meeting of the trust board documents/jan 2015.pdfagenda trust board 26.01.15 page 1 of 2 meeting of...

Agenda Trust Board 26.01.15 of 2

MEETING OF THE TRUST BOARD

A Meeting to be held in public on Monday 26 January 2015 in

Lecture Room 3, Education Centre, Hollins Park, Winwick, Warrington, WA2 8WA commencing at 9.00am

A G E N D A

Open Forum - 15 minute opportunity for the public to ask questions of the Board

Items Time Duration Enclosure

15/01 Patient Story – Over the last 12 months, the Trust has introduced a new approach to supporting those within our services who self-harm including a self harm policy that provides a framework for staff to increase their confidence in providing the right support at the right time.

The patient story focuses on one aspect of supporting those who self-harm, wound care. The board will hear a servicer user’s perspective in addition to hearing from a member of staff from one of our in-patient units who has who been involved in supporting service user’s to safely care for their wounds now whilst with us as an in-patient and also providing them with the confidence and skills to do the same when they are discharged.

9.15 30 mins Verbal

Minutes, Reports and General Business:

15/02 Apologies for Absence 09.45 1 min Verbal

15/03 Declaration of Interest in Agenda items (Bernard Pilkington)

09.46 1 min

Verbal

15/04 Minutes Part 1 Board Meeting held on 24 November 2014

09.47 2 mins

15/05 Matters Arising Matrix from Minutes of Meeting and Committees (Bernard Pilkington)

09.49 2 mins

15/06 Chairman’s Report (Bernard Pilkington) 09.51 5 mins

15/07 Chief Executive’s Business Report (Simon Barber)

09.56 5 mins

15/08 Quality Committee - Minutes of meeting held on 5 November 2014 (Derek Taylor)

- Chairs report of Quality Committee meeting Held on 3 December 2014 (Derek Taylor)

10.01

10.03

2 mins

10 mins

Verbal

15/09 Audit Committee - Minutes of meeting held on 8 October 2014 (Brian Marshall)

- Chairs report of Quality Committee meeting held on 3 December 2014 (Brian Marshall)

10.13

10.15

2 mins

10 mins

Verbal

Agenda Trust Board 26.01.15 of 2

15/10 Charitable Funds Committee Annual Report & Accounts 2013/14 (Sam Proffitt)

10.25

5 mins

Quality and Performance:

15/11 Trust Performance & Quality Report (Executive Directors)

10.30 60 mins

Break at 11.30 approx. 10 mins Strategy Policy & Risk:

15/12 Serious Incidents (Tracy Hill) 11.40 5 mins

15/13

Risk and Assurance Report (Tracy Hill) 11.45 10 mins

15/14 Monitor Compliance Q3 Submission (Sam Proffitt) 11.55 5 mins

15/15 Quality Committee Quarterly Update (Tracy Hill) 12.00 5 mins

15/16

New Clinical System (Rio) Update (Louise Sell) 12.05 5 mins

15/17 Leigh New Build Update (Simon Barber) 12.10 5 mins

15/18 Capital Update (Nick Rowe) 12.15 5 mins

15/19 Changes to Director Portfolios resulting from the Corporate Services Review (Simon Barber)

12.20

5 mins

15/20 Fit and Proper Person’s Requirement - Directors (Nick Rowe) 12.25 5 mins

15/21 Wigan Mental Health Strategy (Simon Barber) 12.30 10 mins

Lunch Break

30 mins

Date of next meeting: Monday 23 February 2015 at 9.00am at Lecture Room 3 Education Centre Hollins Park Winwick WA2 8WA Exclusion of the Public: The Chairman will propose a Part 2 meeting on the basis: "That publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted, and that the public be excluded".

We will always do our very best to make the right decisions for the health and well-being

of our patients and staff.

We will always do our very best to make the right decisions for the health and well-being of our patients and staff

15/04 Minutes of the Trust Board Meeting held on 24 November 2014 Page 1 of 14

Agenda Item No. 5BP (15/04)

MEETING OF THE TRUST BOARD

PART ONE Minutes of a meeting held on Monday 24 November 2014 in Lecture Room 3,

Education Centre, Hollins Park, Winwick, Warrington WA2 8WA Commencing at 9.00 am

Present: Mr B Pilkington Chairman

Mr S Barber Chief Executive Mrs H Bellairs Non Executive Director

Ms G Briers Director of Nursing and Quality Mr A Chan Non Executive Director Dr C Dale Non Executive Director Mrs T Hill Director of HR & OD Ms L Kellie Interim Director of Operations Mr B Marshall Non Executive Director Ms S Proffitt Chief Finance Officer Mr N Rowe Director of Corporate Services Dr L Sell Medical Director Mr D Taylor Non Executive Director

Ms P Tubb Non Executive Director Apologies: None In Attendance: Mrs J Hughes Interim Company Secretary (minutes)

Mr J Heritage Divisional Director Ms J Murphy Clinical Team Manager (item 14/137) Ms J Unsworth Specialist Nurse Practitioner (item 14/137) PC K Shore Cheshire Police (item 14/137)

1

Open Forum There were no questions from members of the public.

2

14/137 Patient Story – Operation Emblem: Street Triage Service Mr Simon Barber, Chief Executive provided an overview of Operation Emblem, a jointly commissioned service by Warrington and Halton Clinical Commissioning Groups (CCG’s), and the Police and Crime Commissioner for Cheshire. It aligns to both the Crisis Care Concordat which was launched in February 2014, and to Parity of Esteem (NHS England). Mr Barber then read a story of the experience of a 33 year old female patient who had been through the service, which provided insight to the joint working between Trust staff and Police. The partnership working resulted in a positive experience for the



3 4 5 6 7 8

patient at a traumatic and upsetting time, without the need for detention under section 136 of the Mental Health Act. The outcome was that the patient was admitted to our services and has since been able to recover fully. The story ended with a personal thank you to the Trust from the patient and her family. Mr John Heritage, Divisional Director, introduced members of the Operation Emblem Team; Jane Murphy, Clinical Team Manager, Jane Unsworth, Specialist Nurse Practitioner and Police Constable Katie Shone from Cheshire Police, who provided a presentation about the service. The Team is made up of two dedicated police officers and two mental health staff from the Trust who jointly attend incidents where the police have been called and there is a concern about a person’s mental health in order to provide urgent and emergency access to crisis care. The team has been very successful in reducing Section 136 detentions, by providing timely interventions for people in crisis. The team provided details of patient stories from two service users experiences of the service:

The Operation Emblem Team responded to a man who had been drinking and threatening to kill himself. They established that he had on previous occasions been arrested and placed on Section 136 of the Mental Health Act for the same reasons. The team were able to establish that the man was experiencing social stress after the death of his girlfriend; however he didn’t feel he had a mental health problem, and therefore in the past would not engage with services. Following intervention and assessment from the Team, he was able to access alcohol services and established ways in which he could help himself. Over the last six months this approach has helped him; he now has a new job and partner, with access to see his children, and there have been no further incidents.

The Operation Emblem team were called to a Warrington address to attend to a lady known to services with a diagnosed severe mental illness. As the team knew her, they were able to recognise she was displaying her known relapse signature. Previously the lady had been detained under section 136 for displaying the same behaviour. The team were able to formulate a plan which enabled her to make choices, and be released to be cared for at her home by her care staff who she knew and trusted. The intervention by the Team avoided detention or lengthy assessments; they provided quality support and care at a distressing time.

The next steps for this service are to ensure it continues to support the Crisis Care Concordat and establish ways the team could engage further, to provide shared learning to other areas looking to provide the service, partnership working with other agencies to improve pathways with North West Ambulance



9 10 11 12 13

(NWAS) and the Police Services and to continue to provide training to police officers and NWAS staff. The Team invited questions of the Board. The Trust Board asked questions relating to how the service is covered. The team explained that there are approximately 100 contacts per month, covered by 10 hour shifts, 7 days a week. The Non-Executive Directors asked about the NWAS pathways and introducing the service to other areas. It was explained that training of NWAS staff has established the ambition to change pathways to avoid journeys to hospital. The service provision for Wigan with Greater Manchester police differs to reflect commissioning requirements. Further discussion followed regarding evaluating the service, where it was established that from the figures available savings of £40k are expected, along with benefits to release police time, and significant reduction in Section 136 costs, the service provides monthly performance indicators and quarterly patient stores to the CCGs. Mr Bernard Pilkington, Chairman, thanked the Operation Emblem Team and Cheshire Police, and said it was a significant step forward for patient care. The Board noted the content of the Patient Story

14

14/138 Apologies for Absence There were no apologies.

15

14/139 Declaration of Interest in Agenda items No interests were declared.

16

14/140 Minutes The minutes of the Part 1 Formal Board Meeting held on 27 October 2014 were accepted as a true and accurate record of the meeting.

17

14/141 Matters Arising Matrix It was noted that all matters arising with a 27 October 2014 completion date were on the agenda for consideration.

18

14/142 Chairman’s Report The Chairman provided a summary of the Part 2 Formal Board Meeting held on the 27 October 2014 and action taken on behalf of the Board since the last meeting.



19 20 21 22 23 24 25

The Chairman provided the Board with an update on the Wigan and Warrington Borough Council relationship meetings where the Trust’s move to borough based model of operational service delivery was discussed. Both meetings were very positive and have helped to strengthen the Trust’s partnership working. The Chairman also informed the Board he had attended a ‘State of Mind’ staff presentation provided by Dr Phil Cooper, Nurse Consultant, and past and present rugby league players. The players shared their stories, of experiencing mental health problems, and how the State of Mind Initiative had helped them. The Chairman added that it seemed men had particular difficulty in accepting help and talking about their problems, and explained that the initiative had gone some way in addressing this. He concluded by encouraging the Trust Board and their teams to attend any future presentations as it was a particularly powerful message. The Chairman informed the Board that the Nominations and Remuneration Committee held a meeting on 11 November 2014 which discussed the appointment of Vice Chair. Two Non-Executive Directors expressed an interest in the role, and following a review of two candidates, a recommendation was made that Mrs Helen Bellairs, Non-Executive Director be appointed to the position. This recommendation was approved by the Council of Governors at their meeting on 18 November 2014. The Chairman thanked both candidates for applying for the position, and also thanked Dr Colin Dale, Non-Executive Director for undertaking the post previously. Mr Barber informed the Board that State of Mind had won the media award from MIND charity, explaining the work done to publicise the initiative, including television programmes and a dedicated State of Mind rugby league games each season. Mrs Bellairs praised the service for encouraging people to access services and gain help. The Chairman informed the Board that Mr Barber had been awarded the NHS Mentor / Coach of the Year Award from NHS North West Leadership Recognition Awards 2014. The Trust Board congratulated Mr Barber on his achievement. Mr Barber went on to inform the Board that the Knowsley Recovery College were also finalists at the same award ceremony, and this was testimony to the work they are doing. Mrs Bellairs asked about the Recovery College service and Ms Briers, Director of Nursing and Quality, explained that it was a virtual service that worked out of the existing recovery services, using local facilities as appropriate. Ms Tubb and Mr Chan, Non-Executive Directors attended the ‘Together Here at 5BP’ coaching event at the Trust on 17 and 18 November. It was an opportunity for past attendees of the Coaching Conversations programme to reconnect with colleagues, recognise successes since attending the course



26 27

and identify further areas of actions for them as individuals. The Board members who attended were impressed and commented that there was a observed blend of realism and optimism among the participants. Mr Barber commented that both the days had ended with very good question and answer sessions demonstrating how we are successfully developing the culture in the organisation. Ms Tubb noted points from the event regarding; concerns and problems were being aired, but with optimism, however it was noted that feedback from the Acute Care Pathway (ACP) review was not getting to frontline staff. Secondly there was a squeeze felt by middle team staff / team managers from pressure to achieve and deliver; however this was dealt with positively, as the staff arranged to meet and support each other to problem solve, and gave people the opportunity and to ask questions. Mr Barber responded explaining that the Executive Team were soon to be discussing this issue to establish the Executive Director’s role in supporting managers. The Board noted the content of the Chairman’s report.

28 29 30 31 32 33 34

14/143 Chief Executive’s Business Report Mr Barber presented his report detailing issues of Trust business and items that impact on the Trust and its services. Mr Barber congratulated Bridgewater Community Healthcare NHS Foundation Trust for achieving Foundation Trust status. Mr Barber also explained that future Intelligent Monitoring reports would be received in part 1 of the Trust Board. Ms Linda Kellie, Interim Director of Operations, commented on the House of Commons Health Committee CAMHS (Child Adolescent Mental Health Services) report, explaining that the report was well researched and gave a true view of CAMHS services. Mrs Helen Bellairs, Non-Executive Director, asked about the Trust’s position in respect of the paper and if there were any areas of concern. It was agreed that the Assistant Director for CAMHs would review the Trust’s position in respect of the report and present a paper for discussion and approval at the Quality Committee Mrs Bellairs asked that the paper also be circulated to the Board members not involved with the Quality Committee. Mr Barber thanked Mr Nick Rowe, Director of Corporate Services and his team for their work in concluding the partnership agreement with the Greater Manchester Fire and Rescue Service. The Board noted the content of the Chief Executive’s Business report.

Action: Director of Nursing and Quality



35 36 37 38 39 40 41 42

14/144 Quality Committee Minutes of meetings held on 8 October 2014 The Board received the ratified minutes of the meeting. Chair’s report on Quality Committee meeting held on 5 November 2014 Mr Taylor, Non-Executive Director and Chair of the Quality Committee held on 5 November 2014 explained that the Committee had received and discussed a number of papers including the Infection Prevention and Control Report which showed green in all areas except for ‘below the elbow’, the Quality Committee wanted to see an improvement and established that staff need more emphasis on what is expected. In addition the removal of desktop sterilisation equipment in podiatry services was discussed, and the committee were assured that the services remain safe. The scheduled complaints deep-dive was undertaken and found that the particular complaint that was reviewed took a long time to finalise, the letters required improvement and were overly clinical in language; the Quality Committee were informed a review of the current complaints process is being undertaken. The Committee discussed the information provided relating to the Psychological Therapies Waiting List, and found there was inconsistency in waiting times. The Forensics Business Stream challenge session was attended by the Assistant Director of Forensic Services, the session provided assurance to the Quality Committee of the good, safe and quality service being provided by the teams. The Board noted the verbal report.

43 44 45 46

14/145 Trust Performance and Quality Report The Board discussed the Quality and Performance report for the period up to October 2014. The Chairman asked each Director to take questions on their individual sections of the Report. Are we delivering our services safely? The Board discussed the report. Mrs Bellairs asked if there was anything the Board should be made aware of



47 48 49 50 51 52 53 54 55 56

from the recent CQC Mental Health Act inspections in addition to the Specialised Commissioning inspection on Secure Services. Ms Briers explained that feedback on the day had not highlighted any areas of immediate concern and that we await the formal feedback that will be reported through the Quality Committee. Do we have sufficient, highly motivated and skilled staff? The Board discussed the report. Mr Allan Chan, Non-Executive Director asked about the high staff turnover. Mrs Tracy Hill, Director of HR and Organisational Development explained that the Trust was aware of the staff turn-over rate and that this was not out with the normal tolerance, once recognition of the recently transferred services was taken into account. Dr Colin Dale, Non-Executive Director questioned the safe staffing level commentary. Ms Briers explained that on some occasions staffing levels may be below the advance planned requirements, however the professional judgement applied can determine that the staffing levels were still safe to provide appropriate safe care due to, for example, lower than expected occupancy levels. Are we delivering to our Patients and Users? The Board discussed the report. Mrs Bellairs noted the continued concern relating to Payments by Results (PBR) clustering. Dr Louise Sell, Medical Director, informed the Board that action had been taken but this had not reduced the trend to date. The Non-Executive Directors asked for reasons preventing staff completing PBR. Ms Kellie explained that where pathways are in place, for example Later Life and Memory Service (LLAMS), it is easier to complete, however some services are not as easy, perhaps leading to non-completion. Dr Sell explained there was a disconnect with some clinicians.. Dr Sell agreed to provide further information to the Trust Board regarding meeting the PBR Target and development of crowd sourcing for PBR clustering. Are we financially viable? The Board considered the information provided. Mr Chan asked about the Trust’s financial performance which was shown as outside the tolerance for performance against the retained surplus. Ms Proffitt,

Action: Medical Director February 2015



57 58 59 60 61 62 63

Chief Finance Officer reported that a number of actions were being taken and the position had improved slightly in October. There remains risk of approximately £0.5m to the year-end forecast which continues to be monitored and managed but the Trust remains on target to meet the year end underlying surplus of £4m. Are we delivering our strategy? The Board noted the report. Do our stakeholders support what we do? The Board noted the report. Mr Taylor asked if there were any outcomes from the bid proposals made to NHS England. Mr Barber explained he had not heard back for the individual schemes. Ms Kellie also advised that the funding would only be available to the end of March 2015, and therefore would have a limited effect. Operational Overview by Business Stream The Board discussed the report and considered the detailed quality information in relation to each business stream. Adults The Board discussed the report. The Non-Executive Directors noted the Performance and Development Review compliance of 65% continued to fall short of the 90% target, and asked if the target was achievable. Ms Briers commented that the size of certain operational teams and the training and number of direct reports to undertake Performance and Development Reviews may impact on compliance. Mrs Hill explained that Trust guidance issued two years ago included that managers are not expected to complete more than eight Performance and Development Reviews and that work was still on-going to achieve this. There was agreement that the target should be achievable. It is necessary to look at what we have done for larger teams with more than eight staff, it was also explained that where staff move, their Performance and Development Review should be portable, with an early conversation to discuss progress and set new objectives from the start. Ms Kellie commented on the action being taken to address referral breaches to the ten day referral target. Each breach is being analysed, causes include incorrect discharge information which is now being addressed and work continues to look at referral rates capacity and demand, as increased breaches is likely to be due to increased referrals.



64 65 66 67 68 69 70 71 72

Dr Dale asked about the new Sanctuary service being provided. Ms Kellie informed the board it was an out of hours service to support those that didn’t need admission, and was based on a Manchester model. It is local Wigan based charity, Compassion in Action that you phone into, and are invited to come in, and can contribute to the avoidance of mental health admissions and Accident and Emergency attendance. Secure Services The Board discussed the report Dr Dale asked a number of questions about the quality inspection undertaken by NHS England, and had we had these before, and if it was a contractual visit, if it was based on national guidance, or a local review, and the potential differences in approaches. Mr Barber explained that all of our five borough Commissioners in addition to NHS England can conduct unannounced visits, and these are are locally determined. Mr Heritage added that the visits were helpful, as it allowed our commissioners to see the services and have quality conversations. Ms Briers added that CCG’s have already been involved in Internal Quality Reviews and these have been discussed in the Quality Contract Meeting with Commissioners and again helped to understand the services from a different perspective than just financial. Later Life and Memory Services The Board discussed the report. Ms Kellie provided further information about involvement in the Wigan Borough ‘Perfect Week’; pop-up memory services were set up in GP practices and staff offered screening to patients. A similar event happened in Warrington Borough three months ago. Learning Disabilities The Board discussed the report. Mrs Bellairs asked about outcomes from the Learning Disabilities away day that discussed the key strategic objectives for the service, and would inform future Clinical Strategy. Ms Kellie confirmed that the Board would be updated on feedback on the event at the next meeting. Physical Health The Board considered the information provided.




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Mrs Bellairs noted the number of high grade pressure ulcers and increase of patient harm and Trust actions. Ms Kellie explained a full report on pressure ulcers is to be discussed at the Quality Committee, adding that a significant piece of work will be required to standardise the approach. The Board discussed the notification that the Musculo-Skeletal Clinical Assessment and Treatment service in St Helens will be terminated from the end of March 2015. GP’s will provide the referrals currently going through the triage service provided by the Trust. The impact of cessation of the service on patients, waiting times and staff was discussed. Mr Chan questioned the over spend within the Centre for Independent Living. Ms Proffitt explained that Commissioners have agreed to fund the over spend, and a review meeting has been set up for future funding. Child and Adolescent Mental Health Services The Board noted the report. Children, Families and Wellbeing The Board noted the report. Ms Tubb asked about the work regarding the recovery plan for Paediatric Speech and Language Therapy service. Ms Kellie, advised she would be in a position to provide feedback at the end of November and a verbal update would be given at the next Board. The Trust Board discussed providing parts of pathways, it was felt that it is less problematic and the Trust performs well where it controls the pathway. Commissioning behaviour and choices, along with the becoming the prime provider for fragmented pathways was also discussed. The Board noted the content of the Quality and Performance Report.


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14/146 Serious Incidents Ms Briers provided the Serious Incidents Report for the period of October 2014. It was noted that serious incident reviews had been commissioned for all seven Serious Incidents reported through the StEIS system. There have been further developments in the governance arrangements, with matrons and quality leads identified as lead reviewers for serious incidents with two day bespoke training provided in November; positive feedback for the training has been received. Ms Briers invited questions. The Board discussed the paper and received the latest position regarding Serious Incidents.



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14/147 New Clinical System (RiO) Update Dr Sell provided an update to the Board on the implementation of the new Clinical System (RiO). It was highlighted that the go live date for cohort one had been revised due to a number of issues identified through testing. This delay is also likely to impact on cohorts two and three, with any dates to be established at the next RiO Project Board meeting. The paper details the revised plan for cohort one, with some amber and red areas, although still areas of work to be done, the revised target date is a reasonable one with an actual go live date of 2 February 2015; to keep in line with organisational reporting. The Board was advised that the Test and Train Work Streams were are on track, along with the Reporting Work Stream which required live data testing and therefore remained amber. Dr Sell informed the Board that the main area of concern was the technical work stream; solutions to technical issues have been identified and work on data quality is still required, the data quality team now report to the Interim Chief Information Officer. The revised go live date has been communicated to the organisation. The Board discussed the update and Mr Chan, Non-Executive Director, commented on the problems the RiO project had experienced relating to programme slippage, recruitment and resourcing the project initially. Mr Brian Marshall, Non-Executive Director, stated that he had overall confidence that the programme was being managed effectively. This view was echoed by the other Non-Executive Directors. The KPMG review to approve the plans for cohorts two and three would also provide assurance for the project. The Board noted the progress to the programme and provided the necessary support to the RiO Programme Board. The Board confirmed their support to the RiO Programme Board’s decision to revise the Cohort 1 go-live date to 2 February 2015.

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14/148 Leigh New Build Update Mr Barber provided the update on the report for the Leigh New Build, noting the green RAG rating against all work stream areas. Mr Barber added that the planned improvement works are moving forward and are on target for completion. The partnership working between the Trust, local residents and Kier has been very good and that this had been commented on during a recent Andy Burnham residents meeting. Security lighting and boarding is now in place around the site, with no problems experienced by local residents. Local Councillors have been supportive with the work undertaken to date and the planned main work starting in January 2015.



91 92

Mrs Bellairs asked about local people being involved in the construction. Mr Rowe advised that Keir expected that approximately 30% of the workforce would be sourced locally. The Board noted the progress on the project and provided the necessary support to the Project Board, and noted the on-going land improvement works

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14/149 Friends and Family Test Update Mr Rowe provided an update of the Friends and Family Test Report outlining Trust preparedness and work undertaken by the implementation group which included operational staff, matrons and quality leads. He advised that all teams will transition from the Patient Experience survey to the Friends and Family Test from 1st December and that formal reporting to NHS England will commence from the end of January 2015. Methods to capture the information include post cards and kiosks using appropriate language to suit each client group. He advised that it would be a challenge to achieve sufficient responses. Mrs Bellairs asked about the reporting, and was advised that the information was available at team level and functional level and would be analysed so that it could be presented at Borough level also. Mr Rowe also informed the Board that data was being collected by different methodologies with trials for SMS text messaging currently being undertaken by the Adult Recovery Teams. The Board noted the contents of the paper and were assured that the Trust has necessary plans in place to deliver the Friends and Family Test in line with NHS England guidance.



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14/150 Safer Staffing Board Report Ms Briers provided an overview of the Hard Truths: Publishing of (Nursing) Staffing Data – six monthly review levels from May to October 2014, to provide the Board with assurance that the level of nursing staff within wards is safe to deliver effective care. Ms Briers explained that during the six month period there had been 13,200 shifts of nursing staff on wards. The judgement to establish if these shifts were safe was developed by the Trust, and complies with ‘Hard Truths’ guidance in the absence of NICE guidance for mental health. The safety of staffing is established by comparing advance planned staffing to actual staffing using the e-rostering system, and taking into account staff sickness and occupancy. Ms Briers added that the system has extended to include escalation plans. This would involve the use of the Trust incident reporting system, Datix, to escalate any staffing concerns to provide assurance that mechanisms are in place to sufficiently monitor and record safer staffing. The Board accepted the report and agreed to the proposed work to review the strategic approach and governance systems to identify and report on staffing levels. The Board noted that it will continue to monitor the monthly exception reports via the Trust monthly Performance Reports and to ensure actions are identified and taken to address any areas of concern with regards to shortfalls in staff capacity and capability. The Board approved this report for publication on the Trust Safer Staffing website page and upload to UNIFY in line with external reporting requirements. The Board agreed to receive an updated report on further developments in June 2015.

Action: Director of Nursing and Quality June 2015

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Closure of Part 1 of the Board of Directors’ meeting Exclusion of the Public The Board of Directors resolved to exclude the press and public from the meeting at this point on the grounds that publicity of the matters being reviewed would be prejudicial to public interest, by reason of the confidential nature of business. Members of the public were requested to leave the meeting room at this point.



107 108

Date of next meeting Monday 26 January 2015 at 9.00 am Lecture Room 3, Hollins Park House, Hollins Park Warrington WA2 8WA

Signed: …………………………………………………. Date: ……………………………. Chairman


15/05 Matters Arising Matrix (Part 1) Page 1 of 4

TRUST BOARD MATTERS ARISING - FOLLOW-UP MATRIX

PART 1 Board Meeting – 27 October 2014

Ref: TRUST BOARD 2014/15 DATE: 24 November 2014

Item/subject:

Decision taken and/or

Action required: Format:

Responsible

Person: Deadline:

Outcome:

29 September 2014 14/90

Patient Story To bring back an update to items discussed as part of the 28 July Patient Story Verbal update GB January

2015

27 October 2014 14/130

Later Life and Memory Services

To provide data on the provision of nursing and care homes within each of the five boroughs Verbal update GB January

2015

27 October 2014 14/130

Physical Health

To provide breakdown information on MSK cohorts, including service users who self-elect not to be seen within ten days.

Verbal update GB January 2015

27 October 2014 14/134

Board Assurance Framework

To provide a breakdown of figures against the Board Assurance Framework harm reduction risks 1845/1846/1847

Board Assurance Framework GB January

2015 On Agenda

27 October 2014 14/134

Board Assurance Framework

To include the Paediatric Speech and Language Therapy waiting times to treatment target on the Risk Register


24 November 2014 14/143

Chief Executive’s Business Report

The paper relating to CAMHs waiting times, to be presented to Quality Committee, should also be circulated to the Board members not directly involved with that Committee.


24 November 2014 14/145

Quality and Performance Report

Dr Sell agreed to provide further information to the Trust Board regarding meeting the PBR target and development of crowd sourcing for PBR clustering.

Report LS February 2015



24 November 2014 14/145


It was agreed that the Board would be updated on feedback from the Learning Disabilities away day that discussed the key strategic objectives for the service to inform future Clinical Strategy, at the next Board meeting.


24 November 2014 14/145


A verbal update on the recovery plan for Paediatric Speech and Language Therapy would be given at the next Board.




TRUST BOARD MATTERS ARISING - FOLLOW-UP MATRIX – ARCHIVE PART 1 2014/15

Item/subject:



Responsible

Person: Deadline:

Outcome:

28 April 2014 14/53

Use of Trust Seal

The Trust Scheme of Reservation and Delegation would be reviewed to ensure that these were consistent with the requirements of the Trust when sealing documents.

Audit Committee and then Board

SP / NR September 2014

Complete

28 July 2014 14/99

Quality and Performance Update

Are we delivering on our strategy? It was agreed that the Chief Executive would consider further the key indicators to be applied to this section of the report taking into account the Board Assurance Framework strategic risks.


SB September 2014

Complete

28 July 2014 14/99


It was agreed that it would be useful to categorise readmissions in relation to whether the readmission was planned or un-planned


LK September 2014

Complete

28 July 2014 14/100

Quarter 1 Update from Quality Committee

It was agreed that the Terms of Reference for the Quality Committee would be reviewed to ensure that the membership and quorum provisions were consistent with the Trust Constitution.

Quality Committee and then Board if required

GB TBC Complete

28 July 2014 14/104

New Clinical System (RiO) Update

It was agreed that the definition of the Red-Amber-Green rating within the report would be included within future reports.

Board Report LS September 2014

Complete

28 July 2014 14/106

Leigh New Build Update

It was agreed that the definition of the Red-Amber-Green rating within the report would be included within future reports.

Board Report SB September 2014

Complete



TRUST BOARD MATTERS ARISING - FOLLOW-UP MATRIX – ARCHIVE PART 1 2014/15

Item/subject:



Responsible

Person: Deadline:

Outcome:

27 May 2014

Open Forum It was agreed that information from the North West Governors events would be shared with the Board through the Chairman’s office.

Circulation off line J T-H/BP On-going Complete

27 May 2014 14/64

Chief Executive’s Report

The Board is required to receive a monthly report detailing the percentage of actual hours of nursing staff each ward had on duty, compared with the planned number of nursing staff hours.

Report GB June 2014 Complete

27 May 2014 14/65

Quality Committee

Minutes from 2 April 2014 - It was noted that the minutes would be amended to reflect the fact that Alan Griffiths was a Governor and not a Non Executive Director of the Trust.

Quality Committee GB June 2014 complete

31 March 2014 14/30

Matters Arising Matrix

An Annual report from the Medical Education Board would be presented to the Board in July 2014.

Report LS July 2014 Complete

30 June 2014 14/85

New Clinical System (RiO)

The Medical Director agreed that further information would be provided to the Board to confirm whether a delay in cohort 1 would impact on other later stages. It was agreed that this would be highlighted to the Board in the next Rio update.

Rio Report LS July 2014 Complete

29 September 2014 14/117

Safe Staffing Levels

More data on safe staffing levels to be included on future Performance Reports

Quality and Performance report

GB October 2014 Complete

29 September 2014 14/113

Adults - Referral to Assessment Times

To provide an update on work being undertaken to address the referral to assessment times and 72 hour follow ups

Quality and Performance report

LK November 2014

Complete

27 October 2014 14/126

Chairman’s Report

To review the format of the Chairman’s Trust Board Report

New format to report against Strategic Themes

BP November 2014

Complete

Agenda Item No.

5BP (15/06)

15/06 Chairman’s Report Page 1 of 5

BOARD REPORT

___________________________________________________________________ DATE OF BOARD MEETING:

26 January 2015

TITLE OF REPORT:

Chairman’s Report

PURPOSE OF REPORT:

To provide an update from Part 2 of the Board meeting held on the 24 November 2014. To provide an update of any actions taken on behalf of the Board since its last meeting.

KEY POINTS/TEAM BRIEF:

• Update from Part 2 of Trust Board meeting of 24 November 2014.

• An update on meetings attended and connections to the Trust’s strategic themes and details of forthcoming events and meetings

• An update of actions taken on behalf of the Board since the last meeting.

ACCOUNTABLE DIRECTOR:

Bernard Pilkington Chairman

RECOMMENDATION TO THE BOARD:

The Board discusses and reflects upon the issues in the report.

Agenda Item No.

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IMPLICATIONS AND LINKS FOR TRUST GOVERNANCE Governance Areas (√ the areas the report supports, or to which it is linked)

√

1. Are we delivering our services safely?

2. Do we have sufficient, highly motivated, skilled staff? √

3. Are we delivering to our patients and users? √

4. Are we financially viable?

5. Do our stakeholders support what we do? √

6. Are we delivering on our strategy?

7. Is the organisation and its services well led?

Does this paper address a risk on the Board Assurance Framework (BAF)?

Yes No √

If yes,

BAF entry No.

Trust High Level Objective (as

above) Description from Board Assurance Framework

Agenda Item No.

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Report to Trust Board

24 November 2014

Chairman’s Report

1. UPDATE FROM PART TWO OF THE BOARD MEETING HELD ON THE 24 November 2014

Below is a summary of the business conducted in Part 2 of the Board meeting held on the 24 November 2014 at Lecture Room 3, Education Centre, Hollins Park, Hollins Lane, Warrington, WA2 8WA.

• Serious Incidents The Board discussed the paper provided by the Director of Nursing and Quality and received the latest position regarding Serious Incidents.

• Leigh New Build Options

The Board discussed the paper provided by Mr Simon Barber, Chief Executive in relation to the delivery options for the new Build Project in Leigh. The Board agreed to proceed with Phase One build as approved at its meeting in July 2014 and proceed to a more detailed design for phase two Later Life and Memory Services.

2. MEETINGS ATTENDED / INFORMATION

The following narrative demonstrates connections to the Trust’s Strategic Themes

i) Do we have sufficient, highly motivated, skilled staff? Staff Christmas Visits I held my Christmas visits to staff within some of the 5 Boroughs Operational Teams throughout December and accompanied by Allan Chan and Derek Taylor, Non Executive Directors, on visits to St Chad’s Clinic and the Later Life and Memory Service, I met our staff based at:

• Huyton Core & Cluster Rehab Centre, Yew Trees Centre, Huyton • A & E Liaison, Whiston Hospital • St Chad’s Clinic (Walk-In Centre), Kirkby • Later Life and Memory Service, Wigan • Wigan Child and Family Helping Hands Centre, Wigan • Wigan RAID Team, Royal Albert Edward Infirmary, Wigan

During these visits I was very impressed with the Walk-In Centre at Kirkby and the joint working arrangements with Aintree University Hospitals NHS FT

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A&E department. Staff are able to gain experience working on both sites and receive joint training from A&E consultants at Aintree. The RAID Team is working extremely well at the Royal Albert Edward Infirmary at Wigan and have developed good working relationships with the Hospital Trust. The Non Executive Directors and I were very impressed by the staff we met during the visits. They were very experienced and demonstrated a great deal of commitment and dedication to our patients and service users. Staff Study Achievement Awards On the 12 December 2014, I presented Staff Study Achievement Awards to a number of our staff who have qualified with accredited study within the last six months. At the Award Celebration event, I presented to awards to 22 staff who have studied Food Hygiene, AMSPAR Medical Terminology, Business Administration, Management, Health and Social Care, Warehousing and Electrical Installation. I was delighted to present these awards to our staff and it is very encouraging to see our staff furthering their education

ii) Are we delivering to our patients and users? Service User and Carer Forums I attended the Adult Joint Service User Carer Forum on 1 December 2014 at Orford Jubilee Neighbourhood Hub, Warrington and the Later Life Forum at The Old Schoolhouse, Huyton on 11 December 2014. These are very productive meetings giving me the opportunity to meet with some of our service users and carers and listen to their experiences of using the Trust’s services.

iii) Do our Stakeholders support what we do?

Meeting for Prospective Governors On 7 January 2015, I attended a meeting for prospective Governors held in the Education Centre at Hollins Park. Presentations were given to members interested in finding out more about the Trust and the role of the Governors in relation to the forthcoming Council of Governors’ Elections. The event was well attended by 14 members, comprising of both public members from a number of our constituencies as well as staff members from across the Trust. FORTHCOMING MEETINGS / EVENTS 21 January 2015 – Wigan Borough Council Relationship Meeting. A verbal update of this meeting will be given at the January Trust Board.

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i) ACTIONS TAKEN ON BEHALF OF THE BOARD A verbal update will be provided to the Board as appropriate.

4. RECOMMENDATION

That the Board notes the contents of this report.

Bernard Pilkington Chairman

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15/07 Chief Executive’s Business Report Page 1 of 5

BOARD REPORT ___________________________________________________________________ DATE OF BOARD MEETING:

26 January 2015

TITLE OF REPORT:


PURPOSE OF REPORT:

To provide a résumé of key issues of Trust business and items that impact on the Trust and its services.


• Access targets in Mental Health • Changes at NHS England • Deanery visit • Monitor’s Medical Advisory Groups


Simon Barber Chief Executive


That the Board notes the contents of the report.

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√

1. Are we delivering our services safely? √






7. Is the organisation and its services well led? √


Yes No √

If yes,

BAF entry No.



Agenda Item No.

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Report to Trust Board 26 January 2015


1. MENTAL HEALTH ACCESS TARGETS

The Department of Health published ‘Mental health services: achieving better access by 2020’ in October 2014. This document sets out national waiting time standards from April 2015 and plans to provide better access to mental health services over the next 5 years. Waiting time standards for mental health will come into effect from 1 April 2015. These are:

• treatment within 6 weeks for 75% of people referred to the Improving Access to Psychological Therapies programme, with 95% of people being treated within 18 weeks

• treatment within 2 weeks for more than 50% of people experiencing a first episode of

psychosis Funding of £40m for each target has been identified nationally. The current position against these new targets across the Trust along with the resource implications are currently being reviewed. The additional funding is being discussed in the 2015/16 contract meetings with the Trust’s commissioners. Monitor considers the targets to have a similar function to access targets used as triggers for governance concerns within acute providers. Consultation was issued in December 2014 to review how these targets should be implemented as part of the standards in the Risk Assurance Framework (RAF). Monitor would like Mental Health providers to begin reporting these from April 2015 but have put forward a number of options for the phasing towards using targets as triggers for investigation. The consultation deadline is the 18th February 2015. In addition to the phasing, Monitor would also like to know whether Trusts see these targets as good indicators of potential governance concerns. 2. CHANGES AT NHS ENGLAND On 1 October 2014 NHS England announced plans designed, in part, to streamline and align the functions and structures which support the organisation to work more effectively – both nationally and regionally – to minimise duplication and make more effective use of resources. In December we were informed of how those changes would look in our region.

We have been told “A single integrated team for the North region has been developed to allow maximum flexibility of working arrangements and to reduce duplication of effort, especially in assurance work. Four geographical locations have been identified in each region, taking into account factors such as: numbers of relationships with CCGs, Trusts, Local Authorities, population size and patients flows.”

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Directors of Commissioning Operations. have been appointed to the following regions, responsible for leading work in each of the four geographical footprints on CCG assurance, direct commissioning and system leadership

• Clare Duggan - Cheshire and Merseyside • Moira Dumma - Yorkshire and the Humber • Graham Urwin - Lancashire and Greater Manchester”

You will see that unfortunately an appointment has not been made to Cumbria and the North East.

3. DEANERY VISIT

The Annual Assessment Visit from Health Education England North West (Mersey) took place on 28 November 2014. I received the report on the 29 December 2014. The report identified several areas of “notable practice” and the GP advisor feedback that we were the only Local Education Provider she had visited in which all GP trainees reported that they are always fully supported to attend their general practice specific training events. With regard to previous requirements, the progress we have made to improve out of hours handover was noted and we are now required to extend this to all tiers of out of hours provision. The report makes 3 recommendations which are that we;

• Review and focus induction to the needs of the trainees. • Review security and car parking. • Review the effectiveness of handover with nursing staff about the medical care of our

in-patients. The full report will be presented at the Quality Committee. 4. MONITOR’S MEDICAL ADVISORY GROUPS

Earlier this month I received a letter from Hugo Mascie-Taylor the Director of Clinical and Patient Engagement at Monitor. In the letter Hugo thanked the Trust for releasing our Medical Director, Dr Louise Sell, to sit on the Mental Health Medical Advisory Group. The letter also listed the following areas where the groups have contributed to shaping Monitor’s work programme.

Those areas have included: • Pricing – giving views on the longer term direction of travel as

well as responding to specific technical questions and research findings;

• Economics – shaping projects on the cost of transferring care to out of hospital settings, the smaller acute project and workforce;

• Regulation – responding to proposals for the Risk Assessment Framework, responding to learning from regulatory interventions, giving provider perspectives on national bodies’ ways of working, and contributing views on the APR process;

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• Competition – review of community commissioning and choice in mental health;

• Development – the role of medical directors on boards, service line management, our developing approach to operational performance improvement.

The letter further stated that “Monitor staff have found the input of the Medical Advisory Groups very useful in shaping work programmes at an early stage, or getting a clinical sense-check on specific proposals or lines of inquiry.”

I would like to formally thank Dr Sell for her contributions outside of the Trust. 5. RECOMMENDATION

That the Board notes the contents of the report. Simon Barber Chief Executive


15/08 Minutes of the Quality Committee 5 November 2014 Page 1 of 13

MEETING OF THE QUALITY COMMITTEE

Minutes of a meeting held on Wednesday 5 November 2014 in the Rossetti Meeting Room, Hollins Park Hospital, Winwick, Warrington WA2 8WA

Commencing at 9.00 am Present: Mr D Taylor (Chair) Non-Executive Director

Mr C Dale Non-Executive Director Ms G Briers Director of Nursing and Quality Dr L Sell Medical Director

Mr A Griffiths Member Governor Ms P Tubb Non-Executive Director

Apologies: Mrs C Molyneux Carer Representative

Mrs T Hill Director of Human Resources & Organisational Development Mrs A Cunliffe Staff Side Representative

In Attendance: Ms L Kellie Director of Operations

Mrs N Flood Professional Lead for Allied Health Professionals

Mrs H Kilgannon Assistant Director Organisational Learning & Development

(Representative for Mrs T Hill) Mrs L Cheung Assistant Director, Integrated

Governance Mr M Kenny Assistant Director, Adult & Secure

Division Mr S Hull Assistant Director, Nursing &

Safeguarding Miss J Chadwick Interim Head of Risk & Patient Safety Mrs W Caton Personal Assistant (Minutes)

77/14 Attendance and Apologies Mr D Taylor, Non-Executive Director and Chair opened the meeting.

78/14 Notes of Previous meeting The Committee agreed the minutes from the previous meeting held on 8 October 2014. Mr C Dale advised that the Trust Board had commended the quality of the minutes.

79/14 Action Log / Matters Arising 54.14.3 Serious Incident Deep Dive – The Medical Director advised that the National Spine does not provide a specific alert system to highlight information added to a patient record which is only evident when the patient record is accessed. 71/14 Risk Management LLAMS Inpatient Wards – The Director of



Nursing and Quality advised work is in progress to look at specific issues highlighted and the Assistant Director of Nursing and Safeguarding has met with the Matrons and Quality Leads to discuss these. Internal Quality Reviews have been arranged and heavy emphasis will be given to observations and the interaction between staff and carers. Work has been commissioned to look at what triggers admissions to LLAMS (Later Life & Memory Services) and to look at the community pathway. The Head of Care Delivery is leading on this. 72.14.3 SI Deep Dive – The Director of Operations confirmed the status of the pathways for the RAID Team which are now in place together with operational guidelines for teams. 72.14.2 SI Process – Mrs P Tubb has now met with the Director of Nursing and Quality and Assistant Director, Integrated Governance to discuss the proposed Serious Incident training. 73.14.1 Complaints Deep Dive - The Director of Nursing and Quality advised the template was created specifically for the committee as a guidance document and is not routinely completed. However, the Assistant Director, Integrated Governance is reviewing the template to be considered for use by reviewers in the future.

80/14 Risk Management 80.14.1 Infection Prevention & Control Update The Assistant Director, Nursing & Safeguarding presented the paper to provide the Committee with the new first quarterly update of progress against the Trusts 2014/15 Infection Prevention & Control Service Plan. This report replaces the Modern Matrons monthly report previously submitted as part of the monthly Performance Report to the Board. The Nurse Consultant, Infection Control was also in attendance to provide further information on audits. Mr D Taylor invited questions and comments. Details of the audit programme were discussed and the Nurse Consultant, Infection Control explained how actions are identified and tracked with further clarification provided on the information contained in the tables in the report as the committee felt this was unclear. Bare Below the Elbow Audit – The Committee commented that the results were low and questioned the reasons for this. The Nurse Consultant, Infection Control advised this originally formed part of the general audit on hand hygiene but is now a stand-alone audit and is completed quarterly. Results for last year were 60-70% compliant and this has now increased to 84% based on the observation of 130 staff. Staff who wear a uniform have excellent compliance whereas amongst staff who do not wear a uniform the compliance is lower. The Medical Director questioned if all staff are aware of the areas where they are required to be bare below the elbow.



The Nurse Consultant, Infection Control advised this is picked up by the Matrons and Link Practitioners and training sessions have been provided for medical staff to discuss the requirements. Staff who work on inpatient wards should be bare below the elbow at all times when dealing with patients. Areas of concern highlighted in community teams have been addressed. Podiatry – The Nurse Consultant, Infection Control advised that work is on-going in relation to the removal of bench top sterilisers due to reprocessing of nail clippers at local level within podiatry services in Knowsley. This is being addressed via a business case and a roll out programme approved and in progress to remove remaining bench top sterilisers from all premises used by Knowsley podiatry staff and replaced by centralised reprocessing or disposable equipment. This will be completed by January/February 2015. A company has been identified to supply the nail clippers and this is currently being addressed via the procurement process. Door Mounted Sanitizer Units – The Assistant Director, Adult and Secure Services asked how the sanitizers on entry to inpatient wards are checked. The Nurse Consultant, Infection Control advised these are checked by the domestic staff and link practitioners. The Committee noted the recommendations in the paper. 80.14.2 Pressure Ulcer Care in CHS The Director of Nursing and Quality provided an update to the committee following the issues highlighted and discussed at the previous meeting. Terms of Reference have been produced in relation to Pressure Ulcer Care to review the care pathways to assess and manage the risk of pressure ulcers within district nursing services in Knowsley. A lead reviewer has been identified and it is anticipated the review will take six weeks to complete. A report will be presented to the Committee in February. A discussion ensued around Trust acquired and non-Trust acquired pressure ulcers and how this was determined and also the grading of ulcers. The reliance on informal carers and the refusal of the patient to accept treatment/advice was also highlighted as a contributory factor. Mrs P Tubb highlighted the need to keep good documentation regarding offers of support to the patient and although this may be refused we have evidence that all guidelines have been followed.

Action: Director of Nursing & Quality February 2015

81/14 Serious Incidents (SI’s) 81.14.1 High Profile Inquest Update The Director of Nursing and Quality presented the paper. Eight inquests were listed for hearing in October 2014; none were identified as high profile. Eight inquests are listed for November 2014 and one identified as an inquest of note for the Committee. This relates to the case of a patient who was subject to a Community Treatment Order (CTO) at the time of death and the Coroner adjourned the original inquest in August 2014 as he required further information. A pre



inquest review was held on 16 October 2014 and the Coroner agreed that the inquest would be heard as an Article 2 inquest and was relisted for 23, 24 and 25 February 2014. 81.14.2 SI Process Update The Director of Nursing and Quality confirmed a meeting has been held with the Assistant Director, Integrated Governance and Mrs P Tubb to discuss the Serious Incident training for Matrons and Quality Leads as requested. Root Cause Analysis (RCA) training took place on 3 and 4 November 2014 for Quality Leads and Matrons and feedback has been extremely positive. The next stage of training is scheduled for 20 & 24 November. 81.14.3 Serious Incident Deep Dive Mr D Taylor introduced the item and invited comments/questions. The Committee highlighted the issues identified in the Executive Summary in relation to:-

• Care Programme Approach (CPA) documents were not kept up to date, particularly risk documents, and there is no written record of contingency plans should patient disengage from services.

• Once patient disengaged the Home Treatment Team did not follow up failed telephone contact with an attempt at a home visit as per draft operational guidance.

The Director of Nursing and Quality agreed this was a concern and although the care provided was good the team knew the patient very well and that knowledge has not translated properly into the records. The Committee agreed the issue in relation to the failed telephone call highlighted under 10.4 (RCA Organisational/Strategic) should also be included in 10.1 (RCA Individual). Mrs P Tubb commented that there have been many issues highlighted from Serious Incident reviews over the years relating to documentation and record keeping and questioned if there are systems in place to improve documentation and suggested if an audit should be undertaken on current internal processes. The Director of Nursing and Quality advised this had been discussed during the Legacy Review and the Records Management Annual Report shows an improving picture. Supervision for clinical staff also includes sampling of case records randomly chosen by the line manager to check the standard of record keeping. A report is received bi-monthly from teams in relation to the sampling of records and in the main the results look reasonable and nothing highlighted to identify any issues. When an audit is undertaken there is huge focus on the management of records and training and following other high profile cases a great deal of work has been done to rectify issues. The Records Management Team undertake the record keeping audits which looks at compliance with standards and the completion of all forms and the sampling of records is undertaken by the manager or deputy manager. The Matrons contact all patients who have had their case notes audited to agree the content. It is acknowledged that the



clinical supervision process needs to be reviewed and steps taken to mandate clinical supervision for staff. Further issues were discussed by the Committee as follows:-

• Prescription of new anti-depressant - The Medical Director advised it was unlikely the medication would work that quickly and the clinical team should have been more aware of this.

• Leave cover arrangements for Consultant – Cover arrangements need to be specific and not in name only. Ward rounds should be covered by another Consultant. This should be highlighted as a Service Delivery issue in the report.

• Discharge Plan – When a patient is discharged there should always be a plan in place.

• Best Practice – Reviewers should always consider best practice and not the current practices of the team.

The Committee commented that overall this is a good review although needs to be clearer and the action plan does not include all the points referred to in the review. Mr D Taylor thanked the committee for the discussion and useful comments.

Action: Director of Nursing & Quality December 2014

82/14 High Level External Reports 82.14.1 Complaints Deep Dive The complainant lodged concerns in relation to the attitude of a member of staff and was distressed by the manner in which the staff member had spoken to him and the accusations of attempted assault by the complainant towards the staff member. Mr D Taylor invited comments and questions. The complaint was discussed in detail and the following issues highlighted:-

• It took 3 ½ months from the issue of the acknowledgement letter to the complainant for the investigation to be concluded and the final outcome letter to be issued. The complainant had not had a qualitative experience and the complaint should have been dealt with in a more timely manner.

The Director of Nursing and Quality acknowledged that all complaints should be dealt with in a timely manner and this had been raised as an improvement action with the Assistant Director of Integrated Governance.

• The language used in the response letter is formal and uses clinical references which may be difficult to understand.

The Director of Nursing and Quality stated the response needs to be meaningful and reported that a questionnaire had recently been sent to 170 people asking key questions in relation to how their complaint



was handled. The response rate was low and no conclusions can be made however the process of dealing with complaints was discussed in detail at the Quality and Safety meeting held on 4 November 2014 and a suggestion for the formation of a Focus Group to discuss this further. The Assistant Director, Adult and Secure Services commented that the style of the original complaint letter should offer a guide to staff as to the type of response that is required. The response should always remain personal and should use the same phrasing as used by the complainant. Mrs P Tubb added that whilst a clinically responsible response is provided this loses the personal touch required. The Assistant Director, Integrated Governance advised that some complaints received are difficult to understand and the complaints team are looking at summarising the complaint in the response letter; i.e. This is what you asked ….. and this is our response…….

• As part of the Complaint Investigation Report it was highlighted that the patient was having trouble sleeping and requested a prescription to aid sleep and was advised this would be discussed and a letter sent to his GP. However, the GP did not receive the information.

The Medical Director queried if anything else had been offered to help the patient sleep other than medication and how do staff receive the appropriate clinical learning to make sure this happens. Mr D Taylor asked how learning from complaints is circulated around the organisation. The Director of Nursing and Quality advised that complaints are discussed at the Quality and Safety meeting and issues are highlighted and discussed. These are local actions in the main but may highlight organisational themes and ‘hot spots’. These findings determine what the training programme for staff should look like and ensure the match of key issues with training. The Assistant Director, Integrated Governance confirmed to the committee that the use of the complaint checklist provided with the Deep Dive papers is being reviewed following feedback received Mr D Taylor thanked the Committee for their comments. 82.14.2 Clwyd Report Action Plan The paper was provided to inform the Committee of progress to date against the Clwyd Implementation Plan. Mr D Taylor invited comments and questions. Mrs P Tubb commented on the layout of the action plan and that it was difficult to follow. The actions in relation to training have been



marked as complete when in fact the training is currently in process and has not been completed. This needs to be amended and the use of different wording considered i.e. on track. The Assistant Director, Integrated Governance confirmed this will be reviewed and amended appropriately. The Assistant Director, Organisational Learning and Development referred to the Hill Dickinson training on inquests and the need to prepare staff for the media. The Assistant Director, Integrated Governance advised the team are currently identifying what this will look like but it will be picked up. The Assistant Director, Integrated Governance advised that whilst guidelines are issued to witnesses who have to give a statement these have not been written in conjunction with Hill Dickinson and examples of a good statement are not currently provided but this is being reviewed. The Committee noted the progress to date and a further paper will be presented in February 2015. 82.14.3 Complaints Thematic Review/Ombudsman Report The Director of Nursing and Quality presented the paper which reported the following:-

• Fifty six complaints were recorded between 1 July 2014 and 30 September 2014

• Two complainants referred their concerns to Parliamentary Health Service Ombudsman

• No complaints were received from families of deceased individuals, whose death was also the subject of an inquest

• No Serious Incident review incorporated a complaint from the family of the deceased

• No claims were received in the Trust that was also linked to a complaint

The top five Trust complaint themes are consistent and are being discussed further via the Quality and Safety meeting. The complaints received by Podiatry services are currently being reviewed by the Assistant Director, Physical Health who has requested a further one month to complete this task and provide a more detailed report. The Director of Operations advised that the Clinical Lead for CAMHS (Child and Adolescent Mental Health Services) has been commissioned to look at the complaints received by the service. Mr D Taylor highlighted an anomaly with the number of complaints reported (56) and the number of complaints in Table 4 (54). This requires clarification and amendment. The Committee discussed the purpose of some of the tables and


Action: Director of Nursing & Quality February 2015

Action: Action: Director of Nursing & Quality December 2014



whether the information is useful and it was agreed to retain the present format which was produced following a previous request from the Committee. However, it was suggested that future reports concentrate on one of the key themes and data is provided in relation to the theme.


Break

83/14 Internal Arrangements 83.14.1 Business Stream Challenge Session – Forensics Mr D Taylor welcomed the Secure Services Leadership Team to the meeting. The Assistant Director, Adult and Secure Services introduced the members of the team:- Daniel Price Jones, Clinical Psychologist Sue Lee, Modern Matron Joanne Donnellan, Ward Manager (Chesterton Unit) The Assistant Director, Adult and Secure Services advised that the Trust has 53 beds commissioned by NHS England over all wards. The service faces challenges balancing quality and risk with the inpatient wards providing most of the risk challenges. Key points to note were:- • Services are based at Hollins Park, HMP Risley, Harrison Centre,

Thomas House and the Brooker Centre • The service consists of Inpatient Wards, Criminal Justice Liaison

Teams, Outreach Teams and Prison Inreach Team. • Quality Assurance mechanisms highlighting the governance

arrangements in internal and external meetings and the use of patient experience

• Quality Measures used include Team Quality Assessment (TQA), NHS England Inspections and Audits, CQUINs and inspections by the Quality Network for Forensic Services (QNFS)

• Details of how Secure Services are living the Culture of Care and embracing the principles of the 6C’s

• Shared Decision Making is being embedded into practice and currently being utilised to facilitate the Smoking Cessation Programme and is being piloted to better inform service users regarding medication.

• Secure Services were a pilot site for the Friends and Family test with data analysed by the Modern matron with suggestions for improvement of services

• The service is currently developing a Hate Crime Initiative and have liaised with the Equality and Diversity Team to progress this

• Recent implementation of a Diversity Café, Spirituality Café and Money Surgery which is accessible to service users, carers and staff. The service has also identified Equality Listeners on all wards and all service users have dedicated Advocate and legal representation

• The PDR (Personal Development Review) process for staff identifies competencies and training needs which are supported by relevant training. An Essentials for Forensics training programme



has been developed that is accessible to all staff and will eventually be offered to service users

• The service employs a dedicated speech and language therapist who supports service users with communication difficulties and is looking at ways to adapt technology into practice to ensure effective communication including tele-conferencing and SKYPE use.

• 2000 incidents were reported during an 18 month period with violence and aggression and self-harm incidents accounting for 70%. Fire related incidents in relation to smoking in bedrooms has been identified as a risk

• Managing Risk and the processes in place; Clinical Workshops/Clinical Assessment, MDT (multi-disciplinary team) Working Pilot, PD (personality disorder) Training, Quality & Risk Meeting, Deep Dive into Serious Incidents, Post Incident De-Brief, Self-Harm Pilot, Peer Review

• Highlights from the risk register included; serious violent incident against staff on an in-patient unit, risk to providing a safe and therapeutic environment to patients on an in-patient unit, and increased risk of illicit substances entering clinical areas

• Actions taken from Serious Incident investigations included more proactive management in order to reduce absconds

• Actions taken to maintain patient safety include; Internal Quality Reviews, Shared Decision Making, Keep me Safe Passport, Diversity/Spirituality Café, Communication Empowerment Scheme, See-Think-Act Training, E4F (Essentials for Forensics) training for patients.

• Complaint themes included Medication, Patient Property, Staff Attitude and Care and included actions taken to address these areas such as Matrons Surgery and Patient Clinical Forums

• Challenges were identified and included; Reducing violence and aggression, Reducing self-harm, Patient Satisfaction/Patient Experience, Risk Management, Shared Decision Making

• Future developments include; Review of inpatient configuration Re-design of community provision and the creation of an offender pathway Prison in-reach and implementation of a clear operational

model Criminal Justice – expansion of services offered with partners Fidelity with Bradley 5

Questions and discussions followed the presentation and areas discussed were; • Recruitment and Retention of Staff - It was established that there

are currently 6 vacancies and there is a high turnover of Band 5 practitioners. This has led to questions regarding recruitment and whether we are recruiting the right kind of person to work in secure services. There is also an issue with medical staff reducing from 3 RMO’s to 2 and issues with medical leadership across the Trust in general that needs to be addressed.

• Activity Workers – The service is creative with the activity worker programme to ensure this is also educational and includes Maths and English. The patients on Chesterton Unit are encouraged to



engage with external agencies as a step towards returning to the community.

The Committee thanked the Leadership Team for attending and found the presentation very informative. 83.14.2 Psychology Waiting Lists Review The Director of Nursing and Quality presented the report which had been provided following a risk highlighted some time ago in relation to Psychology Waiting Lists in Halton. It became apparent this was a wider issue and a broader piece of work was undertaken to review the configuration of psychological therapies across inpatient and community teams within Adult Services including current demand, waiting lists and risk management. The report makes a number of recommendations which need to be approved and action taken. The Assistant Director, Adult & Secure Services advised there were many variables and factors influencing waiting lists including different waiting lists for different therapies and individual staff members and teams were using their own methods to deal with their own waiting lists. The original report is a much larger document which has been circulated to the Divisional Director and other Assistant Directors for consideration and information. The Medical Director commented that there appeared to be a lack of consideration of improvement methodology and the way teams are organised and our current model needs to be reviewed. Psychological intervention is separate and not part of the multi-disciplinary approach and we need to consider if we have the right model and be assured that we have the right teams. Mr C Dale commented on the paper and felt this required further work as many of the findings have not been translated into recommendations. The thresholds for the Recovery Teams need to be clarified and important observations need to be added to the recommendations. Some of the recommendations are modest and weaker than the report merited. Mrs P Tubb shared her concerns at the inconsistency of the services across the Trust and the unacceptable waiting times. Such delays are not consistent with a quality service or patient experience. The role and the responsibility of the Professional Lead was questioned in relation to waiting lists, management of risk and other issues identified. The Director of Nursing and Quality agree that further work was required and that this presentation was an initial scoping document. The Committee agreed the report should be reviewed to ensure all recommendations have been captured. An update including actions will be presented at the December Committee.




83.14.3 Quality Big Dots, Quality Priorities & Sign Up to Safety Update Report The paper was provided to inform the committee of progress to date against the Trust’s Quality Big Dots for year 2, quarter 2 and progress against the 2014/15 Quality Priorities for quarter 2. The report also includes an update on the Sign Up To Safety Campaign. Mr D Taylor invited questions. Mr C Dale noted the decision taken by operations not to undertake an ‘Intentional Rounding’ project in relation to FALLS and queried this decision. The Director of Nursing and Quality advised this is specifically in relation to FALLS and has requested the Matrons to provide information as to what will replace this. The Committee discussed the Quality Priorities data tables in detail and questioned the use of the weighting calculations. The Director of Nursing and Quality explained the reporting process and how the weighting calculations are calculated and agreed to include a footnote in future reports to explain the purpose and calculation. The Assistant Director, Nursing and Safeguarding confirmed outline work has been undertaken in relation to the Sign Up To Safety Campaign and that a number of conversations have taken place with AQuA (Advanced Quality Alliance) around what we currently do. A number of organisations have opted out however representatives at a recent AQuA event were committed to it. The Committee suggested the Trust should pledge to the campaign. 83.14.4 Mental Health Act Compliance & Assurance Report Mr D Taylor introduced the paper which was provided following a request for more information on the current arrangements for assuring compliance with the Mental Health Act. The Head of Care Delivery attended the meeting to respond to questions. Mr C Dale commented the paper was a helpful way forward and provided better assurance on mental health issues however, was unclear where information provided by service users and carers was captured. The Head of Care Delivery advised that Commissioners interview specific patients and in their report outline what they have spoken about and whether their needs are being met. A discussion ensued in relation to the main issues highlighted; Consent to Treatment, Not being informed of rights. It was




acknowledged that some patients are too unwell when admitted to hospital to fully understand their rights and it was queried if this is repeated at a later date and how this is recorded. The Director of Nursing and Quality confirmed the issues needing particular attention and requiring an internal audit are:-

• Consent to treatment • Reading of Rights • Management of Seclusion • Rights of Informal Patients/Locked Door Policy

It was noted some of the dates quoted in the report require amendment and the Head of Care Delivery confirmed this would be dealt with. The Committee noted the recommendations and thanked the Head of Care Delivery for attending. 83.14.5 Records Management Annual Report Mr D Taylor invited questions. Mr C Dale highlighted the ‘Not Satisfactory’ grading in relation to the Trust’s Information Governance Assessment Report for 2012/13/ The Assistant Director, Nursing and Safeguarding, advised this was in relation to the frequency and tools used for training staff. Guidance requires that training is undertaken annually using approved tools however the Trust took a decision to use its own in-house e-learning module based on the national approved tools which staff must complete bi-annually. A decision has now been taken to re-introduce this as annual training. Mrs P Tubb sought assurance that this decision would result in compliance with the CQC (Care Quality Commission) essential standards. The Director of Nursing and Quality confirmed that it would and advised this had been presented to the Audit Committee who overwhelmingly supported the move back to annual completion of training. 83.14.6 Care Programme Approach (CPA) Audit Summary The Director of Nursing and Quality advised the report provides a summary of the findings from the CPA (Care Programme Approach) audit which was commissioned to provide assurance on CPA compliance. A randomly selected sample of 50 care records were looked at. Ten from each borough and included care records from Adult Services, LLAMS (Later Life and Memory Services), Learning Disabilities and Secure Services. The overall results of the audit were extremely positive although some areas are not as strong as we would like.



Areas identified for particular focus are:- • Advanced Statements and Directives • Contingency and Crisis Planning • Service user choice and identification of strengths • Desired outcomes are agreed with the service user • Speech and Language therapy involvement in risk assessment

and management for service users with learning disabilities Mr C Dale commented this was a very helpful paper and requested a copy of the audit paper. The Committee noted the contents of the paper. 83.14.7 CQC Transitional Plan Update The Director of Nursing and Quality advised the paper provides a brief summary of progress on work to date and informed the Committee that the internal audit currently being undertaken by KPMG has not yet been completed. The Intelligent Monitoring draft report was discussed. The Committee noted the contents of the paper.


84/14 External Arrangements There were no external arrangement items

85/14 Any Other Business Identification of a ‘Patient Story’ Mr D Taylor advised this was discussed at Trust Board and agreed that the ‘Patient Story’ can be delivered without the patient having to attend. Mr D Taylor closed the meeting and thanked everyone for attending.

Date & Time of Next Meeting 3 December 2014 Rossetti Meeting Room 9.00 – 1.00

15/09 Minutes of the Audit Committee Meeting held on 8 October 2014 Page 1 of 11


MEETING OF THE AUDIT COMMITTEE

Minutes of a meeting held on Wednesday 8 October 2014 In the Rosetti Meeting Room, Hollins Park, Warrington

Commencing at 1.30pm Present: Mr D Taylor Non-Executive Director

Mrs H Bellairs Non-Executive Director Mr A Chan Non-Executive Director (Chair) Apologies:

Mr B Marshall Non-Executive Director In Attendance:

Ms G Briers Director of Nursing and Quality Mr R Jones KPMG Mr J Cohen KPMG Ms R Gissing PWC Ms S Proffitt Chief Finance Officer Mrs J Fishwick Head of Assurance and Clinical Governance Mr S Hall Assistant Director of Finance Mr S Hull Assistant Director of Nursing Ms L Cheung Assistant Director of Governance Mr P Latham Senior Technical Accountant (minutes)

Action

1 2

14/64 Minutes There were a couple of amendments to the minutes relating to the meeting held on 6 August. These were:

• Page 1 note 3 the “Rio Project Director” should be replaced with “Rio Executive Lead”

• Page 1 note 4 the committee requested that the minutes should be amended to provide greater detail so as to clarify which small standalone systems were being referenced.

Mr A Chan (Non-Executive Director) queried whether the Committee members had received weekly updates on the RIO project as stated in the minutes (page 2 point 9). The Chief Finance Officer reported that the weekly updates would be provided through the project board and not to the Audit Committee. The Committee agreed this was the appropriate route to be taken.

Action: Senior Technical Accountant


3 4 5 6 7 8 9 10

14/65 Matters Arising Mr A Chan presented the actions matrix and noted that not all the actions within the minutes of the previous meeting had been included in the matrix. Reference was made to page 3 note 16 which had an action against the Assistant Director of Finance to investigate if any issues arose from using the same legal firms in the asset transfers. The Assistant Director of Finance informed the Committee that this would be addressed through the matters arising. The Committee noted this but requested that actions should be included in the matrix to ensure that nothing is missed. The Committee then noted that :

• Action 1 on the matrix was on the agenda • Action 2 on the matrix was on the agenda • Action 3 on the matrix had been addressed at the last Board meeting

Property Transfer Update The Assistant Director of Finance provided an update on the progress made in completing the transfer of legal title for the Knowsley Resource & Recovery Centre, Brooker Centre and Leigh Infirmary. Knowsley Resource & Recovery Update The Assistant Director of Finance advised the Audit Committee that the Knowsley Resource and Recovery Centre transfer was completed on 6 May 2014 but the confirmation from the Land Registry was still awaited due to a 3 month backlog. Leigh Infirmary The committee noted that a number of meetings with Wrightington Wigan and Leigh had been cancelled and requested that a meeting take place before the next Audit Committee. An update on progress to be provided at the December committee meeting. Brooker Centre It was reported that Warrington & Halton Hospitals NHS Foundation Trust had obtained the valuation report from the District Valuer and the Assistant Director of Estates & Facilities had sought independent external advice to validate this. At present there was a difference in valuations and negotiations were on going but the Committee noted that the difference was only small and questioned whether the upper valuation should be accepted given the materiality to ensure the transfer could be concluded.

Action: Assistant Director of Finance Action: Assistant Director of Estates Action: Assistant Director of Estates

11

14/66 Risk Challenge Session (Falls and Self-harm) The Director of Nursing and Quality introduced the challenge session and informed the Committee that this was the third challenge session and that at the


12 13 14 15 16 17 18 19

request of the last Audit Committee this would focus on falls and self- harm. The Director of Nursing and Quality introduced the Assistant Director of Nursing to lead on the challenge session The Assistant Director of Nursing tabled a paper and associated metrics to update the Committee on the progress, mitigation and future plans against delivering the Falls Prevention Strategy 2012-15. The Assistant Director of Nursing informed the committee that the strategy was currently in the last year of the three year strategy and that the metrics showed that the reduction in number of falls had been greater in year one and two with percentage reductions of 14% and 22%. The Assistant Director of Nursing explained that in year 2 the focus had been on a critical analysis of falls to inform improved risk assessment and care planning. As a consequence there had been a complete refresh of the strategy in year 3 which involved a move towards improved clinical care and the use of benchmarking to monitor performance against other organisations. In addition, the refresh had also:

• Performed a baseline audit • Reviewed the terms of reference and the membership of the falls

prevention group • Utilised an independent falls specialist to review the current policy and

procedures, identify training needs, review the environmental mapping of wards and provide falls master class sessions for the Falls Champions.

The Trust-wide Baseline Assessment Tool has been completed for NICE Guidance CG161 Assessment and Prevention of Falls in Older People. The NICE Guidance is made up of some 49 recommendations deemed by NICE to be relevant to the subject. After review, 24 of those recommendations were deemed to be relevant to this Trust, and of those 24 recommendations 23 are being met; the one recommendation that is not being met requires a change in policy that is currently underway, but yet to be ratified. The percentage of relevant recommendations being met at this time is 96%, which shows that we are compliant with the NICE Guidance in relation to Falls. When the policy is ratified and implemented, this will take our compliance to 100%. The Assistant Director of Nursing then referred the Committee to the data sheets which showed the level of falls by category of harm for 2013-14 and 2014-15 and asked for questions from the Committee. Mrs H Bellairs (Non-Executive Director) queried whether the target for falls should be zero but with a prescribed confidence limit built in. The Director of Nursing and Quality confirmed the ambition of the Trust was to achieve a zero rate of falls and harm and the Assistant Director of Nursing pointed to the fact that the Trust had engaged in a lot of work to continually improve the situation.


20 21 22 23 24 25 26 27

Mr R Jones (KPMG) informed the Committee that they had seen with other Trusts that the actual number of falls was not necessarily the best measure of performance as the numbers increase when the area is highlighted. The Director of Nursing and Quality confirmed that the approach taken in this area was not just focused on the numbers of falls but rather the whole compliance with guidelines that delivered best practice. Mr A Chan queried if the Quality Committee monitored the performance and Mr D Taylor confirmed that the Quality Committee did receive regular updates on this area through the Big Dots report. The Assistant Director of Nursing then tabled data sheets showing the levels of self-harm occurring within the Trust together with projected numbers for the remainder of 2014-15. The Assistant Director of Nursing explained that this area was managed through a strategic group that received a quarterly report and was responsible for developing the policy and procedures that apply to this area. He explained that from these reviews two areas of high prevalence had been selected for more detailed work. In each of these areas training had been identified and clinical leaders involved in the process to ensure that ownership of the issues was addressed with particular support from the psychologists who work within these units. The impact of this work had resulted in greater insight into the issues and produced a more tailored approach to the reduction of self-harm which had also realised reductions in the numbers of restraint. The Director of Nursing and Quality stated that this approach had resulted in the Trust performing well within this area and that they had identified a number of other measures that impact on self-harm. Mrs H Bellairs welcomed the update but requested that the approach taken within this area be reflected in the Board Assurance Framework so that the Trust Board could gain greater assurance over this area and also that the target levels of falls were reviewed The Committee then had a discussion on the availability of falls metrics, their usefulness given the relative small numbers and how performance should be reported to the Board including other measures including the use of patient feedback. The Assistant Director of Nursing acknowledged that the discussions around this were helpful and he confirmed he would take these forward and build into the work-plan other more appropriate measures. 14/67 Update from the Chair of the Quality Committee Mr D Taylor provided a verbal update on the main items discussed at the meeting. These included:

• A presentation on safeguarding and pressure ulcers in Later Life and Memory Services which demonstrated that the Trust was on top of these

Action: Assistant Director of Governance Action: Assistant Director Nursing


28 29 30

issues • Update on serious untoward incidents which showed that training within

this area had been increased and progress was good with a further update to the Quality Committee being produced for the December meeting.

• Update on the culture of care strategy. • Update on the training levels associated with violence and aggression.

This reported a significant increase in the number of people being trained with current levels now being at 96% of inpatient ward staff.

14/68 Risk Management Update The Director of Nursing and Quality presented a report to the committee to provide high level summary information on risks and to consider progress against achievement of the high level objectives as outlined in the Trust’s Board Assurance Framework. The Director of Nursing and Quality explained that the risks were also monitored by the Quality Committee who take a cross section of risks on the risk register focusing on:

• Discussing risks that have been on the register for 12 months • Risks that have not had an update in 3 months.

In addition, details of risks more than 12 months old go to Trust Board and additional assurance is reflected in the paper presented to the Audit committee. Mrs H Bellairs commented on the number of risks that had fair or limited controls in place and believed it would be useful to amend the narrative against each risk to describe what actions are being taken and what the best outcomes that can be achieved are. The Assistant Director of Governance agreed to make these amendments.

Action: Assistant Director Governance

31 32 33 34

The Committee discussed which area of risk should be selected for the next challenge session at the December meeting. The decision was taken to choose the Cost Improvement Planning process. The Chief Finance Officer queried what the Committee wanted the session to focus on. She explained that the session could focus on the process for the future years’ schemes as they move to become more transformational. The Committee discussed this and decided the session should look at the processes in place for the delivery of the current year schemes but the greater focus should be on process for the future years’ transformational schemes. Mr R Jones (KPMG) informed the committee that an audit on cost improvement plans was being concluded and that it was anticipated that this would provide substantial assurance around the controls in place for cost improvement delivery. He offered to provide the Committee with the audit report at the next meeting to aid the Committee with the challenge session.

Action: Mr R Jones (KPMG)


35 36 37 38 39

The Chief Finance Officer agreed to take the Committee’s comments on board and arrange the session for the next meeting. 14/69 Ratify Trust Policies The Assistant Director of Governance presented a number of policies and procedures that had been reviewed since the last meeting and asked the Committee to ratify them. Mrs H Bellairs queried what guidance had been provided for the voluntary redundancy policy. The Chief Finance Officer informed the Committee that the Director of Human Resources had taken advice on this as part of the corporate services review. The Committee ratified the following policies and procedures:

• Escort Procedure • Placing Patients in Seclusion Procedure • Change Management Policy and Procedure • Voluntary Redundancy Policy and Procedure • Intravenous Therapy Policy and Procedure • Safeguarding Children (MH/LD) & Safeguarding Adults (MH/LD/Physical

Health Services) Support and Supervision Procedure • Fire Safety Management Policy • Energy and Carbon Management Policy • Medicines Management Policy • Administration of Intramuscular Injections Procedure • Administration of Medicines Procedure • The Safe and Secure management of Controlled Drugs Procedure • Disposal of Pharmaceutical Waste Procedure • Non-Medical Prescribing Procedure • The Ordering, Receipt, Storage and Stock Control of Medicines (ex-

controlled drugs) Procedure • Management of Patients Own Drugs Procedure • Prescribing on FP10 Prescriptions Procedure • Prescribing on Trust Prescription Charts • Safe use of Injectable Medicines • Transport of Medicines

The Committee requested that the reason why the policy was being reviewed is included in future reports. 14/70 Review Gifts and Hospitality Register The Head of Assurance and Governance presented an updated gifts and hospitality register.

Action: Chief Finance Officer


40 41 42 43 44 45 46 47 48

The committee reviewed the gifts and hospitality register and queried the procedures for the acceptance of sponsorship from drug companies. The Chief Finance Officer informed the Committee that acceptance of sponsorships had been reviewed recently and no issues had been identified. The Committee noted that the value of the transactions were relatively small but it was decided that the current gifts and hospitality policy should be updated to inform staff of how they should proceed when agreeing to sponsorship from drug firms. The Head of Assurance and Governance agreed to liaise with the Company Secretary to take this forward. The committee noted the contents of the register. 14/71 Review Register of Interests The Head of Assurance and Governance presented a report on the register of interests and informed the Committee that the information is updated at each Board meeting The Committee then had a discussion around the level of detail that should be held within the register and how far down the organisation the information should be held. The Committee decided that all interests should be declared irrespective of whether a transaction between the Trust and the organisation had occurred or was likely to occur. The Committee instructed that the Register of Interests scope be extended to cover the following:

• Assistant Directors • Clinical Leadership Group • Procurement Staff • Estates Staff involved in the award of contracts

The committee noted the contents of the register.

14/72 Aged Debt, Salary Overpayments and Losses Highlight Report The Assistant Director of Finance presented the report to the Audit Committee. The Assistant Director of Finance alerted the committee to some work that KPMG’s counter fraud team were intending to undertake with regard to salary overpayments. The Committee noted the contents of the report.

Action: Head of Assurance and Governance Action: Head of Assurance and Governance


49 50 51 52 53 54 55

14/73 Waivers Report The Assistant Director of Finance presented a report on the number of waivers that had been signed and logged over the period July 2014 to September 2014. The Assistant Director of Finance confirmed that all the waivers that had been authorised did comply with the requirements of the Trust’s Standing Financial Instructions and that they were necessary mainly due to the specialised nature of the services being provided. In particular the majority related to the RiO project and other bespoke systems such as the current clinical system ‘Otter’ that require specialist knowledge to implement and maintain. The Chief Finance Officer informed the Committee that she does refuse to sign any requests that do not comply with the Standing Financial Instructions. The Committee discussed the report and requested that the register only needed to be reviewed by the committee annually at the February meeting and that future reports should also identify how many waivers were rejected. The Committee also queried whether the reason for the waiver needed expanding. The Assistant Director of Finance informed the Committee that the actual waiver form did contain more detail as to why the waiver was being submitted and agreed to forward a completed template to the next meeting for information. The committee noted the contents of the register. 14/74 KPMG - Internal Audit Progress Report Mr R Jones (KPMG) presented the internal audit progress report and informed the committee that the report showed that half the number of audit days had been utilised much of which related to preparatory work for audits to be completed in quarter 3. In addition, two significant audits are yet to start and these were:

• Core Financial Management and Controls for which the scope was being finalised

• Risk Management and Board Assurance framework Mr Jones informed the Committee that the remaining work will be delivered as per the plan. Mr Jones gave an update on audits that had been finalised or drafted and shared with management since the last meeting which included:

• Corporate Governance Part One: Code of Governance – Final report produced and substantial assurance reported.

• Cost Improvement Planning – Draft report produced and substantial assurance reported.

Action: Assistant Director of Finance Action: Assistant Director of Finance


56 57 58 59 60 61 62

• Corporate Governance Part Two: Board Governance – Draft report produced and separate rating being finalised in line with Monitor’s Well-led framework.

The Assistant Director of Finance queried whether the timing and scope of the Core Financial Management and Controls audit would tie in with the external auditor’s requirements. Ms R Gissing (PwC) confirmed she would liaise with KPMG on this matter. Mr R Jones (KPMG) then gave an update on implementation of previous recommendations. Mr Jones reported that significant progress had been made with 158 of the 208 recommendations having been implemented or superseded whilst 39 were not yet due. Of the 11 recommendations due but not yet fully implemented or superseded, 7 relate to Quality Governance that will be picked up as part of the 2014/15 CQC self-assessment review and 4 relate to Information Governance Toolkit that will be picked up by the 2014/15 Information Governance Toolkit review. Mr Jones informed the Committee that following the award of the new contract that the reports in future would include a target rating to be advised by the relevant executive lead. The Head of Governance and Assurance queried why an audit on Quality Governance was not on the list of outstanding audits. The Committee noted that they believed that the audit plan for the year had not changed and no such audit was planned. Mr Jones agreed to investigate this outside the meeting to see if this was included within the CQC audit. Mr A Chan queried the status of RiO and if further audit days were required. The Chief Finance Officer reported that the key areas were being addressed but it had already been agreed that should further days be necessary the Audit Committee would consider extra resources. Mr Jones confirmed this would not be an issue. The committee noted the progress report 14/75 KPMG – Technical Update Mr R Jones (KPMG) presented KPMG’s Technical Update to the Committee which highlighted the main technical issues currently impacting on the health sector. He guided the Committee to refer in particular to:

• Page 9 – Off payroll engagements • Page 11 – Discretionary code for Governors • Page 19-22 – A number of updates relating specifically to Mental Health

Mr A Chan commended the usefulness of the document and queried whether this should be shared with other Board members and Council of Governors. The Committee discussed this and agreed that the best approach would be to upload

Action: Mr R Jones (KPMG)


63 64 65 66 67

the updates onto the intranet and inform the Board and Council of Governors that it can be accessed there. The Head of Assurance and Governance agreed to take this forward. 14/76 KPMG – Counter Fraud Mr J Cohen (KPMG) presented the Counter Fraud progress report to the Audit Committee and informed the Committee of the work that had been completed since the last meeting including:

• Preparing for National Fraud Initiative process by moving forward on the Fair Processing Notice

• Investigation of a Counter Fraud referral for which a verbal update was given

• Delivery of fraud awareness sessions each month as part of the Trust’s induction process

• Scoping of the 2014-15 local Proactive Exercise on Salary overpayments. • Publication of a newly formatted Counter Fraud newsletter

Mr Cohen advised the Committee that appendix 1 within the progress report described the status of the action plan following the recommendations raised in the May 2014 NHS Protect Quality Assessment report and asked the Committee if they required further clarification on any of its content. Mr A Chan queried whether standard 4 had been addressed and Mr Cohen confirmed that this was the case. The committee noted the progress report and also the progress outlined in the report. 14/77 Any Other Business Charitable Fund Request The Assistant Director of Finance presented a charitable fund request to the committee to utilise £12,000 for new equipment for the Health and Wellbeing Centre The Committee approved the request. Payment by Results The Chief Finance Officer informed the Committee that Monitor had recommended that Audit Committees’ should be made aware that they had asked for a sample across Trusts to ascertain their readiness for PbR. She explained that an audit of the work had been undertaken last year within the Trust.

Action: Head of Assurance and Governance


68

The Committee noted the update and requested to be informed if any issues arise. The committee had no other business. . Date of next meeting 3 December 2014 13:30 – 16:30 Bronte Meeting Room Hollins Park Hospital Signed………………………………………………Date:……………………………. Chairman


15/10 Charitable Funds Annual Report and Accounts 2013/14 Page 1 of 3

BOARD REPORT


26 January 2015

TITLE OF REPORT:

Charitable Funds Annual Report and Accounts 2013/14

PURPOSE OF REPORT:

To present the Charitable Funds Annual Report and Accounts for approval by the Board.


The Charitable Funds Annual Report and Accounts for 2013/14 have been completed in accordance with Charity Commission guidance and have been audited by PriceWaterhouseCoopers LLP.


Sam Proffitt Chief Finance Officer

RECOMMENDATIONS TO THE BOARD:

1. To approve the Charitable Funds Annual Report and Accounts 2013/14.

2. The Chair of the Trust is asked to sign and date the Charitable Funds Annual Report and Accounts 2013/14 on behalf of the Trustees.




√


2. Do we have sufficient, highly motivated, skilled staff?



5. Do our stakeholders support what we do?




Yes No √

If yes,

BAF entry No.



(cut & paste it)



Report to the Trust Board 26 January 2015

Charitable Funds Annual Report and Accounts 2013/14

1. BACKGROUND 1.1. The Charitable Funds Annual Report and Accounts for financial year 2013/14

(attached) are required to be prepared and an Annual Return based on these accounts submitted to the Charity Commission by 31 January 2015. These Accounts have been prepared in accordance with relevant Charity Commission guidance.

1.2. The Trust’s auditor has completed an independent audit of the charitable

funds accounts and has issued a ‘clean’ audit opinion. 1.3. The Trust Board, in their capacity as corporate trustees of the Trust’s

charitable funds, is required to receive and approve the Charitable Funds Annual Report and Accounts for 2013/14 prior to submission to the Charity Commission.

2. AUDIT COMMITTEE REVIEW

2.1. The Charitable Funds Annual Report and Accounts for 2013/14 were

reviewed and agreed at the Audit Committee meeting on 3 December 2014 along with the auditor’s independent audit report. At this meeting the members recommended that they be forwarded to the Trust Board for approval.

2.2. The December Audit Committee meeting was the first opportunity to present the charitable funds annual report and accounts for review following the completion of the audit work.

3. RECOMMENDATIONS

3.1. The Trust Board is asked to approve the Charitable Funds Annual Report and

Accounts for 2013/14. 3.2. The Chair of the Trust is asked to sign and date the Charitable Funds Annual

Report and Accounts 2013/14 on behalf of the Trustees. Sam Proffitt Chief Finance Officer

TAR 1

Trustees' Annual Report for the period

From

Period start date

To

Period end date Day 01

Month April

Year 2013

Day 31

Month March

Year 2014

Reference and administration details

Charity name 5 Boroughs Partnership NHS Charitable Fund

Other names charity is known by

Registered charity number (if any) 1061651

Charity's principal address Hollins Park Hospital

Hollins Lane,

Winwick

Warrington, Cheshire

Postcode WA2 8WA

Names of the charity trustees who manage the charity

Trustee name Office (if any) Dates acted if not for whole year

Name of person (or body) entitled to appoint trustee (if any)

1 Bernard Pilkington Chairman 2 Allan Chan Non-Executive Director 3 Colin Dale Non-Executive Director 4 Derek Taylor Non-Executive Director 5 Rupert Nichols Non-Executive Director 1-30Apr 2013 6 Brian Marshall Non-Executive Director 7 Philippa Tubb Non-Executive Director 8 Simon Barber Chief Executive

9 Dean Marsh Director of Finance & Informatics

1Apr to 29May 2013

10 Dr Louise Sell Medical Director 11 Nick Rowe Deputy Chief Executive 12 Therese Patten Chief Operating Officer

13 Gail Briers Director of Nursing &

Governance

14 Tracy Hill Director of HR &

Organisational Development

16 Helen Bellairs Non-Executive Director 11Sep 2013 onwards 17 Sam Proffitt Chief Finance Officer 4Sep 2013 onwards

18 John McLuckie Interim Director of Finance & Informatics

30May to 3Sep 2013

19 20

Names of the trustees for the charity, if any, (for example, any custodian trustees)

Name Dates acted if not for whole year

TAR 2

Names and addresses of advisers (Optional information) Type of advisor Name Address Investment Fund Manager

BlackRock Investment Management (UK) Ltd

33 King William Street

London

EC4R 9AS

Name of chief executive or names of senior staff members (Optional information) Simon Barber

Structure, governance and management

Description of the charity’s trusts

Type of governing document (eg. trust deed, constitution)

Trust Deed

How the charity is constituted (eg. trust, association, company)

Trust

Trustee selection methods (eg. appointed by, elected by)

Elected from Board Membership

Additional governance issues (Optional information)

You may choose to include additional information, where relevant, about:

• Policies and procedures adopted for the induction and training of trustees.

• The charity’s organisational structure and any wider network with which the charity works.

• Relationship with any related parties.

• Trustees’ consideration of major risks and the system and procedures to manage them.

The Charity has a Charitable Funds Committee comprised of the above Trustees which meets on a quarterly basis. A quarterly Charitable Funds Report is prepared for discussion at each meeting. It summarises the value of funds at the end of the period, explains movement in values and highlights significant transactions. Financial Policies and Procedures are published on the Trust’s intranet detailing governance issues relating to Charitable Funds. The Trust’s intranet also contains a section dedicated to Charitable Funds which provides an overview of the Funds, examples of what they can be used for and the procedure for requesting funds, including the necessary forms etc. The Trust manages the funds of Bridgewater Community Healthcare NHS Trust on behalf of that organisation under a Service Level Agreement (SLA). This SLA outlines the roles and responsibilities of each party, including provision for their representative to attend the Charitable Funds Committee.

TAR 3

Objectives and activities

Summary of the objects of the charity set out in its governing document

For any charitable purpose or purposes relating to the National Health Service wholly or mainly for the services provided by 5 Boroughs Partnership and Bridgewater Community Healthcare NHS Trust.

Summary of the main activities in relation to these objects

To provide amenities to service users and carers of 5 Boroughs Partnership and / or Bridgewater Community Healthcare NHS Trust. To provide amenities to staff employed by 5 Boroughs Partnership and / or Bridgewater Community Healthcare NHS Trust. To support other voluntary groups working within the locality whose purpose is consistent with those of 5 Boroughs Partnership and / or Bridgewater Community Healthcare NHS Trust. General Charitable Purposes. The trustees have had regard to the guidance issued by the Charity Commission on public benefit.

Additional details of objectives and activities (Optional information)

You may choose to include further statements, where relevant, about:

• Policy on grantmaking

• Policy programme related investment

• Contribution made by Volunteers

The charity supports a wide range of charitable and health related activities benefiting both patients and staff of 5 Boroughs Partnership and Bridgewater Community Healthcare NHS Trust. In general they are used to purchase additional goods and services that the NHS would not normally provide from revenue funds.

Achievements and performance

TAR 4

Achievements and performance Summary of the main achievements of the charity during the year

5 Boroughs Funds: During the year, donations and other income received totalled £5,573. There were a number of small donations including £265 from the relative of a former member of staff. A total of £3,728 was received from staff deductions for membership of the staff fitness club based at Hollins Park whilst book sales, commission and library fines totalled £356. Total expenditure during 2013/14 was £11,338. This included £3,280 on new gym equipment, maintenance and induction sessions; £850 on various Christmas activities for patients across the Trust; £700 on an interactive psychosis course for service users; £650 for the purchase of self-help and poetry books to support the health and wellbeing of staff; £615 on home safari visits to the Learning Disability inpatient units; £424 for various service user sporting activities; £230 for a canal boat trip for Warrington & Halton Early Intervention service users; £100 for music group activity for service users of the Halton Recovery team. The remaining £4,500 was accessed via petty cash for various therapeutic activities for various wards and teams Trust-wide. Bridgewater Funds: Donations totalled £991 for the year, mainly in the form of small donations. During the year, Bridgewater undertook a review of the administration of their Charitable Funds as they in effect had two funds one managed by 5 Boroughs and another by Wrightington, Wigan & Leigh NHS FT. Their initial proposal was to amalgamate both funds and administer themselves as a new Bridgewater Charity, however this could not proceed under Department of Health guidelines due to the relatively low value of the combined funds. Following discussions, it was agreed that the funds held by Wrightington would transfer to the 5 Boroughs Charity and would be merged with the existing Bridgewater funds. Following approval by Parliament, the transfer of £64,528 took place in March 2014. Total expenditure during 2013/14 was £4,180. This included 10 District Nurse Leg Ulcer Ergo Kits which were purchased at a total cost of £3,540 and are designed to prevent postural stress for District Nurses when applying leg ulcer dressings and also to make it more comfortable for their patients. Two anatomical aprons were purchased at a cost of £310 to help Stoma Nurses explain Stoma surgery to their patients. The remaining £330 was spent on Children’s toys, speech therapy record cards, reward vouchers and printing supplies for various services. All Funds: Income from dividends was marginally down from the previous year at £4,329, however this was due in large part to the sale of a further Charinco & Charishare holdings, to generate a cash injection of £40,000 in accordance with the Charity’s stated policy to ‘spend all expendable funds, rather than to allow funds to accumulate.’ During the year, the Charity recorded an unrealised gain of £8,879 on its remaining Charinco and Charishare investments. Following a loss in quarter 1, there were strong gains during the last three quarters of the year, which continued even after the part sale of the holding in September.

TAR 5

Financial review

Brief statement of the charity’s policy on reserves

The Trust’s policy is to spend all expendable funds on the purpose for which they were donated rather than allow funds to accumulate. The Charity does not have access to regular income streams and instead relies on the goodwill of service users and carers and local organisations through their donations and legacies. Accordingly the only requirement on the level of reserves would be in cases where future expenditure has been approved but not yet expended against a specific donation or legacy.

Details of any funds materially in deficit Not Applicable

Further financial review details (Optional information)

You may choose to include additional information, where relevant about: • The charity’s principal

sources of funds (including any fundraising).

• How expenditure has supported the key objectives of the charity.

• Investment policy and objectives including any ethical investment policy adopted.

The charity’s principal sources of funds are from donations and legacies from the relatives and friends of service users. During the year the funds have continued to support a wide range of charitable and health related activities benefiting both patients and staff. The investment policy requires that all monies, apart from working capital, be invested in securities to maximise the overall return consistent with an acceptable level of risk. The performance of the investments are continually monitored and reported on an annual basis in relationship to other common investment funds.

Other optional information

Declaration The trustees declare that they have approved the trustees’ report above. Signed on behalf of the charity’s trustees

Signature(s)

Full name(s)

Position (eg secretary, chair, etc)

Date

CCXX R1 accounts (SS) 1 04/02/2015

Section A Receipts and payments Unrestricted

funds Restricted

fundsEndowment

funds Total funds Last year

to the nearest £ to the nearest £ to the nearest £ to the nearest £ to the nearest £

A1 Receipts

Voluntary Receipts - 67,007 - 67,007 6,873

Activiites for generating Funds - - - - -

Investment Dividends and Interest - 4,329 - 4,329 4,892

Charitable Activities - - - - -

Other Receipts - 4,085 - 4,085 3,989

Grants Received - - - - -

- - - - -

- - - - -

Sub total - 75,420 - 75,420 15,754

A2 Asset and investment sales, etc.

- 40,000 - 40,000 -

Total receipts - 115,420 - 115,420 15,754

A3 PaymentsCosts of generating voluntary Receipts

- - - - - Fundraising Costs (Trading Activiites)

- - - - - Investment management Costs

- - - - - Costs of Charitable Activities

- 15,518 - 15,518 28,317 Governance Costs

- 12,978 - 12,978 11,999

- - - - -

- - - - -

- - - - -

- - - - -

- - - - -

Sub total - 28,496 - 28,496 40,316

A4 Asset and investment purchases, etc. - - - - -

Total payments - 28,496 - 28,496 40,316

Net of receipts/(payments) - 86,924 - 86,924 - 24,562 A5 Transfers between funds - - - - - A6 Cash funds last year end - - 1,492 - - 1,492 23,070

Cash funds this year end - 85,432 - 85,432 - 1,492

Section B Statement of assets and liabilities at the end of the period

CC16a10616515 Boroughs Partnership NHS Trust Charitable Fund

01-Apr-13 31-Mar-14

No (if any)Charity Name

Receipts and payments accountsPeriod start date Period end date

ToFor the period from

CCXX R2 accounts (SS) 2 04/02/2015

CategoriesUnrestricted

funds Restricted

funds Endowment

funds to nearest £ to nearest £ to nearest £

- 97,367

- -

- 11,935

- 85,432 -

OK OK OKUnrestricted

funds Restricted

funds Endowment

funds to nearest £ to nearest £ to nearest £

- - -

- - -

- - -

- - -

- - -

- - -

Fund to which asset belongs Cost (optional) Current value

(optional) - 20,266

- 83,966

- -

- -

- -

Fund to which asset belongs Cost (optional) Current value

(optional) - -

- -

- -

- -

- -

- -

- -

- -

- -

Fund to which liability relates

Amount due (optional)

When due (optional)

-

-

-

-

Signed by one or two trustees on behalf of all the trustees

Date of approval

Print NameSignature

Details

Details

Bank Account

Debtor to 5 Boroughs Partnership NHST

Creditor to 5 Boroughs Partnership NHST

B1 Cash funds

DetailsB2 Other monetary assets

Details

Total cash funds (agree balances with receipts and payments

account(s))

B4 Assets retained for the charity’s own use

B5 Liabilities

B3 Investment assetsDetails Charinco

Charishare

PricewaterhouseCoopers LLP, 101 Barbirolli Square, Lower Mosley Street, Manchester M2 3PWT: +44 (0) 161 245 2000, F: +44 (0) 161 245 2910, www.pwc.co.uk

PricewaterhouseCoopers LLP is a limited liability partnership registered in England with registered number OC303525. The registered office ofPricewaterhouseCoopers LLP is 1 Embankment Place, London WC2N 6RH. PricewaterhouseCoopers LLP is authorised and regulated by the Financial Conduct Authorityfor designated investment business.

The Charitable Funds Committee

The 5 Boroughs Partnership Charitable Fund

5 Boroughs Partnership NHS Foundation Trust

Hollins Park House

Winwick

Warrington

WA2 8WA

27 November 2014

Dear Sirs,

Audit of financial statements for The 5 Boroughs Partnership Charitable Fund for

the year ended 31 March 2014.

We are writing to set out the findings from our audit for the above named entity in accordance with

International Standards on Auditing (UK and Ireland) (ISAs (UK&I)).

Significant findings from the audit

We are required under ISA (UK&I) 260 “Communication with those charged with governance” to

communicate to those charged with governance significant findings from the audit, including:

Our views about significant qualitative aspects of the entity’s accounting practices, including

accounting policies, accounting estimates and financial statement disclosures;

Significant difficulties, if any, encountered during the audit.

We have nothing to report in respect of the above matters.

Significant deficiencies in internal control

We are required under ISA (UK&I) 265 “Communicating deficiencies in internal control to those

charged with governance and management” to communicate to those changed with governance

significant deficiencies in internal control identified during the audit.

The audit included consideration of internal control relevant to the preparation of the financial

statements in order to design audit procedures that are appropriate in the circumstances, but not for

the purpose of expressing an opinion on the effectiveness of internal control. Our work may therefore

have not identified all significant deficiencies in your system of internal controls which a separate

audit of internal control may reveal.

We have nothing to report in respect of the above matters.

2

Other matters

We are also required under ISAs (UK&I) to communicate to those charged with governance if we have

anything to report on the following:

Uncorrected misstatements;

Matters related to fraud;

Matters related to laws and regulations;

Matters related to related parties;

Subsequent events;

Matters related to going concern;

Any significant facts that bear upon our independence and objectivity; Matters related to the auditors’ report;

Any other matters that, in our professional judgment, are significant to the oversight of the

financial reporting process.

We have nothing to report in respect of the above other matters.

This letter has been prepared solely for your use and should not be quoted in whole or in part without

our prior written consent. No responsibility to any third party is accepted as this letter has not been

prepared for, and is not intended for, any other purpose.

We would like to thank you and your staff for their assistance and co-operation during the auditprocess.

Yours faithfully

PricewaterhouseCoopers LLP

This report is written based upon the Quality and Performance Board Report Definitions and Tolerances Booklet Version 1g- updated on the 18th September 2014

Click here to be directed to the Booklet

Trust Quality & Performance Report for Trust Board

Version 1.0

5 Boroughs Partnership NHS Foundation Trust

Month 9 - December 2014 Trust Board Performance Report

http://www.5boroughspartnership.nhs.uk/assets/uploaded/documents/36661_Board%20Report%20Definitions%20and%20Tolerances-%20Version%201f.pdf

Contents

1. Are we delivering our services safely?– Gail Briers2. Do we have sufficient, highly motivated and skilled staff?- Tracy Hill3. Are we delivering to our patients and users? – Louise Sell4. Are we financially viable? – Sam Proffitt5. Are we delivering our strategy? – Simon Barber6. Do our stakeholders support what we do?- Gail Briers7. Operational overview by Business Stream – Gail Briers

Page 2 of 35

The Board Quality and Performance Report is designed to inform the Trust Board of things we are proud of and things we are concerned about, in particular, whenever measures have triggered pre-defined tolerances at total Trust or business stream level. These measures include national targets and locally-agreed priorities in addition to a number of internally agreed targets to quality assure our services.

Detailed definitions of all these indicators and tolerances together with an overview of the quality and performance cycle within the Trust can be found in a separate booklet, a copy of which is maintained on the Trust website and can be directly accessed via this document.

Each measure falls within one of the following six questions.

• Are we delivering services safely?• Do we have sufficient, highly motivated and skilled staff?• Are we delivering to our patients and users?• Are we financially viable?• Are we delivering our strategy?• Do our stakeholders support what we do?

The detail behind each measure is scrutinised by the various committees and during performance meetings held within the quality and performance cycle referred to above. Where a measure falls outside of tolerance, the narrative will explain what tolerance has been triggered, the details of any corrective action required/taken and will make reference where relevant to previous or future Quality Committee agenda items.

The first six sections consider the above questions in turn from an overall Trust perspective, predominantly where measures are triggered in more than one business stream. This is followed by seven operational summaries in which each of the business streams have used a combination of generic Trust measures together with a number of defined business stream specific measures and tolerances to consider the above questions at a business stream level. The indicators used are listed are below each question.

Context

Page 3 of 35

http://www.5boroughspartnership.nhs.uk/assets/uploaded/documents/36661_Board%20Report%20Definitions%20and%20Tolerances-%20Version%201f.pdf

Key Indicators: Incidents and Patient Harm, Internal and External Quality Inspections, Clinical Audits, Safeguarding, Suicide Levels, Restraints and Seclusion, Staff Safety

All our measures in month are within tolerance.

We are pleased to report that there has been a three-month reduction in the number of medicine reconciliations within our in-patient services.

The Trust’s programme of Internal Quality visits continues and in month a workshop was held to feedback following the targeted quality and safety reviews focused on our four Later Life and Memory Services in-patient units. The workshop provided an opportunity for the reviewers to feedback key findings of the reviews to senior managers and lead clinicians from the Business Stream including good practice identified and areas for further development. An action plan will be developed to address any areas of development. The Later Life and Memory Services Business Stream senior team will be presenting to the Trust’s Quality Committee in February about the outcome of the quality and safety visits and progress in addressing the areas identified within the action plan.

Are we delivering our services safely?

Page 4 of 35

Key Indicators:

Sufficient staff : Safe Staffing Levels, Vacancies, Staff Attendance, Recruitment Pipeline, Agency and Locum Usage Motivated : Staff turnover, Grievances/ disciplinaries, Friends and Family test (staff), Skilled : Training, Clinical and Managerial Supervision, Performance and Development Review (PDR) Compliance, Awards/Recognition, Acting up Posts

The following measures are outside of our tolerance levels

Attendance levels have shown a decrease again in month falling to 93.47%. This is the fourth month in a row. There has been an increase in absence in five of our operational business streams. Increases in absence are also seen in corporate services. In addition to seasonal rises, the Trust is currently engaged in significant organisational change programmes. A programme of support has been developed and offered to those staff experiencing organisational change.

PDR return rates have increased to 77%. This is unfortunately still below the Trust target of 90%. Whilst a number of areas are showing improvement, the largest areas have the lowest compliance. The Chief Nurse/Executive Director of Clinical Operational Services is working closely with managers to determine how consistently our cascade approach to PDR’s is applied.

We have seen a slight increase in the number of vacancies this month, rising from 5.63% to 5.74%. Across the Trust, operational business streams are reporting difficulties in being able to recruit to key posts which have the potential to impact on the quality of services we are able to deliver to our patients and service users. At this point in time the quality of services is not impacted. Physical Health Services whilst reporting difficulty have made progress and continue to work with HR teams to establish alternative approaches to staff resourcing.

Employee of the month was Hayley Thompson from the Weight Management Team, and Team of the Month was Knowsley District Nursing Team.

We publish monthly, as agreed, our compliance against what we normally plan for safe staffing levels on each ward. In the month there were three wards below the threshold of 90% for safe staffing levels. However this did not result in un-safe staffing at any time.

Do we have sufficient, highly motivated and skilled staff?

Page 5 of 35

Key Indicators: Complaints and Compliments, Access to Interventions and Services, Waiting times until Assessment, Delayed Discharges, Out of Area Activity, Did Not Attend Rates, 72 hour and 7 day follow ups, Readmissions, Commissioning for Quality and Innovation (CQUIN), Patients seen who are on a Care Programme Approach (CPA), reviewed and Health of the Nations Outcome Scores (HoNOS) assessed in a timely manner, Meeting Early Intervention Targets, Payment by Results (PBR) Clustering, Friends and Family Test (Patients and Service Users)

The following indicators will all be considered at a Business Stream Level: Community and In-Patient Activity, Length of Stay

We are concerned that the percentages of discharges which are delayed has risen to over 10% in month. This is accounted for predominantly by delays arising in the Later Life and Memory Services and Secure business streams. We engage in weekly dialogue with the CCG and Local Authority at an operational level to find solutions for individual patients and the issue is also addressed with partners at a strategic level by the Director of Operations and Integration. We are reviewing the process by which delayed discharges from our Secure Units are reviewed and managed with NHS England.

Rates of clustering for PbR also remains a concern. The Director of Operations and Integration has implemented a clearer process for senior clinical and operational management accountability and early indicators are that this has impacted positively on the weekly data reported after the cut off for this Board report.

We are proud that our response to emergency assessments across our Adults, Later Life and Memory Services and Child and Adolescent Mental Health Service achieved 94.2%, 90% and 97.1% respectively, whilst our Physchiatric Liaison Service (RAID) in Wigan saw 94.7% of referrals from A&E within an hour. Following some difficulty in achieving the required cases of new psychosis in the Early Intervention teams in quarter 2, we are pleased that the target has been met to date in quarter 3. Regional benchmarking data indicates that our teams are also good at offering prompt assessment following referral and this puts us in a good position to respond to the forthcoming targets in this area.

Are we delivering to our patients and users?

Page 6 of 35

Risk Assessment Framework

Qtr 1 Qtr 2 Oct-14 Nov-14 Dec-14 Qtr 3 3 Month Trend Arrow

a) % Seen within 4 Hours 95% 99.91% 99.89% 100.00% 99.86% 99.88% 99.91%

96.1% 97.3% 95.4% 97.0% 94.0% 95.5%

(546/568) (571/587) (188/197) (196/202) (173/184) (557/583)

(b) having formal review within 12 months Snapshot position - Oct 13 onwards Quarterly 95% 99.9% 99.8% 99.9% 99.9% 100.0% 100.0%

Monitor RAF Guidance Quarterly <7.5% 1.0 5.3% 5.5% 6.9% 5.1% 10.1% 7.3%

Care Quality Commission Periodic

ReviewQuarterly 95% 1.0 100.0% 99.8% 96.5% 98.9% 97.2% 97.6%

Department of Health Quarterly Omnibus

SurveyQuarterly 95%*

(143 cases) 0.5 101.8% 83.9% 87.1% 99.7% 97.2% 97.2%

Quarterly 99% 0.5 99.9% 99.9% 99.9% 99.8% 99.8% 99.8%

a) % open patients on CPA with a valid employment status

Snapshot position - Oct 13 onwards Quarterly 87.0% 89.6% 89.2% 90.0% 90.8% 90.8%

b) % open patients on CPA with a valid accommodation status

Snapshot position - Oct 13 onwards Quarterly 99.5% 99.4% 99.4% 99.5% 99.4% 99.4%

c) % open patients on CPA having HoNOSassessment in past 12 months Quarterly 71.9% 73.4% 72.1% 73.0% 72.9% 72.9%

Care Quality Commission Periodic

ReviewAnnual n/a 0.5 COMPLIANT COMPLIANT COMPLIANT COMPLIANT COMPLIANT COMPLIANT

i) Referral to Treatment Times - AHP Lead in the Community

a) % of Patients on an AHP Pathway with a valid start date

no threshold not applicable not applicable not applicable not applicable not applicable not applicable

ii) Community Treatment Activity - Referralsa) % of Referralslogged within PARIS with a valid priority code

no threshold 63.2% 63.2% 62.5% 62.0% 61.7% 62.3%

iii) Community treatment activity – care contactactivity

a) % of face to face contacts with a valid location type

no threshold 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% ↔

Data completeness: outcomes 0.5

Self-certification against compliance with requirements regarding access to healthcare for people with a learning disability

Data completeness:Community Care Activity 50% 1.0

50%

Minimising delayed transfers of care

Admissions to inpatient services had access to crisis resolution home treatment teams

Meeting commitment to serve new psychosis cases by early intervention teams

Data completeness: identifiers

New Risk Assessment Framework Guidance

A&E 1.0

Care Programme Approach (CPA) patients

Either of the following indicators

(a) receiving follow-up contact within seven days of discharge OR

Department of Health Quarterly Omnibus

SurveyQuarterly 95%

1.0

Indicators Data Source Reporting Frequency Thresholds Weighting

Page 7 of 35

Key Indicators: Variance to Budget- Underlying Surplus, Bank and Agency Usage, Cost Improvement Programmes, Capital Expenditure, Risk Ratings-Capital Servicing Capacity and Liquidity Ratio, Beyond Year End Risk Ratings- Capital Servicing Capacity and Liquidity Ratio

At the end of December the Trust is performing within all tolerances against financial viability indicators.

There has been an improvement in month as action plans to address pressures have continued to positively impact. As a result, the Trust remains on target to meet the £4m underlying surplus and the risk of underachievement of this target has significantly reduced.

This represents a significant amount of effort from budget holders and something we are proud of.

Are we financially viable?

Page 8 of 35

Are we delivering on our strategy?

Key Indicators: Performance against the Trust high level objectives and Strategic Risks reported in the Board Assurance Framework.

We are achieving against all of our indicators with the exception of:

During 2014/15, we will implement year one action of the Informatics Strategy. This means that we will implement our new clinical system (RIO), ensuring that the implementation is consistent with other key priorities of the Informatics Strategy. The RiO cohort one will go live on 2nd February 2015, which represents a delay to the original programme. Planning for cohorts two and three will be completed by the end of March 2015.

Are we delivering to our patients and users - The two non-PBR pathways have been reviewed and are on track. The integrated care pathways approach is being used to support the integrated care pathways work in the Borough of Knowsley focusing on a frail elderly pathway that is in development utilising experience within the Physical Health and Later Life and Memory Services Business Streams. This represents a planned delay to our original timeline.

Page 9 of 35

Do our Stakeholders Support What we do?

Key Indicators: Service user/patient and carer involvement, CCG relationship building, attendance and feedback from Health and Wellbeing Boards, New business wins and losses

In month there were no planned Executive level relationship meetings between Trust Directors and our partners in the five Local Authorities and Clinical Commissioning Groups.

Although there were no Executive level relationship meetings Senior Managers from the Trust continued to proactively engage with partners in Wigan through the Wigan Provider Partnership to consider opportunities for greater collaboration to improve the service user pathway, particularly around strengthening the link between physical health and mental health services which both supports the aspiration of Parity of Esteem and the Trust’s vision of whole-person care.

The Trust continues to engage proactively with our partners through the commissioner led Collaborative Committee on the clinically led redesign of our Later Life and Memory Services in-patient provision. The first meeting of the Committee under the new Chair, the Director of Transformation for Halton, took place on 1st December.

Page 10 of 35

Business Stream – Adults

We will inform the Trust Board of things we are proud of and things we are concerned about, in particular, whenever measures have triggered the pre-defined tolerances at a business stream level.

Are we delivering our services safely? Key Indicators: Incidents and Patient Harm, Internal and External Quality Inspections, Clinical Audits, Safeguarding, Suicide Levels, Restraints and Seclusion, Staff Safety

All our measures are within tolerance in month with exception of harm related to patient falls within the Business Stream. Of the falls that resulted in patient harm, one resulted in a moderate level of harm and seven falls resulted in low levels of harm.

As reported last month, as part of our action plan to standardise the pathway and reduce access times for Psychological Therapies within our Recovery Teams, we committed to contacting all those on the waiting list to ensure they have access to on-going support whilst awaiting the commencement of their therapy. This has happened and we are continuing to progress with our action plan, with the support of the Trust’s Professional Lead for Psychological Therapies. We will continue to report on progress against the plan for the remainder of the year. A report is due back to the Trust’s Quality Committee in April.

Page 11 of 35

Business Stream – Adults Do we have sufficient, highly motivated and skilled staff?

Key Indicators: Staff Attendance, Training, vacancies, Awards/Recognition, Acting up Posts, Performance Development Review (PDR)* Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All our measures are within tolerance in month with the exception of PDR Compliance and Staff Attendance.

PDR Compliance has remained broadly static for a number of months with no improvement noted. In order to support an improvement, the cascade approach to PDR’s will require re-launching across Adult and operational services to improve the position and we will work in partnership with colleagues in the People Directorate to facilitate this.

Disappointingly, Staff Attendance has marginally reduced again in month to 93.60% and still remains just below the Trust target of 95%. That said, the attendance level for qualified staff has slightly improved in month to 93.18%. The Assistant Directors within Adult Services and their teams continue to support teams to manage attendance in line with the Trust policy and to provide targeted support to any areas of particularly high sickness.

Statutory Training, although still below the Trust target of 90% and stands at 86% and continues to be a focus of management attention to further improve the position.

The Business Stream was overall compliant with Safe Staffing in month.

Page 12 of 35

Business Stream – Adults Are we delivering to our patients and users?

Key Indicators: Delayed Discharges, Did Not Attend Rates, Community and In-Patient Activity, Complaints and Compliments, Out of Area Activity, 72 hour and 7 day follow ups, Readmissions, Improving Access to Psychological Therapies (IAPT) Recovery Rates, Length of Stay, Access to Treatment, Waiting times until Assessment, Commissioning for Quality and Innovation (CQUIN), Patients seen who are on a Care Programme Approach (CPA), reviewed and Health of the Nations Outcome Scores (HoNOS) assessed in a timely manner, Payment by Results (PBR) Clustering, Early Intervention

All our measures are within tolerance in month with the exception of Payment By Results Clustering Compliance (PBR), Access Times within our Adult Assessment Teams, DNA Levels and re-admission rates.

We remain particularly concerned that our PBR compliance in month continues to show a reducing trend and stood at the month end at 73%, as opposed to the Trust target of 90%. As has been reported in last month’s report, a significant contributing factor to the performance has been the Clustering launch within two particular Boroughs. Action has been put in place to improve the position and this is having a positive effect on performance which will be reported next month. The management action that has been taken includes weekly monitoring of the position by local managers, with an overview by the relevant Assistant Director.

Access times within our Adult Assessment Teams continue to be below the Trust target of 100%. Of concern is there has been three month downward trend in achievement of the Urgent response category (within 72 hours) across all three of our assessment teams. The management action that will be taken is a review of this position by team to understand causation and any support that will need to be put in place to improve the position.

We are concerned that Did Not Attend (DNA) levels within the Adult Business Stream have breached tolerance and stands at 10.8% (as opposed to the Trust target of 8%). The management action that is being taken is to identify the areas of increasing Did Not Attend levels and possible reasons for this including the continued review of the DNA pathway within the Adult Assessment Teams.

In addition, we are concerned that re-admission rates have also breached tolerance within Adult Services and stood at 10.5% in the month which is above the Trust target of 9%. This has been further investigated and relates to an increase in from our in-patient provision within the Borough of Wigan. The management action that is being taken is to arrange for a clinical overview the re-admissions to understand any patterns or trends and the work will be led by the Matron for Adults Services in Wigan, alongside key Clinicians.

Page 13 of 35

Business Stream – Adults Are we financially viable?

Key Indicators: Variance to Budget, Bank and Agency Usage, Cost Improvement Programmes (CIP’s)

All our measures are within tolerance in month.

Are we delivering our strategy?

Key Indicators: Whole person approach, enhance patient pathways, innovative care solutions though clinical engagement, flexible workforce

Due to the successful impact of the Trust’s alternative to admission project within the Borough of Wigan, the Trust is working with the Clinical Commissioning Group commissioners and the wider system to understand the opportunities for this service to be continued in the 2015/2016 financial year.

Do our stakeholders support what we do?

Key Indicators: Business Wins and Losses, Feedback from External Stakeholder Meetings Indicators: from External Stakeholder

We were pleased in month to be notified that Knowsley Clinical Commissioning Group has decided to support the Trust with additional targeted Mental Health Resilience funding to provide enhanced clinical capacity within Adult the in-patient units within the Borough.

In addition, we have been asked to develop the concept of providing additional targeted support for GP’s in Primary Care to manage and support mental health conditions. The projects we are delivering with the additional targeted Mental Health Resilience funding received will be evaluated and discussed with senior clinicians via the Trust’s Clinical Leadership Group to agree a consistent model should we be successful in attaining recurrent funding for any of this activity going forward. These services are in the process of being operationalised by local teams.

Finally, in month, we were proud to receive feedback from one of our Acute Trust partners about the positive impact of our Psychiatric Liaison service is having on patient flow within both the Accident and Emergency Department and Medical wards.

Page 14 of 35

Business Stream – Secure Services


Are we delivering our services safely? Key Indicators: Incidents and Patient Harm, Internal and External Quality Inspections, Clinical Audits, Safeguarding, Suicide Levels, Restraints and Seclusion, Staff Safety

All of our measures are within tolerance in month.

It is pleasing to note that continuing on from last month’s reduction in the level of incidents which were reported as being at the lowest level since the beginning of the financial year, there has been a further reduction in the level incidents. In addition, restraint has also significantly reduced. Contributory factors we believe to these reductions within particularly in-patient services including the work to proactively support people who self-harm.

Page 15 of 35

Business Stream – Secure ServicesDo we have sufficient, highly motivated and skilled staff?Key Indicators: Staff Attendance, Training, Vacancies, Awards/Recognition, Acting up Posts, *Performance Development Review (PDR) Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All of our measures are within tolerance with the exception of Staff Attendance, Performance Development Reviews (PDR) and Safe Staffing.

It is disappointing that Staff Attendance levels within the Business Stream have fallen below the Trust target of 95% and stand at 92.63% in month, with an increase mainly related to long-term sickness levels. The management action that is being taken is to ensure that staff and managers are supported in line with the Trust managing attendance policy.

It is disappointing that there has been a three-month downward trend in the compliance levels with PDR’s. The management action that is being taken is for local managers to review their position by team and understand the reasons for this reducing trend and take appropriate supportive action to see an improved position. A contributory factor to this reduction will be new employees in some of our teams. Within the month on occasion, two of our in-patient units were below the threshold of 90% for what we normally plan for safe staffing levels. This did not result in any un-safe staffing.

Page 16 of 35

Business Stream – Secure ServicesAre we delivering to our patients and users? Key Indicators: Delayed Discharges, Did Not Attend Rates, Community and In-Patient Activity, Complaints and Compliments, 72 hour and 7 day follow ups, Readmissions, Commissioning for Quality and Innovation (CQUIN), Patients seen who are on a Care Programme Approach (CPA), reviewed and Health of the Nations Outcome Scores (HoNOS) assessed in a timely manner, Admissions and Gatekeeping, Discharge Planning

All of our measures are within tolerance with the exception of Delayed Discharges.

We are concerned that the percentage of discharges which is outside the Trust target of 7.5%, and stands at 12.2% in month. We are reviewing the process by which delayed discharges from our Secure Units are reviewed and managed with NHS England.

Are we financially viable? Key Indicators: Variance to Budget, Bank and Agency Usage, Cost Improvement Programmes

None of our measures are in tolerance in month.

Our pay expenditure is high due to the level of bank costs incurred to support additional observations required predominately within one of our in-patient units.

Are we delivering our strategy? Key Indicators: Whole person approach, enhance patient pathways, innovative care solutions though clinical engagement, flexible workforce

Within the month staff from the Secure Services Business Stream delivered a number of mental health awareness training sessions to Prison Staff. The aim of these sessions was to raise their awareness of mental health issues and where they can get appropriate support for prisoners. The provision of the training, which was very well received, is in line with the Business Stream’s strategy to increase understanding and support for mental health issues within prison settings.

Page 17 of 35

Business Stream – Secure ServicesDo our stakeholders support what we do? Key Indicators: Business Wins and Losses, Feedback from External Stakeholder Meetings Indicators: from External Stakeholder

We are pleased to report that the Trust has received notification from NHS England that funding for our Liaison and Diversion programme to support those engaged with, or at risk of, engaging with the criminal justice system with a mental health issue, has been extended for the next financial year (2015/2016).

Page 18 of 35

Business Stream – Later Life and Memory Services




All of our measures are within tolerance.

We are pleased to report that the number of patient incidents has reduced within the Business Stream for the last three months, with a particularly significant reduction in the numbers of incidents in month. This reduction is contributed to by discharges that took place in the month of service users who had previously been involved in a high number of the previously reported incidents.

We are pleased, as reported in the Quality and Performance report to the Board last month, Later Life and Memory Services in-patient units have each had an internal quality visit. The outcomes of these visits were shared at a workshop with clinical leaders and operational managers within the Business Stream in month with significant areas of good practice identified. Areas for improvement were also noted and an action plan is being developed. Representatives from the Business Stream will be attending the Trust’s Quality Committee in February to report back on the outcome of the internal quality visits and progress against the action plan that has been developed.

Page 19 of 35

Business Stream – Later Life and Memory ServicesDo we have sufficient, highly motivated and skilled staff?Key Indicators: Staff Attendance, Training, Vacancies, Awards/Recognition, Acting up Posts, Performance Development Review (PDR) Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All of our measures are within tolerance with the exception of Staff Attendance, Performance Development Review (PDR) compliance and Safe Staffing levels.

Although below the Trust target of 95% for staff attendance, we are pleased to report that within the Business Stream staff attendance levels have marginally improved for last month to 93.34%, with improvement in the health care assistant staffing group, particularly within our in-patient units. The management action that will be taken is to ensure that staff continue to be managed and supported in line with the Trust policy for managing attendance.

Despite remaining below the Trust target of 90% for PDR compliance, there has been a pleasing improvement in month to 84%, from 75% in the previous month. This improving position is due to more effective recording of PDR compliance at local team level following management action taken to understand the reasons for non-compliance in some of the teams within the Business Stream.

In the month on occasion, one of our in-patient units was below the threshold of 90% for what we normally plan for safe staffing levels. This did not result in any un-safe staffing.

Page 20 of 35

Business Stream – Later Life and Memory ServicesAre we delivering to our patients and users?

Key Indicators: Delayed Discharges, Did Not Attend Rates, Community and In-Patient Activity, Complaints and Compliments, Out of Area Activity, 72 hour and 7 day follow ups, Readmissions, IAPT Recovery Rates, Length of Stay, Access to Treatment, Waiting times until Assessment, Commissioning for Quality and Innovation (CQUIN), Patients seen who are on a Care Programme Approach (CPA), reviewed and Health of the Nations Outcome Scores (HoNOS) assessed in a timely manner, Meeting Early Intervention Targets, Payment by Results (PBR) Clustering Early Intervention

All of our measures are within tolerance with the exception of In-patient occupancy, Delayed Discharges and Payment by Result Clustering (PBR) compliance

It is pleasing to note that occupancy within our Later Life and Memory Services (LLAMS) in-patient units has significantly reduced in month to 76.9% from 93.9% in the previous month. The Business Stream will continue to monitor occupancy levels and the impact of enhanced multi-disciplinary working that has been put in place within our LLAMs in-patient units.

We are concerned that the Business Stream is again outside the Trust target for Delayed Discharges in the month. We have seen an increase in the percentage figure but a reduction in the number of people who have their discharge delayed in month compared to the previous month. This is due to reduced occupancy levels in the month. The management action that continues to be taken includes liaison with Local Authority and Clinical Commissioning Group partners to ensure where possible any further delays to effective discharges are removed and discharges can be occur.

We are disappointed that our PBR compliance still remains below the Trust target of 90% and stood at 86.4% in the month. The management action that has been put in place to improve the position includes weekly monitoring of the position by local managers, with an overview by the Assistant Director.

Finally, we are proud that one of the compliments we received in month related to the way in which the manager and staff within one of our in-patient units supported a service user and their family who were in Australia to be in contact via Skype and take part in the service user’s birthday celebrations and to be able to see the environment in which their family member was being cared for. The impact on the family and the service user was incredibly powerful and is one example of Trust staff supporting the aspirations of our culture of care strategy.

Page 21 of 35

Business Stream – Later Life and Memory ServicesAre we financially viable?

Key Indicators: Variance to Budget, Bank and Agency Usage, Cost Improvement Programmes (CIPs)



Key Indicators: Inpatient Strategy, Community Strategy, Local and National Strategies including Dementia and "Life Story"

We are continuing to work closely with our commissioners via to review Later Life and Memory Service in-patient provision following the success of the implementation of the community pathway.

We are pleased to report that Later Life and Memory Services in Wigan, Halton and Warrington are registered with each Borough Dementia Action Alliance supporting the development of Dementia friendly communities.



We are proud that we have received very positive feedback from commissioners in Wigan about the positive impact on reducing hospital admissions over the Winter period so far of the Trust’s Care Home Liaison service which provides targeted support around medication and behaviour management. The Assistant Director continues to work with our Clinical Commissioning Group colleagues to look at the commissioning of this service in the new financial year.

Page 22 of 35

Business Stream – Learning Disabilities

We will inform the Trust Board of things we are proud of and things we are concerned about, in particular, whenever measures have triggered the pre-defined tolerances at a business stream level. Are we delivering our services safely?

Key Indicators: Incidents and Patient Harm in particular Violence and Aggressive Incidents, Internal and External Quality Inspections, Clinical Audits, Safeguarding, Suicide Levels, Restraints and Seclusion, Staff Safety

All of our measures are within tolerance within the month with the exception of incidents and patient harm. Detail relating to this will be contained within a Part II paper.

Page 23 of 35

Business Stream – Learning Disabilities Do we have sufficient, highly motivated and skilled staff?

Key Indicators: Staff Attendance, Training, Vacancies, Awards/Recognition, Acting up Posts, *Performance Development Review (PDR) Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All of our measures are within tolerance with the exception of Staff Attendance, Performance Development Reviews (PDR) and Core and Statutory Training.

We are disappointed that staff attendance within the Business Stream has continued to be below the Trust target of 95% and stands at 90.33% which is a reduction from the previous month when it stood at 94.03%. The main area being affected by sickness was the in-Learning Disability in-patient unit and one of our community teams. The management action that is being taken is to ensure that staff and managers are supported in line with the Trust’s managing attendance policy.

We are disappointed that PDR compliance within the Business Stream remains static at 79%. The management action that is being taken is to ensure that a cascade approach to PDR’s in place and that managers are reminded of low compliance levels in their teams where appropriate.

Similarly, we are disappointed that Statutory and Core Training compliance has remained static and below the Trust target compared to last month and stands at 82% and 88% respectively. Managers are focusing on ensuring that training compliance improves going forward.

The Business Stream was compliant with safe staffing levels within the month.

Page 24 of 35

Business Stream – Learning Disabilities Are we delivering to our patients and users?

Key Indicators: Admissions, Delayed Discharges, Did Not Attend Rates, Community and In-Patient Activity, Complaints and Compliments, 72 hour and 7 day follow ups, Readmissions, Length of Stay, Commissioning for Quality and Innovation (CQUIN), Patients seen who are on a Care Programme Approach (CPA) and seen in a timely manner All of our measures are within tolerance with the exception of Delayed Discharges.

We are concerned that the Business Stream is again outside the Trust target for Delayed Discharges in the month. We have seen an increase in the percentage figure of those delayed but the same number of people remain a delayed discharge. This increase in the percentage figure is due to reduced occupancy levels in the month. The details of delayed discharges are contained in a Part II item.


Key Indicators: Variance to Budget, Bank and Agency Usage, Cost Improvement Programmes (CIP)

All of our measures are within tolerance. Are we delivering our strategy?

Key Indicators: Assessments for Autistic Spectrum Conditions (ASC) and Community Pathways

There is nothing of note to report this month.




Page 25 of 35

Business Stream – Physical Health



Key Indicators: Incidents and Patient Harm, Internal and External Quality Inspections, Clinical Audits, Safeguarding, Suicide Levels, Restraints, Staff Safety


We are pleased that our teams have submitted their returns for the internal Team Quality Assessment review process. Teams are looking forward to engaging in this process of service improvement.

We still remain concerned about the numbers of Trust acquired pressure ulcers which have increased in month. In addition to the peer review into the management of pressure ulcers that is due to report in early in the New Year, the Business Stream are also seeking to identify benchmarking data to understand how Trust teams perform against other similar services in the management of pressure ulcers including identifying the percentage of active cases that result in pressure ulcers. It is expected that this benchmarking data will be available in mid–February.

Page 26 of 35

Business Stream – Physical Health Do we have sufficient, highly motivated and skilled staff?Key Indicators: Staff Attendance, Training, Vacancies, Awards/Recognition, Acting up Posts, Performance Development Review (PDR) Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All our measures are within tolerance in month with the exception of staff attendance, Personal Development Review (PDR) compliance and statutory training compliance.

We are disappointed that the Business Stream has just failed to achieve the Trust target for attendance of 95% in the month, with the attendance figure standing at 94.47%. The Business Stream is continuing to support staff and managers to effectively manage attendance and support staff in line with the Trust policy. Though it is disappointing the Business Stream hasn’t achieved the Trust target, we are pleased to note that attendance levels have been at, or above, 94% since April 2014 within the Physical Health Business Stream.

Similarly, the Business Stream is disappointed that compliance with PDR reviews and statutory training still remain below the Trust target of 90%, with PDR compliance at 85% and statutory training at 87%. The management action that will be taken includes identifying areas of lower than target compliance and support to local team managers to address any shortfalls.

We are proud that members of the District Nursing Team in the South Locality of Knowsley supported each other during a short period of sickness in the team over the Christmas period by working together to ensure that high quality services continued to be delivered with staff working extra shifts, covering each other’s case loads and one example included a member of staff who had recently been married and was on leave coming into work to support the wider team.

Page 27 of 35

Business Stream – Physical Health Are we delivering to our patients and users?

Key Indicators: Did Not Attend Rates, Community Activity, Complaints and Compliments, Access to Treatment, Waiting times until Assessment, Commissioning for Quality and Innovation (CQUIN)

All of our measures are within tolerance with the exception of those referred to our Musculoskeletal service being offered an appointment within 10 days. Although performance in this team is improving, with an increase in month to 50% (as opposed to 41% in the previous month) the Business Manager and Assistant Director continue to review reasons for this performance including addressing one of the previously highlighted issues which was related to venues for clinic appointments. It is expected that a plan to address the clinic venue aspect, this will be finalised and have begun to be implemented by the end of January.

We are pleased to report that whilst demand over the Christmas period in the Primary Care Walk in Centres significantly increased, as you would expect, as a result of the enhanced staffing levels due to winter resilence funding we were able to ensure that we continued to deliver a high quality responsive service with 99.88% of those attending Walk in Centres being seen in under the target time of 4 hours.

We were pleased to support the wider urgent care system within Knowsley and St Helens by re-locating therapy staff from our teams into Acute Trust settings to help facilitate earlier discharges and transfers from Hospital based services.

We remain concerned about the waiting times within our Speech and Language Therapy services. We have agreed additional resource with our commissioners until the end of the financial year, to support reducing these waiting times and the recruitment and deployment of key therapist is in place.

Page 28 of 35

Business Stream – Physical Health Are we financially viable?

Key Indicators: Variance to Budget, Bank and Agency Usage, Cost Improvement Programmes



Key Indicators: Reduction in Unplanned admissions of patients with Long Term Conditions, Integration, Shared Decision Making

We are pleased to be working with Knowsley Clinical Commissioning Group and Knowsley Borough Council to identify opportunities to provide enhanced physical health nursing input to Care Homes and Nursing Homes within the Borough who are on their journey of service improvement. The Business Stream will be working closely with the Later Life and Memory Services Team who deliver the Mental Health Care Home Liaison service in the Borough to ensure a joined-up approach to the delivery of care support.




Page 29 of 35

Business Stream – Children and Adolescent Mental Health Services





Do we have sufficient, highly motivated and skilled staff?

Key Indicators: Staff Attendance, Training, Vacancies, Awards/Recognition, Acting up Posts, Performance Development Review (PDR) Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All our measures are within tolerance in month with the exception of Staff Attendance, Performance Development Reviews (PDR) Levels and Statutory Training Compliance.

It is of concern that Staff Attendance has reduced again in month from 93.10% in November to 91.86%, with the main areas affected being short-term sickness absence within CAMHS community teams. The management action that is being taken is to continue to provide team members with support in line with the Trust managing attendance policy.

PDR Compliance, though below the Trust target of 90%, has improved marginally in month from 79% in November to 80% in month and the management action that is being taken is to ensure that teams are reminded about the cascade approach to PDR’s.

The Business Stream was compliant with Safe Staffing Levels in month.

Page 30 of 35

Business Stream – Children and Adolescent Mental Health Services Are we delivering to our patients and users?

Key Indicators: Delayed Discharges, Did Not Attend Rates, Community and In-Patient Activity, Complaints and Compliments, Out of Area Activity, 72 hour and 7 day follow ups, Readmissions, Access to Treatment, Length of Stay, Waiting times until Assessment, Commissioning for Quality and Innovation (CQUIN), Patients seen who are on a Care Programme Approach (CPA), reviewed and Health of the Nations Outcome Scores (HoNOS) assessed in a timely manner, Early Intervention


We are concerned, however, about the number of young people who have had to be admitted to In-Patient Units outside of the 5 Boroughs footprint due to the lack of availability within the Trust’s In-Patient Unit which, during the reporting period, was at the highest level during the financial year. The Business Stream Clinical Team continues to prioritise the appropriate admission of young people to the Trust In-Patient Unit from out of area at the earliest and safest possible opportunity.

As reported last month, we remain concerned about the waiting time following initial assessment within our Tier 3 (Community) CAMHS Service for treatment/therapy. The current best practice guidance is that treatment/therapy should commence within 4-6 weeks following initial appointment. Although the situation is improving due to the management actions and additional review clinics that have been put in place, Trust services still have waiting times in excess of best practice guidance. The Scoping Report with recommendations still remains our target to be produced by January for discussion with the Chief Nurse/Executive Director of Clinical Operational Services, Director of Operations & Integration and Clinical Director of Operations Integration.

Are we financially viable ?


A range of management actions have been taken within the Business Stream to improve the financial position, returning the Business Stream to within tolerance year to date and the forecast at year-end. The impact of the positive management action taken will continue to be monitored by the process in place with each Business Stream.

Page 31 of 35

Business Stream – Children and Adolescent Mental Health Services Are we delivering our strategy?

Key Indicators: IAPT, Agile Working, day Services, Develop PAN Borough Services, Shared Decision Making and Single Child Health Clinical Pathway in Knowsley

We continue to monitor the use of the additional two In-Patient beds opened in response to increasing system-wide demand. Occupancy in month is in line with our planning assumption.


Key Indicators: Business Wins and Losses, Feedback from External Stakeholder Meetings Indicator holder

The Trust was unfortunately not successful with our bid to provide a service to Children in Care within one of our Boroughs. We are seeking feedback from the commissioner.

Page 32 of 35

Business Stream – Children, Families and Wellbeing



Key Indicators: Incidents and Patient Harm, Internal and External Quality Inspections, Clinical Audits, Safeguarding, Suicide Levels, Restraints, Staff Safety


Do we have sufficient, highly motivated and skilled staff?Key Indicators: Staff Attendance, Training, Vacancies, Awards/Recognition, Acting up Posts, Performance Development Review (PDR) Compliance, Agency and Locum Usage, Clinical and Managerial Supervision, Safe Staffing Levels

All of our measures are within tolerance with the exception of Performance Development Reviews (PDR) compliance and Statutory Training compliance.

We are proud that attendance levels within the Business Stream have met the Trust target of 95% and in month stood at 95.82% in month, this improving position is largely due to the return to work of individuals who have been absent from the work-place due to long-term sickness episodes in a small number of teams.

Disappointingly PDR compliance still has not achieved the Trust target of 90% in month and stood at 78%. The management action that will be taken is to ensure that Managers are aware of the cascade approach to PDR's that is in place.

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Business Stream – Children, Families and WellbeingAre we delivering to our patients and users?

Key Indicators: Did Not Attend Rates, Community Activity, Complaints and Compliments, Access to Treatment, Waiting times until Assessment, Commissioning for Quality and Innovation (CQUIN)


We are pleased that following reporting last month that the number of those accessing adult weight management within 30 days of opting into service had reduced to below target levels, the position has now improved and performance was in excess of the target in month.





Key Indicators: Single Child Health Clinical Pathway, Shared Decision Making

As part of the Business Streams continued focus on using a shared decision making approach, the Dietetics team continues to roll out the approach with a particular focus on implementing decision grids. A decision grid is populated by the practitioner with relevant information about a range of clinically appropriate care options to enable the service user to make their own decision about which care option best suits the individual. The impact on the service user is to enable them to have choice in care options that best meet their individual life circumstances. The use of a decision making grid approach is known to improve service user experience and support a greater degree of compliance to agreed care choices.

Page 34 of 35

Business Stream – Children, Families and WellbeingDo our stakeholders support what we do?


We are pleased to report the positive feedback the Knowsley Immunisation Team received from the Screening and Immunisation Lead for Merseyside in relation to the Team’s work in being identified as the best performing team in the North West and the fourth in England for the up-take of Human Papilloma Virus (HPV)

Page 35 of 35

Agenda Item No.

5BP (15/12)

15/12 Serious incidents (Part1) Page 1 of 4

BOARD REPORT PART 1

___________________________________________________________________ DATE OF BOARD MEETING: 26 January 2015

TITLE OF REPORT: Serious Incidents November and December 2014

PURPOSE OF REPORT:

To inform the Trust Board of:

• Serious Incident reviews that have been commissioned in November and December 2014

• To provide information on recent and planned Coroners Inquests.


• Seventeen Serious Incidents were reported through the StEIS system in November and December 2014. Serious Incident Reviews were commissioned for fourteen incidents

• Fourteen inquests were heard in November and December 2014.

• Two inquests are listed to be heard in January 2015.

ACCOUNTABLE DIRECTOR: Tracy Hill Director of People and Integrated Governance


Trust Board discusses the paper and receives the latest position regarding Serious Incidents.

Agenda Item No.

5BP (15/12)



√



3. Are we delivering to our patients and users?






Yes X No

If yes,

BAF entry No.

Trust High Level Objective (as above)

Description from Board Assurance Framework

20 Is the organisation and its services well led

There is a risk that the quality and governance assurance processes will not be fully embedded in operations due to a lack of readiness, leading to an inability to provide robust assurances.

Agenda Item No.

5BP (15/12)



Serious Incident and Inquests Report November and December 2014

1. INTRODUCTION / EXECUTIVE SUMMARY

This paper has been developed to provide the Board with information on the Strategic Executive Information System (StEIS) reportable activity. The Board are requested to note recent activity in relation to Serious Incident reviews and assurance processes in place for Serious Incident Reviews.

2. BACKGROUND

This paper is produced as a standing agenda item for the attention of the Board.

3. NEW INCIDENTS COMMISSIONED FOR REVIEW

Seventeen Serious Incidents were reported through the StEIS system in November and December 2014. Serious Incident Reviews were commissioned for fourteen incidents

3.1 StEIS Reportable Reviews

StEIS reportable incidents include:

• sudden, unexpected death of a community patient in receipt of services or who has been involved with our services within the last six months,

• inpatient suicides • unexpected death of an inpatient • suspected suicides of community patients • serious safeguarding allegations • a never event • any incident that is perceived to have possible media attention • absconds from secure units only • serious self-harm

4. ASSURANCE PROCESSES IN PLACE FOR SERIOUS INCIDENT REVIEWS

• High level Information is provided to the Trust Board on a monthly basis which allows the Trust Board to gain assurance that Serious Incidents are being managed effectively.

• The Quality Committee undertake a ‘deep dive’ review of a completed Serious

Incident review at each monthly meeting. • A key function of the Quality and Safety meeting, chaired by the Director of People

and Integrated Governance, is to review Serious Incidents, Complaints, and Inquests. The meeting discusses any themes prevalent, and scrutinises actions and areas of learning for the Trust.

Agenda Item No.

5BP (15/12)


5. GOVERNANCE DEVELOPMENTS

5.1 Serious Incident Review systems

The Trust is continually improving the process to support effective reporting, management and investigation of serious incidents. Revised documentation for serious incident investigations has been developed and have been in use since early December 2014. A cohort of Matrons and Quality Leads has received specially commissioned training in Root Cause Analysis Investigation and Inquests in November 2014. The cohort went ‘live from December 2014 and are leading serious incident reviews.

The Incident Management Policy and Procedure, and Being Open Policy and Procedure have been re-drafted and now include reference to the Statutory Duty of Candour. These were ratified at the December 2014 Audit Committee.

This work supports adherence to the Clinical Commissioning Group and NHS England Cluster Legacy Review Action Plan.

6. INQUEST UPDATE

The Trust was notified of fourteen inquests to be heard in November and December 2014 that required input from Trust staff. Two inquests are listed for hearing in January 2015.

7. SUMMARY

• Seventeen Serious Incidents were reported through the StEIS system in November and December 2014. Serious Incident Reviews were commissioned for fourteen incidents.

• Fourteen inquests were heard in November and December 2014. • Two inquests are listed to be heard in January 2015.

8. RECOMMENDATION The Board is requested to approve the following recommendations:

• To note the paper and receive the latest position regarding Serious Incidents

Tracy Hill Director of People and Integrated Governance

Agenda Item No.

5BP (15/13)

15/13 Risk Assurance Report Page 1 of 7

BOARD REPORT ___________________________________________________________________ DATE OF MEETING:

26 January 2015

TITLE OF REPORT:

Risk and Assurance Report

PURPOSE OF REPORT:

• To provide high level summary information on

risks, this will allow a dialogue to take place on the level of assurance ensuring that risks are being managed effectively.

• to present an opportunity for the Trust Board to view and discuss risks relating to the 2014/15 High level objectives as part of the revised Board Assurance Framework

• to consider the key strategic risks as part of the revised Board Assurance Framework.


• There are a total of 78 open risks, 15 of which

have been mapped against the Board Assurance Framework including one additional risk approved further to the Trust Board report

• there are 24 open risks identified which may impact on the Trust achievement of the High Level Objectives. Four of these appear on the Board Assurance Framework

• there are five Strategic risks mapped against the Board Assurance Framework

• overall 56 risks have not changed their rating from their initial rating including seven risks which entered the risk register from 1 November 2014 onwards. These risks are reviewed at the Quality and Safety meeting.


Tracy Hill Director of People and Integrated Governance

RECOMMENDATION TO THE COMMITTEE:

• That the Trust Board discuss the paper and confirms they are assured robust risk management systems and processes are in place.

Agenda Item No.

5BP (15/13)



√




4. Are we financially viable? √


6. Are we delivering on our strategy? √



Yes √ No

If yes,

BAF entry No.



ALL ALL This is the Risk and Assurance Report which includes a review of the October 2014 Board Assurance Framework.

Agenda Item No.

5BP (15/13)


Board Report 26 January 2015

Risk and Assurance Report


• Effective risk management ensures risks remain live and that the level of control required is sufficient to mitigate the consequence of negative impact to the Trust and that actions to mitigate risks are achieved within acceptable timescales.

• this paper provides a general overview of risk. It outlines actions taken to mitigate the risks and presents the updated Board Assurance Framework (Appendix 1)

• position at 8 January 2015 - there are 78 risks held on the risk register, including 15 that are mapped against the Board Assurance Framework

• all risks identified as having potential to impact on the delivery of the 2014/2015 high level objectives have been identified. A total of 24 risks remain open on the risk register. Of these, four appear on the Board Assurance Framework having an overall rating of 12 or above with fair or limited controls (Table2)

• on the basis of the proposals, the Board Assurance Framework contains 15 risks rated 12 and above, with fair or limited controls, including four risks associated with the Board high level objectives 14/15, five strategic risks and six risks transferred from the risk register.

2. BACKGROUND

• To provide high level summary information on risks which will allow a dialogue to take place, to provide assurance to the Board that there is an effective risk management system in place

• the Board Assurance Framework demonstrates the Trust’s compliance with its governance arrangements and is the key declaration of an effective system of internal control through the Trust’s Annual Governance Statement

• all risks detailed are populated on the risk register but only those meeting the threshold of 12 and above with fair or limited controls feature on the Board Assurance Framework (Appendix 1)

• in addition the strategic risks approved at the February 2014 Board are incorporated into and will always be presented on the Board Assurance Framework

• these risks have been completed by the high level objective owners and signed off by the executive sponsor

• the Board Assurance Framework will continue to be presented at alternate meetings of

the Trust Board.

Agenda Item No.

5BP (15/13)


3. OVERVIEW OF RISK

The risk register consists of all risks reported on the Datix risk reporting system. These include strategic and operational risks; clinical, non-clinical and financial risks. They arise from a variety of sources including risk assessments, audit activity, incident and serious incident reports, external recommendations and risks associated with meeting internal or external targets.

This risk overview provides an update on the overall current risk management position. All risks in the organisation are monitored regularly through the organisations’ Governance Framework.

Table 1 below is a summary of all risks currently open on the Risk Register based on the source of risk and inclusion on the Board Assurance Framework.

Source of Risk BAF risks Non BAF risks Total

High Level Objective risks 4 20 24

Strategic risks 5 0 5

Existing Risk Register risks 6 43 49

Total 15 63 78

Table 1

3.1 Trust High Level Objective Risks Table 2 below summarises the risks identified as having potential to impact on the delivery of the 2014/2015 High Level Objectives. There are a total of 24 risks that remain open on the Risk Register, four of which have an overall rating of 12 or above with fair or limited controls and therefore form part of the Trust Board Assurance Framework.

Trust High Level Objectives 2014/15 Non BAF

BAF

Are we delivering on our strategy? 4 1

Are we delivering our services safely? 3 1

Are we delivering to our patients and users? 2 0

Are we financially viable? 4 2

Do our stakeholders support what we do? 3 0

Do we have sufficient, highly motivated staff? 2 0

Is the organisation and its services well led? 2 0

Grand Total 20 4

Table 2

Agenda Item No.

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3.2 Strategic Risks The Trust Board Assurance Framework also includes five strategic risks summarised below in Table 3. Two of the strategic risks are financial risks and three non-clinical, corporate risks. Four of the risks are rated at 12 with fair controls and one is rated at 16 with limited controls making it a Trust high level risk. Full details of all strategic risks can be found in the Board Assurance Framework in Appendix 1.

ID Opened Title Risk Type

Controls Current Rating

1878 14/05/2014 Risk that commissioners do not see the Trust playing a lead role in the whole person care agenda.

Non Clinical

Fair 12

1879 14/05/2014 Risk that the supporting strategies are not delivering due to them not being aligned

Non Clinical

Fair 12

1880 14/05/2014 Risk of insufficient funding for whole person care in the system

Financial Limited 16

1881 14/05/2014 Risk that our services may be subjected to automatic tendering

Financial Fair 12

1882 14/05/2014 Risk that the workforce to deliver our strategy doesn't exist

Non Clinical

Fair 12

Table 3 3.3 Risk Register In addition to the 24 remaining High Level Objective risks and five strategic risks described above, the Risk Register includes a further 49 open risks arising from a variety of sources. Table 4 below summarises the movement of these risks. Since the beginning of November 2014, 13 risks have closed and 12 new risks were added to the risk register.

Risks unchanged from initial risk rating

Risks reduced from initial risk rating

Risks increased from initial risk rating

Total

Initial risk greater than or equal to 12

9 9 0 18

Initial risk less than 12 25 5 1 31

Total 34 14 1 49

Table 4

Details of the ten non-strategic risks with a current score of 12 or above with fair or limited controls are listed below in Table 5, and full details can be found in the BAF (Appendix 1).

Agenda Item No.

5BP (15/13)


ID Opened Title Controls Current

Rating 1799 30/11/2013 RiO implementation Fair 12 1845 09/05/2014 The harm reduction strategy will not produce the overall 20%

reduction Fair 12

1852 14/05/2014 The Trust does not have robust plans in place for 2015/16 leading to a failure to achieve the agreed Financial Risk Ratings

Fair 15

1864 13/05/2014 Risk that we will not get commissioners to agree the developed pathways

Fair 12

1873 13/06/2014 Risk to in patient service users due to use of 'legal highs' Limited 12 1874 14/05/2014 Risk failure to achieve agreed financial risk rating Fair 15 1887 04/09/2014 Tissue Viability Risk Limited 12 1891 10/10/2014 Increase in waiting times for specialist Intervention in community

teams Fair 12

1901 16/12/2014 Clinical Supervision Limited 16 1905 31/12/2014 Patients unable to regularly access podiatry services within the

Warrington Borough Limited 12

Table 5

3.4 Summary of risks by source and adequacy of controls

Currently all risks associated with the five Strategic risks remain unchanged, having fair or limited controls. Risks associated with the High Level Objectives have 58 per cent good controls compared to 48 per cent in the previous report. Of the operational risks currently on the Trust’s Risk Register 45 per cent have good controls and 67 per cent of the corporate risks on the Risk Register have good controls. Overall 49 per cent of all open risks, compared with 47 per cent in the last report, from all sources have good controls.

Risk Source Fair Good Limited Total

High Level Objectives 10 14 0 24

Strategic Risks 4 0 1 5

Business Stream/Trustwide Operational Risks

16 18 6 40

Corporate Risks 1 6 2 9

Total 31 38 9 78

Table 6

4. GOVERNANCE FRAMEWORK Monitoring of the Board Assurance Framework takes place through the organisation’s governance framework which also provides assurance that robust risk management processes function at each level of the Trust. The Trust Board receive a bi-monthly review of the Board Assurance Framework for discussion.

Agenda Item No.

5BP (15/13)


The Audit Committee also receive a bi-monthly Risk and Assurance Report. The identified risk owner of a risk area will be invited to the committee to participate in a challenge session and discuss the risk. The area that has been selected for this month’s challenge is violence and aggression. This process will particularly focus on those risks that are not being adequately progressed and mitigated, thus providing further assurance and serves the purpose of holding owners to account, and enabling owners to outline any challenges they have, and receive support from the Committee. The Quality and Safety meeting is chaired by the Director of People Services and Integrated Governance. This meeting reviews risk management and mitigation across the organisation. The chair will report any areas of concern to the Quality and Audit committee and where appropriate will commission reviews and discussion at Business Stream Governance Meetings.

5. CONCLUSION There are 78 risks open on the risk register including 15 risks mapped against the Board Assurance Framework consisting of four risks from the Trust’s high level objectives for 2014/15, five strategic risks and six risks from the current risk register. Fifty six risks, from all sources, have a rating that has not changed since the risk was opened; of these 22 have good controls, 27 fair controls and seven limited controls. All such risks are reviewed at the Quality and Safety meeting. There are currently four high level risks open on the risk register, two associated with High Level Objectives, one a strategic risk and one additional risk from the risk register. Further details can be found in the Board Assurance Framework (Appendix 1). 6. RECOMMENDATION That the Trust Board discuss the paper and confirms that they are assured that robust risk management systems and processes are in place. Tracy Hill Director of People and Integrated Governance

Board Assurance Framework 26.1.15

1 of 5

ID Opened Source of Risk

Strategic objective

Risk Type Business Stream/

Directorate

Executive lead title

Description Controls Controls Gaps in Control Initial Rating

allowing for

controls

Mitigating Actions Progress against action plan Current Rating

Date of review

Date of next review

Target Rating

Target Date

1905 31/12/2014 Clinical Reviews


Clinical Later Life and Memory Services

Executive Nurse/Director of Clinical Operational Services

There is a potential risk of increased falls due to patients on the Kingsley ward unable to routinely access podiatry. It is evidenced that poor foot health is a contributory factor to risk of falls. The clinical presentation and acuity of the patients deems that they are unable to attend community aoppointments

Comprehensive risk assessment in place for newly admitted patients, the ward offers interim safe footwear. Relatives are approached to arrange individual podiatry appointments as appropriate

Limited There is no SLA to provide Podiatry on the Kingsley ward

12 Raised through the Trust Falls Strategy group as a concern Staff are aware of the high risk patients ie diabetic and vascular

12 31/12/2014 15/06/2015 2 28/12/2015

1901 16/12/2014 Clinical Audit

Do we have sufficient, highly motivated, skilled staff?

Clinical Nursing and Safeguarding


There is a risk that clinical supervision is not being undertaken as per policy requirements due to a lack of a robust culture within clinical services to support maximising the benefits of effective supervision demonstrated by protected time not being allocated as part of all clinical staff groups workloads leading to a missed opportunity to reflect on cases under their care and practice and professional issues not being explored and therefore the learning cycle not being embedded in practice.

There is a Clinical Supervision Policy and Procedure There is a Management Supervision Policy

Limited Policy and Procedure need to be completely revised together with the Management Supervision Policy

12 The Clinical Supervision Policy against which the audit was conducted became due for review in October 2014. It is to be noted that reaching a review date does not mean that the policy no longer applies and does not need to be adhered to. A desk top review* was held on 22nd October 2010 to ascertain if any new legislation, regulations, recommended practices or changes in organisational structures required reflection within the policy document and the guidance offered to staff. Amendments have been made to the current policy following the desk top review to reflect organisational changes in respect of existing committee structures and designated role titles. This enabled an assurance that the policy remained valid and current in operational terms. The monitoring arrangements within the refreshed policy have also been amended to now conduct a random sample audit on a quarterly rather than annual basis. This will enable tracking of trends and further analysis per workforce group. It is a risk however that more frequent audit may lead to a decreased response rate. Random audit obviously does not compare the same pool of staff and this approach does not account for those who have accessed supervision but not responded.

Further work is planned to take place throughout 2015. A Task and Finish group will be established with an aim to describe and develop a supervision culture and practice within the Trust. A number of potential members have already been identified, including Professional Leads, Staff side, Management, Clinicians and HR. A call for interested staff will be put out to form a focus group to test out recommendations from the Task and Finish group.The quarterly random audit will continue and Assistant Directors will be required to ensure that Managers complete a monthly return of the supervision that has taken place within their teams. The Task and Finish Group will be tasked with recommending what targeted audit will also provide appropriate data to track a shift in supervision uptake.The overall objective will be to realise a single Trust-wide Supervision Policy for all staff with associated procedures for clinicians and non-clinicians. This recognises that every member of staff has a responsibility to develop their knowledge and competence, assume responsibility for their own practice and to enhance consumer protection and safety in the services we deliver to patients. This work will be led by the Professional Leads Group.

12 16/12/2014 30/01/2015 8 31/03/2016

1891 10/10/2014 External influences


Clinical CAMHS Executive Nurse/Director of Clinical Operational Services

There is a risk of young people having to wait for specialist treatment following initial assessment/short term intervention due to an increase in demand and acuity at the point of referral.

A review of processes and systems in community teams. Senior practitioners overseeing caseloads to ensure throughput. All cases waiting to be seen have contact made whilst on waiting list. Review of demand and capacity within community teams. Review of CAPA (Choice and Partnership Approach) in terms of the running of clinics supported by robust administation systems.

Fair Demand for service remains constant

12 Undertake capacity and demand anaysis. Discussion with commissioners

10/10/2014 Action plan commenced. Senior management team engaged in action plan.Update 17/12/2014 All cases have been reviewed during review clinics to look at risk of cases waiting. A number of cases were able to be closed reducing the waiting times. Monitoring ongoing still large numbers of cases waiting for long term intervention and care coordination

12 17/12/2014 30/01/2015 4 27/02/2015

1887 04/09/2014 Incident Reports

Are we delivering to our patients and users?

Clinical Trust Operational


There is a risk of service users developing pressure ulcers. There is also a risk generally of wounds including self harm wounds not being managed in line with NICE guidance due to training needs in staff, lack of procedural guidance and lack of formal SLA's with external providers. This may lead to poor care delivery, possible complaints and litigation.

CHS Tissue Viability Policy has been amended to cover the whole Trust. This is available in draft form and is due to be presented at the Policy Ratification Group. Tissue Viability Nurse Specialist in CHS has opened up basic wound care and pressure ulcer training sessions to all staff. Tissue viability in both mental health and LD group has work plan

Limited No procedural guidance around the management of self harm wounds. No wound formulary. No specific training for self harm wounds. No formal SLA's with external providers. Audits are needed around adherance to Trust policy once ratified and adherance to NICE guidance.

12 Business case developed. Tissue Viability Group work plan. Training sessions available to all staff.

3/10/14. Business case to recruit to additional Tissue Viability speciality nurse approved and now in recruitment pipeline. Terms of Reference for pathway review developed for Community Health Services.

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1873 13/06/2014 Incident Reports




There has been a significant increase in the suspected use of substances colloquially referred to as 'Legal Highs' which have resulted in a number of 'medical emergencies' on Lakeside Unit that have required transfer of in patient service users via 999 ambulance to the local acute trust for emergency assessment and treatment. There have also been other less (medically) urgent incidents attributed to the same cause on both Lakeside and Secure Services in-patient wards. Therefore due to the increased availability of these substances and the lack of legal consequences, there is a risk of service users acquiring and taking legal highs, or sharing them with other vulnerable service users leading to an increased risk of significant and potentially life threatening impact on the physical health of service users in inpatient units across the Trust.

Acceptable Behaviour Agreement Contract, training sessions re management provided by Phil Cooper, regular searches by drug dogs with avaiabilty to call at random if required, random room and property searches, comprehensive risk management plans for individual service users implicated in this behaviour, documented named nurse sessions which advise service users of the risks, documented evidence of medical advice re risks given in Ward Reviews, reviewi of leave arrangements by MDT and seeking agreement to search on return from leave.

Limited Unable to restrict off ward leave for informal service users if they do not consent which also gives rise to risks to vulnerable detained patients who may be given substances by those who are free to leave the ward. No recourse to law (police) as substances are deemed to be 'legal'. Inabilty to discharge service users in breach of the Acceptable Behaviour Agreement Contract if other risks/vulnerabilities are deemed too great to discharge safely.

12 Discussion with Adult and Secure Services Leadership team to consider any further actions 13.06.2014. Agreed Phil Cooper will provide guidance re standardised approach to breaches in Acceptable Behavour Agreement Contract in order to ensure evidence of sound risk assesment is consistently recorded when considering what actions may be available.

2/10/14 Reviewed by adult services on 19th September and the risk controls remain the same but as an operational group we will close risk 1721 and rewrite 1873 to represent both adult and secure services.

12 30/12/2014 30/01/2015 6 30/01/2015

1880 14/05/2014 Strategic Objective


Financial Finance Chief Finance officer

STRATEGIC OBJECTIVE There is a risk that there is insufficient funding for whole person care in the system due to increasing demands and reducing health & social care funding, leading to lack of investment to achieve transformation

The Trust has a current risk rating of 4 for financial control (Monitor). The Trust has a good record of delivering CIP. The Trust is closely linked into discussions around the Better Care Fund in some boroughs.

Limited Engagement and relationships across boroughs with key stakeholders is inconsistent. Current significant pressure in some boroughs health and social care infrastructure.

16 Evaluate engagement and key stakeholder relationship model to consider whether current structures and arrangements are able to best support integrated care. Carry out market intelligence exercise to feed into strategic committee discussions

Update 1st September - The Trust continues to maintain a risk rating of 4 and deliver against its CIP plans. Quarterly meetings are held with the Directors of Finance in all Boroughs to share strategic plans and funding developments. The Trust is working with commissioners to ensure it is involved in the development of the better care fund over the coming years. Update 13/10/14 The Trust continues to maintain a risk rating of 4 and deliver within a 10% tolerance against its CIP plans. Quarterly meetings are continuing with the Directors of Finance in all Boroughs to share strategic plans and funding developments. The CFO is meeting regularly as part of the 2015/16 planning round with the Directors of Finance from the hospital, community, commissioning and local authority in both Wigan and Warrington. These meetings are considering a more integrated approach to planning examining all the long term plans for the local health economy. Update 12/12/14 - No change

16 12/12/2014 30/01/2015 12 31/03/2015

1852 14/05/2014 High level Objective 14/15



Objective 9 There is a risk that the Trust will not have robust plans in place for 2015/16 due to schemes not being identified leading to a failure to achieve the agreed Financial Risk Ratings.

There is a clear process in place, whereby IMB identify the strategic themes with an owner. The owner then has to produce a business case and their progress is managed through the PMO process, and reported to the CIP group via the PMO dashboard. Schemes requiring clinical sign off are routed through the CLG who either approve, ask for further info or amendments, or reject. The schemes approved then form part of either the 2 year operational plan or the 5 year strategic plan. The CIP group is now chaired by the CFO and has a clear link through to IMB. The CIP group is supported by the PMO office, and progress is reported via the PMO dashboard. The following year is reported to the Trust Board quarterly.

Fair Some of the themes have not been converted into definite schemes with clear owners. Business cases have not been produced yet.

15 1. The themes for 2015/16 signed off as part of the 2 year operational plan. 2. The themes are then agreed as actual schemes at IMB with owners 3. Owners produce business cases 4. CIP Group review the business case and agree those that are at risk and either agree further work needs undertaking or require mitigation. 5. decision made as which schemes require CLG sign off, those that do are to be presented to CLG and signed off or referred back for further work to be undertaken 6. progress reported to IMB and for any key strategic decisions 7. Director of Nursing and Medical Director officially sign off schemes and report to CCGs

Update 24/12/14 Some schemes in 2014/15 have a full year effect in 2015/16 and therefore their progress impacts on the future year delivery 1. Dashboard produced showing progress re 2014/15 schemes. 2. CIP Group have agreed those that are at risk and either agreed further work needed undertaking or require mitigation. The themes for 2015/16 were signed off within the 2 year operational plan, but the values have now been revised as part of the Strategic Plan signed off on 30th June. There have been a number of revisions ot the plans as updates have been given to the CIP group. The decision has been made to allocate the gap between the target and potential achievable levels from known schemes, between operational business streams for them to come back in January 2015 with plans on how to deliver their targets.

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Objective 9 There is a risk that the Trust will not have robust plans in place for 2016/17 due to schemes not being identified leading to a failure to achieve the agreed Financial Risk Ratings.

There is a clear process in place, whereby IMB identify the strategic themes with an owner. The owner then has to produce a business case and their progress is managed through the PMO process, and reported to the CIP group via the PMO dashboard. Schemes requiring clinical sign off are routed through the CLG who either approve, ask for further info or amendments, or reject. The schemes approved then form part of either the 2 year operational plan or the 5 year strategic plan. The CIP group is now chaired by the CFO and has a clear link through to IMB. The CIP group is supported by the PMO office, and progress is reported via the PMO dashboard. The following year is reported to the Trust Board quarterly.

Fair The themes have not been agreed as yet

15 1. The themes for 2016/17 are signed off as part of the 5 year strategic plan. 2. The themes are then agreed as actual schemes at IMB with owners 3. Owners produce business cases 4. CIP Group review the business case and agree those that are at risk and either agree further work needs undertaking or require mitigation. 5. decision made as which schemes require CLG sign off, those that do are to be presented to CLG and signed off or referred back for further work to be undertaken 6. progress reported to IMB and for any key strategic decisions 7. Director of Nursing and Medical Director officially sign off schemes and report to CCGs

Update 1/7/14 The themes for 2016/17 have been signed off as part of the Strategic Plan submitted on 30th June Update 4/9/14 The themes for 2016/17 have been signed off as part of the Strategic Plan submitted on 30th June. Work has been undertaken with Finnamore to further theme the schemes for 2016/17 and beyond, and a programme management approach has been proposed to take this forward.

15 24/12/2014 24/01/2015 10 31/03/2015



Non Clinical

Chief Executive

Chief Executive

STRATEGIC OBJECTIVE There is a risk that commissioners do not see us playing a lead role in the whole person care agenda, due to our history as a specialist mental health Trust, leading to the Trust being marginalised within the whole person care agenda.

There is a clear purpose outlining whole person care. Frail elderly pilot completed across Knowsley services supporting the provision of integrated mental and physical health care which is available for commissioner discussion. Senior members of the Trust are well engaged in strategic and operational discussions with partners regarding whole person integrated care.

Fair Not yet fully delivered the benefits of managing mental and physical health services. Partnership arrangements require further development. Some gaps in the Trust's involvement in strategic and operational discussions around whole person care.

12 Firstly, executive high level objective 17 and develop collaboration and partnering framework to deliver whole person care. Evaluate engagement and key stakeholder relationship model to consider whether current structures and arrangements are able to best support integrated care.Establishment of Strategic Committee.

A number of Partnering conversations have taken place. Business has been won in this space. Update 18th November - There is no change to this risk.

12 18/11/2014 30/01/2015 8 31/03/2015



Non Clinical

Finance Chief Finance officer

STRATEGIC OBJECTIVE There is a risk that the necessary supporting strategies are not delivering due to them not being aligned and in place, leading to an inability to achieve our overarching strategy.

The Trust has created a strategic committee involving all executives and divisional directors to ensure alignment and delivery. Planning cycle for strategic planning and delivery in place.

Fair Market intelligence is in development. Internal strategies may not directly link and align to stakeholder/commissioner strategies in all boroughs.

12 Evaluate engagement and key stakeholder relationship model to consider whether current structures and arrangements are able to best support integrated care. Complete market intelligence exercise to feed into strategic committee discussions.

Update 12/12/14 A gap analysis has been produced which was shared with both directors and assistant directors. This analysis identified the supporting strategies that needed development and alignment. This has been discussed at both the strategy committee and the leadership forum. The detailed timetable for this year’s annual plan submission, which links to the production of the Trusts strategy has also been shared at the leadership forum. Meetings have been held with all ADs who have an identified gap, along with support into the outline of the supporting s5retgies and alignment with the Trust strategy. Agreement is in place to produce draft strategies for sharing by the end for December 2014.

12 12/12/2014 30/01/2015 8 31/03/2015




STRATEGIC OBJECTIVE There is a risk that our services may be subjected to automatic tendering due to interpretation of procurement guidance, patient choice and competition regulations, and local authority Best Value guidance, leading to fragmentation of whole person care.

Clarity has been received that services do not need to be subjected to automatic tendering. Relationships within the finance directors communities are facilitating conversations around the tendering process.

Fair No clear steer in terms of which services will be tendered out. Quality trackers for community health services are not as well developed as in other business streams.

12 Update 1st September - There has been a small amount of re-tendering of existing services to date. The Trust has continued to develop relationships with commissioenrs through the divisional director structure. No large scale re-tendering of existing services is planned at this time. Update 13/10/14 There has only been a small amount of re-tendering of existing services to date with significantly more new work secured than lost. The Trust has continues achieve good working relationships and planning with commissioners through the senior operations and Executive relationships. No large scale re-tendering of existing services is planned at this time. Update 12/12/14 No change

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People Services

Director of People and Integrated Governance

STRATEGIC OBJECTIVE There is a risk that the workforce to deliver our strategy doesn’t exist due to the new roles not being clearly defined and commissioned, leading to inefficient delivery of whole person care. This risk specifically links to High Level Objective 5

Mental health nurses and LD nurses are required to achieve an agreed level of competency to manage physical health issues. The Forerunner Fund spend across the Cheshire and Mersey region is to develop the requirementof the future workforce to deliver integrated care. North West programme to improve physical health care for MH and LD nurses.

Fair Workforce plans do not reflect the requirements of the future to deliver whole person care.

12 Full engagement with the Forerunner Fund supported by the Cheshire and Mersey LWEG. Review the competencies required by physical health nurses to manage common mental health conditions. Use the pathway pilot work carried out for frail elderly as a vehicle to review care competencies for integrated care.

Update 1st September - Career framework core areas of competence and summary attributes drafted to define expectations of workforce. Physical health Self assessment inbeded in 14/15 PDR process for clinical staff. Update 30th September 2014 Carrer Framework documents detailing the elements of the framework sent to key stakeholders within the trust including the Joint operations group. Feedback to be received in October with a view to agreeing framework end of October. Operational ADs are supportive of considering new roles as part of the framework. Update 2/1/15 Workforce group established to support Adult and LLAMS redesign, initial work plan agreed. Request to access financial support to develop assistant and advanced practitioners circulated for response by end of January. Clinical pathway project identifying the skills required within each pathway.

12 01/01/2015 30/01/2015 8 31/03/2015





Objective 14 There is a risk that we will not get commissioners to agree and approve the developed pathways

Early engagement of commissioners to ensure they appreciate the benefits of the integration that can be achieved. Provide sufficient evidence and data of the impact and benefits to commissioners. Provide regular communication to commissioners. obtain patient stories to demonstrate benefits to commissioners. develop and propose revised commissioning models with the Commissioners in order to demonstrate efficiencies and benefits to the wider health economy partners (e.g. GPs, secondary care)

Fair Commissioners may not agree to revised pathways as they are reviewing aspects of the services we deliver that may result in retendering

12 Engage with Commissioners by end of June 2014. strategic action area group continue to meet monthly to oversee project. Project Plan developed. Develop revised pathways for LLAMS and Physical Health, (see objective 8) secure agreement within each business stream, and Clinical Leadership Group.

Undertake staff engagement activities. Build pathways into commissioning and contracting discussions at the earliest opportunity. Provide regular communication updates to staff and commissioners on a regular basis

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Clinical Integrated Governance


Objective 1 There is a risk that the harm reduction strategy will not produce the overall 20% reduction from falls due to significant success in previous years which may lead to under performance against the target

Strategy, Policy and Procedure are in place Trust Leads and Champions are in place. The trust-wide Falls Prevention Strategy group meets monthly. There is a MH and LD falls champion forum which meets monthly and a separate CHS Falls Champion forum which meets quarterly. Falls supevision is provided for staff. Care quality records audits by LLAMS includes checks on care plans and falls prevention measures. Reported falls are subject to a critical analysis by matrons. Support from AQUA available via patient safety thermometer work.

Fair Falls policy and procedures being updated to bring these in line with new NICE clinical guideline 161: Falls. Trust e-learning package needs updating to bring in line with NICE 161 guidelines. No training available for bank and agency staff. There are differences with the availability of chiropody/podiatry services across inpatient wards.

12 Falls Strategy Group to continue to meet monthly and falls champions forums to meet as planned. • By end of Quarter 1: o Trust policy and procedures ratified. Completed the NICE Clinical guideline 161 Baseline Assessment. Held events for national falls awareness week during June 2014 and participated with regional working groups. Training for bank and agency staff commenced • By end of Quarter 2: o Completed the NICE Clinical Guideline 161 Falls Audit. Reviewed the Trust training e-learning package. Commenced the “Intentional Rounding” pilot in LLAMS • By end of Quarter 3: o Reviewe the Intentional Rounding pilot with a view to rolling out to other LLAMS wards. Developed falls prevention “Point of Practice” cards for use in clinical practice. Completed a review for availability of podiatry/chiropody services across all wards By end of Quarter 4: o Reviewed the NICE quality standard “Implementation of Vitamin D” (due to be published in Quarter 3) and reviewed the Bone Health Pathway in line with this.

Update 8/7/14 The work plan for Falls is the final year of the three year Falls Strategy. The trajectory calculating the contribution to the overall 10% reduction of harm is included within the new Harm Strategy that will be reported to the Trust Board in July 2014. Update 2nd September - Despite the significant work on-going by the Falls Leads, the position at end Q1 2014-15 indicates an increased trajectory in the number of falls which resulted in the quality account objective of a 10% reduction in harm not being achieved. As a result of this, remedial action agreed and arranged for an external falls expert to review the falls strategy, the on-going work and to assist with benchmarking with similar external services. Work plan in place and on target with actions - Falls policy redrafted and submitted to PRG which will bring the Trust into full compliance with the NICE CG161 - Falls recommendations. Targeted work ongoing within "hot-spot" ward within LLAMS services. Update 1 October - The harm data up to Month 5 (April to August 2014) was reviewed by the Quality Accounts Group in September; where the measurement for harm reduction was agreed to be against the moderate and severe harm only. Results for the 3 areas of Falls, Self Harm and Violence and Aggression, and overall showed a favourable variance against the 10% harm reduction target, and indicated that the Trust is

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1799 30/11/2013 Projects Are we delivering on our strategy?

Non Clinical

Trust Operational

Medical Director

There is a risk that the implementation of Rio will not be completed within the planned timescale and budget due to the lack of an updated project plan and due to the continued unknowns within the project implementation, leading to delay, additional costs and lack of benefits realisation.

A revised business case has been approved by the Trust Board which includes a contingency at the discretion of the Project Board. A draft revised project plan has been circulated to project board and steering group members to inform debate and ensure engagement prior to sign off by the project board. Update 10th March The programme board has now approved the revised project plan and budget.The programme is amber but still expects to deliver on time Update 15th Aug 2014 a piece of work to deliver a benefits realisation project plan by January has been commissioned. An initial report outlining the achievable benefits will be presented to the August CIP group and RiO Programme Board. Update 15/8/14 – the data migration strategy has been approved subject to final clarification of the way in which clinical information will be presented. Benefits realisation

Fair The slippage in the programme was not adequately flagged by the monthly reporting of progress. update Jan 2015, The detailed plans dates and resource for cohorts 2 and 3 taking account of lessons learned from cohort 1 are not yet agreed by the Programme Board.

12 Weekly progress and action chasing reports are now in place

This risk in addition to 1800 has replaced risk 1786. The work to complete the revised project plan is still continuing and is now expected for the February Project Board, i.e. by the end of February . A revised business case has been approved by the Trust Board which includes a contingency at the discretion of the Project Board. A draft revised project plan has been circulated to project board and steering group members to inform debate and ensure engagement prior to sign off by the project board. The plan expected a data migration strategy to be agreed by programme board in April which is delayed and it set out time scales for forms rationalisation whihc is delayed, with potential to delay the go live date for cohort 1. 10/3/14 the programme board has now approved the revised project plan and budget. 20/3/14 The programme board has now approved the revised project plan and budget. Update 4/7/14 Financial forecast being reviewed Update –15th Aug 2014 An assessment by the RiO Programme Director and Channel 3 has identified a significant degree of uncertainty in the extent of business change benefits which will be delivered by the Rio Programme. Quantification of the potential gap requires urgent and detailed assessment of the benefits that will be achieved

12 08/01/2015 09/02/2015 4 30/06/2014

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15/14 Monitor Compliance Quarter 3 Submission Page 1 of 6


26 January 2015

TITLE OF REPORT:

Monitor Compliance Quarter 3 Submission

PURPOSE OF REPORT:

To inform the Board of the financial, governance, quality and membership information to be sent to Monitor for quarter 3.


• The Trust is required to make quarterly information submissions to Monitor.

• These cover the most recent quarter’s year to date performance against plan.

• This is made in the form of a self-certification.




The Board confirms its approval of the submission of the quarter 3 return to Monitor as follows: Finance: The Board anticipates that the Trust will continue to maintain a continuity of service risk rating of at least 3 over the next 12 months. Governance: The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets (after the application of thresholds) and a commitment to comply with all known targets going forward. Other: The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor which have not already been reported.

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Monitor Compliance Quarter 3 Submission

1. INTRODUCTION Monitor’s Risk Assurance Framework is designed to identify when there is a significant risk to the financial sustainability of a provider of key NHS services which endangers the continuity of those services and / or poor governance at an NHS Foundation Trust. In-year monitoring is designed to measure and assess the Trust’s actual performance against plan. The information and analyses Monitor requests from the Trust are those which should already be required by a well-managed board. This information ought to be easily extractable from material the Board routinely receives as part of their oversight of business performance, risk and governance. The Trust must also report to Monitor, via an exception report, any in-year material actual or prospective changes which may affect the Trust’s ability to comply with any aspect of its licence which has not been previously communicated to Monitor. The Trust must submit quarterly reports to Monitor.

2. IN-YEAR REPORTING AND MONITORING REQUIREMENTS

Monitor will review the Trust’s actual quarterly performance against plan together with the Board’s assessment of on-going and future compliance with the Licence.

The quarterly submission includes a financial template, election information, a declaration of risks against healthcare targets and indicators, a governance statement, quality governance metrics and a capital expenditure declaration (added at quarter 2 dependent upon triggering Monitor’s capital expenditure variance thresholds). The information included in the financial templates and governance templates will have been discussed by the Trust Board during the course of its Board meetings with particular reference to the monthly performance report for the end of the quarter.

Within the Governance Statement the Board is expected to confirm the following three statements: 1. Finance The Board anticipates that the Trust will continue to maintain a continuity of service risk rating of at least 3 over the next 12 months. 2. Governance The Board is satisfied that plans in place are sufficient to ensure on-going compliance with all existing targets (after the application of thresholds) and a commitment to comply with all known targets going forward.

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3. Other The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor which have not already been reported. The Trust is reporting a continuity of service risk rating of 4 (the maximum) for the period ended 31 December 2014. The Trust is also expecting to achieve a risk rating of 4 as at 31 March 2015 and to maintain a risk rating of at least 3 over the next 12 months. The target for first episodes of psychosis (FEP's) was breached in quarter 2. Performance against this target is back on track in quarter 3 with 97.2% achieved against a Monitor threshold of 95%.

The Risk Assessment Framework sets out that Monitor will use executive team turnover as one of the potential indicators of quality governance concerns. At quarter 3, the Trust Board has its full complement of 6 voting board members in post. The Trust breached Monitor’s capital expenditure variance threshold at quarter 2 and was required to submit a capital re-forecast along with a Board declaration. At quarter 3, the Trust is within Monitor’s tolerance threshold and therefore there is no requirement to sign a capital expenditure declaration for quarter 3.

At the completion of each Monitor quarterly review the Trust will receive risk ratings and a summary of key issues to be followed up either by the Board or by Monitor, as a report sent to the Chair and Chief Executive.

3. ASSURANCE PROCESS

The information required by Monitor in the quarterly submissions for finance and governance is already collected and presented to the Trust Board through the monthly performance reports. (Refer to Appendix 1).

The Chief Finance Officer is responsible for ensuring the completion and checking of the financial templates and the Chief Nurse & Executive Director of Operational Clinical Services is responsible for completion and checking of the governance templates.

4. RECOMMENDATIONS

The Board is asked to note the content of this report and to confirm the following: 1. The Board anticipates that the Trust will continue to maintain a continuity of

service risk rating of at least 3 over the next 12 months. 2. The Board is satisfied that plans in place are sufficient to ensure on-going

compliance with all existing targets (after the application of thresholds) and a commitment to comply with all known targets going forward.

3. The Board confirms that there are no matters arising in the quarter requiring an exception report to Monitor which have not already been reported.


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Appendix 1 Quarter 3 Submission to Monitor

Quarter 3 Evidence

• No Non Executive Director post became vacant in quarter 3.

• One Executive Director resigned in quarter 3.

• Monthly Reporting of Risk Assurance Framework (performance report).

• Monthly reporting of financial performance as per the performance report.

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Diagram 5: Main categories of in-year submissions for NHS foundation trusts

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15/15 Quality Committee Quarterly Update Page 1 of 9


26 January 2015

TITLE OF REPORT:

Quarter Three Summary of Quality Committee

PURPOSE OF REPORT:

To inform the Trust Board of the activity and use of delegated powers by the Quality Committee for the period October to December 2014.


The Quality Committee was established in June 2013, as a sub-committee of the Trust Board with delegated responsibility to provide leadership and assurance to the Trust Board on the effectiveness of Trust arrangements for quality, ensuring there is a consistent approach throughout the Trust. This paper outlines the work of the Quality Committee for quarter two 2014/15.


Tracy Hill, Director of People and Integrated Services


The Board is requested to review the content of this paper and be assured that the powers delegated to the Quality Committee provide sufficient scrutiny and assurance to the Trust Board for areas within its remit.

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Report to Trust Board (26 January 2015)

Quality Committee Quarter Three Update 2014-15


The Quality Committee was established in June 2013, as a sub-committee of the Trust Board with delegated responsibility to provide leadership and assurance to the Trust Board on the effectiveness of Trust arrangement’s for quality, ensuring there is a consistent approach throughout the Trust, specifically in the areas of:

• Safety (Patient and Health and Safety) • Effectiveness • Patient Experience

The terms of reference outlines the responsibilities of the Quality Committee in carrying out its delegated duties and is included at Appendix A.

2. BACKGROUND

This report informs the Trust Board on the use of delegated powers of the Quality Committee and provides a high level overview of the activity of quarter three 2014-15. The Quality Committee meets monthly; this report covers meeting held on; 8 October, 5

November and 3 December.

3. QUARTER THREE 2014/15 WORK

The Non-Executive Chair of the Quality Committee provides verbal updates to the Trust Board on the activity of the Quality Committee on a monthly basis. Full details of papers received by the Quality Committee for quarter three is included within Appendix B. This paper outlines the decision making, instructions and recommendations made by the Quality Committee within quarter three, shown against the agenda headings. Risk Management The Quality Committee received an overview of the quality review worked which was being undertaken across the Later Life and Memory Services (LLAMS) inpatient areas due to elevated concern following a disciplinary and complaints in the in-patient areas. The Quality Committee received an overview of a Root Cause Analysis Review which had been undertaken of Trust acquired Pressure Ulcers and were informed a full review had been commissioned in Community Health Services. The Quality Committee reviewed and signed off the Cluster Review Legacy Action Plan and evidence, on behalf of the Trust Board, prior to submission to the Clinical Commissioning Groups In December 2014.

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Serious Incidents (SIs) The Quality Committee supported the proposal to install a fire suppression system initially at Peasley Cross, with the intention of roll out across the organisation following a review. This was based on the recommendation of the Fire Service following the two in-patient fires at Peasley Cross. The High Profile Incident updates have provided the Quality Committee with a continued oversight of high level inquests and details of a Regulation 28 received. The serious incident deep dive process continues to monitor the processes and reporting of serious incidents. The Quality Committee received regular updates regarding the improvements and changes to the serious incident process. Internal Arrangements Internal arrangements continues to be the largest part of the Quality Committee Agenda, where it reviews, approves and agrees quality improvement work which is either presented to or commissioned as part of the remit of the Quality Committee. The Forensics and Physical Health Business Streams presented to the Quality Committee as part of a quality assurance challenge session. The presentation and subsequent question and answer session covered quality areas such as; governance arrangements, quality measures and peer reviews, and actions from SIs. The Quality Committee felt the challenge sessions provided a high level of assurance. The committee received an overview of the key issues identified in the Psychology Services review in relation to waiting lists; which had identified much broader issues than those just related to waiting lists. The committee expressed concern regarding the issues raised and requested further work to develop recommendations to address the concerns. This was completed and presented back to the Committee in December. High Level External Reports In response to the Clwyd Report the Quality Committee continues to undertake a monthly Deep Dive Complaint review; this scrutiny exercise has identified improvements which have led to commencement of a review of the complaints process to ensure continued improvement. The Quality Committee scrutinised the Clwyd Report action plan to receive assurance of achievement.

4. CONCLUSIONS

The Quality Committee continues to successfully carry out its delegated responsibilities as outlined within the Terms of Reference, as demonstrated by the scrutiny, decision making, instructions and recommendations highlighted within this paper.

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5. RECOMMENDATIONS

The Board is requested to review the content of this paper and be assured that the powers delegated to the Quality Committee provide sufficient scrutiny and assurance to the Trust Board for areas within its remit.

Accountable Director Tracy Hill Title Director of People and Integrated Governance

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APPENDIX A

Quality Committee Terms of Reference

1. Title: Quality Committee

2. Purpose:

To provide leadership and assurance to the Trust Board on the effectiveness of Trust arrangement’s for quality, ensuring there is a consistent approach throughout the Trust, specifically in the areas of: Safety (Patient and Health and Safety) Effectiveness Patient Experience

3. Reports to: Reports directly to the Trust Board. Monthly verbal reports of any relevant items presented to the Audit Committee meeting by the Chair of the Quality Committee. Annual report to be submitted to the Audit Committee. 4. Duties/Functions:

To oversee the development and publication of an annual Quality Report and Quality Account; ensuring the quality priorities are agreed by the Council of Members are appropriately influenced by stakeholders. Scrutinise Trust Business Streams on the quality of services and delivery against the Quality Report and Quality Account; including quality components of business plans. Business Stream Assistant Directors to present assurances annually to Quality Committee. Seek assurance from the Trust’s Nursing and Governance Directorate of effective risk systems and processes. Examine in-depth, by exception, key risk issues impacting on quality as referred by the Quality and Safety Committee. Seek assurance that learning from complaints, inquests and serious incidents is shared across the Trust. Oversee development and implementation of Trust Quality Strategy. Initiate and monitor investigation of areas of serious concern regarding quality, and seek assurance of completion of any associated resultant actions.

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Review, as required, intelligence and information from internal quality and compliance visits, external Care Quality Commission (CQC) visits, Mental Health Act visits, service CQC self-declarations, Serious Case Reviews, and Serious (SI’s) reviews, and external homicide reviews; with a focus on impact on quality and quality improvement. In-depth review of themes complaints, claims, and SI’s in relation to quality. In-depth ‘deep dive’ review of completed SI reviews and complaints. In-depth review and quality assurance authorisation of key Trust wide clinical policies and procedures. Monitor key performance indicators relevant to the areas of quality. Receive assurance from Trust Patient Experience Group in relation to systems and opportunities for patients, carers, and the public to influence quality decisions and raise any concerns regarding quality. Receive summaries of Annual reports from groups with statutory or regulatory requirement to report directly to a sub Board Committee: Medicines Management Infection Control Safeguarding

5. Authority

The Quality Committee is authorised by the Trust Board to investigate any activity within its Terms of Reference. The Quality Committee is authorised by Trust Board to obtain outside legal or other independent professional advice and the secure the attendance of non-Board members, including non-Trust staff, with relevant experience and expertise if it considers this necessary. 6. Meetings

The Quality Committee will meet every month. 7. Membership

Three Non-Executive Directors (of whom one is the Chair of the Quality Board) Director of Nursing and Quality Medical Director Director of Human Resources and Organisational Development A Service User representative A Carer representative Council of Members representative (Authorisation Committee Chair) Staff Side Chair/Named Deputy

In attendance: Interim Director of Operations

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When a member is unable to attend an appropriate deputy should be sent in their place (where a clear deputy is identified).

8. Quorum

Chair plus four members, one of whom must be a Non-Executive Director If the Chair of the Quality Board is unable to attend, an alternative Non-Executive Director will be nominated to act as Chair Person Members are normally required to attend a minimum of 60% of all meetings. Attendance will be monitored as part of the annual review of the Terms of Reference. 9. Agenda

The agenda will be agreed by the Chair. 10. Reporting Mechanisms

The Chair of the Quality Committee will provide verbal summary/exception report to the Trust Board and to the Audit Committee in respect of meetings held for which minutes have not yet been approved. Minutes shall be approved at subsequent meetings. Approved minutes will be circulated to members. A summary of the approved minutes will be posted on the Trust’s Intranet site, along with the Trust Board papers. The Quality Committee will provide a quarterly update summary to the Trust Board. The Quality Committee will provide an annual report to the Audit Committee. The Chair of the Compliance with Authorisation Committee will provide a verbal summary/exception report to his committee. 11. Review

The Terms of Reference and the functioning of the Quality Committee will be reviewed annually. Monitoring against the Terms of Reference will take place in December of each year. Signed: Date: Revised June 2014 - draft Date for review: June 2015

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APPENDIX B

Quality Committee Agenda items October to December 2014

Agenda Item October 2014

November 2014

December 2014

Attendance and apologies x x x Notes from previous meeting x x x Matters arising matrix x x x Matters arising x x x Risk Management Quality big dots and quality priorities paper x Quality Strategy and Work Plan Update x Infection Prevention and Control update x Serious Incidents High profile inquest update x x x Serious incident process update x x x Serious incident deep dive x x Legacy Cases action plan x Serious incident thematic review x NICHE homicide review x High Level External Reports Complaints Deep Dive x x x Complaints thematic review x Clwyd Report Action Plan Update x Francis, Keogh and Berwick update x Internal Arrangements Business stream challenge session x x Medical Education Board Report Prevention and Management of Violence and Aggression (PMVA) Action Plan

x

Clinical Supervision Audit x CQC transitional plan x x Psychology Waiting Lists Review x x Results of Audit re: Compliance/Consistency around face to face contact with patients

x

MHA compliance and assurance report x CPA audit summary x Culture of Care Strategy x External Arrangements

End.

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15/16 New Clinical System (Rio) Update Page 1 of 8


26 January 2015

TITLE OF REPORT:

New Clinical System (RiO) update

PURPOSE OF REPORT:

To report progress to Programme Board members in advance of the monthly Programme Board meeting.


• Cohort 1 go-live is on target against the re-planned dates of going live on 2 February 2015.

o The Operational procedures have been produced in conjunction with the Services and test scripts written by the RiO team to enable them to perform a series of test cycles for the actual pathways for each.

o A final test by the end users will then be performed prior to go-live.

• The revision to the Cohort 1 go-live date will have an effect on the proposed dates for both Cohort 2 and 3.

o Work has commenced in integrating RiO into the wider Informatics Strategy Implementation Programme.

o The high level re-planning for subsequent Cohorts is progressing and is due to complete in January for approval by the Programme Board to proceed with detailed planning in February.

• The alignment of RiO to the Informatics Strategy has resulted in the project being managed as a significant element of the Strategy plan under the control of the Informatics strategy Programme Manager who joined the Trust in January. The role of RiO Programme Director has lapsed as a result of this development.


Louise Sell Medical Director and Chair of Programme Board


The Programme Board notes the progress on the project and provides necessary support to the Programme team.

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√









Yes No

If yes,

BAF entry No.

Trust High Level Objective (as above)


n/a During 2014/15, we will implement year one action of the Informatics Strategy. This means that we will implement our new clinical system (RiO), ensuring that the implementation is consistent with other key priorities of the Informatics Strategy.

There is a risk that the necessary supporting strategies are not delivering due to them not being aligned and in place, leading to an inability to achieve our overarching strategy.

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Report to Programme Board 26 January 2015

RiO Programme Update

1. INTRODUCTION

This paper is an update to Board on the progress of the RiO Programme. The Board are asked to:

• Note the progress on the Programme and provide necessary support to the Programme team

2. BACKGROUND

In March 2013 the Board approved CSE Healthcare Systems (now Servelec Healthcare) as the preferred supplier of the new clinical system with its “RiO” product and in November 2013, a revised business case was presented and approved by Trust Board.

The RiO Programme Board meets monthly and is responsible for the overall progress of the Programme. It receives reports from the RiO Steering Group and the Design Authority, as agreed under the RiO Programme Governance arrangements in January 2014.

3. PROGRAMME UPDATE

The programme is rated as Amber overall according to the following definition; Red - the programme has or is predicted to depart from planned expenditure and / or timescale and there is no agreed action to bring it back on plan. Amber – the programme has or is predicted to depart from planned expenditure and / or timescale and there is agreed action to bring it back on plan. Green - the programme is on plan to deliver within the planned expenditure and timescale.

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3.1 Programme Red/Amber/Green Ratings

The individual Workstreams Status is reported for Cohorts 1. Re-planning and integration of RiO into the wider IT Strategy Implementation Programme has commenced. The overall status of the Programme is Amber.

3.2 KEY ACTIONS TO DATE

a) Programme Management The RiO Programme Management Function remains Amber reflecting the cohort 2 and 3 planning work. Work has commenced in integrating RiO into the wider Informatics Strategy Implementation Programme. The high level re-planning for subsequent Cohorts is progressing and is due to complete in January for approval by the Programme Board to proceed with detailed planning in February. b) Business Change and Benefits The Reporting workstream is currently Amber. The Business Change Team continue to support the Services in the testing of the Standard Operating Procedures / Guidelines and in the pathway testing being performed against them. The benefits case continues to be developed but is yet to be finalised until RiO is fully planned and integrated into the broader Information Technology Strategy Programme. c) Technical This workstream is reporting Amber. Since the update in December we have detected and resolved issues in Batch Processing.

Current RAG Rating (December RiO Programme Board)

- Project Management - Business Change - Technical

- Data Migration - Reporting - Testing - Training - Build and Configuration - Interfaces - User Group - Cut Over Plan for go-live

Previous RAG Rating (November RiO Programme Board)

- Project Management - Technical

- Data Migration - Reporting - Testing - Business Change - Training - Build and Configuration - Interfaces

- User Group - Cut Over Plan for go-live

2

7

2

0

3

8

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d) Data Migration Data Migration remains Green. The cycles to test the processes for loading the data from the legacy system into the Rio application have commenced. To date two cycles have taken place into the UAT database with no significant issues to report. We have successfully done a migration into the Production database also with no significant issues to report. e) Reporting The Reporting workstream is currently Green. A decision has been taken and agreed with Programme Board that some final testing of reports will be completed post live, when there is live data to support it. All other Reports are on target to be completed in January prior to switch on. f) Testing

The Testing Workstream is now reporting Green. User Acceptance Testing has completed successfully. Final operational acceptance testing prior to go-live is proceeding on schedule. g) Training The Training workstream is reporting Green. The refresher training has commenced and is on track to complete before the end of January. h) Build and Configuration The Build and Configuration workstream is Green as they are primarily supporting tasks to enable Cohort 1 to go live. Planning for subsequent Cohorts remains outstanding. i) Interfaces The Interface workstream is reporting Green overall for Cohort 1. Interfaces planned as part of cohort 2 and 3 activity will be part of the Information Technology Strategy Programme. j) User Group This workstream is Green. The Local Implementation Group is meeting weekly to support Cohort 1. The main focus is the testing against the Standard Operating Procedures.

k) Cut-over Plan for Go-live The revised cut-over plan continues to be reported upon weekly via the Authority to Proceed process and is currently reporting as Green. This is also supported by the project team who hold daily calls to provide additional assurance.

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3.3 ACTION UPDATE FROM LAST PROGRAMME BOARD

Action Status Narrative Information Technology Security end to end check completed

Not Complete

This will be completed prior to Cohort 1 Go Live by the Service Transition lead appointed from the beginning of January

KPMG Audit of Plan complete Not Complete

On hold pending re-plan

All equipment built and delivered to End Users

Complete Laptop build completed

Revised Planning of Cohorts 2 and 3 commenced

Commenced See comments above

Cohort 2 As-is Workshops 100% complete

Deferred Pending re-planning

Lessons Learned process complete

Complete Document produced in December and approved at January Programme Board. Findings are being applied to the planning of the next Cohorts

Trolleys and small building works initiated

Initiated Trolleys received and will be deployed through January

Refresher training – dates confirmed

Complete Schedule issued and attendees starting to book on

UAT for forms letters and RBAC completed

Complete

Data Migration Build complete in line with re-worked design

Complete

Data Migration test loads commenced

Complete

Service Desk Arrangements in place

Complete

Disaster Recovery arrangements tested

Complete

Operational Acceptance Testing planning 50% complete

Complete

Go-live

Not Complete

Now planned February 2nd

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3.4 ACTIONS TO BE COMPLETED BY THE NEXT PROGRAMME BOARD (FEB 2)

• Cohort 1 Go Live with all finalisation of all key activities remaining (as listed) 4. CONCLUSIONS

While the programme overall is reporting Amber (3 workstreams remain as Amber), Cohort 1 remains on target against the revised go-live date of February 2nd.

5. RECOMMENDATIONS

The Board is requested to approve the following recommendations:

• That the Board notes the progress on the Programme and provides necessary support to the Programme Team

Louise Sell Medical Director and Chair of Programme Board

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APPENDIX 1 – CRITICAL PATH MILESTONE PLAN

2014 2015Milestone Start End Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May JuneCommunication Strategy Signed-Off 01-Apr 22-Apr 1st - 22nd

UAT Strategy Signed-Off 24-Feb 22-AprTest Scripts Complete 24-Feb 24-JunUAT Cycle 1 Complete 19-May 30-MayUAT Cycle 2 Complete 28-Jul 15-Aug 8th-19th

UAT Cycle 3 Complete 25-Aug 12-SepData Migration Strategy Signed-Off 17-Mar 22-AprDocument Scanning Strategy Signed-Off 24-Mar 20-MayReporting Requirements Sign-Off (Cohort 1) 25-Apr 26-JunReporting Build Complete (Cohort 1) 07-Apr 28-JulForm Rationalisation Complete 06-Jan 22-AprCore Build Complete 24-Feb 25-AprFuture State Processes Complete (Cohort 1) 25-Apr 25-JunBuild Complete (Cohort 1) 12-May 14-JulTNA and Basic Skills Training Complete 21-Feb 30-JunEnd User Training Complete (Cohort 1) 08-Sep 25-SepWorkstream Plans Signed-Off (Cohort 1) 17-Feb 20-MayCut-Over Plan Complete (Cohort 1) 12-May 24-JunCohort 1 Live TBC TBCWorkstream Plans Signed-Off (Cohort 2) 1st Sept 03-OctWorkstream Plans Signed-Off (Cohort 3) 1st Sept 03-OctCohort 2 Live Mar-15 Mar-15 Mar-15

Cohort 3 Live Jul-15 Jul-15 Jun-15

7th Apr - 31 Dec

27th Oct-2nd-February

1st Sept-31 Dec

28th July- 8th Aug

25th Apr - 29th Aug

12 May - 21st Aug

17th Mar - 29 Aug

17th Feb - 20th May

6th Jan - 22nd Apr

24th Feb - 25th Apr

25th Apr - 25th Jun

12 May - 14 Jul

24th Mar - 20th May

29th Sept - 24th Oct

1st Sept-31 Dec

24th Feb - 22nd Apr24th Feb - 24th June

22nd Sept - 3 Oct

21st Feb - 30 Jun

Planned Dates

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15/17 Leigh New Build Update Page 1 of 7

BOARD REPORT

DATE OF BOARD MEETING:

26 January 2015

TITLE OF REPORT:

Leigh New Build Update from Project Board

PURPOSE OF REPORT:

To report progress to the Trust Board following monthly Project Board meetings.


• The land improvement works are nearing completion and in line with programme.

• The main works mobilisation is complete and the Principal Supply Chain Partner have started on site.


• Simon Barber, Chair of Project Board


Note the progress on the project and provide necessary support to the Project Board.

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√









Yes No √

If yes,

BAF entry No.



(cut & paste it)

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Leigh New Build Update

1. INTRODUCTION

There is established governance for the delivery of the Leigh New Build Project. This includes a Project Board, which meets monthly and into which the Steering Group is tasked to deliver the design and other reports.

2. BACKGROUND

The Trust is pursuing a project to build a new mental health facility on a site at Atherleigh Way, Leigh comprising:

• A new female 20 bed adult acute ward • A new male 20 bed adult acute ward • A new mixed 8 bed PICU ward • A new S136 suite • A new therapy suite including gym/multi-function room • Supporting ward, office and admin accommodation • Accommodation and clinics for the Home Treatment Team • Main entrance block including café, family room and faith room

3. PROGRESS TO DATE 3.1 WORKSTREAM RAG REPORT

PART A – CONSTRUCTION PROGRESS GROUP

Red - the workstream has or is predicted to depart from planned expenditure and / or timescale and there is no agreed action to bring it back on plan. Amber - the workstream has or is predicted to depart from planned expenditure and / or timescale and there is agreed action to bring it back on plan, Green - the workstream is on plan to deliver within the planned expenditure and timescale

RAG Rating at last Project Board

RAG Rating

• None • None • Programme • Construction Activity • Risks • Cost • Communications

RAG Rating at this Trust Board RAG Rating

• None • None • Programme • Construction Activity • Risks • Cost • Communications

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3.2 KEY ACTIONS SINCE LAST TRUST BOARD • The Adult programme being worked to is the programme reported at the last Trust Board

based on mobilisation and critical procurement to enable a start date for the main works of 19 January 2015.

• The contract for the Adults Phase 1 main works has been signed by the Principal Supply

Chain Partner and the Trust. • The land improvement works have continued. Programme and Key Dates The Adult programme being worked to is the same as reported at the last Project Board being the option based on a mobilisation and critical procurement date of 1.12.14. The headline dates for the main works on the existing programme are: Start Finish Mobilisation and critical procurement 01.12.14 19.01.15 Main construction works 19.01.15 10.06.16 Highways Access 19.01.15 06.02.15 Groundworks (Drainage, Foundations) 02.03.15 10.06.15 Roof Coverings 27.04.15 23.09.15 Main Entrance Construction 25.06.15 09.03.16 S136/Sports Therapy 02.07.15 04.01.16 Ward A Fit Out (Female) 15.07.15 11.02.16 Ward B Fit Out (Male) 20.08.15 18.03.16 Off Ward Shared Areas 20.08.15 18.01.16 PICU Construction 16.09.15 22.03.16 Final Commissioning 18.02.16 10.05.16 Contract completion 10.06.16 10.06.16 Construction Activity Key Activity Completed since last Project Board The Principal Supply Chain Partner are continuing to progress the land improvement works on site, the majority of which have been completed by the target date of 16th January 2015. Outstanding works to the existing retaining wall that forms the boundary to Atherleigh Way and access ramp will continue alongside the main works starting on 19th January 2015. United Utilities have now commenced the water diversion works on site, and the excavations have been backfilled Next Activity • The main site works for Phase 1 will commence on site on 19 January 2015. Initial orders

are continuing to be placed to allow the commencement of works.

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• The water main diversion, testing, chlorination and connection will be completed in the

next two weeks. • Continuation of ramp and retaining wall construction. • Drawings for the groundworks and foundations have been received and orders will be

placed for groundworks, steelworks and structural insulated panels (SIPs). Risks Kier has been consulted to request its Construction related risks. Kier gave assurances and an explanation that it is managing its risks. It considers that the two most pertinent risks relate to: 1) Access to sub-contractors in a strong market leading to higher prices. 2) Planning. The Principal Supply Chain Partner is in the process of submitting a

planning amendment to the Local Authority to pick up the various original cost reduction amendments (e.g. changes necessary as a result of omission of the ECT Unit). These are thought to be “non-material” and should be able to be dealt with under the existing planning application. The Trust and the Principal Supply Chain Partner Architect is however working closely with the Local Planning Department to ensure the approved adult scheme is not adversely affected by changes to the development as a resultof the revisions to the LLAMS Phase 2 and the planning permission already granted. The Local Planning Department is keen to work with the Trust to ensure there are no delays to the project.

These risks have been incorporated onto the Trust Risk Register. Costs The £19m loan has been secured with the signing of the Facility Agreement by the Secretary of State for Health. The interest rate is fixed for the duration of the loan at 2.28%. The Trust expects to draw down the full amount of the loan in February 2015. Current in year actual expenditure for Phase 1 is £1.469m (excluding the land purchase and LLAMS design development). The forecast figure is £4.259m. Communications Plans are being developed to mark a significant milestone during the main works that will involve the local community, staff and service users. More details will be issued on Connect and in In View. It has been agreed by the Steering Group that the Trust utilise Instagram which is compatible with both Facebook and Twitter to publicise the progress with the building works. The Communications Team have identified a Service User who will take photographs on a monthly basis but with the capacity to request additional photographs for key milestones. This will complement photographs provided by Kier.

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PART B – PHASE 2 DESIGN DEVELOPMENT GROUP

Red - the workstream has or is predicted to depart from planned expenditure and / or timescale and there is no agreed action to bring it back on plan. Amber - the workstream has or is predicted to depart from planned expenditure and / or timescale and there is agreed action to bring it back on plan, Green - the workstream is on plan to deliver within the planned expenditure and timescale Design Approval A Design Meeting was held on the 8 January 2015. The Option 2 Typology was discussed and the Schedule of Accommodation was reviewed and challenged. Various suggestions for improvement and rationalisation were put forward to the Design Team. It was agreed that there was a need to investigate and make best use of the shared space between the 2 organic wards. The Architects will take on board the suggestions put forward and produce a revised set of visual designs of the Schedule of Accommodation and report back to a future meeting to be held in 2 weeks time. The objective is to sign off the LLAMS design by 27.03.15 Programme and Key Dates The programme is based on instruction to the Principal Supply Chain Partner from the Trust on 1 December 2014. The key dates are taken from the latest Phase 2 mini Guaranteed Maximum Price Programme dated 21.11.14. Sign off of 1:200 drawings 27.03.15 Commencement of Stage 3 design 30.03.15 to 31.07.15 Sign off of 1:50 drawings 19.06.15 Commencement of Stage 4 design 03.08.15 to 20.11.15 Mini GMP/Stage 4 decision 30.10.15 Mobilisation 02.11.15 to 27.11.15

RAG Rating at last Project Board RAG Rating

• None • None • Design approval • Programme and Key Dates • Capital Cost and Monitor

Reporting • Service Model Development • Risks • Communications

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Start on site 30.11.15 Completion Date 28.11.16 Commissioning and handover 28.02.17 Capital Cost and Monitor Reporting The summary expenditure position is as follows:- Sum approved at November Trust Board for LLAMS design development up to 31st March 2015

£250,000

Forecast spend based on Project Plan £181,119 Actual spend to end of M9 £6,035 Service Model Development The service model will be developed after the scheme drawings produced by the PSCP has been signed off. Risks The Risk Register is being maintained and reviewed by the Steering Group. Communications No report as yet. 4. KEY ACTIONS FOR NEXT TRUST BOARD • Conclusion of design development. • Development of the cost estimate leading ultimately to the mini Guaranteed Maximum

Price. 5. CONCLUSIONS The design development is proceeding according to plan. 6. RECOMMENDATIONS The Board is requested to note:

• The progress on the project and provide necessary support to the Project Board. • The on-going land improvement works. Simon Barber Chair of Project Board

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15/18 Capital Update Page 1 of 7

BOARD REPORT


26 January 2015

TITLE OF REPORT:

Capital Report

PURPOSE OF REPORT:

To report on the evaluation of completed capital schemes, the use of delegated powers by the Chief Executive Officer and the Chief Finance Officer and to correct information given to Trust Board at its meeting on 24 November 2014 regarding a property disposal.


• A process and methodology has been developed to evaluate the implementation of capital schemes with a value in excess of £100k. A summary report of evaluations on completed capital schemes is attached.

• At the meeting of the Executive Capital Group on 19

January 2015, the Chief Executive Officer and Chief Finance Officer, used delegated powers to approve a new scheme for the installation of anti-ligature taps at Rivington Ward.

• The Board is asked to approve an additional sum of

money in respect of the scheme to construct a new extension on Kingsley Ward following receipt of tenders.

• At the Trust Board on 24 November 2014 the

completion of the sale of Oakdene was reported. The purchaser has since withdrawn.


Nick Rowe Director of Corporate Services


The Trust Board is asked to consider and note the summary capital project evaluation reports, the additional expenditure approved at Executive Capital Group, the additional expenditure required on the Kingsley Scheme, the continued marketing of the Oakdene property and the revised approach for signing contracts under seal.

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Yes No √

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BAF entry No.



(cut & paste it)

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Capital Report

1. INTRODUCTION

At its meeting on 24 February 2014 the Trust Board considered a Capital Scheme Evaluation on Wakefield House and requested similar reports on other completed schemes with a value in excess of £100k.

Three schemes undertaken in 13/14 and in 14/15 have now been the subject of detailed evaluation by the Project Manager in the Estates Team with input from the Business Sponsor.

2. BACKGROUND

Trust Board is reminded of the process to plan, implement and review capital schemes.

2.1 A Capital Plan covering five years is created by the Trust’s Capital Planning Group.

2.2 The Capital Plan is then recommended for approval by the Trust Board as part

of the Budget and Annual Plan process. 2.3 Individual detailed business cases are presented to the Executive Capital

Group by the sponsoring Assistant Director. Consideration is given to:- a) Is the business case scheme on the approved Capital Plan? b) Is the cost consistent with the estimate in the Capital Plan? c) Are the benefits clear – benefits to patients, staff and the environment? d) Are the financial evaluations clear in terms of revenue impact, impact on the

Trust’s return of capital employed, and the length of payback on the capital invested?

2.4 All supported detailed business cases are presented by the business case

sponsor to a monthly meeting of the Chief Executive Officer and the Chief Finance Officer. If the scheme requires investment of up to £50k it can be approved at that meeting using powers delegated from the Trust Board. If it requires investment greater than £50k a summary business case will be recommended by the Chief Executive for consideration at a meeting of the full Trust Board.

2.5 The Trust Board is notified of the use of its delegated powers and is asked to

consider and approve any summary business cases at its formal meetings.

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2.6 On completion of capital schemes in excess of £100k a post project evaluation

is undertaken and the findings reported to the Trust Board.

3. CHIEF EXECUTIVE/CHIEF FINANCE OFFICER – USE OF DELEGATED AUTHORITY

At its meeting on 19 January 2015 the Chief Executive Officer and Chief Finance Officer used powers delegated to them by the Trust Board to approve:-

Expenditure of £19k on a new scheme to address ligature risks on Rivington Ward. These works result from a review of ligature related incidents that identified that taps in bathrooms and en suite facilities would need to be replaced. This capital project addresses this issue.

The additional expenditure above can be resourced from unused contingencies and

underspends against the approved sum on other schemes within the 14/15 Capital Plan. Trust Board has previously approved schemes to address environmental risks including

taps in areas where service users may not be continually supervised by staff (for example in bedrooms and toilets). This work will address the outstanding risk present on Rivington Ward.

4. ADDITIONAL EXPENDITURE – KINGSLEY SCHEME Following receipt of tenders additional expenditure of £27.4k plus VAT is required in

respect of the scheme to construct a new extension on Kingsley Ward. This is due to additional unforeseen works associated with the reinforced ground floor slab and the necessity to divert several drains, and additional preliminaries because of the difficult access to the site.

An additional £25k plus VAT is required for additional construction costs plus £2.4k plus

VAT extra contingency given the nature of the scheme The following analysis of the lowest tender with the original high level cost plan contained

within the original business case.:-

.

High Level

Cost Plan

Lowest Tender

Construction costs inc preliminaries £90,720 £115,614

Fees £11,080 £11,080

Furniture £11,500 £11,500

Sub - Total £113,300 £138,194

Contingencies £1,620 £4,000

VAT (net of recovery) £19,844 £28,438

Total £134,764 £170,632

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The Executive Capital Group considered the request but as the additional monies

required is outside its delegated powers Trust Board is being asked to approve. 5. SUMMARY OF CAPITAL SCHEME EVALUATION REPORTS

The following reports have been prepared and are summarised as follows:- Environment Risk Phase 2 This is the second phase of a Trust approach to reduce environmental risks within in-patient settings. The scheme addressed medium risks based on incidents over the preceding 12 months. The scheme was considered to be a success in that the contractor worked well with both staff and service users. The scheme sponsor was also very pro-active throughout and always on hand to give advice. The scheme took eight weeks longer than planned due to need to work on a live ward and because of an outbreak of diarrhoea and vomiting on one of the wards being worked on. Nevertheless the scheme was delivered £44k under budget. No contingency was used.

Environmental Risk Phase 2 - Financial Evaluation

Business Case Actual Variance

Constructions costs 240,000 255,120 15,120 Furniture / Equipment 0 0 0 Fees 23,460 15,755 (7,705) Sub-total 263,460 270,875 7,415 Contingency 36,000 0 (36,000) Irrecoverable VAT 44,160 29,193 (14,967) Total 343,620 300,068 (43,552)

Memorandum information: Utilisation of contingency Construction costs 0 Furniture / Equipment 0 Fees 0 Total 0

Health & Well Being Centre This scheme involved the creation of a new Health and Well Being Centre with gym, changing and therapy facilities. The scheme was delivered in 30 weeks against a plan of 27 weeks. The cost plan in the Trust Board report incorrectly allocated £36k as contingency when this was in fact preliminaries. This made delivery of the scheme difficult and the Project Manager

Agenda Item No.

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requested additional funding of £17k for WiFi, lockers and Nurse Call. The final outturn position shows an overspend of £12,141, however this was balanced by the extra £17K approved by the Executive Capital Group.

Health & Wellbeing Centre - Financial Evaluation

Business

Case Actual Variance Constructions costs 240,000 250,000 10,000 Furniture / Equipment 10,000 0 (10,000) Fees 23,460 29,394 5,934 Sub-total 273,460 279,394 5,934 Contingency 36,000 36,000 0 Irrecoverable VAT 44,160 50,367 6,207 Total 353,620 365,761 12,141

Memorandum information: Utilisation of contingency Construction costs 36000 Furniture / Equipment 0 Fees 0 Total 36000

6. CONCLUSION

Both schemes produced the desired outcome in terms of what was proposed in the Business Cases.

Undertaking construction works within clinical or other operational environments is not

straight forward and additional construction costs and the use of contingency monies for design changes as projects moved from high level cost estimates to tendered costs is a recurring theme. This also suggests that the client/principal relationship needs to be improved to ensure full information is agreed to prior to pricing. In addition the need for tight cost management by the Project Manager is paramount; the resource competence to do this will be reviewed, and the need for external support for this will be considered on all future schemes.

The schemes in 2014/15 now show contingency as a separate item which may only be

used for unforeseen matters and after approval by the Executive Capital Group. Use of contractors with proven familiarity with working in such environments has also

proved to be beneficial following the experiences of some of the schemes evaluated.

7. DISPOSAL OF PROPERTY

The completion of the sale of the Oakdene Property was incorrectly reported at the Trust Board meeting on 24 November 2014, when in fact the purchaser did not sign our part of the contract, following the Chief Executive and Chief Finance Officer signing the contract under seal, and subsequently withdrew.

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The property continues to be marketed. In addition the procedure for the signing of

contracts has changed such that Trust authorised signatories will only sign and seal contracts after the purchaser or supplier has signed first.

8. RECOMMENDATIONS

The Board is asked to discuss and approve the Capital Scheme Evaluation Reports and note the use of powers delegated to the Chief Executive Officer and Chief Finance Officer, the additional expenditure on the Kingsley scheme and the continued marketing of Oakdene and the changed procedure for signing contracts.


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15/19 Changes to Director portfolios resulting from the Corporate Services Review Page 1 of 8


26 January 2015

TITLE OF REPORT:

Changes to Director portfolios resulting from the Corporate Services Review

PURPOSE OF REPORT:

To inform the Board of the areas of responsibility for each of the Executive Directors.


• There are changes in the director portfolios • Changes effective from 1 February 2015 • Separate process looking at Estates and

Facilities




That the Board notes the contents of the report.

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√









Yes No √

If yes,

BAF entry No.



Agenda Item No.

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Changes to Director Portfolios resulting from the Corporate Services Review

1. BACKGROUND The Corporate Services Review formally concluded the consultation phase in December 2014. There have been a number of changes in portfolios for the Executive Directors and accompanying changes in structures reporting to the Executive Directors. It is anticipated that those new arrangements will be in place from 1 February 2015.

2. PORTFOLIOS There will be five Executive Director posts reporting to the Chief Executive Officer

Chief Finance Officer responsible for

• Finance • Informatics • Strategic Development and Transformation • Finance will provide a range of technical accounting services, financial planning

(revenue and capital), control the commissioner contracting process and provide on- going contract income management.

• The Informatics department lead by the Chief Information Officer will bring the

planning and execution of Information Management, Information Technology and Information Governance into one area. This department will manage the implementation of the Trust Informatics Strategy and the transformation of Informatics Services to support the delivery of the Trust Strategy.

• Centralisation of Performance Reporting and the creation of a Business Intelligence service for the Trust which will significantly increase the Trust’s information management capability and capacity and improve the quality, consistency and extent of reporting and business intelligence, including the progressive introduction of automation and self-service. This will include the current management accounting function.

• Strategic Development will provide a holistic business development and market intelligence provision, working with operational services to combine quantitative and qualitative data from both within and outside of the Trust to develop an informed operational strategy. The marketing aspect of this function will include interpretation of market information into intelligence and work with the Business Transformation Business Analyst role to ensure services are fit-for-purpose and lead into a robust informed service improvement programme. The future design assumes significant external support for market intelligence.

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• Transformation will be a consolidated team combining Programme Management, Service Improvement and Organisational Development that supports the design and delivery of the Trust’s transformation cost improvement and service improvement programme. Communication will also form part of this department as it is central to the success of any transformation.

Director of People and Integrated Governance responsible for

• Human Resources (HR) Services • Resourcing • Workforce Planning and Information • Learning and Development (L&D) • Occupational Health • Integrated Governance • Company Secretary • The People Services function will embrace the full ‘workforce journey’ for individuals

engaged with the Trust on either a permanent, temporary or agency basis. It will therefore integrate HR services, Learning & Development and Occupational Health.

• There will be further development of self-serve, including the implementation of People

Direct. A Help Desk (supporting HR and L&D) will resolve general and first line queries and triage more difficult queries. HR specialists will support complex, case-based queries and existing case management. HR Business Managers will act as the face of HR and ensure appropriate interventions by other parts of the People Services Function i.e. Resourcing, Learning and Development to support the business with strategic workforce issues.

• There will be a single point of access for co-ordinating, arranging, booking and recording training.

• The future design for Occupational Health reduces costs without impacting on clinical services through changing the skill mix and innovation by utilising technology.

• Integrated governance increases operational ownership of governance through the development of clear assurance and compliance frameworks and devolved corporate functions. It increases customer satisfaction through improved communication and closer working relations with operational and other support services and increase focus in terms of wider Trust compliance and assurance (clinical and non-clinical).

• Company Secretary consolidates the Company Secretary functions from different departments. This will improve the service delivered; reduce operating costs; develop broader skills for the staff involved and provide a more pro-active and focused service.

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Chief Nurse and Executive Director of Operational Clinical Services responsible for • Nursing and quality • Patient engagement, experience and inclusion

• Operational Services

• Nursing and Quality increases customer satisfaction through improved

communication and closer working relations with operational and other support services. These services will be drawn together under a simplified management structure. The design will promote alignment with operational clinical services to consistently deliver quality and safe care with a positive patient experience.

• Engagement, experience and inclusion will provide assurance on Equality and

Inclusion, Patient and Public Involvement/Experience and the Patient Advice and Liaison Service (PALS).

• Operational Services which will be led by a Director of Operations & Integration

and a Clinical Director of Operations & Integration

Medical Director responsible for

• Appraisal & revalidation • Medical engagement & leadership

• Medical education & research

• Medicines management

• Medicines management will provide specialist knowledge and input into business

development processes and opportunities for new business. It will be fully integrated in Operational and Governance services, providing specialist knowledge and input into governance processes. The service will ensure achievement of statutory and regulatory requirements e.g. Medicines Act, Controlled Drug legislation, CQC, NICE, etc. Senior pharmacy roles will support the Incident Review team; lessons learnt process and the Patient Safety Panel.

Director of Corporate Services responsible for Estates & Facilities

• There is a separate process now looking at the outsourcing of the services and the appropriate internal structure that may need to be retained.

Appendix 1 to this paper shows the new portfolios for each of the Directors and their first level reports. Appendix 2 to this paper shows greater detail of the areas of governance, to ensure that all members are aware of where these crucial functions now lie.

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3. RECOMMENDATION

That the Board notes the contents of the report. Simon Barber Chief Executive

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Appendix 1 – Executive and level 2 structure

Chief Executive Officer

Chief Finance Officer

Director of People & Integrated Governance

Chief Nurse & Executive Director of Operational

Clinical Services

Director of Corporate Services

Medical Director

Deputy Director of

Finance

Assistant Director of Strategic

Development & Transformation

Deputy Director of People Services

Deputy Director of Integrated

Governance

Company Secretary

Research Manager

Chief Pharmacist

Associate Medical Director Responsible Officer Appraisal &

Revalidation

Associate Medical Director

Medical & Engagement Leadership

Associate Medical Director

Medical Education & Research

Deputy Director Estates, Facilities

& Supplier Management

Deputy Director Nursing &

Quality

Operations

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Appendix 2 - Integrated Governance


15/20 Fit and Proper Persons Requirement - Directors Page 1 of 12

BOARD REPORT


26 January 2015

TITLE OF REPORT:

Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 Regulation 5 - Fit and Proper Person Requirement – Directors

PURPOSE OF REPORT:

To inform the Trust Board of requirements of Regulation 5 Fit and Proper Persons Requirement – Directors, from the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. The provide proposals for the implementation of the new regulation that demonstrate that the Trust is well led, and continually compliant to this regulation.


The Fit and Proper Persons Requirement – Directors came into effect from 27 November 2014. This regulation forms part of the changes to the Health and Social Care Act which sees the current Essential Standards of Quality and Safety being replaced by ‘Fundamental Standards’. The Care Quality Commission will assess the Trust’s compliance to this regulation in future inspections. Compliance to Regulation 5 will also meet the Directors requirements of the Fit and Proper Person Test as described in condition G4 of the Provider Licence.



RECOMMENDATIONS TO THE BOARD:

The Trust Board is requested to: • Note the content of this report and the

supporting guidance provided. • Discuss and agree the process for

implementing the Fit and Proper Persons Requirement – Directors within the Trust.

• Undertake the initial assessment of the Fit and Proper Persons Requirement – Directors, to be returned to the Company Secretary no later than 28 February 2015, and thereafter at each annual appraisal.




√









Yes No √

If yes,

BAF entry No.



(cut & paste it)




Health and Social Care Act 2008 (Regulated Activities) Regulation 2014

Regulation 5 - Fit and Proper Person Requirement – Directors 1. BACKGROUND

The Health and Social Care Act 2008 (Regulated Activities) detailed the standards of care a service must provide. These regulations were developed into the Care Quality Commission Essential Standards of Quality and Safety, also known as Outcomes / Standards, and have been used by the Care Quality Commission and the Trust to assess the quality of care we provide to date. The Trust Board receives monthly performance information in relation to compliance against the essential standards.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 will change existing regulatory requirements; replacing the Essential standards of Quality and Safety with new Fundamental Standards with effect from November 2014 and April 2015. The Quality Committee has reviewed the Trust’s Transitional Plan which details the work being undertaken to manage the transition to the new fundamental standards, with updates provided to the Trust Board.

2. INTRODUCTION This paper specifically provides an overview of Regulation 5, Fit and Proper Persons Requirement – Directors, only. This regulation came into effect from 27th November 2014. The full guidance is attached and should be read by all Executive and Non-Executive Directors of the Trust. Regulation 5 has been introduced as a direct response to the failings at Winterbourne View Hospital and the Francis Inquiry report into Mid Staffordshire NHS Foundation Trust, which recommended that a statutory fit and proper person requirement be imposed on health service bodies. The intention of this regulation is to ensure that all board level appointments of NHS Provider Trusts carrying on a regulated activity are responsible for the overall quality and safety of that care and for making sure that care meets the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation is about ensuring that those individuals are fit and proper to carry out this important role. Compliance to Regulation 5 will also meet the Directors requirements of the Fit and Proper Person Test as described in condition G4 of the Provider Licence.



This paper provides details of requirements and processes for the implementation of Regulation 5 within the Trust.

3. NEW REGULATORY REQUIREMENT – Fit and Proper Person Requirement for Directors (Regulation 5)

This regulation makes it clear that directors and people in ‘equivalent’ positions of authority are personally responsible for the overall quality and safety of care.

The following are the elements you would expect from an organisation that is meeting the fit and proper person requirement for Directors:

• To be of good character* (see explanation below) • To have the necessary qualifications, skills and experience; • To be able to perform the work that they are employed for after

reasonable adjustments are made; • To supply information, such as certain checks and a full

employment history. • To have never been responsible for, or involved in, any serious

misconduct or mismanagement relating to any office or employment with a service provider.

The following are unfit criteria: (Schedule 4 of the Act) 1. The person is an undischarged bankrupt or a person whose estate

has had sequestration awarded in respect of it and who has not been discharged.

2. The person is subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland.

3. The person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act1986.

4. The person has made a composition or arrangements with, or granted a trust deed for, creditors and not been discharged in respect of it.

5. The person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland.

6. The person is prohibited from holding the relevant office or position, or in case of and individual from carrying on the regulated activity, by or under any enactment.

*Good Character 7. Whether the person has been convicted in the United Kingdom of

any offence or been convicted elsewhere of any office which, if



committed in any part of the United Kingdom, would constitute an offence.

8. Whether the person has been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals.

Information required in respect of persons employed or appointed for the purposed of a Regulated Activity. (Shown below is an extract from Schedule 3 of the Health and Social Care Act 2014) 1. Proof of Identity including a recent photograph 2. Where required for the purposes of an exempted question in

accordance with section 113A(2)(b) of the Police Act 1997, a copy of a criminal record certificate issued under section 113A of the Act together with, after the appointed day and where applicable, the information mentioned in section 30A(3) of the Safeguarding Vulnerable Groups Act 2006 (provision of barring information on request.

3. Where required for the purposes of an exempted question asked for a prescribed purpose under section 113B of tat Act together with, where applicable, suitability information relating to children or vulnerable adults.

4. Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to;

a. Health or social care, or b. Children or vulnerable adults.

5. Where a person has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonable practicable, of the reason why P’s employment in that position ended.

6. In so far as is practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform.

7. A full employment history, together with a satisfactory written explanation of any gaps in employment.

8. Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made,. To properly perform tasks which are intrinsic to their employment or appointment for the purposes f the regulated activity.

9. For the purposes of this Schedule- a. ‘the appointment day’ means the day on which section 30A

of the Safeguarding Vulnerable Groups Act 2006 comes into force.

b. “satisfactory” means satisfactory in the opinion of the Commission.



c. “suitability of information relating to children or vulnerable adults” means the information specified in sections 113BA and 113BB respectively of the Police Act 1997.

4. Inspection of Fit and Proper Person Regulation – Director

Regulation 5 Fit and Proper Person Requirement – Directors will be included in Care Quality Commission’s new inspection approach. They are now able to take enforcement action for breaches of the fit and proper person requirement, in accordance with their Judgement Framework and Enforcement Policy. During inspection the Care Quality Commission will check and monitor the extent to which the provider meets the regulation, during the inspection, on receipt of concerning information and where this is serious systemic failure of a provider. The Trust’s Chairman would be asked to declare that appropriate checks have been undertaken in reaching a judgement that all directors are deemed to be fit and non meet any of the unfit criteria. This will be a self-declaration and would only be followed if there were concerns about the recruitment process.

Inspection of organisations is based around a suite of questions relating to the Care Quality Commission’s five key questions they ask of services; Are services safe, effective, caring, responsive and well-led? The specific key line of enquiry for regulation 5 is:-

W3: How does the leadership and culture reflect the vision and values, encourage openness and transparency and promote good quality care? • Prompt: Do leaders have the skills, knowledge, experience and

integrity that they need – both when they are appointed and on an on-going basis?

• Prompt: Do leaders have the capacity, capability and experience to lead effectively?

The Care Quality Commission may require confirmation that appropriate checks have been undertaken, on appointment and subsequently. This may involve checking personnel files and records about appraisals rates for Directors. They may also expect that Directors have an awareness of the guidelines and have implemented approaches in line with best practice. Where the Care Quality Commission find that during an inspection a Trust does not meet the requirements of ‘good’ for any regulations, then they will consider if regulation 5 has also been breached. Where there is a serious systemic failure of a provider the Care Quality Commission will carry out a



focused inspection, including a review of assessments for the Fit and Proper Person Requirement – Directors, and will use the evidence of such an inspection to inform their judgement about regulation 5 and any breaches that may have taken place. Similarly in the event of an organisation being put into special measures, the Care Quality Commission could assess the effectiveness and robustness of the process for the appointment of Directors.

5. Process for Implementing Regulation 5, Fit and Proper Persons

Requirement – Directors within the Trust. 1 It is the ultimate responsibility of the Chair of the Trust to discharge the

requirements of the Regulation 5, and that all Directors do not meet any of the ‘unfit’ criteria.

2 Regulation 5 will apply to all current Executive and Non-Executive

Directors of the Trust.

3 Regulation 5 will apply to Interim and Associate Director positions regardless of voting rights.

4 Regulation 5 will apply to the Trust’s Nominated Individual – currently the Deputy Director of Nursing and Quality, this will change to Chief Nurse and Executive Director of Operational Clinical Services.

5 All Directors (as described above) will undertake an initial assessment against Regulation 5 to demonstrate compliance to this regulation.

6 All current Directors (as described above) will undertake an annual assessment against Regulation 5 as part of annual appraisal process.

7 All Director appointments will be subject to assessment against

Regulation 5.

8 Outcomes from Regulation 5 assessments will be held and used as evidence to demonstrate the Trust is ‘well–led’ and will be provided to the Care Quality Commission and Monitor in the event of requests or inspections.

9 The Chairman will ensure that all Directors are aware of the Trust’s response, processes and evidence to support the Trust’s compliance to the key lines of enquiry specific to Regulation 5, demonstrating that it is well-led.

10 The processes to undertake the Fit and Proper Persons assessment will be incorporated into recruitment processes and governance arrangements of the Trust, and will take account of best practice publications and new guidance.



6. RECOMMENDATIONS The Trust Board is requested to: • Note the content of this report and the supporting guidance provided. • Discuss and agree the processes for implementing Regulation 5 Fit and

Proper Persons Requirement – Directors within the Trust. • Undertake the initial assessment of the Fit and Proper Persons

Requirement – Directors, to be returned to the Company Secretary no later than 28 February 2015, and thereafter at each annual appraisal.

Nick Rowe Director of Corporate Services Attachment / Link: Care Quality Commission Guidance for NHS Bodies November 2014. Regulation 5: Fit and proper persons: directors and Regulation 20: Duty of candour

20141120_doc_fppf_final_nhs_provider_g End.



Fit and proper person Declaration

5 BOROUGHS PARTNERSHIP NHS FOUNDATION TRUST (“the Trust”)

“FIT AND PROPER PERSON” DECLARATION 1. It is a condition of employment that those holding director and director-equivalent posts

provide confirmation in writing, on appointment and thereafter on demand, of their fitness to hold such posts. Your post has been designated as being such a post. Fitness to hold such a post is determined in a number of ways, including (but not exclusively) by the Trust’s provider licence, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 (“the Regulated Activities Regulations”) and the Trust’s constitution.

2. By signing the declaration below, you are confirming that you do not fall within the

definition of an “unfit person” or any other criteria set out below, and that you are not aware of any pending proceedings or matters which may call such a declaration into question.

Provider licence (Monitor) 3. Condition G4(2) of 5 Boroughs NHS Foundation Trust’s Provider Licence (“the

Licence”) provides that the Licensee shall not appoint as a director any person who is an unfit person, except with the approval in writing of Monitor.

4. Licence Condition G4(3) requires the Licensee to ensure that its contracts of service

with its directors contain a provision permitting summary termination in the event of a director being or becoming an unfit person. The Licence also requires the Licensee to enforce that provision promptly upon discovering any director to be an unfit person, except with the approval in writing of Monitor.

5. An “unfit person” is defined at condition G4(5) of the Licence as: (a) an individual:

(i) who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged; or

(ii) who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or



(iii) who within the preceding five years has been convicted in the British Islands of any offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or

(iv) who is subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986; or

(b) a body corporate, or a body corporate with a parent body corporate:

(i) where one or more of the Directors of the body corporate or of its parent body corporate is an unfit person under the provisions of sub-paragraph (a) of this paragraph, or

(ii) in relation to which a voluntary arrangement is proposed under section 1 of the Insolvency Act 1986, or

(iii) which has a receiver (including an administrative receiver within the meaning of section 29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or

(iv) which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or

(v) which passes any resolution for winding up, or

(vi) which becomes subject to an order of a Court for winding up. Regulated Activities Regulations (Care Quality Commission) 6. Regulation 5 of the Regulated Activities Regulations states that the Trust must not

appoint or have in place an individual as a director, or performing the functions of or equivalent or similar to the functions of, such a director, if they do not satisfy all the requirements set out in paragraph 3 of that Regulation.

7. The requirements of paragraph 3 of Regulation 5 of the Regulated Activities

Regulations are that: (a) the individual is of good character;

(b) the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed;

(c) the individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed;

(d) the individual has not been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity; and



(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual.

8. The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated Activities

Regulations are:

(a) the person is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged;

(b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland;

(c) the person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986;

(d) the person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it;

(e) the person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland;

(f) the person is prohibited from holding the relevant office or position, or in the case of an individual for carrying on the regulated activity, by or under any enactment.

Trust’s constitution 9. The Trust’s constitution places a number of requirements and restrictions on an

individual’s ability to become or continue as a director. A person may not become or continue as a director of the Trust if:

(a) they have been adjudged bankrupt or their estate has been sequestrated and in

either case they have not been discharged;

(b) they have made a composition or arrangement with, or granted a Trust deed for, their creditors and have not been discharged in respect of it;

(c) they have within the preceding five years been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of three months or more (without the option of a fine) was imposed;

(d) they are the subject of a disqualification order made under the Company Directors Disqualification Act 1986;

(e) they are a person whose tenure of office as a Chair or as a member or director of a health service body has been terminated on the grounds that their appointment is not in the interests of the health service, for non-attendance at meetings, or for non-disclosure of a pecuniary interest;



(f) In the case of a non-executive director, they are not a member of the Foundation Trust;

(g) Directors of the Trust must behave in accordance with the NHS Foundation Trust Code of Governance;

(h) Each Director will uphold the seven principles of public life as detailed by the Nolan Committee.

Declaration

I acknowledge the extracts from the provider licence, Regulated Activities Regulations and the Trust’s Constitution above. I understand and agree to checks being undertaken to confirm the accuracy of my responses to this self declaration. I confirm that I do not fit within the definition of an ‘unfit person’ as listed above and that there are no other grounds under which I would be ineligible to continue in post. I undertake to notify the Trust immediately and if I no longer satisfy the criteria to be a ‘fit and proper person’ or other grounds under which I would be ineligible to continue in post come to my attention. Name: ____________________________________ Position: __________________________________ Signed:__________________________ Date:______________________ As Chairman I have reviewed this self-assessment, and declare that I am sufficiently assured, that the above fully complies with Regulation 5 – Fit and Proper Persons Requirement – Directors; Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the Trust’s Provider Licence Condition G4. Signed __________________________ Date:______________________ (Chair)

End.

Regulation 5: Fit and proper persons: directors and

Regulation 20: Duty of candour

Guidance for NHS bodies November 2014

Regulation 5: Fit and proper persons: directors and Regulation 20: Duty of candour – Guidance for NHS bodies 2

The Care Quality Commission is the independent regulator of health and adult social care in England Our purpose We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. Our role We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care.


Contents

Foreword 4

Introduction 6

CQC’s operating model 6

Overview of the new regulations 9

Regulation 5: Fit and proper persons: directors 9

Regulation 20: Duty of candour 14

Our approach to guidance on regulations 17

Guidance for providers 18

Regulation 5: Fit and proper persons: directors 19

Regulation 20: Duty of candour 28

Appendix A: Description of terms used in our guidance about the fit and proper requirement for directors 36

Appendix B: Description of terms used in our guidance about duty of candour 38


Foreword We set out a new vision and direction for the Care Quality Commission (CQC) in our strategy for 2013-2016, Raising standards, putting people first, and in our consultation, A new start, which proposed radical changes to the way we regulate health and adult social care services. We developed these changes with extensive engagement with the public, our staff, providers and key organisations. A new start set out the new overarching framework, principles and operating model that we will use. This includes the five key questions that we will ask of all services:

• Are they safe?

• Are they effective?

• Are they caring?

• Are they responsive?

• Are they well-led? Stakeholders and the public across the care sectors welcomed our proposals, which include a more robust approach to registration; the introduction of chief inspectors; expert inspection teams; ratings to help people choose care; a focus on highlighting good practice; and a commitment to listen better to the views and experiences of people who use services. We have published handbooks for providers in each sector, which provide detailed guidance on our new approach to regulating and inspecting services. Within this new approach, we must continue to ensure that providers meet Government regulations about the quality and safety of care. As part of this, we are required to publish guidance for providers to help them meet the requirements of the regulations. New regulations setting out fundamental standards of care will come into force for all care providers on 1 April 2015. However, two of the new requirements – the fit and proper persons requirement for directors and the duty of candour – will come into force for ‘NHS bodies’ on 27 November 2014. The term NHS bodies means NHS trusts, NHS foundation trusts and special health authorities. The introduction of a statutory duty of candour is an important step towards ensuring the open, honest and transparent culture that was lacking at Mid Staffordshire NHS Foundation Trust. The failures at Winterbourne View Hospital revealed that there were no levers in the system to hold the ‘controlling mind’ of organisations to account. The fit and proper persons requirement for directors plays a major part in ensuring the accountability of directors of NHS bodies.


It is essential that CQC uses these new powers well to encourage a culture of openness and to hold providers and directors to account. This guidance on the two new regulations is interim guidance. CQC’s new guidance on implementing all the fundamental standards, which will be implemented in April 2015, will replace, in its entirety, the Guidance about compliance: Essential standards of quality and safety. It will include guidance for all sectors on the fit and proper persons requirement for directors and the duty of candour for all providers. Our current enforcement policy will also be replaced.

David Behan Chief Executive Care Quality Commission


Introduction CQC’s operating model Our provider handbooks set out the details of our new approach for each sector. They describe how we will carry out inspections, make judgements and award ratings to providers. Our approach in each sector reflects common principles that are intended to ensure that health and adult social care services provide people with safe, effective, compassionate, high-quality care, and to encourage care services to improve. Our new operating model describes how we will register, monitor, inspect and award ratings to providers. It is illustrated by the following diagram: Figure 1: CQC’s overall operating model Within this new approach, we must continue to ensure that providers meet Government regulations about the quality and safety of care.


How our guidance on meeting regulations fits into our operating model All registered providers must demonstrate that they are meeting regulatory requirements in order to register with CQC and then continue to deliver regulated services. The law states that our guidance on meeting the regulations must be taken into account in relation to all regulatory decisions that CQC makes. From 27 November 2014, in addition to the existing regulations, NHS bodies, defined as NHS trusts, NHS foundation trusts and any special health authorities carrying on a regulated activity, must meet the new Regulation 5: fit and proper persons: directors and the new Regulation 20: duty of candour. Throughout the text of this guidance, for ease of language, we refer to Regulation 5 as the fit and proper persons requirement for directors (FPPR). Where we use the term ‘provider’ in this document it refers to NHS bodies. Our guidance on meeting the fit and proper person requirement for directors regulation and the duty of candour regulation will be central to both registration and inspection. 1. Registration

As set out in our strategy, we will continue to strengthen our approach to assessing applications for registration with CQC. From 27 November 2014, when considering new NHS applications for registration, and variation applications made by existing NHS bodies, we will take into account the FPPR and duty of candour. We will use this guidance to do this. We do not require NHS bodies to notify us when there is a change to the board membership or where there is a merger or acquisition. However, if the newly formed trust is a new legal entity, then the processes described will apply. We will keep this under review. 2. Inspection

In comprehensive inspections (leading to ratings of individual services and the provider overall), we primarily look for good care, rather than checking compliance with regulations. We have developed characteristics of what good care looks like in partnership with patients, people who use services and subject matter experts, and therefore what would constitute a ‘good’ rating. We will use key lines of enquiry (KLOEs) to assess this, checking whether a provider is delivering services that are safe, effective, caring, responsive and well-led. The characteristics of good care and the KLOEs are set out in our provider handbooks. If we find good care, we will also assess whether it meets the characteristics of an outstanding rating.


However, if we find care that does not reflect the characteristics of good, we will assess whether it requires improvement or is inadequate. We will also consider whether a regulation has been breached. We will take this guidance into account to determine whether or not a provider has complied with the two new regulations. In focused inspections, we either follow up specific concerns from earlier inspections or respond to new, specific, concerning information that has come to our attention. In these circumstances, we assess whether the provider has improved so that it is no longer in breach of regulations or whether the new concern amounts to a breach of regulations. We will take this guidance into account in making these judgements. We will use our enforcement powers as outlined in our Judgement Framework and Enforcement Policy both to protect patients and to hold providers and, in some cases, individuals to account.

http://www.cqc.org.uk/sites/default/files/documents/20120321_final_judgement_framework_for_publication.pdf

http://www.cqc.org.uk/sites/default/files/documents/enforcement_policy_june_2013.pdf


Overview of the new regulations Regulation 5: Fit and proper persons: directors The aim of this regulation is to ensure that all board level appointments of NHS foundation trusts, NHS trusts and special health authorities1 carrying on a regulated activity are responsible for the overall quality and safety of that care, and for making sure that care meets the existing regulations and effective requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.2 This regulation is about ensuring that those individuals are fit and proper to carry out this important role. It will apply to directors – by which, we mean executive and non-executive, permanent, interim and associate positions, irrespective of their voting rights. This regulation will not apply to the board of governors of a foundation trust, but will apply to a governor if they are a member of the trust board. Regulation 5 has been introduced as a direct response to the failings at Winterbourne View Hospital and the Francis Inquiry report into Mid Staffordshire NHS Foundation Trust 3, which recommended that a statutory fit and proper persons requirement be imposed on health service bodies. Health service providers currently have a general obligation to ensure that they only employ individuals who are fit for their role. CQC assesses the fitness of 'corporate' service providers (that is, all providers other than individuals and partnerships) by focusing on the fitness of their ‘nominated individuals’. When assessing the fitness of the nominated individual, we consider whether the provider has taken appropriate steps to ensure that they are of good character, are physically and mentally fit, have the necessary qualifications, skills and experience for the role, and can supply certain information (including a Disclosure and Barring Service (DBS) check and a full employment history). The introduction of the fit and proper persons requirement for directors (FPPR) imposes an additional requirement on directors. It will be the ultimate responsibility of the chair of the NHS body to discharge the requirement placed on the provider, to ensure that all directors meet the fitness test and do not meet any of the ‘unfit’ criteria.

1. NHS foundation trusts, NHS trusts and special health authorities are defined as health service bodies in the regulations. 2. The Health and Social Care Act 2008 (Regulated Activities (Regulations 2014) will come fully into force on 1 April 2015. 3. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Robert Francis QC, http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf

http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf


In addition to the usual requirements of good character, health, qualifications, skills and experience, the regulation goes further by barring individuals who are prevented from holding the office (for example, under a director’s disqualification order) and significantly, excluding people who:

"have been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or providing a service elsewhere which, if provided in England, would be a regulated activity”.

We will work collaboratively with the NHS Trust Development Authority, Monitor and councils of governors on how these proposals fit with the appointments of trust chairs. This will enable valuable information to be shared and will help to avoid imposing additional burden on providers. To meet the requirements of Regulation 5, a provider has to: • Provide evidence that appropriate systems and processes are in place to

ensure that all new directors and existing directors are, and continue to be, fit, and that no appointments meet any of the unfitness criteria set out in Schedule 4 of the regulation.

o This means that board directors should be of good character, have the required skills, experience and knowledge and that their health enables them to fulfil the management function. None of the criteria of unfitness should apply, which include bankruptcy, sequestration and insolvency, appearing on barred lists and being prohibited from holding directorships under other laws. Directors should not have been involved or complicit in any serious misconduct, mismanagement or failure of care in carrying on a regulated activity.

• Make every reasonable effort to assure itself about an individual by all means available.

• Make specified information about board directors available to CQC.

• Be aware of the various guidelines available and to have implemented procedures in line with this best practice.

• Where a board member no longer meets the fit and proper persons requirement, inform the regulator in question where the individual is registered with a health care or social care regulator, and take action to ensure the position is held by a person meeting the requirements.

Directors may personally be accused and found guilty by a court of serious misconduct in respect of a range of already prescribed behaviours set out in legislation. Professional regulators may remove an individual from a register for breaches of codes of conduct.


CQC recognises that individuals may be fit for their roles while, collectively, the board demonstrates a lack of fitness. We will address this in the most appropriate, relevant and proportionate approach on a case by case basis. The provider is responsible for the appointment, management and dismissal of its directors. The provider is responsible, as part of the recruitment and performance management processes, to ensure that FPPR is met. CQC will not undertake a fit and proper persons test of a director or determine what is serious mismanagement or misconduct, but we will examine how the provider has discharged its responsibility under the new regulation. It is a breach of the regulation to have in place someone who does not satisfy the FPPR. Evidence of this could be if: • A director is unfit on a ‘mandatory’ ground, such as a relevant conviction or

bankruptcy. The provider will determine this.

• A provider does not have a proper process in place to enable it to make the assessments required by the FPPR.

• On receipt of information about a director’s fitness, a decision is reached on the fitness of the director that is not in the range of decisions that a reasonable person would make.

CQC will now be able to take enforcement action for breaches of the fit and proper person requirement, in accordance with our Judgement Framework and Enforcement Policy. Where a breach is identified, we will use our existing regulatory powers. Breaches of other regulations may give CQC cause to question whether they have resulted from a breach of this regulation. In response to our consultation on this guidance, people asked for a clearer description of the key terms that are used, and these are given in appendix A. Our approach to the fit and proper persons requirement for directors Our approach to FPPR is part of our new inspection approach. CQC will check and monitor the extent to which the provider meets the regulation at the point of registration, during the inspection, on receipt of concerning information and where there is serious a systemic failure of a provider. During our registration process, we will test out with the provider that they understand the requirements of the regulation and ask them what systems they have in place to ensure that they will be able to meet these requirements.


We will require the chair of the NHS provider to declare that appropriate checks have been undertaken in reaching a judgement that all directors are deemed to be fit and none meet any of the unfit criteria. This will be a self-declaration and we will only follow this up if we have concerns about the recruitment process. This new requirement will not delay providers’ processes for appointing directors, or increase their administrative workload significantly. If we receive concerns about an individual director, we may also ask the provider to check their fitness and provide the same assurance to us. If a provider that aspires to register with CQC cannot demonstrate that it will meet the requirements of the regulation from its first day of business, we may refuse its application. During the inspection process, we will assess whether the provider is delivering good quality care. The specific key line of enquiry (KLOE) and prompts that are relevant for the FPPR are under the ‘well-led’ key question, as follows:

• W3: How does the leadership and culture reflect the vision and values, encourage openness and transparency and promote good quality care?

o Prompt: Do leaders have the skills, knowledge, experience and integrity that they need – both when they are appointed and on an ongoing basis?

o Prompt: Do leaders have the capacity, capability and experience to lead effectively?

Using the ‘well-led’ key question, CQC will confirm that the provider has undertaken appropriate checks and is satisfied that, on appointment and subsequently, all new and existing directors are of good character and are not unfit. This may involve checking personnel files and records about appraisal rates for directors. The inspection team will want to check providers’ awareness of the various guidelines and that they have implemented approaches in line with best practice. We will report on the FPPR under ‘well-led’ in our inspection reports at provider level. If we find that providers do not reflect the characteristics of good as described in our handbooks, we will assess whether they require improvement or are inadequate. We will also consider whether a regulation has been breached, including Regulation 5. Where there is a serious systemic failure of a provider we will carry out a focused inspection, including the FPPR aspects of corporate failure, and will use the evidence of such an inspection to inform our judgements about Regulation 5 and any breaches that may have taken place.


We will not use the fact that a provider is in special measures as evidence or an indication that a director is unfit. However we would, if necessary because of special measures, assess the effectiveness and robustness of the processes for the appointment of directors. We will have regard to any other information that we hold or obtain about directors in line with current legislation on when convictions, bankruptcies or similar matters are to be considered ‘spent’. Where a director is associated with serious misconduct or responsibility for failure in a previous role, we will have regard to the seriousness of the failure, how it was managed, and the individual’s role within that. Information received from a member of the public or the provider’s staff about an existing board member will be dealt with in line with CQC’s safeguarding and whistleblowing protocols where relevant. When a concern arises about the fitness of a director, we will follow a clear process explaining to both the individual and the provider what we intend to do. We will manage this in line with information governance requirements. CQC will convene a panel, led by the Chief Inspector of Hospitals or a person designated by them, to determine whether the information is significant and should be considered by the provider. We will request consent from the director concerned to pass this information to the provider. If we do not gain this consent from the director concerned, CQC will consider whether to share the information, acting in accordance with the Data Protection Act. The response received will either satisfy the Chief Inspector of Hospitals that due process has been followed or lead to a request for further dialogue with the provider, a follow-up inspection, or regulatory action using CQC’s current enforcement policy. CQC will take all circumstances into account when making a decision and would not take action against a provider if we consider it is reasonable for a provider to wait for the decision of a tribunal (such as an employment tribunal) before determining whether a director is unfit. Following this, CQC would then assess whether the provider’s judgement is reasonable, taking account of the tribunal’s decision. There are some core public information sources about providers that we believe are relevant for providers to use as part of their FPPR due diligence. We intend to provide some of these on our website, or indicate where they can be found. For example, this includes, but is not limited to, information from public inquiry reports, serious case reviews and Ombudsmen reports as outlined in our guidance. In all situations, CQC will determine the most appropriate, relevant and proportionate approach to take to meeting this regulation on a case by case basis. These new arrangements will be used to protect people from harm and the risk of

http://www.cqc.org.uk/content/safeguarding-people

http://www.cqc.org.uk/content/report-concern-if-you-are-member-staff


harm. Action taken will be proportionate to the concerns identified and the impact on people who use services. Where a provider is unable to demonstrate that it has undertaken the appropriate checks in the appointment of its board members, CQC will decide whether or not to take regulatory action, and what action to take. CQC will work alongside the NHS Trust Development Authority and Monitor to ensure that the correct processes are adhered to, that information is shared where appropriate and that enforcement activity is used proportionately. Providers may appeal to the First-tier Tribunal against a decision by CQC to take enforcement action. The tribunal hears appeals against decisions of the Secretary of State to restrict or bar an individual from working with children or vulnerable adults and decisions to cancel, vary or refuse registration of certain health care, child care and social care provision. Providers may also challenge by way of judicial review if they consider that a decision breaches public law principles such as being unreasonable, irrational and unfair. Judicial review is a procedure in English administrative law by which the courts in England and Wales may be asked to set aside (quash) allegedly unlawful decisions made by a public body, such as government minister, the local council or a statutory tribunal. As the statutory fit and proper persons requirement for directors is a new regulation, we expect to learn from what we find. We will share our learning from the early stages of implementation and aim to publish this when there is a sufficient body of information available. This learning will also inform the development of our guidance on meeting the new fundamental standards in all sectors. This guidance on Regulation 5 will be updated and incorporated into our guidance, to be issued before 1 April 2015, on meeting all the fundamental standards. Regulation 20: Duty of candour The aim of this regulation is to ensure that health service bodies4 are open and transparent with the “relevant person” (as defined in the regulation) when certain incidents occur in relation to the care and treatment provided to people who use services in the carrying on of a regulated activity. The regulation defines the relevant person as the person using the service and, in certain situations, extend to people acting lawfully on their behalf, for example a person under 16 who is not competent to make decisions about their care and

4 Health services bodies are defined in the regulations as NHS trusts, NHS foundation trusts and special health authorities.


treatment, or a person aged 16 or over who lacks the capacity to make decisions about their care and treatment. If the relevant person cannot be contacted or declines to speak to the representative of the health service body, then the health service body must keep a written record of its attempts to contact or speak to the relevant person. The introduction of Regulation 20 is a direct response to recommendation 181 of the Francis Inquiry report into Mid Staffordshire NHS Foundation Trust 5, which recommended that a statutory duty of candour be imposed on healthcare providers. In interpreting the regulation on the duty of candour, we use the definitions of openness, transparency and candour used by Robert Francis in his report: • Openness – enabling concerns and complaints to be raised freely without fear

and questions asked to be answered.

• Transparency – allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.

• Candour – any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

The regulation and its implementation reflect the approach proposed by the Dalton/Williams review6, including defining a notifiable safety incident to include moderate harm, severe harm, death, and prolonged psychological harm. These definitions are contained within Regulation 20 itself. NHS bodies have been encouraged for some time to voluntarily report moderate incidents. Most NHS bodies are already subject to a contractual duty of candour under the NHS Standard Contract. Contractual requirements are clearly set out in Standard Condition 35 of the contract. CQC already expects registered providers to meet these requirements, and we include this in our inspection approach as part of the key question “Are services safe?” Regulation 20 applies to NHS bodies when they are providing care and treatment to people who use services in the carrying on of a regulated activity only. To meet the requirements of Regulation 20, an NHS body has to:

• Make sure it acts in an open and transparent way with relevant persons in relation to care and treatment provided to people who use services in carrying on a regulated activity.

5. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, chaired by Robert Francis QC, http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf 6. Sir David Dalton and Prof. Norman Williams, Building a culture of candour: a review of the threshold for the duty of candour and of the incentives for care organisations to be candid, https://www.rcseng.ac.uk/policy/documents/CandourreviewFinal.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/02/tech-guide-240214.pdf

http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf

https://www.rcseng.ac.uk/policy/documents/CandourreviewFinal.pdf


• Tell the relevant person in person as soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred, and provide support to them in relation to the incident, including when giving the notification.

• Provide an account of the incident which, to the best of the health service body’s knowledge, is true of all the facts the body knows about the incident as at the date of the notification.

• Advise the relevant person what further enquiries the health service body believes are appropriate.

• Offer an apology.

• Follow this up by giving the same information in writing, and providing an update on the enquiries.

• Keep a written record of all communication with the relevant person. In response to our consultation on this guidance, people asked for a clearer description of key terms that are used. Where these are not already defined in Regulation 20, these are given in appendix B. Our approach to the duty of candour Our approach to the duty of candour is part of our new inspection approach. During our registration process we will test out with a provider that they understand the requirements of the regulation and ask them what systems they have in place to ensure that they will be able to meet these requirements. During the inspection process, we will assess whether the provider is delivering good quality care. Two specific key lines of enquiry (KLOEs) under the safe and well-led questions are relevant to the duty of candour: • S2: Are lessons learned and improvements made when things go

wrong?

o Prompt: Are people who use services told when they are affected by something that goes wrong, given an apology and informed of any actions taken as a result?

• W3: How does the leadership and culture reflect the vision and values, encourage openness and transparency and promote good quality care?

o Prompt: Does the culture encourage candour, openness and honesty?

Our handbooks describe what good care looks like in relation to each of the five key questions. Services that are safe ensure that when something goes wrong, people receive a sincere apology and are told about any actions taken to improve


processes to prevent the same thing happening again. In services that are well-led, candour, openness, honesty and transparency and challenges to poor practice are the norm. Leadership at all levels in the organisation is central to ensuring a culture that supports this. We will report on the duty of candour under the safety key question in our inspection reports at provider level. If we find care that does not reflect the characteristics of good as they are described in our provider handbook, we will assess whether the service requires improvement or is inadequate. We will also consider whether a regulation has been breached. We will take this guidance into account to determine whether a provider is meeting Regulation 20. An internal CQC advisory panel will be set up to support consistency in decision-making and to capture and share learning. Information received from a member of the public or the provider’s staff relating to the statutory duty of candour will be dealt with in line with CQC’s safeguarding and whistleblowing protocols where relevant. When we identify a breach of Regulation 20, we will assess the impact on people and decide whether or not to take regulatory action, and what action to take, in accordance with our Judgement Framework and Enforcement Policy. As the statutory duty of candour is a new regulation, we expect to learn from what we find. This learning will also inform the development of our guidance on meeting the new fundamental standards in all sectors. This guidance on Regulation 20 will be updated and incorporated into our guidance, to be issued before 1 April 2015, on meeting all the fundamental standards. Our approach to guidance on regulations We developed this guidance with the help of patients and people who use services, organisations that represent them, providers, other regulators and professional bodies. We are grateful for their many suggestions. In the guidance, we explain the intention of each regulation. We then consider each element of the regulation in turn, setting out our guidance that providers must have regard to. For each regulation, we provide links to key legislation and guidance that we will consider when making judgements. The listed legislation and guidance is not exhaustive. We expect providers to take account of other relevant guidance that is specific to the services they deliver. We intend our guidance to be as helpful as possible to providers. However, it is not CQC’s role to tell providers what they must do to deliver their services. It is the provider’s responsibility to meet the regulations and to decide how to do this.

http://www.cqc.org.uk/content/safeguarding-people

http://www.cqc.org.uk/content/report-concern-if-you-are-member-staff


Guidance for providers

How to meet Regulation 5: Fit and proper persons: directors and Regulation 20: Duty of candour You can see the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on this link: http://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents

Regulations 5 and 20 come into force for NHS bodies on 27 November 2014.

http://www.legislation.gov.uk/ukdsi/2014/9780111117613/contents


Regulation 5: Fit and proper persons: directors

5—(1) This regulation applies where a service provider is a health service body. (2) Unless the individual satisfies all the requirements set out in paragraph (3), the service provider must not appoint or have in place an

individual— (a) as a director of the service provider, or (b) performing the functions of, or functions equivalent or similar to the functions of, such a director.

(3) The requirements referred to in paragraph (2) are that— (a) the individual is of good character, (b) the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the

work for which they are employed, (c) the individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic

to the office or position for which they are appointed or to the work for which they are employed, (d) the individual has not been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement

(whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity, and

(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual. (4) In assessing an individual’s character for the purposes of paragraph (3)(a), the matters considered must include those listed in Part 2 of

Schedule 4. (5) The following information must be available to be supplied to the Commission in relation to each individual who holds an office or position

referred to in paragraph (2)(a) or (b)— (a) the information specified in Schedule 3, and (b) such other information as is required to be kept by the service provider under any enactment which is relevant to that individual.

(6) Where an individual who holds an office or position referred to in paragraph (2)(a) or (b) no longer meets the requirements in paragraph (3), the service provider must— (a) take such action as is necessary and proportionate to ensure that the office or position in question is held by an individual who meets

such requirements, and (b) if the individual is a health care professional, social worker or other professional registered with a health care or social care regulator,

inform the regulator in question.


SCHEDULE 4 Good character and unfit person tests PART 1 Unfit person test 1. The person is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been

discharged. 2. The person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland

or Northern Ireland. 3. The person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act

1986. 4. The person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it. 5. The person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups

Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland. 6. The person is prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or

under any enactment. PART 2 Good character 7. Whether the person has been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in

any part of the United Kingdom, would constitute an offence. 8. Whether the person has been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work

professionals. SCHEDULE 3: Information Required in Respect of Persons Employed or Appointed for the Purposes of a Regulated Activity 1. Proof of identity including a recent photograph. 2. Where required for the purposes of an exempted question in accordance with section 113A(2)(b) of the Police Act 1997, a copy of a criminal

record certificate issued under section 113A of that Act together with, after the appointed day and where applicable, the information mentioned in section 30A(3) of the Safeguarding Vulnerable Groups Act 2006 (provision of barring information on request).

3. Where required for the purposes of an exempted question asked for a prescribed purpose under section 113B(2)(b) of the Police Act 1997, a copy of an enhanced criminal record certificate issued under section 113B of that Act together with, where applicable, suitability information relating to children or vulnerable adults.

4. Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to— (a) health or social care, or (b) children or vulnerable adults.


5. Where a person (P) has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why P’s employment in that position ended.

6. In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform.

7. A full employment history, together with a satisfactory written explanation of any gaps in employment. 8. Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable

adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity.

9. For the purposes of this Schedule— (a) “the appointed day” means the day on which section 30A of the Safeguarding Vulnerable Groups Act 2006 comes into force;. (b) “satisfactory” means satisfactory in the opinion of the Commission;. (c) “suitability information relating to children or vulnerable adults” means the information specified in sections 113BA and 113BB respectively of the Police Act 1997.

This regulation applies to health service bodies only, from 27 November 2014. It will be extended to all other providers from 1 April 2015, subject to Parliamentary process and approval. This guidance will be updated and incorporated into our guidance, to be issued before 1 April 2015, on all the new fundamental standards. The intention of this regulation is to ensure that all board level appointments of NHS foundation trusts, NHS trusts and special health authorities carrying on a regulated activity are responsible for the overall quality and safety of that care, and for making sure that care meets the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This regulation is about ensuring that those individuals are fit and proper to carry out this important role.

It will apply to executive and non-executive, permanent, interim and associate positions, irrespective of their voting rights. The regulation applies to the governor(s) of a foundation trust who sit on the trust board as representatives of the board of governors. Any further use of the word ‘director’ will encompass the above description only. ‘Provider’ will be used throughout this document to refer to NHS trusts, NHS foundation trusts and special health authorities providing regulated activities.

There is further guidance below about each component of the regulation to which NHS bodies must have regard.

Summary of the regulation


Component of the regulation Providers must have regard to the following guidance in relation to this component:

5(3)(a) the individual is of good character

• Providers must make every effort to ensure that all available information is sought to confirm that the individual is of good character, and have regard to the matters outlined in Schedule 4, Part 2 of the regulations when assessing whether an individual is of good character. Robust systems must be in place to ensure continuous assessment of the temperament, character and empathy of staff. It is not possible to outline every character trait an individual should have but among them we would expect to see that the diligence processes take account of honesty, trust and respect.

• If a provider discovers information that suggests an individual is not of good character after they have been appointed to a role, the provider must take appropriate and timely action to investigate and rectify the matter.

• Where, following the application of a robust process, a provider deems the individual suitable despite the individual being convicted of an offence and/or removed from the register of a professional health or social care regulator, the reasons should be recorded and information about the decision should be made available to those that need to be aware.

• It is for providers and not CQC to identify that particular directors are fit and proper persons. Note: • By “timely” we mean as soon as can be achieved in order to minimise harm or potential harm to

people receiving services. We would assess action taken on a case by case basis, but would expect providers to take immediate action to protect people from harm and introduce and complete investigations quickly, evidencing reasons for any delay that any reasonable trust would avoid.

5(3)(b) the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed

• Where specific qualifications are deemed by the provider as necessary for a role, the provider must make this clear and should only employ those individuals who meet the required specification, including any requirements to be registered with a professional regulator.

• The provider must have appropriate processes for assessing and checking that the individual holds the required qualifications and has the competence, skills and experience required, (which may include appropriate communication and leadership skills and a caring and compassionate nature) to undertake the role. These must be followed in all cases and relevant records kept.



• The provider may consider that an individual can be appointed to a role based on their qualifications, skills and experience with the expectation that they will develop specific competence to undertake the role within a specified timeframe.

• There is already a range of good guidance documents for providers that cover value-based recruitment, appraisal and development, and disciplinary actions including dismissal for chief executives, chairs and directors. CQC, the NHS TDA and Monitor will publish a joint document for CEOs and chairs to direct providers to these sources on or after 27 November 2014.

• We expect all providers to be aware of the various guidelines and to have implemented procedures in line with this best practice, as well as the seven principles of public life (the Nolan Principles)7 and joint guidance from CQC, Monitor and NHS TDA on recruitment, performance management and disciplinary arrangements for CEOs and directors (due to be published on 27 November).

5(3)(c) the individual is able by reason of their health, after such reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed

• People in position of control within health service bodies must be physically and mentally fit. This does not mean that people who have a long-term condition, a disability or mental illness cannot be in such a position. This aspect of the regulation relates to the ability to sustain the management function.

• When appointing relevant individuals the provider must have processes for considering a person’s physical and mental health in line with the requirements of the role.

• Wherever possible, the provider must make reasonable adjustments to enable an individual to carry out the role.

7 The 7 principles of Public Life. (The basis of the ethical standards expected of public office holders). Committee on Standards in Public Life, Lord Nolan, 31 May 1995

https://www.gov.uk/government/publications/the-7-principles-of-public-life

https://www.gov.uk/government/publications/the-7-principles-of-public-life



5(3)(d) the individual has not been responsible for, been privy to, contributed to or facilitated, any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity, and

• The provider must have processes in place to assure itself that the individual has not been responsible for, privy to, contributed to, or facilitated any serious misconduct or mismanagement in the carrying on of a regulated activity. This includes investigating any allegation of such and making independent enquiries.

• The provider must not appoint any individual who has been responsible for, privy to, contributed to, or facilitated any serious misconduct or mismanagement (whether lawful or not) in the carrying on of a regulated activity.

• In the case of a director being convicted of breaching a health and safety requirement on the basis of the way the entire management team organised and managed the activities of their organisation, providers are expected to ascertain the role of the individual so that they can make a judgement about whether or not it means they are unfit. Where the evidence demonstrates that the breach is attributable to the individual’s conduct, CQC would expect a provider to find that the individual is unfit.

• While CQC will have regard to information on when convictions, bankruptcies or similar matters are to be considered ‘spent’, there is no time limit for considering serious misconduct or responsibility for failure in a previous role.

Note: • “Serious misconduct or mismanagement” means behaviour that would constitute a breach of any

legislation/enactment that CQC deems relevant to meeting these regulations or their component parts. “Serious misconduct” might be expected to include assault, fraud and theft. “Mismanagement” might be expected to include mismanaging funds and/or not adhering to recognised practice, guidance or processes regarding care quality within which the individual is meant to work. These are not exhaustive lists.

• “Responsible for, contributed to or facilitated” means that there is evidence that a person has intentionally, or through neglect, behaved in a manner that would be considered to be, or would have led to, serious misconduct or mismanagement.



• “Privy to” means that there is evidence that could lead the provider to reasonably conclude that a person was aware of serious misconduct or mismanagement but did not take the appropriate action to ensure it was addressed.

5(3)(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual.

• Only individuals who will be acting in a role that falls within the definition of a “regulated activity” as defined by the Safeguarding Vulnerable Groups Act 2006 will be eligible for a check by the Disclosure and Barring Service (DBS).

• Providers must seek all available information to assure themselves that directors are not unfit, as defined in Schedule 4 Part 1. Robust systems should be in place to assess directors in relation to bankruptcy, sequestration, insolvency and arrangements with creditors. In addition, providers should establish whether the individual is on the children’s and/or adults’ safeguarding barred list and whether they are prohibited from holding the office in question under other laws such as the Companies Act or Charities Act.

• If a provider discovers information that suggests an individual is unfit after they have been appointed to a role, the provider must take appropriate and timely action to investigate and rectify the matter.

• Where a provider deems the individual is suitable despite not meeting the characteristics outlined in Schedule 4, Part 1 of these regulations, the reasons must be recorded and information about the decision should be made available to those that need to be aware.

Note: • Each person will define “appropriate” according to their own particular circumstances. In essence

it means suitable or proper for the circumstances. CQC would take into consideration all aspects surrounding decision-making to determine appropriateness. We would expect to see processes in place that include disciplining and dismissing directors where relevant.

• By “timely” we mean as soon as can be achieved in order to minimise harm or potential harm to people receiving the service. We would assess action taken on a case by case basis, but would expect providers to take immediate action to protect people from harm and introduce and complete investigations quickly, giving evidence of reasons for any delay which any reasonable person would avoid.



5(6) Where an individual who holds an office or position referred to in paragraph (2)(a) or (b) no longer meets the requirements in paragraph (3), the service provider must—

(a) take such action as is necessary and proportionate to ensure that the office or position in question is held by an individual who meets such requirements, and

(b) if the individual is a health care professional, social worker or other professional registered with a health care or social care regulator, inform the regulator in question

• The provider must regularly review the fitness of directors to ensure that they remain fit for the role they are in. The provider must determine how often to review fitness based on the assessed risk to business delivery and/or to the people using the service posed by the individual and/or role.

• The provider must have arrangements in place to respond to concerns about a person’s fitness after they are appointed to a role, identified by itself or others, and the provider must adhere to these.

• The provider must investigate, in a timely manner, any concerns about a person’s fitness or ability to carry out their duties, and where concerns are substantiated, then it must take proportionate, timely action. The provider must demonstrate due diligence in all actions.

• Where a person’s fitness to carry out their role is being investigated, appropriate interim measures may be required to minimise any risk to people who use the service.

• There are some core public information sources about providers that we believe are relevant for providers to use as part of their FPPR due diligence. We intend to provide some of these on our website, or indicate where they can be found. These include the following (this list is not exhaustive): o Any provider whose registration had been suspended or cancelled due to failings in care in

the last five years or longer if the information is available because of previous registration with CQC predecessor bodies.

o Public inquiry reports about the provider. o Information where we are notified about any relevant individuals who have been disqualified

from a professional regulatory body. This information would be shared with the individual and the provider in accordance with the Data Protection Act.

o Serious case reviews relevant to the provider. o Homicide investigations for mental health trusts. o Criminal prosecutions against providers. o Ombudsmen reports relating to providers.



• We will act in accordance with the Data Protection Act 1998 concerning any information that is classed as “personal data” about an individual within the meaning of the Data Protection Act.

Relevant legislation Relevant guidance NHS Provider Licence May 2014 http://www.monitor-nhsft.gov.uk/sites/default/files/publications/Licence%20application%20guidance%20final.pdf Companies Act 2006 http://www.legislation.gov.uk/ukpga/2006/46/part/8/chapter/2 The Protection of Freedoms Act 2012 http://www.legislation.gov.uk/uksi/2012/3006/contents/made Safeguarding Vulnerable Adults Group 2006 http://www.legislation.gov.uk/ukpga/2006/47/contents Protection of Freedoms Act 2013 http://www.legislation.gov.uk/ukpga/2012/9/contents/enacted

Professional Standards Authority – standards Nov 2013 http://www.professionalstandards.org.uk/library/document-detail?id=89114436-21e2-47df-b5a0-7d5308b66b8e Charities Commission guidance 2013/2014 http://www.charitycommission.gov.uk/detailed-guidance/ Disclosure and Barring identity checking guidance July 2014 https://www.gov.uk/government/publications/dbs-identity-checking-guidelines Disclosure and Barring Service https://www.gov.uk/government/organisations/disclosure-and-barring-service Equality and Human Rights Commission: employment statutory code of practice http://www.equalityhumanrights.com/sites/default/files/documents/EqualityAct/employercode.pdf

http://www.monitor-nhsft.gov.uk/sites/default/files/publications/Licence%20application%20guidance%20final.pdf



http://www.legislation.gov.uk/ukpga/2006/46/part/8/chapter/2

http://www.legislation.gov.uk/uksi/2012/3006/contents/made

http://www.legislation.gov.uk/ukpga/2006/47/contents

http://www.legislation.gov.uk/ukpga/2012/9/contents/enacted

http://www.professionalstandards.org.uk/library/document-detail?id=89114436-21e2-47df-b5a0-7d5308b66b8e

http://www.professionalstandards.org.uk/library/document-detail?id=89114436-21e2-47df-b5a0-7d5308b66b8e

http://www.charitycommission.gov.uk/detailed-guidance/

https://www.gov.uk/government/publications/dbs-identity-checking-guidelines

https://www.gov.uk/government/publications/dbs-identity-checking-guidelines

https://www.gov.uk/government/organisations/disclosure-and-barring-service

https://www.gov.uk/government/organisations/disclosure-and-barring-service

http://www.equalityhumanrights.com/sites/default/files/documents/EqualityAct/employercode.pdf

http://www.equalityhumanrights.com/sites/default/files/documents/EqualityAct/employercode.pdf


Regulation 20: Duty of candour

20. (1) A health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. (2) As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a health service body must—

(a) notify the relevant person that the incident has occurred in accordance with paragraph (3), and (b) provide reasonable support to the relevant person in relation to the incident, including when giving such notification.

(3) The notification to be given under paragraph (2)(a) must— (a) be given in person by one or more representatives of the health service body, (b) provide an account, which to the best of the health service body’s knowledge is true, of all the facts the health service body knows about the incident as at the date of the notification, (c) advise the relevant person what further enquiries into the incident the health service body believes are appropriate, (d) include an apology, and (e) be recorded in a written record which is kept securely by the health service body.

(4) The notification given under paragraph (2)(a) must be followed by a written notification given or sent to the relevant person containing— (a) the information provided under paragraph (3)(b), (b) details of any enquiries to be undertaken in accordance with paragraph (3)(c), (c) the results of any further enquiries into the incident, and (d) an apology.

(5) But if the relevant person cannot be contacted in person or declines to speak to the representative of the health service body— (a) paragraphs (2) to (4) are not to apply, and (b) a written record is to be kept of attempts to contact or to speak to the relevant person.

(6) The health service body must keep a copy of all correspondence with the relevant person under paragraph (4). (7) In this regulation—

“apology” means an expression of sorrow or regret in respect of a notifiable safety incident; “moderate harm” means— (a) harm that requires a moderate increase in treatment, and (b) significant, but not permanent, harm;


“moderate increase in treatment” means an unplanned return to surgery, an unplanned re-admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another treatment area (such as intensive care); “notifiable safety incident” means any unintended or unexpected incident that occurred in respect of a service user during the provision of a regulated activity that, in the reasonable opinion of a health care professional, could result in, or appears to have resulted in— (a) the death of the service user, where the death relates directly to the incident rather than to the natural course of the service user’s illness or underlying condition, or (b) severe harm, moderate harm or prolonged psychological harm to the service user; “prolonged psychological harm” means psychological harm which a service user has experienced, or is likely to experience, for a continuous period of at least 28 days; “relevant person” means the service user or, in the following circumstances, a person lawfully acting on their behalf— (a) on the death of the service user, (b) where the service user is under 16 and not competent to make a decision in relation to their care or treatment, or (c) where the service user is 16 or over and lacks capacity (as determined in accordance with sections 2 and 3 of the 2005 Act) in relation to the matter; “severe harm” means a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions, including removal of the wrong limb or organ or brain damage, that is related directly to the incident and not related to the natural course of the service user’s illness or underlying condition.

This regulation applies to health service bodies only, from 27 November 2014. It will be extended to all other providers from 1 April 2015, subject to Parliamentary process and approval. This guidance will be updated and incorporated into our guidance, to be issued before 1 April 2015, on all the new fundamental standards. The intention of this regulation is to ensure that providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on behalf of them) in general in relation to care and treatment, and specifically when things go wrong with care and treatment, and that they provide them with reasonable support, truthful information and an apology when things go wrong. The regulation applies to NHS bodies when they are carrying on a regulated activity. There is further guidance below about each component of the regulation to which NHS bodies must have regard.

Summary of the regulation


Component of the regulation Providers must have regard to the following guidance in relation to this component

20(1) A health service body must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity.

The Being Open Framework referenced below provides guidance on the action that organisations can take to create a culture that supports staff to act in an open and transparent way. In meeting this component of the regulation, providers must consider the following: • There should be a board level commitment to being open and transparent in relation to care and

treatment.

• The culture of the organisation should encourage candour, openness and honesty at all levels, as an integral part of a culture of safety that supports organisational and personal learning.

• The provider should have policies and procedures in place to support a culture of openness and transparency, and ensure these are followed by all staff.

• The provider should take action to tackle bullying, harassment and undermining in relation to duty of candour, and must investigate any instances where a member of staff may have obstructed another in exercising their duty of candour.

• The provider should have a system in place to identify and deal with possible breaches of the professional duty of candour by staff who are professionally registered, including the obstruction of another in their professional duty of candour. This is likely to include an investigation and escalation process that may lead to referral to their professional regulator or other relevant body.

• The provider should make all reasonable efforts to ensure that staff operating at all levels within the organisation operate within a culture of openness and transparency, understand their individual responsibilities in relation to the duty of candour, and are supported to be open and honest with patients and apologise when things go wrong.

• Staff should receive appropriate training, and there should be arrangements in place to support staff who are involved in a notifiable safety incident.

• In cases where a relevant person informs the provider that something untoward has happened, the provider should treat the allegation seriously, immediately consider whether this is a notifiable safety incident and take appropriate action.



20(2) As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a health service body must–(a) notify the relevant person that the incident has occurred in accordance with paragraph (3) and 20(3) The notification to be given under paragraph (2)(a) must– (a) be given in person by one or more representatives of the health service body, (b) provide an account, which to the best of the health service body’s knowledge is true, of all the facts the health service body knows about the incident as at the date of the notification, (c) advise the relevant person what further enquiries into the incident the health service body believes are appropriate, (d) include an apology, and (e) be recorded in a written record which is kept securely by the health service body.

• When a notifiable safety incident has occurred, the relevant person must be informed as soon as reasonably practicable after the incident has been identified. The NHS Standard Contract requires that the notification must be within at most 10 working days of the incident being reported to local systems, and sooner where possible.

• All staff working within a provider must have responsibility to adhere to that organisation’s policies and procedures around duty of candour, regardless of seniority or permanency.

• The Being Open Framework referenced below provides guidance on how to ensure good communication with the patient, their families and carers.

• Regulation 20 defines what constitutes a notifiable safety incident. It includes incidents that could result in, or appear to have resulted in, the death of the person using the service or severe harm, moderate harm, or prolonged psychological harm. These terms are defined in the regulation (see above).

• Where the degree of harm is not yet clear but may fall into the above categories, the relevant person must be informed of the notifiable safety incident in line with the requirements of the regulation.

• The NHS body is not required by the regulation to inform a person using the service when a ‘near miss’ has occurred, and the incident has resulted in no harm to that person.

• There must be appropriate arrangements place to notify the person using the service who is affected by an incident if they are 16 years and over and lack capacity to make a decision regarding their care or treatment (as determined in accordance with sections 2 and 3 of the 2005 Mental Capacity Act), including ensuring that a person acting lawfully on their behalf is notified as the relevant person.

• A person acting lawfully on behalf of the person using the service must be notified as the relevant person where the person using the service is under 16 and not competent to make a decision regarding their care or treatment.

• A person acting lawfully on behalf of the person using the service must be notified as the relevant person, upon the death of the person using the service.



• Other than the situations outlined above, information should only be disclosed to family members or carers where the person using the service has given their express or implied consent.

• A step-by-step account of all relevant facts known about the incident at the time must be given, in person, by one or more appropriate representatives of the provider. This should include as much or as little information as the relevant person wants to hear, be jargon free and explain any complicated terms.

• The account of the facts must be given in a manner that the relevant person can understand. For example, the provider should consider whether interpreters, advocates, communication aids etc. should be used, while being conscious of any potential breaches of confidentiality in doing so.

• The provider must also explain to the relevant person what further enquires they will make. • The provider must ensure that a meaningful apology is given, in person, by one or more

appropriate representatives of the provider to relevant persons. An apology is defined in the regulation as an expression of sorrow or regret. The NHS Litigation Authority has produced guidance on making an apology (see below), which states that saying sorry is not an admission of legal liability.

• In making a decision about who is most appropriate to provide the notification and/or apology, the provider should consider seniority, relationship to the person using the service, and experience and expertise in the type of notifiable incident that has occurred. The Being Open Framework referenced below provides guidance on this.

Note: • On occasion, a provider may discover a notifiable safety incident that happened some time ago,

or one that relates to care that was delivered by another provider. The provider that discovers the incident should work with others who are responsible for notifying the relevant person of the incident. Please see below for guidance regarding “reasonable attempts”.



20(2) As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a health service body must–

(b) provide reasonable support to the relevant person in relation to the incident, including when giving such notification.

• The provider must give the relevant person all reasonable support necessary to help overcome the physical, psychological and emotional impact of the incident. This could include all or some of the following:

o Treating them with respect, consideration and empathy. o Offering the option of direct emotional support during the notifications, for example from a

family member, a friend, a care professional or a trained advocate.

o Offering access to assistance with understanding what is being said e.g. via interpretative services, non-verbal communication aids, written information, Braille etc.

o Providing access to any necessary treatment and care to recover from or minimise the harm caused where appropriate.

o Providing the relevant person with details of specialist independent sources of practical advice and support or emotional support/counselling.

o Providing the relevant person with information about available impartial advocacy and support services, their local Healthwatch and other relevant support groups, for example Cruse Bereavement Care and Action against Medical Accidents (AvMA), to help them deal with the outcome of the incident.

o Arranging for care and treatment to be delivered by another professional, team or provider if this is possible, should the relevant person wish.

o Providing support to access its complaints procedure. o The Being Open Framework referenced below provides guidance on how to support

patients, their families and carers when a patient safety incident has occurred.

20(4) The notification given under paragraph (2)(a) must be followed by a written notification given or sent to the relevant person containing—

• The provider must ensure that written notification is given to the relevant person following the notification that was given in person, even though enquiries may not yet be complete.

• The written notification must contain all the information that was provided in person including an apology, as well as the results of any enquiries that have been made since the notification in person.



(a) the information provided under paragraph (3)(b),

(b) details of any enquiries to be undertaken in accordance with paragraph (3)(c),

(c) the results of any further enquiries into the incident, and (d) an apology.

• The outcomes or results of any further enquiries and investigations must also be provided in writing to the relevant person through further written notifications, should they wish to receive them.

20(5) But if the relevant person cannot be contacted in person or declines to speak to the representative of the health service body–

(a) paragraphs (2) to (4) are not to apply, and (b) a written record is to be kept of attempts to contact or to speak to the relevant person.

• The provider must make every reasonable attempt to contact the relevant person through all available communication means. All attempts to contact the relevant person must be documented.

• If the relevant person does not wish to communicate with the provider, their wishes must be respected and a record of this must be kept.

• If the relevant person has died and there is nobody who can lawfully act on their behalf, a record of this should be kept.

(6) The health service body must keep a copy of all correspondence with the relevant person under paragraph (4).

• A record of the written notification must be kept by the provider, along with any enquiries and investigations and the outcome or results of the enquiries or investigations.

• Any correspondence from the relevant person relating to the incident must be responded to in an appropriate manner and a record of communications should be kept.


Relevant legislation Relevant guidance

Mental Capacity Act 2005 http://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf Department for Constitutional Affairs: Mental Capacity Act 2005 Code of Practice https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Capacity_Act_code_of_practice.pdf Care Quality Commission (Registration Requirements) Regulations 2009 http://www.legislation.gov.uk/uksi/2009/3112/made

The following guidance is relevant to Regulation 20, and should be taken into account by providers: NHS Standard Contract 2014/15: Updated Technical Guidance (Appendix 5: Contractual requirements relating to Duty of Candour) http://www.england.nhs.uk/wp-content/uploads/2014/02/tech-guide-240214.pdf NHS National Patient Safety Agency, Being Open Framework provides guidance on communicating about patient safety incidents with patients, families and carers http://www.nrls.npsa.nhs.uk/beingopen/?entryid45=83726 Definitions of levels of harm included in: National Patient Safety Agency, Seven Steps to Patient Safety http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787 Care Quality Commission (Registration Requirement) Regulations 2009: Regulations 16 – 18 outline the notifications required by CQC http://www.legislation.gov.uk/uksi/2009/3112/made NHS Litigation Authority, Saying Sorry http://www.nhsla.com/claims/Documents/Saying%20Sorry%20-%20Leaflet.pdf General medical Council, Good Medical Practice 2001, Guidance on ‘duty of candour’ http://www.gmc-uk.org/publications/24152.asp

http://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf

http://www.legislation.gov.uk/ukpga/2005/9/pdfs/ukpga_20050009_en.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Capacity_Act_code_of_practice.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/Mental_Capacity_Act_code_of_practice.pdf

http://www.legislation.gov.uk/uksi/2009/3112/made



http://www.nrls.npsa.nhs.uk/beingopen/?entryid45=83726

http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787

http://www.nrls.npsa.nhs.uk/resources/collections/seven-steps-to-patient-safety/?entryid45=59787

http://www.legislation.gov.uk/uksi/2009/3112/made

http://www.nhsla.com/claims/Documents/Saying%20Sorry%20-%20Leaflet.pdf

http://www.nhsla.com/claims/Documents/Saying%20Sorry%20-%20Leaflet.pdf

http://www.gmc-uk.org/publications/24152.asp


Appendix A: Description of terms used in our guidance about the fit and proper requirement for directors Fit and proper person The purpose of the fit and proper person requirement for directors aims to ensure that NHS trusts are not managed or controlled by individuals who present an unacceptable risk either to the organisation or to people receiving a service. The regulation is about ensuring that directors are fit and proper to assume responsibility for the overall quality and safety of care delivered. CQC does not offer a clearance service for NHS trusts to confirm that particular individuals are fit and proper persons. CQC will look at the extent to which the provider meets the regulation by checking that the provider has made every reasonable effort to assure themselves of the suitability of their directors and that consequently those directors are fit and proper persons. A fit and proper person ‘test’ has been in use across other bodies and sectors for some years, such as HMRC in the management of charities and the aviation sector. It has the same purpose which is to prevent people from being appointed or remaining in a position of authority or control when they are not fit to do so. Good character Character determines the response to any given situation and good character will ensure that the response is the correct one, regardless of the circumstances and within agreed processes and systems. It is not possible to outline every character trait that an individual should have. However, among them we would expect to see that the diligence processes take account of honesty, trust and respect. Individuals should not have been complicit with significant care failures and none of the definitions of unfitness should apply to that individual. These include the appearance of the individual on barred lists of the Safeguarding Vulnerable Groups Act 2006, and/or any decisions made by any professional regulatory bodies that have resulted in removal from their registers. CQC will have regard to information on when convictions, bankruptcies or similar matters are to be considered ‘spent’. A caring and compassionate nature Caring is one of CQC’s key questions against which we rate and we expect this attribute to be at the core of those delivering health care. During inspections we explore whether staff are caring towards people receiving services and whether they are treated with compassion. One way of doing this is by asking people receiving services how they feel when they are being treated or spoken with by staff in that service, and asking staff how senior leaders set the tone and culture of the organisation in this respect.


Serious misconduct and mismanagement This is determined by the provider through checks at the appointment stage or afterwards and CQC is not involved in this process. In response to comments received, we have fleshed out what serious misconduct might include. We would suggest this could include assault, fraud, theft, breaches of health and safety regulations, intoxication while on duty, any breach of confidentiality, disobedience of lawful and reasonable instruction, and disrespect in the workplace. This is not an exhaustive list. Mismanagement would indicate, for example, that a director has dealt with responsibilities badly or carelessly, by mismanaging funds and/or not adhering to recognised practice, or following guidance, internal or external processes within which he or she is meant to work. As stated in the guidance, a director must not have been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement in carrying on a regulated activity. Individuals should not have been complicit with significant care failures. Physically and mentally fit People in a position of control within NHS trusts must be physically and mentally fit. This does not mean that people who have a long term condition, a disability or mental illness cannot be in such a position. This aspect of the regulation relates to the ability to sustain the management function. Reasonable and what one deems reasonable Each person will define reasonable according to their own particular circumstances. In essence it means ‘fair’ and with ‘sound judgement’, and CQC would take into consideration all aspects surrounding decision-making to determine reasonableness. Director This includes executive directors, non-executive directors and associate directors who are members of the board, irrespective of their voting rights. Directors may be existing, interim or permanent. Generally an executive director of an NHS trust holds a position on the board of the NHS organisation, so as well as being in control of a department or directorate, they may also have decision-making responsibility within the organisation. Non-executive directors sit on an NHS organisation’s board but do not directly manage either a financial function or a department or directorate. How values-based recruitment can help meet the requirement An organisation must determine its values and recruit against them. Values embedded within all aspects of recruitment could, for example, make it more difficult for people to be untruthful on their application form as the systems in place would carry out all necessary checks. This could help an organisation to recruit ‘honest’ staff who share the values of the organisation.


Appendix B: Description of terms used in our guidance about duty of candour Cancelling treatment

Where planned treatment is not carried out as a direct result of the notifiable safety incident. Reasonable amount of time

A reasonable amount of time is not defined in the regulation. However, the NHS Standard Contract requires that the notification must be within at most 10 working days of the incident being reported to local systems, and sooner where possible. Appropriate written records

Records are complete, legible, accurate and up to date. Every effort must be made to ensure records are updated without any delays. Act in an open and transparent way Clear, honest and effective communication with patients, their families and carers throughout their care and treatment, including when things go wrong, in line with the definitions below. We will use the following definitions of openness, transparency and candour used by Robert Francis in his report: • Openness

Enabling concerns and complaints to be raised freely without fear and questions asked to be answered.

• Transparency

Allowing information about the truth about performance and outcomes to be shared with staff, patients, the public and regulators.

• Candour

Any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it.

How to contact us Call us on: 03000 616161 Email us at: [email protected] Look at our website: www.cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Follow us on Twitter: @CareQualityComm

mailto:[email protected]

http://www.cqc.org.uk/

https://twitter.com/carequalitycomm

Agenda Item No.

5BP (15/21)



26 January 2015

TITLE OF REPORT:

Wigan Mental Health Strategy

PURPOSE OF REPORT:

To present to the Board the approved Mental Health

Strategy for Wigan.


The Joint Mental Health Commissioning Strategy (2014-2019) sets out a vision for mental health services over the next five years.

The strategy aligns with Wigan’s Integrated Care Strategy and focuses on parity of esteem for mental health by making it part of the integrated system.

The document was considered by the Wigan Leaders meeting on 16th October.

The document was approved by the Wigan Borough Clinical Commissioning Group on 25 November 2015.




That the Board endorses the contents of the report.

Agenda Item No.

5BP (15/21)



√









Yes No

If yes,

BAF entry No.


above)


Agenda Item No.

5BP (15/21)


MEETING: Governing Body – Open Meeting Item Number: DATE: 25th November 2014

REPORT TITLE:

Joint Mental Health Commissioning Strategy

REPORT AUTHOR:

Paul Lynch – Assistant Director – Strategy & Collaboration

PRESENTED BY:

Gary Cook – Secondary Care Consultant Member of Governing Body

RECOMMENDATIONS/DECISION REQUIRED:

The Governing Body is asked to endorse the Joint Mental Health Commissioning Strategy 2014-2019

EXECUTIVE SUMMARY The Joint Mental Health Commissioning Strategy (2014-2019) sets out a vision for mental health services in the Borough over the next five years. The strategy aligns with Wigan’s Integrated Care Strategy and focuses on parity of esteem for mental health by making it part of the integrated system. The document was considered by the Wigan Leaders meeting on 16th October. The strategy contains an action plan for delivery, setting out the timescales for the proposed changes.

FURTHER ACTION REQUIRED:

None

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Healthy People, Healthy Place

Joint Mental Health Strategy

For Adults of All Ages 2014 to 2019

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DOCUMENT CONTROL PAGE T

itle

Joint Mental Health Strategy (2014-19) S

up

ers

ed

es Current Mental Health Strategy

Au

tho

r Paul Lynch (Assistant Director – Strategy & Collaboration)

Rati

fic

ati

on

NHS Wigan Borough CCG Governing Body Wigan Health & Well Being Board

Rev

iew

Annual Basis

Ve

rsio

n

His

tory

09/11/2014 Version 3.0

Date Placed on the Intranet/Sharepoint: Following Approval

EqIA Registration Number TBC

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Contents

Section Contents Page

Executive Summary 3

1 Introduction 4

2 What Do We Mean By Mental Health? 6

3 National & Local Context 8

4 What do we Know About our Population and Mental Health 13

5 Our Strategy for Mental Health: the Next Five Years 14

6 Next Steps 26

Appendix 1 Key Information about Our Population and Mental Health 29

Appendix 2 The Current Financial Picture 32

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Executive Summary This is Wigan Borough’s strategy for mental health for the next five years. It has been developed by Wigan Borough Clinical Commissioning Group, working with Wigan Council.

The strategy is for adults of all ages. However, it will align with the Child and Adolescent Mental Health Services Strategy.

Mental Health is important to everyone. We know that people with good mental health are better able to live fulfilled lives and contribute to their communities. We also know that people who have mental health problems often face exclusion and are likely to have other problems related to their mental health condition, such as with employment, housing, drugs and alcohol or debt.

Historically, mental health has not been afforded the same priority as physical health. The Government’s approach, titled ‘Parity of Esteem’ is about addressing this. We are clear in Wigan that we want to achieve parity of esteem for mental health. We recognise that this may mean some changes in the proportion of our budgets that we currently invest in mental health.

Information that we have about our population tells us that we have a high number of people in the Borough who are at risk of poor mental health. This is mainly because we have relatively high levels of deprivation and a large number of people who have long-term conditions.

The strategy has been informed by a wide-ranging programme of engagement with patients, the public, service users, and staff working in and leading services linked to mental health and the voluntary sector.

There are many programmes of work underway nationally and locally that link to this strategy. Foremost amongst these is the drive for greater integration of care. We believe that we can move towards parity of esteem for mental health by making this strategy a central part of our approach to integrated care.

We have therefore set out our strategic aims under the three pillars of our vision for integrated care. Our aims include: aligning mental health much more with our established Integrated Neighbourhood Teams; connecting people with mental health problems back to advice and support in their communities as part of our approach to developing community resilience; new, more personalised, approaches to recovery and crisis care; a commitment to tackling the stigma and discrimination attached to mental health and a campaign to do this; and building local leadership in mental health through the establishment of a Strategic Board and Primary Care Clinical Champions.

We have set out an action plan for this as well as some of the measures to enable us to tell whether we are delivering the strategy.

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1. Introduction

1.1. Mental health is important at every stage of our lives. Almost everyone will have experienced a mental health problem or know someone who has.

1.2. Mental illness has a profound effect on many people. Not only because it is often more debilitating than physical illness but because people with mental health problems often find it harder to work, make connections, be involved in their communities, find good housing and sometimes experience stigma and discrimination.

1.3. Mental Health problems have a significant impact on wider society. It is estimated by the UK Faculty of Public Health that the economic and social costs of mental health problems in England are about £105 billion – taking into account costs for health and social care, loss of economic output and human costs.

1.4. We know that some basic things affect people’s mental health such as having a good job, feeling included and connected to their community, having a stable and safe place to live or not being in significant debt.

1.5. For many people in our Borough, mainly because we still have high levels of deprivation, some of these factors are absent. We therefore have a high number of people who are at risk of having poor mental wellbeing.

1.6. We also know that a significantly higher proportion of our population has a long-term condition than the England average (21.7% compared to 16.9%). Having a long-term condition increases the risk that an individual will have a mental health problem

1.7. We therefore need to have a clear strategy for improving mental health and well-being in our Borough. This document sets out our vision for mental health services over the next five years. It is a strategy for all adults over the age of 18. It is very important however, that it links closely with the emerging Child and Adolescent Mental Health Services (CAMHS) strategy. We know that many mental health problems are present before adulthood so a well-managed transition between child and adult services is essential.

1.8. OUR COMMITMENT is to achieve genuine parity of esteem for mental health in our Borough. We value mental health equally with physical health.

1.9. We believe that the best way of achieving parity of esteem for mental health is to ensure that mental health is an essential part of our overall approach to Integrated Care.

People with severe mental illnesses die on average 20 years earlier than the general population

1 in 4 people experience a mental health problem during their life.

DID YOU KNOW?

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1.10. Our Integrated Care strategy is built on three pillars. These are:

1.11. All three of these themes will underpin our approach to improving mental health in the Borough. Our approach to integration is to develop services that are built around the needs of patients and are delivered in a joined up way. We will put greater emphasis on intervening early and providing support at home and in the community. We will be innovative in the way we approach this – drawing on the great knowledge and skills available in the voluntary sector.

1.12. Our approach to mental health will align with our other major transformation programmes – including the Health & Well Being Strategy, the Primary Care Strategy, the CCG’s Five Year Commissioning Plan and the Council’s Transforming Adult Social Care and Health programme. It will also reflect the national picture as set out in strategies such as ‘No Health without Mental Health’ and ‘Closing the Gap’.

That health and social care services should support people to be well and independent and to take control of their own care.

That health and social care services should be provided at home, in the community or in primary care, unless there is a good reason why this should not be the case.

That all services in our Borough should be safe and of a high quality and part of an integrated and sustainable system led by primary care.

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2. What do we mean by Mental Health?

2.1. Mental health is an issue that is important to everyone. It includes our emotional,

psychological, and social well-being. It affects how we think, feel, and act. It also

helps to determine how we handle stress, relate to others, and make choices.

2.2. There are several ways of defining mental health, but we have used the version

below from the Mental Health Foundation as a good starting point:

2.3. Most people, including experts working in mental health services, describe different

types of mental health problems for adults in the following ways:

Common mental health problems: such as anxiety, depression, phobias and panic and the consequences of personality disorders (affecting people of all ages)

Severe and enduring mental health problems: including psychotic disorders (for example, schizophrenia and bipolar affective disorders affecting people of all ages) and personality disorders.

Organic dementia: including Alzheimer’s disease and vascular dementia. This

mostly affects people over the age of 75.

2.4. We also know that people with mental health problems often find it harder to work, make connections, be involved in their communities, find good housing and sometimes experience stigma and discrimination because they have a mental health problem.

2.5. The factors that affect mental wellbeing for everyone are also the things that people with mental health problems are at risk of being excluded from. This is illustrated below (figure 1).

Being mentally healthy doesn’t just mean that you don’t have a mental

health problem.

If you’re in good mental health, you can:

Make the most of your potential

Cope with life

Play a full part in your family, workplace, community and among friends

Some people call mental health ‘emotional health’ or ‘well-being’ and it’s just as important as good physical health.

Mental health is everyone’s business. We all have times when we feel down or stressed or frightened. Most of the time those feelings pass. But sometimes they develop into a more serious problem and that could happen to any one of us. Everyone is different. You may bounce back from a setback while someone else may feel weighed down by it for a long time.

Your mental health doesn’t always stay the same. It can change as circumstances change and as you move through different stages of your life.

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Figure 1. Factors that affect mental wellbeing:

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3. National and Local Context

3.1. National Context

3.1.1. The main national policy is called ‘No Health Without Mental Health’ and was written by the Department of Health, with other Government departments in 2011. This policy says that people should plan, commission and provide different kinds of support locally so they can demonstrate:

More people will have good mental health More people with mental health problems will recover More people with mental health problems will have good physical health More people will have a positive experience of care and support. Fewer people will suffer from avoidable harm Fewer people will experience stigma and discrimination.

3.1.2. The Government has also developed the concept of ‘parity of esteem’. This means that mental health should be treated as importantly as physical health by everyone who commissions and provides public services. This is described in the ‘Closing the Gap’ document (2014).

3.1.3. This strategy recognises the impact that mental health problems have on wider society. It was estimated by the UK Faculty of Public Health that the economic and social costs of mental health problems in England were £105.2 billion in 2009-10 – taking into account costs for health and social care, loss of economic output and human costs.

3.1.4. There are a number of other important national polices that we have taken into account in developing this mental health strategy:

There is a national drive for integrated care. This includes the Better Care Fund, which accelerates the pooling of budgets across health and social care. This provides us with a great opportunity to join up services in mental health around the needs of patients.

The Care Act came into effect in April 2015. This brings together many different parts of current policy. It includes a new national approach to eligibility for social care services, a new duty to promote wellbeing, the extension of eligibility criteria to include carers and changes to how people are assessed to pay for services. All of these things will have an impact on mental health services.

As part of ‘parity of esteem’ priorities and reflecting recent legal decisions, the Mental Capacity Act, deprivation of liberty and adult safeguarding are becoming ever more paramount.

In 2015 the Government will begin to introduce new national standards for waiting time limits for mental health services. One reason that this is particularly important is that it begins to bring mental health services to an equivalent standing to those for physical health – where national waiting standards have been in place for more than a decade.

3.2. Local Context

3.2.1. The amount of money that we have to spend on public services in Wigan is not going to increase at the same rate as it has done in the past. This means that the CCG and Council need to find different ways of commissioning services.

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3.2.2. Our response to this is set out in our strategic programme of work including our Integrated Care Strategy, the CCG’s Commissioning Plan, the Primary Care Strategy and the Adult Health and Social Care Modernisation Programme.

3.2.3. Our central aim is for people to be well and independent so that they do not require the intervention of services. We will support people to do this by connecting them to their communities, building the resilience of these communities, and enabling people to manage their own conditions.

3.2.4. When care is needed we want it to be provided in a multi-disciplinary way, led by primary care and to be delivered in people’s homes or communities – rather than in the most expensive parts of the system such as hospitals and nursing and residential care.

3.2.5. We know that at the moment we are commissioning and providing services that are not as joined up as they could be on an individual basis or across organisations. People are still working in their own organisations rather than as a whole system and from the person and their families’ point of view there are lots of barriers that get in the way. All of the major strategies will address this.

3.3. What People Have Told Us

3.3.1. In a series of ‘Shaping your NHS events’ led by the CCG in 2014, the top ten priorities for our health and care economy, identified by local people were:

3.3.2. All of these important priorities apply to mental health services and this strategy reflects this.

3.3.3. To develop this mental health strategy we have worked with people who use health and social care services including mental health services, carers, a range of people who provide primary, community, social and voluntary services, some people who mainly provide mental health services, other clinical staff and a range of public sector managers. We also carried out a survey on mental health of all the GP practices in the Borough.

I want to be able to get the help I need easily at any time, day or night. I want to be treated by professionals who care about me. I should only have to tell my story once. I need to be supported to stay independent. Doctors and professionals should be open and explain things in a way I

can understand I should be able to get an appointment with a doctor within a reasonable

amount of time. I want more education to help me manage my own care properly and

keep myself well. My family and/or carers should be listened to more. When I am discharged, I want the things I need to be ready for me. Mental health should be seen as being just as important as physical

health.

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3.3.4. People have told us we need to develop the following areas, and these have been categorised under the three main themes of our Integrated Care strategy.

Supporting people to be well and independent and take control of their

own care

An easy way to get information, advice and support in a timely way. This should be available for everyone to support mental wellbeing;

An easier way for people with mental health needs to access support and community resources;

More people leading their own care and support through personalised approaches, self-management, peer support and personal budgets/personal health budgets.

Providing Services at home, in the community or in primary care

Easier access to different kinds of psychological evidence-based therapies;

An easier way for people with mental health needs to access support and

community resources;

Integrated working with primary care that include a clear focus on supporting

people with mental health needs;

24 hour seven day a week crisis services based in the community;

Timely assessments for carers and access to information, advice and support.

Safe and high quality services as part of an integrated system led by

primary care

A more joined up approach for people with mental health needs.

Clear waiting times for different services;

A single care plan, that includes a crisis plan developed with the individual and

their family;

Individual plans for recovery using local resources and expert support;

An approach for everyone including older adults and people with dementia that

does not separate physical from mental health but works with the person and their

needs.

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3.4. Other Local Drivers

3.4.1. There are other important programmes of work happening locally that provide the context for this strategy:

People at the heart of Scholes

‘People at the heart of Scholes’ is an approach that has been championed in the area of Scholes in Wigan, but is being promoted as an approach for other parts of the borough. Particular streets or localities are supported to recognise the skills that people have locally and to look at the talents everybody has to make a contribution to the community.

Unemployment, homelessness and difficult issues

Wigan Council, including Public Health, is developing different ways to support people who might experience unemployment, homelessness or other difficult issues. We are working together to support people to have the healthiest lifestyle possible including stopping smoking, taking more exercise or eating differently. These are also some of the principles in the Wigan Deal, set out at the beginning of 2014;

Liaison psychiatry service / RAID

Since the beginning of 2014, a liaison psychiatry service has been fully operational within Wrightington, Wigan and Leigh NHS Foundation Trust, utilising the RAID (Rapid Assessment, Interface and Discharge) model. The service is a responsive 24/7 service for people suspected of having an underlying mental illness. This prevents crisis presentation that requires expensive health and social care packages of care.

Specialist services

Some specialist services for people with mental health needs are commissioned by NHS England. These are usually commissioned from a small number of providers – some of which are outside of this Borough. We want to ensure that only people who really need these services are being referred to them and that people can return to the local area as soon as possible;

Hospital and community care and support

Like all other parts of the health and social care system, the number of hospital beds that there are available for people with acute mental health problems has reduced. In Wigan, we have followed this trend, but we need to make sure that we have the right balance of community support for people and the right number and type of beds available locally when people need them

Care and support closer to home

We know that, compared to other areas, we have proportionately high number of acute beds for mental health. The aim of this strategy is to have a greater proportion of mental health care and support provided closer to people’s homes. However, we need to ensure, through joint working, that we do have enough beds in future for people who need them. An Options Appraisal has been developed locally for this.

Post natal and perinatal depression

We also need to recognise the impact of post natal and perinatal depression, anxiety and other mental health problems on mothers and fathers and the impact that this has on the developing foetus and child. We need a joined up approach across services for all ages to address these issues.

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Carers’ Strategy

Family carers, volunteers and friends make a major contribution to the way in which people in the area are supported. As part of the overarching Integrated Health and Care Strategy, a new Carers’ Strategy is being developed that will reflect the impact of caring for someone with a mental health need and how people with mental health needs are often informal or family carers in their own right.

Integrated Neighbourhood Teams

One of the major innovations in the Borough are the Integrated Neighbourhood Teams, based around primary care and working with people who are most at risk of being admitted into hospital. We are planning to extend and enhance the teams by increasing the number of different organisations involved and looking to focus more on prevention and early intervention for people.

Building Stronger Communities Partnership

The plans and services developed by the Building Stronger Communities Partnership are an important link to this overall mental health strategy. In particular, we need to think about intensive community orders, the joint domestic violence service and the mentally disordered offenders’ agenda. The wider Transforming Justice programmes may offer further opportunities to integrate a broader mental health agenda with the various points of the criminal justice system.

Safeguarding Safeguarding is also an important consideration. The Building Safer Communities Partnership and Adult Safeguarding Board have brought together key work areas over the last 18 months. Aligning the mental health strategy into these areas of work will identify further areas that will require integration.

Substance Misuse Substance Misuse – dual diagnosis of substance misuse and mental health is a significant issue as this impacts on an individual’s ability to recover in the longer term from mental health problems. We therefore need to recognise this within our plans.

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4. What do we know about Our Population & Mental Health?

4.1. In order to plan, we need to have an understanding of the population we serve. We have mainly used information from the from Office of National Statistics (ONS) projections and Wigan’s Mental Health Joint Strategic Needs Assessment (2012). The details of this can be found in Appendix 1, but from the information we have, we can conclude that:

The number of people who are at risk of having poor mental wellbeing in Wigan is high because we still have high levels of deprivation;

We have a high number of people who have alcohol and drug problems in the area, which has a significant link to mental health problems;

We have a high number of people admitted to hospital for some mental health conditions. These are the same conditions where we are not identifying as many people as we would have expected;

People with severe mental health needs also have a number of other long term conditions and are at risk of dying early because of them;

The number of people with severe and enduring mental health needs is likely to increase;

The population of Wigan will increase, with more people living over the age of 75. We know that the number of people with a diagnosis of dementia will also increase.

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5. Our Strategy for Mental Health – The Next Five Years

5.1. Introduction to our Strategy

5.1.1. This section describes our strategy for mental health. In identifying what to plan for we have used:

The information we have collected about the population of Wigan and current

services;

What people have told us they think the plan should include and we have been

testing out ideas as we have developed it;

National and local plans and policies.

5.1.2. We also know we need to understand how much money we spend on mental health between the CCG and Wigan Council and where we spend it. Appendix 2 sets out the current spend on mental health. We recognise that, to deliver this strategy, we may need to increase the proportion of our overall budgets that we spend on mental health. At the same time we may need to also think about how we allocate our spend within mental health, gearing this more to prevention and early intervention.

5.2. Assessing Where We Are Now

5.2.1. In 2014 the Department of Health made clear that not enough progress was being made in mental health. They published ‘Closing the Gap’ in February. This set out clear actions that were going to be taken at a national level to help make ‘No health without Mental Health’ happen. We have taken those actions and looked at where Wigan is at the moment and there are many opportunities to improve.

5.2.2. The table below reflects the feedback from senior leaders across the system in interviews to inform this strategy. Individual organisations may be able to score themselves with more green than red or amber, but we have taken a ‘whole system’ approach. We have also identified the actions, through this strategy, to close the gap (there are more details on these actions below).

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5.3 Closing the Gap - Where is Wigan Now?

Priority

Green = a lot of progress

has been made

Amber = starting to make progress

Red = little or no progress

Action to Close Gap

High quality services commissioned in an integrated way.

This strategy starts that process, pockets in other places.

Strategy makes clear that Mental Health is part of integrated system

Information/ dashboards linked to outcomes. Not yet on a joint basis.

Set of local mental health metrics to be developed – part of Wigan Integrated Care Dashboard

Access and waiting times clearly defined for different parts of the service.

The strategy will start this process.

Local implementation of new national mental health waiting time standards – 2015/16 onwards

Specific services for different populations. Some good pockets but not integrated.

Use of risk stratification tools to target populations

Increasing access psychological therapies via primary care

The strategy builds on the current provision.

Link IAPT teams to Integrated Neighbourhood Teams

Commissioning for outcomes through clusters.

Clusters are starting to be used but not linked to outcomes across providers

Move towards outcome-based contracts

Increasing choice and personal budgets. Not yet for most.

Wigan Integrated Care Strategy & Better Care Fund set out plans to expand personal budgets – mental health to be included in this

Agreed quality measures. Not yet across the system

Set of local mental health metrics to be developed – part of Wigan Integrated Care Dashboard

Focus on and evidencing carer involvement. Some pockets.

Strategy makes a commitment to developing a joint approach to working with carers of people with mental health needs

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Priority

Green = a lot of progress

has been made

Amber = starting to make progress

Red = little or no progress

Action to Close Gap

Better integration across every level across physical and mental health.

Not yet Strategy makes clear that Mental Health is part of integrated system

A different response to self-harm (a comprehensive assessment).

Developing

System wide approach to implement NICE guidelines and deliver Public Health Outcomes Framework indicators

No one turned away in a crisis (backed up by a new agreement across Government agencies).

In some parts. Local Implementation of GM Crisis Concordat

Promoting Health and Wellbeing as early as possible.

Developing Strategy recognises importance of promoting well-being and its impact on mental health

Improving the quality of life for people with mental health problems.

Pockets A number of initiatives in the strategy support greater parity of esteem

Increasing accommodation that supports recovery.

Not at the moment

Strategy provides commitment to develop housing and support for people with mental health problems

Liaison services and diverting people from the criminal system as a priority.

Not connected well into wider mental health system

RAID model in place and plans to expand

Increasing and promoting work opportunities for people with mental health needs.

Little evidence.

Strategy makes commitment to support people with mental health problems in employment

5.3. There are many local examples of excellent practice in mental health services. However, it is clear, from the analysis above and the demographic information we describe, that we do have some way to go before we can say that we have delivered true parity of esteem for mental health. Below we describe the actions we are going to take to address this.

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5.4. The Strategy

5.4.1. We want to see a radical change in the way that people with mental health problems are supported: a model of care for the Borough that supports people at any stage in their mental illness at any place and at any time.

5.4.2. We want to give much greater emphasis to the interventions which limit, reduce or remove factors that lead to poor mental health. We will move towards an agreed single care plan and an agreed care planner who will help people to access any part of the service when they need to. The work of the existing Integrated Neighbourhood Teams will support this.

5.4.3. We have used the triangle of care to describe how services can be organised to support people. The triangle below provides a summary of the different levels or mental health care and who is the lead-commissioner for each of them. This will help us in organising how commissioners and providers respond to the challenges in this strategy.

5.4.4. We can then start to describe the kind of support and care services that might be in place for people and their families at each tier of the triangle. What is important is that people might move between the different parts of the triangle at different times.

5.4.5. We have developed our new strategy around the three central themes in our Integrated Care Strategy. We believe that by mental health part of our approach to integrated care will be an important step towards parity of esteem.

LA (Public Health/CCG)

CCG/LA

CCG/NHS England

Public Health (LA) I’m OK

I need help now

Help

I need some help

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PILLAR 1: Health and social care services should support people to be well

and independent and to take control of their own care

1. Advice & Support

1.1. We will develop a new way of supporting people with mental health problems to get access to information, advice and support – and we see this as being done principally through primary care, including via the community connector roles that we are developing and the Integrated Neighbourhood Teams. The main types of advice and support will be:

Practical: to include debt management, fuel poverty, homelessness support, access to safe and settled accommodation, and employment support, building on the employment and skills hub being developed.

Social: to include community learning, community connections, peer support and volunteering in order to reduce loneliness and social isolation and promote health and wellbeing.

Physical Wellbeing; to include exercise, diet and weight control and ‘lifestyle services’

1.2. These services are important promoting positive mental health and wellbeing and can help to prevent people being excluded. They are the tier one (I am ok) services of our triangle of care. This work will align with the current work being undertaken by the CCG and Wigan Council on linking people to their communities and providing advice and support.

2. Peer Support & Co Production

2.1. There is potential for us to see people with mental health needs and their carers as part of the workforce in our area. Many people are often the experts in their own care.

2.2. Peer support is where people connect to other people who have had the same experiences, which can be important in helping to feel connected and included. As part of our approach to supporting recovery we will want to develop more peer support opportunities, shared decision making and self-management.

2.3. Co-production means actively involving people in how they want their support to be developed as individuals and involving people who have experience and ideas about services in new developments and ideas from the beginning. We will ensure that people with mental illness are involved in a collaborative effort to develop their care plans with professionals. Supporting this will be the important role that mental health advocacy plays.

3. Personal Budgets

3.1. We know a small number of people in Wigan currently have a personal budget if they have a mental health need. We will review together the current system that we have in place, involving experts by experience and carers to understand if they are helpful in supporting people to access these budgets and aim for a year on year increase from April 2015. We are particularly interested in how we can support people to have joint (health and social care) personal budgets.

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PILLAR 1: Health and social care services should support people to be well

and independent and to take control of their own care

4. Carers

4.1. We know we need to keep reviewing how assessment of carer needs and access to appropriate respite is working for carers. We are going to develop a joint approach to working with carers of people with mental health needs as part of implementing this mental health strategy. This will link to the overall Carers’ Strategy that is being developed for the Borough.

5. Tackling Stigma

5.1. We will adopt a ‘no one should experience stigma and discrimination because of mental ill health’ principle in the area rather than ‘fewer people will’. It will also be important for the NHS and Wigan Council, as major employers in the area, to take a lead role in this By April 2015 we will have a coordinated reducing stigma strategy across the borough. It will include using different media, communication and educational approaches and adopting a positive approach to mental health issues. We will also require all organisations that provide health and social care services to sign up for the Time to Change campaign to end mental health discrimination.

5.2. All services, including the IAPT programme, may need to do more to provide tailored approaches in order to improve access for certain groups in our community who are at risk of exclusion.

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PILLAR 2: Health and social care services should be provided at home, in

the community or in primary care, unless there is a good reason why this

should not be the case

1. Recovery

1.1. We know through all the evidence that has been used to develop ‘No Health Without Mental Health’ that there is no one way of ‘delivering’ recovery; every individual will have different ideas about what recovery means for them.

1.2. For some people, recovery will not mean ‘getting back to normal’ but will mean having contact with people who understand the impact that an enduring mental health need can have, and also can connect with the talents that someone has.

1.3. Our new approach to commissioning recovery will not be to commission a ‘recovery service’ but to focus on ensuring that people can be connected back to their communities. This could be via the community connector roles that are currently being developed and the Integrated Neighbourhood Teams. These roles will work closely with the care-coordinator that most people in secondary mental health services will already have through the Care Programme Approach.

1.4. We will build up ‘recovery hubs’ in localities that reflect the different kinds of populations we support. The recovery hubs will change and develop over time and may include different things in each locality. There are examples of this from elsewhere, including in Lambeth where a collaborative has been established working across the community to support people suffering from mental distress http://lambethcollaborative.org.uk/.This approach has peer support at its heart.

1.5. Some examples of what might be available in a hub are:

1. Expert help and support to think about returning to work and different ways of meeting a personal goal;

2. Access to other people who have had similar experiences and share similar interests;

3. Information and easy to use systems for personal budgets and personal health budgets which we will want to link together for people with enduring mental health needs;

4. Carer support systems;

5. Access to counselling and support about specific issues;

6. Information and support about housing;

7. Dementia Friendly Community information

1.6. The diagram below illustrates that the Recovery Hub will be developed around the needs of individuals.

http://lambethcollaborative.org.uk/

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2. Assessment & Care Planning

2.1. We want to ensure that people and their carers will no longer have to be referred into different parts of the service or have lots of different assessments. This approach may also mean that over time we have other areas of care for older people, including intermediate care or acute inpatient beds, that are not separated into mental and physical health. We will start to review this as part of the implementation of this strategy.

3. Housing

3.1. We will develop more housing and support specifically for people with mental health needs as we know that a lack of housing and support is having an impact on individuals’ rehabilitation and recovery at the moment; some people have to stay in hospital longer than they need or want to. We will work with housing and support partners and move towards a model that is focused on rehabilitation always being provided in the least restrictive environment as appropriate to the circumstances of the individual.

3.2. This will need to include some housing and support options that provide 24-hour support for people. As part of increasing the number of people who use a personal budget or integrated health budgets we will work to support people to be able to commission support in their own home or with other people in similar circumstances. We will have developed a new model for residential rehabilitation, ranging from 24 hour housing and support to floating support by the end of 2015/16 using a range of housing and support budgets. These services fit into tiers two and three of the triangle of care.

4. Employment

4.1. Supporting people with mental health problems to remain in, or to enter employment, is important to supporting them to remain well and independent. It is also important to note that a high proportion of Wigan’s working age population are employed in Small and Medium sized Enterprises (SMEs), which often do not have access to occupational health support to assist with returning to, or maintaining employment with a mental health problem.

4.2. We are committed to supporting people to remain in employment through improving access to health and care services when they are absent from work and this will include rapid access to counselling services. We will also use the advice and support available in communities to help people with mental health problems enter employment. The voluntary sector will have an important role here. There are some examples of innovative practice from elsewhere that we will explore – for instance, in Sussex there is an initiative on joint working between IAPT and Job Centre Plus.

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5. Crisis Care

5.1. Locally, we know that there are a lot of people using acute mental health beds. The pressure on these beds arises from a number of sources. For example, people are sometimes arriving at the acute hospital in mental health crisis and the police are often called on to respond to people in crisis. We know through the work of the Building Stronger Communities Partnership that we do not currently have shared agreement about what a crisis is and different agencies and professional see ‘crisis’ in a different way.

5.2. There is a lack of alternatives to hospital admission, such as crisis houses for people, to use in the area as part of a joined up crisis system. There are also a number of different examples around the country where organisations, including experts by experience, provide a safe and supportive space at different times of the day and night as part of the local joined up response. Linked to this, it will be very important to engage the police in this work. In London, for example, commissioners, working with the police, have set a target of dramatically reducing the number of people who end up in a police cell following a mental health crisis. This is to be classified as a ‘Never Event’ in London to support this change.

5.3. By December 2014, each area in England is required to develop its own local Crisis Concordat. This will be built into our delivery plan for this strategy. We are working with other local areas to develop a Greater Manchester wide Crisis Concordat.

5.4. Once the Greater Manchester Concordat is agreed we will put robust arrangements in place for local audit of this and will also consider whether further improvements can be made to local arrangements. We will build on local innovative practice, such as the Sanctuary in Leigh, to expand these alternatives.

6. Self-Harm

6.1. As noted in the demographic analysis earlier in this document, self-harm is a major issue facing us. We will ensure a system-wide response to this, as recommended in the ‘Closing the Gap’ document, and that we meet the relevant NICE standards.

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PILLAR 3: All services in our Borough should be safe and of a high quality

and part of an integrated and sustainable system led by primary care

1. Integrated Neighbourhood Teams

1.1. The Integrated Neighbourhood Teams, established in 2013, are at the centre of our integrated care plans. We need to make sure that this system is inclusive of people with mental health needs, including dementia.

1.2. We will adopt a tailored approach to this that incorporates, for example, people within IAPT services, and those under the Care Programme Approach (this is national approach that states that people with severe mental health problems should have a specific care-coordinator and care plan). The approach will be different depending on the severity of the person’s mental illness, but the aims will be the same: to ensure early intervention; co-ordination of service responses; and to connect people back to the support available in their communities, including self-management support.

1.3. By April 2015 we will have reviewed an approach called risk stratification which identifies people to be referred to the Integrated Neighbourhood Teams and ensure that we have data from services linked to mental health within the system.

2. Out of Area Placements

2.1. We commission some out of area services for people with more severe mental health conditions who challenge local services.. By the end of 2016/17 we will have moved to a position where we have expert and dedicated services for people that provide 24 hour care and support working as part of a joined up service that might be provided by different providers. These services fit into tiers 3 and 4 of the triangle of care.

3. Dementia

3.1. We have begun mapping the current services available for people with dementia and their families and thinking about new ways of supporting people into the future. This includes offering more people access to diagnosis, local community based services and developing the skills and assets of the wider community and people who might be involved in caring for someone with dementia. There are already some examples of local innovation, such as the weekly dementia café in Leigh, and we will build on these to deliver this strategy.

4. Drug & Alcohol Services

4.1. We have already made changes in the way drug and alcohol services for adults are commissioned and delivered. It is important that commissioners and providers of these services are involved in the delivery of this mental health strategy. We will build on the work that the Drug & Alcohol services are already doing with the Integrated Neighbourhood Teams and ensure that we have a co-ordinated approach to supporting people with mental health problems related to drugs and alcohol.

5. Primary Care

5.1. GPs of the future will need to become leaders in mental health care. This will not mean they need to become mental health specialists, but it does mean that they will need to know as much about mental health as they do about physical health. This will support the move towards parity of esteem.

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5.2. We know that around a third of GP consultations involve a mental health issue. Working with Health Education England, we will support primary care to have access to a wide range of opportunities to increase understanding of mental health and mental health issues linking into accredited training where possible.

5.3. Within each of the CCG’s commissioning localities we want to identify a ‘mental health champion’ to be one of the system leaders to help implement this plan. The primary care clinical champions will link into one of the members of the CCG governing body taking a particular interest in mental health.

5.4. As part of the changes this plan sets out, we would want to see primary and secondary services becoming more integrated and the skills of people with clinical and professional training in mental health part of a co-ordinated approach. The plan will move more IAPT and counselling approaches into primary care, expert mental health skills into the integrated teams and crisis and recovery services working within agreed localities.

6. Waiting Standards

6.1. The Government has set out that, from 2015/16, access and waiting time standards will be introduced for mental health services. We will ensure that we deliver on these standards at a local level.

7. Strategic Board

7.1. We will start our new approach to commissioning mental health services together by establishing a Strategic Board. The Board will take a broad strategic view of mental health in the Borough, bringing together a range of agencies. It will be part of the system we have put in place to support integration, reporting to the Health and Wellbeing Board. It will also align with existing contract and quality meetings with mental health providers. There will be representation from patients and the public, as well as the voluntary sector. Wigan Borough CCG will be responsible for the organisation and development of the board and the work programme.

7.2. The Board’s membership will ensure alignment with a number of work areas so that we have a joined up approach to mental health. These will include:

The Integrated Care Strategy;

The Child and Adolescent Mental Health Services (CAMHS) Strategy;

The Building Safer Communities Partnership;

Learning Disabilities;

Drugs & Alcohol;

Safeguarding;

The Primary Care Strategy;

Healthwatch

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7.3. Under the Strategic Board, we will continue to build up our joint understanding of how we use the resources we have in both organisations including money spent out of area and in care homes and share this information with each other (called an aligned budget model).

8. New Contract Models

8.1. Through developing this mental health strategy, it has become clear that we need to work together to understand more about how we could use new contracting mechanisms to support the changes we want to make.

8.2. One of the real opportunities we have identified in developing this plan is the potential to use mental health clusters and new contracting models into the future. Once the new mental health board is established we will make this a priority for development.

9. Workforce

9.1. Local staff will drive the quality of local services and we will need to consider how we invest in a workforce that will work in a more integrated way – in particular, recognising the links between mental and physical health.

9.2. We know that as we move forward with this plan, staff working in these services will need to be able to work with one assessment and one team rather than lots of assessments by many different staff in different teams. We will be working with providers to ensure people get a co-ordinated service and this will mean a different way of thinking about what the ‘team’ is.

10. Technology

10.1. Our overarching Integrated Health and Care plan says that IT systems that allow information to be shared across organisations are essential to the delivery of our plans. We have begun to make progress in this area, for instance through the introduction of the Medical Inter-operability Gateway (MIG). This is a system which allows for the sharing of secure data between health systems. We intend to take this further so that people are genuinely in control of their own care records. We will ensure that any specific issues relating to mental health services are included in the development of this approach. We will also make sure that local plans being developed around telehealth include mental health.

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6. Next Steps

6.1. Action Plan

6.1.1. In developing the mental health strategy we have already started to understand some of the important first steps and where we still have a lot of work to do. We know that our plan will adapt and change over time but we have set out some dates in the plan to act as milestones. Our action plan is set out in the table on pg 27.

6.2. How will we know we are delivering these changes?

6.2.1. In developing this plan we have started to think about some important things we would want to understand locally to measure how successful we are being in delivering this strategy. We will develop a local outcomes framework for this purpose. This will build on existing frameworks such as the NHS Outcomes Framework, the Adult Social Care Outcomes Framework and the Public Health Outcomes Framework.

6.2.2. Some of the outcome measures could include:

a) People and families moving from child and adolescent mental health services into adult services in a planned way.

b) An increase in the number of people of all ages who have a personal health budget, personal budget or direct payment who are known to secondary mental health services.

c) A reduction in the number of people placed out of area that have long term mental health problems including people who challenge services.

d) The percentage of people known to services who have a care plan written in a language that makes sense to them.

e) A reduction in the number of people who are waiting to move on from the crisis service including acute beds following agreement that the person would no longer benefit from crisis support.

f) An increase in the range of housing and support available for people with mental health needs including 24-hour support.

g) A reduction in the number of professional assessments someone receives prior to support and care being offered.

h) A year on year increase of people with identified mental health needs being supported through the integrated team model.

6.2.3. As part of working together to deliver this mental health strategy we will involve people who have expertise and experience in helping us. We will continue our active engagement as we implement the strategy. As well as people working in current services, we will develop a single way of involving people and their families in helping to continue to shape the strategy and be included in the local leadership approach.

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Summary of Actions in the Strategy

STRATEGY AIM

INITIATVE DELIVERY YEAR

SU

PP

OR

TIN

G P

EO

PL

E T

O B

E

WE

LL

AN

D I

ND

EP

EN

DE

NT

Develop a new way of supporting people with mental health problems to get access to information, advice and support

Q4 2014/15

Develop peer support, co-production and self-management opportunities

2015/16

Increase the number of people with mental health problems who have a personal budget

2015/16

Ensure that the new Carers Strategy is implemented in a way that supports carers of people with mental health problems

2015/16

Put in place a ‘no stigma’ campaign and require all providers and commissioners of mental health services to sign up to the ‘Time to Change’ campaign

Q1 2015/16

CA

RE

TO

BE

PR

OV

IDE

D

AT

HO

ME

OR

IN

TH

E

CO

MM

UN

ITY

Develop a new approach for Recovery 2015/16

Move towards having one assessment and care plan for people with mental health problems

2016/17

Implement a new model for residential rehabilitation 2016/17

Put in place a co-ordinated plan for people with mental health conditions to enter and remain in employment

2015/16

Implement the Greater Manchester Crisis Care Concordat and then develop local arrangements to audit and enhance this

Q3 2014/15

Ensure a system-wide response to self-harm that meets NICE standards

2015/16

CA

RE

TO

BE

PA

RT

OF

AN

IN

TE

GR

AT

ED

SY

ST

EM

Align our approach to mental health (including IAPT and the CPA) to the work of the Integrated Neighbourhood Teams in primary care

Q1 2015/16

Review the risk stratification tool to ensure that it can better identify those with mental health problems and the impact that mental health has on a range of services

Q4 2014/15

To reduce out of area placements - implement expert and dedicated services for people that provide 24 hour care and support as part of a joined up service

2015/16

Enhance community-based care for dementia patients 2015/16

Offer training in primary care mental health to local GPs 2015/16

Create a new GP Clinical Champion role for each of the CCG’s six commissioning localities

Q4 2014/15

Implement, at a local level, the new national waiting standards for mental health

Q1 2014/15

Establish a new Mental Health Strategic Board – with links to a range of strategic areas across the economy

Q4 2014/15

Carry out a mapping exercise of all current mental health spend in Wigan Borough

Q4 2014/15

Implement new contracting models for mental health 2016/17

Ensure mental health features prominently in workforce plans for integrated care

2015/16

Ensure mental health is incorporated in economy-wide strategies for IT and technology

2015/16

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Appendices Appendix 1: Key Information about Our Population and Mental Health

Appendix 2: The Current Financial Picture

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Appendix 1: Key Information about Our Population and Mental

Health

Population & Demography

Wigan Borough has a projected population of 324,012 people for 2014/19.

255,815 are aged 18+. This is expected to grow by 3.1% in the next 5 years.

Wigan’s population is older than the national average with a higher percentage of people aged 65-74. This is significant because of the forecast increase prevalence of dementia.

In the next 5 years, we expect to have 23.3% more people aged 75+.

In the next 5 years, the number of working age adults will grow less than 1% and there will be a reduction in the percentage of 16-17 year olds.

Wigan Borough is 95.5% English/Welsh/Scottish/Northern Irish/British. This is higher than the England average of 80%. However, we know that the number of people from different ethnic groups is increasing and we need consider how we respond to people from different communities in the future.

Deprivation

It is estimated that 30.3% of adults in Wigan live in areas that are classified as being in the ‘most deprived’ group (Index of Multiple Deprivation 2010). This is significantly higher than the England average of 20.3%.

We estimate that over 75,000 adults live in areas classified as in the top 20% most deprived in the country

Employment

Figures from 2010/11 suggest that the unemployment rate for working age adults in Wigan, 55.4 people unemployed per 1,000, is better than the England average of 59.4 per 1,000.

Wigan has a higher rate than the North West and England average for the number of people claiming out of work benefits – and one of the main reasons for claiming such benefits is a mental health condition.

Nationally, the Centre for Mental Health estimates that only 10% of people using mental health services are in employment; around half of those using services say that they would like to work.

The Health of our Population

In 2011/12, the rate of hospital admissions for alcohol-attributed conditions in Wigan was 33.5 incidences per 1000 - significantly higher than the England average of 23.0 per 1000.

21.7% of the Wigan population are living with a Life Limiting Illness compared with the England average of 16.9% (data from 2001). There is a clear link between long term conditions and mental health: at least 46% of people with a mental health illness have a long term condition.

The number of people aged 18-75 in Wigan in drug treatment was estimated at 6.1 people per 1,000 (2011/12). This is higher than the England rate of 5.2.

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Mental Health Need

There are different ways of estimating how many people have a mental health need at a given time. This is called prevalence.

We have estimated the need by applying the figures from the adult psychiatric morbidity study to what the figures from the Office for National Statistics say will be happening for the population of Wigan.

For people in England the prevalence of common mental health problems or common mental disorder (CMD) is estimated to be 16.2% and the most common form was mixed anxiety and depressive disorder with a prevalence of 9.0%.

At the North West rates, it is estimated that, in a given week, 43,594 people in Wigan experience clinically significant symptoms (symptoms) of a CMD, 18,985 males and 26,408 females. By 2019/20, due to demographic change, the number of people experiencing symptoms is anticipated to increase by 1,132.

Based on data from the period 2009/10 to 2011/12, the CMH Profile shows rates of hospital admission for mental health conditions in general, and depressive disorders and Alzheimer’s disease in particular, significantly exceed the England average in Wigan.

We also know that people with severe and enduring mental health needs have a life expectancy that can be up to 20 years lower than other people. In Wigan in 2009/10, 67% of a sample of people who had been to hospital with a mental health problem had one or more long-term condition including diabetes and circulation and heart problems.

We know that people with mental health problems are still more likely to smoke and in Wigan in 2009/10 over 11% of people who were admitted to hospital with some sort of breathing or respiratory problem had a diagnosed mental health problem, which is higher than you would expect as a proportion of the population.

Severe & Enduring Mental Health Problems

In terms of severe and enduring mental health problems, we are including here people who have a diagnosis of psychosis, antisocial personality disorders (ASPD) and borderline personality disorders (BPD). Based on the national figures 1,024 people in Wigan are expected to have psychosis, 884 people have ASPD and 1,154 people have BPD, a total of 3,062.

In addition, assuming that the percentage of people with psychosis not receiving treatment is the same as the England average, an estimated 359 people Wigan, in 2014/15, have psychosis and are not receiving treatment for their condition.

Dementia

Based on prevalence data from Dementia UK (2007), the NHS England Dementia Prevalence Calculator estimates the prevalence of dementia in in Wigan Borough to be 1.06%. This estimate is lower than the national average, 1.08%, in the same period.

Assuming the prevalence of dementia in Wigan has not changed since 2007, in 2014/15 an estimated 3,443 people will be living with dementia. This number is expected to grow to 3,540 by 2019/20.

Depression

The prevalence of diagnosed depression among adults, reported in the Wigan 2013 CMH Profile is 10.4%. If you apply this prevalence estimate to the 2014/15 adult population, this gives an estimated total of people with depression as 26,565.

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Self-Harm

Based on data from, 2011/12, the CMH Profile indicates that Wigan has significantly higher rate of hospitalisation for self-harm, 328 incidences per 100,000 than observed nationally (207 per 100,000).

What does this tell us?

Overall, we can say that the number of people who are at risk of having poor mental wellbeing in Wigan is high because we still have high levels of deprivation:

We have a high number of people who have alcohol and drug problems in the area, which has a significant link to mental health problems.

We have a high number of people admitted to hospital for some mental health conditions. These are the same conditions where we are not identifying as many people as we would have expected.

People with severe mental health needs also have a number of other long term conditions and are at risk of dying early because of them.

The number of people with severe and enduring mental health needs is likely to increase.

The population of Wigan will increase, with more people living over the age of 75. We

know that the number of people with a diagnosis of dementia will also increase

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Appendix 2: The Current Financial Picture

We know that if you join up the money we use to commission mental health services we spend over £45 million, including the cost of primary care prescribing, which is nearly £5 million. We still have work to do to build up a complete picture of the current mental health spend including continuing healthcare and public health and this is an early action in this strategy.

The graph below shows the current spend by organisation and spend area:

Wigan Borough CCG and Wigan Council indicative spend on Mental Health 2013/14

Note: this does not include the cost of staffing employed by the council or CCG and other detailed costs.

It is difficult to make any real comparisons at the moment with other parts of the country as the information available is not as comprehensive as for secondary care. However, we will explore how we can do this as part of the implementation of this strategy. Investing in early intervention in mental health can provide real benefits across the economy. For instance, research by the Centre for Mental Health found that for every £1 spent on early intervention in psychosis there is a saving of £15 to the economy as a whole (about £7 of this benefit is to health services).