 MD Board Briefing Paper Page 3 of 4
Age Team Diagnosis Summary
Definition 83 Memory
service Dementia in alzheimer's disease, atypical or mixed
Patients died at Arboretum Nursing Home CoD 1a) Squamous cell carcinoma of the right lung
Expected Death
89 Memory service
None Given Informed the patient had passed away, patient had yet to be seen by Trust services. CoD:- 1a) Ischemic heart disease b) Old age
Natural death
78 ECMHTOA Walsall
Recurrent depressive disorder, unspecified
Patient had been admitted to The Manor hospital a week before with a chest and urine infection. Trust were informed today (27th March 2017) that he died on Friday evening. CoD:- 1a) Pneumonia
Natural Death
82 ECMHTOA Walsall
Dementia in Alzheimer's disease, atypical or mixed
Visited Leighswood residential home to see service user, notified by manager that she had died in Walsall Manor Hospital last week. Accessed Fusion to find out date of death, cause terminal illness. Death was expected. CoD:- 1a) Pneumonia b) Asthma
Natural Death
78 Memory service
None Given Saw details on fusion that patient had passed away. CoD:- 1a) Perforated Cecal Volvulus
Natural Death
78 CMHTOA Walsall
Dementia in Alzheimer’s disease, atypical or mixed
Patient marked as deceased on OASIS by the Clinical Team. Patient had been discharged from services in November 2016 and was receiving care in Winehalla Nursing Home.
Natural Causes
53 CRS Walsall north
Paranoid schizophrenia
Patient had been recently admitted to Walsall Manor with sepsis, where they eventually passed away. Patient was open to palliative care and known to be ill with cancer. Patients physical health had deteriorated badly over the last few months due to this however her mental health had remained stable. Patient marked as deceased on OASIS
Expected death
70 CRS Dudley North
Persistent delusional disorder, unspecified
Phone contact from nursing staff at Holbeche House to inform us that patient passed away on 30th March'17. She had recently been in Russell’s Hall Hospital and was diagnosed with Bone Cancer. Patient marked as deceased on OASIS
Expected death
Recommendation To note and discuss the report Board action required To receive the report for assurance
Enc 16 MD Board Briefing Paper Page 4 of 4
Board meeting date: 4 May 2017
Agenda Item number: 7.3
Enclosure: 17
Report Title:
Guardian of Safe Working – Quarterly Report
Accountable Director:
Kate Gingell – Joint Medical Director
Author (name & title):
Dr Amitav Narula Consultant Psychiatrist, Guardian of Safe Working
Purpose of the report: To receive the quarterly report from the Trust’s Guardian of
Safe Working (GoSW) Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: None
Date reviewed: N/A Key points or recommendations from Committee:
N/A
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
Responsive
Effective
Well-led
Safe
The role and work of the Guardian of Safe Working has a direct impact on the safety of services provided in the Trust.
Guardian of Safe Working Report Page 1 of 10
Title Guardian of Safe Working – Quarterly Report Introduction The new junior doctors contract was introduced into Psychiatry from 1st February 2017 and new rotas have been implemented both at Dorothy Pattison Hospital (DPH) and Bushey Fields Hospital (BFH). Having started preparations for its introduction in August 2016 work has been done with junior doctors, clinical supervisors and medical secretaries to ensure that all are aware of when the junior doctor will be doing routine work, day or night on calls, and time off in the week. All trainees and clinical supervisors have access to the Allocate Exception reporting system which is a way of monitoring the safety of the new rota. In addition at induction in February and April 2017 Dr Narula as Guardian of Safe Working (GoSW) ensured that he introduced himself in this role and his responsibilities. We are learning about new issues that arise both on a local and national level which we have fed back to NHS employers and BMA IRO. Dr Narula has attended and is a member of the West Midlands GoSW group as well as attending the second National Meeting on 1st March 2017. The most significant issue that has arisen since the implementation has been when a junior doctor is on sick leave and organising internal locum cover. Summary of key points, issues and risks • New Junior Doctor Contract introduced into Psychiatry on 1st February 2017.
• All junior doctors on new contract and those Higher Specialist trainees who joined DWMH on 1st
February 2017.
• As of 17th April 2017 no exception reports.
• Locum costs Dudley and Walsall
• Locum policy needs to be developed including a bank of locums.
• Consultant away day 10/03/2017 to get feedback about implementation.
• Junior doctor forum on 21st April 2017 at BFH to include LNC Representative, BMA Industrial Relations Officer (IRO) and Guardian of Safe Working as per the new contract.
Further detail (if required) New Contract Update Rollout of the contract is being carried out in line with the national implementation timeline from August 2016 to October 2017. Introduction of the contract for psychiatry trainees took take place on 1st February 2017. Foundation Year 1 doctors (FY1) have been on the new contract since December
Guardian of Safe Working Report Page 2 of 10
2016 but are employed by acute trusts (Walsall Manor and Russells Hall Hospital) and don’t do out of hours work at DWMH. They have been signposted to the acute trust Guardian of Safe Working with any issues related to their work schedules. Foundation Year 2 (FY2) will transfer to the new contract in April 2017. Core Trainees (CT) will be on the new contract from February 2017. Since the last report we have confirmed that existing core trainee doctors in the trust can choose to be on the new contract and all have agreed and correct payment was made in February pay. This efficiency was appreciated by all junior doctors. One Higher Specialist trainee in Old age Psychiatry in Walsall who is doing non-resident on call continues to have issues with his salary. High level data Number of doctors in training (DPH): 9 Number of doctors in training (BFH): 19 Amount of time available in job plan for guardian to do the role: 0.5 PAs Admin support provided to the guardian (if any): 0 Grade BFH DPH TOTAL FY1 3 1 4 FY2 3 2 5 CT1 2 2 4 CT2 2 1 3 CT3 1 1 ST4+ 4 2 6 GP 4 1 5 TOTAL 19 9 28
a) Exception reports (with regard to working hours) Specialty No. exceptions
carried over from last report
No. exceptions raised
No. exceptions closed
No. exceptions outstanding
Psychiatry 0 0 0 0 Exception reporting is the mechanism for all doctors employed on the 2016 Junior Doctors Contract to inform the Trust when their day to day work varies significantly and/or regularly from the agreed work schedule. The reports are raised electronically using the ‘Allocate’ Exception Reporting system. The educational / clinical supervisor receiving the exception report will review the content and then discuss it with the doctor to agree what action is necessary to address the issue. NHS Employers has developed 2 flow charts to help the process of exception reporting:
(1) Training issues flowchart (2) Safe working flowchart
Guardian of Safe Working Report Page 3 of 10
These flowcharts have been posted in the junior doctor mess, offices and Postgraduate Centre and distributed to all medical teams. A copy is included in the appendix of this report. Currently no exception reports have been recorded as on 17th April 2017. b) Work schedule reviews Generic work schedules outlining working pattern; a breakdown of pay; training opportunities and key contacts whilst in post were issued 8 weeks prior to transitional dates in line with the code of practice. The doctors with their clinical supervisors will personalise generic work schedules outlining both service and educational activity. The work schedule along with the rota should accurately reflect the actual activities of the doctors working time including, education, handovers, breaks and rest periods. Currently no work schedule reviews have taken place as no exceptions reports have been recorded. Work schedule reviews by grade F1 0 F2 0 CT1-3 0 ST4+ 0
c) Rota Gaps In Dorothy Pattison Hospital we have a gap in the rota due to one trainee going on maternity leave from March 2017 this post is being covered by an agency locum. Currently no rota gaps in Bushey Fields Hospital. d) Locum bookings Internal locum carried out by trainees February 2017 Locum work by trainee Date Grade Reason
for locum Number of hours worked
Rate per hour (£)
Total (£)
Opted out of WTR?
BFH 9/2/2017 Ct2 sickness 4.5 30.37 136.67 y 20/2/2017 Ct2 sickness 12.5 28.93 361.63 y 22/2/2017 FY2 sickness 12.5 24.45 305.63 y 23/2/2017 CT3 sickness 12.5 36.67 458.38 y DPH 6/2/2017 CT2 Gap in
rota 12.5 £30 375.00 Y
7/2/2017 CT2 Gap in rota
12.5 £30 375.00 y
Total February 2017 £2012.31
Guardian of Safe Working Report Page 4 of 10
Those junior doctors that undertook night oncalls were given the following day off and this was done in consultation and good will of the supervising consultants therefore avoiding the need to go to agency locum doctors. However this left the medical teams in the daytime without their junior doctor so that work had to be covered by senior medics on the teams. Postgraduate office once notified of the junior doctor sickness immediately contact other junior doctors to check their availability to undertake an internal locum pay based on the T&Cs of new junior doctor contract. March 2017 BFH Locum work by trainee Date Grade Reason
for locum Number of hours worked
Rate per hour (£)
Total (£)
Opted out of WTR?
BFH n/a n/a n/a n/a n/a n/a n/a DPH n/a n/a n/a n/a n/a n/a n/a Agency February 2017 Locum work by Agency Locum Date Grade Reason
Total February 2017 £1641.74 March 2017 Locum work by Agency Locum
Date Grade Reason
for locum Number of hours worked
Rate per hour (£)
Total (£)
Opted out of WTR?
BFH - - - 0 0 0 - DPH 6-12.3.17 Agency
(ST3) Gap in rota
47.75 43.17 2061.37 N/A
Guardian of Safe Working Report Page 5 of 10
13-19.3.17 Agency (ST3)
Gap in rota
52.25 43.17 2255.63 N/A
20-26.3.17 Agency (ST3)
Gap in rota
15.50 43.17 669.13 N/A
27-30.3.17 Agency (ST3)
Gap in rota
54.50 43.17 2352.76 N/A
Total March 2017 £7338.89 e) Vacancies Vacancies by month LOCATION Grade Month
FEB 2017
Month 2 MARCH 2017
Total gaps (average)
Number of shifts uncovered
BFH CT/GP/FY2
0 0 0 0
DPH CT/GP/FY2
0 0 0 0
Total 0 0 0 0 f) Fines Nil Qualitative information A new form was developed when junior doctors a swapping oncalls this not only ensures that both doctors have confirmed the swap but also both Clinical Supervisors sign the swap off and record in their team diaries. Junior doctors are reminded to inform their teams of swaps and to arrange in advance if clinics are to be cancelled. A discussion has occurred in Dudley to have the junior doing the day shift to be available Monday to Friday for assessment with Psychiatric liaison team, getting advice from the team doctor under which the patient would be under. Although FY1 doctors in BFH do not undertake oncalls they are expected to inform the clinical supervisor if they are doing a shift for Russells Hall Hospitals, to ensure they comply with safe working. Issues arising Rota gaps remain challenging, may compromise patient safety and affect our ability to deliver
adequate training. So far we have no exception reports regarding the safe working or educational need of the junior doctors.
Our ability to provide internal cover for rota gaps may be reduced by the terms of the new contract and currently good will from consultant colleagues who give permission for their junior to do a night oncall and have the following day off.
Data has shown that majority of locum shifts were covered by internal junior rather than an agency locum which not only keeps costs down but also ensures that these doctors know how the systems work in the trust giving more safe effective care.
In a LNC meeting and also the GoSW conference other organisations have developed a locum policy.
Guardian of Safe Working Report Page 6 of 10
Currently awaiting guidance on how to formally record those trainees who have opted out of the Working Time Regulations (WTD)
Ongoing issues with regard to Higher Specialist Trainees out of hour payments based on the T&Cs of new contract.
Lack of administrative support is hampering the ability of the GOSW to undertake their role and may prevent us being able to effectively monitor breaches, particularly of the 48 hour condition. Also a lack of understanding from HR about the new junior doctor contract.
Actions taken to resolve issues So far no exception reports in this quarter. Postgraduate office and HR are dealing with the out of hours payment issues with regard to Higher Specialist Trainee. This will need to be resolved before August when we expect at least 2 new Higher Specialist Trainees will join DWMH on the new contract. Conclusion The Trust has made good progress in the implementation of the new Junior Doctors Contract. The feedback from junior doctors and consultants so far has been positive. We have been proactive in educating medical teams about the new rota and the subsequent impact it will have on day to day clinical activities e.g. clinics. In reviewing the data for the last quarter with no exception reports, the current working hours are safe. Issues have arisen about organising locums and developing a locum bank and this needs to be developed in parallel with a locum policy. Appendices: (1) NHS Employers Training issues flowchart (2) NHS Employers Safe working issues flowchart (3) Oncall swap form Recommendation That the Board receives and note the report for assurance on the work of the Guardian of Safe Working. Board action required As recommended.
Guardian of Safe Working Report Page 7 of 10
Appendix 1
Guardian of Safe Working Report Page 8 of 10
Appendix 2
Guardian of Safe Working Report Page 9 of 10
Appendix 3
Guardian of Safe Working Report Page 10 of 10
Board meeting date: 4 May 2017
Agenda Item number: 7.4
Enclosure: 18
Report Title:
Director of Nursing Report
Accountable Director:
Rosie Musson, Acting Director of Nursing
Author (name & title):
Rosie Musson, Acting Director of Nursing
Purpose of the report: To update the Trust Board on key issues pertaining to portfolio
of the Director of Nursing
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: None
Date reviewed: N/A Key points or recommendations from Committee:
None
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
Service delivery issues relate to all aspects of the CQC domains. Responsive
Effective Well-led Safe
Enc 18 Director of Nursing Report Page 1 of 3
Title Director of Nursing Report
Introduction This report for the Director of Nursing aims to update the Board on pertinent issues and challenges relating to the nursing portfolio. Summary of key points, issues and risks Trust Supportive Visits Following the success of the first round of Trust Supportive Visits, the CQC steering Group has agreed to hold a second round of the Trust peer review process. The reviewers will once again utilise the standards that have been developed by the Quality and Governance MERIT work stream, with a feedback / outcome report planned to be submitted to the June CQC Steering Group meeting It is planned that there will be two full day reviews that will take place in Inpatient services, on the 4th May for Walsall and the 15th May for Dudley. The visits will have representatives from the Trust (both operational and medical staff) undertaking a peer review of the services. The visits will also have specialist review support from Expert by Experience members, Health watch, CCG Quality leads, Infection Control, Estates and Facilities and pharmacy staff. Updated revalidation standards and guidance Published by the NMC The Nursing and Midwifery Council (NMC) has updated its revalidation standards and guidance in line with a planned review and stakeholder feedback. All documents except the Code have been revised. The standards and guidance includes new examples of circumstances which would not count towards practice hours, changes in how to revalidate and the guidance sheet, changes to the continuing professional development (CPD) examples, amendments to the alternative support arrangements guidance sheet, clarification what will happen applicants declare they are not able to meet the revalidation requirements due to health reasons. The Trusts Revalidation Lead is ensuring that guidance provided to nurses is updated to support the changes made by the NMC. National Nurses Day The Trust will be celebrating National Nurses Day on the 12th of May. There will be a series of events for staff throughout the Trust to participate in. National Nurses Day is celebrated
Enc 18 Director of Nursing Report Page 2 of 3
annually on Florence Nightingales Birthday to raise awareness of the important role nurses play in society and thank nurses for their work. Recommendation The Board is asked to note the updates within Director of Nursing Portfolio. Board Action Required As recommended.
Enc 18 Director of Nursing Report Page 3 of 3
Board meeting date: 4 May 2017
Agenda Item number: 7.5
Enclosure: 19
Report Title:
Enhancing Quality through Safer Staffing Levels - Monthly Exception Report
Accountable Director: Rosie Musson – Acting Director of Nursing
Author (name & title):
Rosie Musson – Acting Director of Nursing Makhan Singh – Principal Consultant, Informatics and Performance
Purpose of the report:
This report provides the Trust Board with:
• A summary report of planned and actual staffing for March 2017, which has been submitted to NHS Choices as part of a national staffing return and is available on the Trust’s website.
• Exception reporting for variances and any concerns relating to safer staffing
• Trend analysis monthly average fill rate • Bank and agency actual hours analysis v’s substantive
hours
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: Workforce Committee
Date reviewed: 25 April 2017
Key points or recommendations from Committee:
Received the report and noted the key headlines and actions being taken. The Committee will receive in May further assurance regarding the frequency of staffing falling below the locally agreed standard of minimum of two qualified nurses per shift. The Committee members are reviewing the draft metrics for effective and safe rostering.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 1 of 10
Strategic Objective(s) to which this paper relates: High quality
services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring Responsive Ensuring staffing levels are responsive to meeting patient need Effective Well-led Safe Ensuring staffing levels are adequate to deliver safe care
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 2 of 10
Title Enhancing Quality through Safer Staffing Levels
- Monthly Exception Report Introduction This report provides the Trust Board with: • A summary report of planned and actual staffing which has been submitted to NHS
Choices as part of a national staffing return and is available on the Trust’s website. • Exception reporting for variances and any concerns relating to safer staffing. • Trend analysis monthly average fill rate. • Bank and agency actual hours’ analysis against substantive hours. • Update on the integration of safer staffing data into the Trusts integrated dashboard.
Summary of key points, issues and risks The Data represents March 2017 and a monthly trend analysis for a 12 month period. Across the inpatient areas the overall fill rates are 99.38%, with 97.76% for registered staff and 100.32% for care staff. This indicates the Trust is meeting the optimum level of fill rates. Typically where our care staff rates exceed 100%, this is due to temporary staff being used to support patient observations, increases in acuity or changes in skill mix. Ward managers and Clinical Leads are empowered to be responsive and flex staffing to meet patient acuity. Where staff have concerns about staffing levels the reporting takes place through the Trusts incident reporting processes. In March there were no incidents reported related to safer staffing in inpatient services. As reported in last month’s report this information is collected manually however, from April the data will be automated and linked to the electronic rostering system. Trust standard has in place a locally agreed standard of the minimum of 2 qualified members of staff per shift. Due to inpatient vacancies the Director of Nursing has sought further assurance that when the ward plans to drop below this standard, mitigations are in place to maintain patient safety. Assurance has been provided that full consideration is given to skill mix when using temporary staff however on night shifts this has resulted in with one qualified member of staff being on duty with back up from the qualified senior nurse and experienced HCAs. Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 3 of 10
Update on Actions being taken and timelines The following actions are being taken to ensure temporary staffing is used effectively and efficiently –
• Vacancy review has been completed for inpatients; the Trust faces challenges in relation to the recruitment of Band 5 nurses and has a proactive recruitment campaign in place.
• Inpatient Establishment review undertaken • Optimising recruitment processes for bank staff – a successful initial drive. Now a rolling
programme supported by coms campaign. • Implementation of best practice rostering metrics • Integrating safer staffing reports into the Trusts integrated dashboard, to enable greater
triangulation and trend identification. This will be from the 1st of April and reporting to Workforce Committee in May and Trust Board
• Development of a sustainable temporary staffing hub, bringing together bank office and e-rostering – this has been identified as a cost pressure for 2017/18. Options will be explored in the context of TCT partnerships for longer term delivery of effective temporary staffing.
Recommendation To note and discuss the monthly data return submitted providing details of planned and actual staffing at ward level. Board action required The Board of Directors is asked to:
• Note and discuss the monthly data return submitted, providing details of planned and actual staffing at ward level. Data represents March 2017 and a 12 month trend analysis.
• Note the work underway to enable to most efficient safe and effective use of nurse staffing in inpatient service, this will focus on all professional groups, including therapists.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 4 of 10
1. Nursing and healthcare staffing fill rates March 2017 The data submission was made on 12th April 2017 of March data. The following table provides a summary of the planned verses actual staffing levels on the inpatient wards.
Planned Actual Planned Actual Planned Actual Planned Actual
RMN Care Staff RMN Care Staff Average fill rate - registered
nurses/midwives (%)
Average fill rate - care staff (%)
Average fill rate - registered
nurses/midwives (%)
Average fill rate - care staff (%)
Lowest range – less than 80% Highest range – greater than 150%
Low range – greater than 80% but less than 90%
High range – greater than 120% but less than 150%
Greater than 90% but less than 120%
Comments Across the inpatient areas the overall fill rates are 99.38%, with 97.76% for registered staff and 100.32% for care staff. This demonstrates an optimum range of fill rate for qualified and care staff for the demand (number of staff identified as required by the ward to meet patient acuity).
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 5 of 10
2. Exception Report on Variance – March 2017 No safer staffing incidents reported in March 2017 3. Trend Analysis average fill rate
The following table shows a monthly trend of the total average fill rates planned verses actual for the Trust. This demonstrates that staffing levels are flexed to meet the increases and decreases in patient acuity, which is currently informed by clinical expertise.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 6 of 10
The below table shows percentage of hours in 2016/17 split by bank hours, agency hours and substantive hours for all registered nurses. Further work is being undertaken to enable this data to be triangulated and ensure we are utilising temporary staffing in the most effective and efficient way.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 7 of 10
5. Registered Nurse Hours – Substantive V’s Temp Staff Fill Rate The below table shows percentage of Registered Nurse Hours – Substantive V’s Temp Staff Fill Rate for individual wards. Further work is being undertaken to enable this data to be triangulated and ensure we are utilising temporary staffing in the most effective and efficient way. Vacancy rates are impacting on fill rates alongside increased patient acuity requiring increased observations.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 8 of 10
6. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates
The below table shows percentage of hours in 2016/17 split by bank hours, agency hours and substantive hours for all care staff. Vacancy levels and increased patient acuity requiring high level observations are impacting on use of temporary staff. In some instances managers are utilising care staff to fill qualified gaps in the roster. Where skill mixes are changed this is to ensure staff utilised provide the greatest continuity of care for service users. The change in skill mix is occurring more on night shifts and on occasions falling below the trust standard of two qualified members of staff per shirt. The impact is being monitored and breaches of the trust standard of two qualified per shift will be reported in future safer staffing reports.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 9 of 10
7. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates
Further analysis of registered nurse hours by ward for March month is presented in the below table.Vacancy levels and increased patient acuity requiring high level observations are impacting on use of temporary staff.
Enc 19 TB Safer Staffing Levels on Wards - May 2017 Page 10 of 10
Board meeting date: 4 May 2017
Agenda Item number: 7.6
Enclosure: 20
Report Title:
Director of Operations Report
Accountable Director:
Lesley Writtle, Interim Director of Operations
Author (name & title):
Lesley Writtle, Interim Director of Operations
Purpose of the report: To update the Trust Board on key issues pertaining to service
delivery in the directorate of operations.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: None
Date reviewed: N/A Key points or recommendations from Committee:
N/A
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
Service delivery issues relate to all aspects of the CQC domains.
Responsive Effective Well-led Safe
Enc 20 Director of Operations Report Page 1 of 4
Title Director of Operations Report Introduction The report for the Directorate of Operations aims to update the Board on pertinent issues and challenges relating to operational service delivery. Summary of key points, issues and risks The Trust implemented a revised service line structure in December 2016. The four service lines are as follows: Urgent and Access: Early Access Service (EAS) Crisis Resolution teams Psychiatric Liaison and Urgent Care Street Triage
Early Intervention: Child and Adolescent MH Services, including i-CAMHS Eating Disorder services Regional Deaf CAMHS service Primary MH Services, including IAPT Early Intervention in Psychosis teams
Community: Community Recovery Services Employment Services Psychological Therapies ‘Hub’ Community MH Teams for Older People Day Services Memory Assessment Service Walsall Carers’ Service
Inpatients: All Inpatient Services (4 wards for Older People, 5 wards for working age Adults) Section 136 Suites Home Treatment Services Bed Management
The Trust is currently in the process of re-aligning all management information systems to support this new configuration of services with effect from April 2017. All aspects of operational service delivery continue to be busy, with the additional challenge of service transformation within many services. The following sections give updates by service line: Early Intervention Services
• The Dudley Access/ Mental Health Assessment Service will start to be fully operational from 1st May offering a 24 hour access/assessment point for urgent referrals. This has removed the cut off at 5pm between office hours services (EAS) and Out of Hours Services (Crisis).
Enc 20 Director of Operations Report Page 2 of 4
• The Trust is attending a meeting regarding development of Perinatal Mental Health Services next week as part of planning services across the Black Country with Wolverhampton CCG as the lead commissioning group.
Community Services
• CRS & CMHT across Walsall remain very concerned with the expected plans for disintegration of S75 and especially how the case work of the integrated Social Work will be managed with allocation of Care Coordinators. Each Social Worker could have between 25-40 patients. The OAMH enhanced working arrangements and staffing were based upon the team having 6 Social Workers as part of the integrated workforce. Already LA have taken back the AMHP roster plus set up a new funding panel process with the dissolution of the Joint Commissioning model. Meetings at a senior level between the Trust and the Local Authority are happening urgently to improve dialogue during this very difficult period. The Director of operations is undertaking a review of risks from a service delivery/impact perspective.
• The Community team for Older People in Walsall has continued to try and recruit to
enable the implementation of new ‘enhanced’ working arrangements. A fourth round of Recruitment for Band 6 CMHNs has taken place leaving only 1 post vacant to require further advert. Agency is covering while awaiting new starters to be cleared. The 7 day a week interim 9-5 cover arrangement has been initially deemed to have had a positive impact for patients and families. The key performance indicators for this team have improved, Copies of Care Plans remains a challenge but not to the extent seen in March. CMHNs Band 6 staff are all expected in post in June 2017.
• As part of the redesign of Older Peoples services in Walsall, Interviews took place on
11th April for the new Community Mental Health Nurse Practitioner Posts. There were 10 applicants, short listed to 5 but 3 withdrew and 1 did not attend interview. The 1 candidate interviewed was very appointable and has been given a conditional offer. This raises considerable risk and focused attention will be given to fill these posts as soon as possible.
• The transformation of Older Peoples Mental Health services in will be subject to public
consultation. The Project Team continues to meet.
• Workshop with BCPFT at Broadway North took place to identify opportunities to undertake partnership work in developing services across Black Country for Recovery, Vocation and Employment services for MH. Further workshops planned and in light of the proposed closure of BWN Recovery College. HoS meeting LA for further clarification on timescales for BWN and Team Manager post.
Inpatient Services
• The teams working in inpatient services in both boroughs continue to work hard to manage access and bed pressures on a day-to-day basis.
Enc 20 Director of Operations Report Page 3 of 4
• Work continues on the refurbishment of Clent Ward at Bushey Fields Hospital.
• Interviews have been held for substantive and bank qualified nursing staff and offers have been made to suitable individuals.
Social Care Lead Issues
• The Trust continues to participate in negotiations with the two Local Authorities regarding the future of the ‘Section 75’ integration arrangements.
Recommendation The Board is asked to note the updates within operation services. Board Action Required To receive the report.
Enc 20 Director of Operations Report Page 4 of 4
Board meeting date: 4 May 2017
Agenda Item number: 7.7 Enclosure: 21
Report Title:
Integrated Reference Costs & Education & Training Collection Processes 2016/17
Accountable Director:
Rupert Davies, Interim Director of Finance and Performance
Author (name & title):
Tracy Simmonds, Income and Costing Accountant Paul Chamberlain, Head Of Financial Planning
Purpose of the report: To obtain Board approval of the costing process that supports
the calculation of the 2016/17 Integrated Reference Costs & Education & Training submission.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: None
Date reviewed: N/A Key points or recommendations from Committee:
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
Not directly applicable
Responsive
Not directly applicable
Effective
Reflects the effective use of resources
Well-led
Reflects the management of services
Safe
Not directly applicable
Enc 21 Combined Costs Collection Page 1 of 8
Title Integrated Reference Costs & Education & Training
Collection Processes 2016/17 Introduction NHS Provider Trust Boards were required to sign off the process for calculating the Trust reference costs for the first time in 2012/13. This was designed to raise the profile of costing in the NHS, and is required for the 2015/16 return. Summary of key points, issues and risks NHS organisations have collected Reference Cost information on an annual basis since 1997-98. It is the average unit cost to the NHS of providing defined services in a given financial year to NHS patients in England and is collected by the Department of Health. Costing and Reference Costing is now part of the remit of NHS Improvement (NHSI), representing their increasing responsibilities around the setting of tariff prices. NHSI have developed Approved Costing Guidance 2016/17, which brings together NHS costing and cost collection guidance into a single framework. The framework consists of 4 chapters, The Costing Principles, Mental Health Clinical Costing Standards, Reference Costs & Education & Training Guidance for 2016/17 and PLICs Acute Collection Guidance for 2016/17. For 2015/16 there were two mandatory national cost collections: the business-as-usual (BAU) reference costs collection, & the integrated cost (IC) collection. The IC collection consisted of the education & training (E &T) costs collection alongside a second reference costs collection in which the costs of E & T were netted off reference costs services. The IC collection was seen to be a major improvement in NHS costing & a big step towards aligning & understanding costs for patient services & education & training. Initial findings from the first IC collection suggest that nationally education & training are being subsidised from patient services income but data collection needs to improve further to have confidence in these findings. For the 2016/17 collection the BAU & IC cost collections will be combined into a single submission, with a single timescale & governance process. The new collection will be called the combined cost collection (CCC). Board confirmation should be obtained at a Board meeting in advance of the CCC collection submission. Historically, NHS costing has not been given due prominence at Board Level. It is felt that more senior management involvement in the costing process & an increased use of costing information to support management decisions will help to improve the quality of costing data and ensure that this important function is adequately resourced. Improving the quality of the costing data will ensure more accurate price setting, and provide a sound commercial basis for service provision, strengthening the finances of the organisation. Enc 21 Combined Costs Collection Page 2 of 8
Further detail Context/Background Costing is the process of calculating how much a product or service will cost. The changes to the combined costs collection (IC) in 2016/17 are designed to:
a. Support the development of price setting b. Improve data quality, validation & assurance c. Ensure the collection remains fit for purpose
Reference costs are the unit costs to the NHS of providing healthcare to NHS patients. • Since 1998 the DH has collected and published unit cost information, known as Reference
costs. Reference Costs are designed for central control purposes, with the main objective of supporting a national service tariff. It is annual exercise of collecting data at the level of the trust.
• Mental Health Trusts annually submit Reference Costs to the Department of Health to show
the average cost of providing defined mental health services on a Trust by Trust basis. The scores are used to benchmark Trusts and provide information for performance management purposes.
• Reference Costs are the average cost to the NHS of providing a defined service in a given
financial year. They result from a requirement in the 1997 White Paper ‘The New NHS’, that stipulates that detailed cost information is to be collected, and that unit costs are to be produced and published.
• Reference Cost data is used by the NHS to performance manage and benchmark their
services.
Education & Training costs are the unit costs of training placements at provider level within the NHS. • To ensure that providers are reimbursed fairly for the training that they deliver the
Department Of Health (DH) introduced transitional tariffs for non-medical placements and undergraduate medical placements from 1 April 2013. A similar transitional tariff for postgraduate/medical trainees came into effect on 1 April 2014.
• The annual E&T cost collection exercise, introduced in 2013/14, was established to improve understanding of the costs of placements at provider level to support the replacement of the current transitional tariffs with a more transparent set of tariffs which reflect the actual costs of the placements.
• In 2013/14 and 2015/15 the DH required all NHS providers to complete two mandatory
costs collections: the reference costs and E&T costs collections.
Enc 21 Combined Costs Collection Page 3 of 8
• In 2015/16 there was a move to national cost collections for business as usual (BAU)
reference costs & an integrated cost collection. The integrated cost collection consisted of the E&T costs collection alongside a second reference costs collection in which E&T costs were netted off reference costs services.
In 2016/17 the two cost collections will be brought together into a single timetable with a single governance process, the new collection will be called the 2016/17 combined cost collection (CCC). The Health and Social Care Act (2012) gave Monitor responsibility for the national tariff and for pricing and costing of NHS-funded services in England. Monitor has now merged with the Trust Development Authority to form NHS Improvement (NHSI). NHSI has now taken on Monitors role for the pricing of NHS services. Accurate and comparable cost data is fundamental to supporting NHSI develop their role in pricing NHS services in England. Patient-Level Information and Costing Systems (PLICS) are increasingly used by health care providers for internal management and benchmarking purposes across the NHS. In the long term therefore, the aspiration is to be able to collect patient-level cost data from all providers. However, not all providers have patient-level systems in place at this time and further work is required to understand how this data can best be used to inform prices. In the short to medium term therefore, collecting average cost data or “reference costs” (which is already a mandatory requirement for all NHS providers) will continue, while also starting to collect patient-level costs. By 2019 PLICS will replace reference costs as the single mandatory national cost collection for Acute Trusts. Robust and timely cost data that accurately reflects the costs of delivering care to patients and service users is vital to the day-to-day management of health services. It will be even more important as the NHS looks to meet the significant pressures of demographic change, rising levels of chronic disease and new technology within a difficult financial climate. The NHS increasingly needs to develop new ways of working, new pathways and transformed services to meet these challenges. The impact of any changes on outcomes and service user experience will need to be accompanied by a full understanding of the current costs of delivery, future costs if no changes are made and the costs of alternative methods of delivery. This comprehensive understanding of costs will require a knowledge of costs at the individual patient and service user level if the NHS is to truly understand what drives costs. High-quality costing data can only be delivered with the involvement of clinicians, ensuring allocation methods and final costs accurately reflect the reality of how care is delivered. But high-quality data – particularly at the patient and service user level – can also provide a basis for engagement with clinicians. This engagement between finance and clinical professionals will be vital to the improvement of services and elimination of waste. Mental health services are continuing to move towards using a ‘cluster’ currency for both costing and payment purposes.
Enc 21 Combined Costs Collection Page 4 of 8
Key issues/Options available The framework consists of four chapters prepared by NHS Improvements, which are intended to consolidate existing costing guidance for the NHS: Chapter 1: The Costing Principles Chapter 2: Mental Health Clinical Costing Standards
Chapter 3: Combined Costs Collection Guidance
Chapter 4: PLICS Acute Collection Guidance Providers use cost data to manage services and improve operational efficiency. Cost data is also used to support the development of pricing and currency design for reimbursement purposes There are seven principles that should be applied to all NHS costing exercises: Principles of NHS costing Principle 1 – Causality Show the causality or relationship between activities and the resources consumed to deliver those activities. Principle 2 – Transparency Ensure that the cost allocation process is transparent. Principle 3 – Consistency Enable consistency of approach regardless of NHS service provided. Principle 4 – Accuracy Ensure confidence in the patient-level costing data by basing it on reliable source data.. Principle 5 – Materiality Focus costing effort on the materiality and variability of costs. Principle 6 – Stakeholder Engagement Effective Costing requires stakeholders to contribute to and effectively use costing information. Principle 7 – Totality Produce reliable and comparable results that include all of an organisation’s costs. Our current approach is to follow a top-down calculation process – allocating total costs down to lower levels, such as the total costs incurred by particular services within a care group using occupied bed days, attendance and contacts or, more recently, by clusters. Since 2013/14 the Trust has used a new Costing System that uses financial data from the general ledger to produce costs at a service level, which are then used to calculate a cost by cluster.
Enc 21 Combined Costs Collection Page 5 of 8
Assigning general ledger costs into direct, indirect and overhead groups improves the ability to analyse information at the organisational and service user level. It provides an understanding of costs that arise directly as a result of service user care and those that are more loosely tied to service user care. Costs for each ledger code are apportioned to service level using the following methodologies: Direct costs relate directly to patient care & can therefore be allocated directly to the appropriate service.(example of direct costs - ward costs) Indirect costs are indirectly related to the delivery of patient care, but cannot always be specifically identified to service lines. These costs are usually apportioned on an activity basis e.g. patient catering and linen, apportioned on an occupied bed day basis. Overhead costs are the costs of the support services that contribute to the effective running of a Trust. These costs cannot be traced or easily attributed to patients, and are therefore allocated via an appropriate cost driver e.g. HR costs apportioned on staff numbers. The Trust complies with Monitor’s high level costing principles, and in terms of the HFMA costing standards, varies between bronze, silver and gold – the variation being dependent on the quality of the data available to inform the costing. The Costing System is then able to produce a total fully absorbed cost for each service, which is then pivoted across the 21 care clusters using the cluster profile for each service line creating a total cost for each care cluster. Activity data is then applied to derive the unit cost requirement for the submission - a ‘cost per cluster day’, ‘cost per assessment period’ & ‘cost per initial assessment’ & ‘cost per contact’ for non clustered services. Costs are prepared with due regard to the principles & standards of NHS costing guidance & represent an accurate reflection of services provided within the Trust in cost & activity terms. To make cost information more credible and help organisations understand their business/organisation better and to better inform national cost collection and PbR tariff setting, the Department of Health (DH) now recommends Patient-Level Information and Costing System (PLICS). We aspire to move to ‘PLICS’, this process builds costs from the bottom up, identifying wherever possible the specific resources consumed in the treatment of individual service users – for example, the costs of a drug. This is not always possible. For instance, it is difficult to assign medical and nursing staff time exactly to each service user. However, costs can be allocated with reasonable accuracy using, say, the number of ward round visits to a service user or the time spent on a ward, with adjustments made for the intensity of the nursing support needed by an individual service user. Indirect or overhead costs – such as the costs of payroll, the human resources department or the finance team – can also be divided among all service users based on appropriate allocation and apportionment methods. Once accurate service user cost data is derived, it can be aggregated to provide higher level costs – clusters or service lines – for analysis. But users will always be able to drill beneath these high-level figures to understand how the costs were made up by individual service user interactions. Enc 21 Combined Costs Collection Page 6 of 8
For most organisations, the main driver for undertaking clinical costing is to deliver high quality internal business information. Understanding the robustness or the limitations of the information presented to senior management is very important if decisions are to be taken on the back of this information. In relation to team resource, within finance, the team has 0.69 wte of a Band 6 Income and Costing accountant to perform the costing work. Additional finance resource is also required together with resource within both Informatics and Education & Training functions to provide the appropriate activity information.
1. Established a Project Implementation Group, including Finance, Information Clinical Staff and PbR lead.
2. Specified input feeds and what outputs the Trust will require from the system. Discussed with Managers and Clinicians what information will help them in their decision making.
3. Arranged local demonstrations for the Project Implementation Group. Arranged site visits to see systems in practice The Board is required to satisfy themselves that:
(a) The cost return has been prepared in accordance with the approved costing guidance, which includes the combined costs collection guidance.
(b) The information, data and system underpinning the return are reliable and accurate. (c) There are proper internal controls over the collection and reporting of the information
included in the combined costs collection, and those controls are subject to review to confirm that they are working effectively in practice.
(d) Costing and E&T teams are appropriately resourced to complete the return, including the self-assessment quality checklist and validations, accurately within the timescales set out in the combined collection guidance.
(e) The content of the return is not inconsistent with internal and external sources of information.
The Director Of Finance and Education Lead are responsible for the accurate completion of the combined costs collection return and are both required to sign off the ‘statement of directors’ responsibilities for the 2016/17 collection. Recommendation The Board is recommended to (or provide details of non-compliance): a) Approve the costing process ahead of the collection; b) Confirm that the Director of Finance has, on behalf of the Board, approved the final
reference cost return; c) Approve that the reference cost return has been prepared in accordance with NHS I’s
Approved Costing Guidance, which includes the reference cost guidance; d) Confirm that information, data and systems underpinning the reference cost return are
reliable and accurate;
Enc 21 Combined Costs Collection Page 7 of 8
e) Confirm there are proper internal controls over the collection and reporting of the information, and these controls are subject to review to confirm that they are working effectively;
f) Confirm costing teams are appropriately resourced to complete the reference costs return accurately within the timescales set out in the reference costs guidance.
Board action required Trust Board members are asked to discuss the contents of the report and agree the recommendations as detailed within the report.
Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary
Purpose of the report: To present the Board Assurance for discussion and provide assurance to Board that the risks are being appropriately managed.
Action required from the Board Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: Quality & Safety Committee, Finance & Performance Committee and Workforce Committee Date reviewed: 12 April 2017, 21 April 2017 and 25 April 2017
Key points or recommendations from Committee:
All the Committees were assured that the Strategic Risks were being appropriately managed. The Quality & Safety Committee has recommended that a separate TCT Partnership project risk register be developed. The Finance & Performance Committee highlighted two potential additional gaps in assurance regarding the risk around the Trust’s financial sustainability and the Workforce Committee have highlighted the need to review the prevailing origins of the risk of staff retention in the first quarter of 2017/18.
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
The Board Assurance Framework covers all of the CQC domains.
Title Board Assurance Framework (BAF) – Quarter 4 2016/17 Introduction The Board Assurance Framework for 2016/17 has been reviewed and revised through discussion at Board Development Sessions in March and June 2016. The risks included in the Board Assurance Framework have been agreed through the Board Development Sessions as those strategic risks to the delivery of the Trusts overarching priorities. Within the reporting process the Committees of the Board have a significant role in monitoring the strategic risks within their Terms of Reference to ensure that they are being managed effectively and provide assurance through that work to the Board. Summary of key points, issues and risks Through the discussions at the Board Development Sessions the reporting template has been revised to include a more comprehensive summary of the issues around the reported risk which encompass:
• Initial and mitigated risk score • The origins of the risk • Impact on CQC domains and risk consequences • Risk Controls and reporting Mechanisms • The positive assurances received • The Gaps in Control and Assurance mechanisms and any actions to address those
gaps The initial and mitigated risk scores have been calculated using the matrix in the Trusts Risk Management Strategy. The Assurance Framework at Quarter three has been comprehensively reviewed and prepared in collective discussion with the Executive team and discussed at the Finance and Performance and Workforce Committees respectively. The Quality and Safety Committee at its meeting on 12 April reviewed Strategic Risk 3 – Failure to Achieve Quality of Care and Strategic Risk 5 - Management, Maintenance and Strategy for the Estate. The Committee recommended that a project risk register be established for the TCT Partnership. Members of the Board reviewed the strategic risks included in the BAF for reporting in 2017/18 at a Board Development Session on 30 March 2017 and also recommended that a separate Strategic Risk on TCT Partnership is reported through the BAF. The Finance and Performance Committee at its meeting on 21 April 2017 reviewed Strategic Risk 2 – Financial Sustainability. The Committee through the discussion at the meeting remained assured that the risk was being appropriately managed. The Workforce Committee at its meeting on 25 April 2017 reviewed Strategic Risk 4 – Ability to Recruit and Retain Staff. Through the discussion at the meeting the Committee remained Enc 22 BAF-Q4_2016_17 Page 2 of 6
assured that the risk was being appropriately managed. In managing this strategic risk through the first quarter in 2017/18 the work to define the numbers of staff that the Trust is actively recruiting too will give further positive assurance about the management of this risk however the Committee highlighted the need to review the prevailing origins of this risk, particularly for the retention of staff. The BAF and the Operational Risk Register The BAF and the operational risk register should be aligned such that the high red rated operational risks inform the development of the BAF at the start of the financial year, and therefore the Board will see the high level red rated risk reflected in the origins of and gaps in either the control or assurance of the Strategic risks in the BAF. Further detail The Board Assurance Framework at Quarter 4 is appended to the report. The tables below outline the movements in the Strategic risks in Quarter 4: SR1 – Sustainability of the Organisation Positive Assurance The positive assurance reference A8 has been
updated to reflect NHS Improvement’s implementation of the Single Oversight Framework (SOF) and the Assurance that the Board can take through the Trust remaining in Segment 2 of that Framework. Additional assurance on the sustainability of the organisation can be taken from the month 12 financial position reported to Finance & Performance Committee in April 2017
Reporting Mechanisms The frequency of the NHS Improvement IDM meetings has been amended to quarterly – reflecting the Trust’s segmentation under the SOF.
Gap in Control / Negative Assurance A deadline for a number of actions to address gaps in assurance or provide additional positive assurance have been amended during the quarter – Assurance that the Annual Plan action plan has been delivered will not be known until a review has taken place in May 2017. The actions and deadlines around the Trust’s engagement in two key partnerships have been amended and the associated deadlines altered to the end of the second quarter.
Assured Level Q2
Assured Level Q3
Assured Level Q4
Trend
12 12 12 On the basis of the review at quarter four it is not proposed to alter the current risk and rating against this risk. Enc 22 BAF-Q4_2016_17 Page 3 of 6
SR2 – Financial Sustainability Control Mechanisms The strength of the Financial Planning, budget
monitoring and management has been revised to Green on the basis of the positive forecast outturn and Month 12 finance report to Finance & Performance Committee. However the strength of the use of reserves to offset financial risk has been revised down to Amber.
Positive Assurance Additional positive assurance is received through the finance report to the Committee at Month 12 with regard to the end of year financial position.
Gap in Control / Negative Assurance The date for the development and implementation of the Older Adults Model has been revised to July 2017 and the actions to mitigate against slippage in the CIP for 2016/17 have been amended. Additional negative assurance has been received in relation to contractual penalty notices and the management costs of the Section 75 agreement.
Assured Level Q2
Assured Level Q3
Assured Level Q4
Trend
12 12 12 On the basis of the review at quarter four it is not proposed to alter the current risk and rating against this risk. SR3 - Achieving quality of care Control The strength of the CQC Action Plan as a control
mechanism to improve quality has been demonstrated by the outcome of the CQC Inspection and has therefore become Green
All Service Developments now have a project workbook incorporating a QIA and therefore the strength of this control has improved from Red to Amber
Positive Assurance Additional positive assurance in terms of the published CQC Inspection Report which gives the Trust an overall rating of Good and pertinent to this risk the Caring, Responsive and Safe Domains are all rated Good
Gap in Assurance Develop Protocol for the onBoard walks including how outcomes are incorporated into the governance of the Trust.
Assured Level Q1
Assured Level Q2
Assured Level Q3
Assured Level Q4
Trend
12 12 12 8 On the basis of the review at quarter four it is proposed to improve the Risk rating score to 8, although it remains an Amber Risk. Enc 22 BAF-Q4_2016_17 Page 4 of 6
SR4 – Ability to recruit and retain staff Positive Assurance Additional assurance has been received in terms
of the agreed vacancy control process as part of the Transforming Care Together Partnership.
Reporting Mechanisms The reporting mechanisms have been amended to reflect that Workforce performance is now reported to the Workforce rather than the Finance and Performance Committee.
Gap in Control / Negative Assurance The target for the completion of the outstanding actions has been amended from April 2017 to July and June 2017 respectively.
Assured Level Q2
Assured Level Q3
Assured Level Q4
Trend in Assured Level
12 12 12 On the basis of the review at quarter four it is not proposed to alter the current risk and rating against this risk. SR5 - Management, Maintenance and Strategy for the Estate Control Trust Board has approved an Estates Plan to help
mitigate this risk and therefore provides an additional assurance mechanism. The implementation of the Overarching Fire Safety Action Plan and the detailed work to deliver that plan is an additional Control mechanism to the management of the Estate.
Reporting Mechanism The Fire Safety Action Plan is being driven by and Monitored at an operational level through a short term Fire Safety Group.
Positive Assurance Additional positive assurance received through the approval of an estates plan and an overarching Fire Safety Action Plan.
Gaps In Control The Actions have been revised to reflect the approval of the Estates Plan and move into implementation and that the actions to address Fire Safety Management have been subsumed into the overarching action plan as appropriate. There are three actions that were due to be completed by March 2017
Assured Level Q1
Assured Level Q2
Assured Level Q3
Assured Level Q4
Trend in Assured
Level 16 12 12 12
On the basis of the review at quarter four it is not proposed to alter the current risk and rating against this risk.
Enc 22 BAF-Q4_2016_17 Page 5 of 6
Recommendation
• That the Board be assured that the Strategic Risks that form the BAF are being managed appropriately.
Board action required The Board is asked to:
• Review the Board Assurance Framework at quarter 4
Enc 22 BAF-Q4_2016_17 Page 6 of 6
Enc 22 BAF2016-17-Q4-Draft-V1 Page 1 of 1
Dudley & Walsall Mental Health Partnership NHS Trust
ASSURANCE FRAMEWORK
QUARTER 4 - 2016/17
Enc 22 BAF2016-17-Q4-Draft-V1 Page 2 of 2
Ref. Strategic Risk Executive Director Board Committee Meeting Date
SR1 Sustainability of the Organisation Chief Executive Board 04-May-17
SR2 Financial Sustainability Director of Finance Finance & Performance Committee 21-Apr-17
SR3 Achieving quality of careDirector of Nursing and OperationsJoint Medical Director
Quality & Safety Committee 12-Apr-17
SR4 Ability to recruit and retain staff Director of People and Corporate Development Workforce Committee 25-Apr-17
SR5 Management, Maintenance and Strategy for the Estate Director of Nursing, Operations and Estates Quality & Safety Committee 12-Apr-17
All Overall Assurance Company Secretary Audit Committee 22-May-17
All Overall Assurance Company Secretary Trust Board 04-May-17
Dudley & Walsall Mental Health Partnership NHS Trust
ASSURANCE FRAMEWORK
CONTENTS
Enc 22 BAF2016-17-Q4-Draft-V1 Page 3 of 3
REFQ2 REFQ3
Q4 A1
A2A3
REF A4A5
A6
A7A8A9A10A11A12A13A14A15A16A17A18
REF RAG A19O1 Red A20O2 AmberO3 AmberO4O5O6O7 REF DEADLINEO8O9O10
REF RAG REF FREQUENCY RAG
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2016/17
STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 5 x 3 = 15CURRENT ASSURED
LEVEL
These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4 x 3 = 12What is the strategic risk to be controlled?
Trend in Assured
Level
Partnership Report Trust Board
EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence
be located?
IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Annual Plan Approved Trust Board
STRATEGIC RISK
SR1 Sustainability of the Organisation Chief Executive Board Amber
POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / Meeting
Approved Memorandum of Understanding for MERIT and TCT Partnership and Dudley MCP Trust Board
Transform Services to improve the patient Experience and the quality of services
What are the key potential consequences (up to 4) of the risk? Approved Budget for 2016/17 Trust Board
PC1 There would be a gap in the provision of services to patients that would have implications across the whole of the local and regional health economy.
NHS Improvement - Single Oversight Framework - Segmentation 2 IDM
PC3CQC Inspection Report CQC Website
Sign off of the 2015/16 accounts and 2015/16 annual report as a "going concern" Audit Committee
Become the preferred provider of prevention and recovery services for mental health and wellbeing within Black County and beyond
Sign off of the 2016/17 CIP plans and quality impact assessments Trust Board
PC2Agreed Contracts with the Trust's two main Commissioners Trust Board
Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CREWS domains QGAF / BGAF review under the Well-Led Framework Board Development / Trust BoardAll Domains PC4
CIP/PMO & PMO/Business Growth Reports Trust BoardService Development Business Cases MExTResearch and Development Annual Report Q&S Committee & Trust Board
Potential or actual origins that have led to the risk… IMPACT LEVEL
Report to Finance and Performance Commiteee - Month 12 Position Finance and Performance Committee
ORIGINTrust’s ability to influence, pick up and respond to local and national external drivers for change
What are the most significant origins (up to 10) which could or have led to the risk?Red
AmberGreen
GAP ACTION PLAN
G1 Implementation of the Annual Plan Action Plan Plan is in place with quarterly milestones and reporting ro Board
Ability to influence the commissioning of services that allow the Trust to be the preferred provider of Mental Health / well being services Obstacles to innovation, growth and development opportunities The GAPS IN CONTROL / NEGATIVE ASSURANCES are…
What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?
Strength
What are the key controls (up to 10) that are in place to mitigate these risks?
RedAmberGreen
What are the key reporting mechanisms (up to 10) that will provide assurances that the key controls are effective? (E) = External assurance.
RedAmberGreen
G3
March 2017
May 2017
G2 Benefits Realisation through Partnership Working Partnership Workstream Scoping and delivery of workstream actions Nov-17The risks are CONTROLLED by… Strength The REPORTING mechanisms are…
Standardised project management approach across the Trust
Project Management theough Sharepoint is being rolled out across the Trust, it is being trailed for service development projects in quarter 4 2016/17 and for all projects in the first quarter 2017/18
Jun-17
CONTROL REPORTING MECHANISMG4 Understanding challenges in Walsall to improve
partership
Board to Board and combined leadership meetings
Continue to be an active member of the Partnership Board
March 2017
Sept 2017Green
C2 MERIT Vanguard Partnership Green R2 Management Executive Team Meetings Monthly
C1 CIP Service Development PMO Green R1 Trust Board (and Board Development) Monthly
Programme management approach to the ownership, monitoring and management of CIPs through the PMO
Assessment of Implementation of the Internal Audit Diagnostic Review Recommendations Jul-17
Green
GreenG5 Understanding MCP model and requirements of the
procurement process
Discussing with partners and CCG to ensure full understanding of the model and processEstablish the outcome of the prime provider under the CCG tender process and implications for the Trust.
March 2017
Sept 2017
C4 Healthy Walsall Partnership Amber R4 Board Sub Committees Generally Monthly
4 weekly Amber
G6
C3 Transforming Care Together (TCT) Partnership Green R3 CIP Programme Board
C6 Financial & Annual Business Planning Process Green R6 NHSI IDM (e)
C5 Dudley MCP Vangaurd Partnership Red R5 Workforce Committee
C7 Research and Development Strategy Green R7 MERIT & TCT Partnership Boards (e) Monthly / 6 weekly
GreenG9
C10 R10G10
C9 Sustainabilty and Transformation Plan Amber R9
Enc 22 BAF2016-17-Q4-Draft-V1 Page 4 of 4
REFQ2 REFQ3Q4
A2REF A3
A4A5A6A7A8A9A10A11A12A13A14A15A16A17
REF RAG A18O1 Amber A19O2 AmberO3 RedO4 AmberO5 Red O6 AmberO7 Red REF DEADLINEO8O9O10
REF RAG REF FREQUENCY RAG
G9
G8
Strength
RedAmberGreen
G3 Programme management approach to the ownership, monitoring and management of CIPs through the PMO
Assessment of Implementation of the Internal Audit Diagnostic Review Recommendations
GreenS75 agreement, management cost element of contract
Conclude negotiations develop response plan in the eventuality of the issue widening to include the whole of the S75 agreement
GreenG7
G4 Contract penalties being applied,
Engage with CCG to agree to action plan; undertake externally sourced review of IAPT services across both Dudley and Walsall; consider long term involvement in the service upon consideration of report
Operation of tariff requires internal efficienciesDifficult Contract Negotations with CCG's inluding CCG QIPPsContracts are predomianely block therefore overactivity not paid for
Agency Use Escalation and Monitoring Process
What are the key controls (up to 10) that are in place to mitigate these risks?
RedAmberGreen
What are the key reporting mechanisms (up to 10) that will provide assurances that the key controls are effective? (E) = External assurance.
C4 Partnership Working Amber R4 Audit Committee Regular
Jul-17C2
Jul-17Amber
Monthly Green
G6
Programme management approach to the ownership, monitoring and management of CIPs through the PMO Amber R3 Finance and Performance
Committee
Green
Reserves / Provisions to offset financial risk Amber R2 Management Executive Team Meetings Monthly
Annual Financial Plan including budget monitoring and management Green R1 Quarterly Performance Reviews quarterly
Jul-17
Challenge to deliver annual CIP target GAP ACTION PLAN
G1 CIP delivery for 16/17 - impact of QIPP schemes on CIP projects 3 schemes slippage Older Adults business case being developed
The GAPS IN CONTROL / NEGATIVE ASSURANCES are…National context - Proposed financial settlement from 2017/18
What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?Vacancy rate higher than target and high level of Reliance on Agency Staff to cover vacancies
Feb 2017July 2017
G2 CIP Delivery for 16/17 schemes slippage
Alternative proposals, discussions with Commissioners monitored through PMOFive schemes carried forward for delivery in 2017/18 and the shortfall in two of the schemes has been added to the 2017/18 CIP target
Mar 2017Oct 2017The risks are CONTROLLED by… Strength The REPORTING mechanisms are…
What are the most significant origins (up to 10) which could or have led to the risk?Red
AmberGreen
Size of the Trust and place in the local health economy / regional health economy
Potential or actual origins that have led to the risk… IMPACT LEVEL
ORIGIN
Trust BoardWell Led Domain PC4
Financial Outturn Forecast including impact of CIP / QIPP & CQUINs Trust BoardFinance Report to Finance & Performance Committee at Month 12 Finance & Performance Committee
Transform Services to improve the patient Experience and the quality of services
What are the key potential consequences (up to 4) of the risk? Annual internal audit of the CIP Process Audit Committee
PC1 Loss of organisational control
Ad hoc reporting to F&P and Board Finance & Performance Cttee / Board
PC3Inability to maintain safe and effective local services
Monthly Returns to NHS Improvement NHS Improvement Portal
Financial System Audit - internal audit plan approved Audit CommitteeBecome the preferred provider of prevention and recovery services for mental health and wellbeing within Black County and beyond
Managemant and Committee Reports monthly - Strong cash position Finance & Performance Committee / MExT / Board
PC2 Negative financial impact on local health economyDevelopment of Financial information for partnerships and STP Board Development
Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CREWS domains Contracts with two main Commissioners signed
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2016/17
STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) @ 16/2 Red: 5 x 4 = 20CURRENT ASSURED
LEVEL
These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Red: 4 x 3 = 12What is the strategic risk to be controlled?
STRATEGIC RISKEXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence
be located?
Trend in Assured
Level
IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Sign off of the 2016/17 CIP plans and quality impact assessments Trust Board
SR 2 Financial Sustainability Director of Finance Finance & Performance Committee Amber
POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / Meeting
Audit CommitteeYear end Audit process - sign off of accounts and audit letter giving good assurance on some of the key financial systemsA1
REF RAG A17O1 Recruitment of Clinical Staff Red A18O2 Higher turnover of Staff Red A18O3 Working torwards the national Agency Staffing Cap AmberO4 Clinical Supervision RedO5 Small Bank service AmberO6 Continuous need to deliver Cost Improvements RedO7 Increasing emphasis on working with our Partners AmberO8 CQC Inspection outcome and recommendations Red REF DEADLINEO9 West Midlands Quality Review Outcomes Red
O10 Patient Experience Feedback AmberO11 Amber
REF RAG REF FREQUENCY RAG
IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Quality and Safety Cttee Chairs reportQuality and Safety Reports to Quality & Safety Committee and Trust Board Q&S Committee / Trust Board
STRATEGIC RISKEVIDENCE
What is the report received that provided that assurance? Board / Committee / MeetingQuality Account presented and approved by Trust Board Trust Board
SR 3 Achieving quality of careDirector of Nursing and
Annual Report on Infection, Prevention and Control Trust Board
Trend in Assured
Level
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2016/17
STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) Red: 5 x 4 = 20 CURRENT ASSURED
LEVEL
These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Amber: 4 x 2 = 8What is the strategic risk to be controlled?
EXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?
Become the preferred provider of prevention and recovery services for mental health and wellbeing within Black County and beyond
PC2Not a provider of choice and negative impact on likelihood of GPs promoting the Trust
Patients health and well being at risk Reduction in patient referrals and related income
PC3Increase in patient complaints and poor patient experience with a poor net promoter scoreIMPACT ON CQC CREWS domains
Transform Services to improve the Patient Experience and Quality of Services
What are the key potential consequences (up to 4) of the risk?
PC1
AllDomains PC4 Non compliance with our regulatory requirements and commissioner contracts, potentially resulting in greater external regulation no longer being able to Safer Staffing Report
Royal College of Pschiatrists Centre for Quality Improvement (CCQI) Accreditations (Reported through the Quality Account)A10 Trust Board
CQC Good Inspection Report Trust Board
Trust BoardNursing Strategy Trust Board
Potential or actual origins that have led to the risk… IMPACT LEVEL
Medical Directors Report to Board / Nursing Director report to BoardAnnual Report on Research and DevelopmentStaff Survey Results What are the most significant origins hich could or have led to the risk?
What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?
GAP ACTION PLAN
ORIGIN Staff Friends and Family Results Trust Board
The GAPS IN CONTROL / NEGATIVE ASSURANCES are…
Mar 2017May 2017Mar 2017May 2017
Whistleblowing Policy approved and quaretly freedom to speak up Report Trust Board
The risks are CONTROLLED by… Strength The REPORTING mechanisms are… Strength
G1 Delivery of the Priority Activities 2016/17 Action Plan with Quarterly Milestones agreeed and Monitored Quarterly
G2 Delivery of the Quality Priorities Implement Actions to deliver quality Priorities 2016/17
G3
Lack of capacity appropriately skilled managers and clinicians
CONTROL REPORTING MECHANISM
Green
What are the key controls that are in place to mitigate these risks?Red
AmberGreen
What are the key reporting mechanisms that will provide assurances that the key controls are effective? (E) = External assurance.
RedAmberGreen
C1 Agreement of Priority Activities in the Annual Plan 2016-17 Green R1 Quality & Safety Committee Monthly
C2 Quality Impact Assessment carried out for all CIP schemes Green R2Sub Committees and groups reporting to Quality & Safety Committee
Monthly
Green
Green
Monthly GreenC3 Quality Improvement Strategy & Quality Priorities for 2016/17 Green R3 Trust Board
C4
C6 OnBoard Walkabouts Amber R6
C5 Process in place for staff to raise concerns and whistleblow that are regularly reviewed Amber R5 Quartely Performance Reviews GreenQuarterly
6 weekly Green
CQC Action Plan Green R4 Finance & Performance Committee Monthly
C7 Nurse Revalidation Green R7
C10 Clinical Audit Green R10
Medical Revalidation Green R9
C8 Experts by Experience Visit Feedback and Reviews
C11 Service Development Quality Impact Assessmment Amber R11
Green R8
Annual Green
CLRN - Clinical Research Network Midlands (e) Monthly
C13
C9 Internal Audit reports (e) Ad hoc Green
CCG CQRM meetings (e) Monthly Green
6 monthly
6 monthly
Green
Green
Green
GMC PEST training survey feedback (e) West Midland Deanery Feedback on Foundation Training schemes (e)
Mortality Review Group
Essential skills training clinical role specific Health Education England - Workforce Return (e)
CQC reports and visits (e)
R15
R16
CQC Meetings & Progress Updates (e)
Monthly / Quarterley
Green
Three Monthly IDM (e) Quarterly Green
Ad hoc Green
External stakeholder visits (e) Ad hoc Green
R12
C14 Postgraduate training scheme under West Midlands School of Psychiatry with training placements for junior medical Green R14
C12 Research and Development Green
R13Green
TBC
Quality Improvement Strategy not fully implemented Implement the Quality Improvement Strategy in accordance with plans by achieving 2016/17 deliverables and milestones
Mar 2017May 2017
QIA on negative quality impact
Project Management through Sharepoint is being rolled out across the Trust, it is being trailed for service development projects in quarter 4 2016/17 and for all projects in the first quarter 2017/18
CQC Action Plan Approved and update reports to Quality & Safety Committee Trust Board / Quality & Safety CtteeQ&S CommitteeQuality Priorities 2016/7 approved
Quality & Safety CommitteeClinical Audit PlanTrust BoardAnnual Medical Revalidation Report to Board Nurse Revalidation Report
Review Procedures and Processes to identify any learning and i
Jun-17
G5 Rolling out availability of esential skills trainig to all front facing clinalposts
Profiling of staff and breaking down of clinical and essential skills in the next stage of the roll out. Profiling for Medical workforce oustanding after which the revised matrix will be built into the Mandatory Training Policy
Jul-17
G6 CQC Inspection Report - Recommendations Implemention of the CQC Action Plan
G7 Assurance of the effectiveness of the Freedom to Speak up and Whistelblowing Policy and processes Jul-17
G4
Develop Protocol for the onBoard walks including how outcomes are incorporated into the governance of the Trust Jul-17
Evaluation of the implementation of the revised recruitment process
April 2017
July 2017
EXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?
IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Implementation of Staff Engagement Programme / Report to Board Trust Board
STRATEGIC RISKEVIDENCE
What is the report received that provided that assurance? Board / Committee / MeetingRegular workforce report to Trust Board Trust Board
SR 4 Ability to recruit and retain staff Director of People and Corporate Development Workforce Committee Amber
POSITIVE ASSURANCE
Regular workforce report to Finance & Performance Committee
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2016/17
STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) Red: 5 x 4 = 20CURRENT ASSURED
LEVEL
These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Red 4 x 3 = 12What is the strategic risk to be controlled?
Trend in Assured
Level
Finance & Performance Committee
Become the preferred provider of prevention and recovery services for mental health and wellbeing within Black County and beyond
CQC Report Trust Board
PC2 Increased use of agency staff with negative impact on quality and cost of care including lack of continuity of care
Internal Audit Report on Staff Engagement Audit Committee
Develop the organisational culture and capabilities to support high quality service delivery
Delivery of poor care (with potential high incidents and complaints)
Quality Report (reporting of incidents) Trust Board
PC3 Impact on capability to deliver activity to contractService Experience Reports Trust Board
Safer Staffing Report Trust Board
IMPACT ON CQC CREWS domains Use of Temporary Labour monitoring report Finance & Performance Committee
Transform Services to improve the patient Experience and the quality of services
What are the key potential consequences (up to 4) of the risk? Outcome of Staf Survey Results Trust Board
PC1
Caring Responsive and Safe Domains PC4Negative impact of remaining staff on job satisfaction and morale
TCT Partnership Vacancy Control Process Workforce Committee
Lack of suitable candidates
Potential or actual origins that have led to the risk… IMPACT LEVEL
What are the most significant origins (up to 10) which could or have led to the risk?Red
AmberGreen
ORIGIN
Competition from other local and larger TrustsCarrying larger than target vacancy rate The GAPS IN CONTROL / NEGATIVE ASSURANCES are…Staff morale, motivation and resilience in an ever changing environment National Shortage of staff in certain disciplines
What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?
GAP ACTION PLAN
G2 Service Recruitment PlansThe risks are CONTROLLED by… Strength The REPORTING mechanisms are… Strength
G1 Effectivess of Recruitment Process
CONTROL REPORTING MECHANISMG4
Green
What are the key controls (up to 10) that are in place to mitigate these risks?
RedAmberGreen
What are the key reporting mechanisms (up to 10) that will provide assurances that the key controls are effective? (E) = External assurance.
RedAmberGreen
G3
C1 Recruitment plans in place for all higher risk areas Amber R1 Trust Board Monthly
C2 Close liaison with the University Green R2 Workforce Committee Monthly
Green
AmberG4
Monthly Green
G5
C3 Leadership Development Programme Amber R3 Staff Partnership Panel
C4 Staff Engagement Programme and Staff Survey Action Plan Green R4 Staff survey (e) Annually
C6 Recruitment Process Amber R6
C5 Use of temporary Labour (Monitoring Process) Green R5 Internal audit reports (e) GreenG6
Ad Hoc
G8
R8
C7 R7
C9 R9
C8
C10 R10G10
G9
Enc 22 BAF2016-17-Q4-Draft-V1 Page 7 of 7
REFQ2 REFQ3Q4 A1
A2
A3REF A4
A5A6A7
A8
A9
A10
A11A12
PC5 A13
A14A15A16A17A18
REF RAG A19
O1 Amber A20
O2 AmberO3 AmberO4O5O6O7 REF DEADLINEO8O9O10
REF RAG REF FREQUENCY RAG
Health & Safety Executive Visit and Report on the Trust's management of the water supply
DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2016/17
STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 4 x 5 = 20CURRENT ASSURED
LEVEL
These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4 x 3 = 12What is the strategic risk to be controlled?
Trend in Assured
Level
Independent Engineer for Water Management Presentation to Board - Assurance around the implications of the water management issues Trust Board
EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be
located?
IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Annual Report from Independent Engineer Quality &Safety Committee
STRATEGIC RISK
SR 5Management, Maintenance and Strategy for the Estate
Director of Nursing, Operations and Estates Quality & Safety Committee Amber
POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / MeetingPLACE Survey outcomes and action plan approved MExT / Capital Planning
Transform Services to improve the patient Experience and the quality of services
What are the key potential consequences ( of the risk? Independent Risk Assessments Water Management Group
PC1 Impact on the quality and safety of the care that the Trust is able to provide its patients
Trust Board
PC3 Failure meet specific needs of Trust's client GroupTrust Board
PC2 Potential restriction on the services the Trust could deliver and it capacity resulting in failing to comply with its contractual obligations with Commissioners
Estates Gap analysis completed Quality &Safety Committee
IMPACT ON CQC CREWS domains Infection Prevention and Control Sub Committee Exeception Report and risk report the normalisation of water monitoring in the Trust Quality & Safety Committee
Bushey Fields Refurbishment Plan approved
Safe, Effectiveness Domain PC4 Failure achieve outcome 6 facests surveyEstates Plan Trust BoardOverarching Fire Safety Action Plan Quality & Safety Committee
Failure to comply with legal compoants Fire, water electricity and health and safety
Potential or actual origins that have led to the risk… IMPACT LEVEL
ORIGINRecommendations from Previous Independent Reports on the trust's Estate not being acted upon through changing priorities and demands on personal
What are the most significant origins (up to 10) which could or have led to the risk?Red
AmberGreen
GAP ACTION PLAN
G1 Impact of implementation of the Estates Plan Monitor delivery through the Estates and Capital Planning Sub Committee
Water Management Issues in 2015/16, ongoing across all hospital sitesLimitations of Bloxwich Hospital for our client group served The GAPS IN CONTROL / NEGATIVE ASSURANCES are…
What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?
Strength
What are the key controls (up to 10) that are in place to mitigate these risks?
RedAmberGreen
What are the key reporting mechanisms (up to 10) that will provide assurances that the key controls are effective? (E) = External assurance.
RedAmberGreen
G3
Sep-17
G2 Fire Safety Management within the Trust Incorporated in the Fire Safety Action Plan Sep-17The risks are CONTROLLED by… Strength The REPORTING mechanisms are…
Electrical Safety across all Trust Sites (non HV) Develop action plan around developing accurate drawings and schematics to aid understating of system connections. Mar-17
CONTROL REPORTING MECHANISM
G4 Ventilation Systems and the management of ventilation systems
Authroising Engineer to be appointedA full appraisal of assets is to be completed (December 2016)Policy to be written along with procedural guidance (December 2016)
Mar-17Green
C2 PLACE Survey R2 Finance & Performance Committee Monthly
C1 Estates Plan Amber R1 Trust Board Monthly
Green
Green
Green
G5 Gas Safety across the Trust Policy, procedure and documentation to be standardizedAudit of Gas safety certificate to ensure compliance Mar-17
C4 Approved Business Case Process R4 Fire Safety Working Group Bi-Weekly
Monthly Green
G6
C3 Capital Programme overseen by Estates and Capital Planning R3 Estates and Capital Planning
GroupGreen
Green
C6 Independent Risk Assessments for 3 hospital sites Green R6 ERIC Returns published through HSCIC website (e)
C5 Annual Ligature Assessment Review R5
Stakeholder Conference Calls / Meetings with exteral stakeholds inc HSE and Public Health England
Green
Annual Amber
G8 Green
GreenG7
Ad Hoc
C8 Authorising Engineer in place for Electrical Safety Green R8 CQRM's (e) Monthly
C7 Appointed Independent Engineer for Water Management Green R7 Three Monthly IDM (e) Quarterly
GreenG9
C10 R10G10
C9 Implementation of Fire Safety Action Plan Green R9
Board Meeting Date: 4 May 2017
Agenda Item number: 8.2 Enclosure: 23
Report Title: High Level Operational Risk Register
Accountable Director: Lesley Writtle (Interim Director of Operations) Rosie Musson (Acting Director of Nursing)
Author (name & title): Neil Tong (Risk and Assurance Facilitator)
Purpose of the report: • The purpose of this report is to provide the Trust Board with the Red Risks for the period ending 28 March 2017 and in doing so provides the committee with information on: o Any new red risks being escalated to the High Level
Operational Risk Register o Any red risks being downgraded from the High Level
Operational Risk Register. o Any updates to red risks currently held on the Trust
High Level Operational Risk Register.
Action required from the Committee
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Key points or recommendations from Committee:
Committee: The details within this report was reviewed by: • Quality and Safety Committee • Finance and Performance Committee • Workforce Committee Date reviewed: 8 March 2017 – Quality and Safety Committee 24 March 2017 – Finance and Performance Committee 27/03/2017 – Workforce Committee The risks enclosed within this risk register were approved by Quality and Safety Committee with a number of risks referred to Finance and Performance Committee, Mental Health Act Scrutiny Committee and Workforce Committee in line with the requirements of the risk. Following a review MHASC recommends that risk 319 is downgraded
Enc 23 High Level Operational Risk Register for TB Page 1 of 12
Strategic Objective(s) to which this paper relates:
High quality services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring Some of the risks held on the register have the ability to directly or indirectly impact upon the care/services offered
Responsive The Trust Wide Risk Register Provides a representation of the Trusts “Red Risks” and the responses to managing/action planning these risks; some (due to the nature of the risk) provide a response to a short term or long term issue
Effective Some of the risks held on the Trust Wide Risk Register impact upon the future viability / effectiveness of the Trusts operations.
Risk FINAN 1 specifically relates to the long term outlook in relation to CIP
Well-led Some risks held on operational risk registers Pertain to issues around service redesign and may have impacts upon leadership and staffing issues
Safe The appropriate management of risk is central to the provision of a quality, safe service. In particular CQC Outcome 16 – Assessing and monitoring the quality of service provision
Enc 23 High Level Operational Risk Register for TB Page 2 of 12
Title High Level Operational Risk Register Introduction
It is the purpose of this report is to provide the Trust Board with the Red Operational risks held across the Trusts Risk Registers (for the period 28 March 2017) and in doing so provides Trust Board with information on: • Any new red risks being escalated to the High Level Operational Risk Register. • Any red risks being downgraded from the High Level Operational Risk Register Any
updates to red risks currently held on the High Level Operational Risk Register. There are currently 9 risks being presented as part of this report. This is being done in line with the Trusts risk management strategy and further details of these are included within table 1.1.
Summary of key points, issues and risks There are 9 risks included within this report which are applicable for presentation to the Trust Board. A summary of these risks are detailed within table 1.1. The full details of these risks are articulated in appendix 1 It is recommended by Mental Health Act Scrutiny Committee, that following evidence from the Trusts supportive visits and corroborated with the Trusts CQC visit in November 2016, it arrived at the conclusion that the Trust was not using blanket restrictions and that this particular risk 319 could be downgraded. As such MHASC is formally recommending that this risk is downgraded however acknowledges that there is still further work to be done in relation to ensuring consistent application of the Trusts Search policy. Table 1.1. – Summary of risks Risk ID
Risk Description
Impacts Opaerationally (and
Status of risk
FINAN 1 Inability to meet CIP targets, funding for Mental Health, QIPP (and in longer term the Dudley MCP) have the potential to impact upon the long term financial viability for DWMH. Issues Include: * CIP and QIPP requirements from existing baselines * Reduction in investment by Local Authorities * In longer term, the Dudley MCP plans can be expected to require on-going efficiencies through internal CIPs * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward (Risk related to long term challenges around CIP and not
Source – Financially driven risk with quality implications. Existing
Addition information This risk has been updated by the Acting Director of Finance to include information in relation to MCP and QIPP requirements
=
Enc 23 High Level Operational Risk Register for TB Page 3 of 12
Risk ID
Risk Description
Impacts Opaerationally (and updates)
Status of risk
HR 002 Reduction in Local Authority Funding for Mental Health Social Care Workforce. This has the potential to impact on service delivery and on the viability of the S75 agreements and has the potential to place operational pressures on clinical teams and operational viability of some services
Source – Risk to quality of service driven by a reduction in local authority funding. Existing risk already reported to Quality and Safety Committee Addition information Risk has been updated to include impact on service provision and additional required actions
=
314 A complex interface between electronic and paper clinical records presents challenges to staff when assessing and caring for patients across inpatient and community services. This may lead to an inconsistent approach being taken to clinical risk management, having implications upon continuity of patient care planning and risk management.
In addition to this a decision regarding the procurement of the Clinical System has been delayed for it to be considered by the relevant TCT workstream.
Source – Major project already enacted by the Trust to replace existing clinical system. CQC assessment highlighted that interface between electronic and paper system is a clinical risk and as such interim measures are being put in place to mitigate the risk along with long term measures (the replacement of OASIS) Addition information / update Board were advised that the decision regarding the procurement of the Clinical System has been delayed for it to be considered by the relevant TCT workstream,
Whilst an IT solution will help there was however some discussion that an IT solution is not the cure all for the issues that have been picked up through the CQC inspection about our medical record keeping, so we should still be actioning what we can to strengthen our record keeping within the constraints of our existing systems.
=
315 An inconsistent approach is being taken to the management of clinical risk management and care plan development was identified by the CQC. This is likely to have implications upon continuity of patient care planning and risk management.
Source – CQC visit highlighted that this is a recurrent issue
Addition information Trust has purchased a license agreement for writing person centered care plans. The standards are supported by the CCA and NHS improvement.
Trust supportive visits have noted that whilst the updating of risk assessments on OASIS has improved, there are still issues within inpatient areas of care plans not being patient centered.
=
317 Some staff may not be receiving a regular appraisal of their performance in their role or always may not always receive appropriate ongoing or periodic supervision. Where this is occurring the Trust cannot always evidence this due to a lack of central monitoring mechanism for supervision.
This can therefore result in the provider not ensuring staff are suitably skilled enough to ensure that they can meet people's care and treatment needs.
Source – CQC highlighted that this was a risk to the Trust
Addition information Quarterly “pulse check” of supervision to check how many staff within given areas have received supervision is being completed.
There has been an improvement in the uptake of appraisals. Supportive visits have noted that the recording of supervision has improved however this is still not always being recorded consistently.
=
Enc 23 High Level Operational Risk Register for TB Page 4 of 12
Risk ID
Risk Description
Impacts Opaerationally (and updates)
Status of risk
320 The Trust has a lack of clearly defined processes and policies in respect to the use of personal alarms, the provision of call alarms which allied to an additional need for personal safety training for staff has the ability to impact upon the health and safety of both staff and patients, especially when staff are working on their own.
Source – The Trusts CQC visit highlighted this as a risk to the Trust.
Addition information Supportive visits noted that there are still issues with alarm protocols within certain inpatient areas, review of community areas is still ongoing.
=
322 The Trusts assessment by the CQC noted that there may be a lack of evidence to support that calls within the Trusts Crisis team are responded to in a timely manner
Source – The Trusts CQC visit highlighted this as a risk to the Trust.
Addition information As noted a new crisis call log has been established and a standard for incident reporting has been agreed Whilst no incident forms have been entered in relation to this issue since the CQC visit, there is at this stage audit results to indicate the number of calls which are being returned and the average response time for these. Audit has been completed and has been presented to Clinical Audit and Effectiveness Committee. A decision needs to be made in respect to any risks highlighted by the audit.
=
EF002 Fires Safety Management within the Trust and lack of assurances in respect to certain arrangement regarding fire safety
Source – Gap analysis of assurances undertaken within estates. Issue escalated via Estates Risk Register
Addition information Fire safety working group has now been convened and is meeting on a weekly basis to address the identified issues.
=
319 It is noted through the CQCs Feb 16 assessment that there is inconsistent use of blanket restrictions which were sometimes not in accordance with the MHA code of practice and that this, allied with the failure to make patients aware of their rights may lead to dissatisfaction with service, de-facto detention and failure to adhere the MHA Code of Practice.
Source – CQC highlighted that this was a risk to the Trust
Addition information It is recommended by Mental Health Act Scrutiny Committee, that following evidence from the Trusts supportive visits and corroborated with the Trusts CQC visit in November 2016, it arrived at the conclusion that the Trust was not using blanket restrictions and that this particular risk 319 could be downgraded. As such MHASC is formally recommending that this risk is downgraded however acknowledges that there is still further work to be done in relation to ensuring consistent application of the Trusts Search policy.
▼
Enc 23 High Level Operational Risk Register for TB Page 5 of 12
Further detail (if required)
Further details of the risks are outlined in appendix 1 Recommendation
It is recommended that the Trust Board approve the enclosed copy of the High Level Operational Risk Register and approve the recommendation to downgrade risk 319
Action required
To approve the risks included within this report and note the action taken to date in managing these and to agree the downgrading of risk 319
Enc 23 High Level Operational Risk Register for TB Page 6 of 12
Current Red Risks
R isk N o .
R isk D esc rip tion
S o u rce o f R i s k
D a te Iden tified
P r i n c i p l e O w ne r o f R i s k
O t h e r C o n t r i b u t o r s
In itia l S co re
S L
C o n t r o l s
C u r r e n t
S c o r e
S L
Fu rthe r A c tio ns R equ ired
R e s id u a l
S c o r e
S L
S o u rces o f A ssu rance
D a te o f R ev ie
Fu rthe r C o m m en ts
F INA N 1 Inab ility to m ee t C IP ta rge ts , fund ing fo r M en ta l H ea lth , Q IP P (and in longe r te rm the D ud ley M CP ) have the po ten tia l to im pac t upon the long te rm financ ia l v iab ility fo r D W M H . Issues Inc lude : * C IP and Q IP P requ ire m en ts fro m ex is ting base lines * R educ tion in investm en t by Loca l A u tho r ities * In longe r te rm , the D ud ley M CP p lans can be expected to requ ire on -go ing e ffic ienc ies th rough in te rna l C IP s * E ffic iency o f 4 pe rcen t has been expe rienced fo r a nu m be r o f yea rs and w ill be expe rienced go ing fo rw a rd (R isk re la ted to long te rm cha llenges a round C IP and no t "In Y ea r P os ition ")
F in a nc e P ro jec tions / D a t a
28 /02 /2011
M a rk A xce ll Rupert Davies 5 4 R ed
20 D e ta iled deve lop m en t o f cos t im p rove m en t p rog ra m m e A pp roach to C IP has been ag reed a t F inance C o m m ittee P M O B oa rd es tab lished
Leve l o f C IP has been co m m un ica te to ope ra tiona l tea m s fo llo w ing LTF M re fresh (Ju ly 2013 )
A rrange m en ts fo r m on ito ring p rog ra m m e o f C IP no w in p lace C IP ta rge ts be ing m e t th rough ag reed d ises tab lish m en t C on tinue to m anage locu m m ed ica l cos ts as ag reed th rough F & a m p ;P Q ua lity Im pac t A ssess m en t fo r a ll 2014 /15 and 2015 /16 and 2016 /17 sche m es a ll upda ted F inance tea m m e m be rs o f S e rv ice T rans fo rm a tion w o rk g roups and a lso dec is ion m ak ing P rog ra m m e B oa rd A c tive pa rtne r o f the M en ta l H ea lth P rog ra m m e B oa rd m a in fo ru m fo r co m m iss ione r lia ison . S ens itiv ity ana lys is bu ilt in to cu rren t p lans and fu rthe r deba te had rega rd ing m on ito r assum p tions and T rus t app roach to m itiga tion . R e m ode lled e ffic iency p lan due to changes in M on ito rs requ ire m en ts , ag reed by T rus t boa rd , F inance and P e rfo rm ance co m m ittee and M E x T
R epo rting a rrange m en ts to boa rd enhanced s ince A ugus t 2013 to p rov ide m o re de ta il on sche m es as w e ll as qua lity im pac t assessm en ts M on ito ring o f bank , agency and locu m s no w fo rm s pa rt o f finance repo rt and d iscuss ion a t bo th F and and M E X T .
5 3 15 R ed d
T rus t B oa rd to cons ide r ne w co m m un ica tion on C IP th rough tea m b rie f, bu ild ing on p rev ious co m m un ica tions , to ensu re tha t the m essage is w e ll unde rs tood rega rd ing the sca le o f the cha llenge
W o rk requ ired to ensu re P O D s and repo rting fra m e w o rk is linked e ffec tive ly in to co m p le ted Q ua lity Im pac t A ssess m en ts (O ngo ing ).
R ev ie w o f repo rt fro m rev ised P O D s and repo rting fra m e w o rk accord ing ly
E xp ressions o f in te res t fo r an ex te rna l pa rtne r in deve lop ing C IP p lans fo r 2017 /18 , 2018 /19 and 2019 /20
5 1 G reen
5 V a rious F inance and P e rfo rm ance repo rts inc lud ing :
R epo rts to B oa rd
R epo rts to F & P C o m m i tt e e inc lud ing ind iv idua l ac tion p lans on p ressure a reas .
R epo rts to M EX T
R ev ie w s by ex te rna l assessors inc lud ing T D A , H D D and M on ito r
In te rna l aud it repo rts a round C IP g iv ing fu rthe r as s u ranc e
E x te rna l bench m a rk ing o f p lans
01 /02 /2017
R isk has been upda ted by the A c ting D irec to r o f F inance to inc lude in fo rm a tion in re la tion to M CP and Q IP P re q u ire m e n ts .
Enc 23 High Level Operational Risk Register for TB Page 7 of 12
R isk N o .
R isk D esc rip tion
S o u rce o f R i s k
D a te Iden tified
P r i n c i p l e O w ne r o f R i s k
O t h e r C o n t r i b u t o r s
In itia l S co re
S L
C o n t r o l s
C u r r e n t
S c o r e
S L
Fu rthe r A c tio ns R equ ired
R e s id u a l
S c o r e
S L
S o u rces o f A ssu rance
D a te o f R ev ie
Fu rthe r C o m m en ts
H R 002 R educ tion in Loca l A u tho rity F unding fo r M en ta l H ea lth S oc ia l C a re W o rk fo rce . T h is has the po ten tia l to im pac t on se rv ice de live ry and on the v iab ility o f the S 75 ag ree m en ts and has the po ten tia l to p lace ope ra tiona l p ressures on c lin ica l tea m s and ope ra tiona l v iab ility o f so m e se rv ices
F eedback F ro m S takeho lde rs / P
30 /05 /2012
M a rsha In g ra m
Rosie Musson
Hassan Omar
4 4 R ed
16 S ec tion 75 ag ree m en ts p rov ide fo rm a l p la tfo rm as the bas is fo r any fu rthe r nego tia tions in fund ing and resou rce changes
Jo in t app roach ag reed w ith W a lsa ll M B C rega rd ing im p le m en ta tion o f fund ing reduc tions . R isk A ssess m en ts on loss o f pos ts has been co m p le ted R egu la r d iscuss ions be ing he ld a t P a rtne rsh ip O pe ra tions G roup . A dd itiona l sho rt te rm capac ity has been co m m iss ioned
4 4 R ed
16 D iscuss ions ongo ing a t P O G (M on th ly )
4 2 A m be r
8 R epo rts to M EX T
U pda tes to B oa rd
01 /02 /2017
R isk has been upda ted to inc lude im pac t on se rv ice p rov is ion and add itiona l requ ired ac tions
314 A co m p lex in te rface be tw een e lec tron ic and pape r c lin ica l reco rds p resen ts cha llenges to s ta ff w hen assessing and ca ring fo r pa tien ts ac ross inpa tien t and co m m un ity se rv ices . T h is m ay lead to an inconsis ten t app roach be ing taken to c lin ica l risk m anage m en t, hav ing im p lica tions upon con tinu ity o f pa tien t ca re p lann ing and risk m anage m en t.
In add ition to th is a dec is ion rega rd ing the p rocu re m en t o f the C lin ica l S ys te m has been de layed fo r it to be cons ide red by the re levan t T C T w o rks trea m ,
F eb 2016 C Q C V is i t
19 /05 /2016
R up e rt D a v i e s
Dan Howard
IM&T
David Crook
Bob Yardley
4 4 R ed
16 R ev ie w o f risk assessm en t te m p la te has been co m p le ted in line w ith CP A requ ire m en ts to ensu re tha t s ta ff p rac tice is in line w ith bes t p rac tice T ra in ing needs ana lys is has been looked a t ac ross the T rus t to ensu re tha t inpa tien t s ta ff can upda te e lec tron ic risk assessm en ts on O A S I C onsu lta tion w ith ove r 60 c lin ica l an c lin ica l ad m in s ta ff to deve lop the bus iness case and spec ifica tion fo r the ne w c lin ica l sys te m has been unde rtak en S upp lie rs have sub m itted responses to the Inv ita tion to T ender (ITT ) Inpa tien t a re be ing tra ined to upda te FA C E risk assessm en ts on the O A S sys te m , to ensu re tha t co m m un ity s ta ff a re a w a re o f risks w h ich m ay have e m e rged du ring the pa tien ts inpa tien t s tay R e fe rence S ite V is its have occured S ys te m D e m ons tra tions unde rtaken
s4 4 R ed
S
d IS
16 F u ll bus iness case app roved and con trac t s igned
R o ll ou t o f ne w c lin ica l sys te m co m m ences
Iden tifica tion o f p re fe rred supp lie r
4 1 G reen
4 R epo rts to M E x T R epo rts to IG IM & T co m m ittee
01 /02 /2017
B oa rd w e re adv ised tha t the dec is ion rega rd ing the p rocu re m en t o f the C lin ica l S ys te m has been de layed fo r it to be cons ide red by the re levan t T C T w o rks trea m , in the con tex t o f the dec is ion fo r the 3 T C T pa rtne rs to look ac tive ly a t ho w w e m igh t w o rk as one co m b ined o rgan isa tion .
W h ils t an IT so lu tion w ill he lp the re w as ho w eve r so m e d iscuss ion tha t an IT so lu tion is no t the cu re a ll fo r the issues tha t have been p icked up th rough the C Q C inspection abou t ou r m ed ica l reco rd keep ing , so w e shou ld s till be ac tion ing w ha t w e can to s treng then ou r reco rd keep ing w ith in the cons tra in ts o f ou r ex is ting s y s t e m s .
Enc 23 High Level Operational Risk Register for TB Page 8 of 12
R isk N o .
R isk D esc rip tion
S o u rce o f R i s k
D a te Iden tified
P r i n c i p l e O w ne r o f R i s k
O t h e r C o n t r i b u t o r s
In itia l S co re
S L
C o n t r o l s
C u r r e n t
S c o r e
S L
Fu rthe r A c tio ns R equ ired
R e s id u a l
S c o r e
S L
S o u rces o f A ssu rance
D a te o f R ev ie
Fu rthe r C o m m en ts
315 A n inconsis ten t app roach is be ing taken to the m anage m en t o f c lin ica l risk m anage m en t and ca re p lan deve lop m en t w as iden tified by the CQ C . T h is is like ly to have im p lica tions upon con tinu ity o f pa tien t ca re p lann ing and risk m an a g e m e n t.
F eb 2016 C Q C V is i t
19 /05 /2016
R o s ie M usson
Dr Mark Weaver
Dr Kate Gingell
Patient Safety and Compliance Team
Bob Yardley
4 4 R ed
16 R ev ie w o f risk assessm en t te m p la te has been co m p le ted in line w ith CP A requ ire m en ts T ra in ing needs ana lys is has been looked a t ac ross the T rus t S po t check o f ca re inpa tien t ca re p lans have been unde rtaken O u tco m e o f spo t checks in re la tion t risk assessm en ts has been p resen te to M HA S C
s4 4 R ed o d
16 R egu la r spo t checks o f risk assessm en ts to be co m p le ted (S ep t 2016 and ongong )
O u tco m e o f spo t checks in re la tion to risk assessm en ts to be p resen ted to M HA S C (O c tobe r 2016 ) to check tha t ca re p lans a re pa tien t focused and con ta in recovery based goa ls
4 1 G reen
4 R epo rts to M H A S C
C lin ica l A ud it o u tc o m es
13 /02 /2017
T rus t has pu rchased a license ag ree m en t fo r w riting pe rson cen te red ca re p lans . T he s tanda rds a re suppo rted by the C CA and N H S im p rove m en t.
T he re w e re a nu m be r o f inconsis tenc ies no ted in respect to ensu ring C lin ica l R isk A ssess m en ts a re upda ted sys te m a tica lly an tha t ca re p lans a re pa tien t f o c u s e d
317 S o m e s ta ff m ay no t be rece iv ing a regu la r app ra isa l o f the ir pe rfo rm ance in the ir ro le o r a lw ays m ay no t a lw ays rece ive app rop ria te ongo ing o r pe riod ic supe rv is ion . W he re th is is occurring the T rus t canno t a lw ays ev idence th is due to a lack o f cen tra l m on ito ring m echan is m fo r s up e r v is io n .
T h is can the re fo re resu lt in the p rov ide r no t ensu ring s ta ff a re su itab ly sk illed enough to ensu re tha t they can m ee t peop le 's ca re and trea tm en t n e ed s .
F eb 2016 C Q C V is i t
19 /05 /2016
A sh i W il l ia m s
Mark Axcell
Marsha Ingram
Learning and Development Team
Patient Safety and Compliance Team
Quality Team
4 4 R ed
16 S upe rv is ion po licy has been rev ie w e and no w con ta ins the reco rd ing requ ire m en ts A ud it too l to rev ie w cu rren t leve ls o f co m p liance aga ins t supe rv is ion has been deve loped A pp ra isa l upda tes and app ra isa l ra te a re p resen ted to M E x T on an ongo ing A pp ra isa l da ta is p rov ided to w a rd m anage rs , w ith co m p liance da ta be ing p resen ted to T rus t boa rd C o m m un ica tions s tra tegy has been deve loped and im p le m en ted in respect to c lin ica l supe rv is ion . C lin ica l S upe rv is ion R eg is te r has been deve loped and has been co m m un ica ted v ia W ednesday W ire
d4 4 R ed s
16 S po t check aud its to be unde rtaken to rev ie w the con ten t and the qua lity o f supe rv is ion (ongo ing bas is )
A n op tions app ra isa l w as p resen ted to the T rus ts CQ C s tee ring g roup and a sho rt te rm (E xce l B ased so lu tion w as ag reed ). F u rthe r w o rk is ongo ing to look a t an e lec tron ic so lu tion to th is .
4 1 G reen
4 R epo rts to T rus t B oa rd
R epo rts to M E x T
S po t check aud it res u lts
13 /03 /2017
Q ua rte rly "pu lse check " o f supe rv is ion to check ho w m any s ta ff w ith in g iven a reas have rece ived supe rv is ion is be ing co m p le ted . S upe rv is ion has a lso been added to the "W a lkabou t" check lis ts P o ten tia l e lec tron ic so lu tions to cen tra lly reco rd ing supe rv is ion is s ti be ing exp lo red , w ith ex is ting sys te m s such as E S R and E -ros te ring sys te m be ing scoped fo r s u i ta b i l i ty .
N e w C lin ica l S upe rv is ion reg is te r has no w gone live and has been co m m un ica ted v ia W ednesday W ire
d
Enc 23 High Level Operational Risk Register for TB Page 9 of 12
322 T he T rus ts assessm en t by the C Q C no ted tha t the re m ay be a lack o f ev idence to suppo rt tha t ca lls w ith in the T rus ts C ris is tea m a re responded to in a tim e ly m anne r
F eb 2016 C Q C V is i t
19 /05 /2016
M a rsha In g ra m
Rosie Musson
Crisis team
3 5 R ed
15 A ne w c ris is ca ll log has been dev e loped A s tanda rd has been ag reed tha t if a ca ll is no t re tu rned w ith in the hou r an inc iden t fo rm w ill be sub m itted P rocesses have been co m m un ica ted to s ta ff A ud it in to co m p liance has been c o m p le ted
3 5 R ed
15 C a ll log to be re -aud ited and a risk deep d ive to be p resen ted to Q ua lity and S a fe ty C o m m ittee (A p ril 2017 )
R epo rt in to co m p liance to be p resen ted to C lin ica l A ud it and E ffec tiveness C o m m ittee
3 1 G reen
3 Inc iden t figu res C lin ica l A ud it R e s u lt s
03 /04 /2017
A 2nd aud it has been co m m iss ioned in re la tion to assessing the response tim es a round c ris is ca lls .
T he ins ta lla tion o f a c ris is ca ll log is m en tioned w ith in the T rus ts CQ C repo rt (fro m N ov 2016 v is it) as a pos itive s tep . W h ils t the in itia l issue a round a "lack o f log " has been add resse the w ill need conc lude w he the r the response tim e is app rop ria te . T h is is to be fu rthe r rev ie w ed in ligh t o f the CQ C repo rt by the C Q C s tee ring g roup .
R isk N o .
R isk D esc rip tion
S o u rce o f R i s k
D a te Iden tified
P r i n c i p l e O w ne r o f R i s k
O t h e r C o n t r i b u t o r s
In itia l S co re
S L
C o n t r o l s
C u r r e n t
S c o r e
S L
Fu rthe r A c tio ns R equ ired
R e s id u a l
S c o r e
S L
S o u rces o f A ssu rance
D a te o f R ev ie
Fu rthe r C o m m en ts
320 T he T rus t has a lack o f c lea rly de fined p rocesses and po lic ies in respect to the use o f pe rsona l a la rm s , the p rov is ion o f ca ll a la rm s w h ich a llied to an add itiona l need fo r pe rsona l sa fe ty tra in ing fo r s ta ff has the ab ility to im pac t upon the hea lth and sa fe ty o f bo th s ta ff and pa tien ts , especia lly w hen s ta ff a re w o rk ing on the ir o w n .
F eb 2016 C Q C V is i t
19 /05 /2016
R up e rt D a v i e s
Phil Clark (Head of Estates)
Andrew Foley (Health and Safety Officer)
Team Manager
Tom Jinks
4 4 R ed
16 C o m m un ica tion has been issued to tea m m anage rs rega rd ing the use o f pe rsona l a la rm s w ith a reques t to deve lop an ind iv idua l loca l p ro toco l. A g ile w o rk ing po licy has been deve loped w h ich h igh ligh ts ro les and responsib ilities in respect to the use o f m ob ile dev ices w hen lone w o rk ing Lone w o rk ing po licy has been re -co m m un ica ted co m m un ica ted to s t a f f . P rov is ion o f ca ll a la rm s a t A ncho r M eado w and pop la rs has been rev ie w ed R ev ie w o f a ll trus t p re m ises to be co m p le ted and assessed aga ins t ag reed s tanda rds fo r a la rm sys te m s (co m p le ted ) A T NA has been co m p le ted in respect to iden tify ing w ha t s ta ff requ ire pe rsona l sa fe ty tra in ing , inc lud ing a rev ie w o f the con ten t o f such tra in ing
4 4 R ed
16 F unding requ ire m en ts a re to be iden tified / h igh ligh ted v ia E s ta tes and C ap ita l P lann ing (Jan 2017 )
A s ix m on th ly rev ie w o f T rus t a la rm s to be co m p le ted (Janua ry 2017 )
A T NA to be co m p le ted in respect to iden tify ing w ha t s ta ff requ ire pe rsona l sa fe ty tra in ing , inc lud ing a rev ie w o f the con ten t o f such tra in ing (S ep t 2016 )
R epo rt in to tra in ing co m p liance a round pe rsona l sa fe ty tra in ing to be p resen ted to Q ua lity and S a fe ty C o m m i tt e e
4 1 G reen
4 C o m p le tion o f loca l p ro toco ls
A ud it resu lts
E s ta tes and C ap ita l P lann ing P ape rs
03 /04 /2017
A rev ie w o f th is risk is to be conduc ted by the T rus ts C Q C s tee ring g roup , in ligh t o f the ou tco m e o f the N ove m be r 2016 v is it.
Enc 23 High Level Operational Risk Register for TB Page 10 of 12
R isk N o .
R isk D esc rip tion
S o u rce o f R i s k
D a te Iden tified
P r i n c i p l e O w ne r o f R i s k
O t h e r C o n t r i b u t o r s
In itia l S co re
S L
C o n t r o l s
C u r r e n t
S c o r e
S L
Fu rthe r A c tio ns R equ ired
R e s id u a l
S c o r e
S L
S o u rces o f A ssu rance
D a te o f R ev ie
Fu rthe r C o m m en ts
341 F ire S a fe ty M anage m en t w ith in the T rus t
E x is ting R epo r ting S y s t e m s
19 /05 /2016
R up e rt D a v i e s
Phil Clark STK (Fire Safety Advisors)
Marsha Ingram
Rosie Musson
Neil Tong
5 4 R ed
20 A ll s ites m a in ta ined by the T rus t have a spec ific F ire R isk A ssess m e in P lace . P P M s a re in p lace as requ ired by H T M s A ll m a ttresses a re 5 and o r 7 C rib ra te d . M anda to ry tra in ing is in p lace . F ire S a fe ty P o licy has been upda ted and re -ra tified N u m be r o f fire requ ired fire m a rsha ls has been iden tified A D T and M id w es t F ire S e rv ices hav been co m m iss ioned to p rov ide a se rv ice w h ich add resses so m e o f th gaps in assurance .
5 4 nts R ed
e
e
20 A g reed nu m be r o f fire m a rsha ls to be tra ined . T h is has been co m p le ted fo r the T rus ts hosp ita l s ites . The nex t phase o f th is w o rk w ill focus on co m m un ity a reas
S u itab le and su ffic ien t assessm en t o f fire risk assessm en ts to be unde rtaken a long w ith an aud it o f docu m en ta tion . (H osp ita l S ites to be co m p le te by the end o f A p ril 2017 )
T e s ting o f s ta tu to ry requ ire m en ts to be co m p le ted (A p ril 2017 ).
P rog ra m o f fire doo r rep lace m en t fo r the D o ro thy P a ttison S ite (da te TB C )
A ssu rances to be w o rked up in re la tion to E lec tric ity a t w o rk regu la tions and the associa ted 5 yea r tes ting . (A con trac to r has a lready been con tac ted rega rd ing the co m p le tion o f th is w o rk , co m p le tion da te TB C )
P rog ra m o f m a ttress rep lace m en t to be co m p le ted to ensu re tha t a ll m a ttresses a re ra ted as C rib 7 (C o m p le tion da te TB C )
5 2 A m be r
10 S T K F ire M anager
F ir e c o m p a r tm e n ta tio n a s s e s s m e n ts
F ire R isk a s s e s s m e n ts
T ra in ing figu res
03 /04 /2017
F ire sa fe ty g roup has bee m ee ting on a w eek ly bas is and w ill con tinue to m ee t on a b i-w eek ly and has unde rtaken w o rk to ensu re tha t the re is an app rop ria te p rov is ion o f fire m a rsha ls w ith in an inpa tien t a rea . T he focus o f th is p iece o f w o rk has no w sh ifted to co m m un ity s ites .
In add ition to th is a
p rog ra m o f fire sa fe ty aud its be ing led by S T K a re in the p rocess o f be ing co m p le ted , fo r the T rus ts hosp ita l s ites . T he se aud its invo lve physica l checks o f the s ites fo r assurance pu rposes and checks o f ex is ting pape rw o rk fo r aud it and assurance pu rposes.
A ud it in to assurances has been co m p le ted fo r 1 o f the hosp ita l s ites (D o ro thy P a ttison H osp ita l). It no ted 3 a reas w h ich requ ired im m ed ia te ac tion na m e ly : - E lec tric ity a t w o rk regu la tions (5 yea r tes ting ) - F ire doo rs requ ire rep lac ing - M a ttresses - it w as no ted tha t the re w e re no C rib 7 M a ttresses
T he se a re in the p rocess o f be ing ac tioned by E s ta tes .
n
Enc 23 High Level Operational Risk Register for TB Page 11 of 12
Recommendation to Downgrade R isk N o .
R isk D esc rip tion
S o u rce o f R i s k
D a te Iden tified
P r i n c i p l e O w ne r o f R i s k
O t h e r C o n t r i b u t o r s
In itia l S co re
S L
C o n t r o l s
C u r r e n t
S c o r e
S L
Fu rthe r A c tio ns R equ ired
R e s id u a l
S c o r e
S L
S o u rces o f A ssu rance
D a te o f R ev ie w
Fu rthe r C o m m en ts
319 It is no ted th rough the C Q C s F eb 16 assessm en t tha t the re is inconsis ten t use o f b lanke t res tric tions w h ich w e re so m e tim es no t in accordance w ith the M HA code o f p rac tice and tha t th is , a llied w ith the fa ilu re to m ake pa tien ts a w a re o f the ir righ ts m ay lead to d issa tis fac tion w ith se rv ice , de -fac to de ten tion and fa ilu re to adhe re the M H A C ode o f P rac tice .
F eb 2016 C Q C V is i t
19 /05 /2016
R o s ie M usson
Marsha Ingram
Mark Weaver
Kate Gingell
Nageena Bibi
Least Restrictive Practice Group
4 4 R ed
16 C o m m un ica tion has been issued to s ta ff in re la tion to Leas t R es tric tive P o lic ies and P rocedu res Im m ed ia te rev ie w unde rtaken o f a ll in fo rm a l pa tien ts and the ir righ ts C o m m un ica tions have been issued in re la tion to the righ ts o f in fo rm a l pa tien ts S tanda rd ised pos te r and lea fle t has been ag reed and p rin ted fo r a ll inpa tien t a reas in respect to in fo rm a l pa tien ts (and leave a rrange m en ts ) A ud it o f pa tien t has been co m p le ted to de te rm ine leve l o f co m p liance w ith p o l i c y A ud it o f "righ ts o f pa tien ts " has been ca rried ou t to de te rm ine leve ls o f co m p liance aga ins t s tanda rds .
4 3 A m be r
12 Leas t R es tric tive P rac tice T ra in ing to be de live red ac ross a ll inpa tien t w a rds and a ll s ta ff g roups (O ngo ing w ith regu la r re freshe rs )
A ud it o f pa tien t sea rches to be co m p le ted to de te rm ine leve l o f co m p liance w ith po licy and p resen ted to M HA S c ru tiny C o m m ittee .
4 1 G reen
4 M HA S c ru tiny C o m m ittee M ins / P ape rs
C lin ica l A ud it and E f f e c t i v e n e s s C o m m i tt e e
03 /04 /2017
W h ils t the T rus ts N ove m be r 2016 v is it fro m the C Q C h igh ligh ted an im p roved pos ition in re la tion to the use o f b lanke t res tric tions , the re a re ho w eve r s till so m e cha llenges in re la tion to the im p le m en ta tion o f the T rus ts S ea rch P o licy , w ith bo th in te rna l aud its and c lin ica l aud its no ting issues in re la tion to th is a rea .
Enc 23 High Level Operational Risk Register for TB Page 12 of 12
Board meeting date: 4 May 2017
Agenda Item number: 9.1
Enclosure: 24
Report Title:
Communications and Engagement Report – 2016/17 Quarter 4
Accountable Director:
Mark Axcell, Chief Executive Officer
Author (name & title):
Rebecca Salari, Interim Communications and Engagement Manager
Purpose of the report: To inform the Board on progress against communications and
engagement work plan.
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: MEXT
Date reviewed: April 18th 2017
Key points or recommendations from Committee:
None
Strategic Objective(s) to which this paper relates: High quality
services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
The report provides information on how the Trust plans to engage and communicate with stakeholders and build strong relationships that will support its role as a responsive, effective and well-led organisation. It describes progress against our plans to develop the tools and target the messages that are appropriate for our diverse stakeholder groups.
Title Communications and Engagement Report – 2016/17
Quarter 4 Introduction This is the quarterly communications and engagement report that updates progress against the Communications and Engagement Strategy 2015 -19. Summary of key points, issues and risks Strategic partnership communications
We held two all day Transforming Care Together (TCT) engagement events in March and April for senior clinical and support services staff which were led jointly by Mark Axcell and Tracy Taylor. These events were aimed at senior managers and provided an opportunity for staff to be part of shaping how TCT will look in the future and to explore how we define and deliver the benefits of working together in partnership. Next steps:
• Mark Axcell and Tracy Taylor will be leading a number of listening events for all staff across the three sites to provide an update on progress, discuss the benefits of the programme and to answer any queries or concerns.
• A TCT focused newsletter will be circulated to members across each organisation outlining the partnership details and how members can find out more information and get involved.
• A series of drop in sessions are being arranged for patients and members of the public over the coming months to find out more information about the partnership and the benefits.
Sustainability and Transformation Plan (STP) – we sit on the joint communications group and meet regularly to discuss the communications and engagement of the STP within the Black Country. The communications plan for the Mental Health and Learning Disability workstream has been drafted. As a group we’ll be looking at our forward plan of engagement highlighting the benefits which the development of the Black Country STP will bring to healthcare locally. Internal communications review The communications team has produced an internal communications review as part of the planned communications audit. The review includes a set of recommendations for how communications can be improvedacross the Trust. As part of the review the communications team conducted a survey which was augmented by sessions with engagement champions, EBEs and staff side. As part of our improvement work around internal communications, we Enc 24 Trust Board Communications report Q4 2016-17 Draft Page 2 of 10
have introduced a pilot video Team Brief for all staff. The first video Team Brief was circulated to all staff via a YouTube link on Tuesday 11 April. We have also worked with a design team to update the homepage of our Intranet site so that it is easier to navigate for staff. The homepage was created with the input from our staff engagement champions. Recruitment The communications team supported the workforce development team with a recruitment event hosted by the Royal College of Nursing (RCN) at the beginning of March. The event was a great success with more than 50 nurses registering their interest to work with us. All suitable candidates who expressed their interest were contacted following the event. We have completed two days of filming for a Trust recruitment video which we will use to promote vacancies at the Trust via our social media channels such as Facebook, Twitter, Linked in and our public facing website. We will also be supporting the new Bank programme with internal and external communications. Staff awards The communications team has produced a proposal for this year’s staff awards taking into account feedback received from last year’s awards. We have decided to hold this year’s staff awards ceremony on Friday 22nd September. It will be held on the same day as the Annual General Meeting, later in the evening. The communications team is now in the process of planning the awards and is recruiting a project committee group to support with the organisation of the event. We are planning to secure sponsorship for this year’s event to support with the cost of the awards. Campaigns Talking Therapies – the marketing campaign included Facebook advertising, bus advertising, a four week radio campaign with Black Country radio, a mail out of service leaflets to local stakeholders, promotional events and press releases. It has proved effective at generating more interest in the service as we have monitored a significant increase in visitors to the services website. We are working on a proposal to identify new ways of promoting the service across the boroughs in 2017-18. We are waiting for budget information which will influence the methods of promotion suggested. Mental Health Awareness Week (MHAW) - the communications team have a number of activities planned during MHAW. We will be running a series of patient case studies throughout the week on social media and internally about the benefits of our services and how we have helped patients on their road to recovery. We will be supporting the equality and diversity team with a series of wellbeing events, focusing on five ways to wellbeing. National nurses day falls on Friday 12 May during MHAW and to celebrate the day we will be sharing a selection of compliments from patients regarding our nursing staff.
• Supporting with ongoing campaigns such as the recruitment campaign, Talking Therapies and Smoking Cessation
• Supporting with communications on service closures including Walsall Carers Support Service
• Supporting the Trust’s health and well-being strategy • Dawn Jones Art prize
In Quarter 1, 2017/18 we will be focusing on:
• Supporting with communication around the Transforming Care Together (TCT) partnership work
• Reviewing the Communications and Engagement Strategy and prioritizing areas of focus
• Implementing the recommendations from the internal communications review • Coordinating the Recognising Success awards ceremony and Annual General Meeting
Further detail (if required) Appendix 1: Updated communications and engagement action plan 16/17 Appendix 2: Communications and engagement dashboard, Q4, 2017 Recommendation The Board is asked to receive the report and further appendices for information and discussion. Board action required There are no actions for Board.
Clinical Supervision – The Seven Eyed Model (1,656) Systems Training for Emotional Predictability and Problem Solving (978) Work experience shadowing application form (770)
Matters Arising At their previous meeting the Non-Executive Director (NED) Assurance Group (The Group) had identified a number of actions. The status of the main items are as follows: • The governance structure diagram had been updated and circulated to the
Assurance Group for onward sharing at Trust Boards as required • The arrangements for management of disagreements on the steering group has
now been articulated within the approved Memorandum of Understanding (MOU) which has now been circulated to the group Furthermore, the position with the following actions were also noted:
• Stakeholder presentation has been shared with all stakeholders • The Communication Strategy Action Plan has been shared • The programme risk register will be shared routinely with Trust/company
secretaries.
Furthermore, the Group has asked: • for the Communications Strategy and plan to be provided for its next meeting and • for further clarity to be provided on how funding is expected to be managed
through the STPs (if that is to be the route), going forward, together with any potential impact on MERIT funding, should any of the participating Trusts not achieve their quarterly control targets.
Chair’s Group relationship and function feedback Waheed Saleen from Birmingham and Solihull Mental Health NHS Foundation Trust introduced feedback from the Chairs and NEDs meeting where the issue of the NED Assurance Group was debated. It was agreed that the group saw this as an important group to provide valuable assurance to respective boards and as such would continue to be supported. The Value Proposition has been revisited via the MERIT report at the first meeting in the New Year.
Enc 25 MERITVanguardNEDAssuranceGroupReport Page 2 of 4
The MERIT Plan for 2017/18 is included which clearly sets out the objectives and oversight arrangements for the work programme and associated risks and issues. It was noted that at the meeting, the Chief Executive Officers were asked to deliver a consistent message, which will need to be agreed by the Steering Group and in addition, have a consistent attendance when attending NED Assurance meetings which can be inconsistent. The group considered the existing governance arrangements which detailed the relationship between the NED Assurance Group to the Steering Group and Trust Boards. The agreement relating to company secretaries sharing administrative arrangements was supported, as were the existing meeting rotation arrangements. Assistance of the Project Lead to Trust secretaries was welcomed. The funding positon from NHSE was noted and it was acknowledged that these were subject to change whilst the focus from the centre is on delivering control totals. It was highlighted the discussion around risks had been productive and the group felt assured the Risks and Issues are being managed effectively. Deliverables Following a debate on key deliverables for the MERIT programme, it was noted that a number of tangible benefits need to be clearly outlined within the context of effective communication to key stakeholders. Tangible benefits across the four Trusts were suggested. These related, in the first instance to consideration of consistent approaches to reducing agency usage and bed management. A further area for broader consideration was a patient story describing how the benefits of collaborating across organisations are experienced by service users. Project Management The Head of the Merit Programme, Shakeel Sabir presented the MERIT Risk Management Strategy which outlined the approach to managing project risks. The risk register was assessed and whilst the group considered the amber risks, attention focused on red risks which related to future funding and meeting control totals. Future funding has been confirmed and the risk level has been reduced. Programme Implementation Plan Position Positive progress across the following workstreams was noted and the challenge to continue implementation acknowledged. The position across the two clinical workstreams (Crisis Care and the Recovery Culture) and five Enabling Workstreams (workforce, IT, research and innovation, quality governance and equality and diversity) was described.
Enc 25 MERITVanguardNEDAssuranceGroupReport Page 3 of 4
It was noted that the ground work needed to be in place to support implementation of collaborative works is, in the main completed and once Standard Operating Procedures, setting out practical processes are agreed, a number of initiatives can move towards the implementation phase. Steering Group Report The Chief Executive (CE) of CWPT, Simon Gilby, highlighted the role of the steering group and their specific focus on impact and benefit. The CE described positive progress across a number of workstreams such as the co-ordinated approach to bed management and patient records. Further necessary work with regard to developing a shared bank is progressing, as is the joint work with regard crisis care, recovery and removing the stigma of mental health. The Group agreed that progress across workstreams could be made more tangible and the evaluation leads would be invited to a future NED Assurance Group meeting to describe progress in more detail. Date and Time of Next Meeting 6th July, 9am to 12pm, Seminar Room, FF, Dorothy Pattison Hospital, Alumwell Cl, Walsall WS2 9XH
Enc 25 MERITVanguardNEDAssuranceGroupReport Page 4 of 4
Board meeting date: 4 May 2017
Agenda Item number: 10.1b
Enclosure: 26
Report Title:
MERIT Vanguard Overview Report
Accountable Director:
Mark Axcell – Chief Executive
Author (name & title):
Mark Axcell – Chief Executive
Purpose of the report: The attached updates the Board on progress with the MERIT
Vanguard. Action required from the Board Decision / Approval
Gain assurance
Discussion
Information
What other Trust Committee or Group has considered the key elements of this report?
Committee: N/A
Date reviewed: N/A
Key points or recommendations from Committee:
The Board is asked to note progress with the MERIT Vanguard.
Strategic Objective(s) to which this paper relates: High quality
services
Inclusive partnerships
Leadership culture
Responsible workforce
Supporting strategies
Effective/efficient resources
The CQC domains that this report relates to are:
Please give brief details:
Caring
The MERIT Vanguard aims effect all CQC domains
Responsive Effective Well-led Safe
Enc 26 MERIT Vanguard Overview Report Page 1 of 2
Title MERIT Vanguard Overview Report Introduction MERIT alliance is an equal partnership between four trusts:
• Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) • Black Country Partnership NHS Foundation Trust (BCPFT) • Coventry and Warwickshire Partnership NHS Trust (CWPT) • Dudley and Walsall Mental Health Partnership NHS Trust (DWMHT)
The programme consists of two clinical workstreams (Crisis Care; and Recovery Culture) and five enabling workstreams (Information Technology; Workforce; Quality Governance; Equality & Diversity; and Research & Innovation). The report outlines the main achievements in the reporting period and that planned for the next along with the key risks and issues in the workstreams and their mitigations. Summary of key points, issues and risks The Crisis care pathways have been validated by Mental Health Leads and incorporated into the website and a demonstration of Crisis Care Website (with postcode search facility) has been carried out to the Crisis Care workstream and Experts by Experience. The Draft Crisis Competency framework has also been updated by the Crisis Care workstream
The MOU (Framework) for Governance (Safety and Quality) is under review to align to Bed Management MOU and SOPs. Serious Incidents and RCA training sessions have been delivered within the Vanguard and Mental Health First Aid training is underway.The vanguard also received a visit from South West London Mental Health Trust and is receiving a visit in the next quarter from West Yorkshire Mental Health NHS Trust The report attached outlines the main achievements in the reporting period and that planned for the next along with the key risks and issues in the workstreams and their mitigations. Mental Health Strategies has done an early progress and scoping report. The purpose of this report which is appended is to provide a picture of progress and impact to date of the MERIT programme. Given the early stage of the programme this focuses primarily on the implementation of the programme to date and is an opportunity to reflect on what has been achieved to ensure that action is taken, where possible, to address the barriers identified. Recommendation That the board receive this quarterly update on progress with the MERIT vanguard Board action required To receive the report for assurance.
Enc 26 MERIT Vanguard Overview Report
MERIT Vanguard Programme Highlight Reports - April 2017
• Standard Operating Procedures (SOP) schedule created with SOP Leads identified across the Vanguard
• Crisis care pathways validated by MH Leads and incorporated into the website
• Demonstration of Crisis Care Website (with postcode search facility) carried out to the Crisis Care workstream and Experts by Experience
• Initial output from the Bed Management task and finish group • Delivery of Recovery co-production workshop at Leadership event • Mental Health First Aid training underway by trainers across MERIT • Draft Crisis Competency framework updated by the Crisis Care
workstream • Completion mock inspection pilot review in BCP, DWMH and BSMFT • Continuation of Mock Inspection app development • MOU (Framework) for Governance (Safety and Quality) under
review to align to Bed Management MOU and SOPs • Research and Innovation in progress for Crisis Care Workstream • Serious Incidents and RCA training sessions delivered within
Vanguard • Completion of Privacy Impact Assessment • Visit from South West London Mental Health Trust to MERIT • Identification of Senior MERIT Evaluation Lead (CWPT DOF)
Risk / Issue • There is a risk Local Commissioner (CGs and local authorities) will
not fund models developed through the Vanguard. (Risk Ref 4 *) • Continued Clinical and Operational engagement, input and buy-in
from all four Trusts (Risk Ref 3)
Mitigation • Early engagement with Commissioners to be carried out Lead by
the Steering Group supported by Workstreams • Steering group and Clinical Oversight group to support the
continued engagement. Areas of low engagement to be identified and progressed by each Trust
Key risks and issues
Main achievements this reporting period
Main achievement planned for next reporting period
Overall Programme Status
Current Amber Previous Amber
Enc 26
• Joint MERIT CEO and Mental Health STP Lead discussion • Initial cohort of SOP creation complete to support coordinated
bed management approach • Demonstration of Crisis Care Website (with postcode search
facility) carried out to Clinical Quality Oversight Group • Revision of Crisis Care website incorporating feedback received • Bed Management system pilot in Coventry and Warwickshire • Creation of Draft Evaluation Report for review by Steering
Group and submission to NHSE • Legal advice / counsel for Information Sharing Agreement • Completion of Workforce workstream prioritisation • Completion Recovery systematic review • Adoption of Requol toolkit across the Vanguard • Scoring system for Mock Inspection App to be agreed • Development of Mock Inspection Tool App • Serious Incidents and RCA training deployed – 4 sessions • Finalisation of the research search results protocol and initial
production of the logic models for Recovery workstream • Crisis Care Navigation website communication and
engagement plan development • Visit from West Yorkshire Mental Health Trust to MERIT
HIGHLIGHT REPORT Reporting Date: 31/03/2017 Work-stream: Crisis Care Reporting Period From: 01/03/2017
To: 31/03/2017 WS Lead:
PM: George Tadros
Mohammed Ajaz Summary Update Draft Crisis Care and ICT PID completed including crisis care feedback, forwarded for review/sign off at next Crisis Care meeting taking place on 28th March 2017. Bed Management Task and Finish Group has been set up and have begun discussions on SOPs and deciding on sequence of deliverability and priority. PIA stage 2 currently under review with the aim to be signed off shortly. ICT leads met with IG and have agreed that consent is not required and that the four Trusts will be following the direct patient care route. Lisa Cummins, from Coventry and Warwickshire Trust, will be the lead for legal matters; Mills & Reeves have been instructed and will provide timeline for data Sharing Agreement and project costs by the end of March 2017. A Task and Finish Group has been setup for communications and policy review for ESHR. CSU Communications lead has begun work on communication plan with service user inclusion in discussions. Work is ongoing. Web developers will present website demonstration at the crisis care work stream on the 28th March 2017. It is anticipated that the website will go live in April 2017. Main achievements this reporting month Main achievements planned for next reporting month
• PIA stage 2 under review with a view for sign off at the end of the
month • Comms plan for ESHR has been devised • Purchase order raised for web development and work currently under
way • Service user event with web developers
• Task and Finish group are due to attend and present at the next COSG
(7th April 2017) which will include workshop delivered by all four Trust Bed Managers.
• Website development to receive final sign off • Fair Processing notices and Comms strategy do be developed • Task and finish group to review bed management SOPS • Web developer finalise website
Key Risks & Issues Risk / Issue • Loss of Control for individual organisations (one dominates) • Bed management SOPs not implemented by agreed timescale (May) Staff resistance Organisations fail to agree on solutions Delay in ESHR due to issues with contract IT infrastructure on wards
Mitigation • Clear Governance framework; active engagement with all
organisations; any disputes to be reported and escalated • Set up BM Task and Finish group to discuss SOP and timescales for
implementation , also invite Bed managers to COSG to discuss and re-plan accordingly after discussions
Summary Update ICT workstream met with IG colleague who will liaise with Mills and Reeves to address any outstanding questions which seem to have been answered by collective PIAs. IG colleague to provide further update to ICT work stream for further analysis. Comms Task and Finish Group for implementation of Comms strategy / campaign and local policies has been set up regarding ESHR. Bed Management viewer and infrastructure requirements meeting held including a demo. Bed Managers are committed to using the viewer for information only purposes. BSMHFT bed viewer is preferred choice as it can be accessed by MERIT Alliance. Clinical Quality Oversight Scrutiny Group has requested a demo of BSMHFT bed viewer at their April meeting. Task and Finish Group made up of Bed and Service managers from all Trusts to attend in order to agree sequence of SOPs deliverability Amended contract (wrong framework used by Intersystems) received from InterSystems. Final comments by ICT workstream to be discussed ahead of sign-off with deadline of 3rd April 2017. New Comms lead recruited and will be based at CWPT. CSU will continue to support MERIT group for the time being Main achievements this reporting month Main achievements planned for next reporting month • PIA review undertaken • Task and Finish Group set up for Comms strategy regarding ESHR • Procurement process complete for ESHR. • Infrastructure for ESHR in place, Coventry to host and PO has been
raised • VPN connections in progress of being setup via BSMHFT and CWPT
• InterSystems Contract to be signed off
Key Risks & Issues Risk / Issue • Black Country Partnership have advised they cannot confirm that
additional hardware/software or Staff Resourcing for implementation required to deploy the Electronic Shared Healthcare system (Intersystems) due to their current financial situation.
Mitigation • Identify what resources are needed once we have received finalised
Summary Update Positive feedback has been received regarding progress made by the work stream. Jenny Treanor highlighted we are on track against targets the 1st year objectives. All four trusts have signed off adoption of Refocus and ReQol. Unpacking local delivery plans (for baselining) is to be completed during April and next steps supported. These will include a review of systems (patient patient paperwork, supervision, policies etc) in support of the refocus upskilling of the workforce/cultural change. BCPFT have developed a plan around ReQol and similar plans are taking shape across MERIT. We are approaching the MERIT IT lead to explore options. The refocus on recovery merit event was held on the 1st March and supported conversations around culture change that will enable/support the changes required to embed the change in behaviours across our trusts. The meeting between ACD & the crisis lead was cancelled (re: embedding recovery elements into competency/training frameworks). ACD has inputted into the crisis competency framework but in terms of crisis skills/competencies/systems (Inc. paperwork) there’s acknowledgement of the cross over yet no firm plan in place. MHFA aspect is now being led under Equality & Diversity (Lakhvir Rellon) but understood the two work streams could merge.
Main achievements this reporting month Main achievements planned for next reporting month • Recovery Practices event completed. Several Added value outcomes – further
cemented relationships and understanding of the work stream across MERIT, several local action plans were initiated (e.g. creation of local recovery group) and the graphic is to be used across the 4 trusts to support wider comms steps.
• Stakeholder engagement continues – presentation at West Midlands EI network event • Liaised with NHS England re: development of change agents. • Continued development of culture change steps – met with HEE and Jane Boothroyd • Delivered co-production workshop at Leadership event • Refocus and ReQol adopted across all 4 trusts. • Reviewed bespoke TRIP measure with Dorset lead.
Confirm evaluation elements and support with Jenny Treanor. Discuss culture change steps with Helen Billings/Julia Cross. Continue skills development plan development/conversations with relevant leads. Confirm team recovery readiness measure. Explore wider funding streams for recovery initiatives (Timebank/MHFA etc.). Confirm budget for 17/18 and plans for recovery. To meet all trust recovery leads (following up from 1st March event) and confirm local plans for baselining & ReQol delivery plans 17/18. Confirm co-production elements/support with Mark Hillier for 17/18.
Key Risks & Issues 1) Involvement of governance will be crucial in the roll out of ReQol across all Trusts. Risk there’s lack of involvement in planning/representation/awareness of requirements. 2)Potential costs for ReQol roll out haven’t been explored (IT option)s and risk of variation across Trusts. 3) Skills development programme content and funding to be confirmed. 4) Communication will be critical during the next few months – plan needs confirming. 5) Funding for wider initiatives (timebank/skills development/MHFA etc). 6) Lack of agreement with crisis framework
Mitigation 1 – Continued invites to meetings/local leads engaging trust governance leads. 2) - Engagement with MERIT IT lead. Engagement with local trust leads. 3) engagement with workforce lead/OD lead/MERIT programme lead and focus on local delivery plans. 4) – Early meeting with new comms post to ensure effective comms plan and stakeholder engagement. 5) – As part of 4 – funding workshop and stakeholder engagement planned. Plans to be developed with MERIT Programme lead.
HIGHLIGHT REPORT Reporting Date:31/03/2017 Work-stream: Workforce Reporting Period From: [01/03/17] To: [31/03/17] WS Lead: PM: Julia Cross & Lee Walker
Summary Update The workforce lead attended March CSOG where revised priorities were agreed. As a result of this and previous direction from the steering group the Workforce project plan has been revised and reflects the objectives and priorities. The plan for the enabling work supporting the crisis work stream has been confirmed and a meeting is scheduled to confirm recovery elements (specifically the training requirements and supporting engagement actions). Following further discussions with the OD lead regarding inter-dependencies, separate steps will be taken covering the cultural/skills development context of the clinical work streams.
Main achievements this reporting month Main achievements planned for next reporting month • Revised priorities agreed • Confirmed all sub groups and terms of reference • Concluded plan for enabling work and actions in respect of HR priorities (e.g.
passport) • Crisis Competency framework - revised draft framework and supporting paper
presented to the Crisis Steering Group . Further comments invited and steps for engagement workshop (s) initiated.
• Shared bank – 1st recruitment sub group meeting planned (6th April). • Agreed resource for temporary passport specialist project support. • Reviewed 2 shared bank projects (findings to be shared with group). • MERIT stand supporting the RCN job fair on 2 and 3 .3. 2017.
• Further stakeholder engagement planned (with steering group members) • Confirm recovery training elements (scope implementation/costs/functionality) and
elements relating to cultural change • Further discussions re: OD & support for clinical work streams (steps not picked up via
MERIT OD plan) • Scope/cost Introduction to coaching in support of clinical work streams • Evaluation of RCN event and next steps initiated • Crisis Competency framework – Confirmation/running of workshop • Agree terns of reference for recruitment sub group and tasks /plan (6th April) • Shared bank - present position/updated options to SG in April re plans for sharing
temporary staffing resources . • Recruit training passport project support • Training data mapping initiated (data) and develop action plan for staff passport • Review previous recruitment data with Jenny Treanor • Confirm benefits measurement/review of LOGIC • Confirm any inter dependency with streamlining plans • Collate/populate template for training venues across MERIT • Initiate review of options for shared e-learning.
Key Risks & Issues Risk 1 – HRD representative's capacity for engagement / conflicting priorities Risk 2 – Unable to secure specialist support for training passport
Risk 1 – Previously escalated to MERIT programme lead/continued relationship building Risk 2 – Agency options and further dialogue with workforce colleagues
HIGHLIGHT REPORT Reporting Date: 31/03/2017 Work-stream: Organisational Development Reporting Period From: 01/03/17 To: 31/03/17 WS Leads: Tracey Wrench and Helen Billings
Summary Update OD – Detailed commissioning for both steering group and service improvement components have taken place and conversations/next steps with the clinical work streams.
Main achievements this reporting month Main achievements planned for next reporting month OD update • Commissioned David Shaked for service improvement model • Commissioned Chris Birbeck for steering group support • Outline plan for 28th April • Drafted report for COG • Sent application to WMAHSN • Commenced OD task and finish group
OD update • Agree session plan for steering group with steering group • Agree plan for 28th April • Commence clinical workstream OD task and finish work • Liaise with organisations not yet engaged
Mohammed Rahman Summary Update A solution option for the development of the “Time to Shine” application has been received. This will be shared with the IT work-stream in early April to gain agreement to proceed with the recommended solution. The last of the four RCA training sessions has been completed and brings the total number of people trained through this programme to 66.
Main achievements this reporting month Main achievements planned for next reporting month
A solution option has been provided by CWPT IT department for the development of the “Time to Shine” application.
4 of 4 Serious Incidents and RCA training sessions have now been delivered with 66 people trained to date.
Project plan and Logic Models to be reviewed and updated. Gain agreement to proceed with solution option. Commence software development.. Memorandum of Understanding (MoU) for Safety & Quality
Governance to be submitted for sign-off by CQOSG.
Key Risks & Issues Risk / Issue If barriers to information sharing across the Trusts cannot be
addressed then this may limit the effectiveness of the “Time to Shine” model and governance framework.
If the solution option is not agreed by the IT work-stream then this may further delay the development of the application and alternative solutions will need to be explored.
If funding for the work-stream is not secured for 2017/18 then this may impact the quality of the outputs to be delivered.
Mitigation Work-stream to work through what information is required for
sharing and develop an agreement (if required) to support the “Time to Shine” model.
Engage with the IT work-stream members to gain support for the proposed solution.
Work-stream to be clear on the activities and resources required and engage with key decision makers.
HIGHLIGHT REPORT Reporting Date: 31/03/17 Work-stream: Research & Innovation Reporting Period From: 01/03/17
To: 31/03/17 WS Lead:
PM: Swaran Singh
Mohammed Rahman Summary Update A lead for the work-stream has been identified and in post since the start of March. Plans have been agreed regarding the remaining general allocation for the work-stream; monies have been allocated to pay for open access charges for the publications and attendance at a recovery focused conference to help disseminate the recovery research findings. The Recovery review is now expected to be completed by the end of May 2017. The relatively novel approach to completing the reviews (i.e., combining realist review techniques with systematic search procedures) has contributed to the difficulty in estimating the time required. As highlighted previously, the Crisis Care review may require an additional 6 months to complete, this does not take into account the lead time in recruiting a researcher. Outline plans have been agreed for 2017/18 and are dependent on securing the resources needed to complete the activities. Main achievements this reporting month Main achievements planned for next reporting month
Work-stream lead replacement identified. Crisis Care – report on current status of review completed with outstanding
activities identified. Recovery – registration on PROSPERO completed. Recovery – report on progress to date and plans to complete review
completed.
Project plan and Logic Model to be reviewed and updated. Recovery – systematic search to be completed. Recovery – initial results of search to be discussed with Recovery work-
stream lead. Recovery – data extraction completed. Recovery – quality assessments on selected articles completed. Crisis Care – plans to be agreed in how to proceed with the Crisis Care review.
Key Risks & Issues Risk / Issue If required funds for the work-stream cannot be secured for 17/18 then it
may result in not fulfilling the objectives set out in the logic model. Crisis Care and Recovery reviews have not been completed.
Mitigation Work-stream to be clear on the activities and resources required and
engage with key decision makers. Plans to be revised and agreed with resource secured to complete the
reviews in 2017/18.
HIGHLIGHT REPORT Reporting Date: 31/03/2017 Work-stream: Evaluation Reporting Period 01/03/2017 to 31/03/2017 WS lead
PM: Jenny Treanor (MHS) Mohammed Rahman
Summary Update We have to deliver our first progress/scoping report to NHS England by mid/late April. This will contain a detailed evaluation plan for each element of the programme. The draft report will come to the April MERIT SG for review. Metrics data is not available yet due to resourcing issues within MERIT. Whilst this is not yet critical (as work programmes which will impact on the metrics are not yet live), this does need action to address as soon as possible. We now have an evaluation delivery group established (with finance and clinical reps) and an agreed MERIT evaluation lead identified.
Main achievements this reporting month Main achievements planned for next reporting month Programme of first phase evaluation interviews completed with key internal
stakeholders by MHS. Evaluation Delivery Group re-established with agreed lead and met on 16th
March. Neil Mulholland (CW) appointed as MERIT evaluation lead. Evaluation plan fleshed out as agreed with each workstream Scoping report drafted. MHS have liaised with CSU regarding A&E data and with bed managers regarding
data feeds from them.
Evaluation scoping report will be finalised and send to NHSE. JT and MR to meet with each BI lead to ensure they are clear re
expectations on metrics data collection and identify resource implications of this work.
Further progress on metrics work to enable baselining data to be identified where possible.
Continue work to put together a more detailed project plan for the evaluation over 2017.
Key Risks & Issues 1. Resourcing - the MERIT BI lead is doing this on top of a very busy “day job” . With conflicting priorities. BI leads at other organisations also stretched. MERIT BI lead has escalated this to his manager. He has not been able to do any work on the metrics during March due to other commitments. 2. The quality and availability of some of the data is proving challenging 3. Some work programmes are still not clear (in terms of timescales particularly) which makes planning the evaluation challenging.
Mitigation 1.BI leads at each Trust have been asked to identify what further resource they need to move this forward. Shakeel has agreed to action this once made aware. 2. Dashboard will highlight any data quality concerns. We are working with CSU and bed managers to look at alternative sources for data. 3. The evaluation timetable will be reviewed regularly to ensure it reflects changes in the programme.
HIGHLIGHT REPORT Reporting Date: 31/03/2017 Work-stream: Communication
Reporting Period From: 01/03/2017 To: 31/03/2017
Lead: PM:
Louise Butler Filippa St Aubin d’Ancey / Christine De Souza
Summary Update Productive month promoting MERIT to a wider audience. Events included Refocus on Recovery, RCN Jobs Fair, Royal College of Physicians Annual Conference. EDS Forward Thinking Leadership Conference. Ongoing day-to- day work to develop pace and joint working helping to raise MERIT brand across the partnership. Newsletter #1, social media and website all creating ‘traffic’ for MERIT. Main achievements this reporting month Main achievements planned for next reporting month • Main animation completed and signed off, final version available for
wider use w/b 1.4.17. • Crisis care animation in progress, theme submitted to lead – now in
studio production. • Recovery animation postponed to new financial year. • Sam Jones’ video signed off ready for FYFV launch as part of proactive
week of promoting vanguards starting 31 March until 7 April. • EbyE video completed awaiting sign off • Interactive website demo to crisis care team and service user • Mini comms plan for crisis care workstream including ESHR, website
and bed management prepared and submitted. Associated news releases in draft
• Refocussing on Recovery article for newsletter • Copies of the visual as prints for each trust ordered delivered early
April. • ME in MERIT concept, leaflet wording draft design concept underway
Promote animation and videos through traditional media and via social media, key stakeholders and other sources Promote interactive website Finalise comms plan and rollout communications for crisis care ESHR and Bed Management. Develop strategy and roll out of ME in MERIT with Experts by Experience. Work in partnership with newly appointed in house communications manager to help maintain proactive communications.
AOB New in house communications manager Steve Thomas appointed. Meeting arranged with current provider MLCSU. MLCSU to support one day a week for three months to help smooth transition. MLCSU to supply other services on call off and cost basis thereafter.
DRAFT MERIT Vanguard early progress and scoping report
CONTENTS Page No. 1. Executive summary 3 2. Introduction 4 3. Progress and impact to date 4 4. Feedback from formative interviews – lessons learned 10 5. Summary 20 Appendix One: Updated logic model for Recovery Culture workstream
1. EXECUTIVE SUMMARY The MERIT programme has made considerable progress over the last 12 to 18 months in:
building relationships and trust between managers and staff across the Alliance building a more in depth understanding of issues, cultures and services developing clear work programmes embedding governance structures embedding programme management structures and support, and delivering some early improvements.
This work should prove a sound platform from which to launch a range of planned initiatives in 2017/18. As anticipated with such a large and complex change programme there have been a number of challenges which have hampered progress. Despite some significant change in the structure of the four organisations involved, and a wide range of other, sometimes conflicting priorities, the trusts remain committed to delivering the MERIT programme. The people that we interviewed, to inform this report, were able to identify some significant lessons learned from the work to date. Some of these require action, in order to ensure that maximum progress can be made, going forward. This report should be used as an opportunity to reflect on what has been achieved and to ensure that action is taken, where possible, to address the barriers identified. Key recommendations The MERIT Steering Group should time to reflect on what has been achieved so far and what and how the programme will deliver in the next 12 months. Ensure this has full support from each Trust’s board. Focus on the key deliverables the Trusts have signed up to in their recent joint letter to the Vanguards programme. Ensure that experts by experience are given a greater role in developing and embedding the various initiatives. Improve communication and engagement regarding the MERIT programme within the four trusts and monitor the effectiveness of this. Ensure that the culture change is supported at all levels Ensure each Trust has the appropriate resources, from the MERIT funding stream, to play its full part.
3
2. INTRODUCTION
The purpose of this report is to provide a picture of progress and impact to date of the MERIT programme. Given the early stage of the programme this focuses primarily on the implementation of the programme to date. This report is designed to provide formative feedback to the MERIT Alliance and to NHS England.
3. PROGRESS AND IMPACT OF THE MERIT PROGRAMME TO DATE 3.1 Background The Acute Care Collaboration (ACC) vanguards are broadly focused on two challenges:
To reduce avoidable variations in the cost and quality of acute care. This includes
tackling variations by provider, by type of service and by the day or time at which patients require care.
To address challenges to the sustainability of acute hospital services. This includes responding to financial and workforce pressures, in addition to meeting new service standards, while maintaining local services for patients.
The MERIT Alliance was accepted as an ACC Vanguard in late 2015, bringing together four West Midlands NHS Trusts who deliver mental health services. A Value Proposition (VP) was submitted in February 2016 detailing what the Vanguard hoped to achieve and why and applying for funding to deliver this programme. The Alliance identified three clinical priorities within mental healthcare, where they face the greatest challenges, and could make the most impact immediately, and where they could potentially deliver tangible benefits through horizontal integration. These were:
crisis care recovery culture, and seven day working in acute services.
The VP also stated the intention of the Vanguard to develop shared innovative models for support services to enable the delivery of these new clinical models:
Research and innovation (R&I) Staffing, workforce planning Information technology Equality, diversity and Inclusion, and Quality governance.
The original governance framework also included:
4
A clinical network group A patient, carer and staff reference group An evaluation group A communications sub group.
When funding was announced there was a shortfall in the allocation. The programme was therefore revised with the complete removal of Seven Day Working from the programme. The amount of money available for a number of support functions (such as business intelligence hub, clinical pathway modelling and research and innovation) was also reduced.
3.2 Context
The local context, and the significance of both local and national context for the Vanguard work will be explored in more detail in future reports. Below are some brief elements of context which are likely to be of interest.
Services provided - two trust provide primarily mental health services whilst two provide significant other services such as general community services in addition to mental health services.
Foundation Trust status - two of the MERIT Trusts are foundation trusts and two are not.
Size - the largest two MERIT trusts have around 4,000 staff whilst the smallest has under 1,000.
Mergers – during the period the two smaller trusts (BCP and DWP) signed a partnership agreement and will be additionally merged with Birmingham Community Healthcare NHS Foundation Trust from October 2017.
The MERIT trust services are commissioned by ten different CCGs and cut across three STP areas.
All four trusts have significant health inequalities, diversity and deprivation within their largely urban populations.
The four mental health trusts which form MERIT have not formally worked together across their borders before.
3.3 Progress with the work programme to date
The original logic models were produced based on the plans and knowledge available at the time of VP submission. During the first year of the programme changes have taken place in the logic models for the two clinical workstreams as a result of:
Intelligence obtained about services and systems at each trust which in some cases challenged original assumptions made about each other’s services
Scoping research – including literature reviews and “grey” research (making contact with colleagues at other trusts and organisations for example)
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Not all trusts wishing to proceed with elements of the work at the same pace and differences in interpretation regarding some of the original plans.
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Overall the last year has been focused on:
Getting the workstream groups fully operational Forming strong working and trusting relationships between staff and managers
across the four trusts. Finding out how things work at each other’s trusts. Looking outside the trusts to identify how things work in other places and what
this might mean for MERIT plans. Revising plans based on the above. A project management and governance structure has been put, and bedded in.
We have summarised below, progress against the original planned outputs for year one of the programme, by workstream where applicable and as detailed in the VP. We have also commented where the plan has been changed for year two based on the scoping research and local discussions and developments.
TABLE ONE: Progress to date on year one outputs identified within the Value Proposition
Crisis Care - Shared access to clinical information/care records Work undertaken to review and understand current clinical information systems (and
associated support) at all four trusts. Clear interoperable standard (HL7) agree for identifying data so that all can view it
regardless of which system it comes from. Approach agreed and signed off by all four Trusts. IG issues, including legal implications, reviewed and addressed. Host trust identified. Contract signed with Intersystem to deliver software solution. Contract agreed in such a way that other Trusts wishing to sign up can do so without
high start-up costs (replicability). Task and Finish group setup for communications and policy review for ESHR. Working with chief clinical information officers to get clinical input to the work. Communications lead has begun work on communication plan with service user
inclusion in discussions. Delivery timescales agreed for 2017.
Crisis Care - Shared approach to bed management with care closer to home and joint operational policy and collaboration plan for a single bed management function
Work undertaken to review and understand current bed management arrangements at all four trusts.
Substantial debate around concerns from each Trust regarding the realities of sharing beds.
Memorandum of Understanding signed by each Trust which establishes that each Trust will retain ultimate control over use of its own beds.
ICT solution identified to enable sharing of bed management information across the four trusts.
Work ongoing to develop a range of standard operating procedures to support all
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elements of good practice in the management of bed and of patients (and their family) who are admitted to a bed out of their home area (whether another MERIT bed or out of MERIT area).
Delivery timescales agreed for 2017.
Crisis Care - Care pathways developed using evidence based practice which has been evaluated
Crisis services across all four Trusts have been comprehensively mapped. Researcher started, but not yet completed, an evidence based review of crisis care. Website developer appointed to develop pathways website which will enable both
professionals and people in need of urgent mental health care to identify which services are available to them.
Website developed and demonstrated. Currently being refined as per feedback from professionals and service users.
Communications plan being developed. Whilst this initiative will not change the care pathways it is hoped it will change the
ways that they are used so they are used more effectively. Delivery timescales agreed for 2017.
Crisis Care - All organisations working to the same crisis care clinical model (adapted for local variation)
A set of core competencies for staff working in crisis care has been developed and signed off across all four trusts.
A review has been undertaken of related current training availability across MERIT which identified scope to share some training approaches (e.g. some trusts have e-learning packages which can be shared).
Next steps are to produce a gap analysis based on assessment of all relevant staff against these competencies at each trust.
A plan for addressing these training needs will then be produced. Delivery timescales agreed for 2017.
Crisis Care - All service users have an agreed, person centred, crisis plan and criteria agreed for inpatient treatment at admission
The bed management work has been extended to focus not just on managing beds but managing patients in those beds. This will include a review of the processes for when patients are admitted for inpatient treatment at another MERIT trust or out of area, in order to ensure that the subsequent treatment can be as effective as possible. This work is currently ongoing through the development of a number of standard operating procedures. Recovery Culture - Research evidence based models of recovery and workshops held with stakeholders to agree a service model The Vanguard has undertaken a comprehensive, evidence based review of recovery
practice in conjunction with the MERIT Research and Innovation team. This research based approach uses innovative methodology (combining intensive stakeholder input and a series of comprehensive literature reviews) to better understand how to improve recovery in mental health services (Baxter et al., 2014).
The approach taken was based on three steps: realist review methodology to build a theoretical logic model of sustainable
recovery an interactive, iterative process in which the researcher, clinical experts, and
stakeholders feed into the developing logic model
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systematic review methods to furnish the logic model with objectively collected empirical evidence.
The systematic review summary paper is available on request and a number of publications are planned. In addition to this work, the workstream lead and members have made contact with a wide range of organisations and individuals with experience and expertise in mental health recovery.
As a result of this, a recovery model has been developed which will direct the elements of the work to be implemented in 2017. This is based on a clear, evidence based, theory of change and an understanding of what the “active ingredients” in that model should be.
Requol has been selected as an recovery focused outcome measure to be implemented across the Alliance.
Re-focus methodology will also be used across all four trusts, but exact implementation details are still being worked out.
A number of engagement workshops have been held involving staff and experts by experience.
See appendix one for new draft logic model. There is not currently a detailed implementation plan. Each Trust is currently developing its own approach to implementing the model, based on its needs and its pre-existing recovery services and practices (which differ by Trust). Recovery Culture - Framework for recovery culture agreed between the alliance and across communities, linking with communities in a new supportive way.
The research synthesis provides an underpinning model for linking with communities in a new supportive way.
12 Mental Health first aid trainers have been fully trained. Plan is in place to implement Mental Health First Aid training across the Vanguard
area, although it has not yet been clarified which groups this training will target. Other elements of the work are in development.
Recovery Culture - Baseline pre-existing recovery services and practices in the alliance A systematic baseline of pre-existing recovery services and practices within the Alliance has not been undertaken, although informally this data has been collected via the workstream group.
Workforce workstream - Staff moving between the four trusts will have a statutory and mandatory training passport. Implementing a joint, flexible staffing bank. Scoping of workforce issues completed. Agreed recruitment plan across the four trusts. Post registration training and mental health training accessible to all staff in the four trusts. The workforce is able to work on all sites across the Alliance. Statutory and mandatory training passport extended to include post registration and mental health. Joint training across the four trusts. Recruitment campaign operating across the four trusts. A consistent approach, across the four trusts to recruitment, retention, training and flexible staffing. Development of a shared flexible staffing functioning across the Alliance, with a single team base. Joint approach to delivery of Equality Delivery System.
The Workforce workstream has struggled to establish itself and agree clear objectives. There have been a number of reasons for this. The initial workforce workstream lead left after six months and it was several months before a new lead was recruited. The new lead has struggled with poor attendance from MERIT trusts to the group. There
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was also a lack of clarity regarding understanding of this workstream’s objectives when the new lead took over.
In particular the objective to develop a shared flexible staffing function has proved
contentious. This is a clear example of an element of the programme where the MERIT objectives appear to conflict with Trust’s individual objectives. It appears that the relative positions of each Trust with regard to flexible staffing were not well understood when the objective was set. One Trust, for example only has 25 trust on its bank. Another has just signed a contract with NHS professionals for them to deliver this service. It is unlikely that the benefits of a shared flexible staffing function with be shared equally amongst the trusts. Recruiting staff to an enhanced bank will come with costs. The exact staff groups to be included has not been agreed. Work is continuing to agree whether and how this objective may be delivered in 2017.
Objectives around streamlining statutory and mandatory training between the Trusts
and ensuring that training received at one MERIT trust is recognised by another appear to have more support and there is a clear mandate to move this work forward. Likewise the work to develop and agree a shared and/or best practice approach to staff recruitment has made some progress.
It has now been agreed that in 2017 the workforce workstream will concentrate on
four elements: - Recruitment - to cover joint events and sharing best practice - Training - to cover training passport and e-learning. Other workstreams are also
looking at the scope for shared training in areas including ICT and Governance. - Transformation support to clinical workstreams including planning training and
staff engagement - Temporary staffing – exact scope still to be agreed.
11. Collaboration of ICT across the Alliance, which will allow for the sharing of resources. Performance information standardised across the Alliance. Consistent recording and reporting of clinical information across the Alliance. Development of a shared project library. Development of shared procurement initiatives Development of shared ICT training across the Alliance. 13. Other enabling workstreams - Quality Governance, Equality and Diversity, Research and Innovation (where not captured above) Research outputs as detailed above A CQC preparation/improvement tool has been chosen, refined to meet the needs of
the Alliances and piloted. Work is ongoing to develop an app to make use much easier and more effective.
Plans in place to use this tool proactively across the Alliance to drive improved clinical practice
80 staff trained in RCA and hope to use these to do more Serious Incident investigations across MERIT and save average spend of £50k on using externals
Equality and Diversity leads working together on a number of cross MERIT initiatives and supporting workstreams to ensure E&D issues are addressed in their plans.
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4. FEEDBACK FROM FORMATIVE INTERVIEWS
In order to inform this scoping report we interviewed workstream leads and members and others who have had a key involvement in MERIT including the four Chief Executives. We asked them about progress made, barriers and enablers to that progress and what lessons they had learned from their involvement in the Vanguard to date, both to inform future progress of the work within MERIT and to advise other sites hoping to replicate this work. We have captured their views below.
4.1 What has helped progress?
Passionate leadership The “positive support, enthusiasm and drive” from the Vanguard Chief Executives was cited as a significant factor in driving the programme forwards. We were also told that the clarity of vision and passion plus hard work and determination of the workstream leads – in particular the clinical workstream leads, had been crucial in enabling the work programmes to make progress. They have had to be tenacious in the face of, at times, high levels of uncertainty and resistance to elements of the work and have risen to the challenge superbly. There is a belief that the MERIT programme is “the right thing to do” and is “the future” which is also a key driver for the people involved. Support for the workstreams Workstreams were grateful of the support they had received from project managers and, where administrative support was provided this was reported to being very helpful in enabling workstream leads to concentrate on progressing work. Linking together the workstreams When the programme started there was a lack of clarity regarding how the workstreams would work together to support and enhance each other’s work. Although there remains a potential for this to improve in some areas, overall interviewees felt that this had progressed well with good links in place between the workstreams which was enabling synergies to grow. Linking up with other people and organisations doing similar work Being part of a Vanguard has “given permission” for involved staff to make links with similar work more so than was the case previously. Many interviewees felt that this had raised the profile of both their trust and their specific initiatives which had been both positive and motivational. Doing this across four trusts meant that all trusts were able to benefit from links which only one trust had made. For example, the CX of CWPT is very involved with the West Midlands Mental Health Commission and has been able to make useful links for MERIT here. Clear governance structure in place
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There were mixed views from interviewees regarding the governance structure in place to support the Vanguard work. Some felt that it was clear and effective whilst others felt that it could still be improved. The role of the Clinical Oversight and Scrutiny Group was largely welcomed as a positive step which enabled senior clinical managers to play a vital role in ensuring both input and oversight.
4.2 What have been the barriers to progress?
Resourcing and the tension between MERIT and the day job Although significant levels of extra resource have been dedicated to progressing the MERIT programme there remain concerns regarding. This has been a limiting factor in how quickly the programme can progress. This is a wide ranging change programme across four organisations who are all very busy and some of whom have significant financial pressures. Many interviewees reported that there was a real tension between doing the MERIT work and doing “the day job”. There were significant concerns about capacity. Many of those in key roles felt that they were having to do the MERIT work on top of their other responsibilities because backfill was either not resourced or not realistic given the nature of their (often senior) role. There were some specific areas where interviewees felt that a lot more input and support should have been provided and could have enabled more effective progress. This included:
Administrative support to the programme Organisational Development support to Executives and Workstream leads Business Intelligence and analysis Communications and engagement Expert by Experience input Continued dedicated Project Management Support
“..we don’t have any capacity to do the MERIT work within the trust as far as I am concerned…” …“it’s like walking a tightrope balancing the MERIT work vs what we are doing for our own stakeholders…” “…normal businesses will get in the way if we don’t dedicate real time and resource to making the changes happen. …” “….each Trust had own internal road map for ICT development which conflicted with MERIT requirements…”
Changes in configuration during the first year Many interviewees felt that the changes within the MERIT trust configuration (and the process undergone to get to that point) had at times hindered the progress of some of the MERIT work with staff and managers from those trusts reluctant to commit to parts of the MERIT programme (even though the organisation has
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previously signed up to these) in the light of the uncertainty over their organisations future. This led to considerable “angst” and in some cases “back peddling” on programmes which it was thought had been agreed. This has also impacted on capacity, with some organisations losing several senior staff. Whilst the ongoing impact of this has now been fully recognised and acknowledged, several interviewees felt that they had not been fully addressed and therefore still had the potential to considerably delay programme delivery going forwards. In addition the changes in the external landscape – with for example STPs forming and the West Midlands Commission for Mental Health established (each with their own strategic visions and set of priorities) has led people to ask where should their loyalties lie? Additionally parts of the Alliance cut across a number of different Vanguards which have their own vision and direction of travel which in some cases “clash” with what MERIT is trying to achieve. For example the MCP vanguard in Dudley is re-commissioning all of its services leading to additional pressures for two of the organisations.
“…aligning strategic and operational development across four Trusts is a significant challenge….” “….let’s take a little time out to reflect and reinvigorate. Let’s be really clear on what we want to deliver and the infrastructure to do this….”
Governance It took time to get Governance arrangements in place. Workstream leads were not initially clear who could sign off changes to their programmes and at times workstreams were given conflicting messages from the Steering Group and the Clinical Quality Oversight and Scrutiny Group (CQOSG). The relationship between these two groups in terms of offering programme direction and sign off would benefit from formal clarification. A couple of interviewees suggested that a corporate MERIT workstream would have been a useful addition, focusing on corporate governance, board assurance, legal matters etc. In addition it was felt that there was scope to improve governance further by:
Steering group members taking a more proactive role in managing their relationships with their own boards and
Steering group members taking a clearer lead on specific sub-specialist areas. This has started to emerge for example the CWPT Chief Executive has good links with the West Midland’s Combined Authority and so represents MERIT there. It was suggested that it may support both cohesion and efficiency if steering group members could more formally identify and agree roles that they specialise in.
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Providing more role clarity for those attending workstreams in terms of expectations and authority back in their home organisation
Differences in understanding regarding what the programme would deliver Despite having a Value Proposition and Logic Models which were signed off by each MERIT board and the MERIT steering group, differences in understanding regarding what the programme will deliver have emerged throughout the year. This has resulted in delays in moving elements of the programme forward as the partners try to work this through and bring all trust along on the journey.
One very senior manager said that because of the challenges of working across four trusts, with different expectations and aspirations..
“..it’s the most frustrating project I have ever been part of…” Support from NHS England A number of interviewees felt that changes and at times a lack of clarity/support from NHSE had been a barrier to progress.
4.3 Lessons learned from work so far
There was considerable agreement from interviewees regarding the lessons they had learned from their involvement in the Vanguard work so far. This section summarises what they said. The benefits of working with colleagues from other MERIT trusts Many people were surprised at how much they had learned and benefitted from working closely with colleagues from other trusts (and within their own trusts). They had developed a much better understanding of how their trusts could help each other to perform better and work collaboratively in a range of ways across clinical and non-clinical services. This has been evidenced not just in the progress with the MERIT work, but in progress and benefits in other areas within the trusts not included in the MERIT programme. For example bringing together IT managers from across the Trusts (who did not know each other previously) or Nursing Directors (to pick just two of many examples) had led to a range of benefits. Some of these are tangible such as being able to take an approach which works from another Trust and not re-invent the wheel, e.g. if one Trust has an e-learning package which another Trust can pick up and use straight away. Other benefits have been more intangible such as the benefits of having colleagues in similar roles who can offer well informed advice and support to each other. It would be fair to say that these benefits were only able to emerge following a period of relationship building between these individuals which, understandably took some time to develop. Whilst some people interviewed were frustrated that progress had been too slow, others felt that it could not have been any faster given
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the time that it takes to build trusting and meaningful professional relationships. This in itself is a culture change as there was no previous history of collaborative working between the four Alliance trusts. Interviewees said:
“…we can help each other both to perform better and in other ways…” “…..improvement methodology takes time. Changing culture takes up to five years. This is a culture change programme in many ways. Then we are asked to implement it in nine months with no certainty re recurrent funding. Given nothing was in place before we started we have done really well. If we all did everything the same we would not need to be a Vanguard….” “..despite all the frustrations, I think this is as fast as we could go in the circumstances….”
The need to balance localism vs centralism. It has taken time for all of those involved in the MERIT programme to come to an understanding of what “working together in a Vanguard alliance” really means. This is still a work in progress at different levels within the organisations. At first, as reflected in parts of the VP, there was more of view that it would involve getting all trusts to deliver care and services in the same way and bringing all up to the level of “the best”. Through the process of developing relationships and understanding each others local context, history and starting point (for example around service configurations, clinical services, resources, support services etc), and sometimes through the process of trying to implement things centrally, those involved have come to realise how important it is to balance the local needs of each trust with the central “needs” of the Alliance to deliver the programme. This has led to a change in understanding and led to more sensitivity regarding what these things might mean in different trust settings and what this means for programme delivery. An example of how this is playing out in practice is the Recovery Culture work. Each Trust is in quite a different position in terms of its thinking, resources and practice to date around recovery. Although there is now a clear evidence based logic model and a number of key tools identified which can support this model, each trust will come up with its own implementation plan based on local circumstances. A need for Organisational Development (OD) support to the programme and better earlier understanding If doing this work again a number of people said that they would recommend having OD support into the programme from the start. This would have been useful to:
support individual workstream leads and SG members, and support the wider culture change work.
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They suggested that OD support should have started with input at the beginning of the programme to help to identify and explore the differences between the four organisations so that ongoing transformation work was based on:
a clearer understanding of cultural norms and differences between the trusts a clearer understanding that this type of partnership working is materially
different to working within organisations an understanding of what challenges were likely to arise and providing support and strategies to help people overcome these.
For example one Trust has a history of being entrepreneurial, innovative and working collaboratively with external bodies whereas another has a history of more limited exposure to change and innovation and is financially “very challenged”. Addressing this and similar issues explicitly at the beginning, in a supportive environment, might have helped to smooth the way in progressing the programme. Many large scale change programmes offer leaders considerable personal mentoring or coaching or intensive personal support. This has not been built into the programme and several people felt that this would have been beneficial, particularly for key players such as workstream leads and programme managers. In addition it was stated that many people had not been given the chance to attend or take advantage of wider opportunities which the Vanguard was exposed to such as external workshops or training, which would have been beneficial to both the programme and their own personal development. There is now a plan to include an OD element in the work going forward. Interviewees said:
“….it would have been better to deliver up front support to the workstream leads in terms of capacity and coaching to enable them to move at faster pace….” “…Don’t underestimate culture. We didn’t assess at the beginning how different we really were or consider this in detail. We assumed we were all trying to achieve the same things – i.e. the best for patients and as quickly as possible, but other trusts have not really given it the attention it needs and just assumed it would not really happen. …” “……there should have been more analysis at the beginning of each Trusts culture and systems and processes as they related to key elements of the programme. For example with bed management - Board managers had very different visions and trusts had very different set ups. If this had been tested more at the beginning it may have taken more time but the work could have ultimately progressed more smoothly. As it was the workstream pushed ahead with what they thought was the mandate, but when it came to
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defining how this would be operationalised it became clear that all Trusts did not have the same vision or expectations…..”
“….workstream chairs should have had support. They were just left to it. Sink or swim. All have swam but this has been very stressful for them and this should be recognised….” “….in hindsight we should have asked at the start “why have we not done all this before? “ The answers might have been helpful in enabling us to identify potential barriers and blockers up front. You’ve got to do it despite all the issues. It will help sustainability of the four organisations….” “…You have to consider and factor in all the variables at each Trust and get buy in. Not just say this is what we are doing and you must do it…” “…we have been too tokenistic with clinicians to date. We can’t just tell them to do MERIT. We need OD support to help facilitate this….”
A need for better communication One of the strongest messages to come out of the scoping interviews was the need for a much more effective approach to communicating throughout each MERIT trust. Most people interviewed felt that generally communication within trusts about the MERIT work had been poor. They felt that, to date, most staff within all four Trust were unaware of the work which the Vanguard was planning and had done to date. This has evidenced by conversations that the evaluation team have had with MERIT trust staff. Communication of potential benefits to clinicians of working within the MERIT framework was also emphasised. There was also concern that, whilst all four Trusts had signed up to the Vanguard programme, this had not been understood or interpreted in the same way at each Trust. Interviewees felt that more specific communications regarding the implications of the work with other senior managers would have helped smooth the pathway for elements of the programme. One workstream member told us:
“I don’t know the strategic direction of the MERIT or funding for the future or key deliverables and this concerns me…”
“….the workstream leaders have been inspirational and could not have done more, but they can’t take people along with them without help. We need more communication at all levels and bridging between very top and bottom of organisations…”
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“…Even now many Trust staff do not know anything about the MERIT work…”
A need to involve more people Linked to this a number of interviewees, looking back at the year, felt that more people should have been involved in the programme sooner and in particular that senior operational and clinical leaders should have been more involved in the programme from the beginning. One person said
“..we should have involved a wider cohort of people/staff in the Vanguard at earlier. It’s felt a bit like “a group of people in a cupboard” running and developing the programme…” Another said “.we should have had closer involvement of senior clinical managers from board level, in the early stages. The CQOSC now provides this but it would have been useful to have this from the outset….”
There was also a suggestion from some that they should have involved some external bodies in the programme at an earlier stage. Commissioners and Public Health colleagues were mentioned specifically. In addition some interviewees were disappointed that third sector organisations had, to date, not been significantly involved in the work. However, it was also felt that the Vanguard had been a catalyst too in encouraging people to look outwards. Workstream leads and others have made a wide range of connections outside their own Trusts, with both local and national individuals and organisations, which they would not have made without the Vanguard.
“… we need to be courageous. To look outside the Trust for inspiration. Trusts are very insular with lots of group think which stifles innovation. The vanguard has given people space and permission to do this….” “… we need to get commissioners on board asap and find ways of
engaging them…” “…positively MERIT can really help in areas such as the WM authority. We have an infrastructure and can up the learning curve…..”
A need to involve service users and carers (experts by experience/EBEs) much more centrally A significant number of those interviewed felt that the Vanguard should have involved EBEs at a much earlier time in the development of the programme. Whilst some events had been held to engage EBEs and they had been invited to some meetings, it was felt that they had not been put at the heart of the programme and there was no sense that they were in any way driving the programme or elements of it.
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As mentioned above, there has also been very limited involvement of the third sector in the programme. Very recently the Alliance has appointed a head of service user involvement and several of the workstreams (most notably Recovery Culture and Equality and Diversity) have taken steps to involve EBEs much more fully in their work. Going forward many people felt that this was an area which should now continue to develop with the appointment of a MERIT patient experience lead. Building the ME in MERIT brand for service user and carer input through the workstreams and across the programme was viewed as a positive step forward.
“….we should have services users more at the heart of design and implementation…” “…we should proactively use the MERIT to draw together experts by experience( users and carers) into a powerful and influential collective across the trusts, ideally sustainable over time…. until we do this we may do good work to some degree, but it will lack the input of our main stakeholders”
A need to analyse and understand based on analytics Several people interviewed felt that the programme would have progressed more quickly it there had been more data analysis at the beginning of the programme to drive a fuller understanding of systems, processes and patient flows. To some degree they felt this was due to the speed with which the Vanguard application had to be made. On an ongoing basis obtaining BI support to collect the metric data required has also been challenging with the Vanguard unable currently to collect this data due to pressures on its resources in this area. The original application included significant resources for a Business Intelligence Hub and for data modelling of patient flows across the four trusts. Because the funds received fell short of those asked for, this element of the programme was significantly reduced. Whilst this explains the gaps here it may be useful to re-visit this area going forward. A need to engage colleagues involved in the workstreams Engagement within some workstreams has been, and remains, an ongoing issue. At the beginning many workstreams struggled to get people to attend meetings due to a lack of understanding of the importance of this work and the realities of managing the Vanguard work at the same time as other (sometimes conflicting) priorities. This conflict remains a challenge for most people working on the MERIT project. Whilst most workstreams have now resolved these issues, the workforce workstream continues to face problems in getting attendance and engagement from all four Trusts. In addition some workstreams faced difficulties as they felt that the “wrong” people were originally asked to attend including staff who did not have sufficient
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seniority and who were unclear why they have been involved and what their responsibilities were in progressing the work within their own organisations. Two workstreams (workforce and Research and Innovation) have faced delays due to their workstream leads leaving the organisation and this inevitably caused delay in agreeing and moving forward with their work programmes.
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Projects delivering shared benefits are easier to implement It is clear from a review of progress to date that those elements of the programme that will benefit all four trusts equally (such as the shared access to patient records or developing a crisis care website) are more straightforward to implement that those where trusts perceive that they are unlikely to benefit equally (e.g. flexible staffing bank or shared bed management). Equally where an ongoing cost is likely to be incurred the smaller (and less financially viable) trusts have been more cautious and wanted to slow progress which is understandable but has sometimes felt frustrating. A need to take time to take stock given the changing configuration of the Trusts involved As mentioned above, the internal context in which MERIT is being delivered has changed during the first year of the programme. This has seen closer partnership working between DWP and BCP and the subsequent takeover of BCP by the much larger Birmingham Community NHS Foundation Trust (BCFT). The Chief Executive of BCFT now represents the combined trust on the MERIT steering group. BCP has faced considerable financial challenges during the year which was one of the drivers behind the merger. A number of senior people whom we interviewed felt that, given this significant change, it would be sensible to:
take a step back from the current rapid implementation programme and do a “stock take” of how the programme goes forward.
Even without the merger it has become apparent over the last 12 months that different trusts have different appetites for the pace of change and level of risk which have led to some difficult discussions. Maturity and flexibility has been required by very senior leaders who have had to lead the programme and they remain committed to the programme.
“..we need to be realistic and keep re-visiting our ambitions…” “..we need to make sure we clearly understand our own share of what to deliver and when and can speak openly and honestly…..”
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5. SUMMARY Much positive progress has been made over the last 12 to 18 months. Perhaps most fundamentally the Trusts are still working to a common goal with passion and enthusiasm. Whilst tangible deliverables are yet to fully emerge, the trajectory of change is positive. It is also the case that all participants are aware of the barriers that need to be addressed. Our interview feedback highlights a willingness to overcome these obstacles for the common good of delivering better outcomes and reduced variation for mental health service users.
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APPENDIX ONE - RECOVERY DRAFT LOGIC MODEL
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Board meeting date: 4 May 2017
Agenda Item number: 10.2
Enclosure: 27
Report Title:
MExT Committee Chair’s Report
Committee:
MExT meeting held on 18 April 2017
Author (name & title):
Rupert Davies, Interim Director of Finance (Deputizing) Paul Lewis-Grundy Company Secretary
Action required from the Board
Decision / Approval
Gain assurance
Discussion
Information
Key issues and Risks MExT received verbal updates on the following items:
• Chief Executive’s Update • Key Operational updates (including Social Inclusion/S75 and POG update) • Quality Improvement Priorities & CQUIN Update focusing on 2017/18 • Nursing Director’s briefing update • Medical Director’s update • Financial position as at month 12 including CIP Update
MExT received the following reports
• Walsall Older Adults Inpatient Options Appraisal • Communications Bulletin • Financial Plan 2017/18 • Mandatory Training and Appraisal compliance • IR35 Action Plan • Influenza Campaign 2016/17 • Service Business Development Update
Interfaces with other Committees The business that was discussed by MExT interfaces with the following Committees/Groups:
