dudley and walsall mental health partnership nhs trust ... · dudley and walsall mental health ....

Dudley and Walsall Mental Health Partnership NHS Trust

Papers for the Trust Board Meeting Wednesday 7th September 2016

1.00pm-4.05pm

Conference Room 1, Trafalgar House, King Street, Dudley

PUBLIC MEETING OF THE TRUST BOARD

1.00pm, Wednesday 7th September 2016

Conference Room 1, Trafalgar House, King Street, Dudley

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. Patient Story Ms Ingram Enc 1 1.00pm

2. Apologies Mr Reid Oral 1.30pm

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

Mr Reid Oral

4.

Minutes of the Previous Meeting To approve the minutes of the Board meeting held on 3 August 2016

Approval Mr Reid Enc 2

6. Matters Arising/Action Schedule Continuity Mr Reid Enc 3

5. Summary Report of Confidential session of Trust Board held on 3 August 2016 Information Mr Reid Enc 4 1.35pm

7.

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

Information

Mr Axcell

Enc 5 1.40pm

8. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

8.1 Trust Integrated Performance Dashboard (Month 4)

Assurance

Mr Davies Enc 6 1.50pm

8.1.1 a b c

Quality Quality and Safety Committee Chairs Report Mental Health Act Scrutiny Chair’s report from meeting held on 18th August 2016

• Mental Health Act Scrutiny Minutes from meeting held on 23rd June 2016 and 18th August 2016

Quality Report

Assurance

Dr Murphy Mrs Cooper Mrs Pugh

Enc 7 Enc 8 Enc 8A Enc 8B Enc 9

1.55pm 2.05pm 2.10pm

ITEM Purpose Board Lead Format Timings

8.1.2 a b c d e f

Finance, Performance and Workforce Audit Committee Chairs Report Finance Report Contract Performance Performance Dashboard Cost Improvement Programme (CIP) Progress Report Workforce Report

Assurance

Mrs Cooper Mr Davies Mr Davies Mr Davies Mr Davies Ms Ingram

Enc 10 Enc 11 Enc 12 Enc 13 Enc 14 Enc 15

2.10pm 2.20pm 2.30pm 2.40pm 2.50pm 3.00pm

8.3 Medical Directors’ Report

Assurance Dr Gingell /Dr Weaver Enc 16 3.15pm

8.4 Director of Operations and Nursing Report

Assurance Ms Pugh Enc 17 3.25pm

8.5 Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Assurance Ms Pugh Enc 18 3.35pm

9. LEADERSHIP, CULTURE & WORKFORCE

9.1 Service Experience Desk Q1 Report Ms Ingram Enc 19 3.45pm

10. FOR ASSURANCE

10.1

EMExT Chair’s Report from 16 August 2016 meeting

Assurance/ Information Mr Axcell Enc 20 3.55pm

11. ANY OTHER BUSINESS

12. QUESTIONS FROM MEMBERS OF THE PUBLIC

Questions from members of the public pertaining to agenda items.

Oral

4.00pm

13. DATE AND TIME OF THE NEXT MEETING

Mental Health Form (10.00am) followed by the Annual General Meeting (1.00pm) – Friday 16 September 2016, Brierley Hill Civic Hall Public Trust Board meeting - Wednesday 3rd October, The Board Room, Canalside, Bloxwich

4.05pm

Enc 1 Patient Story front sheet Page 1 of 6

Board meeting date: 7th September 2016

Agenda Item number: 1

Enclosure: 1

Report Title:

Patient Story Accountable Director:

Marsha Ingram, Director of People and Corporate Development

Author (name & title):

Tracy Cross, Service Experience Officer

Purpose of the report: To provide the Board with a patient story. Patient stories

ensure that the patient’s voice is recognised as being centrally important in the drive for service improvement. The focus is on improving the patient’s journey, to compliment clinical care and maximise the patient experience.

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:

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

Listening to feedback of our services and responding appropriately, providing channels for service users, carers and stakeholders to share their views with us

Responsive Feedback is timely and appropriate, actions are taken to address issues

Effective

Investigations and reviews are thorough and balanced. This report is considered as part of each service line’s quarterly performance


review Well-led

Provides information to Board and its committees in order to support effective action and decision making about service experience feedback

Safe

Triangulation with Safeguarding and serious incidents supports safe service delivery and resolution


Title Patient Story

Introduction Patient Stories aim to enhance the Board’s understanding of the service user experience, what we do well and areas for improvement and through the development of our patient story protocol we now use different approaches to identify patients to tell their story. This quarter the story has been shared by a former complainant of services. The patient made a complaint in 2012 regarding the care and treatment she received, however, was not happy with the response received, as she was not advised of any procedures or systems that had been put in place to prevent the incident from re-occurring. The complaint was upheld and appropriate action was taken but the patient was not advised of this. The patient then submitted a follow on complaint as she was not satisfied that all of the issues raised had been addressed. The patient also submitted an informal concern in 2016 regarding her dissatisfaction with the attitude of her CPN. The Service Experience Officer who took the concerns invited the patient to participate in Patient Story to share her experiences further. Summary of key points, issues and risks A summary of the issues raised are included here:

Crews Profile

Positive Evidence Challenges

CARING

• CPN advised patient about POWHER

• Care and compassion

shown by a nurse on Ambleside Ward

• Attitude of staff from Home Treatment at initial assessment at patient’s home, staff and on Ambleside Ward and the Consultant Psychiatrist during review

• Patient was not involved in planning her

care or development of care plan • Patient not offered any advocacy or

support during review • Patient was not aware of who their named

nurse was • Lack of respect shown by staff on

Ambleside and Kinver Ward • Patient felt that staff did not engage in


conversation with her as an inpatient • Lack of time spent to explain what is going

to happen and why • Lack of communication by CPN when

going on leave or off sick

RESPONSIVE

• Timely referral was made to Home Treatment by patient’s GP which led to early assessment

• Home Treatment reacted to

patient needs by offering medication to help her feel calmer during ward review

• Nurse did not listen to the patient’s concerns about the medication that was to be administered

• Patient felt that her complaint was not

dealt with effectively and was not advised of any procedures or action taken to prevent the incident from happening again

• Patient was not aware of her rights

EFFECTIVE

• Lack of communication during ward review • Patient’s questions were not answered • Lack of information and advice offered to

patient about her care and treatment • Multidisciplinary working – lack of

communication between DPH/Manor and patient

WELL LED

• Patient was concerned that making a complaint would be detrimental to her treatment as Ward Manager was the investigating officer.

• Patient has not received an up to date

care plan

SAFE

• Patient was given incorrect medication which led to admission to A&E

• Patient did not feel safe in hospital due to

side effects of incorrect medication that was administered


• Fear and threat of section

• Concerns regarding communication failure with CPN, lack of care plan and

appointments being cancelled was passed to SED and raised as an informal concern. The case is now closed, although the patient still felt that the issues raised had not been fully resolved.

• Following this, the patient’s new CPN proactively arranged a meeting with Acting Clinical Lead and Acting Team Manager to discuss the patient’s concerns regarding her CPN being an agency worker, lack of communication from CPN and with development of her care plan.

• Following a meeting with Anchor Meadow the patient stated that she felt she was able to speak openly and honestly and that she said what she needed to say, although she felt it took a while to get her point across. She stated that she wanted them to ‘see the bigger picture’ about how events have impacted on her mental health. The patient felt it was a good meeting and was grateful for their time.

• The Acting Clinical Lead advised the patient that their meeting was a learning experience for the team.

• The patient was encouraged to meet with the Service Experience Officer to participate in Patient Story to further explore her issues and provide an opportunity to help us understand how we can improve different aspects of our service delivery and care provided.

• The patient has now been allocated a new CPN and has stated that she has been very engaging and keen to work with her to develop her care plan. The CPN also liaised with the manager from CRS South Walsall to further explore the patient’s concerns about her previous CPN being an agency worker and to ensure that she has now been provided with a welcome pack.

• The patient has sent a letter to Anchor Meadow to thank them for their time and listening to her concerns.

• Due to anxiety issues the patient meets with her psychiatrist at home. However, following participation in patient story, the patient has now stated that she will attend the Outpatients Department as her anxieties were reduced now that she has been back to Dorothy Pattison Hospital.

• Through the complaints submitted, discussions with the patient and following patient story the patient has stated that she would like teams and staff to learn from the mistakes that have been made through her journey through mental health services. She has suggested that patient stories and complaints information should be shared as part of staff training and professional development.

• The SED Complaint’s Policy has been updated since the patient made her initial complaint in 2012 to include feedback and lessons learnt from complaints to improve service design and delivery. The Patient Story protocol now incorporates feedback on any resulting outcomes or improvements that have been made as a result of the patient sharing their story and sharing of good practice will be captured and reported to the patient.


Further detail (if required) At the time of writing the patient has indicated that she will attend Board to present her story. The patient would like feedback regarding any action taken and would value the opportunity to meet with staff involved in her original complaint. Recommendation The Board receives the paper for information and assurance. Board action required The Board listens to the patient’s story and receives the report.

of 16

Enc 2 MINUTES OF THE TRUST BOARD MEETING OF

DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST

Held on Wednesday 3rd August at 1.00pm The Board Room, Canalside, Bloxwich

PUBLIC SESSION

Present Mr B Reid Chair Mr M Axcell Acting Chief Executive Officer Mr R Davies Interim Director of Finance, Performance and IM & T Mr Higgs Non-Executive Director Ms Ingram Director of People & Corporate Development Mr D Matthews Non-Executive Director Ms W Pugh Director of Operations, Nursing and Estates Mr P Rana Associate Non-Executive Director In Attendance Mr Paul Lewis-Grundy Company Secretary Mrs Linda Wix Minute Taker ITEM ACTION 71. APOLOGIES

Apologies for absence were recorded from Dr Gingell, Joint Medical Director, Mrs G Cooper, Non-Executive Director, Ms O Clymer, Associate Non-Executive Director, Dr S Murphy, Non-Executive Director.

72. 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.

73. MINUTES OF THE PREVIOUS MEETINGS

To approve the minutes of the meetings held on 7th July 2016. Minute 62.3.2 Finance Report

of 16

The word “surplus” at bullet point 6 to be removed. Minute 66.1 High Level Opertional Risk Register “Quality & Safety” to be added to the resolution. RESOLVED: That the minutes of the meetings held on 7th July 2016 be approved subject to the amendments outlined above and would be signed by the Chair following the completion of the above amendments.

74. MATTERS ARISING/ACTION SCHEDULE

The items on the schedule had either been closed or had a completion date in the future. Item 61 Chief Executive Officer’s Overview Mr Davies confirmed that a response had been received from NHS Improvement (NHSI), although this was a generic letter sent to all providers and did not deal with the specific issues related to the Trust. He agreed to share the letter with members via Email. ACTION: Circulate the letter from NHSI to members via Email. The Chair requested that the formulation of the new Workforce Committee be added to the Action Schedule. ACTION: Add the formulation of the new Workforce Committee to the Action Schedule with the item to remain outstanding until the Committee is operational RESOLVED: That the matters arising and the assurance given where those actions have been completed be noted.

Mr Davies Mr Lewis-Grundy

75. SUMMARY REPORT OF THE CONFIDENTIAL SESSION OF TRUST BOARD HELD ON 1 JUNE 2016

Members noted the content of the confidential summary of the meeting held on 7th July 2016 RESOLVED: That the Board received the report for information.

76. CHIEF EXECUTIVE OFFICER’S OVERVIEW

Mr Axcell made reference to the following: • Transforming Care Together (TCT)

of 16

• MERIT & Dudley CCG Vanguard • Walsall CCG Healthy Walsall Partnership Board • Black County & West Birmingham STP • Recognising Success Awards

Mr Axcell provided an overview of the Walsall Partnership Board meeting that had been held on 27th July. Mr Axcell advised members that Dudley CCG had been working with health and care organisations across Dudley including the Trust and involving local people over the last 18 months. The CCG had used this feedback to help design a new model of care and services have already stated to work in new ways to improve things for local people. The CCG are now formalising these improvements and enabling things to work even better as it plans to procure a new Multi-specialty Community Provider (MCP) and are formally consulting on these proposals. To this end, an 8-week consultation had been launched on Friday 15th July 2016 and would include public meetings, a campervan touring the borough to capture views of local people, some public ‘deep dive’ sessions into the scope, characteristics and the outcomes for diabetes, respiratory and primary mental health services. Referring to the upcoming ‘Recognising Success’ Awards, Mr Axcell advised that there would be one category where staff would be invited to vote and that this was a new initiative. The Chair provided an overview of the process he had experienced previously. Mr Axcell confirmed that the person nominated would be filmed, if the staff member was comfortable with this approach, and the film would be put into the public domain. Mr Axcell referred to the contracting for 2017/18 with the standard contract out for consultation and the aim would be to negotiate a 2 year contract. The Chair queried the implications for the Trust. Mr Davies advised that this was not clear and further guidance would be issued which would explain items within the contract that could be changed within the 2 year timeframe. It was anticipated that contracts would be agreed and signed off by the end of December 2016 for 2017-19. Mr Rana referred to the New Data Security Standards for Health and Social Care, stating that given the impending renewal of the internal OASIS application the Trust should ensure that the chosen contractor/provider complied with the new safety standards and that the Trust should respond to the consultation. Mr Davies advised that he would take this forward with the Head of Business Intelligence. ACTION: Ensure that the Head of Business Intelligence

Mr Davies

of 16

responds to the New Data Security Standards for Health and Social Care and that the selected contractor for the OASIS application complies with the new safety standards. RESOLVED: That the Board:

• Noted the information and actions contained within the report

• Identified any further specific action required and agreed timeframes for completion.

77. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

77.1 Trust Integrated performance Dashboard (Month 2)

Mr Davies referred to the following:

• Sickness - Trust Sickness in June 2016 was 4.94%, compared to 4.98% as reported in May 2016.

• Mandatory Training compliance was 81.3% at the end of month three, which was below the new 90% threshold.

• Copies of Care Plan – the Trust was below the agreed 95% threshold (94.3%).

• The overall Continuity of Service risk rating for the month remained green.

• The overall Financial Sustainability risk rating for the month remained green.

• The overall Governance risk rating for the month was green with a score of 0.

RESOLVED: That the Board noted the content of the report.

77.2 QUALITY

77.2.1 Quality & Safety Committee Chair’s Report

Ms Pugh presented the report advising that the Committee had met on 13 July 2016. Incidences related to disruptive aggressive behaviour and dangerousness had been reviewed in depth and a verbal update would be provided at the next Quality & Safety Committee and subsequently to the Board via the Quality & Safety Committee Chair’s Report.

Ms Pugh stated that there had been a substantial drop in incidents during the decanting of older adult patients to other wards following the water incident. The reasons for this were being explored and findings would be reported to the Quality & Safety Committee.

of 16

Ms Pugh advised that there had been an increase in incident reporting in the Early Intervention Services which was due to a change of practice and the recording of CAMHS Deliberate Self Harm.

Ms Pugh advised that the Estates Risk Register had been reviewed in depth. Risk EF001 – Water Hygiene and Water Management and Risk EF002 – Fire Safety Management within the Trust would be monitored and reviewed by the Committee to ensure that there was increased fire training and that assurance could be given related to the provision of adequate fire alarms.

Ms Pugh was pleased to report that there had been a 27% decrease in the number of falls over the last year following the introduction of a falls action plan which had been monitored closely at Quality and Safety Committee.

The Committee had received annual reports and had made a recommendation that the Board approve these. The Chair stated that these reports would be taken on an individual basis for approval.

Health & Safety Annual report

Mr Higgs queried whether any concerns had been raised related to audit of the Estates Department. Ms Pugh advised that this was specifically related to the chemical installation at Dorothy Pattison Hospital to ensure an appropriate infrastructure was in place.

The Board approved the Health & Safety Annual Report.

Fire Annual Report

Ms Pugh advised Mr Higgs that a full fire risk assessment had been undertaken and that the risk would always remain high due to the nature of the clients.

The Board approved the Fire Annual Report.

Security Annual Report

Mr Davies reminded colleagues that security had been reviewed and documented. Mr Matthews queried whether this had taken place prior to the CQC visits as sites that still did not have fire alarms in place could be identified by the CQC in future visits.

The Board approved the Security Annual Report.

RESOLVED:

That the Board

• accepted the report for assurance about the

of 16

exercise of delegated authority by the Quality and Safety Committee

• approved the following reports o Health & Safety Annual Report o Fire Annual Report o Security Annual Report

77.2.2 Quality Report

Ms Pugh presented the report. The Chair stated that the absence of benchmarking within the report meant that it was difficult to gain an understanding of Trust performance. Ms Pugh confirmed that benchmarking or appropriate narrative would be included in future reports.

ACTION. Include benchmarking data or appropriate narrative in future reports.

Ms Pugh advised Mr Higgs that she did not anticipate that there would be negative reporting or financial liability for the Trust in relation to the death in the community and recovery service that was being reviewed by the District Coroner.

Ms Pugh advised the Chair that a plan related to safeguarding training was in place and would be monitored by both the Quality & Safety Committee and the Mental Health Act Scrutiny Committee. A report on the progress made against the action plan would be submitted to the Board in September.

The Chair identified an inaccuracy in the figures for CQRM Dudley and CQRM Walsall. Ms Ingram thought that this could be due to an element of double counting. This would be checked and rectified.

ACTION: Check the CQRM figures and rectify any inaccuracies.

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

Ms Pugh

77.3 FINANCE, PERFORMANCE & WORKFORCE

77.3.1 Finance & Performance Committee Chair’s Report

Mr Higgs provided an overview of the discussions held.

The Committee had requested that the original surplus target of £700k, the £1.2m stretch target and the £1.7m reset stretch target be tracked on a monthly basis. The Trust was currently £177k ahead of plan and would have needed to be £120k ahead of plan to be in line with £1.2m stretch target and £240k ahead of plan to be in line with £1.7m. This demonstrated that the Trust was behind on £1.7m reset target, although he anticipated that this would change to a more

of 16

favourable position over the coming months.

In response to a query from the Chair, Mr Davies advised that the revaluation of the Trust’s estate would realise £1.15m for the current financial year. The Chair advised that this could impact positively on CIP schemes and the Trust could make public statements that it had achieved the control total and the CIPs for the year. Focus could then move to identifying CIPs for 2016/17 to put the Trust in a more favourable position. Mr Axcell advised that the alternative valuation method of the Trust’s estate had yet to be scrutinised by the Audit Committee and a recommendation made to the Board as to whether to take this forward.

The Chair warned that NHSI were likely to increase the control total as a result of the monies realised from the revaluation of the Trusts estate. Mr Matthews advised that this should be directed into service improvement for the population of Dudley and Walsall.

Mr Higgs highlighted the liquidity ratio which was in excess of 60 days giving the Trust an NHSI sustainability rating maximum score of 4.

RESOLVED: That the Board:

• Accepted the report for assurance about the exercise of delegated authority by the Finance and Performance Committee.

• Endorsed the decisions and recommendations made by the Finance and Performance Committee.

77.3.2 Finance Report

Mr Davies advised that :

• The Trust had delivered a Month 3 surplus of £299k which represented a favourable variance against plan of £177k YTD (based on a planned surplus for the year of £700k).

• The Trust had now agreed with NHSI a revised ‘stretch’ target of £1.7m which would be reflected in the Month 4 financial statements.

• Pay expenditure was £286k in surplus against budget YTD, which was being driven by surpluses within Community and Trust wide Reserves.

• Bank & Agency spend equated to £539k in month which was down from the Month 02 spend of £681k.

• Agency spend was marginally behind plan by £8k in relation to the overall £4.05m Agency target for the year

• Non-Pay expenditure is £210k in deficit against budget YTD.

• Reserves are over committed by £210k reflecting the impact of un-devolved CIP yet to be allocated down to

of 16

service lines. • The Trust wide Activity position at Month 03 was

reflecting a breakeven performance • The Net position was an over-performance of £176k,

however, after taking account of the impact of the CIP target that has been applied to activity, being £176k , overall performance was breakeven to plan.

• The Trust’s Cost Improvement Target for the year was £2,500k and schemes had been developed for the year equating to £2,664k. The anticipated delivery of schemes taking into account the PYE of schemes starting later in the year is £2,555k which was ahead of the required target.

• The Capital Programme had been agreed at £2,748k for the year.

Mr Davies advised that the CIP PMO was being audited. The alternative schemes identified by the CIP PMO that were ‘RAG’ag rated green were unlikely to be achieved. Mr Davies advised the Chair that it may be possible to recast the numbers and take the pressure of CIP focus on next year’s plan. The Chair reiterated that it would be a significant step to start now as future work may involve the reconfiguration of services which would take time. Mr Axcell advised that he would prefer to review the first quarter CIP figures and any new schemes would have to be Quality Impact Assessed. Mr Matthews stated that the £1.4m shortfall on CIPs could be offset by the use revaluation monies as discussed previously and this would require approval by Audit Committee and Trust Board.

Referring to the agency usage, Ms Pugh advised the Chair that agency usage related to Health Care Assistants was a challenge. In response to a query from Ms Ingram, Ms Pugh confirmed that whilst a recent HCA recruitment drive had been successful, increase use of agency HCAs was due to acuity of patients and consequent high levels of observations. Mr Matthews stated that historically the Trust was more reliant on agency staff during the last quarter due to annual leave being taken before the end of the financial year. Mr Higgs advised that the Finance & Performance Committee had queried an increase in corporate spend and this should be reduced £80-£90k. Mr Axcell confirmed that the corporate teams were being reviewed. The Chair advised that a tracking system should be implemented to update the weekly position on agency costs including comparison to the trajectory. It was agreed that Mr Davies would set up a weekly tracking system. Action: Set up a weekly tracking system related to the position on agency costs including comparison to the

Mr Davies

of 16

trajectory. Mr Rana advised that there would be troughs and peaks during the Winter months and it was imperative that savings were made in the preceding months. RESOLVED: That the Board received the report for assurance and noted the content.

77.3.3 Contract Performance Report

Mr Davies presented the report and invited questions from members. Taken as read.


77.3.4 Performance Report

Mr Davies asked for the report to be taken as read as it had been reviewed in depth by the Finance and Performance Committee. He advised that workforce, mandatory training, appraisals and sickness were risk items.

Mr Matthews referred to the percentage (56%) of complaints responded to within the timeframe. Ms Ingram advised that a piece of work undertaken and changes implemented which included escalating delays to the Executive Team and training more people to undertake investigations including corporate staff. The changes had realised a temporary improvement and the Executive Team were reviewing whether the changes had been effective in the long term. An update would be provided to the Board via the Quality & Safety Committee Chair’s Report in November.


77.3.5 CIP PMO Report

Mr Davies advised that there were 32 projects in 2015/16 of which 30 were delivered and closed down. Two schemes have been carried over into 2016/17 at the request of the Executive Sponsor:

POD085 Catering Review POD088 Corporate Clinical Leadership Structures

These schemes had delivered savings; however they are being monitored for any negative impact, and will be

of 16

reassessed for closure in quarter 2.

There are 28 projects for the current year, of which three are under review and subject to approval prior to implementation, these schemes are: Redesign of Day Opportunities (£40,800) Older Adults Establishment Review (£77,500) Medical Services Establishment Review (£350,000)

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

77.3.6 Workforce Report

Ms Ingram referred to the following:

Vacancies – There were currently 187.6 FTE contracted vacancies across the Trust increasing the vacancy rate to 16.8%. The Trust target vacancy rate is 10%. Turnover – The 12 Month Turnover rate had decreased from 14.96% to 12.47%. Sickness Absence – The 12 month rolling sickness rate had increased from 4.85% in Month 2 to 4.91% reported in Month 3. Appraisal – Compliance had decreased from 74.5% to 69.8%, this is still below Trust target. There are 262 employees in the Trust that haven't had an appraisal recorded in the last 12 months. The executive team were implementing focussed actions to improve compliance. Mandatory Training - Mandatory Training compliance had increased from 80.5% in Month 2 to 81.4% in Month 3 and remains below the new target of 90% agreed at MEXT for all mandatory training (IG remains at 95%) as of 1st April 2016. The Trust was developing a programme of targeted work and support to increase and sustain compliance with mandatory training. Ms Ingram advised that a workforce spotlight report had been received by the Finance and Performance Committee that had outlined actions to be taken. The Chair advised that the formation of the new Workforce Committee would impact positively on the issues related to workforce faced by the Trust. RESOLVED: That the Board received the report for assurance and information and noted the content.

78. CQC Report and Detailed Action Plan

of 16

Ms Pugh presented the report advising that as part of the development of the action plan, the areas of improvement / main challenges were themed into the areas below:

• Least Restrictive Practice (Searching of patients and rights of informal patients)

• Health records interface / documentation • Alarms - procedures and protocols • Emergency / safety equipment checks • Medication Transportation / recording • Risk assessments and care plans

Ms Pugh advised that Compliance Teams would be visiting areas within the Trust during the second week of September. There had been offers from partners to be involved. Mr Higgs queried whether potential competitors should be invited to be part of the compliance teams. Ms Pugh advised that CQC inspectors were staff members of other organisations and neutral bodies such as members of Healthwatch and Birmingham University would also have some involvement.

Mr Lewis-Grundy asked that it be noted that the full CQC had been appended to the report and the Board had formally received the report. The Chair confirmed that the Board formally accepted the CQC Report and noted the action plan in place to ensure compliance with the recommendations therein.

RESOLVED: That the Board

• formally received the CQC Report • gained assurance from the attached action plan

and agreed the proposed actions • would continue to monitor the action plan and the

progress made in relation to the longer term ongoing actions

79. Medical Directors’ Report

Dr Weaver referred to the following:

• Junior Doctors’ Contract Negotiations • ASD/ADHD Service • Mortality Report

The Trust had been instructed to implement the junior doctors’ contract. The new contract would mean rotas would be altered, although he did not anticipate that this would be an issue as staff were consulted over rotas. A guardian of safe working hours had been appointed jointly with Black Country Mental Health Trust.

Dr Weaver advised that the mortality data had not been

of 16

received in time for circulation prior to the meeting. It was agreed that he would review the data and any issues would be shared with members; otherwise the report would be taken at the meeting in September.

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

80. Director of Nursing and Operations Report

Ms Pugh referred to the following:

• Sepsis Protocol • Johns Campaign • Writing Good Care Plans • Safe Sustainable Staffing Programme

Ms Pugh advised that Erostering data would feed into safer staffing. There had been positive responses from managers related to Erostering and three month’s worth of data had been reviewed which had identified some interesting scenarios. She anticipated that ERostering would impact positively on the bank and agency usage and real time data would be available in September. She advised Mr Higgs that ERostering would produce efficiencies and may be a CIP for 2016/17. She could not at this point confirm the savings that would be realised. She confirmed that the staff mix split by agency and substantive posts identified as percentage rates would be available by October with a report submitted to the Board. ACTION: Submit a report to the Board in October identifying in percentage terms staff mix split by substantive posts and agency. RESOLVED: That the Board received the report for assurance and information and noted the content.

Ms Pugh

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

Ms Pugh advised that there were two wards to note as exceptions, whereby staff fill in part was within the lower category (Ambleside) and lowest category (Malvern). An impact assessment had been completed that provided assurance that safe staffing levels had not been compromised, and during June there were no reported incidents of unsafe staffing levels that related to this ward.

The Board was asked to note that the first e-rostering continues to be implemented and was making good progress

of 16

in line with the agreed project plan.

In response to a query from Mr Matthews, Ms Pugh confirmed that dips in staffing levels were related to short term sick or increased observations. Agency usage requests were escalated to executive level and these had not been refused as they were needed to meet the needs of patients and ensure quality was not compromised.

RESOLVED: That the Board noted and discussed the monthly data return submitted that provided details of planned and actual staffing at ward level. The data represented June 2016 and a 12 month trend analysis.

82. Q1 2016/17 Communications and Engagement Report

Ms Ingram referred to the Summary of the key points and the completed actions. In Q2 the focus would be on:

• Dudley MCP consultation communications • The Trust’s Annual General Meeting • Internal and External Campaigns • Strategic Communications for partnership working • Marketing Dudley Talking Therapies

She drew attention to the Communications and Engagement Action plan for 2016/17 that was appended to the report.

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

83. Benchmarking Analysis: Community and Inpatient Mental Health 2014/15

Mr Davies advised that following submission of the national report the Board had requested a more focussed paper with specific indicators identified. The paper included reference to five national and five internal targets and outcomes would be reported to the Board.

RESOLVED: That the Board received the report for information and approved the action plan.

84. STRATEGIC DEVELOPMENT & DIRECTION

84.1 Merit Vanguard Partnership Update – July 2016

Mr Axcell advised that the Highlight Report for July 2016 outlined the main achievements in the last quarter and the key focus for the following quarter and highlighted the key risks to the work of the Vanguard which were:

of 16

• Funding being provided on a quarterly basis making it difficult to commit spend for programme delivery

• Continued Clinical and Operational engagement and input from all four Trusts

• High Level and Detailed Programme Plan not in place • Evaluation group does not have sufficient membership

to cover patient experience element of the evaluation Mitigations were in place to address these. The overall status had been RAG rated red although this had been downgraded to amber. A detailed update on funding would be received at a meeting later in the month. If the milestones were not achieved monies for the Vanguard would be withdrawn. Mr Davies confirmed to Mr Higgs that this was a self-contained piece of work with income and expenditure. RESOLVED: That the Board received the report for assurance

84.2 Board Assurance Framework (BAF) – Quarter 1 2016/17

Mr Lewis-Grundy advised that the Quality and Safety Committee had reviewed Strategic Risks 3 and 5 and were assured that the risks were being appropriately managed.

The Finance and Performance Committee had reviewed Strategic Risks 2 and 4 with particular focus on Strategic Risk 2. Following robust discussions it was agreed that the risk should be tested through the Management Executive Team meeting prior to it being reported at Q2.

The Chair advised that the red risk rating did not reflect the Trusts financial status. Ms Pugh advised that the BAF had been reviewed by a number of committees and the risk ratings had been challenged. MR Lewis-Grundy advised that the BAF was under review by the internal auditors. Following a robust discussion it was agreed that the BAF would be reviewed by the Executive Team at a future away day and changes made prior to submission to Committees for approval.

ACTION. Executive Team to review the BAF at a future away day and changes made prior to submission to Committees for approval.

RESOLVED:

That the Board was assured that the Strategic Risks that form the BAF were being managed appropriately, subject to further testing of Strategic Risk 2 to be reported at the end of Quarter 2.

Mr Lewis-Grundy

of 16

84.3 High Level Operational Risk Register

Ms Pugh advised that the Trusts Quality and Safety Committee Reviewed the following risks as part of the Quality and Safety Risk Register: o 202 o 225 o 253 o FINAN 1 o HR 002 o 285 o Risk 301 Following a risk spotlight session it was concluded that risk 225 could be downgraded due to CQC feedback. The Trust’s Finance and Performance Committee also reviewed the red risks which had links to the Trust’s finance and performance. These risks were:

• 202 • 253 • FINAN 1 • Risk 301

RESOLVED: That the Board approved the High Level Operational Risk Register, and approved the downgrading of risk 225 from red to amber.

85. LEADERSHIP, CULTURE AND WORKFORCE

85.1 Equality, Diversity and Inclusion Annual Report 2015/16

Ms Ingram presented the report advising that it had been reviewed by Quality 7 Safety Committee.

In response to a query from Mr Rana, Ms Ingram advised that other Trusts experienced similar issues related to individuals sharing information on their religious beliefs or sexual orientation.

She advised that there was an identified pathway to achieve the purple rating.

RESOLVED:

That the Board approved the Equality, Diversity and Inclusion Annual Report 2015/16.

86. FOR ASSURANCE

86.1 EMExT Chair’s report

Mr Axcell presented the report advising that it could be taken

of 16

as read.

86.2 MERIT Vanguard – NED Assurance Group Report

Mr Matthews provided an overview of the discussions of the meeting held on 15th July 2016. The main issues raised were the variation between risk registers and release of funding. There were gaps in workstreams due to the inability of people to attend due the demands of their day to day working. MERIT had great aspirations initially that appeared to be eroding over time.

87. ANY OTHER BUSINESS

The Chair asked that it be noted that David Matthews was leaving the Trust to take up another Non-Executive Director post elsewhere and the Board appreciated the work he had undertaken and his professionalism as the Audit Committee Chair.

88. DATE AND TIME OF NEXT MEETING

The next Trust Board meeting would take place at 1.00pm on Wednesday,7th September 2016 in Conference Room 1, Trafalgar House, King Street, Dudley.

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

1

Enc 3 MATTERS ARISING FROM PUBLIC MEETINGS

Item No.

Date Added Action Responsibility Due Date Update

62.2.4 7 July 2016

Quality Report Annotate future reports to explain the zero compliance with the training requirement for the designated nurse and doctor.

Ms Pugh September 2016

Level 4 compliance is a new requirement for safeguarding training, in line with the intercollegic documentation.

This is not a singular training course and needs to comprise of a variety of avenues over a 10 hour period to address compliance.

A meeting has taken place with the CCGs and an agreement for this to be captured by the lead and then the information will inform ESR due to the complexities of recording requirements. This will likely be concluded in September 2016. Deferred to September.

65 7 July 2016

Enhancing Quality through Safer Staffing Levels – Monthly Exception Report Undertake a piece of work and report on the skill mix, agency, bank and substantive staff included on rotas and provide a report to MExT

Ms Pugh September 2016 Verbal Update at meeting.

144.1 6 Jan 2016

Bed Review Report Mr Axcell advised that whilst action 75.1 had been completed in relation to Under 18 admissions, he was conscious that there was also an action pertaining to Older Adults and Acute and he requested that this be included on the Action

Ms Pugh September 2016

This was discussed at F&P on 25.1.16 and due to the clear links with commissioning and contracts it was agreed a paper would go to the May F&P. Deferred to June 2016 Re the bed review paper. The older adults option paper will be presented to Junes F&P and therefore the recommended paper will be at the July Board.

2

Item No.


Schedule. The adult review paper is being worked upon at present and will be taken to hopefully the July F&P and then the recommended paper to August/September board.

77.2.2 3 August 2016

Quality Report Include benchmarking data or appropriate narrative in future reports.

Check the CQRM figures included in the Quality Report and rectify any inaccuracies.

Ms Pugh Ms Pugh

September 2016 Verbal update at meeting.

9.TB 6 April 2016

Chief Executive’s Overview It was agreed that the Quality & Safety Committee would review the documentation related to the “freedom to speak up” guardian in June with a report to the Board in July.

Ms Ingram October 2016

Policy Group meeting cancelled in August. To be reported to the Board in October.

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

October 2016

Discussions are on-going with the Head of Nursing, Quality & Innovation.

74 3 August 2016

Matters Arising Add the formulation of the Workforce Committee to the Action schedule with item to remain outstanding until the Committee is operational

Mr Lewis-Grundy

October 2016

3

Item No.


67.4 7 July 2016

Staff Engagement & Raising Concerns – Board Update Whistleblowing policy and raising concerns policy to be reported to the Board in September.

Ms Ingram October 2016

The policy will be received by the Quality & Safety Committee in September and reported to the Board in October.

41 1 June 2016

Chief Executive’s Overview Draft plans from the TCT to be shared with members for comment. The CEO’s report in July to reflect the views of the Board on the draft plans.

Mr Axcell

October 2016

To be incorporated when draft plans from work streams are available – estimated October Board

62.2.1 7 July 2016

Quality & Safety Committee Chair’s report

Review under 18 cases on an individual basis, report findings to the Quality & Safety Committee and to the Board via the Chair’s Committee Report in the Autumn.

Ms Pugh October 2016

60. 7 July 2016

Matters Arising/Action Schedule Ensure that all formalities related to the formation of the new Workforce Development Committee were dealt with appropriately.

Mr Lewis-Grundy

October 2016

66.1 7 July 2016

High Level Operational Risk Register Discuss in depth at Finance & Performance Committee the appropriate scoring for Finan 1 CIP and report the

Ms Pugh November 2016

This Action has been superseded by discussions at the Board Development Session. It was agreed that the operational risk register would be reviewed and referred back to their perspective

4

Item No.


decision back to the Trust Board in August.

Committees by November.

60 & 159.2

1st July 2015 3 Feb 2016

Trust paper in response to the Mental Health Taskforce Strategy to be prepared.

Dr Gingell

2nd Sept 2015 December 2016

Dr Gingell advised that this was a significant piece of work to be undertaken and it would be preferable to await the appointment of the Research and Development Manager. The post would go out to advert in April or May. Joint working with MERIT partners would be considered. It was agreed that the completion date would be deferred until December 2016.

25.1 5 May 2016

Trust Integrated Dashboard The Chair requested that a resolution to vacancy rate which was consistently higher than targeted be sought. The Chair requested that the resolution to the low appraisal completion rate be sought.

Mr Axcell Mr Axcell

October 2016 October 2016

80 3 August 2016

Director of Nursing Report Submit a report to the Board in October identifying in percentage terms staff mix split by substantive posts and agency.

Ms Pugh October 2016

84.2 3 August 2016

Board Assurance Framework Q1 Executive Team to review the BAF at a future away day and changes made prior to submission to Committees for approval.

Mr Lewis-Grundy

November 2016

5

Item No.


61 & 74

7 July 2016 & 3 August 2016

Chief Executive Officer’s Overview & Matters Arising Contact Jill Robinson at the NHSI to obtain feedback to the letter regarding the control total.

Mr Davies September 2016

A generic letter had been received from NHSI and it was agreed that this letter would be shared with members. Letter shared with members via Email on 23.8.16. Completed. Closed.

181.5 2 March 2016

Service Experience Desk Report A report to be submitted to the Board in September, to patients’ ability to complain, staff members’ ability to raise concerns, external drivers and best practice adopted by other Trusts

Ms Ingram September 2016

Forms part of the SED Report which is an Agenda item. Completed. Closed.

64 7 July 2016

Director of Nursing & Operations Report Director of Nursing report to highlight on the front cover the matters to be raised during Finance & Performance and Quality & Safety Committee.

Ms Pugh September 2016 Included in report. Completed. Closed.

65 7 July 2016

Enhancing Quality through Safer Staffing Levels – Monthly Exception Report Staffing level control methods to be included in future Director of Nursing reports. Low levels of staffing and high levels of staffing to be included in the report. Identify whether other organisations had identified best practice related to levels of agency staff.

Ms Pugh Ms Pugh

September 2016 September 2016

Incident reporting on reported insufficient staffing incidents triangulated into the report. Once electronic rostering/bank and safer staffing fully implemented a dashboard will be produced and included in the report. Meeting scheduled September to look at integration of safer staffing metrics with workforce report. Allocate network have been approached to look at examples of best practice and the trust continues to engage in regional safe staffing project. Completed. Closed.

76 3 August 2016

Chief Executive’s Overview Ensure that the Head of Business Mr Davies September

2016 Mr Howard will respond to the consultation and has confirmed that the selected contractor will

6

Item No.


Intelligence responds to the New Data Security Standards for Health and Social Care and that the selected contractor for the OASIS application complies with the new safety standards.

comply with the new safety standards. Completed. Closed.

77.3.2 3 August 2016

Finance Report Set up a weekly tracking system related to the position on agency costs including comparison to the trajectory.

Mr Davies September 2016

System in place based upon weekly reporting of requested shifts (bank and agency). This is reported weekly to the relevant operational managers. Completed. Closed.

Enc 4 Summary of confidential session 3 August 2016. 3rd August 2016 Page 1 of 2

Board meeting date: 7 September 2016

Agenda Item number: 5 Enclosure: 4

Report Title:

Summary of Confidential session of Trust Board held on 3 August 2016

Accountable Director:

Ben Reid, Chair


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 3rd August 2016.

Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: None

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

Strategic Objective(s) to which this paper relates:

High quality services


Leadership culture






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 4 Summary of confidential session 3 August 2016. 3rd August 2016 Page 2 of 2

Title Summary of Confidential session of Trust Board held on 3

August 2016 Introduction This report outlines the business considered at the meeting of the Board held in private on 3 August 2016. Summary of key points, issues and risks Service Development and Growth Progress Report Mr Axcell presented the report referring to the Service Development projects. He advised that a report on the development of the Adult Neurodevelopmental Services would be received by the Board later in the meeting. Adult Neurodevelopmental Services Members were advised that the provision of this service by the Trust was being very well received, demand was increasing and the Trust was becoming the preferred provider. The report was received and recommendations in the report to develop the service approved. Director of Nursing Report The Board received an update on water management issues across the Trust. It was confirmed that under the Mental Health Code of Practice the provision of a seclusion room was not mandatory.

For Assurance The Board received the minutes from the following sub-committees for assurance:

• Quality & Safety Committee held on 9th June 2016 • Finance & Performance Committee held on 27th June 2016 • Enhanced Management Executive Team held on 5th July 2016

Recommendation

The Board is invited to note the business transacted in the private session held on 3 August 2016

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

Enc 5 CEO StrategicBrief-September2016-Final Pag


Agenda Item number: 7 Enclosure: 5

Report Title: CEO Strategic Overview and Horizon Scan Accountable Director: Mark Axcell, Acting 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.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: Key points or recommendations from Committee:




Leadership culture

Accountable workforce





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

Effective

Well-led

Safe


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

Summary of key points, issues and risks CHIEF EXECUTIVE UPDATE Transforming Care Together – The TCT partnership board continues to meet on a monthly basis. During September the workstreams will conclude its work and start to report back on findings. Action: To Note MERIT and Dudley CCG Vanguard – The Trust continues to be an integral part of both Vanguards. The CCG are now concluding their public consultation on the proposed MCP model. The Trust continues to have discussions with health economy partners regarding the approach to any tender process. Action: To Note Walsall CCG Healthy Walsall Partnership Board – Walsall CCG Partnership Board have not met during August. Paul Maubach has been appointed as Accountable Officer for Walsall CCG. Action: To Note 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. The multi-speciality community provider (MCP) emerging care model and contract

framework Published by: NHS England Date Published: July 2016

This document describes what being an MCP means, based on assembling the core features from the 14 MCP vanguards into a common framework. In addition, the document includes proposals for how the new voluntary contract may work. It proposes the contract will be a multi-year contract with payment


operating on the basis of a whole population budget, a new pay-for-performance incentive scheme and risk-and gain-share agreement with the hospital sector. Action: The document is being reviewed in conjunction with MCP partners to ensure the approach to any Tender process is in line with guidance and frameworks. Web-link: https://www.england.nhs.uk/wp-content/uploads/2016/07/mcp-care-model-frmwrk.pdf Executive Director: Chief Executive Board Committee: Board 2. New Approach to Safe Staffing

Published by: NHS Improvement This safe staffing improvement resource provides an updated set of expectations for nursing and midwifery care staffing, to help NHS provider boards make local decisions that will support the delivery of high quality care for patients within the available staffing resource. This resource: • sets out the key principles and tools that provider boards should use to measure and improve their

use of staffing resources to ensure safe, sustainable and productive service, including introducing the care hours per patient day (CHPPD) metric;

• identifies three updated National Quality Board expectations that form a ‘triangulated’ approach (‘Right Staff, Right Skills, Right Place and Time’) to staffing decisions; and

• offers guidance for local providers on using other measures of quality, alongside CHPPD, to understand how staff capacity may affect the quality of care.

This safe staffing improvement resource replaces the 2013 NQB guidance

Action: The guidance published by NHS Improvement ‘New Approach to Safe Staffing’ will be incorporated into the on-going work being undertaken by the Trust in relation to safe staffing. This will be included in an update report to be provided to MEXT which also includes an update on e-rostering. Web-link: https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf Executive Director: Director of Nursing, Operations and Estates Board Committee: Quality and Safety Committee 3. National Tariff: Policy Proposals for 2017/18 and 2018/19

Published By: NHS Improvement Published on: 2 August 2016

NHS Improvement with NHS England has launched policy proposals for the 2017/18 and 2018/19 national tariff.

Action: To review and consider the impact upon the future contracting and income framework for the Trust. Web-link: https://improvement.nhs.uk/uploads/documents/Final_tariff_engagement_document_with_cover_uneCm2L.pdf Executive Director: Director of Finance, Performance and IM&T Board Committee: Finance & Performance Committee

https://www.england.nhs.uk/wp-content/uploads/2016/07/mcp-care-model-frmwrk.pdf

https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf

https://improvement.nhs.uk/uploads/documents/Final_tariff_engagement_document_with_cover_uneCm2L.pdf


4. Better Care Fund Operating Guidance for 2016/17 Published by: NHS England

This document provides guidance on the operational requirements for these plans in 2016-17. In particular it sets out:

• the legislation underpinning the Better Care Fund (BCF); • the accountability arrangements and flows of funding; • the reporting and monitoring requirements for 2016-17; • how progress against plans will be monitored and what the escalation process will look like; and • the role of the Better Care Support Team in supporting delivery.

Action: To note the contents of the report and advise the Finance and Performance Committee of the implications of the Guidance, if any, for the Trust Web-link: https://www.england.nhs.uk/wp-content/uploads/2016/07/bcf-ops-guid-2016-17-jul16.pdf Executive Director: Director of Finance, Performance and IM&T Board Committee: Finance & Performance Committee 5. Records Management Code of Practice for Health and Social Care 2016

Published by: NHS England Published on: 29 July 2016

This Records Management Code of Practice for Health and Social Care 2016 is a guide for you to use in relation to the practice of managing records. This Code is relevant to organisations who work within, or under contract to NHS organisations in England. This also includes public health functions in Local Authorities and Adult Social Care where there is joint care provided within the NHS. The Code is based on current legal requirements and professional best practice. It will help organisations to implement the recommendations of the Mid Staffordshire NHS Foundation Trust Public Inquiry1relating to records management and transparency. Action: To review the Code of Practice at a future Information Governance and IM&T Committee and ensure compliance with the Code. Web-link: http://systems.hscic.gov.uk/infogov/iga/rmcop16718.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=7378190_HMP%202016-08-02&dm_i=21A8,4E51Q,M5T16P,G60SJ,1 Executive Director: Director of Finance, Performance and IM&T Board Committee: Finance & Performance Committee Recommendation It is recommended that the Board consider 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.

https://www.england.nhs.uk/wp-content/uploads/2016/07/bcf-ops-guid-2016-17-jul16.pdf

http://systems.hscic.gov.uk/infogov/iga/rmcop16718.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=7378190_HMP%202016-08-02&dm_i=21A8,4E51Q,M5T16P,G60SJ,1

http://systems.hscic.gov.uk/infogov/iga/rmcop16718.pdf?utm_source=The%20King%27s%20Fund%20newsletters&utm_medium=email&utm_campaign=7378190_HMP%202016-08-02&dm_i=21A8,4E51Q,M5T16P,G60SJ,1

Enc 6 Cover Sheet 16_17 Integrated Dashboard Month 4 Page 1 of 3


Agenda Item number: 8.1

Enclosure: 6

Report Title:

Trust Integrated Performance Dashboard (Month 4) Accountable Director:

Rupert Davies – Interim Director of Finance and Performance


Makhan Singh (Principal Consultant, Information & Performance)

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

month 4 of 2016/17

• Quality and Safety • Service User Experience • Efficiency • Resources • Monitor and Trust Development Authority


Decision / Approval

Gain assurance

Discussion

Information


Committee: • Quality and Safety Committee considered elements from

within the Quality and Safety domain, and the Service User Experience domain.

• Finance and Performance Committee considered elements from the Efficiency, Resource and Quality and Safety Domains

Date reviewed • N/A





Leadership culture





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


Caring

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

Effective Well-led Safe


Title Trust Integrated Performance Dashboard (Month 4)

Introduction

• This paper presents the Trust’s performance at the end of month four 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

• Sickness - Trust Sickness in July 2016 is 5.31%, compared to 4.94% as reported in June 2016.

• Mandatory Training compliance is 84.15% as at the end of month four, which is below

the new 90% threshold. • Copies of Care Plan – the Trust is above the agreed 95% threshold (95.2%).

• 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 four

and debate accordingly. Board action required

• Debate the content of the reports accordingly.

Enc 7 Quality and Safety Committee Board Report - august6 (5) (2) Page 1 of 4


Agenda Item number: 8.1.1a

Enclosure: 7

Report Title:

Quality and Safety Committee Chair’s Report

Committee:

Quality and Safety Committee


Rosie Musson – Head of Nursing, Quality and Innovation


Decision / Approval

Gain assurance

Discussion

Information

Title Quality and Safety Summary Report Introduction The Quality and Safety Committee met on the 10th August 2016, where they considered and discussed the Trust’s key Quality and Safety issues. Summary of key points, issues, financial impact and risks The Committee has highlighted the following key points, issues and risks to the Board: Patient’s Story – Actions taken following presentation of Patient Story to Trust Board The Board had previously asked the Quality and Safety Committee to provide confirmation that the Committee had investigated the issues relating to care /communication that had arisen from the recent Patient Story presented to Trust Board. The Committee can confirm that it has received assurance through a report which identified areas of positive practice and an action plan for areas where improvements were required. Following detailed discussion by the Committee it was agreed that confirmation should be given to the Board that the Committee had received assurance and recommend that the action is now closed. Quality Report The Quality Report was presented to the Quality and Safety Committee. The highlights for July are

• There were 323 incidents reported; 3 serious incidents were logged on UNIFY/STEIS and 12 Safety Alert Broadcasts were received and action taken as appropriate.


• Incidents this month were down overall by approximately 10%; the reason for this was that there was a decrease in incidents in Older Adults Services and the data extracted for the report was taken a few days early.

• There were no Duty of Candour cases • Acute and Access Services – incidents had shown a decrease. Disruptive and

Aggressive behaviour remained the highest category. The Committee will receive a more in depth analysis of the incidents in September. Incidents will be cross referenced with incidents of service users who are detained as opposed to incidents of informal service users.

• A further report will be presented to the Committee in October in relation to patients who require a specific assessment based on previous behaviour and current presentation and where there is a risk as regard patients on an acute ward who require for their own safety and that of others more intensive and focused care. This will incorporate the triangulation of incidents. Further to this work a bigger piece of work will be presented to the Committee in January including pathways, evidence based assessments relating to dangerousness.

• Early Intervention Services – it was noted that there was a decrease in incidents. However, incidents in relation to Self-Harming behaviour had increased and were due to recoding of CAMHS Deliberate Self Harm which is considered as moderate harm but not relevant for Duty of Candour.

• The Committee were advised that the Trust will have its first Coroner’s case with a Jury on 22nd and 23rd August.

• The Committee were advised that further work was being undertaken to assure the data quality regarding safeguarding training. It was agreed that a column should be added in the report that goes to Board with the corporate information that was available and the narrative.

Quality and Safety High Level Risks The Committee did not receive a report this month as following the recent Board Development session on risk work is being undertaken to review the operational risks, mitigating actions, tolerance levels and alignment of the strategic risks to the Board Assurance Framework. A themed CQC Risk Register is also being developed. The Committee will receive the revised draft of High Level risks in September. Bloxwich Improvement Plan The Committee received an update on progress made with the Bloxwich Improvement Plan. The Committee noted the positive progress made and received assurance received from Walsall CCG as an outcome of their following a follow-up visit to Bloxwich Hospital A Spotlight session on Older Adults will be presented to the Committee in September. Quality Improvement Priorities & CQUIN The Committee received a Q1 progress report relating to the delivery of CQUINs and Quality Improvement Priorities. Positive progress is being made, however it was flagged that there is a potential financial risk associated with the delivery of the Physical Health CQUIN and Wellbeing CQUIN. The Committee recommends that a referral is made via the Board to the Finance and Performance Committee and they should be requested to qualify the risk and possible mitigations


Clinical Audit The Committee received the Clinical Audit and Effectiveness (including NICE Guidance) Report for Quarter 1 for information and assurance. It was reported that significant work had been undertaken and there is a robust programme in place for the audits which are also cross-referenced with the CQC Plan. The Committee were informed that the following audits had been completed or commenced in this quarter. • POMH – Monitoring of patients prescribed Lithium • Voice of the Child • Dementia Care Mapping The Committee noted the following NICE Guidance which had been published during Quarter 1 and they are in the process of being reviewed. • Psychosis and schizophrenia in children and young people (update) • QS Obesity – clinical assessment and management • QS Diabetes in children and young people The Committee welcomed the new format of reporting the Clinical Audit Plan and agreed that future deep dives sessions should be undertaken on specific audits. Bed Occupancy Levels and Environmental Benchmark within Older Adults and Adults Services There continues to be ongoing scrutiny of incidents within Older Adults and Adult Services. It was agreed that the report on Bed Occupancy Levels and Environmental Benchmark within Older Adults and Adults Services should be brought back to the Committee in December. The Committee were advised that when Linden and Holyrood Wards were brought together the environment was fit for purpose and did not pose any challenges from an environmental point of view. The Committee agreed that assurance should be given to the Board that this worked well with service users with possible behaviour that challenges. Suicide Prevention Working Group The Suicide Prevention Group continues to meet regularly with the aim of implementing the Suicide Prevention Plan and Suicide Prevention Strategy and progress has been made. Work undertaken includes Training, Audit, engagement with stakeholders and complying with the National Confidential Inquiry standards. There is linkage with the Mortality Review Group and their monthly reports are discussed at the Suicide Prevention Group. EBEs Report The Committee received a report from EBEs which highlighted the excellent continuing work that is taking place. A suggestion was made that there should be an away day for EBEs arranged, this suggestion was supported by the Committee.


CQC Action Plan Update The Committee were advised that good progress had been made against the July actions. It was reported that following discussions at the CQC Steering Group, mock type inspections are to take place and a checklist has been developed for the areas picked up in the CQC report. Key question prompts will also be developed and work from the Merit Vanguard will be used to assist staff. The Committee approved the updates and noted the progress made against the actions. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

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

Recommendations and requests for direction The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Quality and Safety Committee.

Enc 8 MHASC Report to Board - august Page 1 of 4


Agenda Item number: 8.1.1b

Enclosure: 8

Report Title:

Mental Health Act Scrutiny Committee Chair’s Report

Committee:

Mental Health Act Scrutiny Committee (MHASC)


Neil Tong – Patient Safety Facilitator


Gain assurance

Discussion

Information

Title Mental Health Act Scrutiny Committee Chair’s Report Introduction The Mental Health Act Scrutiny Committee met on the 18th August 2016, where they considered and discussed key topics around the application of the Mental Health Act within the Trust Summary of key points, issues, financial impact and risks The Committee would like to highlight the following key points, issues and risks to the Board in relation to the Trust Board: Adoption of the 136 multiagency policy It was noted by the Committee that this multiagency policy remained outstanding and had not yet been fully signed off. Whilst the policy has been agreed in principle there were a number of issues which have not been fully resolved and are managed on a case by case basis. The Committee agreed that it should receive a report on the Section 136 policy at its next meeting, highlighting the aspects that hadn’t been agreed and the risks to the Trust for in depth discussion. In the meantime it was considered necessary to highlight this matter to the Board. Mental Health Act Scrutiny Committee Quality Dashboard Incidents, safeguarding data The Quality Report Presented to the Mental Health Act Scrutiny Committee highlighted the following key points:

• There were 13 patients subject to restrictions within Dudley o 8 were subject to DoL's o 5 were detained under the MHA

• There were 15 patients subject to restrictions within Walsall o 8 were subject to DoL’s o 4 were detained under the MHA


• It was noted that there was a reduction in the number of incidents of restraint during July. It was noted that this reduction in the number of restraints was consistent with the noted reduction in the number of incidents categorised as Disruptive Aggressive Behavior during this period.

• It was also noted that of the incidents where restraint was used, there were no instances of face down restraint recorded via the Trusts incident reporting system during the period.

• It was identified that there were 6 incidents categorised as patients failing to return from leave or having absconded during July. It was noted that this represented a decrease based upon the previous month. Further to this it was noted that:

o 1 incident was formally investigated as a serious incident. o The remaining cases have been reviewed and assurance has been given

and rated as low risk in accordance with these individual patient's presentation and behaviours and that in line with the NHS England Serious Incident Framework these did not require investigating.

o The committee noted that whilst they were happy that processes were clearly followed in respect to such decisions, they requested more information on this topic going forward.

• It was noted that there were 3 incidents in respect to the application of the MHA. These were noted as being issues with transferring patients from one site to another for the receipt of ECT. It was reported to the committee that this issue was being looked into.

Risks It was noted that due to work which was currently ongoing around reviewing operational risks for committees, no risk register was being presented to the group this month. It was noted that work was ongoing to align the Trusts risk registers to any issues raised by the CQC. Training Compliance It was noted that the latest Training requirement and compliance levels as set out in the new commissioner contracts were presented to the group. It was noted that there had been some discrepancies historically regarding training data in respect to staff whose roles spanned both localities. It was noted that this issue had now been resolved. Mental Health Act Partnership Group Update Report The Mental Health Act Partnership Group (MHAPG) is accountable to the Mental Health Act Scrutiny Committee (MHASC). The MHAPG also provides assurance to the MHASC of partnership working across all MH service lines and with partner agencies. Points covered include:

• As previously stated within this report it was noted that the Section 135/6 Place of Safety policy is still awaiting sign off.

• It should be noted that the introduction of a Super Cell block out of area had led to the decommissioning of many local police cell units within the Black Country. This change has meant that our medical and AMHPs assessing team will now travel to on the occasions when a members of the public is deemed too risky to attend the s.135/6 suite.

• It is agreed and supported by both local authorities and Trust that the AMHP and the medic(s) from the area in which the patient was arrested would attend the Super Cell block and undertake the assessment.


• AMHPs have noted that since the introduction of the Mental Health Triage team there has been a decrease in the overall number of assessments taking place in the Section 136 suites in both Dudley and Walsall. It was also noted that the relationship between the police, ambulance service and AMHPs had significantly improved with response times for both police and ambulances being quicker.

• The MHAPG assured the MHASC of the positive and effective multiagency cooperation and adherence to the principles as outlined within the MH Act and code of practice.

Quarterly AMHP Activity & Audit Referral Sources Q1

• The main area of source of referrals in Dudley is from Bushey Fields Hospital, with Walsall referrals coming from Crisis / Home Treatment

Mental Health Assessment Outcomes Q 1

• In Dudley in Quarter 1 there was an increase in the number of formal admissions with Section 2's increasing by 9 and Section 3's increasing by 8.Those not admitted decreased significantly.

• In Walsall there was a decrease in formal admissions, from 55 to 43 this is due to a decrease in the number of Section 2's. Section 3's stayed at a similar level. The number of informal admissions and those not admitted increased slightly.

GPs attendance at Mental Health Act Assessments

• The number of GPs attending MHA assessments remains low (less than 1% of GPs attended assessments in the last 4 quarters). Commissioners have been notified of this concern and a copy of this data provided to them.

Section 136 Suite

• In Dudley 42% of assessments undertaken in the 136 suite resulted in clients being admitted to hospital.

• In Walsall 11% of assessments undertaken in the 136 Suites resulted in the clients being admitted into Hospital, with the number of those not admitted increasing during the quarter significantly.

• 63% of Section 136 used were during out of hours in Dudley and 75% in Walsall. CQC Action Plan Those actions which related to the application of the Mental Health Act or were seen as falling under the remit of the committee were reviewed. Whilst there were 3 actions presented to the Committee for which their completion deadline had passed, it was noted within the Committee that these actions had now been completed. As such the Committee noted the assurances and the progress made. CQC Mental Health Act Visits It was noted that since the last meeting there had been Mental Health Act CQC visits to all of the Trusts Working Age Acute inpatient wards. It was noted that there were some issues raised by the CQC MHA reviewer in respect to some comments from some of the patients on Ambleside Ward. As a result the Trust has commissioned an investigation in relation to these concerns and will be forwarding this information to the CQC for assurance.


It was noted that the visits to Langdale, Wrekin, Kinver and Clent Wards were largely positive. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• MExT • CARM / CQRM • Clinical Audit and Effectiveness Committee • Safeguarding Strategic Group • Policy & Procedures Group • Quality and Safety Committee

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

Enc 8A MHAS Cttee Mins 23 06 16 v1.0 (Final)Page 1 of 14

Enc 8A

MENTAL HEALTH ACT SCRUTINY COMMITTEE MEETING

MINUTES OF A MEETING HELD ON 23RD JUNE 2016 AT 14:00 HRS CONFERENCE ROOM 1, TRAFALGAR HOUSE, DUDLEY

START TIME : 14.00 HOURS

Members In Attendance: Mr David Matthews (Chair) Mr Tom Jinks Mrs Deb Cooper Ms Olivia Clymer Dr Mohammad Iqbal Ms Marsha Ingram Ms Nageena Bibi Ms Becky Temple Purcell Mr Neil Tong Mr Hassan Omar

Non-Executive Director Governance Manager Safeguarding Lead Associate Non-Executive Director Consultant Psychiatrist/Clinical Director (present from item 17.1 onwards) Director of People & Corporate Development Mental Health Act Manager Learning & Development Manager Clinical Governance Assistant / NHSLA Facilitator (left after item 23) Head of Social Care

In Attendance: Ms Olive Hewitt Ms Helen King (note taker)

Clinical Quality Improvement Manager Personal Assistant

Apologies: Mrs Gill Cooper Mr Liam Dolan Mr Pawiter Rana Mr Paul Calder Mr Paul Lewis-Grundy Mr Paul Singh Ms Rosie Musson Dr Kate Gingell Dr Mark Weaver Ms Wendy Pugh

Non-Executive Director Associate Director of Operations Associate Non-Executive Director Acting Manager, Carers Service Company Secretary Equality and Diversity Lead Head of Nursing, Quality & Innovation Joint Medical Director Joint Medical Director Director of Operations & Nursing

Minute No

Agenda Item Action

15. APOLOGIES FOR ABSENCE

Apologies were noted as above. Mr Matthews advised that he had been asked to Chair the Committee today in the absence of the usual Chair, Mrs Gill Cooper.

16. MINUTES FROM LAST MEETING

The minutes from 21st April 2016 were agreed as a true and accurate record, with the exception of item 3.3 where ‘NHA’ needed to be amended to read ‘MHA’.


Subject to the above amendment being made, the minutes were approved. Ms Clymer drew attention to the DoLs reporting which she had flagged up at the last Committee meeting, and explained that she was still not happy with the way it was reported. It was agreed that Ms Clymer and Mrs Deb Cooper would discuss this matter further outside of the meeting.

17. MATTERS ARISING

17.1 The actions were discussed and the following updates provided: Item 28.12 – Trends, Triangulation, & other Data Vanguard Project Report to be reported to the Committee in October Ms Ingram had provided an update on this item. The action was regarding the implications of MHA workload for out of area patients in Trust inpatient facilities. It had been confirmed that the borough responsible for the patient would deal with social care / MHA requirements. Action complete and closed. Dr Iqbal entered the meeting.

17.2 Item 37.1 Re: 3 patients identified in Walsall where MHA assessments were being requested as a result of the patients not being able to access other services. The patients had highly complex needs and ADHD, and it was still being argued whether they should have a MHA Assessment undertaken by an AMHP or being looked at by the Complex and Inclusion Team within the Local Authority. This action was closed, but it was acknowledged that this was an ongoing wider issue involving commissioners. It had been decided that any complex and inclusion cases had a case conference at the beginning and were signposted appropriately before things got worse. Action: Mrs Deb Cooper to provide a position statement to the next Committee on this matter. Ms Clymer commented that it was really positive that this was being talked about and the gaps in services identified and resolved.

DC

17.3 Item 37.3 Re: Section 136 – Re: Police bringing patients to the Trust that were not from Dudley or Walsall, and leaving them with the Trust. Mr Omar advised that there was now clarity on the situation. The patient would be taken to the 136 suite of whatever borough they had been picked up in by the Police. So if a patient was picked up in Sandwell they would


be taken to Sandwell, and if they were picked up in Dudley or Walsall they would be brought to the Trust. The Chair requested that the legal position of this continued to be pursued so that the Trust was completely clear on its responsibilities. Action: Ms Ingram to obtain and provide legal advice to the next Committee

17.4 Item 40.1 Once complete the plans for the seclusion beds to be brought to the Committee to ensure Compliance with the MHA Mrs Deb Cooper explained that Ms Musson was the lead for this action. In Ms Musson’s absence Mrs Deb Cooper explained that the seclusion bed at Bushey Fields Hospital had not been signed off yet; there were health and safety issues which needed to be resolved, and the room was not compliant. A meeting was set up regarding this matter soon, but Ms Musson would need to provide the update. Mr Jinks explained that the Trust did not practice seclusion; however the CQC had been insistent that seclusion rooms should be in place, therefore the Trust had agreed to undertake this action. The Chair queried why this work was taking so long to complete, as this action had come from December’s committee meeting. Mr Jinks explained that it was down to estates issues. The Chair asked what was needed in order for this matter to be resolved quickly. Mr Jinks agreed to speak with Ms Musson regarding this. The action would remain open with an update on progress to be provided at the next Committee.

17.5 Item 40.3 Re: Quarterly AMHP Activity and Audit – Ethnicity Information The ethnicity information was included within the report. Action complete and closed.

17.6 Item 41- Re: Risk - look at training compliance and whether it needed to added to the Risk Register Ms Bibi and Dr Iqbal advised that they had delivered 5 training sessions to date; attendance was variable. Mrs Cooper advised that this work was closely tied in to the CQC work. Action closed, as it would be picked up as part of the CQC work being undertaken.


17.7 Item 53 Mr Jinks to raise the issue of GPs lack of MH Act assessment attendance at the next CQRM Mr Jinks had raised the issue of the lack of GP attendance at MHA assessments at both Dudley and Walsall CQRMs. They had both been supportive but wanted audit data before they took the matter further. Mr Jinks advised that the matter was still being discussed. The action would remain open, with an update being provided for the next Committee meeting.

17.8 Item 60 MHA – Exercise of Approval Instructions This item had been placed on the Agenda; however no paper had been received from Dr Gingell. Dr Iqbal would liaise with Dr Gingell regarding this. Action to remain open. Item to be placed on the next Committee Agenda, with a full report expected, as per the action point.

HK

17.9 Item 6 - MHA Quality Dashboard Report Mr Jinks and Mrs D Cooper to bring the data on restraints provided to the CQC to the next Committee meeting, including data on under 18 year olds. On Agenda. Action closed. Mrs Deb Cooper to submit a deep dive/information report regarding DoL’s cases to the Committee every 6 months. The Committee had not yet decided when this report should be submitted. Mrs Deb Cooper advised that they had looked at data and there were delays in relation to authorisation. The Committee were reassured that there were no issues from a patient safety point of view. The plan was to write a formal letter to the Commissioners about this matter. It was decided that the Committee would receive the first deep dive report in October 2016, and at 6 monthly intervals thereafter. A spotlight session on face down restraints to be provided to the next Committee On Agenda. Action closed. Ms Bibi to seek clarity on where the legal responsibility lay, at each stage in the procedure, when a patient was transferred to another hospital for treatment where they required a bed (as opposed to an outpatient appointment). Mr Jinks would also call a patient strategy meeting to look at this issue.


Ms Bibi advised that a Section 17.3 form could be completed, which would go with the patient when they were transferred over to another hospital, so that restraint could be undertaken by the staff there if necessary. Ms Bibi would put together a Section 17.3 form, and governors would be informed. Action to remain open with an update provided at the next meeting.

17.10 Item 11 – MCA/DOLs Project

Mrs Deb Cooper to contact the Communications Team to ask for their support with the MCA/DOLs Project.

Action complete.

Chair to liaise with Ms Ingram about the annual Dawn Jones Art Competition, and whether the art work could be displayed around the Trust following its judging. Ms Ingram advised that this was already part of the plan for this year’s competition. Action closed.

17.11 Item 12 - ‘MHA Code of Practice Polices – Position Statement’ to be put on the MH Act Scrutiny Committee Agenda from this point onwards, until it was ensured that all the polices were in place and RAG rated as green Action complete.

17.12 Item 13 - ‘CQUIN on Avoidable MH Admissions’ to be added to the Committee Agenda as a standing item from this point forward Action complete.

18 MATTERS ARISING FROM THE JOINT MEETING OF THE MHA ALM’S AND THE MHA SCRUTINY COMMITTEE

18.1 Item 2.1 - Ms Musson to undertake audit on CTOs to acquire a baseline to compare with the national picture. The audit would need to feed in to the audit plan, and report back to ALMs. Ms Musson to send the ALMs the audit framework for the audit before it was carried out.

Ms Hewitt explained that the audit was in the plan but had not been started yet.

This action was closed, and a new action opened, as follows:

Action: Report following the audit to be brought back to this Committee. Mrs Deb Cooper and Ms Hewitt to advise Miss King when this item would be coming back to the Committee.

DC/OH


18.2 Item 2.5 MHAS Committee members to discuss and agree on how the Trust could gain assurance regarding proper process when the ALMs undertook their hearings. This then to be feedback to the ALMs. Mr Jinks advised that supervision of the hearings had begun, and had gone well to date. Action closed.

18.3 Item 2.7 - A sheet of what had been followed up on (regarding ALM panel feedback) would be reported to the Committee on a quarterly basis. It was decided that this report would be made to the Committee on a 6 monthly basis, not a quarterly basis. Reports to commence in December 2016.

19. CQC COMPLIANCE SUMMARY – ACTION PLAN UPDATE

Mrs Deb Cooper explained that the action plan submitted to the Committee was the final signed off version. Communications had been sent out to staff, including the positive elements of the CQC report. Executive Leads had been assigned specific actions, which had been emailed to them; everyone was clear with regards to the work which needed to be undertaken. Staff were aware of how important the work was. Meetings were also due to be held with Managers, and Engagement Champions. The issue of least restrictive practice was the biggest change required, and therefore this had been broken down to three Executives. The CQC would be revisiting the Trust before November to look at the areas that required improvement. The Chair asked whether the actions were achievable, to which Mr Jinks explained that the work would be challenging and tight to turnaround in time for the next CQC visit. The Trust also needed to ensure its standards were maintained in all areas, and not just focus upon those identified by the CQC. Mrs Deb Cooper advised that the actions were being gone through at the next DoNs away day, following this they would go to Committees, and then to Trust Board. The Chair queried the level of risk regarding the CQC action plan. Mr Jinks advised that it was amber at present, but it was difficult to gauge accurately as the plan covered a lot. An exception report was being taken to Quality and Safety Committee every month as they were monitoring the overall action plan, however the item was on the MHA Scrutiny Committee agenda as a standing item as there were MHA actions which it needed to own. Action: Mrs Deb Cooper and Mr Jinks to separate the actions out

DC/TJ


specifically relating to the MHA and report this to the next MHA Scrutiny Committee.

20. MHA QUALITY DASHBOARD REPORT, INCLUDING: - DOLS - SECLUSION AND LONG TERM SEGREGATION INCIDENTS - MHA RELATED INCIDENTS - TRAINING, INCLUDING PREVENT, MCA/DOL’S, SAFEGUARDING AND

MHA

Mrs Cooper talked thorough the report highlighting the 2 DoL’s cases applied for in May, and highlighted that there were currently 14 active cases of DoL’s across the Trust. Table 4.2, restraints, would be discussed later on in the meeting during the spotlight session. The Chair highlighted the restraint activity recorded on Linden Ward, 171 cases had been reported over the last 12 months. It was clarified that work was being undertaken with the ward. They were generally low level incidents and about clinical holding skills rather than patient restraint. Mrs Deb Cooper advised that the figures reflected differing ways of working; it was thought that Linden Ward was over-reporting normal clinical interventions. It was important that these were captured somewhere, but perhaps as a near miss or no harm, but definitely not as an incident. Action: Mr Jinks and Mrs Deb Cooper to bring an update on clinical holding data versus restraint data to the next Committee meeting. It may be that clinical holding and restraints may need to be split out within the figures from this point forward. There had been progress with the commissioners regarding sectioned abscond and failure to return from leave. A report had been provided to Quality and Safety Committee benchmarking the Trust against others. Mr Jinks advised that within the national framework there should be more discretion for Trusts, which should bring the numbers down. More detailed information was due to the next Committee on absconds. Mrs Temple-Purcell advised that in the future training reports would be completed. The Committee noted the report for information.

21. DATA ON RESTRAINTS PROVIDED TO THE CQC (including under 18 year olds)

Mr Jinks advised that this report had been requested by the Committee for information. The data had been sent to the CQC around November/December 2015. The spreadsheet tab with incidents, restraints, and long term segregation within the last 6 months was the information which the Committee had requested. The Chair queried the appraisal and revalidation data on slide 12, and


queried the difference between this and data received at Trust Board. Mrs Temple-Purcell explained that this was non-medical appraisal data, and so would be different to that received at Trust Board, which included the medics. It was highlighted that this spreadsheet was the CQCs, the Trust had only populated the fields. The Committee received the report for information.

22. SPOTLIGHT SESSION ON FACE DOWN RESTRAINTS

Mr Jinks and Mrs Deb Cooper talked through the powerpoint presentation on face down restraints. The presentation included the following information:

• Introduction / Context of Face Down Restraint • The National Picture / Latest Guidance • CQC’s View • DWMH Data • DWMH Governance Processes

It was noted that new guidance came after a government investigation into the Winterbourne View Hospital found restraint being used to abuse patients. A similar study by Mind also found that restrictive interventions were being used for too long, often not as a last resort and even to inflict pain, humiliate or punish. The new programme, ‘Positive and Safe’, would support staff to avoid the use of all restrictive interventions. Mrs Deb Cooper highlighted the data, and that there were 51 face down restraints for Older Adults, and 99 for Acute. The Trust had positive behavioural support plans in place if needed. Least restrictive practice was in place within the Trust. The focus was all around de-escalation. It was clarified that the Trust did practice prone restraint. Mrs Cooper explained the process of a patient restraint, and that it may move through several kinds of restraint from start to finish, for instance a patient may be restrained in the prone position, then moved to face up, then sitting, standing etc. As a patient may go through various positions of restraint in one incident, Ms Clymer queried whether restraint was being double counted. Mrs Deb Cooper explained that there was no double counting, if a patient were to go through various restraint positions, if they started in the prone restraint position, even if it was only for a few seconds, the incident was logged as a face down restraint. It was confirmed for the Chair that there were very few complaints regarding restraints. All face down restraints were reviewed as a matter of course, in line with the Trust’s governance policy. Staff injury was also reviewed. The presentation ended and the table was opened up for comments. The


Chair advised that he had found the session to be very useful and informative. The Chair queried whether all people involved in restraint, e.g. those members of staff assisting by holding a specific limb, were trained. It was clarified that they were. However, the Trust was not 100% compliant for MAPA training, because of the duration of the training course. Mrs Temple-Purcell explained that planned interventions always involved staff complaint with their MAPA training. However, unplanned restraints may have to utilise however is on hand. Mrs Deb Cooper explained that all those with bleeps were MAPA trained, and they were the emergency responders. Mrs Temple-Purcell advised that it was difficult to train bank staff in MAPA as it was a 5 day course and bank staff may not have the time to attend due to other commitments. The Trust could not do anything about the course duration as it was regulated and if changed it would affect the Trust’s license. Ms Clymer queried agency staff training, and Bloxwich. Mrs Deb Cooper advised that all agency staff were trained in restraint and safeguarding, the Trust specifically asked for it. It was confirmed that all team members on the ward were trained, not just nurses and medics. MAPA training was seen as part of essential training. The Chair queried whether essential training could be included within the reports to Trust Board soon. Mrs Temple-Purcell advised that it would be ready for the next Committee. Action: Mrs Temple-Purcell to bring the training report, including essential training, to the next Committee, so that the Committee could see compliance against MAPA training.

BTP

23. REVIEW OF RISK REGISTER

Mr Tong advised the meeting that there were no red risks held on the register at present, however there were 7 risks rated as amber. Mr Tong talked the Committee through the risks in turn as detailed in table 1.1 of the report. The following was highlighted in addition to that already detailed within the report:

- Mr Omar highlighted he would pick up on risk 289 ‘local interagency 136 policy’ later on within the meeting.

- Ms Clymer queried how the Trust would measure how the DoLS was embedded (re: risk 258). Mrs Deb Cooper advised that DoLS training was in place, and audit work had been done which provided assurance.

- Risk 269 ‘under 18 admissions to Acute’ was discussed. Trust Board had agreed that the Trust would take under 18 admissions. Ms Ingram advised that there was still an issue with this locally and nationally and therefore there was still a risk there, however the Trust’s mitigations were strong. Dr Iqbal explained that the situation


was difficult to manage and he was of the opinion that the risk should remain open so that it continued to be monitored and was kept visible. It was decided that as part of the risk may be red, the risk would be reviewed with Ms Pugh before the next Committee meeting, and re-considered then.

Action: Mr Tong to review risk 269 with Ms Pugh before the next Committee meeting. It was decided that risks 299 and 257 were separate issues and so the risks would not be merged as suggested. Mr Tong explained that any risks highlighted by the Trusts CQC inspection in relation to the application of the Mental Health Act would be incorporated into the report for the next committee, or as soon as the Trust received formal written feedback. The Committee reviewed and agreed the risks within the Risk Register Report, and that there were no red risks to be escalated to Trust Board at this time. Mr Tong left the meeting.

NT

24. QUARTERLY AMHP ACTIVITY AND AUDIT REPORT

Mr Omar presented the report, which detailed information on the use of the Mental Health Act in Dudley and Walsall, including activity for the last 4 quarters. With regards to table 1, MHA assessments by team and locality, it was noted that these were being done as one team now. With regards to table 4, MHA Assessment Outcomes, it was clarified that ‘not completed’ was when a patient had been transferred somewhere else. Action: Mr Omar to find a different way of recording when a patient had been transferred somewhere else within the MHA Assessment Outcomes table (currently recorded as ‘not completed’). GP attendance was discussed. The Chair highlighted table 2 and the differing figures noted for Crisis/Home Treatment (17 for Dudley and 170 for Walsall). Mr Omar clarified that this had been checked before, and it was due to the way the different services work, it was not an issue, just a matter of different pathways. Ethnicity figures were talked through. Ms Ingram highlighted that it had been shown that, generally, people from the BME community left it later to seek help. This issue was being worked upon by the CDW team. Mr Omar gave the Committee an update on the MHA Partnership Group


Meeting, which was an interagency meeting between police, ambulance, AMHP, and ward staff to discuss issues. There had been good attendance at this meeting, and relationships were positive. A number of issues had been discussed at that Group about the security at Hospital sites and the multi-agency response to the reporting of missing patients. Approval of the Section 136 Policy was discussed at the Group with the Committee requesting clarification on the issues preventing its approval to be reported back to the Committee The Chair asked that work on the resolution of these issues be carried out with an update report back to the Committee. Action: Mr Omar to work on the resolution of the issues highlighted from the MHA Partnership Group, with an update report to be presented back to the Committee.

25. THE MENTAL HEALTH CODE OF PRACTICE – MONITORING COMPLIANCE/DOCUMENTATION AUDIT

Ms Hewitt provided a presentation on the inpatient services documentation audit on MHA, DoLS, capacity and consent. She highlighted the common themes of good practice, and the common themes requiring improvement, as set out within the presentation. She explained that good practice areas were where compliance of 80 – 100% had been reached, and areas requiring improvement were at 50% compliance or below. The Chair queried the percentages. Ms Hewitt explained that from a legal perspective everything should be at 100%, so technically 80% was still a poor performance. Mr Jinks explained that the CQC MHA visit work could be tied in with this audit work as the Trust needed to highlight the things that were being done for the next CQC visit. Action: Miss King to circulate the inpatient services documentation audit presentation to the Committee members. Ms Hewitt explained that the audit conclusions would go to ward managers and acute service lines for action. She clarified for the Chair that there was nothing of serious concern to raise; there was a lot of good work taking place. It was also raised that both Ms Bibi and Ms Hewitt were undertaking audits, to which it was clarified that Ms Bibi was the check and Ms Hewitt the tool. This piece of work would come back to the Committee in August 2016. Action: Further piece of work around this audit to come back to the Committee in October 2016. Action: to discuss the audit further at the next DoN Away Day and provide a verbal update for the next Committee.

HK

OH/NB

DC


26. UPDATE ON MENTAL CAPACITY ACT/ DEPRIVATION OF LIBERTY

PROJECT

Mrs Deb Cooper outlined the project and advised that it had been valuable, but was coming to an end soon. Action: Undertake presentation/spotlight session on Mental Capacity Act/ Deprivation of Liberty Project to this Committee for the next meeting, and then to Trust Board if required. The Committee received the report for information and assurance.

DC

27. POLICIES, INCLUDING MHA CODE OF PRACTICE POLICIES – CURRENT POSITION STATEMENT

Mr Jinks advised that good progress was being made with the MHA Code of Practice Policies. The position statement document would be submitted to the next meeting. Action; Position Statement document to be reported to next meeting

TJ 28. MHA – EXERCISE OF APPROVAL INSTRUCTIONS

Dr Gingell had sent her apologies to the Committee, and no paper had been received for this item. Item deferred to the next meeting.

29. CQUIN AVOIDABLE MH ADMISSIONS – MONITORING

Ms Hewitt and Dr Iqbal were leading on this, and were looking at admissions over the past 2 years. A report would be submitted for the next Committee meeting. It was noted that the Trust Board also received a quarterly report on this matter. Action:CQUIN – Avoidable MHA Admissions – Report to next meeting

OH/Dr I

30. MHA SCRUTINY COMMITTEE TERMS OF REFERENCE (ToR)

Ms Ingram presented the revised ToR in the absence of Mr Lewis-Grundy. The Committee were referred to the paper and advised that the main change was that Associate Non Executive Directors (NEDs) would be members of the Committee in the same way that NEDs were. The meeting decided that in order to be quorate it should have at least 7 members, not 2, as with 2 members there would be no room for discussion. One must be a NED, one an executive director, and at least one should be an operational lead. It was decided that 5 of the members listed under item 4.1 of the ToR would be required in attendance to achieve quoracy. Action: Terms of Reference to be amended to reflect the 7 members required for quoracy and submitted to Board for approval.

PL-G


With the change to quoracy agreed above the ToR were agreed and recommended to Trust Board for approval.

31. AOB

31.1 Matters Arising Item 37.3 Ms Ingram highlighted, that in reference to matters arising item 37.3 regarding Section 136 patients, she had just received the legal advice requested by the Chair. It was clarified that the earlier information provided by Mr Omar was correct. A patient would be taken to the 136 suite of whatever borough they had been picked up in by the Police. This action would now be closed.

31.2 Committee Papers The Chair reiterated the deadline for Committee papers asking that all papers were submitted on time in future. He highlighted the missing and late papers from the Committee today. Achieving the papers deadlines is an issue of good governance and ensured that all attending were able to have time to consider the papers beforehand, ensuring that time during the meeting was used efficiently. The Committee actions were also highlighted; the Chair had managed to close a considerable amount of them today. Ms Clymer stressed the importance of actions being undertaken, and the action sheet updated as appropriate, before each Committee meeting.

32. Date, Time, and Venue of Next Meeting Thursday 18th August 2016 at 2.00pm Conference Room 1, Trafalgar House, Dudley

Signed by Chair Mr D Matthews Signature…………………………………………………… Date …………………………. Document Details

Author Helen King Department Trust Headquarters Organisation Dudley and Walsall Mental Health Partnership NHS Trust Document Type Minutes


Document Title Draft - MHASC Minutes 23.06.16 – v0.1 – 1st draft Version 0.1 first draft

Enc 8B MHAS Cttee Mins 18.8.16 v 1.0 (Final) Page 1 of 7

Enc 8B

MENTAL HEALTH ACT SCRUTINY COMMITTEE MEETING

MINUTES OF A MEETING HELD ON 18th AUGUST 2016 AT 14:00 HRS CONFERENCE ROOM 1, TRAFALGAR HOUSE, DUDLEY

START TIME : 14.00 HOURS

Members In Attendance: Mrs Gill Cooper (Chair) Ms Olivia Clymer Ms Marsha Ingram Ms Nageena Bibi Ms Becky Temple Purcell Mr Neil Tong Mr Hassan Omar Mr Liam Dolan Mr Paul Singh Dr Mark Weaver

Non-Executive Director Associate Non-Executive Director Director of People & Corporate Development Mental Health Act Manager Learning & Development Manager Clinical Governance Assistant / NHSLA Facilitator (left after item 23) Head of Social Care Associate Director of Operations Equality & Diversity Lead Joint Medical Director (from 35.4)

In Attendance: Mrs Linda Wix

Minute Taker

Mrs Margaret Griffiths Apologies: Mr Pawiter Rana Mr Paul Lewis-Grundy Ms Rosie Musson Dr Kate Gingell Ms Wendy Pugh Dr Mohammad Iqbal Mr Tom Jinks Mrs Deb Cooper Mr Steve Nash

Serious Incident Co-Ordinator Associate Non-Executive Director Company Secretary Head of Nursing, Quality & Innovation Joint Medical Director Director of Operations & Nursing Consultant Psychiatrist/Clinical Director Governance Manager Safeguarding Lead Manager, Walsall

Minute No

Agenda Item Action

33. APOLOGIES FOR ABSENCE

Apologies were noted as above. The Chair confirmed that the meeting was quorate

34. MINUTES FROM LAST MEETING

Mrs Cooper asked that it be noted that she offered her thanks to Mr Matthews, Non-Executive Director, for chairing the 23rd June meeting in her absence. The minutes from 23rd June 2016 were agreed as a true and accurate record.


35. MATTERS ARISING

35.1 The actions were discussed and the following updates provided:

35.2 Minute 6 MHS Quality Dashboard Report Ms Bibi confirmed that the Section 17.3 form had been compiled and was awaiting sign off. Completed. Closed.

35.3 Minute 24 Quarterly AMHP Activity & Audit Report The Section 136 policy was still awaiting sign off, although Mr Omar confirmed that the Trust’s Section 136 policy was currently in use there were a number of red areas yet to be agreed Ms Clymer expressed concern that sign up to the policy had been pursued for some time and that as a result there may be an incident which would impact negatively on the Trust. Ms Ingram suggested, and it was agreed, that the Section 136 policy should be an agenda item at the next Mental Health Act Scrutiny Committee meeting, with the aspects that hadn’t been agreed and the risks to the Trust highlighted for in depth discussion at that meeting. Action: Section 136 Policy to be an agenda item at the meeting on 20th October 2016. The Chair confirmed that she would bring this discussion and the implications to the attention of the Board through her Chair’s report.

HO

GC

35.4 Minute 25 the Mental Health Code of Practice – Monitoring Compliance/Documentation Audit Mark Weaver joined the meeting. It could not be confirmed whether the inpatient services presentation had been circulated to members. Item to remain open.

35.5 Minute 30 Mental Health Act Scrutiny Committee ToRs Ms Ingram confirmed that the Terms of Reference had been reviewed and agreed, although the membership structure should be revised as the attendance of more than one Executive Director did not mean that the meeting was quorate. Whilst other Trust Board Committee attendance was based on voting, the Mental Health Act Scrutiny Committee required clinical and operational input. Attendance at future meetings would be monitored and the action closed in the meantime. Completed. Closed.


35.6 Minute 60 Whilst this item had been an agenda item and closed, the paper had not been received and should be including in the action schedule as an outstanding action. The Chair confirmed that she had spoken to Dr Gingell at a meeting and was advised that a paper would be presented to the Committee. It was agreed that the minutes related to this item would be forwarded to Dr Gingell and Dr Weaver to ensure that the action was completed. Action: Send the minutes related to this item to Dr Gingell and Dr Weaver to ensure that the action was completed.

HK

36. MHA QUALITY DASHBOARD REPORT, INCLUDING: - DOLS - SECLUSION AND LONG TERM SEGREGATION INCIDENTS - MHA RELATED INCIDENTS - TRAINING, INCLUDING PREVENT, MCA/DOL’S, SAFEGUARDING AND

MHA - SECTION 17 LEAVE REVIEW/PROGRESS REPORT

Mr Tong took members through the report, highlighting areas of note. He advised that a more reasoned approach was being taken related to absconds given that the majority of patients returned of their own accord without police intervention, albeit later than the agreed time. Mr Tong confirmed to Ms Clymer that any incidents related to absconds were recorded on safeguarding systems. He would follow this up with staff at ward level to ensure that the electronic systems were updated and the incidences closed off. Action: Ensure that staff at ward level are closing off the electronic incident form. Mrs Griffiths advised that she had reviewed failure to return incidents in depth and there had been 21 incidents over Q1. Mr Tong confirmed that an in depth report could be provided to the Committee at the meeting in October given the small numbers involved. Action: provide an in depth report on absconds to the meeting in October. Mrs Temple-Purcell referred to the training report advising that it demonstrated compliance broken down by service line. This was a newly introduced report that had been developed following the CQC visit and was being disseminated to managers on a weekly basis. The most recent and up to date data demonstrates that training was moving in the right direction and work was underway in relation to mandatory and essential training compliance. She was confident that improvements in training compliance would be realised over the next few months. Mrs Temple-Purcell confirmed that work was being undertaken related to the Mental Health Act training plan and external legal specialists had been

NT

NT


approached to deliver some specific sessions. Once the session dates had been finalised the training plan would be shared with members via Email. It would also be an agenda item at the meeting in October. Action: Share the finalised Mental Health Act training plan with Committee members via Email and include the plan as an agenda item for the meeting in October. In response to a query from the Chair, Ms Ingram advised that uptake of PREVENT training would increase every quarter. It currently stood at 81%. The focus was on areas where the Trust was contractually required to provide the training to front line staff. She was confident that based on the trajectory the targets would be achieved. Mrs Temple-Purcell confirmed to Ms Clymer that she was leading on a workstream and authority had been sought from the Home Office to use PREVENT training package. Ms Ingram advised the Chair that some staff were unable to undertaken MAPPA training for health reasons. A five day MAPPA training course had been organised and this would require a significant commitment from staff members to complete. The Committee noted the report for information.

BTP

HK

37. QUARTERLY AMHP ACTIVITY AND AUDIT REPORT Mr Omar took Committee members through the report referring to

exceptions. The committee debated in depth the disparity between Dudley and Walsall and the differing approaches taken and the structures in place. Dr Weaver confirmed that the use of Community Treatment Orders (CTOs) would be discussed at the Consultants away day. The Chair advised that an audit of the use of CTOs had been requested at a previous meeting and the Head of Nursing, Quality & Innovation should be asked to confirm whether this piece of work had been completed. Action: Head of Nursing, Quality & Innovation to confirm whether an audit of the use of CTOs had been completed. Dr Weaver suggested, and it was agreed, that he would identify attendees for a project group to monitor the use of CTOs and their impact on length of inpatient stays and readmission rates. Action: Identify attendees for a project group to monitor the use of CTOs and their impact on length of inpatient stays and readmission rates. Referring to Table 9, the Chair advised that some people from the BME community were reluctant to seek assistance in the treatment of mental health issues. Ms Clymer confirmed that this was acknowledged nationally. Mr Singh confirmed that he would raise this at the MERIT

Rosie Musson

MW


Diversity and Equality Workstream and provide feedback to the Committee in October. Action: Provide feedback from the MERIT Diversity & Equality workstream related to the reluctance of some ethnic groups to seek assistance in the treatment of mental health issues. The Committee received the report for information.

PS

38. MENTAL HEALTH ACT PARTNERSHIP GROUP UPDATE REPORT

Mr Omar advised that the Group included a number of public service members and gave an update on the issues raised at that Group. He highlighted concerns raised by the police service about the inappropriate use of their service which stretched their resources. Within the context of the wider squeeze on public sector finances and the Trust’s own financial plan the Chair expressed her understanding of the comments made. Mr Omar confirmed that the investigation into the case related to two doctors and an AMHP had concluded that it was a case of shared responsibility. Dr Iqbal would respond to the report findings. Dr Weaver advised that an audit trail to include formal completion of documentation highlighting that detention was not recommended due to mental health issues and making any recommendations as to whether the person should be kept in custody. Mr Omar provided an overview of future actions that would be taken related to a person diagnosed with a personality disorder. The Committee received the report for information.

39. CQC ACTION PLAN

Mr Tong advised that the actions presented were all related to the Mental Health Act resulting from the CQC visit in February 2016. The Chair expressed concern that there appeared to be a number of outstanding actions and was advised that the CQC steering group would be taking these forward and highlighting mitigations in place. The CQC report in general raised concern at the appropriate completion of paperwork and further audits undertaken had highlighted errors. Ms Bibi advised that an audit report had highlighted issues related to Section 17 leave forms where patient notes were unavailable. She would be discussing this with ward clerks and providing on ward training to include an Aide memoir. It was agreed that the uptake of training was low and this would be raised with the Director of Nursing, with Ms Bibi attending Acute Service Line meetings. Staffing levels had been identified as the reason for incomplete paperwork. These issues would be highlighted in the Mental Health Act Scrutiny Committee Chair’s Report to the Board. Action: Include concerns related to completion of appropriate paperwork and lack of uptake of training in the Committee Chair’s

GC


Report to the Trust Board. Mr Tong confirmed that the policy referred to in Action 37.2 was completed and was awaiting sign off. The Chair summarised the discussion, advising that the Committee had reviewed the CQC Action Plan and scrutinised those actions that were red RAG rated. The Committee received the report for information and assurance.

40. ALM MEETING FEEDBACK

Mrs Cooper advised that the ALM meeting had not taken place and would be re-scheduled. The Committee received the verbal update for information.

41. AOB

Ms Ingram advised members that Board Committee meeting minutes would be taken in the public session of Trust Board meetings. Members expressed concern given the sensitive nature of some of the discussions. The Company Secretary would be asked to raise this with the Chair of the Trust. Action: Company Secretary to review whether MHASC minutes should be taken in the public session of the Trust Board meeting.

PL-G

Ms Ingram advised that the Coroner had taken the unusual step of holding an Inquest into the death of a patient before a Jury. The outcome would be reported to the Committee in October. The Chair stated that she would be submitted her apologies for the meeting on 20th October. It was agreed that Ms Clymer would chair the meeting in her absence. Dr Weaver provided an overview of a situation related to the completion of Section 17 leave forms and queried whether the forms could be completed electronically. This would be reviewed. Mr Tong advised that the CQC had conducted a Mental Health Act visit on Wrekin, Ambleside, Langdale and Clent Wards the previous day. A visit to Kinver was being undertaken on 23 June 2016. Feedback on the visit to Clent and Wrekin wards had been Positive. The attitude of staff and staffing levels on Ambleside had been raised and these would feed into the action plan. He confirmed that no issues had been raised that directly related to the MHASC.

Agenda/HK


42. Date, Time, and Venue of Next Meeting

20th October 2016 at 2.00pm, Conference Room 1, Trafalgar House, King Street, Dudley

The meeting closed at 4.08pm

Signed by Chair Mrs G Cooper Signature…………………………………………………… Date …………………………. Document Details

Author Linda Wix Department Trust Headquarters Organisation Dudley and Walsall Mental Health Partnership NHS Trust Document Type Minutes Document Title Draft - MHASC Minutes 23.06.16 – v0.1 – 1st draft Version 0.1 first draft

1 1 1

Quality Report Month 4 2016/17

Section 1 Summary of Trust Incidents and

Serious Incidents

Section 1

Summary of Trust Incidents and Serious Incidents

1 July 2016 to 29 July 2016

Cause Group No. Incidents

57.28% of incidents were Patient Safety Incidents (182 of 323 incidents)

3 SIs*0 NeverEvents

37 SIRS**

323 INCIDENTSREPORTED

105Disruptive / Aggressive BehaviourDis

66Serious Harming BehaviourSer

57Clinical Care, Assessment And MHAClin

33Patient AccidentPat

16Access, Admission, TransferAc

10Consent, Communication And

10Medication

9Security

8Health & Safety

4Fire Incident

2Equipment

1Documentation

1Infection Control Incident

1Skin Integrity

Inc

ide

nts

by

Ca

us

e

Disruptive / Aggressive Behaviour: Top Causes

Physical Assault - Pt On Pt 17 incidents

Behavioural - Disruptive 15 incidents

Physical Assault - Pt On Staff 15 incidents

Serious Harming Behaviour: Top Causes

Clinical Care, Assessment And MHA: Top Causes

Patient Accident: Top Causes

Self Harm - Medication Overdose 14 incidents

Self Harm - Cut 11 incidents

Attempted Suicide - Medication Overdose 9 incidents

Clinical - Delay / None Referral 15 incidents

Agency Staff Usage - (Please Provide Details) 12 incidents

Clinical - Treatment / Care Related 9 incidents

1

2

3

1

2

3

1

2

3

1

2

3

Patient - Faint/ Fit / Unwell 10 incidents

Found With Injury 5 incidents

Patient Accident - Cuts / Skin Tear 5 incidents

No.Incidents

Service Line

Acute 185

Older 79

E.I. 33

Other 17

Comm & Rec 8

Unclassified 1

Se

rvic

e L

ine

s

Access, Admission, Transfer Discharge: Top Causes

1

2

3

Failure To Return From Leave 4 incidents

Absconded / Missing (Informal Patient) 3 incidents

323 Total IncidentsReported

* SI: Serious Incidents** SIRS: Security Incidents Reporting System

Quality and Safety Report August 2016

Section 2 Individual Operational Service line Reports

Section 2 - Service Line Reports

Disruptive / Aggressive Behaviour 72 84

Serious Harming Behaviour 39 36

Access, Admission, Transfer Discharge 15 18

Clinical Care, Assessment And MHA 32 17

Patient Accident 9 8

Medication 5 1

Health & Safety 5 7 8.2% 15.1% 11.6% 6.2% 3.4% 44.5%

Security 4 4 2.7% 2.1% 1.4% 2.7% 1.4% 10.3%

Consent, Communication And Confidentiality 2 4 4.1% 0.7% 3.4% 5.5% 2.1% 15.8%

Equipment 1 5 5.5% 2.7% 2.1% 2.1% 0.0% 12.3%

Documentation 0 2 4.8% 0.7% 0.7% 0.0% 0.0% 6.2%

Fire Incident 0 3 2.1% 0.0% 0.7% 0.7% 0.0% 3.4%

Infection Control Incident 1 0 2.1% 2.1% 2.1% 1.4% 0.0% 7.5%

Skin Integrity 0 0 29.5% 23.3% 21.9% 18.5% 6.8% 100%

Grand Total 185 189

Quality and Safety Report August

2016

Incident Cause Group

Trend analysis

Current

Month

Position on previous

monthLast 12 months

Grand Total

Patient Accident

Medication

Other

Grand

Total

Disruptive / Aggressive Behaviour

Access, Admission, Transfer Discharge

Serious Harming Behaviour

Clinical Care, Assessment And MHA

Am

ble

sid

e

Lan

gdal

e

Cle

nt

Kin

ver

Wre

kin

Commentary Chart 2.1.1 - Total Acute & Access incident numbers received by the Trust during the last 12 months

The monthly (mean) average for incidents relating to Acute & Access Services (calculated using data from the last 12 months) is 170.25

• Chart 2.1.1 shows the incident numbers for Acute & Access Services have shown a decrease since the previous month and remains 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. • There has been a decrease in the number of Disruptive / Aggressive Behaviour type incidents •There has been an increase in the incidents reported under the category "Clinical Care, Assessment and MHA". This is a deliberate initiative that the Trust is leading on to enable the timeliness of response of CRHT to be captured as part of the Trust CQC action plan

• Table 2.1.2 - shows a heat map below, where the percentage of inpatient incidents have occured and incident type.

• Langdale reported 15.1% of all of the Disruptive / Aggressive Behaviour type Incidents. A large proportion of these incidents relate to an individual patient who owing to their presentation and risks has required treatment in Long Term Segregration

• 44.5% of all inpatient incidents related to Disruptive / Aggressive Behaviour type Incidents

Table 2.1.1 - Total Acute & Access incidents by Cause Group and showing a position on the previous months figures

2.1 - Acute & Access Service Line

75%

80%

85%

90%

95%

100%

50

100

150

200

250

Be

d O

ccu

pan

cy

Acute and Access Services 12 Monthly Average Mean + 2S.D.

Mean - 2S.D. Acute Bed Occupancy

Table 2.1.2 - Heat Map Total Acute inpatient incidents shown by Incident Cause Group percentage and by ward


Current

Month Last 12 months




Health & Safety 0 1

Medication 3 2 Disruptive / Aggressive Behaviour 6.3% 20.3% 9.4% 3.1% 39.1%

Serious Harming Behaviour 3 4 Patient Accident 17.2% 4.7% 6.3% 4.7% 32.8%

Skin Integrity 1 4 Clinical Care, Assessment And MHA 7.8% 3.1% 1.6% 1.6% 14.1%

Equipment 1 1 Medication 0.0% 0.0% 3.1% 0.0% 3.1%

Access, Admission, Transfer Discharge 1 1 Security 0.0% 0.0% 1.6% 0.0% 1.6%

Consent, Communication And Confidentiality 3 1 Other 3.1% 6.3% 0.0% 0.0% 9.4%

Security 2 0 Grand Total 34.4% 34.4% 21.9% 9.4% 100.0%

Infection Control Incident 0 0

Documentation 0 1

Fire Incident 0 0

Grand Total 79 104

Ho

lyro

od

Grand

TotalCe

dar

s

Quality and Safety Report

August 2016


Trend analysis

Position on previous

month

Mal

vern

Lin

de

n

Table 2.2.1 - Total Older Adults incidents by Cause Group and showing a position on the previous months figures

Chart 2.2.1 - Total Older Adults incident numbers during the last 12 months

0%

10%

20%

30%

40%

50%

60%

70%

80%

0

20

40

60

80

100

120

140

160

180

Be

d O

ccu

pan

cy

Older 12 Monthly Average Mean + 2S.D.

Mean - 2S.D. Older Adults exc Leave

Commentary

The monthly (mean) average for incidents relating to Older Adults Services (calculated using data from the last 12 months) is 111.08 Chart 2.2.1 shows the number of incidents has decreased since the previous month and has now fallen below the 12 month average. Table 2.2.1 shows the total number of incidents broken down by cause group.

• The most reported Incident category is Disruptive / Aggressive Behaviour which has seen a decrease when compared to the previous month. • Patient accidents have generally seen a slight decrease, but remain high on Malvern Ward. The Trust is looking at trends relating to this and all falls are reviewed independently by the Trust Falls Lead in line with the Falls Prevention Strategy

Table 2.2.2 - Shows a heat map below showing where the percentage of inpatient incidents have occurred.

• Linden ward has seen a continued reduction in incidents , particularly relating todisruptive and aggressive type incidents. Upon review, there are a number ofinfluencing factors that have contributed to this reduction including changes to ward environment, the work regarding learning sets, training programmes and dementiaspecific training (in line with Bloxwich Assurance Plan)

• There has also been a targeted piece of work that explores incident reporting thresholds and consistancy across Dudley and Walsall Older Adults Service Line .

2.2 Older Adults Service Line

Table 2.2.2 - Heat Map

Section 2 - Service Line Reports Quality and Safety Report

August 2016


Current

Month

Last 12

months




Security 2 1

Consent, Communication And Confidentiality 1 0

Health & Safety 1 2

Equipment 0 5

Medication 1 1

Documentation 0 0


Fire Incident 1 1


Skin Integrity 0 0


Grand Total 33 40

Previous month

Early InterventionChart 2.3.1 - Total Early Intervention incident numbers during the last 12 months

0

5

10

15

20

25

30

35

40

45

Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16

E.I. 12 Monthly Average

Commentary

The monthly (mean) average for incidents relating to E.I. Services (calculated using data from the last 12 months) is 19.67 • Chart 2.3.1 shows this month has seen a decrease in the number of incidents for the Early Intervention Service line, with 33 incidents reported for the month. • Table 2.3.2 shows the total number of incidents broken down by Cause Group.

Exceptions/Trends

The overall increase in Incidents, specifically in relation to the Category of Self Harming behaviour, is in relation to the recent recording of CAMHS DSH (Deliberate Self Harm). These assessments are carried out generally within peadiatric wards and are reported by iCAMHS. (Walsall) Further work is now being proposed to capture specific elements of these CAMHS incidents and to identtify and understand any trends in these incidents.

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


Incident Cause GroupCurrent Month

Last 12 months




Security 1 1

Consent, Communication And Confidentiality 1 1

Health & Safety 0 0

Equipment 0 2

Medication 1 1

Documentation 0 0


Fire Incident 0 0


Skin Integrity 0 0


Grand Total 8 13

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

18

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 9.83 Chart 2.4.1 shows the incident figures which have fallen below the 12 month average previous month. • Table 2.4.2 shows the total number of incidents broken down by cause group.

Exceptions/Trends

All other incidents relate to individual services and the incidents have no specific trend.

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

Quality and Safety Report August 2016

Section 3 Serious Incidents

Section 3.1 - Serious Incidents Quality and Safety Report

July 2016

SI Number Date of Incident Service Line Incident DescriptionDoC

applicable

Level of

responseCurrent status

2016/19810 25/07/2016 Acute Under 18 Admission NoClinical

ReviewOngoing

2016/19303 16/07/2016 Acute Attempted Suicide - Medication Overdose NoClinical

ReviewOngoing

2016/19288 15/07/2016 E.I. Attempted Suicide - Medication Overdose NoClinical

ReviewOngoing

Chart 3.2 - Total number of Serious Incidents during the last 12 months

0

2

4

6

8

10

12


Serious Incidents Trust Average Mean + S.D. Mean - S.D.

Table 3.1 - List of Serious Incident raised during the month of April 2016

Commentary

The monthly (mean) average for serious incidents across the Trust (calculated using data from the last 12 months) is 3.75

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 are 3 Serious Incidents, 2 linked to Acute Services and 1 linked to Early

Intervention.

Chart 3.2 shows that the number of Serious Incidents remain below the 12 monthly average level. Chart 3.1 illustrates the types of the Serious Incidents that have been reported over the previous 12 months.

Incident Summary

2016/19810 - This was an incident relating to the admisison of an under 18 year old patient (16 year old) who was admitted to a Dudley inpatient ward. the Trust ensured that all appropriate safeguarding procedures were in place and the patient was disharged after a short period to a suitable placement. (Tier 4 placement)

2016/19303 - This incident relates to a attempted suicide through a medication overdose (paracetomol) of an informal patient who was being treated as an inpatient at BFH. The patient left the ward and purchased the paracetomol whislt on leave, from the ward, before taking the overdose . The patient was treated the local acute hospital and returned back to the MH ward the same evening.

2016/19288 - This incident relates to a attempted suicide through a medication overdose (paracetomol) of a patient known to Dudley EI services . A Level 1 clinical review has been undertaken . The patient was disharged from the acute hopsital within 24 hours and admitted to Kinver ward BFH as an informal patient for further assessment and treatment

Chart 3.1 - Summary of the Serious Incident types during the last 12 months

49%

42%

5% 2% 2%Serious Harming Behaviour

Access, Admission, Transfer Discharge

Clinical Care, Assessment And MHA

Fire Incident

Disruptive / Aggressive Behaviour

Section 4 National Guidance:

Safety Alert Broadcasts (SAB's)

Section 4 - CAS Alerts Table 4.1 – Summary of Alerts received during July 2016

Type of Alert Number of Alerts in June

Action not Required

Assessing Relevance

Action Required

Circulated for Information

MDA 1 0 1 0 0 MHRA 0 0 0 0 0 CMO 0 0 0 0 0 DDL 0 0 0 0 0 EFN 7 4 3 0 0 DH – EFA 2 1 1 0 0 DH 0 0 0 0 0 SDA 0 0 0 0 0 NHS – PSA 2 0 2 0 0 Total 12 5 7 0 0

Table 4.2 –Alerts issued during July via the Central Alerting System

Reference Issue Date Alert Title Originated By Response Deadline

EFN/2016/45 28-Jul-16 High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - Reyrolle - LMI - Ring Main Unit DH Estates and Facilities Assessing

Relevance 25-Aug-16

EFN/2016/31 (U) 27-Jul-16 High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - UPDATE - Schneider Electric - Ev ... DH Estates and Facilities Assessing

Relevance 24-Aug-16

EFN/2016/44 26-Jul-16 Low Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - ABB - SACE - EMAX E2N 12 - Cir ... DH Estates and Facilities Assessing

Relevance 23-Aug-16

MDA/2016/010 26-Jul-16 RightSign HIV 1.2.O Rapid Test Cassette, HCV Rapid Test Cassette & HBsAg Rapid Test Cassette â€“ d ... MHRA Medical Device Alerts Assessing

Relevance 16-Aug-16

EFN/2016/14 (U) 22-Jul-16 High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - UPDATE - Schneider Electric - RN ... DH Estates and Facilities Action Not

Required 19-Aug-16

NHS/PSA/RE/2016/006 22-Jul-16 Nasogastric tube misplacement: continuing risk of death and severe harm NHS Improvement Assessing

Relevance 21-Apr-17

EFN/2016/43 21-Jul-16 High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - UPDATE - Reyrolle LM23T - Circui ... DH Estates and Facilities Action Not

Required 18-Aug-16

EFA/2016/004 21-Jul-16 Operating Theatre Ultra Clean Ventilation (UCV) canopies fitted with gel seal HEPA filters DH Estates and Facilities Action Not

Required 04-Nov-16

EFN/2016/26 (U) 19-Jul-16 Low Voltage Hazard Alert - NATIONAL EQUIPMENT DEFECT REPORT (NEDeR) - UPDATE - ABB - SACE - Type E3N ... DH Estates and Facilities Action Not

Required 16-Aug-16

NHS/PSA/RE/2016/005 12-Jul-16 Resources to support safer care of the deteriorating patient (adults and children) NHS Improvement Assessing

Relevance 31-Jan-17

EFN/2016/42 05-Jul-16 High Voltage Hazard Alert - DANGEROUS INCIDENT NOTIFICATION (DIN) - UPDATE - CG Power Systems - 11 ... DH Estates and Facilities Action Not

Required 02-Aug-16

EFA/2016/003 04-Jul-16 Metal waste pipes used for the disposal of laboratory solutions and reagents containing sodium azide ... DH Estates and Facilities Assessing

Relevance 01-Dec-16

During July 2016 there were 12 alerts issued via the Central Alerting System, of these alerts:

o 5 Alerts required no action taking. o The Trust is currently assessing the relevance of 7

alerts. The table below (4.2) outlines a summary of the alerts issues and any action taken.

DWMHT Safeguarding Performance Framework 2016/17

Section 1 • Safeguarding Training Compliance

Section 2 • DoL's• Domestic Violence

• LAC - CAMH's

Section 3 • Safeguarding Children

Section 1 Safeguarding Training Compliance

Safeguarding Training Complaince

DWMH (total) Dudley Walsall CorporateCompliance Target Compliant Required

complianceCompliant

%Compliant Required

complianceCompliant

%Compliant Required

complianceCompliant

%Compliant Required

complianceCompliant

%

Safeguarding Induction 100% 9 9 100% 4 4 100% 5 5 100% 0 0 -Safeguarding Adults Lvl 1 90% 214 260 82% 83 108 77% 93 109 85% 74 78 95%Safeguarding Adults Lvl 2 90% 553 682 81% 298 369 81% 298 370 81% 30 35 86%Safeguarding Adults Lvl 3 90% 413 499 83% 222 265 84% 231 289 80% 15 16 94%Safeguarding Adults Lvl 4 90% 0 6 0% 0 0 - 0 2 0% 0 4 0%Safeguarding Children Lvl 1 95% 220 260 85% 84 108 78% 94 109 86% 79 87 91%Safeguarding Children Lvl 2 90% 549 682 80% 290 369 79% 301 370 81% 25 35 71%Safeguarding Children Lvl 3 95% 408 499 82% 212 265 80% 235 289 81% 15 16 94%Safeguarding Children Lvl 4 100% 0 6 0% 0 1 0% 0 2 0% 0 3 0%Mental Capacity Act 80% 549 687 80% 299 376 80% 301 380 79% - - -PREVENT 75% 555 686 81% 293 373 79% 316 380 83% 16 22 73%Domestic abuse & Violence 20% 100 663 15% 55 365 15% 57 367 16% 1 9 11%

Training Data for month 3

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.

There is work ongoing with ESR to ensure the new training in relation to Domestic Abuse & Violence is captured and recorded accurately.

Adult Safeguard Training - Childrens Safeguarding Training - Q1 - Scoping exercise to identify numbers and training levels required Q1 - Scoping exercise to identify numbers and training levels required Q2 - 90% (Trust Compliance) Q2 - 90% (Trust Compliance) Q3 - 90% (Trust Compliance) Q3 - 90% (Trust Compliance) Q4 - 90% (Trust Compliance) Q4 - 90% (Trust Compliance)

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%

Safeguarding Performance Framework for July 2016

Section 2 Deprivation of Liberty (DoL's)

& Domestic Violence

15 8 17 8

1716

Dudley Walsall

Referred into

MARAC

Jul-16Safeguarding Cases Internally reported as Domestic Abuse

Open To Mental Health

Referred into

MARAC

Open To Mental Health

Alert OnlyReferral


MARAC

Section 2 - DoL's and Domestic Violence

2.2 Domestic Abuse

Total number of cases of Domestic Violence for the current month, these include cases reported within the Trust and Externally notified by MARAC (Multi-Agency Risk Assessment Conference) Commentary

DoL's & MHA Below is 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.There are currently 19 active cases of DoL's across the Trust

Further information relating to Older Adults, health related legal restrictions / provisions • Dudley - 13 patients (8 DoL's & 5 Under MHA)• Walsall - 15 patients (11 DoL's & 4 Under MHA)

Table 2.2 Domestic abuse cases are reported as separate figures to display the prevalence within the service. Case figures are also shown for MARAC (multi agency risk assessment conference), these figures demonstrate how many cases are heard at MARAC where the victim, perpetrator or children are open cases to mental health. • The first table provides information on Cases reported Externally of the Trust which are then checked to see if

these Patients are open to Dudley and Walsall Mental Health.• The second table provides information on Domestic Abuse cases which have been reported internally into our

Trust

Section 3 Safeguarding Children

& Vulnerable Adults

Referral Alert Only Referral Alert Only

8 13 3 10 340 0 0 0 00 0 0 0 00 0 0 0 01 0 0 0 10 0 0 0 00 0 0 0 00 0 0 0 09 13 3 10 35

228

Position of Trust InternalPatient considered High Risk


Dudley Walsall Grand Total

Child Safeguarding Case

Under 18 Admission

FGMSerious Case Review (Child)

Position of Trust External

Total 106 122Number of Looked after Number of Looked after

Under 18 Death

Grand Total


3.1 Safeguarding Children

Graph 3.1 - This graph provides information relating to the last 12 months and shows a breakdown of Safeguarding cases which are just for alert only and those which have been progressed to be continued under Safeguarding Table 3.1 -This shows that the number of Safeguarding cases broken down by case type and showing the locality . This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency.

Table 3.1.1 This table provides information in relation to Looked after Children (LAC), who have been referred or in receipt of our services.

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

05

101520253035

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

2015 2016

Alerts Referral

Referral Alert Only Referral Alert Only

8 35 7 66 1160 10 3 6 190 1 0 0 10 0 1 1 20 1 0 1 20 0 0 0 08 47 11 74 140

FGMGrand Total


Adult

Prevent CasePosition Of Trust ExternalPosition Of Trust Internal


Patient Considered High Risk

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 .

Investigation - Further to the reports previously in relation to concerns received relating to patient care from Bloxwich hospital. The investigation has now been concluded and the Safeguarding team are addressing the actions raised.

Serious Case Reviews (SCR) - currently none Domestic Homicide Review (DHR) - currently none

Table 3.2 - Total number of Vulnerable Adults incidents for the current month

0

50

100

150

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

2015 2016Alerts Referral

Enc 10 Audit Committee Chair's Report Page 1 of 3


Agenda Item number: 8.1.2a

Enclosure: 10

Report Title:

Audit Committee Chair’s Report

Committee:

Audit Committee


David Matthews, Non-Executive Director Mark Banks, Deputy Director of Finance


Decision / Approval

Gain assurance

Discussion

Information

Key issues and Risks Internal Audit Internal Audit presented the following documents to the Committee –

• Progress Report o One Audit had been deferred to the next meeting of the Committee in December due to

the meeting being brought forward – (Care Records), o To support the Trust in addressing some of the concerns raised by CQC the Least

Restrictive Practice review has been brought forward and an additional review of Compliance with the Fit and Proper Person Regulations will be accommodated within the audit plan.

• Outstanding Recommendations Report o 11 outstanding recommendations o No overdue recommendations

In addition, the following Internal Audit Reports were presented to the Committee –

• A CIP / PMO Diagnostic Report in draft which the Committee agreed should be shared with Board members and further discussed with management comments at a Board Development Session in October 2016 with the final report being reported back to Audit Committee

• Recruitment [Efficiency] Processes - Moderate Assurance – the Committee referred this report to the Workforce Committee for information and agreed that a follow-up audit should be in next year’s internal audit plan to further review progress.

• BAF – interim review Level A (Highest Level of Assurance) External Audit External Audit presented the following documents to the Committee –

• External Audit Update – Early part of the Audit year, progress against the plan was on track with the fee letter and progress reports delivered to plan


• Annual Audit Letter – This letter summarises the key findings arising from the work that the

external auditors have carried out at the Trust for the year ended 31 March 2016, focusing on the audit of the Trust’s accounts, review of value for money and the external auditors work on the Quality Account

Anti-Fraud Anti-fraud presented the following documents to the Committee –

• Anti-Fraud Progress Report o Three referrals were open at the time the report was written one was in the process of

being closed and the Committee were assured that the appropriate steps were being taken in relation to one of the other referrals.

o Activities against each of the expected deliverables for the financial year for the anti-fraud work plan were outlined.

Trust Business The following issues were discussed under Trust Business –

• Management Papers – The regular updates on the number and value of waivers, purchase invoices with no orders and losses and special compensations were provided since the beginning of the 2016/17 financial year.

• A report was received on the review of the Trust’s estate and asset valuation. The Committee

approved the proposed revised method of valuation subject to the planned detailed review by external audit and recommended the matter, with an appropriate covering case be referred to the Board following further analysis of the review by the Trust’s external auditors

Security Management

• The security management annual report and work plan was presented. The overlap with the

remit of Quality and Safety Committee which had previously received these reports was highlighted, the Audit Committee receiving the report for assurance that there were appropriate security management processes in place.

NEDs – Review of Work Undertaken by Other Committees • The Chair of the Mental Health Act Scrutiny Committee provided a detailed update of the work

being undertaken by the Committee. The Chair explained the remit of the Committee in terms of assuring that the Trust is meeting all its statutory obligations under the Mental Health Act She highlighted significant link of the work of this Committee to that in responding to the recommendations in the CQC report and also highlighted some ongoing issues in agreeing the Section 136 process with the appropriate agencies. The Committee were keeping under review attendance, particularly the need for clinical input into the discussions that may be reflected in the Committee’s future review of its quoracy and from a governance perspective the timely availability of the papers for meetings remained a concern. The Audit Committee agreed with the Chair of Mental Health Act Scrutiny Committee that a review of the Mental Health Act Scrutiny Committee work plan and a review of the use of CTO’s be included in the internal audit plan.


Any Other Business The Committee received assurance following its referral to the Finance and Performance Committee that the outcomes of the Older Adults review were being followed through The Chair of the Audit Committee on the occasion of his last meeting in the Chair before taking up a position with another Trust was thanked for his work over the preceding six years, particularly his ability to maintain an oversight of all the activities within the Committee’s remit and his determination to ensure the effective governance of the Trust. The Chair then thanked members of the Committee for their work in supporting this Committee during his time as Chair. Interfaces with other Committees The Recruitment (Efficiency) Processes Review has been referred to the Workforce Committee. The Audit Committee received for assurance the Security Management Annual Report and workplan that had been discussed at Quality & Safety Committee. Two pieces of internal audit work - a review of the Mental Health Act Scrutiny Committee work plan and a review of the use of CTO’s resulted from the Audit Committee reviewing the work of other Board Committees. Recommendations and requests for direction The Board is asked to note the report.

Finance Report (Month 04)

1

2

2016/17 DWMHPT Finance Report Month 04 Page

• Key Messages 3

• Overall Summary and RAG Assessment 4-5

• Trust Income Statement: Functional Analysis 8-9

• Cost Improvement Programme 10

• Capital Programme 11

• Financial Performance Metrics / NHSI Key Data 12

• Agency Cap & Agency Spend by Staff Group 13-14

• Cash Flow Statement 15

• Debtor and Creditor Performance 16

• Statement of Financial Position (Balance Sheet) 17

Key Messages : Current Performance

3

Financial Position £493k surplus YTD £93k Favourable variance

• The Trust has delivered a Month 04 surplus of £493k.

• This represents a favourable variance against plan of £93k YTD (based on a revised ‘stretch’ planned surplus for the year of £1.7m).

Expenditure – Pay £531k Favourable variance

• Pay expenditure is £531k in surplus against budget YTD, which is being driven by surpluses within Community, Corporate and Trust wide Reserves.

• Bank & Agency spend equates to £476k in month (split £347k for Agency and £129k for Bank), which is down from the Month 03 spend of £539k.

• Agency spend is marginally behind plan by £24k in relation to the overall £4.05m Agency target for the year (actual spend of £1,770k against £1,746k plan to date).

Expenditure – Non Pay

£534k Adverse variance

• Non-Pay expenditure is £534k in deficit against budget YTD.

• Reserves are over committed by £210k reflecting the impact of un-devolved CIP yet to be allocated down to service lines.

Income & Activity– 2016/17 outturn

£95k Favourable variance (incl £6k contract activity over-performance)

• The Trustwide Activity position at Month 03 is reflecting an breakeven performance and is explained as:

• Dudley CCG is now on block and so has no in-month impact

• Walsall CCG has over-performed by £171k

• Birmingham South Central CCG over-performed by £17k with £3k on other CCGs

• NCAs have over-performed against plan by £74k

• The activity in the Detox beds at Bushey Fields has under recovered by £26k

• The net position is an over-performance of £240k, however, after taking account of the impact of the CIP target that has been applied to activity, being £234k , overall performance is £6k over-performing against plan.

• Bed days for Acute and Older Adults in Dudley continue to be low in comparison to contracted levels.

• Non-contracted Income such as SLA’s and Education Income is ahead of plan and is adding to the current breakeven performance in contracted income mentioned above, giving an overall favourable income position in the month.

CIP plans delivered for 2016/17

Potential risk of £1.362m

• The Trust’s Cost Improvement Target for the year is £2,500k and schemes have been developed for the year equating to £2,664k. The anticipated delivery of schemes taking into account the PYE of schemes starting later in the year is £2,555k which is ahead of the required target.

• At Month 04 CIP schemes have in the main been devolved down to budget areas with the exception of three schemes (OA Day Hospital / OA Establishment Review and Medics Establishment Review, totalling £468.3k).

• Based on current data there is an identified risk of around £1.362m of non-delivery although some of these schemes are being supported on a non-recurrent basis especially in relation to the two income schemes totalling £703k.

Expenditure - Capital

£81k spend YTD • The Capital Programme has been agreed at £2,748k for the year.

• At present there has been minimal spend as the new financial year begins. – a plan of likely spend has been requested via the E&CPG.

Overall Summary and RAG Assessment

4

Commentary

Revenue Position • The plan for the year currently reflects a revised planned surplus position

of £1,705k.

• The Trust is reporting a surplus of £493k as at Month 04 which is £93k ahead of the revised plan.

• Total Income after taking account of the impact of the applied CIP (£703k FYE) is reflecting a £6k surplus position, coupled with other SLA and Educational income giving a total over-recovery of £94k on income.

CIP 2016/17 Delivery • The Trust has a declared plan of £2,500k for 16/17 and has schemes in

place totalling £2,664k.

• There is clear risks to several schemes to the value of £1.362m as detailed on page 10, however, this is being managed on a non-recurrent basis at this time.

Budgetary Reserves • Trustwide Reserves are reflecting a budget of £359k at Month 4 for the

year, of which there is an overspend of £337k due in the main to the non-delivery of CIPs (un-devolved schemes).

Impairment • The position in Month 04 is also reflecting the balance sheet adjustment

following the asset revaluation undertaken in order to support the delivery of £500k towards the revised planned surplus of £1,705k.

• This can be seen on the table opposite as a £16,475k impairment adjustment.

Statement of Comprehensive Income - Financial Position to 31st July 2016 Annual In Month Year To Date Plan Plan Actual Variance Plan Actual Variance

Income £000 £000 £000 £000 £000 £000 £000 Revenue From Activities Revenue-NHS Clinical 61,086 5,096 5,101 5 20,381 20,418 37 Revenue-Non NHS Clinical 786 190 191 1 262 230 (32) Total Revenue From Activities 61,872 5,286 5,292 6 20,643 20,648 5 Other Operating Revenue Revenue-Employee Benefits 413 34 49 15 138 185 47 Revenue-Education & Training 1,094 143 113 (30) 419 485 66 Revenue NHS Non-Clinical 955 82 79 (3) 353 336 (17) Other Revenue 556 46 54 8 185 177 (8) Total Other Operating Revenue 3,018 306 295 (10) 1,095 1,184 88 Total Revenue 64,890 5,592 5,588 (4) 21,738 21,832 94 Expenditure Pay (49,298) (4,274) (4,002) 272 (16,763) (16,182) 581 Non Pay (10,974) (803) (976) (173) (3,469) (3,716) (247) Trustwide Reserves (359) (165) (344) (178) (255) (592) (337) Total Operating Expenditure (60,631) (5,242) (5,322) (79) (20,487) (20,490) (3) EBITDA 4,259 350 266 (83) 1,250 1,341 91 Depreciation (1,473) (123) (123) 0 (491) (491) 0 Amortisation (256) (21) (21) 0 (85) (85) 0 Net Operating Surplus 2,530 206 122 (83) 674 765 91 PDC (865) 68 68 0 (288) (288) 0 Interest Receivable 40 3 4 1 13 14 1 P/L Disposal 0 0 0 0 0 0 0 Net Surplus /(Deficit) 1,705 277 194 (82) 400 492 92

Technical Adj - Impairment 0 0 (16,475) (16,475) 0 (16,475) (16,475) Technical Surplus 1,705 277 (16,281) (16,557) 400 (15,983) (16,383)

Overall Summary and RAG Assessment Continued

5

2,664

2,555

2,500

0 1,000 2,000 3,000

Identified Schemes(FYE)

Identified Schemes(PYE)

CIP Target as perNHS Improvement

£'000

CIP 2016/17

700

1,700

493

0

250

500

750

1,000

1,250

1,500

1,750

£'00

0

Run Rate 2016/17

CumulativePlannedRun Rate(Surplus)

Cumulative'Stretch'RevisedRun Rate

Actual RunRate

2,748

81 0

500

1,000

1,500

2,000

2,500

3,000

£'00

0

Capital Programme 2016/17

CumulativePlannedSpend

CumulativeActualSpend

12,000

12,500

13,000

13,500

14,000

14,500

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

£'00

0

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17Revised Forecast 12,740 12,802 12,846 12,926 13,010 13,325 13,384 13,505 13,384 13,257 13,084 13,450

Original Forecast 12,745 12,812 12,861 12,890 12,924 12,908 12,916 12,986 12,815 12,638 12,414 12,450

Actual 13,374 13,578 14,068 14,325

Forecast vs Actual Cash Balance 2016/17

Trust Summary Income & Expenditure Statement Including Functional Analysis

6

Commentary

• The Trust is showing a £6k over-performance position against contracted activity levels.. It should be noted that this is even after the impact of £234k relating to the CIP target for 2016/17.

• Contracted activity is over-performing in Walsall by £171k but is being offset by the impact of the CIP mentioned above.

• Acute and Older Adult Services are £17k underspent, but there are still overspends within Inpatient areas (including Bank and Agency).

• Corporate areas are currently reflecting 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 yet to be devolved down to service lines.

• The Trust is presently reporting a surplus position for the year to date which is £93k ahead of the trajectory to deliver the £1,705k revised planned surplus at year end.

• The Trust has agreed a revised surplus plan for the remainder of the financial year with NHS Improvement which encompasses benefits released from asset revaluations and addition funding from DoH re STF – these are now reflected in the I&E summary opposite.

Annual Plan In Month Year to Date FOT M04

2016/17 Plan Actual Variance Plan Actual Variance Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS Revenue-Activities 61,586 5,263 5,268 5 20,548 20,585 38 7 Revenue from LAs 286 24 24 1 95 63 (32) (90) Total Revenue from Activities 61,872 5,286 5,292 6 20,643 20,649 6 (83) Corporate Functions Corporate Departments (12,840) (1,075) (1,076) (1) (4,300) (4,080) 221 129 Central Reserves (359) (165) (344) (178) (255) (592) (337) 403 Total Corporate Functions (13,198) (1,240) (1,420) (179) (4,556) (4,672) (116) 532

Operational Services Total Acute & Older Adults (19,566) (1,628) (1,550) 78 (6,539) (6,522) 17 (254) Total Community Services (14,486) (1,213) (1,218) (5) (4,903) (4,762) 141 (195) Medical Services (12,091) (999) (982) 17 (3,971) (3,926) 45 0 Total Operational Services (46,143) (3,840) (3,751) 90 (15,413) (15,210) 202 (449) Total Expenditure (59,342) (5,081) (5,170) (90) (19,968) (19,882) 86 83 Sub Total 2,530 206 122 (84) 675 767 92 0 Interest Receivable 40 3 4 0 13 14 1 0 PDC Dividend (865) 68 68 0 (288) (288) 0 0 Net Surplus/(Deficit) 1,705 277 194 (84) 400 493 93 0

Trust Income Statement – Income

7

Commentary

• The Trust is now operating on a block contract with Dudley CCG and Walsall CCG, with the exception of C&V 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.

• Walsall activity is currently over-performing against Inpatients, CRS and EAS, however, the contract includes a ‘cap and collar’ arrangement of £500k a year which limits the impact of any over/under-performance to £43k per month. Thus the chargeable activity for Month 04 is £171k, despite out-performing this cap (true over-performance is £330k).

• Dudley contract is under-performing at Month 04 by £230k on the traditional currency method – this is due to low Inpatient activity within Older Adults (circa £307k) and Acute (circa £105k) offset by over-performance on EI. However, as we are on a block arrangement there is no adverse financial impact in year.

• NCA’s reflect an over-performance to date.

• In patient detox service at Bushey Fields is currently £26k adrift against the expected activity levels to date.

• CIP of £703k has been applied to activity which means a required over-performance of £59k each month in order to deliver the target.

• Overall the Trust is ahead of plan at Month 04 against it’s contracted income.


2016/17 Plan Actual Variance Plan Actual Variance Var

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

Revenue From NHS Activities

Dudley CCG 28,350 2,363 2,363 (0) 9,457 9,457 0 0

Walsall CCG 27,196 2,266 2,309 43 9,069 9,240 171 500

NHS Walsall 0 0 0 0 0 0 0 0

Sandwell & West Birmingham CCG 2,043 170 170 0 681 681 0 0

Wolverhampton CCG 289 24 25 1 96 97 1 0

Birmingham Cross City CCG 543 45 46 1 181 182 0 0

Birmingham South Central CCG 27 2 2 0 9 26 17 50

South East Staffs & Seisdon CCG 128 11 11 (0) 43 43 0 0

Stafford & Surrounds & E Staffs CCGs 8 1 1 1 3 3 1 0

Cannock Chase CCG 101 8 8 0 34 34 (0) 0

Total Staffs CCGs 237 20 20 1 79 80 1 0

Redditch & Bromsgrove CCG 17 1 2 0 6 7 1 0

Wyre Forrest CCG 33 3 3 0 11 11 (0) 0

NHS South Worcester CCG 2 0 0 0 1 1 1 0

Total Worcester CCGs 51 4 5 1 17 19 2 0

NCA - Adult Neuro 22 7 5 (2) 15 18 3 10

Income - DoH 500 167 167 0 167 167 0 0

Income Generation CIP 703 59 0 (59) 234 0 (234) (703)

NCAs 242 20 41 20 81 158 77 150

CAMHs Deaf 1,384 115 115 0 461 461 0 0

Total NHS Revenue-Activities 61,586 5,263 5,268 5 20,548 20,585 38 7

Revenue - Local Authorities

Walsall MBC 0 0 0 (0) 0 0 (0) 0

Dudley MBC 102 9 9 0 34 34 0 0

Sandwell MBC 0 0 0 0 0 0 0 0

Wolverhampton MBC 0 0 0 0 0 0 0 0

Stafford MBC 0 0 0 0 0 0 0 0

Detox Beds 183 15 16 0 61 35 (26) (80)

Dudley CRI 0 0 0 0 0 0 0 0

NCA - Other HC 0 0 0 0 0 (6) (6) (10)

Total Revenue from LAs 286 24 24 1 95 63 (32) (90)

Total Revenue from Activies 61,872 5,286 5,292 6 20,643 20,649 6 (83)

Trust Income & Expenditure Statement - Corporate Functions

8

Commentary

• Corporate CEO – Slippage against the new Liaison and Diversion whilst the service gets fully established. Anticipating that this area will support anticipated overspends generated by CEO/PA/Non Exec areas. Accrued costs from Disaster recovery (Bounceback) in month (27k).

• Corporate Affairs – Non-recurrent slippage against Business Development is currently offsetting the impact of the CDW reductions in funding from commissioners along with anticipated overspend generated by trust legal costs.

• Corporate HR have been prudent and not started using LDA funds until confirmation of the allocation takes place (hence the slippage). Anticipating remaining CIP to be made on a non recurrent basis.

• Corporate Medical – Slippage generated against the DGOH contract (Pathology/Radiology/Dietetics) – potential CIP opportunity (further investigation needed)…forecast assumes no CIP taken until a decision is made.

• Corporate Estates – Estates position has deteriorated in month due to additional Water Maintenance (£69k) costs along with the premium of using Agency within the service both in management and operational support.

• Corporate Operations – R&D, Compliance/Safety and Operations Directorate are helping the overall position through vacancy slippage. This is offset by one off tax costs relating to student/trainee posts funded through the LDA.

• Corporate Finance – Graduate Scheme costs have been incurred (£35k) of which we are investigating further.

• Corporate IT – General NonPay slippage and DGOH contract slippage has offset cost pressure against the usage of STALIS and agency usage within the IT Department. Further work is still to be done to review the broadband/line rental usage across the trust.

Annual

Plan In Month Year to Date FOT M04

2016/17 Plan Actual Varian

ce Plan Actual Varianc

e Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Corporate Functions Chief Executive (826) (69) (77) (7) (276) (186) 90 44

Corporate Affairs (512) (46) (39) 7 (173) (165) 8 20 Corporate Human Resources &

Dev. & People (1,286) (108) (93) 14 (431) (388) 43 13 Corporate Medical (1,187) (99) (93) 6 (396) (372) 24 87 Corporate Estates (1,332) (111) (181) (70) (442) (565) (124) (278)

Corporate Operations (3,581) (297) (253) 44 (1,194) (1,025) 169 204 Corporate Finance (1,145) (98) (120) (21) (394) (411) (17) (25)

Corporate Performance & IT (2,970) (247) (220) 27 (995) (967) 28 64 Total Corporate Functions (12,840) (1,075) (1,076) (1) (4,300) (4,080) 221 129

Trust Income & Expenditure Statement - Operational Services

9

Commentary

• Acute & Older Adult services underspent by £77k in July, due to management, psychology, Access and Older Adults Community vacancy savings. The overspend against inpatient staffing budgets was negligible this month, compared to an average monthly overspend of £78k in Quarter 1.

• Medical services underspent by £17k in-month, as training budgets are not committed in equal twelfths across the year, and due to fluctuations in monthly drugs costs.

• Community Estates – Changes in rates/rates from the previous year have contributed towards the overspend so far. An analysis has been produced for review of these inflationary pressures.

• Community Management – CIP achievement of targets needs to be reviewed as some schemes may have changed in nature. Currently this is offset by non-recurrent means on Comm. Mgmt Team which is temporary in nature.

• Community continues to generate an underspend led by the PTH/CRS group (£98k) through vacancy slippage. Walsall Employment Support position is expected to be overspent by year end due to the slippage of the Manager now finishing. This could be mitigated by new projects coming on line in 2016/17 (update will be provided once further information is available).

• Early Intervention – Recruitment to the additional £180k within EI has been slow and further slippage is expected. This will support pressures across the other service lines such as Primary Care where IAPT reporting changes nationally means additional costs will be incurred. CAMHS still have a high agency usage which is offset by slippage generated by new CAMHS money in year. This is expected to slow as people come into post.


2016/17 Plan Actual Variance Plan Actual Variance Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Operational Services

Acute and Older Adults

Acute Access (3,476) (296) (277) 19 (1,190) (1,139) 51 (3) Management and Administration (969) (80) (53) 27 (321) (200) 121 247

Acute Services (5,591) (466) (455) 11 (1,867) (1,975) (108) (218) Acute Estates (2,662) (214) (206) 8 (871) (859) 13 (1) Older Adults (6,868) (572) (560) 12 (2,290) (2,350) (60) (279)

Total Acute & Older Adults (19,566) (1,628) (1,550) 78 (6,539) (6,522) 17 (254)

Community Services

Community Estates (678) (56) (59) (2) (226) (237) (11) (33) Management and Administration 16 4 (3) (7) (14) (31) (16) (157) Community Services & Recovery (5,185) (472) (461) 11 (1,737) (1,622) 115 153

Early Intervention (8,640) (688) (694) (6) (2,926) (2,873) 53 (158) Recovery Services 0 0 0 0 0 0 0 0

Total Community Services (14,486) (1,213) (1,218) (5) (4,903) (4,762) 141 (195)

Medical Services (12,091) (999) (982) 17 (3,971) (3,926) 45 0

Total Operating Services (46,143) (3,840) (3,751) 90 (15,413) (15,210) 202 (449)

10

Cost Improvement Programme

Commentary

• Target for 2016/17 = £2,500k.

• Trust has identified schemes for the year which could deliver £2,664k FYE.

• As at month 04 £2,085k of the schemes had been devolved to appropriate budget areas and £579k were being managed centrally in reserves.

• Of those devolved schemes £1,530k have been transacted to date.

• As at month 04 a forward look of the schemes in terms of progress/action/planning would suggest that there are several schemes still at risk of non-delivery. These have been highlighted in the table opposite under the ‘FOT (slippage)’ column and currently equate to £1,363k of risk. These schemes either need to be progressed at pace or mitigating plans put forward in order to ensure the annual target is delivered.

• Of these schemes it can be seen that they are being covered by non-recurrent slippages within the overall finance position. The two income schemes totalling £703k are being covered by over-performance on the Walsall contract and additional NCA income to date.

• Those schemes flagged as Amber currently have mitigation plans being worked up with a view to fully deliver against target, and will reduce the FOT Slippage value accordingly.

Annual Schemes Schemes Transacted to Date Cost Improvement Programmes (by

POD) Ref Plan Devolved Held

Centrally Recurrently Non-Rec Variance FOT Current

RAG £ £ £ £ £ £ (slippage)

Estates - Postage CIP001 10,000 10,000 0 0 0 10,000 -10,000 Acute - Phlebotomy CIP002 12,000 12,000 0 0 0 12,000 -12,000 Acute - Wrekin Option 4 CIP003 400,000 400,000 0 0 0 400,000 -400,000 Community - Walsall CRS CIP004 111,810 93,175 18,635 0 0 111,810 -27,953 Community - Employment Support CIP005 69,584 52,191 17,393 0 0 69,584 -69,584 OA - Dementia Beds CIP006 303,000 303,000 0 0 0 303,000 -303,000 OA - Day Hosp Reconfiguration CIP007 40,800 0 40,800 0 0 40,800 -40,800 OA - Establishment Review CIP008 77,500 0 77,500 0 0 77,500 -77,500 EIA - Developments CIP009 179,680 179,680 0 103,800 9,200 66,680 -60,180 Medics - Establishment Review CIP010 350,000 0 350,000 0 0 350,000 -350,000 CEO - Admin Review CIP011 10,734 5,367 5,367 0 0 10,734 - CEO - Emergency Planning CIP012 10,000 10,000 0 0 10,000 0 - CEO - Office Furniture CIP013 5,000 5,000 0 5,000 0 0 - W&D - Library CIP014 1,531 1,531 0 0 1,531 0 - W&D - NonPay CIP015 8,000 8,000 0 8,000 0 0 - Corp Dev - NonPay CIP016 10,000 10,000 0 0 10,000 0 - W&D - Payroll CIP017 24,000 12,000 12,000 0 0 24,000 -11,982 Finance - Pay & NonPay CIP018 38,500 31,540 6,960 21,840 12,500 4,160 - CEO - PMO CIP019 33,583 33,583 0 33,583 0 0 - IM&T - Subject Access CIP020 2,400 2,400 0 2,400 0 0 - IM&T - Establishment Review CIP021 40,659 40,659 0 40,659 0 0 - Corporate - NI Savings CIP022 90,000 90,000 0 90,000 0 0 - Corporate - Savings (NP Inflation) CIP023 125,000 125,000 0 125,000 0 0 - Corporate - Incremental Drift CIP024 350,000 350,000 0 350,000 0 0 - Corporate - Reduction in Trust Surplus CIP025 250,000 250,000 0 250,000 0 0 - Psych Liaison Overheads CIP026 24,636 24,636 0 24,636 0 0 - MH Urgent Care Overheads CIP027 35,499 35,499 0 35,499 0 0 - Procurement CIP028 50,000 0 50,000 0 0 50,000 - Total CIPs 2,663,916 2,085,261 578,655 1,090,417 43,231 1,530,268 -1,362,999 Annual Target 16/17 2,500,000 Excess of Schemes Above Plan 163,916

Capital Programme

11

Commentary

• Capital expenditure remains minimal YTD with very little expenditure incurred other than in respect of the large IT schemes approved in 2015/16 and slipped due to the Capital to Revenue Transfer in the old year

12

Commentary

• The Trust is monitored by NHS Improvement each month in order to demonstrate Financial Sustainability through the calculation of four metrics: Capital Service Capacity (Revenue available for Debt service and or Capital service), Liquidity (Cash for Liquidity relative to turnover), I&E Margin and I&E Margin Variance from Plan.

• For 2016/17 the Trust Plan is a Financial Sustainability Risk Rating of 4. For Month 04 the Trust is reporting a rating of 4 in line with plan.

• Individually the metrics for the current month reflect:

• Liquidity Ratio score for Month 04 is 4 based on the number of days. This score is in line with forecast.

• The Capital Servicing Capacity score for Month 04 is 5. A score of 2.5 or above will deliver a metric score of 4 and the Trust has achieved a score of 4.

• The Trust is reporting an I&E Margin ratio of 0.3. A score of 1.0 or higher gives a maximum metric score of 4.

• In terms of I&E Margin Variance from Plan the Trust is reporting a ratio of 4 in Month 04. A score of (1.0) or above gives a metric score of 3, whilst above 0 gives a score of the maximum of 4.

• The four metrics are therefore combined to give a combined metric score of 4 for the period.

Financial Performance Metrics

Liquidity Ratio Days 25% weighting value 0 -7 -14 <-14

score 4 3 2 1

Capital Servicing Capacity 25% weighting value 2.5 1.75 1.25 <1.25

score 4 3 2 1

I&E Margin 25% weighting value 1 0 -1 <=-1

score 4 3 2 1

I&E Margin Variance from Plan 25% weighting value 0 -1 -2 <=-2

score 4 3 2 1

subcode Plan Actual Plan Actual Plan Actual Plan Actual

Liquidity Ratio Days 373 59 58 60 60 60 61 57 62Liquidity Ratio Metric 374 4 4 4 4 4 4 4 4

Capital Servicing Capacity 377 3 3 4 3 5 5 5 5Capital Servicing Metric 378 4 4 4 4 4 4 4 4Continuity of Services Risk Rating 379 4 4 4 4

I&E Margin 425 0.9 1.1 1.6 1.8 1.9 2.2 2.7 2.6I&E Margin Rating 430 3 4 4 1 4 4 4 4

I&E Margin Variance 435 1.1 0.2 1.1 0.3 1.1 0.3 1.1 -0.1I&E Margin Variance from Plan Rating 440 4 4 4 4 4 4 4 3

Financial Sustainability Risk Rating 465 4 4 4 4 4 4 4 4

M02 M03 Forecast OutturnM04

NHS Improvement – Agency Expenditure Cap 16/17

Commentary

• 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 Month 4 the Trust is £24k behind plan in terms of anticipated agency spend (£1,770k spend against £1,746k plan).

• The Trust continues to monitor the use of agencies to ensure that only framework approved suppliers are in place and is implementing strict controls around the use of agency to ensure that the target is delivered as afar as possible.

13

Agency Analysis (TFR 3) 2016-17

ACTUALS (£000's) Expenditure In Month as at Agency Staffing Mth 1 Mth 2 Mth 3 Mth 4 Mth 5 Mth 6 Mth 7 Mth 8 Mth 9 Mth 10 Mth 11 Mth 12

Qualified Nursing £114 £144 £128 £107 £0 £0 £0 £0 £0 £0 £0 £0 Medical £101 £95 £107 £86 £0 £0 £0 £0 £0 £0 £0 £0 Other (Incl. Admin, Estates, HCA's , AHP's) £255 £283 £195 £154 £0 £0 £0 £0 £0 £0 £0 £0

Total Agency Staffing £470 £523 £430 £347 £0 £0 £0 £0 £0 £0 £0 £0

Total Employee Benefits Total Staffing Costs (Substantive + Agency + Bank) £4,058 £4,237 £3,991 £4,057 £0 £0 £0 £0 £0 £0 £0 £0

Agency £ as % of Total Staffing (incl Agency) £ 11.59% 12.34% 10.76% 8.54%

Cumulative Position 11.59% 11.97% 11.58% 10.83%

of which, relate to 'pilot' schemes (backfill agency costs circa):

MH Urgent Care Centre £12 £12 £12 £12 Street Triage £10 £10 £10 £10 CAMHs Tier 3+ £25 £27 £26 £23

£47 £49 £48 £45

PLAN (£000's) Expenditure In Month as at Agency Staffing Mth 1 Mth 2 Mth 3 Mth 4 Mth 5 Mth 6 Mth 7 Mth 8 Mth 9 Mth 10 Mth 11 Mth 12

Qualified Nursing £160 £155 £150 £145 £140 £105 £105 £105 £105 £105 £105 £105 Medical £90 £90 £90 £90 £90 £90 £90 £90 £88 £88 £87 £87 Other (Incl. Admin, Estates, HCA's , AHP's) £257 £243 £180 £96 £96 £89 £89 £89 £89 £89 £89 £89

Total Agency Staffing £507 £488 £420 £331 £326 £284 £284 £284 £282 £282 £281 £281

Total Employee Benefits Total Staffing Costs (Substantive + Agency + Bank) £4,122 £4,160 £4,173 £4,136 £4,135 £4,125 £4,125 £4,124 £4,123 £4,126 £4,119 £4,122

Agency £ as % of Total Staffing (incl Agency) £ 12.30% 11.73% 10.06% 8.00% 7.88% 6.88% 6.88% 6.89% 6.84% 6.83% 6.82% 6.82%

Cumulative Position 12.30% 12.01% 11.36% 10.52% 10.00% 9.48% 9.11% 8.83% 8.61% 8.44% 8.29% 8.17%

Agency Spend by Staff Group

Commentary

• As of Month 04 the current spending on Agency staffing equates to £1,770, which when compared to the phased plan of the £4.05m target (£1,746k YTD), means the Trust is marginally behind plan by £24k.

• Despite the fact that the Trust is marginally behind plan overall it can be noted that the level of actual spending has decreased as compared to last month (Month 03 spend was £430k compared to current month spending of £347k).

• Whilst spending around Nursing and Medics shows continuing improvements, ‘Other’ staffing still shows as the biggest area of concern.

• It must be noted however, that the planned level of spending continues to decrease over the coming months in order to ensure we deliver the £4.05m plan. The planned spend for the next two months is:

M05 (Aug) £326k

M06 (Sep) £284k

• This will be a significant challenge for the Trust.

14

In Mth (£000) YTD (£000) Plan Act Variance Plan Act Variance

Agency Staffing Qualified Nursing £145 £107 £38 £610 £493 £117 Medical £90 £86 £4 £360 £389 -£29 Other (Incl. Admin, Estates, HCA's , AHP's) £96 £154 -£58 £776 £887 -£111

£331 £347 -£16 £1,746 £1,770 -£24

Other' represented by: Unqualified Nursing £62 £372 note 1 Admin & Clerical / Maint & Works £51 £253 note 2 Scientific & Technical £41 £262 note 3

£154 £887

note 1 note 2 note 3 Malvern £9.7 Estates £103.7 Walsall CAMHs £63.3 Wrekin £18.6 E-Rostering £46.6 Pharmacy £4.8 Clent £21.2 IM&T £33.6 Dudley CAMHs £61.2 Kinver £30.5 DPH / BF Med Secs £19.8 Dudley Primary Care £61.9 Langdale £60.0 HR £12.2 Walsall Primary Care £9.0 Cedars £40.0 PA's Exec Office £10.2 PT Hub £8.8 Linden £62.0 Various (incl. £26.8 OA Malvern / OT / £36.5 Ambleside £59.6 Primary Care / Mgmt Holyrood £70.8 CAMHs / SED) Adult In-Pats £16.0

£372.4 £252.9 £261.5

all the above relate to Psychology staff with the exception of Pharmacy

Cash Flow Statement

15

Commentary

Cash Flow • The Trust has made an operating deficit of £15,709k in

2016/17, received cash of £576k in respect of depreciation and amortisation and £16,475k of the operating deficit related to fixed asset impairments in the period

• 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 £14k of interest, and spent £402k on capital (£321k on reducing capital payables from the 2015/16 year end and £81k 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 YTD by £31k.

Payables Performance & Aged Debt

16

Commentary on Payables

Better Payment Practice Code • The Trust has achieved the required target for NHS invoices by number and value in the

current month.

• However, It has fallen short in terms of Non-NHS invoices being paid within 30 days by both number and by value, in month and Year To Date and also in NHS invoices Year To Date.

• Performance in April 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 • 24.2% of debt was aged 90 days or older at the end of July (this figure was 42.5% at

the end of the previous month).

• Debt between 91-120 days (totalling £10k) relates in the main to:

• Walsall Healthcare Psychiatric Liaison Medical costs £9.9k

• Debt over 120 days old (totalling £219k) relates in the main to:

• 15/16 CQUIN with Dudley CCG £161.8k

• Overspill beds recharge with Wolverhampton CCG of £10.8k

• Barnet CCG re NCAs of £10.5k

• Walsall MBC £22.8k re salary recharges

Number ValueNon-NHS <75% 75% - 95% >95%Mth 01 77.21% 85.73%Mth 02 88.12% 93.99%Mth 03 85.97% 94.05%Mth 04 80.78% 93.24%Non-NHS YTD 82.38% 90.80%

NHS <75% 75% - 95% >95%Mth 01 91.23% 85.40%Mth 02 92.86% 89.71%Mth 03 95.24% 98.47%Mth 04 100.00% 100.00%NHS YTD 93.98% 92.14%

Better Payment Practice Code

Agreed Tolerances Transactions by

Current 31-60 days 61-90 days 91-120 days 121+ days Total£000 £000 £000 £000 £000 £000£607 £46 £63 £10 £219 £945

Value % of TotalAgreed Tolerances £000 Debt

Over 91 days >20% 10% - 20% <10% £229 24.2%Over 120 days >10% 5% - 10% <5% £219 23.2%

Debt Profile and Value

Aged Debt

64.2%

4.9%

6.7%

1.1% 23.2%

Aged Debt as of July 2016

Current 31-60 days 61-90 days 91-120 days 120+ days

Statement of Financial Position

17

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 Trust’s Land and Building assets have been revalued on a MEA basis in the month resulting in an additional reduction in their value of £19.645m

• Final outturn against capital schemes is reviewed elsewhere in this report

Current Assets • Receivables have increased by £903k in 2016/17

• Cash is £31k higher than the balance at 31 March 2016, an increase in cash is expected in the first 6 months of the year as PDC is paid six monthly

• An analysis of cash flows can be seen elsewhere in this report

Current Liabilities • Payables have increased by just £2k in the financial year.

• There has been a £53k decrease in provisions in the year to date

Tax Payers’ Equity

• The Current Year I&E figure reflects the surplus for the year to date of £492k, offset against the I&E impairment of Land and Building assets of £16.474m.

• The Revaluation Reserve has decreased by £3.171m as a result of the Land and Building valuation.

1 1 1

Contract Performance Month 4 2016/17

2

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%)

97% 98% 95%

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%)

95.8% 93.9% 97.1%

3Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS (Target: Above 99%)

99.9% 100% 100%

4Completion of Mental Health Minimum Data Set ethnicity coding for all detained and informal Service Users. (Target: Above 90%)

91.2% 97.2% 92.5%

5Completion of IAPT Minimum Data Set outcome data for all appropriate Service Users. (Target: Above 90%)

99.3% 100% 97.9%

6 Delayed Transfer of Care (All Reasons). (Target: Below 7.5%) 1.5% 1.5% 1.3%

7aIAPT - Proportion of people who complete treatment who are moving to recovery. (Target Dudley: Above 50%)

N/A TBC N/A N/A TBC N/A

7bIAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50%)

N/A N/A TBC N/A N/A TBC

8aIAPT - number of people who receive psychological therapies. (Target Dudley: 5108 pa; 426 per month)

N/A TBC N/A N/A TBC N/A

8bIAPT - number of people who receive psychological therapies. (Target Walsall: 4328 pa; 361 per month)

N/A N/A TBC N/A N/A TBC

9 Percentage of patients who are provided a copy of their care plan. Target: Above 95%) 95.2% 95.1% 95.5%

10Number of home treatment episodes by crisis teams. (Target Walsall only: 608 pa; 51 per month)

N/A N/A 59 N/A N/A

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%)

75% 75% 75%

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%)

TBC TBC TBC TBC TBC TBC

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%)

TBC TBC TBC TBC TBC TBC

14The proportion of users on CPA who have had a review within the last 12 months. (Target: Above 95%)

95.6% 95.7% 95.8%

15The proportion of users on CPA with a crisis plan in place. (Target: Walsall Only: Q1 - no target; Q2 - 75%; Q3 - 85%; Q4 - 95%)

N/A N/A 95.7% N/A N/A

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))

N/A 85.0% N/A N/A N/A

17 Proportion of in-scope patients assigned to a cluster. (Target: Above 95%) 93.6% 94.7% 94.3%

18Proportion of patients within cluster review periods. (Target: (Dudley Q1 - 70%; Q2 - 80%; Q3 - 90%; Q4 - 95%); (Walsall Q1 - 70%; Q2 - 76.5%; Q3 - 83%; Q4 - 90%))

N/A 71.7% 68.2% N/A

19 Sleeping Accommodation Breach 0 0 0

20 Duty of Candour --- --- ---

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

22 IAPT DNA Rate (Target Walsall Only: Below 13.1%) N/A N/A TBC N/A N/A TBC

23Memory Assessment Service - Face to face initial assessment to be made within 20 days (Target Walsall Only: Above 95%)

N/A N/A 98.0% N/A N/A

24Dudley and Walsall Recovery Outcome Measure - Number of CPA patients assessed using DWROM (Target Dudley Only: Q1 - 65%; Q2 - 75%; Q3 - 85%; Q4 - 95%)

N/A 66.0% N/A N/A N/A

Performance Dashboard Trust Board 7 September 2016

Quality and Safety Domain • The trust reported 346 incidents for the month of July. 197 were Patient Safety Incidents, and non of these incidents were considered for Duty of

Candour Criteria. The Trust reported 3 Serious incidents during the month of July, 2 linked to Acute Services and 1 linked to Early Intervention. 1 was an under 18 admission onto an adult acute ward and 2 were Attempted Suicides.

• CPA Copies of Care Plan – the Trust is above the 95% threshold at 95.2% at Month 4 2016/17. Efficiency Domain • Activity against contract (NHS Activity) – NHS contracted activity remains above the target as at month four. In July, the Trust is reporting 111,556 units of

activity against a target of 108,003. Activity against contract is above target for all service lines. Resources Domain

• The Trust’s Cost Improvement Target for the year is £2,500k and schemes have been developed for the year equating to £2,663k. The anticipated delivery of schemes taking into account the PYE of schemes starting later in the year is £2,555k which is ahead of the required target.

• At month four £1,134k worth of CIP schemes have been transacted and delivered however there are three schemes (OA Day Hospital / OA Establishment Review and Medics Establishment Review, totalling £468.3k that have yet to be 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.

• Of the residual value of CIPs yet to be delivered the three un-devolved schemes and the Income schemes mentioned above relate to circa. 76% and remain at a high risk on non-achievement. Delivery of the full CIP target is key in achieving the financial plan for the year.

• Vacancies – There are currently 186 FTE contracted vacancies giving the Trust a vacancy rate of 16.7%. Contracted vacancies across the Trust have

reduced from 198 FTE in July 15. • Turnover – The 12 Month Turnover rate has decreased slightly from 12.47% to 12.12%. This is within the Trusts targeted range and when benchmarked

against other MH Trusts a comparable figure. • Sickness Absence – The 12 month rolling sickness rate has increased from 4.91% in Month 3 to 4.95% reported in Month 4. This is the fourth month of

consecutive increases in the rolling sickness absence rate. In month sickness has increased from 4.94% in Month 3 to 5.31% in Month 4. • Appraisal – Compliance has increased from 69.8% to 71.2%, this is still below Trust target. This has reduced from 87% in Oct-15. There are 258 employees

in the Trust that haven't had an appraisal recorded in the last 12 months. Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements.

• Mandatory Training - Mandatory Training compliance has increased from 81.4% in Month 3 to 84.15% in Month 4 but remains below the new target of 90% agreed at MEXT for all mandatory training (IG remains at 95%) as of 1st April 2016. As with the Appraisals, new reports are 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.

Trust Level Integrated Dashboard – Commentary

Service Line Summary • Acute Services sickness in-month has increased to 6.13% in month four (5.37%

reported in month three). 12 month sickness has slightly decreased to 6.63% as at July 2016 (6.86% reported in month three). This remains below Target for the 12 month rolling picture due to performance throughout the year and will continue to be monitored.

• Performance for Mandatory Training has increased to 85.67% in month four (75.9% in month three).

• Appraisal performance has slightly increased from 60.19% in month three to 62.16% in month four, therefore this 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.

• This service line overspent by £57k to month 04. The current month position has improved with greater controls on agency usage. The main pressure area remains within Acute ward staffing (£138k overspent YTD), but is being partially offset by various non-ward vacancy savings (psychology and management posts), and non pay savings.

Service Line Summary • Community Services and Recovery in month sickness has increased in

month four to 5.06% (4.10% in month three). • Mandatory training has increased to 81.96% in month four (79.93%

reported in month three). • Appraisals – this service has increased performance to 66.97% in month

four (60.38% reported in June). New reports are in development which will be sent to managers to facilitate planning of appraisals during 2016/17.

• Community & Recovery Services position at month 04 is £87k underspent. The underspend continues to be driven by vacancies within the Psychological Therapy Hub and CRS.

Service Line Summary • Early Intervention sickness has seen a slight increase to 5.53% in month four (5.49%

in month three). The 12 month sickness has slightly increased to 4.68% as at month 4.

• Mandatory training has slightly increased from 87.58% in month three to 87.80% in month four.

• There has been an increase in performance for Appraisals from 85.90% in month three to 89.57% in month four. New reports are in development which will be sent to managers to facilitate planning of appraisals during 2016/17.

• This service line is underspent by £53k as of month 04, again in the main due to a number of vacancies following allocation of funds from commissioners.

Service Line Summary • Copies of Care Plan is below the 95% threshold and Head of Service is reviewing the

reported exceptions with the clinical Teams (Month 4 - 93.5%; Month 3 – 91.4%). • Formal Reviews – month 4 has seen a decrease in Performance from 94.4% in June

to 92% for July. • Older Adults sickness has increased from 6.90% in month three to 7.64% in month

four. The 12 month sickness has slightly increased from 5.36% in month three to 5.49% in month four, this service remains below Target for both sickness indicators and will continue to be monitored.

• There has been a slight increase in performance for appraisals from 63.23% in month three to 64.20% in month four 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.

• Mandatory training remains below the 90% target at 76.04% (76.75% reported in month three).

• This service line is overspent by £60k in month 04 which is primarily due to an overspend on staffing within OA ward staffing. In-Patient budgets are currently overspent by £108k to date.

Enc 14 CIP report August 16 v1 Page 1 of 12


Agenda Item number: 8.1.2e

Enclosure: 14

Report Title:

Cost Improvement Programme (CIP) Progress Report


Rupert Davies, Interim Director of Finance


Jacky O’Sullivan, Clinical Development Director

Purpose of the report: To present to the Board a summary of the current status of the Cost

Improvement Programme for 2016/17 Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: MExT

Date reviewed: 16th August 2016 Key points or recommendations from Committee:

None




Leadership culture






Caring

Plans use evidence based practice to ensure improvements in quality, outcomes and patient experience.

Responsive

Plans are developed to ensure responsiveness to service user needs.

Effective

Plans represent best value to ensure CIP plans are met through efficiency and effectiveness

Well-led

All transformational and service development plans have a project team approach to both development and implementation.

Safe

All plans are assessed for the need for a Quality Impact Assessment and where indicated a full assessment including risks and mitigations is undertaken and monitored.


CIP ideas brainstormed and scoped by Management Executive Team (MExT) and wider

Yes

Idea developed and presented to MExT MExT approve/reject

No Idea archived

Project 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

parameters: • High Quality Services • Inclusive Partnerships • Supporting Strategies • Effective & Efficient Resources • Leadership Culture • Responsible Workforce

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


Title Cost Improvement Programme (CIP) Progress Report

Introduction The purpose of this report is to present to the Board the summary of the current status of the Cost Improvement Programme for 2016/17. Summary of key points, issues and risks 1.0 CIP 2015/16 There were 32 projects in 2015/16 of which 30 were delivered and closed down. 2 schemes have been carried over into 2016/17 at the request of the Executive Sponsor: POD085 Catering Review POD088 Corporate Clinical Leadership Structures

These schemes have delivered savings; however they are being monitored for any negative impact, and will be reassessed for closure in quarter 2. 2.0 CIP 2016/17 £ £

• Target for 2016/17 2,500,000 • Original projects in total (full year effect) 2,663,916

o CIP005 Employment Support – scheme closed -69,854 o CIP009 Early Intervention (£179,680 plan overstated by) -7,200

• Projects in total (full year effect) 2,587,132 • Variance 87,132

The majority of CIP targets are devolved down to team budgets so any slippage is managed at team level, however the 3 schemes still awaiting sign off and the procurement and tendering scheme are still held centrally. A full list of projects can be found in appendix 1 and 2. There are also 4 schemes that will deliver savings non-recurrently; these are listed in appendix 3. There are 28 projects for the current year, of which 3 are under review and subject to approval prior to implementation, these schemes are: Redesign of Day Opportunities (£40,800) Older Adults Establishment Review (£77,500) Medical Services Establishment Review (£350,000)

The first two schemes, whilst covering both boroughs, also link to Walsall CCG’s Quality, Innovation, Productivity and Prevention (QIPP) schemes, and the OIder Adult service model. Planning has begun for this in Walsall and the draft QIA and risk log should be finalised early September for presentation to MExT and the Board. The Older Adult model in Dudley is subject to the development of a business case which is now being progressed for presentation to MExT in September. Of the 28 projects for the current year, 1 has been closed and 12 have delivered, these are listed in appendix 1


It can be seen in appendix 2 that there are 8 schemes with an overall project status of red. The projects are: Postage Walsall Community Recovery Service (CRS) activity and staff establishment Older Adults Inpatient beds (Dementia) Redesign of Day Opportunities Older Adults Establishment Review Medical Services Establishment Review Payroll Performance & IM&T Establishment Changes

Postage (value £10,000) The project is RAG rated red as savings have not been identified. The scheme is being monitored. Savings from waste management is being explored as an alternative scheme. Walsall CRS activity and staff establishment (value £111,810) The project is RAG rated red due to the finance. The scheme links to the Walsall Rehab QIPP scheme which is being progressed. Older Adults Inpatient beds (Dementia) (value £303,000) The scheme has identified red risks, and the finance is RAG rated red. The scheme has been progressed and pathways have been developed. It is anticipated to go live at the end of September in Dudley. Redesign of Day Opportunities (value £40,800) The scheme is pending approval which is subject to commissioning intentions in Dudley and agreement of timelines and the QIA in Walsall, both of which are being progressed. Older Adults Establishment Review (value £77,500) The scheme is pending approval and is subject to the same issues as the scheme above. Medical Services Establishment Review (value £350,000) The scheme is pending approval. A paper will be presented to the CIP Programme Board in September. Payroll (value £24,000) The scheme will not deliver recurrent CIP savings this financial year. The part year CIP target could be met non recurrently which is being explored. Performance & IM&T Establishment Changes (value £40,659) The scheme has red risks which will be monitored. The CIP has been transacted. The CIP Programme Board will be monitoring and tracking the progress of these red rated schemes to report risks, and mitigations to MExT 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 17/18 GREEN Will achieve FYE by March 17


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 No action is required.


Appendix 1 – 2016/17 CIP schemes Closed / Delivered Projects Division / Type Ref Project Title Value (£) Status Operations / Transformational CIP005-16 Employment Support Services Review

0 Closed

Corporate / Transactional CIP012-16 Healthcare Emergency Planning

10,000 Delivered

Corporate / Transactional CIP013-16 Office Furniture

5,000 Delivered

Corporate / Transactional CIP014-16 Library Services

1,531 Delivered

Corporate / Transactional CIP015-16 People & Workforce Development Non Pay

8,000 Delivered

Corporate / Transactional CIP016-16 Corporate Development Non Pay Savings

10,000 Delivered

Corporate / Transformational CIP020-16 Subject Access Requests

2,400 Delivered

Corporate / Transactional CIP022-16 Planned National Insurance Savings

90,000 Delivered

Corporate / Transactional CIP023-16 Corporate Savings

125,000 Delivered

Corporate / Transactional CIP024-16 Incremental Drift

350,000 Delivered

Corporate / Transactional CIP025-16 Reduction in Planned Surplus

250,000 Delivered

Corporate / Transactional CIP026-16 Psychiatric Liaison Overheads

24,636 Delivered

Corporate / Transactional CIP027-16 MH Urgent Care Overheads

35,499 Delivered


Appendix 2 – 2016/17 CIP schemes Active Projects

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 4

RA

G

Mon

th 4

Fi

nanc

ial

Posi

tion

Fore

cast

Yea

r En

d R

AG

Fo

reca

st Y

ear

End

Posi

tion

Postage This project aims to reduce the overall spend on the postal costs going out of the Trust by £10k by increasing efficiency and utilising electronic methods of communication. The forecast year end position is red as savings have not been realised to date and an alternative scheme to deliver the CIP target is being explored. This will be explored further at the next CIP Programme Board.

Wendy Pugh

None 10,000 R A R A 0

No

impa

ct

No

impa

ct

N/A

April 16

R 0 R 0

Phlebotomy The project seeks to provide the Phlebotomy service effectively and efficiently in house, rather than buying it in. The scheme will not be progressed as originally planned but savings will still be made from the Dudley Group of Hospitals contract which will contribute to meeting this target.

Wendy Pugh

None 12,000 G

G G G 0

No

impa

ct

No

impa

ct

N/A

To be confirmed R 0 G 12,000


Acute Services Wrekin Ward

The project is an income generation scheme that aims to provide 5 acute beds on Wrekin ward to another commissioner / provider. The scheme is forecasted to achieve the CIP target, however this is dependent on having a plan in place and the scheme being progressed and monitored. There is potential for the target to be met non-recurrently from over performance on NCA and other contracts. This is currently at £167k at month 4 and work is in progress to ascertain how much of this can be attributed to this scheme.

Wendy Pugh

None 400,000 A A A A A

No

impa

ct

No

impa

ct

1. 28 days readmission 2. The Average Length of

Stay 3. 7 day follow up 4. Bed Occupancy 5. Activity against

Contract 6. Delayed transfers of

care

To be confirmed R 0 G 400,000

Walsall CRS Activity & Staff Establishment

The project is about implementing the findings from the Meridian review and therefore reducing activity and associated workforce. The scheme is linked to the QIPP Rehab service which is being progressed.

Wendy Pugh

None 111,180 R A R A A

No

impa

ct

No

impa

ct

N/A

To be confirmed R 0 A 83,857

Older Adults Inpatient Beds (Dementia)

This project is an income generation scheme to utilise existing capacity in the Dementia Wards to accommodate those patients that have a diagnosis of Dementia who are medically fit for discharge and are Delayed Transfers of Care from WMH/RHH. The scheme is being progressed in Dudley for implementation in September.

Wendy Pugh

None 303,000 R A R R R

No

impa

ct

No

impa

ct

N/A

September 16 R 0 G 303,000


Redesign of Day Opportunities

This project relates to commissioner intentions to redesign Older Adult Day Services. Savings will be realised from transport and catering. The planning is being progressed in Walsall and the QIA and risk logs finalised. A business case is being written for Dudley which will enable commissioner intentions to be clarified.

Wendy Pugh

None 40,800 R R A

No

impa

ct

No

impa

ct

N/A

Pending approval

R 0

Older Adults Establishment Review

The project is about implementing the findings from the Meridian review and therefore reducing activity and associated workforce. This links to the work for the scheme above.

Wendy Pugh

None 77,500 R A A

No

impa

ct

No

impa

ct

N/A

Pending approval

R 0

Early Intervention Service Line Interventions

This project relates to increased efficiency and productivity in the Early Intervention Service line and associated corporate services by providing a number of new service developments within existing overheads. The Head of Service has been asked for proposals to meet the shortfall.

Wendy Pugh

None 172,480 A G A A A N

o im

pact

N

o im

pact

N/A April 16 G 41,333 A 124,000


Medical Scheme Executive

Lead Links to

other projects

Value £


an

Fina

nce

Ris

ks

QIA

EIA

PI

A KPIs Implementation

Month

Mon

th 4

RA

G

Mon

th 4

Fi

nanc

ial

Posi

tion

Fore

cast

Yea

r En

d R

AG

Fo

reca

st Y

ear

End

Posi

tion

Medical Services – Establishment Review

The scheme is about increased efficiency and productivity within the medical service line. A paper will be presented to the next CIP Programme Board.

Mark Weaver /

Kate Gingell

None 350,000 R A A

No

impa

ct

No

impa

ct N/A Pending

approval R 0

Corporate Scheme Executive

Lead Links to

other projects

Value £


an

Fina

nce

Ris

ks

QIA

EIA

PI

A KPIs Implementation

Month

Mon

th 4

RA

G

Mon

th 4

Fi

nanc

ial

Posi

tion

Fore

cast

Yea

r En

d R

AG

Fo

reca

st Y

ear

End

Posi

tion

CEO Led Admin Review

This project aims to review all administration roles across the Trust, reviewing how staff could work closer together, reducing duplication across all areas. The review is now complete and recommendations are due to be discussed in September. Mark Axcell None 10,734 A

G G A A

No

impa

ct

No

impa

ct

N/A

October 16 G 0 G 5,367


Payroll This project delivers a more efficient payroll service through economies of scale and removal of the SBS contract. The original plan will not be progressed as recurrent savings will not be realised this financial year. The target could be met non recurrently, this is under review.

Marsha Ingram

None 24,000 R R R A A

No

impa

ct 9 N/A

To be confirmed R 0 A 12,018

Finance Department – Pay & Non Pay Savings

This project has identified efficiency savings in budgets across all financial services in both pay and non-pay. This project will be fully delivered in September and reviewed for closure.

Rupert Davies

None 38,500 A G G A A

No

impa

ct

No

impa

ct N/A April 16 G 11,447 G 34,340

PMO Efficiencies A review of roles within the Clinical Service Development Team has enabled the PMO facilitator post to be released for efficiencies. The scheme has delivered, however the risks are being monitored. Mark Axcell None 33,583 A G G A A

No

impa

ct

No

impa

ct N/A April 16 G 11,194 G 33,583

Performance & IM&T Establishment Changes

A review of roles with the Performance & IM&T team has released savings within the establishment to deliver this project. The scheme has delivered however the risks are being monitored.

Rupert Davies

None 40,659 R G G R A N

o im

pact

No

impa

ct N/A April 16 G 13,553 G 40,659

Procurement & Tendering

This project will develop a process for maximising best value on non-pay spends influenced by the procurement process. The CIP target will be met with savings from the estates revaluation.

Rupert Davies

None 50,000 A A A G 0

No

impa

ct

No

impa

ct N/A To be confirmed R 0 G 50,000

Key: QIA = Quality Impact Assessment, PIA = Privacy Impact Assessment, EIA = Equality Impact Assessment, KPIs = Key Performance Indicators


Appendix 3 – 2016/17 Non-Recurrent CIP schemes Division Type Project Title Exec Lead Project Lead Value (£) Delivery

Corporate Transactional Band 7 reduction Rupert Davies Mark Banks 12,500 Monthly

Corporate Transactional Liaison & Diversion Overheads Mark Axcell Jacky O’Sullivan 65,395 Monthly

Operations Transactional School Link Pilot Overheads Wendy Pugh Anne Marie Carey 4,500 Monthly

Operations Transactional Walsall Activity Wendy Pugh Paul Chamberlain 85,000

1

Workforce Report Month 4

2

Workforce Report - Contents

Item Page

Key Messages 3

Workforce Dashboard 6

Recruitment 7

Turnover 9

Sickness 10

Appraisal 13

Mandatory Training 15

3

Key Messages

Vacancies – There are currently 201.1 FTE contracted vacancies across the Trust increasing the vacancy rate to 17.8%. Contracted vacancies across the Trust have reduced from 221 Full Time Equivalent (FTE) in June 2015 There are 135 FTE posts that are currently being recruited to. However, the vacancy rate has increased in Quarter 1 as 61.9 Whole Time Equivalent (WTE) have been added to the Trusts funded establishment between April –July 2016. The Trust target vacancy rate is 10%. An agreed recruitment plan was implemented, this initially projected to achieve a vacancy rate of to 11.2% by the end of Q1 2016/17. However, the slower than planned progress in the last five months and the increase in budgeted establishment has resulted in a vacancy rate of 16.8% at the end of Q1 2016/17. Time to recruit measures and KPIs have been developed to set the expectations of recruiting managers and the recruitment team to enable the Trust to measure and improve progress in the recruitment process. As part of the workforce spotlight report a number of other actions are being implemented to improve recruitment (including a roll out of recruitment training for managers), analysis of successful advertising methodologies, analysis of reasons for starting/leaving and improved governance processes. Refreshed service recruitment plans are also being developed. The Trust is also working with it’s formal partners to look at collaborative approaches to recruitment and retention of staff, especially in ‘hard to recruit’ areas, a joint MERIT recruitment event has been planned for 12th November 2016. Turnover – The 12 Month Turnover rate has decreased from 12.47% to 12.1%. When comparing the Turnover (excluding Junior Doctors) 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. Also it was found that when comparing 3 other local MH trusts, DWMH had a lower Turnover rate than 2 of them.

4

Key Messages

Sickness Absence – The 12 month rolling sickness rate has increased from 4.91% in Month 3 to 4.95% reported in Month 4. 12 month sickness was 4.93% in July 2015 and up until Month 4 sickness had seen a reduction overall across the year. However, sickness now remains fairly static when compared with last year. In month sickness has increased from 4.94% in Month 3 to 5.31% in Month 4. Actions already being taken to manage and reduce sickness absence include the revision and publication of new policy templates to support managers; increased HR input into monitoring of progress with long term sickness cases; introduction of a staff health and well being strategy and associated implementation plan. Future actions include development and roll-out of bespoke sickness absence management training for managers; introduction of KPI’s for the Trust to adhere to in terms of Occupational Health referrals for staff who have been absent or continue to be absent to ensure earlier intervention with sickness absence management cases; promoting the benefits of conducting return to work interviews and devising a system for recording and monitoring of compliance, devising reports to assist managers with identifying when staff have hit triggers; and developing a programme of well-being initiatives as part of a national CQUIN scheme for 2016/17. Appraisal – Compliance has increased from 69.8% to 71.2%, this is still below Trust target. This has reduced from 87% in October 2015. There are 258 employees in the Trust that haven't had an appraisal recorded in the last 12 months. The executive team are implementing focussed actions to improve compliance, including :

• Clarity of role and responsibilities for Managers • Capability and performance management, where appropriate • Continued individual level reporting to managers • Continuation of training for managers and staff • ‘Deep dive’ of individual cases where reporting shows that no appraisal has taken place during the last 3 years • Training for individuals to empower themselves to get the most out of the appraisal process • Promotion of positive experiences and value of appraisal process • Exploring options to implement protected learning time • Publish of league tables

5

Key Messages

Mandatory Training - Mandatory Training compliance has increased from 81.4% in Month 3 to 84.2% in Month 4 and remains below the new target of 90% agreed for all mandatory training (IG remains at 95%) as of 1st April 2016. Similarly to appraisals, the Trust is developing a programme of targeted work and support to increase and sustain compliance with mandatory training, including:

• Training capacity increased to achieve the new target levels • Blended training options • E-learning champions , Staff guides, Support from Library in place • Creation of monthly reports to Heads of service highlighting DNAs and place utilisation • Routine booking of new starters onto the first available Induction day in place • Exploring options to implement protected learning time • WebEx pilot • Creation of trajectory tool to plan and monitor compliance • Clarity of role and responsibilities for managers and individuals • Capability and performance management, where appropriate • Centrally allocated training places • Bulk order of SMART card readers to address current gaps • Publish DNA and place utilisation reports alongside league tables • Work through West Midlands Streamlining Project to influence IAT process (work towards training info shared prior

to start date) • Shift towards Induction as Day 1 for all new starters • Work alongside Ward Managers to expand use of MSS alongside e-rostering to plan training activity and release of

staff well in advance

6

Workforce Dashboard 445 Dudley and Walsall Mental Health Partnership NHS Trust

Staff in PostTarget Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16

Headcount 1006 1015 1013 1013 1012 1003 1015 1010 1012 1018 1018 1021Funded Establishment 1099.6 1098.7 1109.5 1111.2 1107.9 1092.6 1096.5 1094.6 1067.5 1082.9 1113.9 1129.4Staff in Post FTE (Contracted) 918.5 928.5 922.7 924.2 925.3 918.4 925.2 919.0 920.2 927.6 926.3 928.3No of Vacancies 181.1 170.2 186.8 187.0 182.6 174.2 171.2 175.6 147.3 155.3 187.6 201.1Vacancy % 10.0% 16.5% 15.5% 16.8% 16.8% 16.5% 15.9% 15.6% 16.0% 13.8% 14.3% 16.8% 17.8%Worked FTE (Substantive) 916.4 925.3 920.2 922.6 920.7 918.3 920.9 926.7 915.2 910.2 927.2 929.8Worked FTE (Temp) 204.6 205.5 184.3 178.4 158.5 166.7 187.5 188.8 193.0 58.9 174.3 138.7Worked FTE (Total) 1,121.0 1,130.8 1,104.6 1,101.0 1,079.3 1,085.0 1,108.5 1,115.5 1,108.2 969.1 1,101.4 1,068.5Turnover % (12 Months) 8-14% 17.82% 15.02% 14.56% 14.16% 14.53% 15.07% 15.10% 15.54% 14.86% 14.96% 12.47% 12.12%

Pay SpendTarget Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16

Funded £ £4.08m £4.01m £3.97m £4.18m £3.92m £4.32m £4.45m £4.28m £4.06m £4.25m £4.14m £4.30mSubstantive Spend £ £3.42m £3.44m £3.36m £3.45m £3.26m £3.32m £3.59m £3.46m £3.47m £3.56m £3.44m £3.58mTemp Spend £ £0.62m £0.68m £0.68m £0.61m £0.49m £0.78m £0.66m £0.76m £0.60m £0.68m £0.54m £0.48mTotal Pay Spend £ £4.04m £4.12m £4.03m £4.06m £3.75m £4.11m £4.25m £4.22m £4.06m £4.24m £3.98m £4.06mVaraince - Budget to Actual £ £35K -£104K -£62K £125K £170K £216K £194K £67K £K £11K £160K £245K

AbsenceTarget Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16

Sickness % (Month) 4.68% 4.74% 4.17% 5.55% 5.85% 5.56% 5.22% 5.39% 4.39% 4.49% 4.98% 4.94% 5.31%Sickness Days Lost FTE (Month) 1,344 1,154 1,581 1,622 1,590 1,485 1,440 1,254 1,233 1,427 1,373 1,531No of Sickness Episodes (Month) 143 143 204 193 151 161 158 160 139 159 148 158Cost of Sickness (Month) £113K £95K £137K £138K £138K £138K £128K £109K £104K £131K £127K £132KMaternity % (Month) 1.68% 1.68% 1.85% 1.89% 1.90% 1.80% 1.77% 1.87% 1.71% 1.53% 1.63% 1.62%Sickness % (12 Months) 4.68% 4.86% 4.80% 4.89% 4.91% 4.90% 4.90% 4.94% 4.86% 4.82% 4.85% 4.91% 4.95%Long Term Sickness % (12 Months) 65.3% 65.9% 65.9% 65.8% 66.9% 67.9% 68.0% 68.7% 67.3% 68.1% 68.7% 68.3%Cost of Sickness (12 Months) £1,316K £1,302K £1,344K £1,360K £1,366K £1,385K £1,410K £1,393K £1,386K £1,420K £1,454K £1,470K

DevelopmentTarget Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16

Appriasals Completed 645 722 727 713 703 676 645 619 600 639 606 638Appraisals Outstanding 208 126 110 135 142 172 218 251 268 219 262 258Appraisals Required 853 848 837 848 845 848 863 870 868 858 868 896Appraisal % 85% 75.6% 85.1% 86.9% 84.1% 83.2% 79.7% 74.7% 71.1% 69.1% 74.5% 69.8% 71.2%Mandatory Training % 90% 82.2% 80.7% 79.0% 79.1% 79.0% 78.9% 77.9% 80.5% 81.7% 81.9% 81.4% 84.2%Essential Skil ls Training % 90% 73.9% 74.7% 76.3% 76.4% 76.5% 78.0% 78.0% 80.7% 83.0% 83.6% 57.6% 59.5%

Jul-16

7

Recruitment

The table above shows the number of vacancies across the trust by Division/Service & Staff Group as at Month 4 46% of the 188 WTE vacancies within the Trust are Qualified Nursing positions Band 5 nurse interviews are taking place during mid August, with successful candidates to start in September-October (9 Whole Time Equivalent)

Staff GroupDivision Service Add Prof

Scientific and Technic

Additional Clinical

Services

Admin and Clerical

Allied Health Professionals

Estates and Ancillary

Medical and Dental

Nursing and Midwifery Registered

Total Vacant WTE

Corporate CAF Corporate Affairs 2.3 2.3CDP Corporate Development and People 0.0 0.0CHX Chief Executive 0.2 2.4 4.0 4.0 10.6FIN Finance 3.7 3.7HR Human Resources 0.5 0.0 0.5OPS Operations 0.9 0.0 7.3 -1.0 8.5 0.8 16.5

Medical MED Medical 0.0 -0.1 21.0 20.9

Operations ACC Access Services 0.6 1.2 0.1 15.4 17.3ACU Acute Services 0.0 12.8 0.0 30.2 43.0AOMGT Acute & Older Adults Management 0.0 4.8 0.2 0.2 5.1COM Community Services 4.4 0.6 3.9 2.8 8.4 20.0EIN Early Intervention 6.7 0.9 4.7 2.6 0.1 14.9 29.9OAS Older Adults 1.0 7.8 2.1 2.0 0.1 18.1 31.1

Total WTE 13.2 25.0 34.5 6.7 8.5 21.2 92.0 201.1% of Total Vacancies 6.6% 12.4% 17.1% 3.3% 4.2% 10.5% 45.7%

8

Recruitment

The table above shows the number of adverts placed on NHS jobs between April – July and the associated Whole Time Equivalent (WTE) by Staff Group. Pooled Band 5 Nursing adverts are not included within the above. Qualified Nursing roles have the lowest number of applications per WTE advertised (Allied Health Professionals advert excluded due single advert during period) with an average of 8. This can be seen as an indicator of the lack of supply of Qualified Nursing staff across the region/nationally.

Staff GroupNo of

advertsWTE

AdvertisedAdvert views Applications

Application to advert view rate

Applications per WTE

Avg no of days

advertisedAdditional Clinical Services 8 16.9 8883 494 5.6% 29 6Additional Professional Scientific & Technical 7 6.5 7947 88 1.1% 14 18Administrative & Clerical 16 16.4 19961 568 2.8% 35 15Allied Health Professionals 1 1.0 1624 2 0.1% 2 34Estates & Ancillary 6 11.0 6140 171 2.8% 16 11Nursing & Midwifery Registered 25 32.1 18458 268 1.5% 8 19Total 63 83.9 63013 1591 2.5% 19 16

9

Turnover

12 Month Turnover has decreased to 12.1% in Month 4 from 12.5% in Month 3. This is within the Trusts targeted range and when benchmarked against other Mental Health Trusts a comparable figure.

17.8%

15.0% 14.6% 14.2% 14.5%15.1% 15.1% 15.5%

14.9% 15.0%

12.5% 12.1%

5.0%

7.0%

9.0%

11.0%

13.0%

15.0%

17.0%

19.0%


DWMH Turnover % by Month

Target Range Turnover %

ServiceStarters FTE

(Month)Leavers FTE

(Month)Turnover %(12 Months)

445 ACC Access Services Level 3 0.0 0.8 5.6%445 ACU Acute Services Level 3 1.5 1.0 13.0%445 AOMGT Acute & Older Adults Management Level 3 1.0 0.0 7.6%445 CAF Corporate Affairs Level 3 0.0 0.8 27.1%445 CDP Corporate Development and People Level 3 0.0 0.0 0.0%445 CHX Chief Executive Level 3 0.0 0.0 43.1%445 COM Community Services Level 3 0.0 0.0 6.9%445 EIN Early Intervention Level 3 4.8 1.7 7.4%445 FIN Finance Level 3 0.0 0.0 10.3%445 HR Human Resources Level 3 0.0 0.9 34.1%445 MED Medical Level 3 0.0 0.0 11.4%445 OAS Older Adults Level 3 0.0 1.6 11.2%445 OPS Operations Level 3 2.0 0.4 25.4%445 Dudley and Walsall Mental Health Partnership NHS Trust 9.3 7.2 12.1%

Sickness

The 12 month rolling sickness rate has increased slightly to 4.95% in Month 4 from 4.91% reported in Month 3. The rolling 12 month sickness absence rate has remained relatively stable but is expected to rise in future months if the current monthly trend continues and as the Trust enters the winter months. The rise in sickness absence rates relates predominantly to an increase in the number of people off with long term sickness absence. It is important for managers to remember to notify payroll when sickness closes to avoid staff being recorded as absent when they are not. 10

445 Dudley and Walsall Mental Health Partnership NHS Trust 4.94% 5.31% 4.95%

445 MED Medical Level 3 3.35% 3.78% 4.76%445 OAS Older Adults Level 3 6.90% 7.64% 5.49%

8.38% 7.04% 4.92%445 OPS Operations Level 3

445 HR Human Resources Level 3 0.00% 0.14% 4.23%

445 COM Community Services Level 3 4.10% 5.06% 5.14%445 EIN Early Intervention Level 3445 FIN Finance Level 3

5.49%1.74%

5.53%5.12%

4.68%2.60%

445 CHX Chief Executive Level 3 1.30% 0.23% 2.90%445 CDP Corporate Development and People Level 3 0.00% 11.29% 1.83%

3.46%445 AOMGT Acute & Older Adults Management Level 3 4.50% 0.56% 2.57%

445 ACC Access Services Level 3 3.41% 3.31%

Service Jun-16 Jul-16Sickness %

(12 Months)4.75%

445 ACU Acute Services Level 3 5.37% 6.13% 6.63%

445 CAF Corporate Affairs Level 3 0.29% 0.30%

4.74%

4.17%

5.55%

5.85%

5.56%

5.22%5.39%

4.39% 4.49%

4.98% 4.94%

5.31%

3.00%

3.50%

4.00%

4.50%

5.00%

5.50%

6.00%


Sickness Absence % v Trust Target

Target Sickness % Rolling 12 month sickness

11

Sickness

Long term sickness accounts for 68% of sickness for the rolling 12 month period to June 2016. The number of open Long Term sickness cases is 32 in Month 4. The top 3 reasons for sickness based on Full Time Equivalent days lost for Month 4 were: 1. Anxiety/Stress – 315 2. Gastro problems - 175 3. Genitourinary &

Gynaecology – 130

1.1% 1.7% 2.1% 1.7% 1.4% 1.5% 2.0% 1.6%

2.87%3.08%

4.55%

3.48%3.32% 3.25%

3.53%3.38%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

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)

ST% LT%

Add ProfScientific and

Technic

AdditionalClinicalServices

Administrativeand Clerical

Allied HealthProfessionals

Estates andAncillary

Medical andDental

Nursing andMidwiferyRegistered

DWMH

Jun-16 3.93% 5.42% 1.98% 7.68% 12.74% 3.56% 6.60% 4.94%Jul-16 3.65% 7.10% 3.14% 10.49% 9.71% 4.05% 5.94% 5.31%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%Sickness Absence Comparison by Staff Group

12

Sickness

When comparing the sickness absence of the trust against other Mental Health organisations in the NHS (54 in total), it was found that the trust can be considered average in terms of % absence. Also it was found that when comparing 3 other local trusts, DWMH were better performing than 2 of them with the Trust reporting the greatest reduction in sickness absence across the period. The grey area indicates the range of sickness absence reported by MH trusts within the period.

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

5.5%

6.0%

6.5%

7.0%

7.5%

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

Rolling 12 month benchmarked sickness absence

DWMH Local Trust A Local Trust B Local Trust C National MH Trusts average

Metric May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16DWMH 5.11% 5.10% 5.03% 4.99% 4.92% 4.85% 4.91% 4.92% 4.89% 4.88% 4.94% 4.94%Lowest MH Trust % abs 2.67% 2.68% 2.69% 2.70% 2.68% 2.64% 2.64% 2.65% 2.69% 2.72% 2.74% 2.76%Highest MH Trust % abs 6.38% 6.42% 6.55% 6.72% 6.94% 7.03% 7.16% 7.19% 7.18% 7.29% 7.34% 7.42%National MH Trusts average 4.88% 4.88% 4.88% 4.87% 4.87% 4.86% 4.85% 4.83% 4.80% 4.79% 4.79% 4.78%

Appraisal

13

Appraisal compliance is tracking at 71.2% at the end of July 2016. This has reduced significantly from the high of 87% in October 2015. There are 258 employees in the Trust that haven't had an appraisal in the last 12 months.

ServiceAppraisals Required

445 ACC Access Services Level 3 67445 ACU Acute Services Level 3 111445 AOMGT Acute & Older Adults Management Level 3 24445 CAF Corporate Affairs Level 3 8445 CDP Corporate Development and People Level 3 5445 CHX Chief Executive Level 3 15445 COM Community Services Level 3 109445 EIN Early Intervention Level 3 163445 FIN Finance Level 3 35445 HR Human Resources Level 3 16445 MED Medical Level 3 87445 OAS Older Adults Level 3 162445 OPS Operations Level 3 94445 Dudley and Walsall Mental Health Partnership NHS Trust 896

58.9% 58.5%

89.6%57.1% 60.0%94.1% 100.0%

Jun-16 Jul-16

75.8% 64.2%

+/-

85.9%

100.0%93.3%

100.0%100.0%

60.2% 62.2%

69.8% 71.2%

71.1% 74.7%63.2% 64.2%

82.6% 75.0%100.0% 100.0%

60.4% 67.0%

75.6%

85.1% 86.9%84.1% 83.2%

79.7%76.1%

71.1%

76.4% 74.5%69.8% 71.2%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 jul

Appraisal % v Trust Target

Target Appraisal %

Appraisal

14

- New starters have been included within the month that equates to 9 months after their start date of employment - Junior Medical & Dental Staff have been excluded from the above figures

258

49

8672 64 55

7046 42

234

0

50

100

150

200

250

300

Non compliant Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 & onwards

Appraisal review expiry by month

Service Non compliant

Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 & onwards

445 CAF Corporate Affairs Level 3 0 0 4 0 0 1 2 1 0 1445 CDP Corporate Development and People Level 3 0 1 0 0 0 1 0 0 0 4445 CHX Chief Executive Level 3 0 0 1 0 1 3 1 1 5 3445 FIN Finance Level 3 14 4 0 2 4 0 4 3 2 5445 HR Human Resources Level 3 0 0 1 1 1 2 3 2 0 9445 OPS Operations Level 3 39 3 4 5 7 5 1 1 7 25445 MED Medical Level 3 22 6 2 10 10 4 10 12 1 23445 ACC Access Services Level 3 24 1 18 8 2 0 3 0 1 10445 ACU Acute Services Level 3 42 6 23 6 0 0 9 4 1 24445 AOMGT Acute & Older Adults Management Level 3 6 2 0 0 2 2 3 1 1 8445 COM Community Services Level 3 36 1 3 8 13 12 9 1 8 26445 EIN Early Intervention Level 3 17 10 15 19 17 19 15 15 8 61445 OAS Older Adults Level 3 58 15 15 13 7 6 10 5 8 35Monthly expiry Headcount 258 49 86 72 64 55 70 46 42 234

Mandatory Training

15

445 Dudley and Walsall Mental Health Partnership NHS Trust

Training Compliance

Competence Target Completed Required % +/- Completed Required % +/-Mandatory Training 90% 6341 7791 81.4% 6584 7824 84.2%Essential Skil ls 90% 3551 6163 57.6% 3635 6114 59.5%Combined Training % 90% 9892 13954 70.9% 10219 13938 73.3%

kMandatory Training

Competence Target Completed Required % +/- Completed Required % +/-Equality, Diversity and Human Rights 90% 789 947 83.3% 824 957 86.1%Fire Safety 90% 723 947 76.3% 788 957 82.3%Health and Safety 90% 801 947 84.6% 819 957 85.6%Infection Control (Clinical) 90% 466 659 70.7% 506 663 76.3%Infection Control (Non Clinical) 90% 247 289 85.5% 260 295 88.1%Information Governance 95% 836 947 88.3% 849 957 88.7%Moving and Handling (Foundation) 90% 828 947 87.4% 852 957 89.0%Moving and Handling (Patient Handling) 90% 115 224 51.3% 122 221 55.2%Safeguarding Adults Level 1 90% 214 260 82.3% 221 258 85.7%Safeguarding Adults Level 2 90% 553 682 81.1% 556 672 82.7%Safeguarding Children Level 1 90% 220 260 84.6% 225 258 87.2%Safeguarding Children Level 2 90% 549 682 80.5% 562 672 83.6%

Essential Skills

Competence Target Completed Required % +/- Completed Required % +/-Clinical Risk Assessment (Suicide Training) 90% 166 476 34.9% 159 467 34.0%Conflict Resolution (Personal Safety) 90% 373 655 56.9% 366 642 57.0%Domestic Violence and Abuse 90% 100 663 15.1% 187 653 28.6%Medicines Management (Competency Framework) 90% 93 332 28.0% 100 331 30.2%Mental Capacity Act 90% 549 687 79.9% 558 690 80.9%Mental Health Act 90% 277 473 58.6% 270 464 58.2%PREVENT - No Renewal 90% 555 686 80.9% 568 689 82.4%Rapid Tranquilisation 90% 47 161 29.2% 51 162 31.5%Resuscitation Level 2 with AED (BLS) 90% 414 655 63.2% 391 642 60.9%Resuscitation Level 3 (ILS) 90% 32 153 20.9% 40 154 26.0%Safeguarding Adults Level 3 90% 413 499 82.8% 409 490 83.5%Safeguarding Children Level 3 90% 408 499 81.8% 421 508 82.9%Violence & Aggression Module A (MAPA®) 90% 124 224 55.4% 115 222 51.8%

Jun-16 Jul-16

Jun-16 Jul-16

Jul-16

Jun-16 Jul-16

Enc 16 MD Board Briefing Paper Template docx DO Page 1 of 4



Enclosure: 16

Report Title:

Medical Directors’ Report Accountable Director:

Dr Gingell and Dr Weaver, Joint Medical Directors


Dr Gingell and Dr Weaver, Joint Medical Directors

Purpose of the report: To update the Board on matters pertaining to the joint medical

directors’ portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


N/A


services


Leadership culture






Caring Responsive Effective Well-led Safe


Title Medical Directors’ Report National and Regulatory guidance None of relevance to the Medical Directors’ report Recent Publications and Hot Topics Review of data security, consent and opt-outs

The recent Policy paper of “Review of data security, consent and opt-outs” written by the National Data Guardian, Dame Fiona Caldicott was published on 6 July 2016.

Before the launch of Dame Fiona’s review, NHS Improvement boss Jim Mackey wrote to CEOs at trusts and FTs saying that in order to reduce the provider deficit from £550m to £250m this year, efforts would be made to reduce paybill growth in selected providers, and savings could delivered through back-office, pathology and elective service functions through regional consolidations.

Dame Fiona was asked that the data standards would fit in with this work. She replied: “I could talk for rather a long time about that. Essentially, trusts have to have people who are responsible for data security. So, whether that is something that can be shared between organisations that are currently independent of each other, I think, would have to be looked at carefully.

“In the end, if a board is going to be accountable for patient data security, they have to know that the people to whom they delegate the actual operation of that are trustworthy and fulfilling their contracts.

“I think it is something for consideration, but, at the moment, I would think that is a step where sharing so-called back-office function on data security – we are probably not quite ready for that. Let’s get data security standards in place across the whole of the health and social care system, seeing if we can do it as economically and efficiently as possible.”

Mental Health Targets

As reported by the BBC, Freedom of information figures suggests a quarter of clinical commissioning groups are ignoring the target to provide intensive treatment within two weeks, which was introduced in April 2016 to give mental health the same referral priority as cancer. NHS England says it is investing more money in services to help meet demand. The waiting-time target requires that any patient aged 14 to 65 experiencing their first episode of psychosis receives treatment within two weeks of referral. But the FOI request, sent to the 209 CCGs in England by the Liberal Democrats, reveals that in some areas this is not happening. Of the 170 CCGs that responded, 23% said they had applied the target to 14- to 35-year-olds only,

https://www.gov.uk/government/organisations/national-data-guardian


and more than three-quarters of those had no firm plans to extend it to 35- to 65-year-olds this year. About 64% of the CCGs that responded did not or could not say what they were spending on early intervention in psychosis; while 32% could not say what their overall planned spending on EIP would be this year. Liberal Democrats health spokesman Norman Lamb said: “It shows that across the country people are not getting the evidence-based treatment set out in the programme.”

Recruitment and Retention

Brexit may damage the ability of the NHS to provide medical expertise in a wide and diverse range of conditions and treatments. The Federation of Specialist Hospitals has written to the times, and articles in the BMJ discuss the risk of a loss of rare skills due to some European doctors and nurses already leaving the NHS.

Local Matters We will be holding the Section 12.2 and Approved Clinician Annual refresher course on the 5th October. Whilst this is specifically organized for medical and clinical staff of the Trust the invitation extends to other colleagues in the partnerships and has had extremely good feedback in previous years. Due to funding that is earned from teaching Grenadian medical students the Trust holds a bi-annual conference on topics of current interest, with an ability to invite national and international speakers. In the past topics have included Adult ADHD; Current thinking in Crisis/Home Treatment services and Pschodynamic Psychotherapy. This year’s conference is on Eating Disorders, to be held on the11th November. Internationally renowned speakers have been invited: Professor Janet Treasure and Dr Dasha Nicholls are among the speakers on what is likely to be a fascinating day. Regular meetings have been arranged to continue the planning of implementation of the Junior Doctors’ contract. We will update on arrangements in following reports. Mortality Report The Mortality Review Group currently meets once every six weeks which means that on occasions there will be two month’s data to present, and on others we may have only one. This month there is the data from June and July. Mortality data is now collected from the Safeguard Reporting system and the Information Department. The information from each system complements the other as the information comes from different sources. Some deaths are informed by the Finance Department, as the patients involved have contact with us via the Social Care Funding Stream rather than clinical contact.


Natural Causes

Expected Death – no further action

Unexpected death – awaiting Coroner’s outcome or investigation instituted

Further information required – for mortality review tool -has mental health condition affected outcome?

Total

June

2

2

2

2

8

July

3

4

2

5

14

All 22 deaths have fuller details which go to the Mortality Review Group, where there is discussion about whether further information is required from GPs or the DGOH. Any deaths that occur prematurely (under the average age of death for the localities, or without sufficient explanation) fall into this category, even if the category is expected death or natural causes. Any unexpected death will either be investigated by the Governance process forming a serious untoward investigation or await the Coroner’s outcome. In addition the ICD 10 code will be included in mortality reports going forward. Coroner’s Regulation 28 rulings are also studied at each mortality review group meeting to see what lessons can be learned. Recommendation That the report be received for information.

Enc 17 DoNs Board Briefing Paper Public Sept 2016 Page 1 of 2



Enclosure: 17

Report Title:

Director of Operations and Nursing Report


Wendy Pugh – Director of Operations and Nursing


Rosie Musson – Head of Nursing and Quality

Purpose of the report: To update the Board on matters pertaining to the Director of

Operations and Nursing portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


N/A


services


x

Leadership culture






Caring The report relates to all domains and supports the Trust in the delivery of the CQC Fundamental Standards of Care

Responsive Effective Well-led Safe

Enc 17 DoNs Board Briefing Paper Public Sept 2016 Page 2 of 2

Title Director of Operations and Nursing Report National Matters Nurse Revalidation - National and Local Picture The Nursing and Midwifery Council (NMC) have produced their first report outlining the results of national statistics for Nurse Revalidation. 91% of nurses due to revalidate nationally between April 2016 and June 2016 have successfully revalidated. This represents 35,000 nurses and of those 28,186 are in England. However 2,324 nurses have either actively or passively lapsed their registration since the new regulation commenced on 1 April 2016 Locally we expected that 17 nurses would revalidate during the first quarter and all have successfully done so (100%) with a further 43 expected to revalidate in quarter 2 ( July 2016 – September 2016) Exception reports will be provided to MEXT. Recommendation As a result of the above the Board is asked to receive the update from the DONs portfolio.

Enc 18 TB Safer Staffing Levels on Wards - Sep 2016 (amended)



Enclosure: 18

Report Title:

Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Accountable Director: Wendy Pugh – Director of Operations, Nursing & Estates Author (name & title):

Rosie Musson – Head of Nursing Quality and Innovation Makhan Singh – Principal Consultant, Informatics and Performance

Purpose of the report:

This report provides the Trust Board with: 1. The summary report of planned and actual staffing which has been

submitted to NHS Choices as part of a national staffing return 2. Exception reporting regarding variances provided by Heads of

Service 3. Trend analysis reporting monthly average fill rate


Gain assurance

Discussion

Information


Committee: None

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




Leadership culture






Caring Responsive Ensuring staffing levels are responsive to meeting patient need Effective Well-led Safe Ensuring staffing levels are adequate to deliver safe care


Title Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Introduction There is now a requirement post publication of the Francis Report 2013 and following the publication of Hard Truths that Trusts fulfill key commitments regarding publishing staffing data. This report provides the Trust Board with: • the 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 including triangulation with incidents reported • trend analysis monthly average fill rate

All Trusts are required to submit data, by ward, which shows planned against actual staff fill rates for inpatient wards. This is provided by total hours for both day and night shifts. The data is broken down by registered nurse and care staff. Trust Boards are asked to receive this published data monthly. The Board will be informed by exception of those wards where staffing fell short, the reasons for the gap, the impact and the actions taken to address this gap. There has currently been no agreement on RAG rate for this data for shortfalls, or oversupply of staffing nationally, although further guidance on this tolerance is expected. However the report has used a rating based on the provisional Information Centre range thresholds which were used to identify outliers from the first submission in May 2014. Summary of key points, issues and risks This set of data indicates sustained improvement in data quality. As reported last month this information is collected manually and further systems have been introduced to improve data quality and reduce the risk of double counting bank and agency staff. Across the inpatient areas the overall fill rates are 99%, with 97.7% for registered staff and 99.7% for care staff. Typically where our care staff rates exceed the planned numbers significantly, this is due to temporary staff being used to support patient observations or changes in skill mix. There are no exceptions to report related to the ranges, but the Board are advised that there were 3 incident reports submitted in July, which have been investigated through the Trusts incident reporting processes. The Trust is incorporating the guidance published by NHS Improvement ‘New Approach to Safe Staffing’ into the ongoing work being undertaken by the Trust in relation to safe staffing. This will be included in an update report to be provided to MEXT which includes an update on e rostering.


The Board is asked to note that e-rostering continues to be implemented and is making good progress. Both the rostering and the bank modules have now been introduced with the commencement of the safer staffing module in September. The introduction of the safer staffing module will be underpinned by the Hurst acuity tool for acute inpatients. The Trust is participating in regional project to develop an acuity tool for older adult wards including dementia specific. Recommendation To note and discuss the monthly data return submitted providing details of planned and actual staffing at ward level. Data represents July 2016 and a monthly trend analysis for a 12 month period. To note:

• The work underway to enable more detailed analysis of staffing data and the current complexities.

• The introduction of e-rostering and the safer staffing framework. Board action required The Board is asked:

• To note and discuss the monthly data return submitted, providing details of planned and actual staffing at ward level. Data represents July 2016 and a 12 month trend analysis.

Enc 18 TB Safer Staffing Levels on Wards - Sep 2016 (amended) Page 4 of 6

1. Nursing and healthcare staffing fill rates July 2016 The data submission was made on 10th August 2016 of July 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

Cedars 930 907.5 1604 1559.75 473 440.75 612.75 623.5 97.6% 97.2% 93.2% 101.8%Linden 930 900 1844.5 1784.5 612.75 602 892.25 860 96.8% 96.7% 98.2% 96.4%Ambleside 862.5 777.5 1380.25 1380.25 333.25 333.25 999.75 999.75 90.1% 100.0% 100.0% 100.0%Langdale 997.5 993.5 1794.5 1787 548.25 526.75 1257.75 1268.75 99.6% 99.6% 96.1% 100.9%Clent 935.25 921.65 1178.15 1217.8 333.25 333.25 999.75 1021.25 98.5% 103.4% 100.0% 102.2%Kinver 810 810 1237.5 1225.5 333.25 333.25 1064.25 1064.25 100.0% 99.0% 100.0% 100.0%Wrekin 888.75 866.25 658.5 673.5 333.25 333.25 666.5 666.5 97.5% 102.3% 100.0% 100.0%Holyrood 663.25 663.25 1278.5 1278.5 333.25 333.25 1053.5 1053.5 100.0% 100.0% 100.0% 100.0%Malvern 870 877.5 1076.5 1072.5 451.5 419.25 827.75 827.75 100.9% 99.6% 92.9% 100.0%Grand Total 7887.3 7717.2 12052.4 11979.3 3751.8 3655.0 8374.3 8385.3 97.8% 99.4% 97.4% 100.1%

Day Night Day Night

RMN Care Staff RMN Care StaffAverage 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% Across the inpatient areas the overall fill rates are 99%, with 97.7% for registered staff and 99.7% for care staff. The overfill result is as expected, as most of the inpatient wards do not have planned staff levels built into their rotas for increased levels of patient observation and complexity. Typically where our care staff rates exceed the planned numbers significantly, this is due to temporary staff being used to support patient observations.


2. Exception Report on Variance – July 2016 For July 2016, the Trust has no exceptions to report to the Trust Board in relation to safer staffing returns; however 3 incidents were reported during the month under the cause group ‘ insufficient staffing levels’ Each incident has been investigated through the Trusts incident reporting processes. The details of the incidents are detailed below: Exceptions Incident Impact Remedial Actions Cedars Ward – Bloxwich Hospital - 29/07/2016

Unable to fill 2 HCA shifts through bank and agency due to lack of availability.

Safe staffing levels maintained, through effective risk management This was supported by the on call manager.

No negative impact on patient safety No action required

Malvern Ward – Bushey Fields Hospital 08/07/2016

Unable to fill 1 HCA shift through bank and agency due to lack of availability.

Safe staffing levels maintained through effective risk management and redeployment of staff from cross wards. .


Malvern Ward – Bushey Fields Hospital 22/07/2016

Emergency admission to ward in the evening resulted in Qualified Nurse on late shift staying over to support with the dispensing of medication.

Safe staffing levels maintained, no reported incidents



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. It shows the improvement in the data quality and significant understanding of the capturing of planned hours of working.

Service Experience Quarterly Report Q1 2016/17

2

Board Meeting date: September 2016

Agenda Item number: Enclosure:

Report Title: Service Experience Report – Q1 2016/17

Accountable Director: Marsha Ingram – Director of People and Corporate Development

Author (name & title): Julie Adams, Service Experience Lead Tracy Cross, Service Experience Officer Kate Cox, Assistant Complaints & Litigations Manager

Purpose of the report: To present Trust Wide quarterly Service Experience data analysis (Q1 2016/17) as part of the Service Experience Strategy. To inform the Board of key themes and areas of feedback.

Action required from Governance and Quality Committee

Decision / Approval

Gain assurance

Discussion

Information

3



Caring Listening to feedback of our services and responding appropriately, providing channels for service users, carers and stakeholders to share their views with us

Responsive Feedback is timely and appropriate, actions are taken to address issues

Effective Investigations and reviews are thorough and balanced. This report is considered as part of each service line’s quarterly performance review

Well-led Provides information to Board and its committees in order to support effective action and decision making about service experience feedback

Safe Triangulation with Safeguarding and serious incidents supports safe service delivery and resolution




Leadership culture





Committee:

Date reviewed:


Is referral to Trust Board required?

Yes

If yes, for what purpose? As part of the regular board reporting schedule

Content Page

Key Messages

5

Service Experience Desk Activity Analysis (including compliments)

6-16

Verbatim feedback EBE/NHS Choices/Walsall SUE 17-19

Service Experience Measures Friends and Family Test (Net promoter) 20

Service Experience Surveys National Community Survey (CQC) Mental Health Forum

Internal Surveys

21-26

Your Experience Matters

27

Raising Feedback 28-29

SE Strategy 30-32

Appendices: 1 Complaints log 4

Service Experience Report Q1 2016/17

5

Key Messages Q1 2016/17

SED Activity

• In Q1 SED received 210 new cases, and handled 3536 contacts • 203 cases are attributable to service lines, the remainder are attributable to corporate functions, trust generic or non-specific • Compliments continue to make up the largest feedback category with 107 received this quarter, EI receiving highest number. EI also

scored highest in 3 out of 5 domains. OA received compliments in all 5 domains and were the most caring service. • 34 complaints received, decrease of 19% (8 cases) compared to Q4, Acute receiving highest number • There are currently 31 live complaints and 17 live concerns in the system • No new notifications were received from the PHSO this quarter,1 case with them closed (partially upheld) • 18 out of 27 complaint responses sent were upheld or partially upheld • 15 out of 27 responses were breached (56%) this has increased from a 31% breach in Q4 • 1 suggestion received for RIS Dudley to review letters in response to referrals and the opt-in process

Service Experience Measures

72% of 393 respondents would be extremely likely or likely to recommend the Trust to family and friends. This quarter shows a decline in the number of responses and levels of satisfaction in the Older Adults and Community service lines.

Service Experience Surveys

Walsall Home Treatment – positive results and improvements since previous quarter Carers Support Service - Asian Women’s Support Group – positive results Birch Day Hospital Mental Health Promotion Group – positive results Recovery Intervention Service Patient Experience Questionnaire (Pre-Intervention) – positive results . Recurring theme around lack of patient information prior to accessing the course Dudley Home Treatment Service User Satisfaction Survey - positive results. Some challenges around patients being given copies of their care plan and knowing who their Key Worker was. Carers Support Service Walsall – Men’s Carer’s Group – positive results Patient Experience Assessment & Feedback Questionnaire Walsall PCMH&TTS – positive results. Some suggestions made regarding length of course, time to access and difficulties with making follow up appointments. Issues have been addressed and changes made. Complaints Handling – positive results when compared to previous years although still concerns around timescales/responses

Verbatim Feedback

Walsall SUE – majority of feedback was positive, in particular around the range of activities taking place. Some concerns from patients regarding not having care plan in place and communication between staff. EBE – positive feedback received regarding activities on the wards. Some concerns from patients who are not aware of who their named nurse is, issues for patients from Walsall who are accessing Dudley inpatient services in terms of time and travel costs and also a lack of patient information and staff attitude. NHS Choices – 2 comments posted this quarter - compliment regarding positive staff attitude and concern about crisis services. Dudley Peer Support Group - negative experiences of the crisis service. Suggestions for improvement offered.

National Measures

Overall the results for 2016 community survey are fairly positive but we have seen a higher proportion of responses in the ‘yes’ to some extent’ category for some of the questions, however, we remain higher than the national average for a number of responses. The 2016 survey shows a decline in satisfaction with organising, reviewing and planning care and improvements in crisis care services and support for wellbeing. A new action plan will be produced and merged with any ongoing actions from 21015.

6

Service Experience Desk - Trust Level Analysis Q1 2016/17

Informal Concerns

Formal Complaints Complaints - PHSO Formal Responses/Breaches

Rec Apr/Jun

Live at 30 Jun

Rec Apr/Jun

Follow-ons rec Apr/Jun

Live at 30 Jun

Notified Apr/Jun

Live at 30 Jun

Responses sent Apr/Jun

Number breached

Acute 13 4 20 1 21 0 3 13 8

Community & Recovery 7 3 8 2 4 0 1 8 4

Early Intervention 19 5 2 1 2 0 0 6 3

Older Adults 5 5 4 0 4 0 0 0 0

Total 44 17 34 4 31 0 4 27 15

Outcome of Complaints Number

Not upheld 9 Upheld 2 Partially upheld 16 Total 27

Reasons for breaches Number

Investigation received late 9 Rejected/queried 3 Delay in allocation 1 Awaiting HoS sign off 1 HR involved 1

12 On target

15 breached

Complaint responses

Q1

Outcome of closed PHSO cases

Number Details

Partially upheld

1

This case related to patient suicide. Two recommendations made relating to record keeping (patient records/local resolution meetings with families).

7

Service Experience Desk – Complaints and Concerns Q1 2016/17

Type Q1 Q4

Compliments 107 ↑ 97

Complaints 34 ↓ 42

Concerns 45 ↓ 60

Enquiries 23 ↓ 33

Suggestions 1 ↓ 5

Suggestion

Team Details

Outcome

RIS Dudley

To review the wording of letters to patients in relation to referrals and to consider contacting the patient to see if they wish to opt in rather than asking patients to contact the Trust.

To be discussed at the Clinical Process Group

8


9


10

Service Experience Desk – Cause Group Analysis

Top 9 Cause Groups

Complaints Concerns Previous Quarter

(4)

Clinical 39 34 ↑

Communication 10 15 ↓

Attitude of staff 16 8 ↑

Appointments 5 4 ↑

Patients Property 4 4 ↑

Admissions/discharge/transfer

arrangements

3 2 ↑

Service information/access

to services 1 3 ↑

Hotel Services 1 2 ↓

Confidentiality 2 0 _

Clinical Complaints Concerns

Inadequate support 13 13

Clinical staff – lack of confidence in ability 4 1

Medication – disputing 4 1

Concern for well being 0 5

Communication Complaints Concerns

Failure with patient 5 5

Failure with family 4 5

Lack of between health bodies 1 3

Failure within team 0 1

Access to service – problems 0 1

Attitude of staff Complaints Concerns

Nursing staff 9 6

Psychiatrist 4 1

Receptionist 1 1

Psychologist 1 0

Other 1 0

Appointments Complaints Concerns

Time to receive 1 3

Cancelled 1 1

Waiting time on day 2 0

General 1 0

Patients property Complaints Concerns

Missing 2 2

Removed 1 2

Theft 1 0

11

Service Experience Desk - Service Line Level – Q1 2016/17

Service Line

Compli ments

Complaints Concerns Enquiries Sugges tions

Acute 17 20 13 1 0

C&R 15 8 7 0 1

EI 44 2 19 8 0

OA 28 4 5 2 0

Service Experience Desk - Service Line Level all categories by team – Q1 2016/17

Acute Ambl

esid

e W

ard

Clen

t War

d

Kinv

er W

ard

Wre

kin

War

d

Lang

dale

War

d

Non

Spe

cific

(SED

ON

LY)

Out

Pat

ient

s (DP

H)

Out

Pat

ient

s (HL

C)

Psyc

hiat

ry

Cris

is R

esol

utio

n - W

alsa

ll

Hom

e Tr

eatm

ent -

Dud

ley

Cris

is R

esol

utio

n - D

udle

y

Hom

e Tr

eatm

ent -

Wal

sall

Gra

nd T

otal

Clinical 5 1 1 5 0 3 12 1 1 6 0 1 3 39Attitude Of Staff 1 0 0 1 4 1 4 0 0 2 0 0 0 13Patients Property 2 0 0 1 2 1 0 0 0 0 0 0 1 7Communication 0 1 0 1 0 0 0 0 0 4 1 0 0 7Admissions/Discharge/Transfer Arrangemen 0 1 0 1 0 0 0 0 0 1 0 0 0 3Appointments 0 0 0 0 0 0 1 0 0 0 1 0 1 3Hotel Services 0 0 0 1 2 0 0 0 0 0 0 0 0 3Service Information/Access To Services 0 0 0 0 1 0 1 0 0 0 0 0 0 2Confidentiality 1 0 0 0 0 0 0 0 0 1 0 0 0 2Other 0 0 0 0 1 0 0 0 0 0 0 0 0 1Grand Total 9 3 1 10 10 5 18 1 1 14 2 1 5 80

C&R CR

S N

ort

h (

Du

dle

y -

PO

P)

CR

S N

ort

h (

Wal

sall

- M

oss

)C

RS

Sou

th (

Du

dle

y -

HH

)

Psy

cho

logi

cal T

he

rap

ies

Hu

b

Re

cove

ry In

terv

en

tio

n S

erv

ice

CR

S So

uth

(W

alsa

ll A

M)

Gra

nd

To

tal

Clinical 0 8 1 1 0 5 15Attitude Of Staff 2 2 2 0 0 0 6Communication 0 2 0 0 0 1 3Appointments 0 1 0 0 1 0 2Discrimination 0 1 0 0 0 0 1Admissions/Discharge/Transfer Arrangements 0 0 0 0 0 1 1Grand Total 2 14 3 1 1 7 28

EI CAM

HS Du

dley (

Elms)

CAM

HS W

alsall

(Can

alside

)

Enha

nced

Prim

ary Ca

re (D

udley

)

PC M

H & TT

S

Gran

d Tot

al

Communication 6 0 7 1 14Clinical 8 1 1 0 10Appointments 3 0 0 1 4Attitude Of Staff 1 0 1 0 2Patients Record 1 0 0 0 1Admissions/Discharge/Transfer Arrangemen 0 1 0 0 1Grand Total 19 2 9 2 32

OA Ceda

rs W

ard

CMHT

OP W

alsa

ll

Linde

n War

d

Mal

vern

War

d

Out P

atie

nts (

DPH)

Out P

atie

nts (

HLC)

Psyc

hiat

ry

Woo

dsid

e (CM

HTOP

)

Gran

d Tot

al

Clinical 1 0 3 2 1 0 1 1 9Attitude Of Staff 0 1 0 1 0 1 0 0 3Service Information/Access To Servic 0 0 0 1 0 0 0 1 2Communication 0 0 1 0 0 0 0 0 1Privacy/Dignity 1 0 0 0 0 0 0 0 1Consent 0 0 0 0 0 0 0 1 1Patients Property 0 0 1 0 0 0 0 0 1Other Areas Of Life 0 0 1 0 0 0 0 0 1Grand Total 2 1 6 4 1 1 1 3 19

13

Service Experience Desk Compliments Trustwide – Q1 2016/17

The Trust received a total of 107 compliments this quarter with EI receiving the highest number (44), followed by OA (28), Acute (17), C&R (15), other services (3). Categories have been added to the recording system to enable more meaningful reporting and positive learning from compliments. The words people quoted in their compliments have been used to form the categories and linked to CREWS. Fig 1 shows that the Trust scored highly in being supportive/helpful and provided quality care. Fig 2 shows our services are extremely effective and have received positive comments in all the CREWS domains.

14

Service Experience Desk Compliments – Service Line Level

Fig 3 shows that EI services have scored the highest in 3 of the 5 domains – effective, responsive and well led. OA is the most caring service, is safe and has received compliments in all five domains.

0

5

10

15

20

25

30

35

40

45

Caring (58) Responsive (55) Effective (90) Well Led (46) Safe (1)

Fig 3 Category type by 4 Service Lines

Acute C&R EI OA

15

Service Experience Desk Compliments – Service Line Breakdown by Department

Acute Ambl

esid

e W

ard

Kinv

er W

ard

Wre

kin

War

d

Lang

dale

War

d

EAS

(Wal

sall)

Out

Pat

ient

s (DP

H)

Crisi

s Res

olut

ion

- Wal

sall

Gra

nd T

otal

Effective 4 0 2 1 1 3 1 12Fun 0 0 1 0 0 0 0 1Medication - Sorted 0 0 0 0 0 1 0 1Quality Care Provided 0 0 0 0 1 0 0 1Recognises When I'm Low 1 0 0 0 0 0 0 1Supportive 3 0 1 1 0 2 1 8

Well Led 2 1 1 0 0 5 1 10Dedicated/Hard Working 2 0 0 0 0 1 0 3Quality Care Provided 0 1 1 0 0 4 1 7

Caring 4 0 1 1 0 1 2 9Caring/Kind/Thoughtful 1 0 0 1 0 1 1 4Friendly 1 0 1 0 0 0 0 2Smiles 1 0 0 0 0 0 0 1Understanding 1 0 0 0 0 0 1 2

Responsive 1 0 0 1 0 2 1 5Advice 1 0 0 0 0 0 0 1Empathy / Compassion 0 0 0 0 0 0 1 1Helpful 0 0 0 1 0 1 0 2Patient 0 0 0 0 0 1 0 1

Grand Total 11 1 4 3 1 11 5 36

C&R Care

r Sup

port

Ser

vice

s (Ki

ngs H

ill)

CRS

Nor

th (D

udle

y - P

OP)

CRS

Nor

th (W

alsa

ll - M

oss)

CRS

Sout

h (D

udle

y - H

ales

)

Psyc

holo

gica

l The

rapi

es H

ub

Rece

ptio

n (D

PH)

CRS

Sout

h (W

alsa

ll AM

)

Gra

nd T

otal

Effective 5 0 3 2 1 1 3 15Always There / Approachable 1 0 1 1 0 0 0 3Good Communication - Families/ 1 0 0 0 0 0 0 1Listens / Engages 0 0 0 0 0 0 1 1Supportive 3 0 2 1 1 0 1 8Time To Talk 0 0 0 0 0 1 0 1Trustworthy 0 0 0 0 0 0 1 1

Responsive 0 1 2 1 1 1 0 6Empathy / Compassion 0 0 1 0 0 0 0 1Extra Mile 0 0 0 1 0 0 0 1Helpful 0 1 1 0 1 0 0 3Spoke To Like A Person 0 0 0 0 0 1 0 1

Caring 0 0 1 1 0 1 3 6Caring/Kind/Thoughtful 0 0 1 1 0 1 2 5Open/honest/direct 0 0 0 0 0 0 1 1

Well Led 0 0 0 1 3 0 1 5Dedicated/Hard Working 0 0 0 1 1 0 0 2Professional 0 0 0 0 1 0 0 1Quality Care Provided 0 0 0 0 1 0 1 2

Grand Total 5 1 6 5 5 3 7 32

16

Service Experience Desk Compliments – 4 Service Line Breakdown by Dept

OA Beec

hes D

ay H

ospi

tal

Ceda

rs W

ard

CMHT

OP

Wal

sall

Holy

rood

Mal

vern

War

d

Mem

ory

Serv

ices

(BVC

)

Out

Pat

ient

s (HL

C)

Woo

dsid

e (C

MHT

OP)

OT(

Dudl

ey C

MHT

OP)

Gra

nd T

otal

Caring 2 3 1 6 9 2 0 5 2 30Caring/Kind/Thoughtful 1 3 1 2 5 1 0 3 2 18Courteous/polite 0 0 0 1 2 0 0 0 0 3Dignity/respect 0 0 0 2 1 0 0 1 0 4Friendly 1 0 0 1 1 0 0 0 0 3Listens / Engages 0 0 0 0 0 0 0 1 0 1Understanding 0 0 0 0 0 1 0 0 0 1

Effective 1 1 3 3 3 1 0 10 1 23Easy To Talk To /Relaxed 0 0 1 0 0 0 0 2 1 4Good Communication - Families/ 0 1 0 2 1 0 0 1 0 5Open/honest/direct 0 0 0 0 0 0 0 1 0 1Personality 0 0 0 0 0 0 0 1 0 1Supportive 1 0 2 1 2 1 0 4 0 11Tower Of Strength 0 0 0 0 0 0 0 1 0 1

Well Led 0 2 1 2 5 1 1 3 0 15Dedicated/Hard Working 0 0 0 0 4 0 0 1 0 5Professional 0 0 0 1 0 0 0 1 0 2Quality Care Provided 0 2 1 1 1 1 1 1 0 8

Responsive 1 2 1 3 0 1 0 5 1 14Advice 0 0 0 0 0 0 0 1 0 1Empathy / Compassion 0 0 0 0 0 1 0 2 0 3Extra Mile 0 0 0 2 0 0 0 0 0 2Helpful 1 2 1 1 0 0 0 2 1 8

Safe 0 0 0 0 1 0 0 0 0 1Felt Safe On Wards 0 0 0 0 1 0 0 0 0 1

Grand Total 4 8 6 14 18 5 1 23 4 83

EI CAM

HS D

udle

y (E

lms)

CAM

HS W

alsa

ll (C

anal

side)

Eatin

g Di

sord

ers (

Wal

sall)

EPC

(Dud

ley)

PC M

H &

TTS

Gra

nd T

otal

Effective 2 10 1 16 11 40Always There / Approachable 0 0 0 1 0 1Easy To Talk To /Relaxed 0 0 0 4 0 4Good Communication - Families/ 0 1 0 0 0 1Listens / Engages 0 0 0 1 0 1Open/honest/direct 0 0 0 0 1 1Personality 0 0 0 0 2 2Supportive 2 7 1 10 7 27Time To Talk 0 2 0 0 1 3

Responsive 0 3 0 8 19 30Advice 0 1 0 1 6 8Empathy / Compassion 0 0 0 0 1 1Helpful 0 2 0 6 12 20Patient 0 0 0 1 0 1

Well Led 1 6 0 3 6 16Dedicated/Hard Working 1 2 0 0 1 4Quality Care Provided 0 4 0 3 5 12

Caring 1 1 0 5 6 13Caring/Kind/Thoughtful 1 1 0 1 1 4Friendly 0 0 0 2 0 2Listens / Engages 0 0 0 2 4 6Understanding 0 0 0 0 1 1

Grand Total 4 20 1 32 42 99

17

Verbatim feedback (including NHS Choices/Walsall SUE/EBE) Walsall SUE Ambleside – patients were positive about the quality of food offered, the ward was clean and tidy and lots of activities taking place. Ward visitors observed a stain on the ceiling and reported this to ward staff. TV/electronic notice board was not working. Langdale – ward was clean and tidy. The activities board was full of information on different activities taking place on the ward and patients were well engaged. A patient advised ward visitors that a member of staff had trodden on his toe and another member of staff apologised to the patient on the staff members behalf. The patient was also concerned about spillages and stains on the ward. Another patient was complaining that doctors do not always pass on messages to staff. The doctor advised the patient that he was changing his medication but did not inform his named nurse and some patients stated that they had no care plan in place. Bloxwich Hospital – ward was clean and tidy and patients were well engaged with staff and in activities taking place on the ward. The food was varied and offered healthy options. NHS Choices Two comments posted this quarter. One compliment received regarding the professional and meticulous attitude of the consultant and staff at Bushey Fields Hospital. A carer described a consultant from the crisis team in Walsall as ‘rude’ and felt that he rushed the patient review and that staff at Bushey Fields are very insensitive. The carer stated that the patient did not have capacity but was admitted as a voluntary patient and all the crisis team can offer is medication. Dudley Peer Support Group At the first Dudley Peer Support Group there was a lot of emotion in the room and negative experiences of the crisis service. Everyone wanted to share their experiences. Patients shared some concerns, a compliment, and also some suggestions for improvement. Service users stated that they wanted a listening ear from the crisis service rather than being offered advice to try and use strategies before making contact. They felt that home treatment visiting times could be improved and that the service should employ service users to support the running of the crisis line. They also stated that there needs to be a clear pathway identified when a person is discharged from HT so they know who and how to access the follow-on services they need. Praise was given for the support received by the Home Treatment team in Dudley. In response to the feedback, a CPN from Hill House gave a presentation about crisis support to ensure that people accessing the service have a clear understanding of the function of crisis services and when/how to access crisis support.

18

Verbatim feedback (including NHS Choices/Walsall SUE/EBE)

EBE Feedback Kinver – more activities are now taking place on the ward as an Occupational Therapist has now been allocated and staff regularly introduce themselves. One patient was complaining that she had only seen her named nurse once in 5 weeks and other patients stated that they were not aware of who their named nurse was. Patients raised concerns about hygiene issues regarding the storage of butter and milk. There is a lack of patient information on the wards and it is not accessible as it located between the air locked doors. Some issues raised by patients waiting for a battery for their hearing aid and insulin being provided too late to a diabetic patient. Patients feel that their experience could be improved if staff could spend more time talking to them about their problems. One patient was particularly distressed and staff did not appear to be talking to her but she was much calmer after EBE/Service Experience Lead had spent time listening to her. Wrekin - service users from the Walsall locality who were on Wrekin, felt that the ward was a nice environment and staff are very engaging. Problems identified were regarding difficulties with travelling over to Dudley, parking issues and accessing food and drink during visiting times. One patient had a concern regarding not knowing who his social worker was and felt that he needed to know so that he could ensure support would be available when going on leave. The patient said that he felt that he could approach staff to discuss these issues. Some patients on the ward were not aware of who their named nurse was. Ambleside - EBEs signposted a lady onto the Carers Support Centre (Local Authority service) as the patient’s sister was not offered any support with her caring needs . No service information was available on the wards regarding the Trust’s Carers Support Service in Walsall. A patient felt intimidated by staff behaviour and was signposted to discuss any issues and concerns. Delay in receiving ward notes prior to discharge was frustrating for a patient and carer due to a lack of communication regarding the reason for delay. A patient gave positive feedback regarding the experience she had with the Home Treatment Team. The patient’s relative also stated how engaging and supportive the Approved Mental Health Practitioner was who attended their home. Much more activities are taking place and patients are enjoying the relaxation sessions. Patients feel that staff do not introduce themselves on arrival or when they are new to the ward. A patient from the Dudley area who was admitted to Dorothy Pattison Hospital wishes to make a complaint regarding the lack of communication from staff on Ambleside Ward. The patient stated that she was advised that she was being discharged and on the following day she received a call from her Psychiatrist saying that she had not been discharged and was only on leave.

19

Verbatim feedback (including NHS Choices/Walsall SUE/EBE)

EBE Feedback Linden Ward Patients were participating in activity and were very engaged with staff. The ward presented a very calm and peaceful atmosphere. Cedars Ward All patients were engaged in activity with staff. Some patients had been transferred from the ward to Bushey Fields Hospital. Patients stated that they didn’t like having to go and felt they were being disturbed. Some had to attend an adult specific ward rather than older adult ward and felt uncomfortable and anxious as there were too many younger people on the ward. However, they did like the idea of making their own cups of tea. Some of the patients went to visit the Birch Day Centre and ‘loved it’. They highlighted how welcoming and caring staff were and they enjoyed participating in the quizzes. The service had arranged transport for families who do not have their own means of transportation, which was very well received. Langdale Ward The lounge area is looking very tired in terms of décor. The floor was dirty and an electric socket by the food hatch was hanging off the wall. This was reported to a member of staff.

Net Promoter – Friends and Family Test The Net Promoter results have been analysed by service line and the results are fairly positive with 72% of the 393 respondents saying they would be extremely likely or likely to recommend the Trust to family and friends. This quarter shows a decline in the number of responses received within the Community (242 in Q1 cf 285 in Q4) and Older Adults (129 in Q1 cf 193 in Q4) service lines in comparison to the previous quarter. There has also been a decline in the number of people who are extremely likely or likely to recommend our service to friends and family. A review of the current process for deploying Friends and Family Test is being undertaken. Due to a decline in the number of responses, overall satisfaction of patients, an increase in the number of ‘don’t knows’ and confusion around how and when the question is asked a proposal is under development to make Friends and Family Test more accessible and wide reaching and to identify ways to improve our scores. We are aiming to ensure that data captured is based on the patients recent experience and reflects their informed opinion and that reporting is more meaningful and can be used to drive continuous improvements through the addition of free-text questions.

Service Experience Measures - Friends and Family Test (Net Promoter)

21

2016 National Community Mental Health Survey (CQC)

The initial survey results manual from the basic sample has now been issued and shows the results from the previous survey, the current year’s survey for the Trust and the results for the current year’s survey for all organisations surveyed by Quality Health. Overall the results are fairly positive but we have seen a higher proportion of responses in the ‘yes’ to some extent’ category for some of the questions, however, we remain higher than the national average for a number of responses. Summary of findings from the survey results manual Organising, Reviewing and Planning Your Care - we have seen a decline in involving patients in agreeing what care they will receive in comparison to 2015, where we were in the top 20% of Trusts and are lower than the national average. We have also seen a 10% decline since 2015 in the care agreement taking into account personal circumstances, how well care and services are organised and for involving patients in decisions about their care. We remain higher than the national average for people being aware of who is in charge of their care and treatment. Treatments – we remain higher than the national average for patients being given information about medication and for medicine checks. A recurring theme from the 2016 survey is a decline around involving patients in decisions about what treatments or therapies to use. Crisis Care - we have seen a vast improvement in responses regarding Crisis Care services, in comparison to the previous year’s survey and the national average. The Trust are higher than the national average for patients knowing who to contact out of hours in a crisis situation and 10% higher than the national average for patients stating they definitely got the help they need when they contacted the team, an increase from the previous years survey (33% 2015 to 54% 2016). Support for Wellbeing – extremely positive results, with an increase in responses in the ‘yes definitely category, in comparison to the previous year and the Trust is higher than the national average for all questions. In 2015 ‘Other Areas of Life’ was a recurring theme for improvement around support for finding work, accommodation needs, physical health, benefits advice and support from people experience similar mental health needs. However, the 2016 survey shows a 10% increase in people being given help with finding support for financial and benefit advice and for finding or keeping work and an improvement in support for physical health needs. Next steps – a management report containing the full and final survey results and analysis will be sent to the Trust mid August, to provide benchmarking data as well as a commentary on the Trust’s performance and key actions that can be taken to maintain or improve it. A presentation will be given by Quality Health to share findings and recommendations.

22

Internal Survey Patient Feedback

Walsall Home Treatment Team Evaluation The results were very positive around patients feeling that they were listened to (84%) and the majority of patients felt fully supported by the team and were satisfied with the arrangements and times of home visits. Although some concerns raised in the verbatim comments regarding appointments being missed. The majority of service users stated that their medication issues and social needs were addressed, and they felt that their family and friends were fully involved and informed. This quarter shows an improvement in the number of service users who felt fully involved in their care plan in comparison to the previous quarter. Carers Survey - The results were positive with 86% of carers strongly agreeing that their needs were met by the Home Treatment Team, giving a rating of between 7-9, an improvement since the previous quarter. Half of the respondents strongly agreed that the visiting times were negotiated and flexible, they were treated with dignity and respect and they felt listened to by the team. However, a small proportion of respondents disagreed. Carers Support Service - Asian Women’s Support Group Questionnaire The results were positive with 69% of attendees stating that the group session was ‘excellent’. Almost all respondents felt that information provided at the group session will support their caring role and they were able to transfer skills learnt from the sessions into everyday life. 92% of participants also felt that the session has given them enough time out of their caring role. Verbatim comments highlighted that carers feel that the meetings gives them a break from their home environment and they appreciated being able to talk and share with others with similar experiences and that it is important to take time for themselves. Birch Day Hospital – Mental Health Promotion Group Client Evaluation The results were positive with 62% of attendees stating that the course has been very helpful. The majority of clients felt that the one-to-one work was very helpful or helpful, with the exception of one attendee. All participants felt that the course has improved their confidence levels and that learning breathing techniques has enabled them to relax more. All agreed that they are more aware of their level of assertiveness and they are more able to say ‘no’ appropriately. Patients also felt that working in a group was helpful and comfortable and the relaxed atmosphere, course structure and course information created a calm environment and they were able to share and learn from each other. Recovery Intervention Service Patient Experience Questionnaire (Pre-Intervention) 75% of participants felt that the service will help them to better understand and address their difficulties and the majority were happy with the venue for the group therapy session. A recurring theme again this quarter was a lack of information given to service users prior to commencing the course. Although verbatim feedback highlighted that some service users were advised about the content and benefits of the session. The majority of service users also stated that it was good to be around other people who are experiencing similar situations and difficulties and that they are not alone, and they were given lots of information about the course to take home following the first session. Only half of respondents were satisfied with the time they waited for their appointment.

23

Internal Survey Patient Feedback Dudley Home Treatment Service User Satisfaction Survey The results were very positive with 100% satisfaction from service users regarding the sensitivity of the assessment process, staff introducing themselves at each visit, for being seen weekly by a doctor, feeling fully involved in their own care and discharge planning. All respondents also received a copy of their discharge plan and were satisfied with the quality and standard of care they received from the team. Results were also positive regarding the support received by the team to assist the patient’s recovery and visits being arranged to suit the patients needs. The challenges identified were regarding service users receiving a copy of their care plan with 38% of respondents stating that they did not receive a copy and some respondents were not aware of the name of their Key Worker. Carers Support Service Walsall – Men’s Carer’s Group The results were very positive with 100% satisfaction from carers regarding the wellbeing presentation. Almost all carers felt it was appropriate to their situation and all stated that it was well presented and they will use the skills they have learnt in everyday life. Verbatim comments highlighted that carers particularly enjoyed learning about new support services and the range of activities available and ways to resolve problems. Patient Experience Assessment & Feedback Questionnaire Walsall PCMH&TTS The results were extremely positive with 98% of patients rating their overall experience of care as ‘very satisfied’ or ‘satisfied’. Verbatim feedback shows that the majority of patients feel that this is an excellent service that has helped to overcome their problems and the group sessions and discussions have enabled them to share experiences and useful information. Respondents also highlighted that the course was informative and helpful and praised staff for their relaxed and friendly manner, and their compassionate and caring attitude. Some suggestions were made regarding the length of the course, as patients feel the course should be longer and more follow up offered. Some concerns were raised by a number of patients regarding the length of time to access the course, difficulties with making follow up appointments with their CPN and the size of the group therapy sessions. In response to the feedback the service have now introduced a rolling programme of courses and have a course starting every 2-3 weeks. The team have also recently introduced a review session at the end of a course that identifies client that may need to continue with treatment so they can be referred on for 1-1 treatment within the service. Complaints Handling Survey The results are positive overall when looked at collectively, 80% of respondents agreed that staff who handled their complaint were polite and helpful and more than half stated that making a complaint was clear and simple, they were informed about the process and timescales, the response letter was clearly written and that the concerns expressed in their original complaint were recognised. The verbatim comments show that the main concerns raised by complainants were regarding the response received to the complaint rather than the complaints handling process itself.

24

Mental Health Forum Feedback Q1 – OCD The forum was held at Brierley Hill Civic Hall in Dudley on 16 June and was well attended by approximately 80 people, including service users, carers, voluntary, statutory and community organisations, Trust members and staff. A total of 40 evaluation forms were received. The event provided an opportunity to network, find out information, ask questions and share feedback about Trust services. SED were in attendance on the day to take any concerns at the end of the forum. The forum commenced with a poem ‘This Old Ghost’, read by one of the Trust’s EBEs, exploring the realities of living with OCD through the creative arts, followed by a presentation on the psychological and psychiatric perspective to OCD. A service user currently accessing Trust services shared his perspective on living with OCD, including signs/symptoms and copying strategies, which was facilitated as an interview session in front of the audience by one of the Trust's EBEs. A carer gave a presentation on looking after someone with OCD and shared her experiences.

The feedback was very positive with 93% of respondents stating that the workshop met their needs and they would recommend future forums. Almost all respondents stated that they agree or strongly agree that the forum was useful ,informative, met their expectations and provided an opportunity to network. Positive • “Interesting insight into OCD and good ability to find out about local mental health groups” • “Good to hear perspectives from carers, professionals and clients, can apply understanding to practice” • “The patient perspective added real life reality to the forum and a human aspect. Useful to hear how it affected them” • “It was interesting and I had some good contact information” • “I found this session particularly useful and given me an insight of affects on the person” • “Very helpful and gave me a great insight on OCD and how it is treated” • “As a sufferer of OCD I found it very informative” • “The realisation of how crippling this is, was very heart wrenching” Challenges • “I think that the object of the forum should have been stated at the beginning and maybe for new attendees, explain what the forums

are and what they hope to achieve” • “Limited opportunity for relevant questions”

25

Complaints Handling Survey Feedback

A satisfaction survey is sent out with all complaint responses where people who have complained about services are asked about their experience of making a complaint so that we can better understand their views of the complaints process to help us learn and deal with complaints more effectively. Complainants are asked about their experience of the process, such as how clear and simple it was to make a complaint, the attitude of the staff who took the initial complaint, the complainant’s knowledge of the process and timescales, clarity about whether the concerns they expressed were recognised and whether the response letter was clearly written. The survey also offers people the opportunity to give further comments regarding the complaints process and suggestions for improvement. A total of 49 surveys have been received since 2013. Response rates vary each year and overall are low in comparison to the number of complaint responses sent.

The results are positive overall, 80% of respondents agreed that staff who handled their complaint were polite and helpful and more than half stated that making a complaint was clear and simple, they were informed about the process and timescales, the response letter was clearly written and that the concerns expressed in their original complaint were recognised. The main concerns identified by complainants in response to the handling of their complaint was regarding the timescales, satisfaction with the response they received to their complaint and with the way the complaint was dealt with on the whole, although, almost half (47%) of the respondents agreed that they were happy with the way the complaint was handled overall. The verbatim comments show that the main concerns raised by complainants were regarding the response received to the complaint rather than the complaints handling process itself. In order to improve response rates and improve the way complaints are handled, to ensure that service users and carers feel confident to speak up, are kept informed and feel that their complaint has made a difference, the Trust are rolling out “My Expectations for Raising Concerns and Complaints”. Published in November 2014, this is a vision that aims to improve complaint handling across the NHS and to make the complaints system better through engagement with service users and carers to define what would make complaining about a service or care received a more positive experience.

26

Complaints Handling Survey Yearly breakdown

The above figures show a breakdown of the survey results by year, this highlights how the amount returned varies each year, so far this year the numbers being returned looks good compared to previous year. 2016-17 shows:- an improvement in the responses to all questions when compared to 2015-16; positive around the process for making a complaint, staff were polite and helpful and their concerns were recognised but almost half of respondents remained dissatisfied with their response and the timescale.

27

Your Experience Matters

Service/Team You Said

We Did

Acute – Kinver ward Due to the number of agency and different types of staff being on the ward, patients stated that it was difficult to know who they can talk to and that they felt less supported when regular staff were not around

Kinver ward now have an allocation board at the entrance to the ward and all patients are allocated a nurse to work with them during each shift and are encouraged to approach them

Acute – Kinver Ward

Patients requested more group walks We will be building group walks into therapeutic timetable to encourage exercise, refreshment and distraction

Estates & Facilities The question regarding room temperature was removed from the PLACE Assessment for 2016 and patient assessors identified that the rooms are often cold on the wards

Estates and Facilities explored temperatures on the wards and provided the patient with a root to escalate this issue

Early Intervention/Primary Care (Dudley & Walsall)

Patients said they were not able to get through to Primary Care in both Dudley & Walsall

Phone lines being increased

Bloxwich Hospital As part of the PLACE inspection EBEs and patients highlighted the poor condition of the communal gardens

Patients and staff on both Cedars and Linden ward tidied up the garden which is now a more relaxing and pleasant environment

28

Service Experience Desk – Raising Feedback

The Trust takes a positive approach to encourage people to give feedback about our services, both good and bad and provide a dedicated helpdesk that handles all concerns, complaints and compliments from people experiencing our services. Information on how to provide feedback is displayed at all sites and on our website. Our Service Experience Strategy describes in detail our approach to how we manage complaints and act on/learn from feedback. 1. Tell us about your experience - Ensuring that there are numerous ways in which people ,can leave their feedback and that these are accessible and simple to use

People are given a varied choice of how they wish to make contact. This could be via website, telephone, email, letter, face to face, visibility sessions, comments form, attendance at forums, patient story or discuss with staff who they are comfortable with who can relay the information for them. Information is displayed at all sites and on our website which is very user friendly and easy to find how to provide feedback.

2. Make sense of the information - Robust analysis and investigation of feedback that is received, free of judgement and preconceptions

An independence matrix is in place in order to ensure independent investigations of complaints. Triangulation Committee meet monthly whereby any trends/concerns are raised, staff involved include SED/Governance/Safeguarding and Quality. Automated monthly reports are sent to HoS and teams. Regular reports presented to Quality & Governance Committee, Board and Commissioners. Quarterly dashboard displayed at main sites.

3. Putting actions in place - Recognising when things have gone wrong and putting in place remedial actions

Complaint Management Action Plan completed and recorded/monitored via the safeguard system. You Said We Did shared with staff/public.

4. Has the action made a difference? - Assessing whether actions have prevented further occurrences or have affected a more positive service experience

A modified version of embedding lessons process for complaints is being reviewed. Recurring themes in concerns regularly monitored and taken to triangulation.

5. Involving staff at all stages - Engaging with staff during the whole process to ensure that good practise is recognised and buy-in and accountability is understood

SED engage with teams Trustwide around the user led vision of complaints and is included in the SED Trust Induction. Service Experience performance dashboard displayed at main sites. Increase in number of investigating officers. Data available more widely and frequently via the BI Hub.

29

Service Experience Desk - Raising Feedback /Complaints Handling

DWMH have a reputation for being proactive in our patient/service user engagement and involvement.

BEST PRACTICE What best looks like and which Trusts have it right in complaints handling is a longstanding question with no real answer according to the National NHS Complaints Managers Forum. Benchmarking in relation to complaints is very limited and not particularly helpful when trying to compare specific areas of complaints handling. However we have anecdotal feedback that we have low/med levels of formal complaints compared to other Trusts. The main reason for this, we believe, is that we focus on resolving issues immediately, de-escalating situations; staff and EBEs help with this directly at the point of occurrence and also we are a fairly small Trust.

With regard to complaints and promoting openness, there are some lessons to learn from other Trusts that we might consider:

• Put a pad and pencil on patient’s lockers at their bedside • Ask patients/carers before leaving if there is anything we could have done better during their stay • Have an “openness” tab on the internet showing what we do in easy view picture format with sound – explaining the complaints process/what

will happen etc Have easy read complaints leaflets • Complaints training via e-learning

On a wider perspective we are currently doing some comparative analysis on Friends and Family Test data to gain some view of how we compare to other trusts for overall patient satisfaction. We are also working with Staff Engagement to explore the links between staff surveys and patient survey results and reviewing best practice of those trusts that perform well in both.

EXTERNAL ASSURANCES NHS Improvement (TDA) recognise the Trust for positive practice in both patient/service user experience and involvement, we were asked to meet with them for the opportunity to learn from our organisation. Care Quality Commission During the recent CQC inspection evidence was highlighted as to the positive approach to learning from complaints and service user feedback. They found a pro-active approach to involving patients and came across examples of services that had acted upon patient feedback to enhance experience. Patients informed CQC that the Trust listens to and learns from complaints. Several patients and carers shared examples of concerns they had experienced and how staff managed and resolved these and that the outcomes and actions were communicated to them. All staff were aware of the complaints policy. Understanding ModernGov (Specialist Complaints Training Organisation) Our complaints procedure has been endorsed by a specialist trainer who carried out external complaints training for the Trust on behalf of the training providers Understanding ModernGov. We were asked specifically if our Complaint Management Action Plan (CMAP) could be shared as an example of good practice during training with other Trusts. This organisation is a leading training provider who works with the public sector and provides market-leading learning and development solutions which have been used by some of the largest organisations in the UK. The trainer has specialist knowledge in this field and many years of experience in journalism/ communications and currently writes guidance documents for and works closely with Department of Health.

30

Service Experience Strategy – Action Plan 2016/17

1. Tell us about your experience

Ensuring that there are numerous ways in which people ,can leave their feedback and that these are accessible and simple to use

2. Make sense of the information

Robust analysis and investigation of feedback that is received, free of judgement and preconceptions

3. Respond with action

Recognising when things have gone wrong and putting in place remedial actions

4. Has the action made a difference?

Assessing whether actions have prevented further occurrences or have affected a more positive service experience

5. Involving staff at all stages

Engaging with staff during the whole process to ensure that good practise is recognised, and buy-in and accountability are understood

31

SE Strategy – Q1 2016/17

Domain Strategic Objectives 2016/17

Lead / Source

Progress RAG Rating

Tell us about your experience

1. There is a range of systems, technologies and opportunities for service users and carers to give feedback at all stages of their recovery journey 2. Efficient and effective systems are in place for monitoring and acting on the experience of under-represented groups

Introduce a standard PREMS survey linked to CREWS across all teams

TC C/fwd

A proposal that sets out how the PREMS survey will be deployed across all teams has been produced and awaiting sign off. A meeting has been arranged with Clinical Process Group to take this forward.

Friends and Family Test process to be reviewed. Obtain feedback from staff within teams regarding methodology; liaise with CCG regarding Mi Experiences App as a method of deployment

TC Meeting held with Associate Director of Operations and CRS leads in order to discuss methodology/deployment of FFT. Feedback being sought from staff regarding preferred method of deployment.

Audit availability and accessibility of SED leaflets and posters on sites

TC EBEs are monitoring availability and accessibility of SED literature during their ward visits/site visits across the Trust.

Development of an ‘Easy Read’ version of the SED leaflet, incorporating the principles of ‘My Expectations’.

JA EBE given the project of producing Easy Read version of SED leaflet. SED main leaflet under revision

Welcoming complaints assurance to be included in SED leaflet

JA Currently under review

Trial national Complaints Handling Questionnaire

JA Not yet available

Making sense of information

3. There is an integrated and effective system for receiving, acting and reporting on service experience feedback including triangulation and cross referencing

Integrate Safeguard information with the Trust’s Business Intelligence Hub (BIH)

KC Data is now available on the BI Hub.

32

SE Strategy – Q1 2016/17

Domain Strategic Objectives 2016/17

Lead / Source

Progress RAG Rating

Putting actions in place

4. A simple, integrated approach is in place to agree appropriate actions and ensure clear accountability for delivery

Set up automatic action alerts via safeguard

KC Automatic actions alerts have been set up.

Action plan management via the BIH

KC/JA

Ready to be trialled end Q2

Has the action made a difference?

5. There is an effective system for ensuring that lessons from feedback are learned and embedded 6. Communicating feedback to all key stakeholders is regular, consistent and clear 7. The Trust learns from external intelligence, benchmarking and best practice

Launch an integrated embedding lessons process specifically for complaints and concerns.

JA C/fwd

Actions/embedding lessons process being piloted. Now included in the policy. Further work to be done on embedding lessons when Governance posts are filled

Implement TDA Patient Experience Tool

TC

TDA Tool Version 2 is now established and self-assessment tool to be carried out by end Q2.

Involving staff at all stages

8. Complimentary feedback from users and carers is widely shared and celebrated 9. All staff are aware of their roles and responsibilities in relation to promoting, recording, reporting and acting on feedback 10. All staff have a detailed knowledge of feedback relating to their own service area

Audit complainant satisfaction of the Trust’s complaints process

JA/TC Audit completed

Share patient stories with staff to develop knowledge of feedback relating to their service.

TC Feedback shared with staff at Service Line meetings and Triangulation group.

Promote the user-led vision ‘My Expectations’ more widely with staff to improve awareness of raising concerns and complaints

JA/KC

My Expectations included in SED induction. Promoted at Service Standard meetings. SED have presented at 11 team meetings throughout the Trust in order to promote the vision. Other teams arranged throughout the year.

Share YSWD wider via a regular slot in monthly Team Brief and via a page on public website

JA Completed

Service Case Number

Date Received

Department Category Details Of Complaint Current Status Breach?

A 6904 29/06/2016 Outpatients (DPH) Appointments - Cancelled Appointments are constantly cancelled or changed. Patient would like to be offered another appointment.

Awaiting JMD sign off N/A

C&R 6903 29/06/2016 CRS North (Walsall) Inadequate Support CPN did not offer any support with the issues patient is having with his medication and it's side effects.

Awaiting JMD sign off N/A

A 6901 29/06/2016 Crisis Resolution (Walsall) Inadequate Support Patient has rung Crisis several times and she feels that they fob her off and just want her to get off the phone as soon as possible.

Close Due To No Response N/A

A 6899 28/06/2016 Outpatients (DPH) Attitude Of - Psychiatrist Patient's wife is not happy with the attitude of the doctor her husband saw on 27/06/16.

Undergoing Investigation N/A

EI 6874 28/06/2016 CAMHS Dudley Communication - Lack Of Between Health Bodies Patient's Doctor at Russell's Hall Hospital has not received correspondence from CAMHS.

Awaiting HoS sign off N/A

C&R 6859 23/06/2016 CRS South (Walsall) Inadequate Support Patient is worried after a recent episode led her to go to A&E. She has requested further support from the team.

Undergoing Investigation N/A

OA 6882 22/06/2016 Linden Ward Sectioning Decision - Disputed The patient's son wants to know why his mother was not put on a Section 3. With Chief Executive N/A

A 6873 20/06/2016 Crisis Resolution (Walsall) Inadequate Support Patient feels that the Crisis team are getting tired of her, when she told them that she was cutting herself, they advised her to try to cope with it.

Response sent 20 days

A 6864 14/06/2016 Crisis Resolution (Walsall) Communications - Failure With Patient Patient is not happy that it took Crisis 2 hours to return her call, although she is not sure if it was them calling as she does not answer her house phone.

Closed Due To No Response N/A

C&R/A 6860 13/06/2016 CRS North (Walsall)

Outpatients (DPH)

Inadequate Support

Clinical Staff - Lack Of Confidence In Ability

Family are not happy that services have been withdrawn due to the patient swearing at staff and she is now only being seen once every 6 months.

Patient's family would like a second opinion about her eating problems.

With Chief Executive N/A

A 6852 09/06/2016 Crisis Resolution (Walsall) Confidentiality - Breach The ex-patient's brother has told him that he has been speaking to the hospital regarding his mental health.


A 6846 06/06/2016 Home Treatment Dudley Appointments - Waiting Time on Day

Communications - Failure With Patient

First appointment the team was 45 mins late, the second appointment should have been on the morning, but the team did not turn up until 5pm.

Why did the patient have to call the team to see where they were, they should have called him to advise if they were running late or needed to cancel.


OA 6841 03/06/2016 Outpatients (DPH) DoLS - General Unhappy with the content of the DoLS report. Undergoing Investigation N/A

A 6839 02/06/2016 Crisis Resolution (Walsall) Inadequate support When the patient called Crisis, they told her to distract herself by knitting, cooking or walking a dog.

Closed Due To No Response N/A

A 6818 20/05/2016 Out Patients (DPH) Attitude of Psychiatrist

Clinical staff - Lack of confidence in Ability

Information Supplied by Service - Quality of

Medication - Disputing

Clinical - Assessment

Dr did not introduce himself and made the comment "It is meds or weight loss; you can't have both" wen she queried her weight.

Dr didn’t seem to have read over patients notes and answered questions for himself.

Dr advised that the patient would need to see GP to be referred for counselling, however the Dr should have done this.

Concerns about weight gain was not addressed.

Appointment was hurried and concluded within 5 minutes.


OA 6808 20/05/2016 Out Patients (HLC) Attitude of receptionist The patients wife is not happy that the receptionist refused to make an appointment for them and to let her speak to the Dr.

With Chief Executive N/A

A 6801 18/05/2016 Wrekin Ward Medication - Prescription error

Patients Property Removed

Clinical Staff - Lack of Confidence in ability

Attitude Of -Nursing Staff

Drugs/Alcohol Related

Medication - Delay In Receiving

Arrangements - Discharge

Patients leg swelled up due to have been given wrong prescription.

Whilst on the ward a staff member took a letter and prescription out his bag without his permission and removed his morphine patch.

Unhappy with how the staff treat patient and other patients.

Staff came into patients room and went through patients bag without permission.

Patients coming up to patient asking for cocaine and cannabis.

Painkiller medication not given in a timely manner.

Patient made to wait for long time after expressing intention to self-discharge from the ward.


A/C&R 6796 16/05/2016 Home Treatment Walsall

CRS South Walsall

Placement

Clinical - Assessment

Appointments - Waiting time on Day


Patients Property - Missing

Inadequate Support

Mother of patient not happy where son has been placed and wants him moved closer to home.

Son had not been taking medication and all the doctor did at the assessment was increase his medication and take bloods.

Mother and patient waited hours to be seen, patient ended up running off.

Informed that the medication patient had been given should not have been given at the same time.

Patient was taken from home in dressing gown but was not sent with him when he was moved to Manchester.

AMHP offered no support as could not find anything wrong with patient.

Awaiting AD sign off N/A

EI 6794 16/05/2016 PC MH & TTS Communications - Failure with patient Patient unhappy with the lack of communication regarding her appointment. Closed Due To No Response N/A

OA 6789 13/05/2016 Linden Ward Communication Failure with Family

Clinical staff - Lack of confidence in ability

Patients Property - Theft

Nurses do not communicate with family.

Son feels like he is being lied to by staff and there is lack of supervision.

Son suggests that there has been a theft of his mother's clothes.


C&R / A 6773 06/05/2016 CRS South Dudley

Outpatients Dudley

Attitude of - other

Requested Change of - Consultant

Whilst on the phone to Hill House the patient heard someone say "Is that the D**** I think it is" and then he heard them laughing.

Wished to change teams.


A 6756 28/04/2016 Langdale Ward Visiting rights

Attitude of nursing staff

Patients mother escorted out of the hospital by the police, she felt this was due to an argument she had had with her son on a previous visit.

Mother not happy with nurse who asked her about hers and her sons finance affairs and because she told her it was non of her business the nurse called her an unpleasant name.

Closed due to no response N/A

A 6749 26/04/2016 Langdale Ward Attitude of Nursing staff Patient not happy with the way staff member conducted herself on a supervised visit between the patient and his family.


A 6747 26/04/2016 Crisis Resolution (Walsall) Inadequate support

Communication failure with family

Attitude of Nursing staff

No help provided by Crisis at the time it is needed.

Promised calls back but this never happens.

Person spoke to was horrible and showed no understanding or compassion for the heartache the family are going through.


A 6745 22/04/2016 Clent Ward Communication Failure With Family


Care Plan - Lack Of

Friend concerned that patient was discharged back into care of his mother by consultant but mother was not advised of this and due to patient behaviour did not want him to come back to her house.

Friend wants to know why the patient was put in taxi by staff and told to go to housing because his mother did not want him.

Friend advices that the family have not been given any advice on any on going care.

Awaiting AD Sign Off N/A

C&R 6740 22/04/2016 CRS North (Dudley) Attitude of - Nursing staff Patient is not happy with staff attitude. Closed due to no response N/AA 6732 19/04/2016 Ambleside Ward Attitude of - Nursing staff

Inadequate Support

Patients property - Missing

Mother of patient said the nurse said "I'm glad I don’t have a daughter like yours".

Patients mother unhappy with the response off the nurse when she asked if her daughter had her medication, she said the nurse said "She is a grown women if she's not going to come and collect her medication, I'm not going to chase after her".

Patients property has gone missing since being on the ward.


A 6730 19/04/2016 CRHT (Walsall) Attitude of - Nursing staff

Inadequate Support

Patient unhappy with attitude of staff as when they took pleasure of telling the patient that his care co-ordinator and consultant were discharging him.

Patient told ward he was feeling suicidal and had tablets with him but he was told he was physically fit to go home and the home treatment team would

Undergoing investigation N/A

C&R 6733 18/04/2016 CRS North (Walsall)

Psychological Therapies Hub

Attitude Of - Psychiatrist

Appointments - Time To Receive

Continuity Of Care

Requested Change Of Consultant

Discrimination - Gender

Patient not happy with Drs attitude.

Patient still waiting for a date to be assessed since being referred to physiologist for suspected PTSD in Nov 2015.

Patient feels her treatment has not been helped by rarely seeing the same Dr.

Patients requested to be seen by a female Dr.

Dr has shown lack of respect for patients gender identity.

Reopened Case 48 days

C&R 6711 12/04/2016 CRS South (Walsall) Inadequate Support

Communications - Failure with patient


Patient does not feel the correct support was provided by the team.

Team never answer or return calls.

Patient not happy about being discharged.


A/OA 6705 08/04/2016 CRHT (Dudley)

Malvern Ward

Arrangements - Admission

Medication - Prescription Error

Attitude of - Nursing staff

Patient did not agree with her sectioning.

Patient stated she was given the wrong medication and sometimes the wrong dosage.

Staff would make inappropriate comments to her and her family.

Awaiting HoS sign off N/A

A 6704 08/04/2016 Ambleside Ward Confidentiality - Breach

Section 17 Leave - Arrangements

Inadequate support

Requested change of - Consultant


Medics disclosed information to patients family when she requested not to.

Patients leave was wrong.

Patient feels she is not making progress due to lack of support.

Patient requested to change her consultant.

Medication was incorrect.

Withdrawn N/A

A 6693 04/04/2016 Langdale Ward Attitude of - Nursing staff Staff intimidation and intrusion. Response sent 37 daysC&R 6690 03/04/2016 CRS (Dudley) Attitude of - Psychologist Not happy with the Psychiatrists attitude. Response sent 39 days

Enc 20 EMExT Chair Report September 2016 V1(Final) Pag


Agenda Item number: 10.1 Enclosure: 20

Report Title:

E-MExT Committee Chair Report

Committee:

E-MExT meeting held 16th August 2016


Mark Axcell, Acting Chief Executive Paul Lewis-Grundy Company Secretary


Decision / Approval

Gain assurance

Discussion

Information

Key issues and Risks CEOs Update including strategic planning, update from board and horizon scanning The report made reference to CIP Plans and the departure of two of the Non-Executive Directors and noted that a recruitment process was underway to identify replacements. Quality/CQUINs It was noted that the Quality Improvement Priorities update report was presented to Quality and Safety Committee last week.

All Quality Improvement Priorities had met their quarter one objectives.

The Committee noted that the Physical Health CQUIN scheme was reported to Quality and Safety Committee, and that this year it included the community service.

Director of Nursing Report The Committee received updates on:

• Mental Health Act CQC visits • PLACE results which had been released into the public domain. • Bloxwich Improvement Programme

CIP Update There were 7 red RAG rated schemes for 2016/17, although the majority of the schemes were RAG rated green and expected to deliver by year end.


Financial Positon as at Month 2

An update was received as follows:

• The Trust was reflecting a surplus position of £493k, which was £93k ahead of the planned year end surplus of £1.7m.

• Pay budgets were £581k in surplus, which reflected the level of vacancies within the system

• Overall combined income is £95k in surplus of which £6k is due to over-performance against contracted activity.

• Walsall CCG is a block contract but is over performing by £171k on admitted bed days. • Dudley CCG is a block contract with a break-even position.

Workforce Report Month 2

The Committee noted the following:

• There were approximately 187 FTE contracted vacancies across the Trust, resulting in a vacancy rate of around 16%.

• The Trust had agreed to increase the reporting on mandatory training, essential training and appraisals to weekly reporting.

• The ESR Systems Manager provided an overview of the appraisal and mandatory training reports.

• Any ‘e’ learning undertaken was immediately compliant and recorded on ESR. • There was a slight delay with the recording of any class room based training due to the

processing of the attendance sheets. • It was noted that the weekly reports would exclude those members of staff on long term

sick and maternity leave.

The Committee received updates on:

• The re-deployment register • Recruitment • DBS • Service Line Update • Food and Hydration Strategy • Communications • Environment

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

• Audit Committee • Quality & Safety Committee • Finance & Performance Committee • Trust Board


Recommendations and requests for direction The Board is asked to receive this report from E-MExT for information and assurance.

dudley and walsall mental health partnership nhs trust ... · dudley and walsall mental health ....

Documents