public meeting of the board of directors …...public meeting of the board of directors will be held...

PUBLIC MEETING OF THE BOARD OF DIRECTORSwill be held at time 9:30 am on Thursday 29 March 2018

in the Cypress Room, Bridge Community Church, Rider Street, Leeds, LS9 7BQ___________________________________________________________________

A G E N D A

Members of the public are welcome to attend the Board meeting, which is a meeting inpublic not a public meeting. If there are any questions from members of the public

please could they advise the Chair or the Head of Corporate Governance in advance ofthe meeting (contact details are at the end of the agenda).

LEAD

1 Sharing stories – Perinatal Service: Positive Steps Partnership

2 Apologies for absence (verbal) SP

3 Declaration of interests for directors and any declared conflicts of interestin respect of agenda items (enclosure)

SP

4 Minutes of the previous meeting held on 22 February 2018 (enclosure) SP

5 Matters arising (verbal) SP

6 Actions outstanding from the public meetings of the Board of Directors(enclosure)

SP

7 Chief Executive report (enclosure) DH

PATIENT CENTRED CARE

8 Chief Operating Officer Report (enclosure) JFA

8.1 Combined Quality and Performance Report (enclosure) JFA

9 Director of Nursing report (enclosure) CW

9.1 Safer Staffing February 2018 (enclosure) CW

9.2 Progress report in relation to the application of the Smoke-freePolicy (enclosure)

CW

10 Medical Director’s quarterly report - information on the work of theContinuous Service Improvement Team (enclosure)

CK

11 Mortality Review: Learning from Deaths – Mortality Data Quarter 3 (1October – 31 December) 2017 (enclosure)

CK

WORKFORCE

12 Workforce and Organisational Development Report (enclosure) ST

USE OF RESOURCES

13 Report from the Chief Financial Officer – February 2018 (enclosure) DH

14 Assurances on the General Data Protection Regulation (GDPR) (enclosure) DH

15 Approval of the Standing Financial Instructions (enclosure) DH

GOVERNANCE

16 IG Toolkit – Board approval prior to submission (enclosure) DH

17 Approval of the Terms of Reference for the Strategic InvestmentCommittee (enclosure)

SP

18 Approval of the Terms of Reference for the Mental Health legislationCommittee (enclosure)

SW

19 Glossary (enclosed for information)

20 Chair to resolve that members of the public be excluded from the meetinghaving regard to the confidential nature of the business transacted,publicity on which would be prejudicial to the public interest

SP

The next public meeting will be held on Thursday 26 April 2018 inTraining Room 3, Becklin Centre, Alma St, Leeds, LS9 7BE

Questions for the Board can be submitted to:

Name: Cath Hill (Head of Corporate Governance / Trust Board Secretary)Email: [email protected]: 0113 8555930

Name: Prof Sue Proctor (Chair of the Trust)Email: [email protected]: 0113 8555913

1

Annual Declaration of Interests for members of the Board of Directors

(Declared for the year 2017/18)

Name

Directorships,including Non-executiveDirectorships, held inprivate companies orPLCs (with theexception of those ofdormant companies).

Ownership, or part-ownership, of privatecompanies, businessesor consultancies likelyor possibly seeking todo business with theNHS.

Majority or controllingshareholdings inorganisations likely orpossibly seeking to dobusiness with the NHS.

A position of authorityin a charity or voluntaryorganisation in the fieldof health and socialcare.

Any connection with avoluntary or otherorganisationcontracting for NHSservices.

Any substantial orinfluential connectionwith an organisation,entity or companyconsidering enteringinto or having enteredinto a financialarrangement with theTrust, including but notlimited to lenders orbanks.

Any other commercial orother interests you wish todeclare.This should include politicalor ministerial appointments(where this is information isalready in the public domain– this does not includepersonal or privateinformation such asmembership of politicalparties or votingpreferences)

Declarations made in respect ofspouse or co-habiting partner

EXECUTIVE DIRECTORS

Sara MunroChief Executive

None. None. None. None. None. None. None. None.

Dawn HanwellChief FinancialOfficer and DeputyInterim ChiefExecutive

None. None. None. None. None. None. None. PartnerDirector / owner ofWhinmoor Marketing Ltd.

Clare KenwoodMedical Director


Cathy WoffendinDirector of Nursingand Professions


Joanna ForsterAdamsChief OperatingOffice


Susan TylerDirector ofWorkforceDevelopment


AGENDAITEM

3

2

Name

Directorships, includingNon-executiveDirectorships, held inprivate companies or PLCs(with the exception ofthose of dormantcompanies).

Ownership, or part-ownership, of privatecompanies,businesses orconsultancies likely orpossibly seeking to dobusiness with theNHS.


A position of authorityin a charity orvoluntary organisationin the field of healthand social care.


Any substantial orinfluential connectionwith an organisation,entity or companyconsidering entering intoor having entered into afinancial arrangementwith the Trust, includingbut not limited to lendersor banks.

Any other commercial orother interests you wish todeclare.This should includepolitical or ministerialappointments (where this isinformation is already in thepublic domain – this doesnot include personal orprivate information such asmembership of politicalparties or votingpreferences)


NON-EXECUTIVE DIRECTORS

Susan ProctorNon-executiveDirector

DirectorSR Proctor ConsultingLtdIndependentcompany offeringconsultancy onspecific projectsrelating to complexand strategic mattersworking with Boardsand senior teams inhealth and faithsectors. Investigationsinto current andhistoricalsafeguarding matters.

None. None. None. AssociateCapsticksLaw firm.

None. MemberLord Chancellor’sAdvisory Committeefor North and WestYorkshire

ChairSafeguarding Group,Diocese of York

MemberVeterinary NurseCouncil (RCUS)

PartnerEmployeeCapitaFinance company.

John BakerNon-executiveDirector

None. None. None. None. None. ProfessorUniversity of Leeds

None. PartnerCBT TherapistPennine Care NHS Trust

Helen GranthamNon-executiveDirector

Director,Entwyne Ltd

DirectorEntwyne Ltd.

DirectorEntwyne Ltd

None Consultant forMHR and PennaPLC

None None PartnerDirector of Entwyne Ltdand Employee of LeedsBecketts University

3

Name









MargaretSentamuNon-executiveDirector

Non-executiveDirectorTraidcraft PLCFights povertythrough trade,practising andpromotingapproaches to tradethat help poor peoplein developingcountries transformtheir lives.

None. None. PresidentMildmayInternationalPioneering HIVcharity deliveringquality care andtreatment,prevention work,rehabilitation,training andeducation, andhealthstrengthening inthe UK and EastAfrica.

None. None. None. None.

Susan WhiteNon-executiveDirector


4

Name









Steven Wrigley-HoweNon-executiveDirector

Non-executivedirector- The RehabGroupAn independentinternational group ofcharities andcommercialcompanies whichprovides training,employment, healthand social care, andcommercial servicesfor over 80,000people each year inIreland, England,Wales, Scotland andPoland.

None. None. Non-executivedirector- TheRehab GroupAn independentinternational groupof charities andcommercialcompanies whichprovides training,employment,health and socialcare, andcommercialservices for over80,000 peopleeach year inIreland, England,Wales, Scotlandand Poland.

Non-executivedirector- TheRehab GroupAn independentinternational groupof charities andcommercialcompanies whichprovides training,employment,health and socialcare, andcommercialservices for over80,000 peopleeach year inIreland, England,Wales, Scotlandand Poland.

None.

.

None. PartnerDentist Hunmanby DentalPractice.

Martin WrightNon-executiveDirector


5

Declarations pertaining to directors being a Fit and Proper Person under the CQC Regulation 5 and meeting all thecriteria in the Provider Licence and the Trust’s Constitution to be and continue to be a director

Each director has been checked in accordance with the criteria for fit and proper persons and have completed the necessary self-declaration forms to show that they donot fit within any definition of an “unfit person” as set out in the provider licence, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 or theTrust’s constitution; that they meet all the criteria for being a fit and proper person as defined in the Social Care Act 2008 (Regulated Activities) Regulations 2008; andthat there are no other grounds under which I would be ineligible to continue in post.

Executive Directors Non-executive Directors

SM PL DH CK JFA ST SP MS HG SW JB SWH MW

a) Are they a person who has been adjudged bankruptor whose estate has been sequestrated and (in eithercase) have not been discharged?

No No No No No No No No

Aw

aiti

ng

co

mple

tion

ofche

cks

No No No

Aw

aiti

ng

co

mple

tion

ofche

cks

b) Are they a person who has made a composition orarrangement with, or granted a trust deed for, anycreditors and not been discharged in respect of it?

No No No No No No No No No No No

c) Are they a person who within the preceding fiveyears has been convicted of any offence if asentence of imprisonment (whether suspended ornot) for a period of not less than three months(without the option of a fine) being imposed on you?


d) Are they subject to an unexpired disqualificationorder made under the Company Directors’Disqualification Act 1986?


e) Do they meet all the criteria for being a fit and properperson as defined in the Social Care Act 2008(Regulated Activities) Regulations 2008.

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Agenda item 4

LEEDS AND YORK PARTNERSHIP NHS FOUNDATION TRUST

Minutes of the Public Meeting of the Board of Directorsheld on held on Thursday 22 February 2018 at 9:30 am

in the Cypress Room, Bridge Community Church, Rider Street, Leeds, LS9 7BQ

Board Members Apologies VotingMembers

Prof S Proctor Chair of the Trust Prof J Baker Non-executive Director Mrs J Forster Adams Chief Operating Officer Miss H Grantham Non-executive Director Mrs D Hanwell Chief Financial Officer and Deputy Chief Executive Dr C Kenwood Medical Director Mr P Lumsdon Interim Director of Nursing Dr S Munro Chief Executive Mrs M Sentamu Non-executive Director Mrs S Tyler Director of Workforce Development Mrs S White Non-executive Director Mr M Wright Non-executive Director Mr S Wrigley-Howe Non-executive Director (Senior Independent Director)

In attendanceMrs C Hill Head of Corporate Governance / Trust Board SecretaryDr L Cashman Guardian of Safe Working (for minute 18/029)Six members of the public (one of whom was a member of the Council of Governors)

Action

The Chair opened the public meeting at 9.30 am. She welcomed membersof the Board and those observing the meeting.

18/023 Sharing Stories (agenda item 1)

Prof Proctor welcomed Mr Steve Taylor (Service Delivery Manager forCarers Leeds and LYPFT) and Jill Fairley (Carer). Mr Taylor highlighted thework that his team do in supporting carers. He firstly drew attention to thedocument ‘Leeds Commitment to Carers’. He noted this was a citywideinitiative that had been launched in 2016 to encourage organisations tocommit to how they can support carers. He added that this complementsthe work currently underway in the Trust in relation to the Triangle of Care.Mr Taylor then explained the three main initiatives namely: staff awarenesstraining; introducing experienced-based co-design into practice; anddeveloping a carer pathway.

Mrs Fairley spoke about her experience as a carer. She highlighted inparticular the importance of completing the work around the Triangle of Careand ensuring this was completed and implemented within the Trust. She

2Template V1 - July 2017

also expressed her views in relation to the importance of staff understandingthe boundaries of confidentiality to ensure that family members are notexcluded from the care of service users.

The Board supported the work being done to support carers and alsoacknowledged the important support carers provide to the Trust’s services.Mr Lumsdon reiterated the commitment the Trust had to carers noting thatthe work in relation to Triangle of Care was linked into the Trust’sgovernance structure and that carers would be part of that work. Prof Bakernoted that an implementation plan for Triangle of Care had been presentedto the Quality Committee in late 2017 and expressed concern at thecomment that there was currently no dedicated lead for this work. MrLumsdon made assurances that going forward this work would be placedwithin the new structure for patient experience and overseen by the ChiefNurse. Mr Taylor also noted that the Trust had been awarded Level Onemembership of the Triangle of Care and that work was now starting inrelation to stage two which would need to be completed by December 2020.

Mrs White asked about staff awareness training and the roll-out of eTraining.Mr Taylor noted that because there was currently no dedicated lead for theTriangle of Care work, the introduction of staff awareness training hadstalled and the sections in the training in relation to confidentiality were notyet available.

Mrs White asked about introducing experience co-design into practice andhow this would be approached. Mr Taylor noted the importance of capturingpeople’s experience to create a ‘library’ of resources to help raiseawareness and to feed into the training.

Dr Munro acknowledged the links that Mr Taylor already had within theorganisation and noted that the incoming Director of Nursing andProfessions, Mrs Woffendin, would be overseeing the work in relation tocarers.

Prof Proctor asked about the Leeds Commitment to Carers and when theBoard should expect to be engaged in this formally. It was agreed that thiswork would be taken forward through the Service User Forum.

CW

18/024 Apologies for absence (agenda item 2)

There were no apologies for absence.

18/025 Declaration of interests for directors and any declared conflicts ofinterest in respect of agenda items (agenda item 3)

Prof Proctor advised that Mr Lumsdon had declared a change in hisinterests noting that on the 19 February 2018 he was appointed as anexternal advisor to the Board for Norfolk and Suffolk NHS Foundation Trust.Prof Proctor also advised that in relation to her declared interests herhusband was now employed by a company called Link and was not workingfor CAPITA. It was noted that copies of the updated forms would be filed in


the Corporate Governance Office.

No other director advised of any change in their declared interests, and nodirector at the meeting advised of any conflict of interest in relation to anyagenda item.

18/026 Minutes of the previous meeting held on 25 January 2018 (agenda item4)

In relation to minute 18/001 (Sharing Stories) third paragraph on page 2, MrsForster Adams noted that it should have said “Mrs Forster Adams asked ifthere was any likelihood that delayed transfers of care would reduce giventhe amount of work being done with partners.”

In relation to minute 18/006 (Liaison Psychiatry Services accommodation),Mrs Forster Adams asked for it to be noted that this should have read“suitable accommodation” and not “temporary accommodation”.

In relation to minute 18/015 (Report from the Chair of the Audit Committee),Mr Wright asked for the double negative to be amended.

The minutes of the meeting held on 25 January 2018 were accepted as atrue record with the inclusion of the above points of clarification.

18/027 Matters arising (agenda item 5)

There were no matters arising that were not included on the agenda.

18/028 Actions outstanding from the public meetings of the Board of Directors(agenda item 6)

Prof Proctor presented the action log which showed those actions previouslyagreed by the Board in relation to the public meetings, those that had beencompleted and those that were still outstanding.

In relation to the Combined Quality and Performance Report (minute 18/010,January 2018), Mrs Forster Adams noted that the matter of the servicemodel for the Gender Identity service would be picked up at the nextContract Management Board and a verbal report made to the March Board.

With regard to the action from the Chief Executive’s Report in relation toOAPs (minute 17/137 – July 2017), Dr Munro noted that this matter hadbeen discussed in two contexts. Firstly, in relation to where the individualswere placed and the ongoing contact they have with friends and family,which she indicated was to be reported through the Quality Committee.Secondly, she noted there was a wider piece of work in relation to keyquality metrics including those that would inform what is measured inrelation to quality and that these would inform the Quality Plan and would beincluded in the monthly Combined Quality and Performance Report (CQPR).

JFA


Dr Kenwood noted that one of the points for discussion later in the agendawould be whether the Quality Plan was an operational plan or whether it wasa strategic plan; there to create the right conditions to foster quality. Sheindicated that the view was that it was the latter and that whilst the qualityissues around Out of Areas Placements (OAPs) were important these do notfit within the Quality Plan as a specific item. Prof Proctor then noted theimportance of the Board gaining assurance on the learning from OAPsthrough the CQPR and the work of the Board sub-committees. Mrs ForsterAdams also advised that NHS Improvement (NHSI) now requires Trusts todevelop a set of quality measures in relation to impact of OAPs and thatthere would be work over the coming weeks to refine these in the light of theNHSI guidance.

Mrs White noted that there was now a care manager in place who regularlyvisited people placed out of area with a view to repatriating or dischargingservices users. She suggested that they be invited to a sharing storiessession. This was agreed by the Board and Mrs Hill agreed to schedulethis.

In relation to the action from the Chief Operating Officer’s report (minute18/008 – January 2018), Mrs Forster Adams asked if this item could bereported through the Finance and Performance Committee and for anyissues to be escalated to the Board by the Chair of that committee. Thiswas agreed by the Board.

With regard to the final three items on the action log, Mrs Forster Adamsasked the Board to agree that these are explored in the July workshop. Thiswas agreed, noting that the Board would be likely to discuss patient flow ateach meeting given the importance of this matter.

CH

The Board received a log of the actions and noted the timescales andprogress.

18/029 Guardian of Safe Working Hours quarterly report (agenda item 11)

Dr Cashman firstly gave an outline of the role of the Guardian of SafeWorking Hours. She then presented the quarterly report and noted thatwhilst there had been some vacancies within the medical workforce shemade assurances that these had not led to any significant rota gaps; that themajority of rota gaps have been covered; and that there had been no patientsafety issues in relation to these gaps.

She also noted that in the quarter reported on, there had only been twoexception reports made by medics relating to hours worked. She indicatedthat these had been successfully dealt with and there had been no issues ofconcern arising.

Mrs White sought assurance that the junior doctors were made aware of the


reports. Dr Cashman indicated that they were reported to the quarterlyJunior Doctor’s Forum.

Miss Grantham asked about the exception reporting and whether there wasan inclination not to report. Dr Cashman outlined some of the reasons whyreports may not be made and assured the Board that in most circumstanceslocal arrangements were made to cover shifts but these were not alwaysreported through the electronic system. She added that doctors wereencouraged to enter these onto the computer and were assured thatformalising these events would not have any consequences for individuals.She noted that raising awareness in relation to this was ongoing.

The Board received the quarterly report. It agreed that the Guardian wouldpresent the annual report each year but that quarterly reports would bepresented by the Medical Director unless there were any issues for whichthe Guardian felt necessary to attend. Mrs Hill agreed to note this on thework-schedule.

CH

18/030 Chief Executive’s report (agenda item 7)

Dr Munro presented the Chief Executive’s report. With regard to thenational planning guidance, Dr Munro noted that the Board would soon needto consider the plans that were in place to achieve to the control total prior tothe Operational Plan for 2018/19 being submitted at the end of April.

Prof Proctor noted the significant achievement by Dr Peter Trigwell in beingawarded a Silver Level national clinical excellence award and asked for aletter of congratulations to go to him from the Board.

Prof Proctor also noted that Mrs Sentamu would be the Board level directorsponsor for the work being done by the Equality and Diversity team as partof a new national programme to improve equality and inclusion in theworkplace.

Prof Baker asked about the financial modelling for Eating Disorders and therisk of the new model for service delivery not going live on 1 April 2018 inlight of the financial position not having been finalised. Dr Munro outlinedthe work being undertaken to ensure this plan remains on track, noting thatall possible means were being pursued to agree the financial position. ProfBaker specifically asked if the Board’s positon on not taking risks was theright one given the importance of this. Mrs Forster Adams clarified theposition noting that the Board had agreed the model for service delivery andnoted that at the time this had been agreed, there had been confidence thatthe financial position would be clarified shortly thereafter. Mrs Hanwellassured the Board that the model would improve the financial position withinthe system and that as such was confident that an agreement would bereached prior to 1 April. Mr Wrigley-Howe assured the Board of thediscussions that had taken place at the Finance and PerformanceCommittee noting that it had received a detailed update on this.

CH


The Board received and discussed the Chief Executive’s report.

18/031 Quality Strategic Plan (agenda item 8)

Dr Kenwood presented the Quality Strategic Plan noting that it seeks tobring together international evidence and local activity in a coherent andsystematic way which can be communicated within the Trust. However, sheadvised that whilst there had been staff engagement in relation to the Planthere was still more work to do and that this would take place over thecoming months.

She noted that at the April Quality Committee meeting there would be anopportunity to understand where and how things are reported in thegovernance structure including the information set out in the appendices ofthe Quality Strategic Plan.

Dr Kenwood noted that the ambition of the Quality Plan was getting thetension right between the culture and the ownership of quality at the frontline by staff and the service users and carers. She indicated that theintention was to create a climate where quality can flourish and also to knowwhere there were issues of concern in relation to quality issues.

Dr Kenwood added that following the last Board meeting a further element ofthe plan had been included in relation to working with.

Mr Lumsdon commended the Plan and noted the way in which this wouldsupport the work of front-line staff in providing high quality care to serviceusers. Miss Grantham also commended the Plan and suggested thatfollowing the sharing stories session earlier whether it should includesomething in relation to the information required by service users andcarers.

Mrs White acknowledged service user experience as a key driver for quality,noting that this needs to be strengthened more widely in the Trust. This wassupported by the Board. Mrs White also asked about the statement whichstated that the Trust would “define the benefits and pitfalls of using astrategic partner for delivery” and sought clarification on this point. DrKenwood explained the origin of this statement and noted the work to look atquality improvement modelling tools and how this might be done inpartnership with other organisations.

Mrs Sentamu asked about the resources needed to deliver the Plan. DrKenwood explained the linkages between the portfolios of all the executivedirectors and the work being done to look at the resources required overallwhich was noted by the Board.

Mrs Sentamu also asked about the statement that there was a lack ofengagement of staff in the dissemination and implementation of NICEguidelines and sought clarification as to why this was. Dr Kenwood


indicated that this had come from a recent (limited assurance) internal auditreport. She also explained the wider connections of using the guidelineswithin clinical practice.

Prof Proctor noted that there was still work to be done to look at thealignment of the five Strategic Plans. She asked where discussion aroundthe alignment of risks and culture would take place. Dr Kenwood indicatedthat this was a strategic risk on the Board Assurance Framework and thatthe link between culture and learning is complex which can only be changedincrementally. She added that this was being picked up through thegovernance structure including the way in which meetings are chaired toensure that learning was approached in a positive way and used to benefitthe development of services and as a measure of quality. Prof Proctoroutlined the importance of ensuring these risks are taken account of; thatgood practice is shared and learnt from; and that pockets of resistance areidentified and addressed.

Miss Grantham asked for there to be consideration as to how the quality ofsupervision is monitored and how this embeds the principles of learning. DrMunro noted that at the April Board meeting she would be bringing a papersetting out the cross cutting priorities to be reported through the Board andits sub-committees which would be connected to the Strategic Objectivesand the Board Assurance Framework. Mrs Tyler noted that at the MayBoard workshop there would be a facilitated discussion around culture andwhat the Board’s role was in influencing this.

Mrs White asked where teaching and research link into the Plan. DrKenwood advised that there were links through the Research andDevelopment Strategy and through the development of a quality dashboard.Mr Lumsdon noted that this also links into the Nursing and Allied HealthProfessions strategies.

Prof Baker noted that this was the start of a long journey and that the workdone in the next 12 months would be pivotal to this. He added that therewas a need to assess and measure quality in a meaningful way and ensurethat the Trust uses patient experience to support the delivery of services.

The Board received and endorsed the Quality Strategic Plan.

18/032 Combined Quality and Performance Report (CQPR) (agenda item 9)

Mrs Forster Adams presented the CQPR noting that this was still in theprocess of being developed and was set out in four parts reporting on themetrics for: service targets; financial performance; workforce indicators; andquality measures.

She added that the Finance and Performance Committee had seen thismonth’s metrics in relation to the service and finance sections, but that dueto the timing of meetings the Quality Committee had not seen this month’s


data and had only received metrics in relation to the previous month’s data.

In relation to the workforce metrics, Mrs Forster Adams reported that thisinformation would be reported on a quarterly basis to the Board. She addedthat the Finance and Performance Committee had also agreed a set ofmetrics on which it would want to receive information regularly.

With regard to service indicators, Mrs Forster Adams noted the in-depthdiscussion that had taken place at the Finance and Performance Committee.She added that there were a number of areas of under-performance anddrew attention in particular to those for the Autism Service and GenderIdentity Service. She indicated that for the Autism Service the numbersreported were very small but that the proportion of under-achievement wassignificant and related to the availability of staff in the service which wouldbe addressed through a formal recovery plan that was currently indevelopment.

In relation to patient flow, Mrs Forster Adams assured the Board that thishad been picked up in detail at the Finance and Performance Committeemeeting which had looked at length of stay, out of area placements anddelayed transfers of care. Mr Wrigley-Howe supported the comments madeby Mrs Forster Adams, in particular the way in which the report would beused at Board and in its sub-committees. He also noted that the issuesaround patient flow would be picked up in a Board workshop in July. ProfProctor asked for this to also look at variations within the Trust.

Prof Baker noted that the information in the report in relation to Out of AreaPlacements did not make any differentiation between service users beingcared for in NHS, third sector and private providers. Mrs Forster Adamsagreed to report this information to the Quality Committee.

In relation to serious incidents, Prof Proctor asked if the Board should beconcerned at there being no incidents reported as being indicative of ‘underreporting’. Mr Lumsdon assured the Board on the process of reportingincidents. However, he noted that the more important part of the processwas learning from the incidents once reported. Prof Baker noted that theinformation in the CQPR showed a disconnect between the severity andnumber of reports shown for January. Mr Lumsdon agreed to bring anupdate back to the March Board meeting in relation to this information. DrMunro asked that future reports to have a narrative for those where incidentsthat were not STEIS reportable showing what these were. It was alsorequested that the report showed details in both figures and percentages toprovide greater clarity.

Prof Proctor asked what was being done to increase the uptake of theFriends and Family Test. Mr Lumsdon indicated that the team leaders hadbeen asked to get feedback from service users and collate this within thesystem. He also indicated that the Trust was looking at the way in which theFriends and Family Test would be facilitated going forward as the we werean outlier in having this work outsourced.

JFA

JFA

CW


Mrs Tyler indicated that the Staff Family and Friends Test also did not havea good response rate, although she noted that the data it provided was veryuseful. She added that there was work to look at how issues around thismight be addressed including the way in which technology might be used.

Dr Munro noted that there was a lot of work ongoing to look at how the Trustreceives feedback from staff, service users and carers and the way in whichit is used in a meaningful way.

With regard to the data around complaints, Mrs Sentamu noted that one ofthe themes that consistently came up was in relation to staff attitude andasked what was being done to pick this up. Mr Lumsdon noted that it wouldbe useful to break this down further to allow a greater understanding. ProfBaker added that the Quality Committee would be looking at this at somepoint in the year.

In relation to ethnicity data, Mrs Sentamu noted the improvement inperformance for service users seen in our services, but noted that for thosenot yet seen performance was below the target. Mrs Forster Adams notedthe impact that the waiting list in the Gender Identity Service had on theability to achieve this. Mrs Forster Adams agreed to include a more detailedupdate in relation to this in the next report.

Mrs Sentamu also asked about the target for the Crisis Team to answer thephone within one minute, noting that this had reduced and asked if thereview of the crisis pathway would include resources to meet the target.Mrs Forster Adams indicated that this would be part of the review.

In relation to the issue of trends Mrs Forster Adams noted that a newperformance manager had been appointed and that it would be their role tomake changes to the way in which the report was presented, includingtrends. Mr Wright noted the need to ensure that the report does not becometoo complicated and suggested ways in which the information might bepresented.

CW

CW

The Board received and discussed the Combined Quality andPerformance Report and noted performance against metrics.

18/033 Director of Nursing report (agenda item 10)

Mr Lumsdon presented the Director of Nursing report. He noted that theCQC inspection had now completed and that the draft report was awaited.

In relation to complaints he noted that progress had been made but that toomany were overdue. He assured the Board that work was ongoing withinthe complaints team to look at how complaints are responded to effectivelyand appropriately.

He then reported that on a recent visit to Bluebell Ward and outlined his


findings and observations of the ward, the staff who work there and hisdiscussions with some of the service users.

Mrs White asked the Board to recognise the excellent work of the CQCProject Group and the way in which they had managed the recentinspection.

The Board received the Director of Nursing Report and noted the content.

18/034 Safe Staffing Report – January 2018 (agenda item 10.1)

Mr Lumsdon presented the safe staffing report as at January 2018 and drewattention to the main points. He highlighted in particular the difficulties in therecruitment of Healthcare Support Workers. Mrs Tyler acknowledged thesedifficulties and added that there was an ongoing recruitment process inrelation to all professional staff. She indicated that at Parkside Lodge fourHealth Support Staff positions had been offered. She also noted that the HRteam was working with the Specialist Services and Learning Disabilitydirectorate in relation to the talent screening tool which assesses potentialapplicants.

Mrs White asked about the roll-out of the acuity / establishment tool. MrsForster Adams indicated that this would be considered at the Boardworkshop in July.

Prof Baker asked about the NHS Improvement guidance in respect ofcommunity staffing levels and what was being done to address therequirements. Mr Lumsdon noted that this had been received and wasbeing considered and how the report will be amended to reflect this. ProfProctor asked that this be shown in the report to the March Board.

Prof Baker also asked about staffing levels in community services, notingthat this now does not seem to feature in this report. Mrs Lumsdon notedthat there had been an update to the Board in a previous report following asafe staffing visit to one of the community services. He indicated that furthervisits were to be scheduled and that these would be reflected in futurereports. Dr Munro reminded the Board of the work in relation to theCommunity Service’s redesign, noting that caseload and capacity would bepicked up as part of that. Mrs White advised the Board of the difficulties ofbenchmarking the levels required and suggested that one way to establishsafe levels was through the safer staffing visits.

Mrs White also noted that a national benchmarking report in relation tocommunity services had been received by the Finance and PerformanceCommittee and had shown that the Trust’s costs for community serviceswere lower than average. Prof Proctor asked for the Finance andPerformance Committee to look at issues such as reference costs,community staffing levels in some detail.

CW

ST / CW


Prof Baker noted that when learning disabilities advertise for Health SupportWorkers they attract a large number of applicants and asked if there wasany learning from this. Mrs Forster Adams outlined the work that had beenundertaken to learn from successful recruitment fairs, noting that a paperwould be taken to the Workforce and Organisational Development Group forconsideration and wider learning.

Prof Baker also sought assurance that the four members of staff recruited toParkside Lodge would be supported until such time as they took up theirpositon. Prof Proctor suggested that if there was to be a significant gapbetween the date of appointment and the start date this could be noted inthe report in order to understand if there was any risk. Dr Munro noted therisk to the individual ward that this poses. She noted the need to ensure thatif there was a gap between recruitment and start date that teams aresupported in managing this situation in terms of safe staffing.

ST

The Board received and discussed the Safe Staffing Report.

18/035 Estates Strategic Plan (agenda item 12)

Mrs Hanwell presented the Estates Strategic Plan. She indicated that itsmain driver was the local and national context in which the Trust wasoperating; looking at how best to use the Trust’s owned, leased and PFIestate in order to support the delivery of high quality care. She noted thatthere were a number of key principles set out in the Plan to support the otherstrategic plans and that there was still further work to do to ensure alignmentwith these plans.

In relation to culture and how changes in estate impact on changing patternsof work, behaviour and the use of technology, Mrs Hanwell advised theBoard that this was one of the biggest risks facing the implementation of thePlan.

The Board commended the paper. Mr Wright asked about the refinancing ofthe PFI estate and noted the impact that changes in the market place willhave on this. He indicated that since the refinancing had been put forward,interest rates had risen which had the effect of reducing the financial benefitto the Trust. He added that as these continue to rise so the benefitcontinues to decrease, thereby leaving the Trust with a decreasing windowof opportunity. Mrs Hanwell acknowledged that this would be the casenoting that the Board had agreed not to rush into making any decision butwould take a considered approach to this and understand all theimplications.

With regard to the immediate disposals, Mr Wright sought assurance thatthese would be ready for vacant possession at the time of the sale andasked if there was a project plan in place to manage a smooth transition forstaff and services. Mrs Hanwell assured the Board that there was a planand noted that there had been considerable work with staff which was still


ongoing in relation to re-location.

Mr Wright also asked if there was a medium to long-term project plan for thechanges to the use of the estate including the PFI estate noting that therewould need to be a process of engagement, and ideally for this to becompleted before the investment strategy was agreed. Finally, Mr Wrightasked if there was a project manager to oversee the individual elements ofthe Estates Strategic Plan. Mrs Hanwell again noted that work was ongoingto develop the medium to long-term project plan and also that the team wasworking to complete this. However, she acknowledged that there may be aresources gap around capacity which would be looked at by the executiveteam.

Prof Proctor asked where the ongoing monitoring of the Estates StrategicPlan and the development of the PFI pathway would take place. MrsHanwell indicated that this would be picked up by the Estates SteeringGroup with reports going to the Finance and Performance Committee.

Miss Grantham asked about change management capacity in particularengagement with staff and the management of stakeholders. Dr Munro firstlyexplained the amount of engagement there had been by the executivedirectors in relation to the current disposals. She then noted the links acrossthe Strategic Plans to ensure the ability to deliver the changes set out in thisand the other Plans.

Miss Grantham also asked how messages to service users would bemanaged as the estate is changed, also noting that as this was now a publicdocument consideration needs to be given to the communication plan. TheBoard acknowledged the need to ensure this was communicated bothinternally and externally. Dr Munro agreed to pick this up with Mr Tipper,Head of Communications.

Mr Wright asked if there was a programme of events with staff to explain thechanges. Dr Munro indicated that these have been scheduled to beundertaken by the Senior Leadership Team after Easter.

SM / OT

The Board considered and approved in principle the Estates StrategicPlan.

18/036 Report from the Chief Financial Officer – January 2018 (agenda item 13)

Mrs Hanwell presented the financial position as reported at month 10 notingthat this was overall within planned tolerances. She noted that the actualdelivery was underpinned by non-recurrent measures and a range ofsignificant variances against specific budgets.

Mrs Hanwell noted that the underlying run-rate continued to deterioratelargely as a consequence of the out of area cost pressures, which after non-recurrent revenue support from Leeds CCG, was forecast to be £1.1m


overspent in the year. She added that the inpatient staffing pressures remainand were subject to an establishment review. She indicated that the Trustremains in dialogue with NHS England regarding the contract adjustment forForensic ward closures and that it was anticipated that a resolution would bereached at the end of February.

With regard to capital expenditure year-to-date Mrs Hanwell reported thatthis was broadly in line with the revised forecast position.

DH

The Board received the Chief Financial Officer report and discussed thecontent.

18/037 Report from the Chair of the Mental Health Legislation Committeemeeting held 8 February 2018 (agenda item 14)

Mrs White gave a verbal report of the Mental Health Legislation Committeemeeting that had taken place on 8 February 2018. She outlined the keyareas of discussion which included:

The first report on the 10% caseload audit of mental health legislationdocumentation was received. It was noted that this had resulted in avery positive outcome that had provided sufficient assurance that thesystems and processes in place would mitigate against defectivedetentions. Mrs White indicated that this had led to arecommendation to reduce the risk score in relation to the defectivedetentions risk on the risk register

Progress in relation to the work with third sector partners to improveaccess for people from BAME backgrounds to the Trust’s crisisservice

A risk in relation to S36 of the Mental Health Act and the reduction inthe time allowed to assess people detained under S136 of the MentalHealth Act. She noted that this was not a problem with meeting theassessment time but that the problem was with finding the individualsa bed which, she noted, was part of the issue the Trust was facing inrelation to capacity more widely. Mrs White indicated that this issuewas being taken forward by the Mental Health Legislation OperationalSteering Group

A risk in relation to the work carried out by Local Authority partnersand the delays they are experiencing in assessing Deprivation ofLiberty Safeguard applications. She also noted that this was beingtaken forward by the operational group

The revision of the Terms of Reference for the committee, noting thatthese would be brought to the March Board meeting for ratification.

With regard to the issues in relation to the lack of beds, Prof Baker soughtclarification that this was only in relation to adults, which Mr Lumsdonconfirmed.

SW


The Board received a verbal report from the Chair of the Mental HealthLegislation Committee and noted the content of the update.

18/038 Report from the Chair of the Quality Committee for the meeting held 13February 2018 (agenda item 15)

Prof Baker gave a verbal report of the Quality Committee meeting that hadtaken place on 13 February 2018. He outlined the key areas of discussionnoting that it had been a challenging meeting in relation to the itemspresented to the committee at the meeting but that further discussion wouldbe scheduled at the April meeting in relation to its work plan.

He reported that the key areas of discussion were:

The Quality Strategic Plan, noting that the committee had receivedthis on a number of occasions and had taken the opportunity to inputto the content

The Nursing and Allied Health Professionals’ strategies The complaints process and assurance on progress with developing

this. Prof Baker noted that there still needed to be assurance onlearning from complaints

The Cost Improvement Programme, noting that this would bepresented to the next committee meeting so it can better understandthe how decisions are made in relation to the impact on quality

Information feeding through from the Trustwide Clinical GovernanceGroup, noting that the highlight report had provided assurance andinsight into the issues being dealt with in that committee, and thatwhilst there was nothing to escalate to the Board, there were anumber of items that the committee would be monitoring.

In relation to the Trust Incident Review Group, Prof Baker reported that heand Mr Wrigley-Howe had undertaken to attend some of the meetings of thisgroup to gain assurance on this process.

He also reported that there was a commitment by the committee to continueto look at the information it requires, and noted that workforce reporting inrelation to quality was being strengthened which he welcomed.

Mrs White noted that there is an area of cross-over between the QualityCommittee and the Mental Health Legislation Committee in relation tomechanical restraint. Prof Baker indicated that this had been discussed atboth the Trustwide Clinical Governance Group and the Quality Committeeand that he was assured that there was a policy in place in relation to this.Dr Kenwood noted that this matter was still on the agenda for both theTrustwide Clinical Governance Group and the Quality Committee in relationto not just mechanical restraint but restrictive interventions more widely. MrLumsdon noted that in relation to mechanical restraint, these incidents werefew and that ultimately there would be a detailed report to the Board in June. CW


The Board received a verbal report from the Chair of the Quality Committeeand noted the matters discussed.

18/039 Report from the Chair of the Finance and Performance Committee forthe meetings held 20 February 2018 (agenda item 16)

Mr Wrigley-Howe gave a verbal report of the Finance and PerformanceCommittee that had taken place in February. He outlined the key areas ofdiscussions which included:

An update on the procurement of an electronic patient record system Forensic and Learning Disability vacancies, noting that Mrs Forster

Adams had been asked to bring a further report to the next committeemeeting in relation to the actions being taken to address this

Penetration testing and cyber security, noting that assurance hadbeen received on the actions being taken to ensure the Trust’ssystems were as safe as possible.

The Board received the verbal report from the Chair of the finance andPerformance Committee and noted the issues discussed.

18/040 Update on the position of the Deputy Chair of the Trust (agenda item17)

Mrs Hill advised the Board that at its meeting on the 14 February 2018 theCouncil of Governors had firstly, agreed to extend the term of office for theDeputy Chair from one year to two years, noting that this would provide abetter opportunity to experience and develop into this role; and secondly,had agreed to appoint Mrs White to this position with effect from 15 February2018 for a period of two years.

The Board noted the appointment of Mrs White as Deputy Chair of the Trustwith effect from 15 February 2018 for a period of two years.

18/041 Glossary (agenda item 18)

The Board received the glossary.

18/042 Any other business

Prof Proctor advised the Board of the sad news that John Mason, previousgovernor of the Trust and a regular attendee at the Board meetings, hadpassed away. She asked for the Board’s condolences to be passed onto hisfamily and noted that details of the funeral would be made known tomembers of the Board.


18/043 Resolution to move to a private meeting of the Board of Directors

At the conclusion of business the Chair closed the public meeting of theBoard of Directors at 12:45 and thanked members of the Board andmembers of the public for attending.

The Chair then resolved that members of the public be excluded from themeeting having regard to the confidential nature of the business transacted,publicity on which would be prejudicial to the public interest.

Signed (Chair of the Trust) ………………………………………………………

Date ……………………………………………………………………………

1BOARD OF DIRECTORS – Cumulative Action Log (public board)

Cumulative Action Report for the Public Board of Directors’ Meeting

OPEN ACTIONS

ACTION(INCLUDING THE TITLE OF THE PAPER THAT GENERATED THEACTION)

PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Sharing Stories (minute 18/023 – February 2018)

NEW – The Board asked about the Leeds Commitment to Carers andwhen it would expect to be asked to engage in this formally. It wasagreed that this would be taken forward through the Service UserForum in the first instance.

CathyWoffendin

Managementaction

CLOSED AS A BOARD ACTION

An external review of the Trusts patient experience, serviceuser and carer involvement is currently being commissioned

and will commence with a workshop to scope and obtaininitial views across these areas. In addition the Director ofNursing and Professions has organised to meet with key

individuals from the Leeds Carers group.

Actions outstanding from the public meetings of the Board ofDirectors (minute 18/028 – February 2018)

NEW – The Board agreed that the care manager who regularly visitedpeople placed out of area with a view to repatriating or dischargingservices user should be invited to a sharing stories session. Mrs Hillagreed to schedule this in.

Cath Hill Managementaction


This has been added to the schedule of Sharing Stories

AGENDAITEM

6



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Guardian of Safe Working Hours quarterly report (minute 18/029 –February 2018)

NEW - It was agreed that the Guardian would present the annualreport each year, but that quarterly reports would be presented by theMedical Director, unless there were any issues which the Guardian feltit necessary to attend the Board for. Mrs Hill agreed to note this on thework-schedule.

Cath Hill ManagementAction


The annual cycle of business has been updated

Chief Executive’s report (minute 18/030 – February 2018)

NEW – The Board asked for a letter to be sent to Peter Trigwell fromthe Board congratulating him on achieving a Silver Level nationalclinical excellence award.

Cath Hill /Sue Proctor

ManagementAction


Combined Quality and Performance Report (CQPR) (minute 18/32– February 2018)

NEW - The Trust is looking at the way in which the Friends and FamilyTest would be facilitated going forward.

CathyWoffendin

ManagementAction


This action is being picked up as part of the review of Trustspatient experience, service user and carer involvement



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Safe Staffing Report – January 2018 (minute 18/034 – February2018)

NEW – The Board noted the work that had been undertaken to learnfrom successful recruitment fairs and that a paper would be taken tothe Workforce and Organisational Development Group forconsideration and wider learning.

JoannaForsterAdams

To go to theWorkforce and

OD Group


This has been passed into the schedule of work for the group


NEW - Data around the themes to come from complaints will be lookedat by the Quality Committee.

CathyWoffendin

To go to theQuality

Committee


This is on the work schedule for the Quality Committee andwill be discussed at the April meeting as to when and how

this will go to the committee.

Estates Strategic Plan (minute 18/035 – February 2018)

NEW - It was noted that the Estates Strategic Plan was now in thepublic domain and that there should be a communications plan bothinternally and externally to support this. Dr Munro agreed to pick thisup with Mr Tipper, Head of Communications.

Sara Munro Managementaction


This forms part of the next round of engagement sessionwhich start in May



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Ratification of the Terms of Reference for the Quality Committee(minute 18/017 – January 2018)

It was agreed that there would be consideration as to how Mrs Hanwellcould provide assurance to the committee other than by permanentmembership. Mrs Hanwell agreed to speak to the new Director ofNursing about this.

DawnHanwell

ManagementAction


This will be added to the matters to be discussed at the AprilQuality Committee meeting in respect of what is reported tothe committee, when and by whom. Discussions will also

pick up who attends the meeting and how often

Report from the Chief Financial Officer – January 2018 (minute18/036 – February 2018)

NEW - The Trust remains in dialogue with NHS England regarding thecontract adjustment for Forensic ward closures and that it is anticipatedthat a resolution would be reached at the end of February.

DawnHanwell

ManagementAction

COMPLETED

A reduction in the contract has been agreed to take accountof the two ward closures


NEW - It was noted that the information in the report in relation to Outof Area Placements did not make any differentiation between thoseservice users in NHS, third sector and private providers. Mrs ForsterAdams agreed to report this information to the Quality Committee.

JoannaForsterAdams

To go to theQuality

Committee


This has been added to the Quality Committee forward plan



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS


NEW – It was noted that a national benchmarking report in relation tocommunity services had been received by the Finance andPerformance Committee and had shown that the Trust’s costscommunity services were lower than average. Prof Proctor asked forthe Finance and Performance Committee to look at issues such asreference costs, community staffing levels in some detail.

CathyWoffendin

To go to theFinance andPerformanceCommittee


This has been added to the Finance and PerformanceCommittee forward plan

Chief Operating Officer report (minute 18/008 – January 2018)

It was agreed that there needs to be more work done to understand theissues in relation to the input of data for mental health clustering andthat a report would be brought back to the March Board meeting.

JoannaForsterAdams

March Boardof Directors’

meeting

To be reportedto the Finance

andPerformance

committee


This has been added to the Finance and PerformanceCommittee forward plan



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS


NEW - There were a number of requests for information in the CQPRin relation to the Quality Section:

Clarification on an apparent disconnect between the severityand number of incidents reported in January on pages 17 and18.

A narrative to provide further details on those incidents thatwere not STEIS reportable

For the data to contain both figures and percentages.

CathyWoffendin

March Board COMPLETED

Included in the March Board report


NEW – An update in relation to the ethnicity data for those serviceusers not yet seen.

JoannaForsterAdams


This has been included in the performance report


NEW - It was agreed that the NHS Improvement guidance in relation tosafe staffing be reflected in the report to the March Board.

CathyWoffendin


Included in March Safer Staffing Report and the Director ofNursing and professions report



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Report from the Chair of the Mental Health Legislation Committeemeeting held 8 February 2018 (agenda item 14)

NEW - The revised Terms of Reference for the committee, to bebrought to the March Board meeting for ratification.

Sue White March Board COMPLETED

On the March Board agenda

Combined Quality and Performance Report (minute 18/010 –January 2018)

It was noted that at a previous Board it had been reported that therewas a new service model due to be implemented by NHS England inregard to the Gender Identity service. It was noted that the outcome ofthis was still awaited and agreed that an update would come to theFebruary Board meeting.

JoannaForsterAdams

FebruaryBoard ofDirectors’meeting

Verbal updateto the March

Board ofDirectors’meeting

We are still awaiting NHS England publishing the new servicemodel

This matter will be picked up at the March ContractManagement Board

Director of Nursing report and Safer Staffing 1 November to 31December 2017 (minute 18/011 – January 2018)

The Board asked for there to be a focus on the training, developmentand ongoing supervision for bank staff in a future workforce report.

Susan Tyler March Boardof Directors’

meeting

COMPLETED

This has been included in the March Board report



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Combined Quality and Performance Report (minute 18/10 –January 2018)

With regard to staff sickness due to stress the issue of what could bedone to help staff avoid becoming stressed and to help managersmanage with the prevention of stress related sickness in their teams,Mrs Tyler agreed to build this into a future workforce report to theBoard.


meeting

COMPLETED

This has been included in the March Board report

Chief Executive’s report (minute 18/007 – January 2018)

It was agreed that information about the Leeds Health and CareAcademy and asked would be made available at the February boardmeeting.


meeting

COMPLETED

This has been included on the March Board agenda

Medical Directors’ report (minute 17/211 – November 2017)

Dr Kenwood noted agreed to bring further information on the work ofthe Continuous Service Improvement Team to the Board.

ClaireKenwood

March Boardof Directors’meeting –

COMPLETED

This will be the substantive quarterly Medical Director’s report

Action plan relating to the fire enforcement notice (17/189 –October)

An update report on the progress with the smoke-free policy to bebrought back to the March Board.

CathyWoffendin

March Boardof Directors’

meeting

COMPLETED

This has been added to the March Board agenda



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Approval of the Trust’s Strategy (minute 17/205 – November 2017)

With regard to this suite of documents (Trust Strategy and the fivestrategic plans) it was agreed that there would be a board workshop tolook at their alignment and an agreement as to the key outcomes tomonitor delivery of the three strategic objectives. Mrs Hill agreed tofactor this into the Board development programme for 2018/19.

Cath Hill April Board ofDirectors’meeting

(As there is noBoard

workshop inApril this willcome to the

private Boardmeeting)

Clinical Services Strategic Plan refresh (minute 18/009 – January2018)

The comments and suggestions made in relation to the ClinicalServices Plan will be considered for inclusion in the refresh of the Plan.

JoannaForsterAdams

April Board ofDirectors’meeting

ONGOING

Comments received by the Board have now been included inthe Plan and implementation will be monitored by the

Workforce & OD Group. The plan will be submitted to AprilBoard in conjunction with other strategic plans for assurance

on read across and consistency.

Director of Nursing report and Safer Staffing 1 November to 31December 2017 (minute 18/011 – January 2018)

The Board supported the pro-active relationship management forstudents and asked for a report on this to be included in a futureworkforce report.

Susan Tyler May Board ofDirectors’meeting

The recruitment of student nurses and associatedrelationship management needs to be co-ordinated betweenthe workforce and nursing directorates. This matter will bebrought back to the Board once a co-ordinated approach is

agreed.



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Report from the Chair of the Quality Committee for the meetingheld 13February 2018 (agenda item 15)

NEW - Mr Lumsdon noted that the in relation to mechanical restraintthese were only small numbers and that ultimately there would be adetailed report to the Board in June.

CathyWoffendin

June Board ONGOING

The Quality Committee will receive a report in respect ofrestrictive practices and assurances will be made back to the

Board by the chair of the committee through the Chair’sreport

Report from the Chief Operating Officer (minute 17/207 – November2017)

With regard to patient-flow management and capacity the Board notedthat there was a comprehensive piece of work which would take placein early 2018. Mrs Forster Adams agreed to include an update on thiswork in the Chief Operating Officers’ report to the January Boarddetailing progress with this.

JoannaForsterAdams

FebruaryBoard meeting

2018

Finance andPerformanceCommittee in

April 2018

July Boardworkshop

This and the following three items are linked and will bepicked up together in a Board workshop in July 2018

Actions outstanding from the public meetings of the Board ofDirectors (minute 18/006 – January 2018)

It was agreed that there would be an update on the work around theinternal skill-mixing work and the application of the acuity tool would bebrought to the April Board which would also include a review of thecontractual arrangements to ensure there is adequate investment toprovide the right level of staffing in the services.

JoannaForsterAdams

July Boardworkshop

Ditto above



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Actions outstanding from the public meetings of the Board ofDirectors (minute 18/006 – January 2018)

It was agreed that patient flow would be looked at in more detail in theMay Board development session.

JoannaForsterAdams

July BoardWorkshop

Ditto above


NEW - In relation to patient flow, it was noted that this was to be pickedup in the July Board workshop. It was agreed that this would alsohighlight any variances in flow within the Trust.

JoannaForsterAdams

July Boardworkshop

Ditto above


CLOSED ACTIONS

(3 MONTHS PREVIOUS)


PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Chief Executive’s Report (minute 17/137 – July 2017)

It was noted that OATs was a key risk for service users, and agreedthat as a separate piece of work the top four or five top key prioritiesfrom both the service user and organisational perspective should beidentified that can be used as a measure of quality. Prof Proctor askedfor the initial work to come back to the Board-to-Board meeting inSeptember for consideration.

PaulLumsdon /

ClaireKenwood /

JoannaForsterAdams

Board toBoard

September2017

FebruaryBoard ofDirectors’meeting

COMPLETED

The Quality Plan in on the agenda for the Februarymeeting

Report from the Chair of the Audit Committee for the meeting held19 January 2018 (minute 18/015 – January 2018)

Prof Proctor asked for a copy of the outstanding management actionsreport to be provided to her so assurances around completion could befactored into the audit plan.


End January2018

COMPLETED



PERSONLEADING

BOARDMEETING TO

BEBROUGHTBACK TO /

DATE TO BECOMPLETED

BY

COMMENTS

Report from the Chair of the Audit Committee for the meeting held19 January 2018 (minute 18/015 – January 2018)

Mrs Hill agreed to provide the non-executive directors with the datethat Prof Proctor was meeting with internal audit so ideas for theInternal Audit Plan could be provided for consideration.


End ofJanuary 2018

COMPLETED

Workforce and Organisational Development Strategic Plan (minute17/214 – November 2017)

It was noted that there was still further work to address the commentsmade by the Board and for any cross-cutting themes from the otherstrategic plans to be reflected in the document. It was agreed that thefinal version would come back to the Board for ratification.

Susan Tyler April Board ofDirectors’meeting


Comments received by the Board have now beenincluded in the Plan and implementation will be

monitored by the Workforce & OD Group.

The key priorities will be reported to the Board in Aprilalong with those from the other strategic plans

MEETING OF THE BOARD OF DIRECTORS

PAPER TITLE: Chief Executive Report

DATE OF MEETING: 29 March 2018

PRESENTED BY:(name and title)

Dawn Hanwell – Chief Financial Officer and Deputy ChiefExecutive

PREPARED BY:(name and title)

Dr Sara Munro – Chief Executive

THIS PAPER SUPPORTS THE TRUST’S STRATEGIC OBJECTIVE/S (please tickrelevant box/s)

SO1 We deliver great care that is high quality and improves lives. SO2 We provide a rewarding and supportive place to work. SO3 We use our resources to deliver effective and sustainable services.

EXECUTIVE SUMMARYThe purpose of this paper is to inform the board on some of the activities of the ChiefExecutive which are undertaken to support the delivery of the Trusts strategic objectives.

This month’s reports covers:

1. Staff Engagement,2. Strategy and priorities,3. Regulatory update,4. System update,5. Executive Team update,6. Reasons to be proud.

Do the recommendations in this paper haveany impact upon the requirements of theprotected groups identified by the EqualityAct?

State below‘Yes’ or ‘No’ If yes please set out what action has

been taken to address this in your paperNo

RECOMMENDATION

The Board is asked to note the content of the report.

AGENDAITEM

7

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integrity | simplicity | caring

CHIEF EXECUTIVE’S REPORT: 29 MARCH 2018

The purpose of this report is to update the board on the activities of the Chief Executive since the

last board meeting.

1. Introduction

The purpose of this paper is to update the board on the activities of the CEO.

2. Staff Engagement

During the past month I have undertaken two clinical service visits to Becklin and the East North

East CMHT. The purpose of the visit to Becklin was to arrange for a NED at Leeds Teaching

Hospital Trust to spend a morning visiting our services to develop their own understanding of

mental health services and the work of the trust. This will help us continue to develop our

relationship with the acute trust for the benefit of service users. Maureen Cushley, Gail Galvin and

Judith Barnes gave a very good insight into the acute and crisis services and the feedback has

been very positive.

When visiting the team at ENE CMHT the main focus of discussion was on the planned redesign

of our community mental health services and the trusts plans to procure a new electronic patient

record. This brings both opportunity and challenge for our community teams as we work through

these important programmes of change to improve the service we provide to service users in the

community.

Out staff survey results for 2017 have now been published and shared across the organisation.

Susan Tyler will be providing a more detailed update but the highlights are continued improvement

in our overall results with particular highlights in staff health and wellbeing, experiences of BME

staff appraisal and training and support from managers. Results are being shared at team and

service level similar to last year as the evidence suggests taking action at a local/team level is

more effective than adopting trust wide action plans that cannot address the differences in staff

experiences across departments.

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An independent analysis of all staff survey results has been published by Listening Into Action with

scatter plots that enable trust’s to compare themselves against their sector. We feature very

positively compared to the mental health sector showing an improved position compared to peers

and a continued positive trend year on year for the trust.

3. Strategy and priorities

Now the Trusts strategy and the supporting strategic plans have all been finalised the executive

team have met to review and agree the key priorities for the year ahead. This will be finalised as

next month to ensure it incorporates our operational plan and financial planning for 2018/19, and

any actions that arise from our CQC inspection.

Engagement events are being scheduled for the coming months for the senior leadership team to

discuss with staff our priorities and what this means for them going forward.

4. Regulatory Update

4.1 CQC

I am delighted to confirm the outcomes of the inspection of our specialist supported living service

have now been published on the CQC website. The service has moved from requires

improvement to good overall and outstanding for caring. This is testament to the excellent

leadership provided by Gill Galea and her team. The report details the impact our staff in this

service has on the quality of lives of those who we support. I would like us to pass on our formal

thanks to all the staff in the service on behalf of the Trust Board.

At the time of writing we are working through the draft reports from our well-led inspection as part

of the factual accuracy process. Once this has been concluded and the reports finalised we will be

able to share the outcomes.

4.2 NHSI

We submitted our draft operational plan for 2018-2019 to the regulator as required on the 8th

March 2018. This was a refresh of the two year plan previously submitted along with a revision of

our financial planning in response to the updated planning guidance which impacted on our control

total. The final submission is due on the 30th April and will be signed of at the next Trust Board

meeting.

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4.3 Contracts for 2018/19

Following a number of meetings with the executive team and our commissioners we have now

agreed our contracts for 2018/19 with Leeds CCG and NHSE. I am pleased to confirm this

includes additional investment in our liaison psychiatry service, recurrent funding for memory

support workers which is provided by the Alzheimers society, and funding for the new care model

for Eating disorder service for West Yorkshire which goes live on the 1st April. We have also

secured ongoing support for the costs of out of areas placements with a mid-year review in

September 2018. We will be closely monitored by the CCG and NHSI on our improvement

trajectory for OAPs and we are confident about the leadership and management arrangements we

now have in place for this.

5. System Update

5.1 Mental health Collaborative Work stream

New Care Models

The NCM for Eating Disorder services which we lead and CAMHS, led by LCH will go live on the

1st April 2018. A significant amount of work has already been undertaken ready for the go live

date including service user engagement, recruitment of new staff as well as redesign of clinical

pathways. Updates will be provided later in the year as the services develop and the impact for

patients and staff is monitored.

The national NHSE team for new care models have now confirmed there will not be a wave 3 of

the current programmes. The rationale for this is the desire to embed this approach more widely

through the regional specialist commissioning teams. We are arranging meetings with NHSE to

discuss the opportunities for Yorkshire and Humber in the longer term.

Capital Priorities

Dawn Hanwell is the mental health lead in the STP capital planning group. As part of the national

bidding process we have put forward three priorities for capital funding for mental health which

cover rehabilitation, assessment and treatment for learning disability services and PICU provision.

These will be submitted to the Department of Health alongside priorities for the rest of the STP.

5.2 West Yorkshire and Harrogate Partnership

The focus of the executive group in March was the memorandum, of understanding for the

partnership which continues to develop. Key areas that are still not fully articulated are the

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governance and oversight arrangements and what this means for organisations and current

oversight arrangements with the arm’s length bodies.

5.3 Leeds Plan

The Board to Board that was scheduled for the 22nd March 2018 has been cancelled and the next

meeting will be held in July.

5.4 The West Yorkshire Mental Health Services Collaborative – Committees in Common

The West Yorkshire Mental Health Services Collaborative (WYMHSC) is the coming together of

the four mental health and community NHS trusts in West Yorkshire (Bradford District Care

Foundation Trust, Leeds and York Partnership Foundation Trust, Leeds Community Healthcare

NHS Trust, and South West Yorkshire Partnership Foundation Trust) to work collaboratively to

ensure high quality, sustainable mental health services now and into the future.

In its private session the Board will be considering the documentation to help formalise this way of

working with partners.

6. Executive Team Update

Welcome to Cathy Woffendin, now in post as the Director of Nursing and Professions and today

will be Cathy’s first board meeting. Paul Lumsdon our interim finished on the 13th March after a

handover period.

Susan Tyler, our most experienced executive director has confirmed now that she will be retiring

from the NHS on the 31st May 2018. Susan is such an experienced and valued member of the

executive team and the trust board and I know she is going to be difficult to replace. I will confirm

in due course the arrangements for when Susan finishes.

7. Reasons to be Proud

7.1 Snow, snow and more snow

Our staff showed true grit and determination to keep services running safely during the recent

snowy conditions. We thought we had seen the worst of the weather after the first spell, but it’s fair

to say the whole of Leeds was caught off guard with the heavy snowfall on 8 March. Thank you to

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everyone who battled through the elements to get to work, covered for a colleague in another

unfamiliar team or worked over and above the norm. I have heard some amazing stories of night

staff staying on past their shifts, walking long distances through the snow and helping one another

out to get in and out of work. All this to ensure we provide safe care to our patients.

7.2 Specialist Supported Living Services

Specialist Supported Living Services rated good overall and outstanding for caring. As noted

above this is a huge achievement and I am very proud of Gill and all the staff in the service for the

work they do and the difference they make which has been recognised by the inspectors.

7.3 Chief Pharmacist

Elaine Weston our Chief Pharmacist is about to retire. I want to wish Elaine well in her retirement

and thank you for 16 years of service to the trust in which she has made a real difference to the

quality and safety of care we provide to service users. Our new Chief Pharmacist will be Jane

Riley who is returning to the Trust after three years as Chief Pharmacist and Accountable Officer

for Controlled Drugs at South West Yorkshire Partnership NHS Foundation Trust. Jane will join us

at the end of April.

Dr Sara Munro

Chief Executive

March 2018


PAPER TITLE: Chief Operating Officer report



Joanna Forster Adams - Chief Operating Officer





EXECUTIVE SUMMARYThis report identifies any significant operational issues during January and February 2018and responds to issues raised by Board members for consideration and update.

It includes:

Adverse Weather Update

A summary from our stocktake of actions taken to improve our OAP Acute and PICU

performance

An update on the background and details of the mental health clustering work and

our on-going work.




RECOMMENDATION

The Board are asked to note the content of this report and discuss any areas ofconcern.

Identify any further work required and agree timeframes and prioritisation.

AGENDAITEM

8

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CHIEF OPERATING OFFICER BOARD REPORT: MARCH 2018

1. Introduction

This report identifies any significant operational issues during January and February 2018 and

responds to issues raised by Board members for consideration and update.

It includes:

Adverse Weather Update

A summary from our stocktake of actions taken to improve our OAP Acute and PICU

performance

An update on the background and details of the mental health clustering work and our on-

going work.

2. Adverse Weather Update

The very low temperatures and significant snowfall across much of the UK on the evening of 27

February and morning of 28 February had a major impact on our services and the ability of staff to

get into work and provide care. As a result we took the step of invoking organisation wide business

continuity arrangements on 28 February 2018.

A team of people came together to coordinate our response and our logistical arrangements and

we met frequently throughout the period directly connected to and communicating with our front

line services. This process was repeated on 8th March 2018 in response to unexpected heavy

snowfall which again disrupted access to our services and logistics in terms of getting staff to their

place of work over the period of the morning and early afternoon.

In line with our EPRR processes we established our objective in activating business continuity

arrangements as:

To ensure we are providing optimum care to the most vulnerable service users and to

ensure safety is maintained in our urgent and emergency care services.

Actions taken to achieve this objective were:

To keep communications with our staff

To assure them that their safety was paramount

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To quickly establish that we should prioritise urgent care and the support of our most

vulnerable patients

To cancel all non- essential activities and direct available and local staff to priority areas of

work.

Ensure staffing levels in inpatient, crisis and urgent care services were adequate and

consequences of travel difficulties were being supported, monitored and mitigated

Logistically redirect staff to our priority areas and ensure core activities could continue

Prioritise urgent work by community teams and use telephone and other forms of

communication where appropriate to ensure the safety of those in our care

To communicate widely with our service users to cancel and reappoint outpatient and other

non- urgent appointments.

2.2 Service Impacts

Directly as a result of the 3 days we enacted our business continuity arrangements the following

activity was affected:

In our Leeds based core MH services, 81 outpatient appointments were cancelled. 42 of

these have now been reappointed (52%) within 4 weeks of cancellation.

In our Specialist services, 50 outpatient appointments were cancelled. 19 were reappointed

(38%) within 4 weeks of cancellation.

We maintained contact with service users routinely expecting visits to determine level of

urgency and need. We maintained our crisis response throughout and similarly our acute

and urgent services.

There were no reported incidents directly resulting from the disruption resulting from the

diverse weather.

We have a recovery plan in place to ensure that any impacts of this episode of disruption are

rectified.

3. Mental Health Clustering Update

3.1 Background

Mental Health Clusters were originally introduced in 2009 to support the move to Payment by

Results in Mental Health Services. Following a period of testing of this approach, it was agreed

that payment tariffs using clusters as the currency would not be effective as a mental health

payment model. In 2016 NHS England set out a requirement to move towards payment

approaches in mental health which have a payment component linked to achieving agreed quality

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and outcomes. In 2017 LYPFT were asked by the Leeds North Clinical Commissioning Group to

propose an approach that will move the Trust toward having a robust measurement mechanism to

support an outcome based contract. Cluster pathways and outcomes frameworks are supporting

the development of this work.

3.2 Use of cluster information

Cluster pathway and outcomes development has been an integral part of key projects within

LYPFT. We have produced the following in line with our clustering information:

Intervention tables with activity codes aligned to demonstrate compliance including:

Assessment

care co-ordination

psychological therapies

psychological wellbeing

medicines management

physical health

lifestyle & social recovery

Family/carer interventions.

Knowledge, Skills, Values, Attitudes (KSVA) Frameworks aligned to the interventions to

inform training needs analysis rated as:

informed/general

skilled practice/enhanced

Expert/specialist.

Detailed outcome frameworks – list of clinician reported and patient reported outcome

measures and rating scales.

In terms of finance, cluster activity is also used to inform reference costs and will continue to do so

during 2018/19. Cluster information is provided and reviewed on a quarterly basis to the Leeds

CCG Activity & Finance meeting.

3.3 Performance summary over last 12 months

The percentage of those people in scope who have been clustered is a Key Performance Indicator

(KPI) with a target of 90% completion. This is submitted on a quarterly basis as part of the

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schedule reporting for our CCG contract. The percentage has remained above 89% since

November 2017 and we continue to aim for improvements and sustained levels of performance.

3.4 On-going targeted improvement areas

Cluster completion

Cluster accuracy

Data Quality.

In order to continue to provide accurate clustering information we are working alongside clinical

staff to support these targeted areas of improvement. Specifically the supporting actions we are

taking include:

The frequent provision of cluster reports

Performance monitoring information at team leaders and service level.

A standing item for consideration and debate as part of our clinical governance forums.

A specific senior role to undertake cluster training lead and management of our clustering

work.

A programme of data quality improvement.

3.5 Summary of the future of clustering in MH Services

The Service Development Improvement Schedule (SDIP) agreed with Leeds CCG in 2017/2018

supported the testing of cluster 16, people with a psychosis with co-morbid substance misuse and

17, people with a psychosis who are difficult to engage as pilot areas to determine how we might in

future attach payments to outcomes for service users clustered in these areas.

In 2018/19 we will shadow run reporting against these metrics and share learning with

commissioners to inform contract development beyond March 2019.

Mental Health Trusts around the country are at different stages of outcomes contract development.

Many are using cluster care pathways to inform this work. Cluster superclass level pathways and

85.00%

86.00%

87.00%

88.00%

89.00%

90.00%

Actu

al

Period

Proportion of Inscope Patients assigned to a Cluster

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frameworks will likely continue to be used. LYPFT has links with other Trusts to support learning

and development of this work.

There is no clear directive from NHS England about the continued use of clusters. The advice is to

move away from block contracts to outcomes based contracts, and encourage Trusts to explore

methods and approaches to do this.

4. Stock take of OAPS Performance (November 2017 to February 2018)

4.1 Current position and further improvement actions

The Board have previously been updated on the range of actions we have taken and processes

established to manage our patient flow and minimise the number and impact of out of area

admissions.

The updated diagnostic and review undertaken in February/March, highlighted a number of further

improvements and refinements to the actions we had taken. These additional or improved actions

include:

Increased frequency and discipline of our capacity management arrangements led by our

Inpatient Service Manager. These include strengthening representation from adult acute

wards, rehabilitation services, the discharge team, service and operational managers and

representatives from our Crisis Assessment service. This results in improved collective

ownership and responsibility to problem solve and has enabled better communication.

There has been an increase in short term use of leave beds as a means of managing

demand.

A case manager has been seconded from the community team to work with out of area

providers to facilitate discharge to our community services.

A regular meeting of Consultants, ward managers and operational managers has been

utilised to focus on capacity and flow. This meeting is now supporting the clinical teams and

operational managers to work together to share ownership of capacity and demand across

the service.

4.2 NHSI trajectory

As part of the 5 year forward view for Mental Health, NHS Trusts have been challenged to

eliminate the use of out of area placements by April 2021. NHS Improvement (NHSI) has asked all

STP areas to submit trajectories for how Trusts intend to achieve this. The trajectory for LYPFT

includes acute (both OPS and working age) and PICU out of area placements but not dementia

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placements which are counted as specialist beds. Our trajectory is determined by predicting the

impact of our established actions over a 3 year period and will be closely managed and measured.

Performance against the trajectory will be reported and monitored as part of the Single Oversight

Framework and will be added to our performance reporting schedules. The fortnightly admission

and discharge performance group will look at a range of data and performance measures to

ensure that not only is the trajectory being met but that quality of care offered is not compromised.

Joanna Forster Adams

Chief Operating Officer

March 2018


PAPER TITLE: Combined Quality Performance Report





Joanna Forster Adams - Chief Operating OfficerPaper coordinator: Fiona Coope - Senior Performance Manager


SO1 We deliver great care that is high quality and improves lives SO2 We provide a rewarding and supportive place to workSO3 We use our resources to deliver effective and sustainable services

EXECUTIVE SUMMARYThe attached Combined Quality Performance report includes activity information fromFebruary 2018 (unless indicated otherwise).

Included are our agreed sets of metrics for Service, Quality, Workforce and FinancialPerformance.

The reintroduced Workforce metrics and measures of performance in this report are inarrears and relate to January 2018. It should be noted that this core set of metrics will besupported by quarterly performance reporting against our set of strategic measures asoutlined in our Workforce strategic plan.

As previously reported at Board, this report continues to be under development. Ourtimelines for the production and analysis of data still need further improvement so that ourBoard sub committees can consider our performance domains at a more granular level.More specifically, at the February Quality Committee it was agreed that we would refresh ourquality metrics and measures to ensure that they were consistent with achieving our qualitystandards and objectives. This work will be undertaken in April and May 2018.

As the Quality committee and Finance and Performance committee were not scheduled tomeet in March, the Board have received the full report for information to determine anyareas of significant concern.Do the recommendations in this paper haveany impact upon the requirements of theprotected groups identified by the EqualityAct?



AGENDAITEM

8.1

2

RECOMMENDATION

The Board are asked to: Review and note the content of this report Identify any concerns or additional work required for consideration by our scheduled

April Board sub committees. Acknowledge the further work which is still to be completed and developed during the

coming months.

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COMBINED QUALITY PERFORMANCE REPORT

Lead Director: Joanna Forster Adams, Chief Operating Officer

Date: March 2018 (reporting February 2018 data, unless otherwise specified)Board Meeting

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Unless otherwise specified, all data is for February 2018

This document presents our agreed and reported monthly metrics and provides a narrative update

where there are material changes, concerns or highlights which Board members should be aware

of.

Areas of improvement in month include:

Crisis plan within 24 hours

Ethnicity recording (seen only)

DTOC

OOA Placements

At care group level the performance framework is being replicated across service areas, with each

service/team having a relevant performance dashboard. Services are now receiving a one-page

scorecard each month, based on the measures required or developed at a local level, which have

been agreed through our governance processes.

The Board report format provides details of our performance against our mandated NHSI, CCG

and Standard NHS Contract requirements. These are categorised under 4 domains with narrative

provided where we have material concerns or can highlight positive results which provide

assurance to the Board. The 4 domains are as follows with subsequent sub-headings:

Service Performance

Access & Responsiveness: Our response in a Crisis

Access and Responsiveness: Our Specialist Services

Our Acute Patient Journey

Our Community Care

Clinical Record Keeping : Mandated requirements

Quality Performance

Effectiveness

Caring / Patient Experience

Safety

Introduction

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Workforce (monthly in arrears)

Finance

Further work has taken place to categorise each metric under the CQC 5 Key Lines of Enquiry

domains. These are shown at the end of the document:

Safe

Effective

Caring

Responsive

Well-led

The Board, in their November workshop, requested kite marks to be used as a measure in which

each KPI is assessed to provide assurance that the data quality meets dedicated standards. This

work is being progressed through our recently appointed Performance Manager and our report in

April will include an update of the work to date.

In the interim, the following monthly variance indicators have been used to identify if the position of

the metric has either improved, not changed or deteriorated from the previous month.

Key:

Green

Position improvedsince last month

Blue

Position unchangedsince last month

Red

Position deterioratedsince last month

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Service Performance – Chief Operating Officer


Our crisis and acute liaison services aim to provide urgent assessment and care for those service users inacute crisis. This set of performance data indicates the speed and accessibility of our services in thesecases. We are exploring how we measure on-going care provision and the outcomes this affects forpeople in crisis.The measures contained within this section indicate that our accessibility and responsiveness is largelyachieving or close to achieving our aims. However, interpreting and active management of the dataenables improvements and targets work where we identify issues. From a quality perspective it isimperative that we are able to consistently optimise our accessibility and responsiveness which is a keyarea of focus in our improvement and development work.

Crisis response time to answer phone

The Crisis Team via the Single Point of Access(SPA) aim to answer calls within 1 minute asstandard.

In February 82.47% (3,364) calls were answeredwithin the 1 minute standard.

Calls answered within 1 minute = 3,364 (82.47%)

Calls answered within 5 minutes = 3,903 (95.69%)

There were a total of 4,079 calls attempted and allcalls were answered.

Clearly we aim to improve performance to ensurethat we can always rapidly respond to those most incrisis. We are actively working to makeimprovements to consistently achieve the standard.Recently appointed additional staffing capacity willassist with this together with a range of monitoringand technological improvement actions. This isoverseen by our Crisis Service Manager.

Operationally we have a messaging system whichalerts callers to the fact that we will respond asquickly as possible and asking them to hold.

Calls answered within the 1 minute standard82.47% (3,364)

Total calls made and answered 4,079

Access & Responsiveness: Our response in a Crisis

Length of time taken to answer call

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Crisis Plan within 24 hours

This indicator measures the percentage of crisisplans input into the central reporting system within a24 hour time period.This indicator alerts us to our response to serviceusers referred or accessing our services in a crisis.This means that assessments and plans are putinto place and recoreded electronically so thatinformation can be accessed by practitioners. Thissupports the safety and consistency of care forindividual service users.We have seen improvement in the month andclosely monitor this standard in order to ensure thatour care records support care delivery for those inmost acute need.

Trust performance 99.09%Local Target 95%

Percentage of people with a Crisis AssessmentSummary and formulation plan in place

This indicator measures the percentage of patientsthat have a completed assessment summary andformulation plan in place.

The position in December was 97.52% with amarginal deterioration in month. However,consistent achievement of the standarddemonstrates that formulated and robust supportplans are established. From a quality perspectivethese plans are routinely audited with resultsperiodically reviewed through Trust Wide ClinicalGovernance.

Trust performance 96.03% (Jan)Local Target 95%Leeds Contract

Admissions to inpatient services had access tocrisis resolution / home treatment teams

This target is mandated and achieved ensuring thatadmissions are appropriate and that alternatives toinpatient care re explored and enacted whereappropriate and possible.

Trust performance 95.8%National Central Return 95%

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Timely Access to a MH Assessment by the ALPsteam in the LTHT Emergency Department

This is a key responsiveness target and an area forfurther development supported by ourcommissioners and partners in 2018/2019. Weroutinely achieve the standard required across boththe Leeds General Infirmary and St James’s site.We work in close partnership with A and Epractitioners although at times of peak surge anddemand it can be a significant challenge to achievethis standard. This can be due to irregular andunpredictable patterns of presentation in A and E,the availability of practitioners across both sites andtravel time to transfer and also the longstandingissue of the availability of suitable facilities to reviewpatients by our team.We work on a weekly basis with the A and Eleadership team to determine where improvementcan be made and resolve any immediate concerns.Senior leaders within LTHT provide positivefeedback on our service and responsiveness butare also keen to work with us to make theimprovements signalled in the planned 2018/2019developments.

Trust Performance 85.64%Local Target 90%

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This section will be further developed to indicate a range of performance measures for our more specialistlocal and regional services. At this point the area of focus from a contractual perspective continues to beour Gender identity service where although we are seeing month on month improvement, we continue tosee volumes of demand which far outweigh the scale of the commissioned service. The response onrecent commissioner consultation is overdue although we are now anticipating a proposal for significantchanges in the service model which we will consider in due course.

Gender Identity Service Average WaitingTime to First Offered Appointment

This shows the average waiting time to firstassessment appointment (excluding initialscreening) for new referrals to the Genderservice. There is no formal target, but this ismonitored nationally in all gender services dueto the increasing demand and concerns aboutresultant waiting times for all of the nationalgender services.Our February position represents a significantlyimproved position from last month, where wewere reporting an average 401 day wait. This isconsistent with the increased staffing and thechanges that have been made to assessmentprocesses within the gender service, although –as previously – this may deteriorate againdepending on the level of demand for theservice, which continues to outstrip theavailable resources. We continue to workclosely with our NHS England commissioners inrelation to this.

Trust Performance 369

Gender Identity Service Waiting List

This relates to the number of people on thegender waiting list for their first assessmentappointment. Again, this represents animproved position in month (from 894 peoplewaiting) and is consistent with the steadilyimproving trajectory over the last year, as aresult of increased capacity and revisedprocesses within the service (and despite thecontinued increase in the number of referrals).


Access and Responsiveness: Our Specialist Services

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We continue to experience significant pressure in our Acute inpatient services although it is clear that thepatient flow work programme is demonstrating that where we can make change and improvements this isnow starting to impact. We have seen improvements in our delayed transfers of care and continue to makeprogress with partners and commissioners in ensuring that our service users are able to exit inpatientservices when sufficiently recovered. The major area of on-going work in this area relates to EMI provisionwhere Leeds CCG are working to establish a strategic plan to address the current demand and expectedrise in demand over the coming years. Results of this work will be reported in the next quarter.We have seen an improvement in our out of area admissions in month and are closely managing andmonitoring progress. We are establishing our NHSI required improvement trajectory and are in the processof determining the quality metrics we will establish to ensure that we sustain our quality aims in the pursuitof improvement in this area.

Admissions to adult facilities of patients whoare under 16 years old

Trust performance 0National (SOF), no Target

Bed Occupancy rates for (adult acute) inpatientservices

Bed occupancy continues to be a significantchallenge across our services although we haveseen improvements in flow but they are yet tocreate any additional capacity. This continues to bean area of focus in our acute patient flow workprogramme.

Trust performance 98.9%Local Target 94-98%Leeds Contract – Acute wards

Delayed Transfers of Care

This represents a positive reduction in our DToCposition, as a result of detailed work previouslyreported that has been on-going between us, ourcommissioners and our adult social care partners.This work continues and is actively managed aspart of our acute patient flow work programme.

Trust total in month 11.2%Local Target 7.5%

Our Acute Patient Journey

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Out of Area Placements

Acute out of area placements have steadilydecreased during February. This has been inpart due to a marginal decrease in the levels ofdemand for admission due to the embedding ofthe capacity management arrangements led bythe Acute inpatient service lead and her teampreviously reported. This remains a key area offocus and our work to support service userswho are out of area continues with positivereported results.

83% of service users newly placed out of areain February were detained under the MentalHealth Act. This closely mirrors the rate of 84%for people detained on the adult acute wardsincluding PICU.

We continue to aim to admit all Leeds patientsto LYPFT beds. In February however, we had 2PICU service users as inpatients in Londonbased services and 3 acute adult service usersinpatients in the south of England. We continueto work closely with colleagues in BDCT andSWYFT to determine how we can maximise thepotential for all admissions within the WestYorkshire footprint. This is part of the acutecare STP work stream where we are activelysharing positive practice from other acuteproviders.

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Our core standards for community services are reported in this section where we have seen improvementin all areas of activity – with marked improvement in our memory services. Our community and older adultservices are subject to on-going review and improvement in order to maximise clinical outcomes andprovide high quality experience for our services users. We will be developing appropriate measures in thisarea in line with the timescales for our community services review.

7 Day Follow Up

This mandated safety target has been achieved thismonth, representing an improved position.

There was one breach in the ENE locality butthe circumstances of this case have beenexamined and were compounded by thehousing status of the individual services user.The service user was located by staff and ishoused in supported accommodation. There isnow regular engagement with the team.

Trust Performance 98.81%National (SOF) Target 95%

The SSE locality part triage by telephone on day 2 which forms part ofthe assessment. This produces a spike in reported performance andconsideration is being given as to how we can normalise theperformance data to provide robust internal benchmarking.

Waiting Times for Community MH Teams forface to face contact within 14 days

The overall community mental health teamperformance across the service has been achievedagainst this target at 81.6%Both South and East localities are exceeding the80% consistently. There is on-going improvementwork in the West locality which is being overseenand supported by the Community Services Managerand Clinical Lead.

Trust Performance 81.06% (Q4 to date)16/17 Target 80%17/18 No Target Agreed

Our Community Care

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Waiting Times Access to Memory Services;Referral to first Face to Face Contact within 8weeks

The service has proactively reviewed pendingreferrals to ensure that assessment is plannedwithin target timescale, and implemented aprocess system improvement which directlyalerts staff to appointment dates which do notplanned to occur within timescale of target.This has contributed to an upward trajectoryagainst the access target.

There is on-going improvement work andperformance monitoring established in order tofurther refine and improve our accessibility.

Trust Performance 85.6% (Q4 to date)Local Target 90%

Memory Services – Time from Referral toDiagnosis within 12 weeks

System improvement has been implemented whichnow enables recording of planned date ofdiagnostic appointment, to enable robustmonitoring, and work to ensure the deployment ofappropriate medical capacity to provide diagnosiswithin our access timescales. These actions havehad positive impacts on achieving and improvingthe performance significantly above the local target.

Trust Performance 71.84% (Q4 to date)Local Target 50%

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Care Programme Approach Formal Reviewswithin 12 months

Reporting of February data is suspended until Aprilin order to resolve the outstanding data qualityissues and provide an accurate reflection of ourperformance. However, reviews for Service usersin our Core Leeds and Specialist services exceedour 95% target established in our contractrequirements.

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This set of mandated data recording issues includes a significant issue on on-going concern where someteams and services are struggling to communicate with GP’s within our locally contracted standards.Whilst we are targeting improvement actions in these areas we anticipate that improvements specified inour EPR re-provision will enhance this further in future.

Data Quality Maturity Index (MHSDS)

This metric includes the mean measurement of thefollowing criteria:

Ethnic category General Medical Practice Code (patient

registration) NHS Number Person stated gender code Postcode of usual address Organisation code (code of commissioner)

Trust performance 96.9%National (SOF) Target 95%

Data Completeness – identifiers

This metric has been agreed to be removed fromthe end of March due to the MDSDS indicatorreplacing this.

Trust performance 99.6%Local Target 97%

Ethnicity recorded (seen patients)

This relates to service users who have beenphysically seen by our services, rather than thosethat are accepted and waiting. We are nowachieving this target.

Trust Performance 91.4%Local Target 90%

Clinical Record Keeping: Mandated requirements

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Ethnicity (NHS Standard Contract)

As reported previously, there are a significantnumber of service users waiting to be physicallyseen by our services (especially in the Genderservice) and therefore compliance with this targetfor all service users accepted will continually remaina challenge. This is understood and accepted bycommissioners.

Trust Performance 83.6%National Target 90%

NHS Number

This metric measures the completeness of NHSnumbers populated within the central reportingsystem.


The following services have failed to reach thetarget within Q3

Leeds Care Group total: 66.8%

Adult acute inpatients : 69.1%PICU 50%

CMHTs:Assertive Outreach 15.6%CMHT ENE 65.5%CMHT SSE 72.1%CMHT WNW 65%Younger People with Dementia 44%

Overall the SS&LD care group have reached thetarget with a position of 94.4% throughout Q3.However, Personality Disorder Services under-performed against this standard reporting 75% inthe quarter.

Timely Communication with GPs notified in 10days

This currently is local contract target which we havestruggled to achieve and make demonstrableimprovements.From April 2018 this metric will become morechallenging and will require GP communicationwithin 7 days. This will be included in the nationalstandard contract.The current communication requirement includesdischarge or any “significant change in treatment”.

Work is currently underway within the trust toensure this new metric can be captured from thenew financial year and we are targeting areas forimprovement so that accurate and timelycommunication is established consistently in ourteams. An update report will be provided to theFinance and Performance committee at the end ofquarter 1 and issues of on-going concern reportedto the Board.

Trust Performance 68.4% (Q3)

Local Target 80%

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Proportion of in scope patients assigned to acluster

At this stage we continue to measure against theprevious 90% target. A detailed update on this issueis reported in the Chief Operating report March2018.

Performance 89.1%No Target Agreed – measured against 90%

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Quality Performance – Director of Nursing


This report covers a quality perspective across the organisation for the month of February 2018.

The Nursing, Professions and Quality team continue to work across both care groups to

strengthen internal processes to ensure more seamless systems, which will expedite and improve

the quality and increase turnaround time for complaints.

The new Director of Nursing and Professions, who commenced her role on the 1st March 2018 is

arranging an external review of the Trusts patient experience, carers and involvement processes;

the findings of which will be presented to board for consideration.

Work will continue to support the Board and understand future requirements for metrics and how

these can be both meaningful and measured.

Healthcare Associated Infections – C.difficile

We continue to report zero C.difficile incidents.

Trust Performance 0

Healthcare Associated Infections – MRSA

We continue to report zero MRSA incidents.

Trust Performance 0

NHS Safety Thermometer Harm Free Care

The Safety Thermometer metric is compiled from 29wards/teams. During February, 2 community teamsand 1 inpatient ward submitted nil returns which hasreduced the figure to below the target. The 3Woodland Square ward closed on 28 Feb forrefurbishment, which was the date of capture for thereturn.

An engagement exercise is being undertaken in thecoming months to support clinical teams aroundguidance.


Effectiveness

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Service Users In Employment

Trust Performance 10.9%No Target

Service Users In Settled Accommodation

Trust Performance 59.3%National (SOF) Indicator – No Target

Data and narrative to be included from April. Mortality

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A responsive way of collecting and responding tofeedback internally is the ‘’You said we did’’meetings framework. As an example, users of theGender ID service recently said thatimprovements needed to be made to the timetaken from referral to the service, to being able toaccess the service as the waiting time was toolong. The service responded by reviewing thecare pathway; introducing a community outreachworker programme; 1 to 1 appointments, drop insessions and social activities to support safespaces.

Other external feedback is currently providedthrough the NHS Choices website and CareOpinion. The postings are used to help staff /teams get involved and understand the benefits offeedback provided. In February there were x9postings. The ICS (West), Gender ID, CAS andMalham House all received compliments.

Malham House also saw x2 concerns raisedabout staff attitudes and poor support; PICU sawan issue raised about restrictive interventions,cleanliness and catering; cultural competence wasraised about female ward at the Becklin and aconcern was raised about medical student’sattitudes. All are responded to through joint workwith the services to address and agreeimprovements.

Friends and Family Test

The one response received was about secondarycare community services at Linden House. Theresponder was unlikely to recommend this serviceas felt that a waiting time of 4 weeks to be seenwas too long.

The Friends and family test is currentlyadministered externally by Quality Health.

The Director of Nursing and Professions isinvestigating the low numbers as a matter ofurgency and will update the board verballyaround the challenges of the system we areusing.

There are a number of other internal and externalfeedback mechanisms across the services.

An external review has been agreed to look at thevision, outcomes and good practice areas forPatient experience and involvement.

LYPFT received only x1 friends and familytest response in February 2018.

Nationally Published Indicator

Caring / Patient Experience

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Leeds Care Group

SS&LD

Complaints

The trust received 10x complaints throughout February: 3x Leeds Care Group

6x Specialist/LD Care Group

1x Corporate

Leeds Care Group - In the LCG, the 3 complaints relatedto aspects of clinical care and were severity level “2”.

During February the Care Group closed a total of 10xcomplaints with 12x remaining overdue. Mitigation for theoverdue complaints is as follows:

7x are near completion and the delays includeinvestigator capacity and obtaining service userconsent.

1x is with the Care Group for sign off.

1x consent has not been received. The complaintsdepartment are working to obtain this as service useris currently in prison. Complainant is fully aware of theissue.

2x have been placed on hold: 1x coroner inquest and1x on hold due to criminal proceedings.

1x is extremely complex and requires expert opinion.A meeting has been arranged with the investigatorand Interim Deputy Chief Operating Officer to agreethe best way forward.

SS&LD - Specialist Services received 6x complaintsduring the month of February.

The themes related to 3x all aspects of clinical care; 1xreferral, 1x discharge and 1x patient property.

3x complaints had a severity rating of ”1”2x complaints had a severity rating of “2”1x complaint severity rating “3”.

The severity 3 complaint was in relation to a potentialclaim.

Specialist Services closed 1x complaint in February, with27x remaining overdue. The status of the overduecomplaint responses are as follows:

8x are with the Care Group for sign off.

3x have been placed on hold as are subject to HRdisciplinary investigation.

5x have been responded to by the Associate Directorand are awaiting further clarity before logging asclosed complaints.

1x is extremely complex. Complainant has been kept

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*Chart shows figures for LCG & SS&LD only,Corporate complaints are not included

Data from NHS Improvement (Model Hospital)for Q2 17/18:

Complaints per 1,000 wtestaff

National median (MHtrusts)

18.75

LYPFT 26.18

fully informed regarding the extension.

10x are near completion.

The Complaints Manager has a meeting scheduled withthe Interim Deputy Chief Operating Officer next week toreview and improve upon this current position.

The Trust requests that all final complaint responses aresent to the complainant within 30 working days. There areexceptions to this providing the complainant and theComplaints Manager have agreed to an extension due toextenuating circumstances. Of all the overdue complaints,all the complainants have been kept up to date with theprogress and provided with an explanation for theextension.

The extensions have been agreed with the followingmitigation:

Staff sickness absence.

Complexity of issue.

Consent not received from service user.

Despite attempts, delay in discussing the complaintfurther for required clarification.

Corporate – Corporate services received 1x complaintrelating to the complaints process. This complaintremains within timescale and has been rated as a severity“1”.

Trust Performance: 10Local Indicator

New indicator, added in as per request fromQuality Committee

Complaints – within 3 working days of the Trustreceiving the complaint, an acknowledgementletter is received

All complaints received in February 2018 wereacknowledged within 3 working days.

Trust Performance 100%Local Indicator


Complaints – Within 3 working days of the Trustreceiving the complaint, the investigator isallocated by the Care Group

LCG – 100% complianceThe 3x complaints received were allocatedwithin 3 working days.

SS&LD – 50% complianceOf the 6x complaints received, 3x were allocatedto an investigator within 3 working days.

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Corporate - 100% complianceThe 1x complaint received was allocated within3 working days.


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Complaints – Within 20 working days of the Trustreceiving the complaint, the investigator sendsthe draft report to the Complaints team to bechecked and approved

Within Q3 the complaints team received NILcomplaints within 20 working days.

Trust Performance N/aLocal Indicator


Complaints – Within 30 working days of the Trustreceiving the complaint, the response is sent tothe complainant

Within Q3 the following percentage ofcomplaints were sent to the complainant within30 working days:

LCG - 12% (3x)SS&LD - 13% (3x)Corporate – 50% (1x)

Though the response rates are monitored by thecomplaints team who maintain progress updatesand provide a two week reminder of theapproaching deadline, the response rateremains low as it is affected by previouslydiscussed factors such as coroner’sinvestigations, disciplinary issues andinvestigator capacity issues.


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Patient Advice and Liaison Service (PALs)

145 x PALS enquires were received in February.

A breakdown by care group is as below: 93x - LCG

27x - SS/LD

03x - Corporate

22x - Not given

The nature of the enquires were logged asbelow:

66x - were concerns.

1x - was a compliment.

66x - were information requests.

12x - were support required.

Of the 145 x enquires – 3 x were unresolvedand referred to the complaints team.


Data and narrative to be included from April withQ4 data.

Patient Outcomes

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Leeds Care Group

SS&LD

Incidents

Of all the incidents within February, key highlights foreach care group are as below:

Leeds Care Group 72% of incidents were reported as severity 1 – no

harm.

20% of incidents were reported as severity 2 – lowminimal harm.

2% of incidents were reported as severity 3 –moderate harm.

All incidents reported as severity 3 and 4 werediscussed at the Learning from Incidents &Mortality Meeting (LIMM) and any action requiredwas fed back to the teams including good practice

6% of incidents were reported at severity 5 –deaths. All were reviewed at LIMM and actiontaken as appropriate.

A number of staff were contacted via letter fromthe Deputy Director of Nursing thanking them fortheir professionalism and offering support inrelation to severity 3 incidents in which theyexperienced physical harm from service users whilstproviding care and treatment.

SS&LD 72% of incidents were reported as severity 1 – no

harm.

23% of incidents were reported as severity 2 – lowminimal harm.

3% of incidents were reported as severity 3 –moderate harm.

All severity 3 and 4 incidents were discussed atLIMM and actioned accordingly. Good practice andaction required feedback to relevant staff.

2% of incidents were reported as severity 5 deathand all were reviewed at LIMM with action taken asappropriate.

2x deaths were reported to LeDer.

The themes were: Clinical Patient Care; Self-harm;Violence (SU to Staff) and Violence (SU to SU). Asabove all serious incidents are discussed andresponded to at LIMM.

Trust Performance: 1,060 incidents recorded

Safety

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Incidents reported within 48 hours from incidentidentified as serious

The Trust reported one incident as Serious(Severity 3 with potential to be Severity 4)in February 2018. The incident was in relationto the power outage at the Newsam Centre.

Trust Performance: 100% (Feb)Local Target 100%

Never Events

We continue to report zero never events.

Trust Performance 0National Target 0

Restraints and Restrictive Interventions

During February 2018 there were x233 incidentsof restraint across the organisation which is adecrease from the previous month.

26/233 of the restraint incidents included the useof the prone position which is a decrease fromthe previous month.

Oversight of restraint and restrictive interventiondata continues to be reported to the MentalHealth Legislation Operational Steering Groupon a quarterly basis.

Trust Performance: 233

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There were 101 new detentions under the MHA inFebruary 2018 as follows:

Legal Status Number

s.2 54

s.3 32

s.4 1

s.37n 1

s.37/41 1

s.5(2) 11s.5(4) 1

Community Treatment Order 14

Total 115

There were 14x new community treatment orders(CTO’s).

No. of patients detained under the MHA

There has been no significant increase or decreasein the number of patients detained under the MHA inFeb 2018 compared previous months in this financialyear.

The total number of detained patients, includingCTO’s as of 28 Feb 2018 = 464

Agreed reporting for CQUINs to be clarified andincluded in sub-committee reports from Aprilwith Q4 data.

CQUINs

1059/1624 front line staff vaccinated.

Uptake increased by 10% from 55% to65.65%

This year’s vaccination uptake by area datasuggests low uptake areas from last yearhave improved between 10-20%.

Flu Uptake

The NHS England strategic objectives for the flu planand the associated Clinical Commissioning GroupCQUINs’ aim is to actively offer the influenza vaccineto 100% of eligible staff with intermediary targets setat For the 2017/18 season these are:

50% uptake or less = no payment

50-60% uptake = 25% payment



70% uptake or above = 100% payment

The Compliance figures for the Flu CQUIN forLYPFT at the end of the campaign was 65.65%

This means that LYPFT has successfully met anintermediary target of 65-70% with a 75% CQUINNpayment.

LYPFT has successfully met a payment of 75%for the first time.

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Safeguarding Adults and Children


Medication Errors

Falls by severity and care groups

In the context of reporting falls

Severity 1 describes no injuries. Severity 2 describes first aid, minor service

interruption. Severity 3 describes medical treatment

given, moderate service interruption.

Severity 1 FallsJan 18 Feb 18

LCG 47 46SS&LD 09 08


LCG 14 12SS&LD 06 02


LCG 0 0SS&LD 0 0

Falls

Across LYPFT all reported service user falls arereviewed at the newly formed Trust-wide Falls &Pressure Ulcer Improvement Forum. The forum isresponsible for developing specific improvementgoals in relation to reducing the number of reportedfalls and pressure ulcers, promoting safety and well-being for service users, and demonstrating our abilityto learn from incidents.

The majority of the severity 1 & 2 falls occur in LeedsCare Group occur within the Mount on wards 1 & 2(the Dementia Inpatient Unit).

In order to learn from and reduce falls both dementiainpatient services at The Mount are implementingthe falls ‘safety huddles’.

One of the key learning points have been the focusupon the wider teams’ contributions to the fallhuddles in terms of a shift in culture where allmembers of the wider inpatient team (including wardhouse-keepers) are invited to contribute and bemade aware of those service users who are most atrisk of a fall.

To support this work, a clinical audit has beenidentified as part of the LYPFT priority audits whichhas a focus on falls prevention at The Mount.

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Unless otherwise specified, all data is for January 2018

Appraisals

Work continues to support the transition from paperrecords to Ilearn recording for Trust appraisal. Thisincludes a continued programme of training tosupport staff and managers.

Trust Performance 80.1% Local Target 85%

Compulsory Training

Trust wide compulsory training compliance continues

to be maintained above the Trust target of 85%. The

Learning and Organisational Development Team are

working with the subject matter experts to review the

training needs analysis and associated training

delivery models to support higher levels of

compliance.


Clinical Supervision

There are a number of work streams in place to

support improvement, including the introduction of

care group audit of compliance against the Trust

clinical supervision policy and monitoring of

performance both locally and at care group level.

The transition from local records to using Ilearn for

clinical supervision continues to develop and this

includes support for staff locally to use the system

and system enhancements to ensure Ilearn meets

local and organisational requirements.


Staff Turnover

The turnover target is being changed as part ofsome refreshed workforce metrics from 1 April andlikely to be reduced to 10%.Our performance for the trust is currently 12.7%below the existing target. Analysis of turnover datawas shared in the January Board Workforce Report.


Workforce

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Sickness due to MSK

The target of 9.8% is being reviewed and refreshedas a result of the new Workforce Strategic Plan anda new target implemented from 1 April 2018. This isshowing an improvement from the last month.Proactive and preventative interventions continue tobe provided by the Trust physiotherapist.

Trust Performance 14.38% (12 months to Jan)

Local Target 9.8%

Sickness Absence Rate

The target of 3.70% is being reviewed and refreshedas a result of the new Workforce Strategic Plan anda new target implemented from 1 April 2018.Sickness absence has been decreasing with thetrend showing a reduction over the last 6-7 monthsalthough showing a very slight increase in January.


Local Target 3.70%

Sickness due to Stress

The target of 15% is being reviewed and refreshedas a result of the new Workforce Strategic Plan anda new target implemented from 1 April 2018. Thiscontinues to be a challenge across the Trust withOH, HR and Well-being practitioner workingcollaboratively to support employees and local healthand wellbeing groups being developed.


Local Target 15%

The number of vacancies at 28th February was309 wte:

Specialist Services had 155 wte Leeds 60 wte Corporate services 94 wte

The main type of vacancies are:

Nursing 117 wte Support worker 116 wte Admin and Estates 79 wte

AHP vacancies – 7 wte of which 4 wte areOccupational Therapists

Vacancies

Monthly meetings are taking place betweenAssociate Directors and HR to plan monthlyrecruitment events for nursing and HSW posts basedon vacancies and hotspots. Vacancy hotspotsinclude Clifton House and Forensics Services, TheMount and Specialised Supported Living Services.The Recruitment team is also working with theMedical Directorate to support Consultantappointments.

Trust Performance 12% (Feb)

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Chief Financial Officer

This section highlights performance against key financial metrics and details known financial risksas at February 2018. Further detailed financial analysis and actions taken to address risks arecontained within the Chief Financial Officer report. The financial position as reported at month 11 iswithin plan tolerances, although this was achieved predominantly though non-recurrent measures.

Single Oversight Framework – Finance Score

The Trust achieved the plan at month 11 with an overall FinanceScore of 1 (highest rating).

Income and Expenditure Position (£000s)

£3.23m surplus income and expenditure position at month 11.Overall net surplus £79k better than plan and achieved a rating of1(highest rating).

Cost Improvement Programme (£000s)

CIP performance at month 11 is £2.87m below plan. £2.57m CIPachieved (47%) compared to the planned position of £5.43m.

Cash (£000s)

The cash position of £54.07m is £5.18m above plan at the end ofmonth 11 and achieved a liquidity rating of 1(highest rating).

Finance

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Capital (£000s)

Capital expenditure is behind the original plan at £1.47m to month11 (36% of year to date original plan). The main reason is thereview of the tender process on the PFI refurbishment works. Thecapital plan was reforecast in year and the year to date position isbroadly in line with the revised plan.

Agency spend (£000s)

Compares actual agency spend (£4.0m at month 11) to thecapped target set by the regulator (£5.2m at month 11). The Trustreported agency spending 23% below the capped level andachieved a rating of 1.

Areas of financial risk as at February 2018:

On-going pressure on OAPs not sufficiently mitigated by non-recurrent CCG income. Further deterioration in underlying run rate.

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Acronym/Term

Full Title Definition

ASC Adult Social Care Providing Social Care and support for adults.

EMI Elderly Mentally Infirm Is a secure unit for the Elderly Mentally Infirm – providing 24 hour care.

CPA Care Programme Approach The Care Programme Approach (CPA) is a way that services are assessed, planned, co-ordinated and reviewedfor someone with mental health problems or a range of related complex needs. You might be offered CPAsupport if you: are diagnosed as having a severe mental disorder.

MDT Multi-Disciplinary Team A multidisciplinary team is a group of health care workers who are members of different disciplines(professions e.g. Psychiatrists, Social Workers, nurses, physio or occupational therapists.), each providingspecific services to the patient

Tier 4 CAMHS Tier 4 Child AdolescentMental Health Service-

Child and Adolescent Mental Health (CAMH) Tier 4 Children’s Services deliver specialist in-patient and day-patient care to children who are suffering from severe and/or complex mental health conditions that cannot beadequately treated by community CAMH Services.

S136 Section 136 Section 136 is an emergency power which allows service users to be taken to a place of safety from a publicplace, if a police officer considers that you are suffering from mental illness and in need of immediate care.

CAS Crisis Assessment Unit The Leeds Crisis Assessment Service (CAS) is a city-wide acute mental health service. It offers assessment topeople 18 years and over who are experiencing acute mental health problems that may pose a risk tothemselves and/or others, who require an assessment that day or within the next 72 hours.

Our Crisis Assessment Service (CAS) works across health, social care and the voluntary sector to improveaccess to appropriate mental health services. It consists of:

LADS Leeds Autism DiagnosisService

The Leeds Autism Diagnostic Service (LADS) provides assessment and diagnosis of people of all intellectualability who may have autism who live in Leeds.

CTM Clinical Team Manager The Clinical Team Manager is responsible for the daily administrative and overall operations of the assignedclinical teams. The person is responsible for the supervision of all employed clinical staff. They serve as theprimary leadership communications link between the teams and departments throughout the organisation. TheClinical Team Manager is responsible to ensure the overall smooth day to day operations, employeeengagement and a high quality patient experience while achieving departmental and organisational goals.

Never event Never Events Never events are serious, largely preventable patient safety incidents that should not occur if the availablepreventative measures have been implemented.

AHP Allied Health Professionals Allied Health is a term used to describe the broad range of health professionals who are not doctors, dentistsor nurses. Allied health professionals aim to prevent, diagnose and treat a range of conditions and illnessesand often work within a multidisciplinary health team to provide the best patient outcomes. Examples of AHP’sinclude psychologists, physiotherapists, occupational therapists, podiatrists and dieticians.

TOC Triangle of care The 'Triangle of Care' is a working collaboration, or “therapeutic alliance” between the service user, professionaland carer that promotes safety, supports recovery and sustains well-being principles.

Glossary

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Lead co-ordinator Fiona Coope, Senior Performance Manager, with contributions from:

Andy Weir, Interim Deputy Chief Operating Officer / Associate Director Specialist & Learning Disability ServicesEddie Devine, Interim Associate Director for Leeds Care GroupNichola Sanderson, Deputy Director of NursingDave Brewin, Deputy Director of FinanceIan Bennett, Head of Operational Quality and Governance DevelopmentNikki Cooper, Head of Performance Management and InformaticsIan Burgess, Senior Information ManagerKerry Playle, Senior Information Manager

Paper authors

JT/29Mar/15/16finalCEW/16CH


PAPER TITLE: Director of Nursing report



Cathy Woffendin, Director of Nursing and Professions


Cathy Woffendin, Director of Nursing and Professions


SO1 We deliver great care that is high quality and improves lives.SO2 We provide a rewarding and supportive place to work. SO3 We use our resources to deliver effective and sustainable services.

EXECUTIVE SUMMARY

The purpose of this report is to outline the initial focus of work involving the Director ofNursing and Professions over the first two weeks of commencing employment with the Trust.




RECOMMENDATION

The Board is asked note the contents of this report and to continue to support the staff andservices with their ongoing initiatives.

AGENDAITEM

9

of 4


Director of Nursing and Professions Report

The new Director of Nursing and Professions commenced employment with the Trust on 1 March

2018 and was requested by the Chair to compile a written report for Trust Board. This report

highlights the initial areas of focus within the first two weeks of being in post. Future reports will be

produced quarterly in line with the boards business planning cycle and provide progress against

key strategic objectives within this portfolio.

1. Patient Experience and Involvement

An independent external review of the Trust’s Patient Experience and Involvement systems and

Processes will be commissioned. Initial work and discussions have commenced to consider the

areas of scope of this review. Service Users, Carers and Board members, along with other key

individuals will be consulted and engaged within this process in the next few months. The focus of

this work will also review the Friends and Family Test feedback which is currently provided through

an external provider, Quality Health, and provides limited information and poor response rates.

2. Safer Staffing

A Safer Staffing Steering Group has been established to progress the work of the recently

published Safe, Sustainable and Productive Staffing “An Improvement Resource for Mental

Health” (NHSI January 2018)

This improvement resource makes specific reference in adopting the expectations set out by The

National Quality Board (NQB) in its July 2016 publication, “Supporting NHS Providers to deliver the

right staff, with the right skills in the right place at the right time”.

Safe, Sustainable and Productive Staffing outlines the expectations and framework within which

decisions on safe and sustainable staffing should be made to improve health outcomes. In the

absence of a national tool for mental health services it has proved problematic to ascertain

baseline staffing figures based on acuity and need for each area. The newly published

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improvement resource will assist the Safer Staffing Steering Group in defining this area of work

and in providing a comprehensive annual staffing review for Board. The group’s terms of

reference are currently being developed with the first meeting planned for April 2018.

3. Flu Vaccination

Flu Uptake

NHS England strategic objectives for the flu plan and the associated Clinical Commissioning

Group CQUINs’ aim is to actively offer the influenza vaccine to 100% of eligible staff with

intermediary targets set for the 2017/18 season these are:

50% uptake or less = no payment




70% uptake or above = 100% payment

Flu figures at the end of the campaign have reached 65.65%. This is the highest compliance to

date and this achievement is to be congratulated.

LYFPT will be discussing with CCG colleagues the expectation of receiving 75% payment.

Row Labels

Number of PF staff

vaccinated

Patient facing staff in

the Trust %Vaccinated

Additional Clinical Services 340 532 64%

Allied Health Professionals 170 246 69%

Medical and Dental 108 173 62%

Nursing and Midwifery Registered 438 671 65%

Grand Total 1056 1622 65.65%

Last year comparison/trajectory:

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4. Complaints

The current position as of the 12 March 2018:

Leeds Care Group

In Oct 2017 the Leeds Care Group had 38 overdue complaint responses. This figure has reduced

month on month with the current position much improved.

The Leeds Care Group currently has a total of 30 complaints, 18 of which have been responded to

within the 30 day timescale the remaining 12 are still in progress. A summary of these are outlined

below:

7 are near completion.

1 is with the Care Group for sign off.

1 consent has not been received. The Complaints department are working to obtain this as

service user is currently in prison. Complainant is fully aware of the issue.

2 have been placed on hold: 1x coroner inquest has concluded, to date no details of the

complaint have been received. 1x on hold due to criminal proceedings.

1 is extremely complex. The complainant has been kept fully informed regarding the

extension

Specialist/LD Care Group

In Oct 2017 the Specialist/LD Care Group had 28 overdue complaint responses. Although there

was an improvement in reducing this figure in Nov and Dec 17, the current position is that of the 36

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complaints in process, 27 complaints have not been responded to within 30 working days. A

summary of these is as follows

8 are with the Care Group for sign off.

3 are subject to HR disciplinary investigation.

5 have been responded to by Andy Weir and are awaiting further clarity.

1 is extremely complex. The complainant has been kept fully informed regarding the

extension.

10 are near completion.

Sam Marshall has a meeting scheduled with Andy Weir next week to review and improve upon this

position.

Corporate/Estates

Corporate/Estates has 2 complaints in process, both are within current timescales.

KPI 1 – Acknowledgement of complaint within 3 working days

In February 2018 the complaints team acknowledged 100% of complaints were received within 3

working days.

5. CQC

The trust received the CQC report on the 14th March and has two weeks to review the report for

factual accuracy and return to CQC

Cathy Woffendin

Director of Nursing and Professions

JuT29Mar/13CW/14amend1512/14CH


PAPER TITLE: Safer Staffing 1 February 2018 to 31 February 2018



Cathy Woffendin - Director of Nursing and Professions


Linda Rose - Head of Nursing and Patient ExperienceAndrew McNichol - HR Systems ManagerLaura Booth - e-Rostering Team Manager


SO1 We deliver great care that is safe, effective and improves livesSO2 We provide a rewarding and supportive place to workSO3 We deploy our resources to deliver effective and sustainable services

EXECUTIVE SUMMARYThe purpose of this report is to provide assurance of the current position with regards to theNational Quality Board (NQB) Safer Staffing requirements across the two operational careservices in Leeds and York Partnership Foundation Trust, to the Board of Directors and thepublic.

The report provides assurance that all efforts are being made to ensure detailed internaloversight and scrutiny is in place to ensure safer staffing levels are maintained.

This report provides information on 26 inpatient units for the periods 1 February 2018 and 28February 2018 and includes details of any notable exceptions to the planned staffing levels.

This month’s report also includes some information about the New National Quality Board(NQB) improvement resources for learning disabilities and mental health services.




RECOMMENDATION

The board is asked to review and discuss the staffing rates in the Unify report –particularly those areas that have provided a narrative as a result of being identified asexceptions of note.

The board to consider the current reporting format which will be reviewed at futuremonthly Safer staffing meetings.

AGENDAITEM

9.1

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REPORT TO THE BOARD OF DIRECTORSSAFER STAFFING – FEBRUARY 2018

1. Background

All hospitals are required to publish information about the number of Registered Nurses (RN) and

Health Support Workers (HSW) on duty per shift on their inpatient wards.

Full details of staffing levels are reported to public meetings of our Board of Directors and made

accessible to the public (via the Unify Report (Appendix A) at the NHS Choices website. Safer

staffing information is also accessible to the public via the Trust’s own website.

In addition to this the Trust is required openly display information for service users and visitors in

all of our wards that shows the planned and actual staffing available at the start of every shift.

2. Purpose of this report

The purpose of this report is to provide assurance of the current position with regards to the

National Quality Board (NQB) Safer Staffing requirements across the two operational care services

in Leeds and York Partnership Foundation Trust, to the Board of Directors and the public.

Detailed internal oversight and scrutiny is in place to ensure safer staffing levels are maintained.

The report highlights the ongoing work that is being undertaken to support safer staffing.

Rose Ward closed in January 2018 and this report now provides information on 26 inpatient units

for the period 1st February 2018 to 28th February 2018. The report includes details of any notable

exceptions to the planned staffing levels for February 2018.

3. Updates

3.1 New National Quality Board (NQB) improvement resources for learning disability and

mental health services.

The NQB in its July 2016 publication “Supporting NHS providers to deliver the right staff, with the

right skills, in the right place at the right time: Safe, sustainable and productive staffing” outlines

the expectations and framework within which decisions on safe and sustainable staffing should be

made to improve health outcomes. It ensures delivery of safe, effective, caring, responsive and

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well-led care on a sustainable basis, and that organisations employ the right staff with the right

skills in the right place and at the right time.

In January 2018 the NQB released 2 additional improvement resource papers for ensuring Safe,

sustainable and productive staffing (listed below):

An improvement resource for learning disability services

An improvement resource for mental health services

These improvement resource papers make specific reference to adopting the above expectations

in mental health and learning disability services whilst recognising the nuances that exist in these

provisions. The content has been developed by a reference group of sector leaders and was

informed by a review of literature, multi-professional experience and in consultation with service

users and carers. They aim to provide quality and consistency through the recommendations for

board accountability and expectations of clinical leaders at service and team levels.

Example dashboard templates to monitor safe, sustainable and productive staffing, and escalation

processes have been developed, as well as an outline of a strategic staffing review. These

resource papers also recommend documents and metrics that should be considered relevant to

safe, sustainable and productive staffing in mental health and learning disability services.

The Trust has reviewed the recommendations outlined in both of the improvement resource

papers and is now giving consideration to the existing Safe Staffing reporting processes to assure

that the scope of information currently included in the Board Report provides the required details .

To ensure this work is programmed the Director of Nursing has requested that a Safer Staffing

Steering Group is developed; the first meeting is planned for April. Many of the recommendations

outlined in the resource papers are currently implemented across the organisation and are

integrated in the daily decision making of ward managers which are reflected in the narrative

included in the exception reports to the Board.

4. February 2018 - Exception reports against Planned and Actual staffing

The e-Rostering manager has identified key areas with staff rates outside of tolerance in 3 or more

areas. The exception reports are presented in a narrative format detailing the activities and issues

at ward level in order to provide assurance of awareness of the issues of concern and actions

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being taken to mitigate those concerns. Detailed data can be presented on request around

incidents, staffing levels, temporary staffing usage, skill mix and vacancies should this be required.

4.1 The Mount Ward 2

February 2018Type PlannedRegHoursDay ActualRegHoursDay PercentRegDay Type ActualRegHoursNight PercentRegNight

HCW 1,135.5 1,679 147.86% 580.5 1,161 200.00%

NURSING 796.5 834.71666667 104.80% 602 419.25 69.64%

There are higher than usual Health Support Worker (HSW) numbers during both the day and night

and lower Registered Nurse (RN) numbers at night during February. This was due acuity levels

where x2 service users required within eyesight observation and engagement levels for the

majority of this period.

Temporary Staffing (41%)

Contributory factors to an increase in temporary staffing usage included providing additional cover

to meet the HSW vacancy factor and provision of additional staff to meet the increase in bed

number occupancy in the absence of the equivalent budget increase.

Vacancies

The vacancy issue remains on the Trust risk register – Registered Nurse pressures are less

problematic but Health Support Worker vacancies remain high particularly on the dementia wards.

The service continues to host regular recruitment events and at the most recent event, recruited x1

band 5 RN and x4 band 3 HSW’s across services at the Mount. Ward 2 recently had x1 successful

HSW candidate who is currently moving through the recruitment process.

Further substantive HSW interviews are scheduled for March. It is therefore expected to see a

reduction in the usage of temporary HSW staff in the next few months.

Staff Unavailability

There was x1 HSW off sick throughout February and x1 HSW off sick for early part of February.

Both HSW’s are now back at work and being provided with return to work support.

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Incidents

The data tells us that there has been an increase in violent and aggressive incidents towards staff

during February. The antecedents to this are in relation to two recent admissions to the service

where staff have made attempts to provide personal care interventions. Additional staff have been

provided to ensure that the required interventions are managed safely and compassionately. The

majority of the incidents are low level severity 1 and the leadership team are continuing to monitor

this and support staff.

Matron Comments

Safe staffing continues to be a focus of management supervision with Ward Managers and the

services endeavour to predict any shortfall as far in advance as possible.

4.2 Newsam Ward 1 PICU


HCW 1,249.5 2,250 180.07% 605 1,729 285.79%

NURSING 1,101.5 836 75.90% 550 483.5 87.91%

There are higher than usual HSW numbers during both the day and night and lower RN numbers

during the day and night in February. This was due to high levels of acuity throughout. This

necessitated x400 hours of seclusion which required x2 staff; x31 days of 1:1 within eyesight

observations and x9 days of 2:1 within eyesight observations.

Vacancies

There are currently x5 Registered Nurse vacancies and x1 Health Support Worker vacancy. There

were no successful candidates identified at the most recent band 5 recruitment event and as a

result, these vacancies are currently being re-advertised. An apprentice is due to start at the

beginning of March which will mean that the Ward will be fully staffed for HSWs.

The acute service Ward managers at the Newsam Centre and The Becklin Centre are due to

reschedule a meeting to discuss supporting each other with staffing capacity as several of the

wards have similar levels of vacancies. Ward 1 Newsam has been able to staff the ward safely

with a combination of the good will of staff being flexible with off duty requirements, changing shifts

at short notice and the support of regular bank staff and colleagues across the service.

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Unavailability

There were higher than usual levels of sickness absence during February, none of which were

work related. There is also x1 HSW on a Career Break. Sickness absence has now resolved and

staff are being provided with the appropriate return to work support.

4.3 3 Woodland Square


HCW 808.5 590 72.97% 294 283.5 96.43%

NURSING 549 364.5 66.39% 294 231 78.57%

There are lower than usual HSW numbers both during the day and lower than usual RN numbers

during the day and night in February. This was due to the unit been closed for renovations and

necessary staff were redeployed to others areas as required based on occupancy levels and

acuity.

Vacancies

There are currently x2 RN vacancies at 3 Woodland Square. The service has recently recruited x1

band 5 and has redeployed staff from another service in order to relieve staffing pressures.

There is also x1 HSW vacancy. This vacancy has been appointed to following interviews held at

the beginning of March.

Matron Comments

The service continues to have difficulties in recruiting band 5 RN’s. In order to address this issue,

the skill mix at Parkside Lodge will be amended in the new financial year. This will have a positive

impact on the staffing levels at 3 Woodland Square, as the staff will work across both units. The

service will also introduce band 4 Nursing Associates. This will provide a career pathway for some

of the excellent HSWs currently working within the service and will hopefully help to alleviate the

band 5 problem. Steps are also in place to forge better relationships with universities, to support

an increase in in training applications for LD Registered Nurses.

4.4 Bluebell Ward


HCW 646.5 1,258.5 194.66% 600.04 878.76666666 146.45%

NURSING 936 573.5 61.27% 600.04 267.91666675 44.65%

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There are higher than usual HSW numbers both during the day and at night and low RN numbers

during the day and night in February.

Bluebell has not been able to meet the planned establishment of x2 Registered Nurses during day

shifts for some time due to recruitment issues. In practice, the ward has been able to ensure that

x1 RN has been on duty for all shifts supported by x3 HSWs.

Following the closure of Rose ward and the redeployment of x14 staff to Bluebell Ward, the

establishment has now increased. The increase will provide an improvement in staffing levels but

recruitment will need to continue to improve the RN vacancy rate further.


There has been a high proportion of leave in the month of February, some of which is related to

Rose Ward staff supporting the delivery of clinical services by not taking booked leave during this

difficult period. In addition there has been training with the OD team and other unavailability is due

to sickness and special leave.

An ‘All-In Meet and Eat’ ward meeting has been introduced on Bluebell ward where staff who are

not on shift will come in for a monthly staff meeting and discuss ward-based agenda items and

issues that have been raised by the staff group. This is recorded as unavailability on the February

rota.

Matron Comments

Bluebell has experienced a high degree of change due to staff from Rose Ward joining the team.

This has had a positive impact on the staffing of the ward; on general performance; increasing

activity with patients and clinical supervision. Clifton House continues to be subject to

reconfiguration of services and the management team are working closely with Commissioners

and partnership providers within the STP to support a design of service which will meet the needs

of our STP in the longer term. A recruitment campaign will be redesigned to reflect any agreed

future reconfiguration.

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4.5 Becklin Ward 4


HCW 678 1,295 191.00% 616 968 157.14%

NURSING 1,156.5 869.5 75.18% 583 595 102.06%

There are higher than usual HSW staffing numbers during the day and night and lower RN

numbers during the day in February. This was due to due acuity where additional staffing was

required to support x1 service user who was nursed on within eyesight observations for the entire

month of February and another service user who was intermittently placed on within eyesight

observations when undergoing ECT treatment.

Vacancies

There are currently x4.4 RN vacancies on Ward 4 Becklin. There is also x1 HSW vacancy which

has now been filled by an apprentice.


There is currently x1 RN on long term sick and x1 HSW was off sick throughout February and has

now returned.

5. Conclusion

Staffing pressures The Mount continue to remain on the Risk Register with further recruitment

events planned for the coming months. The Mount also had to escalate outside of its usual

resource for staffing in this report.to ensures that service delivery and patient care were not

compromised.

The acute inpatient service also report recruitment difficulties in terms of Band 5 Registered

Nurses and are working across the service to ensure staffing capacity is met.

Service changes at Clifton House resulted in the closure of Rose Ward. Staff have been

redeployed to Bluebell Ward and this has increased staffing levels there however there is still a

shortfall in RN staff within the service which has been mitigated by redeployment of staff from

other areas until vacancies are filled

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This report presents the mitigation to a number of exceptions affecting the delivery of safer

staffing; however there were no breeches to patient safety and a Registered Nurse was available

of all shifts.

6. Recommendations:

The Board is asked to receive the report and note the contents.

Discuss any issues raised by the content

JuT29Mar/13CEW/14CH

1

Appendix A

Unify Report February 2018

Ward name TypeDay - planned

hoursDay - actual

hoursDay - fill rate

(%)Night - planned

hoursNight - actual

hoursNight - fill rate

(%)

ASKET CROFTHCW 794.5 752.8 94.8% 616.0 690.5 112.1%

NURSING 534.0 691.5 129.5% 308.0 297.0 96.4%

ASKET HOUSEHCW 385.5 615.3 159.6% 308.0 363.0 117.9%

NURSING 387.0 388.3 100.3% 308.0 299.3 97.2%

BECKLIN WARD 1HCW 470.6 1,168.3 248.3% 605.0 637.0 105.3%

NURSING 938.5 832.5 88.7% 616.0 616.0 100.0%

BECKLIN WARD 2 CRHCW 644.0 816.2 126.7% 644.0 791.0 122.8%

NURSING 644.0 597.0 92.7% 632.5 561.0 88.7%

BECKLIN WARD 3HCW 726.0 1,052.0 144.9% 616.0 660.0 107.1%

NURSING 853.5 821.0 96.2% 616.0 605.0 98.2%

BECKLIN WARD 4HCW 678.0 1,295.0 191.0% 616.0 968.0 157.1%

NURSING 1,156.5 869.5 75.2% 583.0 595.0 102.1%

BECKLIN WARD 5HCW 621.0 1,281.1 206.3% 605.0 1,056.0 174.5%

NURSING 1,092.5 1,056.6 96.7% 616.0 606.5 98.5%

YORK - BLUEBELLHCW 646.5 1,258.5 194.7% 600.0 878.8 146.5%

NURSING 936.0 573.5 61.3% 600.0 267.9 44.6%

YORK - RIVERFIELDSHCW 505.0 1,351.0 267.5% 600.0 653.7 108.9%

NURSING 626.0 858.0 137.1% 300.2 257.2 85.7%

NICPM LGIHCW 352.5 327.0 92.8% 231.0 231.0 100.0%

NURSING 892.0 948.7 106.4% 588.0 640.5 108.9%

NEWSAM WARD 1 PICUHCW 1,249.5 2,250.0 180.1% 605.0 1,729.0 285.8%

NURSING 1,101.5 836.0 75.9% 550.0 483.5 87.9%

NEWSAM WARD 2 FORENSICHCW 781.5 1,012.8 129.6% 602.0 722.0 119.9%

NURSING 732.0 629.5 86.0% 301.0 335.0 111.3%

NEWSAM WARD 2 WOMENSSERVICES

HCW 753.0 964.5 128.1% 602.0 612.8 101.8%

NURSING 618.0 586.5 94.9% 301.0 290.3 96.4%

NEWSAM WARD 3HCW 718.5 1,107.5 154.1% 580.5 602.0 103.7%

NURSING 683.5 558.5 81.7% 279.5 322.5 115.4%

JuT29Mar/13CEW/14CH

2

Ward name TypeDay - planned

hoursDay - actual

hoursDay - fill rate

(%)Night - planned

hoursNight - actual

hoursNight - fill rate

(%)

NEWSAM WARD 4HCW 661.5 1,072.0 162.1% 616.0 737.0 119.6%

NURSING 804.0 882.0 109.7% 605.0 616.5 101.9%

NEWSAM WARD 5HCW 1,024.5 1,311.0 128.0% 891.0 1,032.8 115.9%

NURSING 703.5 701.3 99.7% 308.0 345.0 112.0%

NEWSAM WARD 6 EDUHCW 625.5 1,051.0 168.0% 588.0 1,062.3 180.7%

NURSING 704.0 913.3 129.7% 294.0 420.0 142.9%

PARKSIDE LODGEHCW 1,359.5 2,091.3 153.8% 882.0 1,510.8 171.3%

NURSING 1,096.0 805.0 73.4% 294.0 315.0 107.1%

2 WOODLAND SQUAREHCW 610.5 345.5 56.6% 294.0 294.0 100.0%

NURSING 576.5 588.0 102.0% 294.0 294.0 100.0%

3 WOODLAND SQUAREHCW 808.5 590.0 73.0% 294.0 283.5 96.4%

NURSING 549.0 364.5 66.4% 294.0 231.0 78.6%

MOTHER AND BABY THE MOUNTHCW 633.0 970.5 153.3% 583.0 951.5 163.2%

NURSING 762.0 682.0 89.5% 550.0 499.0 90.7%

THE MOUNT WARD 1 NEW (MALE)HCW 1,459.0 1,949.5 133.6% 903.0 1,633.5 180.9%

NURSING 674.5 808.5 119.9% 322.5 322.5 100.0%

THE MOUNT WARD 2 NEW(FEMALE)

HCW 1,135.5 1,679.0 147.9% 580.5 1,161.0 200.0%

NURSING 796.5 834.7 104.8% 602.0 419.3 69.6%

THE MOUNT WARD 3AHCW 1,111.3 1,220.8 109.9% 616.0 714.2 115.9%

NURSING 791.3 723.2 91.4% 297.0 310.0 104.4%

THE MOUNT WARD 4AHCW 1,176.3 1,265.1 107.6% 605.0 675.2 111.6%

NURSING 761.5 794.2 104.3% 308.0 320.0 103.9%

YORK - MILL LODGEHCW 1,152.3 1,255.3 108.9% 616.0 1,056.8 171.6%

NURSING 1,263.0 1,159.3 91.8% 616.0 674.4 109.5%

29Mar/13/12Maramended0934/13CW/14CH/


PAPER TITLE: Progress report in relation to the application of the SmokefreePolicy





Paul Lumsdon - Interim Director of Nursing and ProfessionsCathy Woffendin - Director of Nursing and Professions


SO1 We deliver great care that is safe, effective and improves lives SO2 We provide a rewarding and supportive place to workSO3 We deploy our resources to deliver effective and sustainable services

EXECUTIVE SUMMARYThe purpose of this report is to provide assurance of the current position with regards toSmokefree.

It shows the reduction in incidents following the re-instatement of designated smoking areasand also that the Trust is compliant with the Notice served at the Becklin Centre by the WestYorkshire Fire and Rescue Authority.




RECOMMENDATION

The board is asked to note the report.

AGENDAITEM

9.2

of 2


SMOKEFREE UPDATE

The Trust went smoke free from 1 April 2016.

During the summer of 2017 feedback from staff in the form of surveys and direct discussion have

led to difficulties. These included:

• Inconsistent approach to challenging patients who continued to smoke in

prohibited areas;

• Desire for further training and support;

• More direct support and leadership

As a result of this feedback further consultation was undertaken as to how best continue the

Trust’s commitment to a smokefree environment. It was felt to ensure safety that with effect from

the 9 October 2017, as an interim measure, that the Trust would allow service users to smoke in

designated areas and these would be decided locally for a reduced number of locations to reduce

some of the tensions that had surfaced.

A Fire Certificate Notice was issued in October 2017. Subsequent assessment felt the Trust had

demonstrated and implemented the changes to address the unauthorised smoking and the

compartmentation works would continue. On 6 November written confirmation was received from

West Yorkshire Fire and Rescue Authority which stated they were satisfied with the actions taken

by the Trust such that the enforcement notice was deemed to be complied with.

The staff supported the idea of Smokestop Leads, not just for inpatient areas, but in the community

teams who support patients who may be heading towards an admission and importantly those who

have stopped smoking during admission to continue a healthier lifestyle on transfer from inpatients

to community services.

A newly appointed Smokestop Lead will commence employment on 14 May. The individual has

previous experience within stop smoking services and respiratory medicine and will report to our

physical health care lead, Michelle Higgins.

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Continued engagement with staff both inpatient and community settings will facilitate an increased

understanding of the threshold of training and support required to become totally smokefree.

The Smokefree policy has been amended to reflect the position of having some designated areas

until the Trust works through these current issue.

There has been a marked reduction in smoke related incidents; in January 36 incidents, February

22 incidents and currently for March there has been 1.

Paul Lumsdon – Interim Director of Nursing and Professions



PAPER TITLE: Medical Director’s report



Dr Claire Kenwood - Medical Director


Richard Wylde - Head of Continuous Improvement


SO1 We deliver great care that is high quality and improves lives SO2 We provide a rewarding and supportive place to work SO3 We use our resources to deliver effective and sustainable services

EXECUTIVE SUMMARY

This paper was produced in response to the board action associated with the MedicalDirectors’ report (minute 17/211 – November 2017), in answer to Mrs White’s request forfurther information on the work of the Continuous Service Improvement Team which sitswithin the Medical Directorate.

This paper gives an overview of what continuous improvement (CI) is and an update on theTrusts Continuous Improvement Team. It also includes a section on how we use CI at thetrust, how we link to the wider CI community and how CI will support the Quality StrategicPlan.




RECOMMENDATION

The Board are asked to note the content of this paper and discuss any areas ofconcern.

The Board are asked to acknowledge and support the on-going work to build a cultureof continuous improvement.

AGENDAITEM

10

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MEDICAL DIRECTORS REPORT, MARCH 2018Continuous Improvement and the Continuous Improvement Team

The purpose of this report is to give the Board an overview of what Continuous Improvement is

and an update on the Trusts Continuous Improvement Team following the November 2017 Board

meeting. It includes an overview of what continuous improvement is, how we use CI at the trust,

how we link to the wider CI community and how CI will support the Quality Strategic Plan.

1. What is Continuous Improvement

Continuous improvement (CI) is a mindset that strives to always be looking for better ways to do

things. This search for better ways of doing things leads to products, services, workflows and other

aspects of an organisation becoming more optimal and efficient. These efforts can take place as

“incremental” improvement over time or “breakthrough/step change” improvement all at once.

It is comprised of elements such as training, tools, and widespread process improvements

(including response to new technologies), it is the integration of these items into all areas of the

business that determines its effectiveness. CI is successful when all these elements are a

symbiotic part of the organisation, working without overhead. This process helps the organisation

compete more effectively by improving both the quality of service delivery and cost basis to deliver

across all elements of the business.

2. Why Continuous Improvement?

Continuous improvement is particularly good at helping when faced with complex problems, where

underlying issues aren’t obvious or completely understood, where solutions depend on changes in

human behaviour and when ‘what to do for the best’ isn’t known at the onset.

Continuous improvement utilises the expertise of people closest to the issue – staff and service

users, as well as system leaders – to identify potential solutions and test them. Done well, this can

release great creativity and innovation in tackling the complex issues which services have

struggled to solve.

The types of problems we can tackle using Continuous Improvement, are those which require not

only changes in behaviours and processes, but also hearts and minds.

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Continuous improvement supports personal and organisational learning and development, whilst

driving performance and quality. It helps to bring about improvement in problems by:

Focusing on outcomes and aims

Trying to give everyone a voice

Using specific tools and techniques

Bringing people together to improve and redesign the way care is provided

3. Continuous Improvement Theory

There is no one theory for Continuous Improvement but a collection where no one approach is

better than the others and some may be used simultaneously.

Among the most widely used tools for continuous improvement is a four-step quality model - the

plan-do-study-act (PDSA) cycle, also known as Deming Cycle or Shewhart Cycle:

Plan: Identify an opportunity and plan for change.

Do: Implement the change on a small scale.

Check: Use data to analyse the results of the change and determine whether it made a

difference.

Act: If the change was successful, implement it on a wider scale and continuously assess

your results. If the change did not work, begin the cycle again.

Other widely used methods of continuous improvement — such as Six Sigma, Lean, and Total

Quality Management — emphasise employee involvement and teamwork; measuring and

systematising processes; and reducing variation, defects and cycle times.

4. Continuous Improvement at LYPFT

The LYPFT Continuous Improvement Cycle provides a framework for

continuous improvement within the Trust.

It compromises of 3 overarching areas; Empowering, Improving and

Sustaining, which are supported by 5 key stages: Begin and

Purpose Define and Scope, Understand and Plan, Pilot and

Implement, Sustain and Share.

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5. LYPFT Continuous Improvement Team

The CI Team is based on the management corridor at The Mount and consists of a CI Lead, 2 CI

Advisors and a CI Project Support Officer. The team works with clinical and corporate teams to

transform good ideas into sustainable workable solutions designed to improve and deliver quality

for everyone using our services.

As a resource the team can be accessed by all staff across the trust, this can be via an informal

conversation or a formal request for support. Either way, the approach used by the CI Team is to

provide the space, time, tools and support to teams and individuals, as we know that staff have the

ideas and the solutions for improvement.

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5.1 CI Team Activity

The CI Team have supported a wide range of departments from corporate teams such as Estates

and HR to Ward based and Community based Teams. Since January 2017 the team have

supported a total of 23 improvement projects and activities across the organisation. Below are 3

examples of this work: -

Example 1

The Younger People with Dementia (YPWD) service contacted the CI team to ask for support in

streamlining their referral management processes. Staff feedback to senior management they felt

parts of the referrals process were inefficient, time consuming & prone to errors. Specialist process

improvement skills were required to harness the team’s enthusiasm.

As a first step the CI team worked with the service to produce a process map for the referral

management procedure providing a detailed view of each process step. Following on from this

work, a series of ‘activity follows’ were performed which provided the team with a quantifiable view

of the effort required to manage the referral process. This surfaced blockages, issues & barriers for

the process to operate smoothly. Additional information was gathered from Cognos to support this

work.

A brief summary of the findings have been provided below: -

Referral Quality: 40% of referrals received did not contain all the service user information

clinicians required in order to offer an Initial Assessment Appointment. Handling poor

referral quality consumed 6 hours of staff time per week & resulted in service users referral

being ‘postponed’ for an average of 35 days until all the correct information was gathered.

Service Inconsistencies: mechanisms for communicating with referrers were processed on

a case by case basis. Individualised responses were provided to referrers consuming 2.5

hours of staff time per week. The timeliness of service communications was sporadic; an

average of 9 days to process replies was recorded, detrimentally impacting the services

ability to meet KPIs.

Stakeholder Awareness: stakeholders did not have a good understanding of the scope of

the service & the referral quality requirements.

In an Away Day setting, the CI team presented the Process Map to the service & facilitated

process improvement discussions. Discussions were recorded, themed & a number of action plans

were created, simplified below: -

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Referral Quality: to create an YPWD referral form and a service inclusion/exclusion criteria

document.

Standardised Responses: to create standard service responses to all common occurrences.

Stakeholder awareness: to develop and deploy a marketing and communications strategy.

Process improvement work streams were managed through weekly improvement huddles. The

creation of the services improvement products were managed collaboratively, with CI Team

providing oversight & support. Following a 4 month pilot period a summary of the impact of the

improvement products is below:

Referral Quality: referrers provided the YPWD team with correct complement of service

user information within 23 days, the referral form & standardised letter response resulting in

a 12 day improvement.

Standardised responses: activity follows performed following the integration of improvement

products (standard letter templates) reduced the referral management effort from 6 hours to

2 hours per week.

Stakeholder awareness: the Memory Services webpage experienced a 52% increase in

page visits during the pilot. Positive feedback was received from referrers during

engagement events. The service experienced a 14% improvement in referrals being

submitted with the correct information from the outset.

An End of Project report is scheduled for release in June 2018, providing sufficient time for the true

impact of the improvement interventions to be available.

Example 2

The Head of Serious Incident Administration asked the CI Team to support a piece of work which

was aiming to improve the reporting of serious incidents in the organisation. Adhering to nationally

mandated (NHS England) reporting guidelines for serious incidents was proving challenging for a

variety of reasons. Facilitation & process mapping expertise was requested to map current and

future state of reporting serious incidents.

Stakeholders involved in the reporting of serious incidents were identified and invited to attend an

away day. During the away day, the current state was mapped and reviewed, enabling

issues/challenges to surface for detailed community discussions. The second phase of the day

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involved working in teams to map a proposed future state taking into consideration mitigating

actions or interventions to overcome the issues/challenges with the current process.

The Serious Incident team had gained an invaluable insight into the challenges faced by all

involved in the reporting of serious incidents and gathered the intelligence required to deploy a

revised serious incident reporting model informed by those integral to the process.

Example 3

The Leeds Autism Diagnostic Service (LADS) was

commissioned in 2013 to serve a maximum of 16

service users per month. During 2017, the service

received an average of 32 referrals per month, with

the highest month recorded being October at 48

referrals. The steady increase in referral numbers

overtime has correlated with a decrease in KPI

performance. Whilst Key Performance Indicator

compliance is good at ((12 week (92%) and 26 week (62%)) the service is keen to explore

efficiency opportunities in the pathway to improve it further.

The Continuous Improvement Team’s task is to work with members of the service to identify

efficiency opportunities within their referral pathway in aiming to create staff capacity & improve

KPI compliance.

This project is working progress having commenced in February 2018, however to date a process

map of the current state has been produced which is currently under review by the service and a

team away day has been planned for late March.

5.2 CI Team Wider Connections

Whilst the CI Team have supported a wide range of departments across the trust, they are also

actively involved in the wider CI Community both locally and nationally. They have recently spoken

at the UK Visas and Immigration national Improvement event in Liverpool about CI in the NHS and

have built strong relationships with the following:

The Health Foundation – An independent charity committed to bringing about better health

and health care for people in the UK

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Institute for Continuous Improvement in Public Services – a charity working to ‘Embed

continuous improvement in the delivery of public services through education’. To this end,

ICiPS is a catalyst for the creation, collation, and dissemination of information that supports

the creation of continuous improvement cultures.

Yorkshire and Humber Improvement Academy – a team of improvement scientists,

patient safety experts and clinicians who are committed to working with frontline services,

patients and the public to deliver real and lasting change for the great people of our region.

Leeds Institute for Quality Healthcare – a partnership initiative between the University of

Leeds, the three Clinical Commissioning Groups, Leeds City Council and the three NHS

Trusts in Leeds which has developed a system-wide approach to leadership and quality,

using data analysis and improvement techniques to make changes with patients, careers

and families.

Institute for Healthcare Improvement – an independent not-for-profit organization based

in Cambridge, Massachusetts, is a leading innovator, convener, partner, and driver of

results in health and health care improvement worldwide.

NHS Improvement – responsible for overseeing foundation trusts and NHS trusts, as well

as independent providers that provide NHS-funded care. Their priority is to offer support to

providers and local health systems to help them improve.

6. What is next for Continuous Improvement Team

While the team will continue to give tailored support to individuals and teams based on their needs,

the CI Team is in the process of developing a plan to support the delivery of the Trusts Quality

Strategic Plan. The CI plan is based on the recommendations within the White Paper from the

Institute for Healthcare Improvement called ‘A Framework for Safe, Reliable and Effective Care’

January 2017.

The maturity matrix within the Framework for Safe, Reliable and Effective Care model was applied

to LYPFT. The assessment concluded the organisation was ‘just at the beginning’ of the

improvement journey. Below is a High Level Draft Plan that outlines the key developments over

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the next 18 months, enabling LYPFT to progress up the maturity matrix to ‘making progress’ and

beyond.

Continuous Improvement Team: Draft Operational Plan overview 2018/19


PAPER TITLE: Mortality Review – Learning from Deaths – Mortality DataQuarter 3 (1 October – 31 December) 2017



Dr Claire Kenwood, Medical Director


Pamela Hayward-Sampson, Serious Incident Investigator



EXECUTIVE SUMMARY

All Trusts are required to provide quarterly mortality data to the Trust Board. This paperincludes the mortality data for Quarter 3. In addition the paper summarises a sample ofmortality reviews that took place in both Quarter 2 and 3, identifying learning andrecommendations.




RECOMMENDATION

The Board is requested to:

Consider the mortality data and information provided within this report.

Receive this information for assurance of the work ongoing within the Trust to improve

mortality review and data collection, noting the improvement demonstrated within the

Learning From Deaths Maturity Matrix.

AGENDAITEM

11

of 11


MORTALITY REVIEW – LEARNING FROM DEATHS – MORTALITY DATA QUARTER 3

(1 OCTOBER to 31 DECEMBER 2018)

INTRODUCTION

This paper provides the board with the mortality data for Quarter three, along with key themes from

the learning identified.

The mortality data is collated weekly at the Learning from Incidents and Mortality Meeting (LIMM),

where all deaths are reviewed and actions agreed with regards to level of investigation, as below:

1. Level 0 - Reviewed and not LYPFT death, close, no code required.

2. Level 1 - No concerns, no further action, close and code death.

3. Level 2 - Further information required, i.e. updated datix or if a fact find has been

completed, await updated fact find and discuss at the next week’s meeting. Code death.

4. Level 3 - Carer/staff member has raised a concern about the care – complete investigation

and feedback findings and learning to LIMM. Code death.

5. Level 4 - Potential gaps in care identified- Concise report required and feedback findings

and learning to LIMM. Code death.

6. Level 5 - Unexpected, unnatural death or more serious concerns noted about gaps in care

– Comprehensive Root Cause Analysis investigation to be completed and learning shared

through the Care Groups and the Trust Incident Review Group. Code death.

The information is obtained from the Trust Incident reporting system (DATIX) and from the NHS

PAS system, to ensure all deaths are discussed. We continue to use the Mazars coding for deaths

as agreed with the regional trusts. In addition to this we also comply with reporting all Learning

Disability Deaths to Bristol University, via the LeDer system. More recently we have implemented

the Structured Judgement Review, which is a case note review of a death to establish any learning

or good practice, where the death does not require a comprehensive review but there may be

some questions in particular in relation to physical health needs.

Context

This paper provides information to the board for Quarter 3 mortality. This relates to all deaths

identified via the incident reporting system and the NHS Spine data. LIMM continues to develop

as a group and has recently revised the way that deaths are reviewed. The changes are reflected

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in the data provided, which shows a reduction in number of deaths coded by LYPFT. This is due to

the decision by the group not to code patients deaths were they have had limited contact with

specific services such as Nursing Home Teams and Memory Services, as LYPFT are not the

primary provider of care to the patient. This is in line with our Trust Policy and also replicates what

other local trusts are doing and is supported by Mazars. In April 2018 a case note review of 20

random notes for this cohort of patients will be completed to ensure that any learning is identified

and shared and provide additional assurance around learning from deaths.

In addition, the first Learning From Deaths Steering Group meeting was held in January 2018, with

a focus on how we plan to improve and developed the shared learning across the organisation.

We continue to link with Trusts within the STP footprint and wider. The Serious Incident

Investigators are working with the Suicide Prevention Plan within the STP and the regional

mortality NHSI programme.

Table 1Mortality Data - Quarter 3

Quarter 3 Learning From Deaths and Incidents Total

Total number of deaths 1st October to 31st December 2017 151

Awaiting Cause of Death confirmation 2

Not our death (i.e. patient died at LTHT, Hospice) 114

ENE 1 (Expected Natural Death -Expected to occur within a timeframe) 12

ENE 2 (Expected Natural Death - Expected death but not expected in the timeframe) 10

UN 1 (Unexpected Death from Natural Causes i.e. cardiac arrest/stroke) 3

EU (Expected Unnatural Death i.e. alcohol or drug dependency) 0

UN 2 (Unexpected Natural Death from natural cause but did not need to be)2

UU (Unexpected Unnatural Death)10

Of the above total number of deaths, 1 death was reported to LeDer as thedeceased service user had a learning Disability. No concerns regarding carewere identified.

Two deaths were coded UN2. One required no further action from LIMMfollowing a further review and one is subject to a Structured Judgement Review,which is currently being completed.

Of the above total number of deaths, 8 deaths were confirmed as requiringfurther investigation in line with the NHSE Serious Incident Framework. Twodeaths were subject to a concise investigation and were reported via the FallsGroup. Only one report has been completed and processed through the TrustsGovernance process and the learning is included in this paper.

There were no complaints raised by carers of staff with regards to a patientscare prior to death, therefore no investigations have commenced as a result ofthis.

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Table 2

Summary of Mortality Data Quarter 3

Table 3, 4 and 5

Mortality Date Quarter 3, by month

17/18 Q3

EN1 12

EN2 10

UN1 3

UN2 2

UU 10

NOD 114

0

20

40

60

80

100

120

Nu

mb

er

of

de

ath

s

Mortality Data Qtr 3

20%

14%

12%

54%

Mortality - October 2017

EN1

EN2

UU

NOD

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2% 11%11%

76%

Mortality - November 2017

EN1

EN2

UU

NOD

6% 4% 3% 1%

86%

Mortality - December 2017

EN1

UN1

UN2

UU

NOD

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Key Learning from deaths identified

A number of recommendations have been made following completed reviews of deaths for quarter

2 and 3 and a sample of these is described below:

Death of Service user who was an inpatient who died following a fall from a height after

failing to return to the ward following absconsion.

This was completed with the support of an independent external Consultant Psychiatrist.

The review did not find a root cause but a number of service delivery problems were noted.

The Face risk assessment was not updated after an initial absconsion and a review of the

risk assessments was recommended, focusing also on the carrying forward of obsolete

information. In addition it was recommended that staff be reminded to update risk

assessments and this will be completed through the service governance structure.

The recommendations included a review of the entrance doors to the hospital to aid a delay

in the opening and closing of the two sets of doors, which could prevent a service user from

absconding whilst under supervision but not impact on the everyday use of this entrance for

staff and the public. This has been completed and the doors now have a press button which

delays the opening.

Death of a service user who died from ligature 1 year after initial assessment.

A structured judgement review was completed. The review highlighted good practice with

regards to the assessment completed by The Crisis Team. This was a thorough

assessment, completing in a timely way and responsive to the service user’s needs at this

time. One element of learning was highlighted with regards to signposting the service user

to 3rd sector providers for support with alcohol use. This has been fed back to the team and

the learning has been shared at the Clinical Improvement Forum. Using the structured

judgement review codes, overall the care provided was rated as good.

Death of a service user who died from ligature two months after discharge from mental

health services and Forward Leeds.

The service user had a history of alcohol excess; the serious incident investigation was completed

with Forward Leeds. The Service user was under the care of the recovery team and was not

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referred to the Specialist Drug and Alcohol Service at Forward Leeds, despite meeting the criteria.

The Service User was referred for Care Coordination and there was a delay of a month for

allocation. A learning review has been arranged to feedback the findings with the team, including

good practice identified in relation to assessment and care coordination.

Death of a service user who died by self-poisoning whilst under the care of Intensive

Community Service.

The learning identified that the service user did not see the same member of staff twice

which led to inconsistency and staff not fully understanding the risks the service user

presented to himself. This was partly due to staffing problems at the time within the service.

The staffing has now been resolved following a review and merge of two Intensive

Community Services. The unit based treatment ceased as a result of this review to aid staff

to provide more home based care. As a result of the learning the team has revised the MDT

meetings and improved formulation and decision making. Further learning identified was the

lack of GATE assessment from Street Triage; this is now being reviewed by the Crisis

Service.

Death of a Service User by ligature two months after discharge from the Community Mental

Health Team.

The learning identified included an inappropriate referral to the Journey Programme when

significant risks of suicide were identified and excess alcohol intake at the time of referral. A

decision was made not to provide a period of care coordination after 1 assessment, with no

communication with Forward Leeds, despite the service user having being in receipt of

Forward Leeds care at the time. A period of care coordination would have provided a better

understanding of the service users social and mental health needs, including potential

safeguarding concerns. A home visit was not completed at the time of assessment which

would have enabled the community team to formulate a plan with the service user around

his social and housing concerns. The trust is working with Public Health and Forward Leeds

with regards to alcohol and substance misuse and suicide. This work is being progressed

through SPAN (West Yorkshire Suicide Prevention Advisory Network) and the investigation

was completed with Forward Leeds to share learning. A feedback learning review is taking

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place with the team in March. The planned community services review will address a

number of the recommendations in this review.

Conclusion

The Board is requested to:

Consider the mortality data and information provided within this report.

Receive this information for assurance of the work ongoing within the Trust to improve

mortality review and data collection.

Note the attached Learning From Deaths Maturity Matrix (Appendix 2) and the progress made over

three time points.

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Appendix 1

Mazar Tool for Mortality Review

Mortality Review within LYPFT NHS Foundation Trust – Codes

Expected Natural death – (EN1): a death that was expected to occur inan expected time frame e.g. people with terminal illness or withinpalliative care services. These deaths may not be investigated but could be included in a

mortality review of early deaths

Expected unnatural death – (EU): A death that was expected but not fromthe cause expected or timescale. e.g. some people who misuse drugs,are dependant upon alcohol or with and existing disorder. These deaths should be investigated

Expected Natural death – (EN2): A death that was expected but was notexpected to happen in the time frame. e.g. someone with cancer or livercirrhosis who dies earlier than anticipated. These deaths should be reviewed and in some cases would benefit

from further investigation

Unexpected natural death – (UN2): An unexpected death from a naturalcause but did not need to be e.g. some alcohol dependence and wherethere may have been care concerns.Level 3 – DATIX

These deaths should be reviewed and a proportion will need to beinvestigated

Unexpected natural death – (UN1): any unexpected death which are fromnatural cause e.g. a sudden cardiac arrest condition or stroke. These deaths should be reviewed and some may need an

investigation

Unexpected unnatural death – (UU): An unexpected death from unnaturalcauses e.g. suicide, homicide, abuse, neglect. These deaths are likely to need investigation

These deaths are likely to follow the Serious Incident process

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Appendix 2Maturity MatrixNB - The bold text depicts our current position. The blue shaded box highlights our position in November 2017, the greenhighlights the progress made from this time (January 2018)

Progress Level1 – 4

Early Progress indevelopment

Firm Progress indevelopment

ResultsAchieved

Exemplar

Key ElementsA) We know our

deathsWe know our highimpact deaths: Inpatient deaths

Deaths under the mentalhealth act

Coroners cases wheresuicide is a potential

We know our deathswhere people are seenregularly and are onour case load

We know all deaths onour current case load

We know all our deathsfrom those in contactwith services over thelast 6 months

B) We work with ourpartners toinvestigate thelearning fromdeaths in Leeds

We know our partnersand meet to talk aboutmortality and learningfrom deaths

We have agreements inplace that ensure thatthe right primeinvestigator leads thelearning review after adeath

For each of ourpartners we shareinvestigations orinvestigation resultsdependant on the deathand the most efficientand effective way tolearn

We have clear sharedlearning across thesystem

C) We have clearorganisationalstructures to learnfrom deaths

We have a central teamwhere deaths areconsidered andinvestigations andlearning are

There is a sharedunderstanding betweencare services andsupport services aboutthe contribution and

There is a sharedunderstanding throughoutthe organisation – fromthe frontline to the Board– of the structures,

There is a matureframework aroundlearning from deaths thatis seen as ‘business asusual’. This is evidenced

1 2 3 4

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ResultsAchieved

Exemplar

coordinated challenge of learningfrom deaths anddiscussions take placewithin governancemeetings

supports and contributionof learning from deaths

by the inclusion acrossthe governancestructures and reflectedin regular assurancereports shared widelyabout the learning andthe system of learningfrom deaths.

D) We have the rightdata

We know our numbersof deaths and numbersof each investigationtype

We have a record of thelearning from the data

We understand this datain terms of the themesand integrate this withother data sources

We analyse our data interms of preventability inline with validatednational definitions andapproved methodology(yet to be developed formental health andlearning disabilities)

E) We have a systemof proportionatereviews

We have clear criteriafor each type of review

We have trained staffwho can carry outproportionate reviews:RCASCJ notes reviewLeDeR

We can audit against ourcriteria for scope of deathand our criteria forinvestigation and providethis information in ourassurance reports

We have supportsystems in place for staffto continuously learn andimprove their skills andcontribute nationally tothe dates aboutproportionality andvalidity especially for newmethodologies

F) We have clearstructures andsupports to helpus cascade thelearning fromdeaths andimprove care

We identify ‘lessons tobe learnt’ using validand recognisedmethodology (RootCause Analysis ,Structured ClinicalJudgement notes

We work across theorganisation to build a‘just culture’ thatsupports true learningeven in the mostdifficult ofcircumstance

We have systems inplace to ensure thatlessons learnt arefollowed by action; thatthis action is evidencebased and that theoutcomes are understood

We learn across systemsto maximise learning andimprovement Across the

organisation Across Leeds

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ResultsAchieved

Exemplar

review- yet to bevalidated for mentalhealth, LeDeR reviews– yet to be validated)

and modified as required Across the STPfootprint

Across the ‘NorthernAlliance’ of mentalhealth trusts

G) We support thefamilies andfriends of thosewho have beenbereaved

We meet our duty ofcandour obligationsWe included family andothers in investigationsWe respond toconcerns raised byfamilies and investigateeven where internalthreshold forinvestigation are notmet

We have supportavailable for those whoare bereaved fortraumatic deaths suchas suicide and this runsparallel to but isintegrated with theinvestigation process.

We have systematicsupport availableinternally where this isrequestedWe make ourselvesapproachable andresponsive to anyconcern about death andseek this out proactively.Staff, families and carerswill be proactivelysupported to raise anyconcerns about the caregiven to patients whohave died.

We provide (withpartners) a systematicand comprehensivesupport service for thebereaved across thesystem in line with thecriteria of the ChiefNurse NHSE – yet to bepublished

H) We have a lowthreshold forlooking atpotential learningwhenever staff orfamily raise aconcern about thecare provided

We systematicallyfollow duty of candourarrangements for thedeaths which constitutea serious incidentreview. We includefamilies in theinvestigation processto the extent they wishto be involved.

We model a just culturethrough learningreviews so staff feelable to raise concernsat any level.

We ask about concernsafter death with bothfamilies and staff in acompassionate andsensitive manner.

We actively seek allfeedback for serviceimprovement in everyarea as routine practiceand this includes learningfrom deaths.


PAPER TITLE: Workforce Board Report



Susan Tyler – Director of Workforce Development


Lindsay Jensen – Deputy Director of Workforce Development andAngela Earnshaw – Head of Learning and OD


SO1 We deliver great care that is high quality and improves livesSO2 We provide a rewarding and supportive place to work SO3 We use our resources to deliver effective and sustainable services

EXECUTIVE SUMMARY

The paper provides an update and information on 3 areas;

NHS Staff Survey 2017 Results,

Supporting our Staff with Stress management

Bank Staff – training, development and support




RECOMMENDATION

The Board of Directors is asked to:

Note the outcome of the 2017 Staff Survey results, and support the identified next

steps.

Note and support the action to support staff with stress related conditions.

Note and support the update on the Training, development and supervision of bankstaff.

AGENDAITEM

12

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WORKFORCE PERFORMANCE REPORT – BOARD OF DIRECTORS MEETING 29 MARCH

2018

The Workforce Performance Report will focus on the following key areas:

Section 1 - NHS Staff Survey 2017 Results

Section 2 - Supporting our Staff with Stress management

Section 3 - Bank Staff – training, development and support

Section 1 - NHS Staff Survey 2017 Results

1. Introduction

The purpose of this report is to provide a summary of the main points from the outcome of the

2017 survey for The Leeds and York Partnership NHS Foundation Trust (LYPFT). The results

were made public on 6 March 2018.

2. Background

The 2017 LYPFT Staff Survey ran from 2 October-1 December 2017. The official sample size for

the Trust was 2,393 which represented a full census of all substantive staff in post on 1 September

2017.

Once again we deployed a Task & Finish Group and an extensive communications campaign to

encourage participation. Our response rate target for 2017 was 55%, and we successfully over-

achieved this with a final response rate of 56.3% (1,347 staff), which was a +3.3% increase on

2016 (in total an extra 82 members of staff participated over 2016 numbers). This response rate

was +4% above the national average for all mental health and learning disability trusts in England

(in 2016 LYPFT were +3% above the national average).

We continued to deploy a mixed mode delivery method (electronic/paper), however in 2017 we

moved from 24% of staff receiving an electronic version of the survey to 53% of staff receiving this

electronically. This shift has not impacted negatively on our response rate.

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As in previous years the detailed content of the questionnaire was summarised and presented in

the form of 32 key findings. These key findings are structured around nine themes as follows:

Appraisals and support for development

Equality and diversity

Errors and incidents

Health and wellbeing

Working patterns

Job satisfaction

Managers

Patient care and experience

Violence, harassment and bullying

The official report provides our Trust’s data as Key Finding level with:

Percentage scores, i.e. percentage of staff giving a particular response to one, or a series

of, survey questions.

Scale summary scores, calculated by converting staff responses to particular questions into

scores. For each of these scale summary scores, the minimum score is always 1 and the

maximum score is 5, with the higher the score out of 5 the better.

3. Results

It is important to note that we continue to make improvements in our overall scores. The 2017

results show that 22% of the Trust’s key finding results are now above the average for all mental

health and learning disability Trusts in the England. This is a 3% increase on last year (2016 -

19%). Additionally we have reduced our worse than average scores, which in 2017 stands at 25%

of our overall key finding scores in comparison to 38% in 2016.

When comparing the 32 Key Finding for 2017 versus 2016 scores we have:

Remained static in 5 areas

Improved in 21 areas

Declined in 6 areas

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Staff engagement

The survey also provides an overall indicator of staff engagement for the Trust, possible scores

range from 1 to 5 with 1 indicating that staff are poorly engaged and 5 indicating that staff are

highly engaged. The Trust’s engagement score has increased for the third year in a row and now

stands at 3.74, against a national average of 3.79 for 2017.

Local highlights

The Trust’s results show significant improvements in two local key areas this year compared to the

2016 scores, which include a reduction in the number of staff experiencing physical violence from

services users and the support that staff feel they are receiving from their immediate managers.

Key Findings 2016 2017 Difference

KF22: Percentage of staff experiencing physical violence

from patients, relatives or the public in last 12 months

27% 22% -5%

KF10: Support from immediate managers 3.88 3.95 0.07

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Local lowlight

The Trust’s results show one area locally where staff’s experience has deteriorated and this is the

staff’s satisfaction with the quality of care they feel that they are able to deliver.

Key Findings 2016 2017 Difference

KF2: Staff satisfaction with the quality of work and carethey are able to deliver

3.90 3.81 -0.09

Comparison against other Trusts

The results also show that the Trust is performing better than the national average for mental

health and learning disability trusts in the top five key areas:

A reduction in the number of extra hours staff are working

A reduction in the number of staff attending work when feeling ill

An increase in the number of staff who, when witnessing errors/near misses or incidents,

report them

An increase in the number of staff who, when experiencing bullying and harassment, report

these incidences

A reduction in the number of staff who have felt unwell due to work related stress.

Additionally the bottom five areas where the Trust is performing unfavourably against the national

average are:

Staff motivation at work

Effective team working

Lower levels of staff reporting the most recent experience of physical violence

Effective use of service user feedback

Fairness and effectiveness of procedures for reporting errors/near misses.

4. Equality and diversity analysis

The 2017 results have been analysed to identify whether responses indicated any notable

variances or themes for equality groups. The survey included questions about the respondent’s

age, gender, ethnicity, sexual orientation, religion and disability. Due to the low number of

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responses, demographic data against sexual orientation is not published. It should be noted that

unlike the overall Trust scores, the demographic data breakdown is not weighted.

As reported for the 2016 Staff Survey: variances in responses between men and women and

people from different age groups were highlighted, but no discernible patterns were identified.

Similar to the 2016 results, overall responses from disabled staff were less positive for 30 out of 32

key finding areas, when compared to responses from non-disabled staff. In total 18% of

respondents reported as disabled, an increase of 1% from last year. The definition of disabled

includes a long-standing health problem, illness or disability.

Overall staff engagement score levels for those with a disability are 3.62 compared to the Trust

overall score of 3.74. Overall responses from staff with a disability were less positive in 30 out of

32 key finding areas.

The areas with the highest negative differentiation in responses for disabled staff are detailed in

the table below.

Key finding Disabled Non disabled

2016 2017 2016 2017

KF17 Percentage of staff feeling unwell due to

work related stress in last 12 months

51% 50% 32% 34%

KF18 Percentage attending work in last 3 months

despite feeling unwell because they felt pressure

73% 66% 55% 45%

KF15 Percentage satisfied with the opportunities

for flexible working patterns

50% 52% 61% 64%

KF26 Percentage experiencing harassment,

bullying or abuse from staff in last 12 months

39% 30% 18% 17%

5. Workforce Race Equality (WRES) Staff Survey Indicators

The national WRES was introduced in April 2015 and provides a national framework to enable

NHS organisations to identify areas of potential inequalities: to benchmark progress against similar

organisations and to implement actions to improve workforce race equality over time.

13% of overall responses were from Black and Minority Ethnic (BME) staff and overall responses

were significantly more positive than for respondents who identified as White. There have been

improvements against two out of the four WRES Staff Survey indicators:

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Ethnicity - WRES Metrics Findings Trust %For 2017

Nationalaverage

Trust %For 2016

Percentage of staff experiencingharassment, bullying or abuse from patients,relatives or the public in last 12 months

White 29% 32% 31%

BME 36% 36% 40%

Percentage of staff experiencingharassment, bullying or abuse from staff inthe last 12 months

White 19% 21% 22%BME 18% 26% 17%

Percentage believing that Trust providesequal opportunities for career progression orpromotion

White 88% 87% 89%BME 81% 77% 78%

Percentage of staff experiencingdiscrimination at work from manager/teamleader or other colleagues in the last 12months

White 6% 6% 6%

BME 8% 14% 8%

6. Next steps

The Trust has invested in producing additional team level reporting results this year. During

February-April 2018 we are working with local service managers to use the data to highlight areas

of success and areas for improvements at a team level.

Service managers will then work within their local teams to identified and implement local action

plans.

The Senior Leadership Forum in June 2018 will be focussed on sharing updates from these

localised action plans

Section 2 - Supporting our staff with stress management

1. Pro-active action towards the management of stress

We offer staff through the Occupational Health & Well-being Service Fast Track Appointments for

Work Related Stress using the Firstcare system which enables early intervention and support as

OH receive a management or employee referral for a day 1 alert from First-care for any work-

related stress absence. This new service commenced in July 2017 and was promoted at the end

of last year through the H&WB Roadshows. Employees are supported to complete the HSE

Stress Management Standards questionnaire by OH and then a discussion, advice and support is

given to the employee to look at some possible actions they may take to address the

stressors. Managers are encouraged to discuss and develop an appropriate action plan; by

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agreeing any actions required by both the employee and the line manager as soon as possible. A

12 month evaluation of this service will be conducted in July 2018.

Fast track stress appointments and team stress management interventions have also been

promoted by OH at the SS&LD HWB forum.

A good example of this is in response to an issue pro-actively identified by HR in the SS/LD Care

Group, a HSE team assessment has been undertaken on 2 wards at Newsam Centre. Both wards

have completed team stress questionnaires and the results have been fed back to the individual

teams. The OH intervention has been to identify the stressors and notify the teams. The teams

themselves will now be responsible for taking forward an action plan to resolve and address

issues.

The OH & Well-being Service provide Physical Health Checks for all staff. This service

commenced in July 2017 and again was promoted via the H&WB Roadshows. Physical health

check clinics have been arranged for teams across the Trust.

2. Personal Resilience Training Staff Offer

Personal Resilience Training has continued to be delivered offering staff training in skills,

strategies and insights that help resilience grow. Two modules have been delivered as part of the

Management Essentials programme to 28 people over the last 12 months. In addition the module

has been presented to 56 people as part of team development sessions. This offer is being

reviewed as part of the overall review of the programme going forward.

Our Employee Assistance Programme which provides individual counselling support aswell as

other forms of support and advice continues to be promoted throughout the Trust and actions are

in place to increase the level of communication and engagement this year in order to increase

uptake of the services provided.

3. Local Care Group H&WB Actions

The SS&LD H&WB Forum is established and ongoing. Actions have included:

The LD service has had focus groups on the staff survey

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Liaison Psychiatry have included Band 6’s in local Clinical Governance meetings, the ALPS

team are planning breaks and looking at their processes to reduce additional hours being

worked and are trying to support flexible working more proactively.

The Perinatal Service have daily safety huddles, local debriefs, externally facilitated debriefs

and a Team Away Day.

The Addictions team have introduced some ‘protected time’ to focus on administration and

development.

In the LD service, the out of hours nurses are giving more focus to management tasks with the

expectation that this will reduce the burden of such duties during normal working hours.

In the Leeds Care Group, they are in the process of establishing a local H&WB group; however

they have been working on other initiatives and programmes which should have a positive impact

on wellbeing for staff these include the Safe Wards Model which will be implemented by December

2018 with formal evaluation starting in January 2019. There have been improvements to the work

environment, for example, a night time security guard at Becklin and the installation of toughened

glass on Wards 3 & 4 Becklin which staff have found reassuring and supportive. A research

project to look into violence and aggression is complete and a group is being set up to review and

address the findings. R and D approval has recently been received for a staff burn out project and

questionnaires will shortly be circulated to staff.

CAS have introduced protected time for a team talk session facilitated by Errol Reid to support

staff in their day to day workings. Furthermore, Acute Inpatients and PICU have introduced a

Band 5 Forum alongside the existing Band 6 Forum.

Section 3 - Training, development and supervision of Bank staff

In March 2018 a new Clinical Lead for the Bank started work in the team with their role being to set

up systems and processes to support bank staff in delivering safe and quality services through

providing supervision opportunities and revalidation for qualified staff , review of training and the

model of employment. This post has taken some time to recruit to and therefore some of our plans

have been delayed waiting for the post holder to take up the role and there is a lot to do over the

next 12 months. This role will also work closely with the Nursing, Professions and Quality

Directorate. We are currently reviewing the flexible bank model, alongside reviewing the

employment contract. In addition we are working closely and collaboratively with our local NHS

Trusts and have met with regional Bank managers with a view to establishing best practice and

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what needs to be in place to establish and deliver a collaborative bank to reduce agency costs

across the Trust and the wider system.

Currently we have an agreed suite of compulsory training that applies to bank staff and these are

monitored and managed through the e-rostering and bank systems with bank staff having access

to e-learning and face to face training in the same way as other substantive staff. There is work

taking place to review the level of training required and how we can streamline this to accept

training from other Trusts to speed up the recruitment process and reduce the burden of training

whilst maintaining safety. There is an agreed training rate paid and agreed for face to face training.

A bank forum has been set up to discuss and improve the experience of bank workers across the

Trust and a new bank monthly newsletter will be developed to inform them of opportunities and

what’s happening in the Trust to improve communication.

Recommendations

a) The Board of Directors is asked to note the outcome of the 2017 Staff Survey results, and

support the next steps identified above.

b) Note and support the action to support staff with stress related conditions.

c) Note and support the update on the Training, development and supervision of bank staff.

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Change since 2016 survey

Appendix 1

Summary of all Key Findings for Leeds and York Partnership NHS Foundation Trust

Key

Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the 2015survey.

Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the 2015survey.

Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2015survey.

For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores forwhich a high score would represent a negative finding. For these scores, which are marked with an asterisk and initalics, the lower the score the better.

LYPFT change’s since 2016

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Change since 2016 survey (cont)

Appendix 1 /ContinuedSummary of all Key Findings for Leeds and York Partnership NHS Foundation Trust

Key

Green = Positive finding, e.g. there has been a statistically significant positive change in the Key Finding since the 2015survey.

Red = Negative finding, e.g. there has been a statistically significant negative change in the Key Finding since the 2015survey.

Grey = No change, e.g. there has been no statistically significant change in this Key Finding since the 2015survey.


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Appendix 1 /Continued


Key

Green = Positive finding, e.g. better than average.

Red = Negative finding, i.e. worse than average.

Grey = Average.


LYPFT comparison against all mental health and learning disability trusts in Englandin 2017

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Key

Green = Positive finding, e.g. better than average.

Red = Negative finding, i.e. worse than average.

Grey = Average.


LYPFT comparison against all mental health and learning disability trusts in Englandin 2017 (cont)

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Key

Green = Positive finding, e.g. better than average, better than 2015.! Red = Negative finding, e.g. worse than average, worse than 2015.

'Change since 2015 survey' indicates whether there has been a statistically significant change in the Key Findingsince the 2015 survey.

-- Because of changes to the format of the survey questions this year, comparisons with the 2015 score are notpossible.

* For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores forwhich a high score would represent a negative finding. For these scores, which are marked with an asterisk and initalics, the lower the score the better.

Change since 2016Survey

Ranking compared withall mental health in 2017

Appraisals & support for development

KF11. % appraised in last 12 mths No change Above (better than) average

KF12. Quality of appraisals No change Average

KF13. Quality of non-mandatory training, learning or No change Averagedevelopment

Equality & diversity

* KF20. % experiencing discrimination at work in last 12 No change Averagemths

KF21. % believing the organisation provides equal No change Averageopportunities for career progression / promotion

Errors & incidents

* KF28. % witnessing potentially harmful errors, near No change Averagemisses or incidents in last mthKF29. % reporting errors, near misses or incidents No change Above (better than) averagewitnessed in last mth

KF30. Fairness and effectiveness of procedures for No change ! Below (worse than) averagereporting errors, near misses and incidents

KF31. Staff confidence and security in reporting unsafe No changeAverage clinical practice

Health and wellbeing

* KF17. % feeling unwell due to work related stress in No change Below (better than) averagelast 12 mths

* KF18. % attending work in last 3 mths despite feeling No change Below (better than) averageunwell because they felt pressure

KF19. Org and mgmt interest in and action on health No change Averageand wellbeing

Working patterns

KF15. % satisfied with the opportunities for flexible No change Above (better than) averageworking patterns

* KF16. % working extra hours No change Below (better than) average

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Key

Green = Positive finding, e.g. better than average, better than 2015.! Red = Negative finding, e.g. worse than average, worse than 2015.

'Change since 2015 survey' indicates whether there has been a statistically significant change in the Key Findingsince the 2015 survey.

-- Because of changes to the format of the survey questions this year, comparisons with the 2015 score are notpossible.

* For most of the Key Finding scores in this table, the higher the score the better. However, there are some scores forwhich a high score would represent a negative finding. For these scores, which are marked with an asterisk and initalics, the lower the score the better.

Change since 2016Survey

Ranking compared withall mental health in 2017

Job satisfaction

KF1. Staff recommendation of the organisation as a No change ! Below (worse than) averageplace to work or receive treatment

KF4. Staff motivation at work No change ! Below (worse than) average

KF7.% able to contribute towards improvements at No change Averagework

KF8.Staff satisfaction with level of responsibility and No change Averageinvolvement

KF9.Effective team working No change ! Below (worse than) average

KF14. Staff satisfaction with resourcing and support No change Average

Managers

KF5. Recognition and value of staff by managers and No change ! Below (worse than) averagethe organisation

KF6. % reporting good communication between senior No change ! Below (worse than) averagemanagement and staff

KF10. Support from immediate managers Increase (better than 16) Average

Patient care & experience

KF2. Staff satisfaction with the quality of work and care! Decrease (worse than 16) Averagethey are able to deliver

KF3. % agreeing that their role makes a difference to No change Averagepatients / service users

KF32. Effective use of patient / service user feedback No change ! Below (worse than) average

Violence, harassment & bullying

* KF22. % experiencing physical violence from patients, Decrease (better than 16) Averagerelatives or the public in last 12 mths

* KF23. % experiencing physical violence from staff in No change Averagelast 12 mths

KF24. % reporting most recent experience of violence No change ! Below (worse than) average

* KF25. % experiencing harassment, bullying or abuse No change Averagefrom patients, relatives or the public in last 12 mths

* KF26. % experiencing harassment, bullying or abuse No change Averagefrom staff in last 12 mths

KF27. % reporting most recent experience of No change Above (better than) averageharassment, bullying or abuse


PAPER TITLE: Report from the Chief Financial Officer - Financial Position -February 2018 (Month 11)



Dawn Hanwell, Chief Financial Officer & Deputy Chief Executive


Dawn Hanwell, Chief Financial Officer & Deputy Chief Executive


SO1 We deliver great care that is high quality and improves lives.SO2 We provide a rewarding and supportive place to work.SO3 We use our resources to deliver effective and sustainable services.

EXECUTIVE SUMMARYThe financial position as reported at month 11 is overall within plan tolerances. As previouslynoted the actual delivery is wholly underpinned by non-recurrent measures and a range ofsignificant variances against specific budgets.

The underlying monthly run rate is in deficit largely as a consequence of the out of area costpressure and the inpatient staffing pressures which remain subject to an internal review. Thenon-recurrent revenue support from Leeds CCG’s for OAPs still leaves a forecast gap ofc£1m in 17/18 which has been offset by other non- recurrent savings.

As previously noted we have now reached a resolution with NHS England regarding thecontract adjustment (£0.58m) for Forensic ward closures.

Capital expenditure year to date is broadly in line with our revised forecast position.Do the recommendations in this paper haveany impact upon the requirements of theprotected groups identified by the EqualityAct?



RECOMMENDATION

The Board of Directors is asked to:- Consider the month 11 financial position for 2017/18, with overall surplus marginally

above plan and a reported Finance Score of 1. Noting overall Single OversightFramework assessment by our regulator remains 2.

AGENDAITEM

13.

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BOARD OF DIRECTORS

29 MARCH 2018

REPORT FROM THE CHIEF FINANCIAL OFFICER - FINANCIAL POSITION - FEBRUARY 2018(MONTH 11)

1. The Purpose

This report provides an overview of the reported financial position at month 11 (February 2018),

including the key areas of performance. It highlights the key areas of concern, noting that whilst we

still have recurrent risks, we are now confident that the year-end position will be achieved.

Based on previous consideration and discussion by the Board, the report provides assurance that

we continue to deliver the overall financial position and mitigate our financial risks in year, but

remain challenged in resolving some key issues going into the planning period for 2018/19.

2. Key Performance Indicators

A summary of overall performance against key metrics as at month 11 is shown in the table 1

below:

Table 1

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2.1 Statement of Comprehensive Income

Table 2 below summarises the income and expenditure position at month 11, showing an overall

net surplus of £2,336k (pre STF) and £3,232k inclusive of STF. This delivers the overall required

Control Total target at month 11. The position includes a number of variances (both positive and

negative) that underpin the position non-recurrently. The overall cumulative one off benefits

included in the position is c£1.8m.

The key variances are:

Out of area placements (OAPs) - are an escalating cost pressure (£3.78m at month 11)

which is negatively impacting on operating expenditure. Month 11 clinical income reflects

£2.89m additional benefit representing the year to date impact of the further non-recurrent

financial support provided by Leeds CCG (total for year £3.15m now confirmed).

CIP stretch - the non-recurrent stretch CIP has not been delivered.

Vacancies – the overall pay cost is significantly underspent predominantly due to the scale

of vacancies in corporate functions and Junior Doctors.

One off and prior year benefits – there is a material benefit from unplanned benefits which

offset the level of unidentified non-recurrent CIP and other pressures.

NHS England contract income claw back relating to temporary forensic ward closures.

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Table 2

Table 2a shows the reported performance in each month and cumulatively, inclusive of non-

recurrent measures that have offset the key pressures noted above.

Table 2b shows the actual in month performance excluding the non- recurrent items (OAPs

support and one off items phased evenly in 12ths). This shows a more representative presentation

of the underlying in year performance, which is a deficit position. Notably if the OAPs cost pressure

was managed or fully mitigated the actual position would be in surplus, which is more aligned to

our planned underlying breakeven position.

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Appendix 5 shows the divergence between in month reported surplus (2016/17 and 2017/18) and

underlying position compared to plan. Appendix 6 shows the divergence between cumulative

reported surplus (2016/17 and 2017/18) and underlying position compared to plan.

Operating income is above plan at month 11 primarily due to £2.89m non-recurrent CCG

contribution to OAPs pressures offset by a shortfall against the planned cost per case activity

levels and a delayed development.

Pay spending is below plan at month 11 due mainly to vacancies in corporate services and doctors

in training. An analysis of vacancies at directorate level and staff type is included in appendix 3.

The majority of vacancies within Leeds Care Group (60 wte) and Specialist & LD Care Group (155

wte) are being filled by temporary staffing.

Non Pay is above plan at month 11 primarily due to out of area placement pressures and CIP

shortfalls.

Table 3 shows the key budget variances at directorate level which are contributing to the overall

position. Budget performance is presented at appendix 1.

Table 3

A more detailed analysis of the key variances for month 11 at directorate level is show at appendix

1a.

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3. Cost Improvement Plans

The level of unidentified savings (£2.94m) remains one of the key risks (note the Control Total is

predicated on identifying and achieving a significant level of non-recurrent CIP - £2.664m). In

addition, the identified CIPs are £0.24m (10%) behind plan at month 10 as detailed in table 4

below.

The actions as previously reported are on-going, including efforts to accelerate assets disposals

however it is now likely that these will now contribute to the 18/19 plan rather than 17/18.

Table 4

4. Capital

The original capital plan for the year was £4.9m. A reforecast was produced at quarter 3, based on

the known impact of issues previously noted (pause on PFI refurbishment tender, and slippage on

timeline for EPR re-procurement). Capital expenditure year to date is £1.47m and our full year

target spend has been re-assessed and reported to the regulator as estimated at c£1.8m.

However we are cautious that this will be delivered due to some marginal slippage into April 18.

Appendix 2 provides full details of capital spend by scheme compared to plan and appendix 2a

shows the monthly profile of spend compared to plan.

5. Cash Flow

The cash position of £54.07m is £5.18m above plan at the end of month 11. This is due unplanned

increase in cash linked to the 16/17 year-end bonus STF funding (£0.9m), slippage on capital

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investment activities noted above, and the timing of releasing provisions (c£1.0m). Liquidity

increased to 106 days operating expenses.

Appendix 4 shows the cash plan phasing for 2017/18 and actual cash balances for 2016/17 and

month 11 of 2017/18.

6. Use of Resources Score

The key metrics which make up the score by which the regulator assesses and monitors overall

financial performance is detailed below in table 5.

Table 5

The Trust achieved the plan at month 11 with an overall Finance Score of 1.

Capital Service Cover

Measures the ability to repay debt, based on the amount of surplus generated. The Trust scores

relatively poorly on this metric due to the higher level of PFI debt repayment. As the overall level of

surplus is set to increase over the year this metric should remain a rating of 2. A surplus in excess

of £6.7m is required to achieve a score of 1 on this metric.

Liquidity

Measures the ability to cover operational expenses after covering all current assets/liabilities. The

healthy cash position of the Trust pushes this rating up significantly. The Trust reported a liquidity

metric of 106 days, achieving a rating of 1.

Income and Expenditure (I&E) Margin and Variance in I&E Margin

Measures the surplus or deficit achieved expressed as a percentage of turnover and provides a

comparison to the planned percentage. The Trust has reported a 2.3% (rating of 1) I&E margin

and is 0.01% (rating of 1) positive variance to plan.

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Agency Cap

Compares actual agency spend (£4.03m at month 11) to the capped target set by the regulator

(£5.24m at month 11). The Trust reported agency spending 23% below the capped level and

achieved a rating of 1.

7. Conclusion

The financial position as reported at month 11 is overall within plan tolerances. As previously noted

the actual delivery is wholly underpinned by non-recurrent measures and a range of significant

variances against specific budgets.

The underlying monthly run rate is in deficit largely as a consequence of the out of area cost

pressure and the inpatient staffing pressures which remain subject to an internal review. The non-

recurrent revenue support from Leeds CCG’s for OAPs still leaves a forecast gap of c£1m in 17/18

which has been offset by other non- recurrent savings.

As previously noted we have now reached a resolution with NHS England regarding the contract

adjustment (£0.58m) for Forensic ward closures.

Capital expenditure year to date is broadly in line with our revised forecast position.

8. Recommendation

The Board of Directors is asked to:

Consider the month 11 financial position for 2017/18, with overall surplus marginally above

plan and a reported Finance Score of 1. Noting overall Single Oversight Framework

assessment by our regulator remains 2.

Appendix 1

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Directorate Level Budget Performance at February 2018

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Appendix 1a

Key variances at directorate level:

Leeds Mental Health Care Group

Non-pay pressure (£2.5m) linked to placing clients out of area. PICU staffing pressures (£0.41m) from additional observations. Pressures primarily from high use of temporary staffing at the Mount dementia

wards (£0.36m) and Becklin wards (£0.4m). Whilst community pay budgets are in balance, overspending in West locality

is being offset by underspending in other community services. £14k shortfall on CIP plan.

Specialist and Learning Disability Care Group

Temporary closure of Westerdale & Rose wards is generating a £759kunderspend which is offsetting £179k overspending on other Forensic wards.This position reflects partial recovery of contract income for the temporaryward closure, which has now been agreed with NHS England commissioners.

Under trading against cost per case activity targets for Chronic Fatigueservices resulted in a £144k shortfall.

£383k Parkside Lodge staffing pressures from additional observations due tocomplexity of client mix is offset by community Learning Disability teams£398k underspend.

Vacancies (£46k CAMHS, £134k Eating Disorders). £179k shortfall on CIP plan. Locked Rehabilitation OAPs pressure £744k.

Corporate/Reserves

Pay under-spending resulting from doctors in training vacancies and lowerthan planned protection costs linked to the new junior doctor contract.

Pay under-spending due to vacancies, Workforce £115k, Chief Nurse £147k.Chief Financial Officer £237k.

£32k shortfall on CIP plan. Reserves deficit due to unidentified CIPs which are unallocated to individual

budgets. Leeds CCG non recurrent OAPs contribution.

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Appendix 2

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Appendix 2a

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Appendix 3Vacancy analysis

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Appendix 4

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Appendix 5

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Appendix 6


PAPER TITLE: Assurances on the General Data Protection Regulation (GDPR)



Dawn Hanwell, Chief Financial Officer and Deputy Chief Executive


Carl Starbuck, Information and Knowledge Manager



EXECUTIVE SUMMARYThis report presents the GDPR Action Plan & Audit Assurance Statement.

The Trusts Information and Knowledge manager has prepared a formalised action plan tosupport the Trust in becoming ready for the enactment of the General Data ProtectionRegulation on 25 May 2018.

The Plan lists the steps to be taken to enact the new Data Protection legislative frameworkwithin the Trust, aligned to the ICO document - “12 Steps to Compliance with the GeneralData Protection Regulation”. The Plan was presented and approved by the IG Group alongwith the Audit Assurance Statement, approving the plan & assurance statement.

The plan is now in progress, with collaborative working across relevant departmental leadsto progress the aspects of the plan relevant to their areas and personal data processingaspects of their department’s work.Do the recommendations in this paper haveany impact upon the requirements of theprotected groups identified by the EqualityAct?



RECOMMENDATIONThe Board of Directors is asked to:-

Note the assurance provided by the Trust’s GDPR plan and the assurance statement of theinternal auditors.

AGENDAITEM

14.

A teaching organisation providing mentalhealth and learning disability services

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GDPR Action Plan 2017 – 2018

The approach to implementing theGeneral Data Protection Regulation

forLeeds & York Partnership NHS Foundation Trust

Carl Starbuck – Information & Knowledge ManagerData Protection Officer | Freedom of Information Officer

Deputy Caldicott Guardian


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Background

The EU General Data Protection Regulation (GDPR) will apply in the UK from 25 May2018. The Government has confirmed that the UK’s decision to leave the EU will not affectthe commencement of the GDPR. The Regulation forms the basis of the Data ProtectionBill, which is currently going through Parliament (Lords: September 2017) and will ensurecontinuity after Brexit.

The aim of the reforms is to modernise data protection laws for the digital age, protectingpeople’s privacy whilst allowing the social and economic benefits of information technologyto be exploited.

Although the principles of data protection have not substantially changed, the GDPR placesgreater focus on evidence-based compliance. It introduces new duties in relation toaccountability, transparency and data subjects’ rights, as well as harsher penalties - up to~£17m (€20m) - for organisations that fail to comply.

Some requirements of the GDPR, such as mandatory breach notification, are establishedgood practice in the health sector. NHS Digital has confirmed that organisations whichperform well in their Information Governance Toolkit scores will have a good baseline towork from. However, the Regulation requires that specified actions are taken, and evidenceis made available to demonstrate the necessary operational change.

Approach

Allied to a timetabled audit plan via Audit Yorkshire, The following plan sets out thedeliverables and milestones to be achieved ahead of, and beyond, the enforcement of theGDPR on 25th May 2018, likely (but unconfirmed at the time of writing) to be enacted as theData Protection Act (2017).

Throughout this planning document, the main reference material & basis for our plans willbe the Information Commissioner’s Office document - “12 Steps to GDPR Compliance”.

The plan will be expressed as actions, or a note on current compliance where appropriate,aligned to the ICO’s 12 Steps. Extracts from the 12 Steps document will be presented initalic throughout the plan.

Although 25th May 2018 is a major milestone on the GDPR compliance journey, it isappropriate to maintain an awareness that DoH / NHS policy may lag behind legislation,and that the embedding of best practice aligned to GDPR & the compounding of knowledgeand expertise will continue beyond this date.


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Step 1 – Awareness

You should make sure that decision makers and key people in your organisationare aware that the law is changing to the GDPR. They need to appreciate theimpact this is likely to have and identify areas that could cause complianceproblems under the GDPR. It would be useful to start by looking at yourorganisation’s risk register, if you have one.

Implementing the GDPR could have significant resource implications, especiallyfor larger and more complex organisations. You may find compliance difficult ifyou leave your preparations until the last minute.

Commentary: Through briefings from internal & external sources (IG Group & team, PWCbriefing pack to Board etc.), and the engagement of Audit Yorkshire to assesspreparedness and compliance via the proposed audit project, it is clear that this step hasbeen initially met. Ongoing work on this plan will embed GDPR throughout the Trust overthe months ahead.

Actions: Workstreams in the remaining 11 areas of the plan will improve the levels ofunderstanding and awareness throughout key stakeholders and the wider Trust, and viareporting to appropriate committees on the progress of this plan and the audit project.

Key Milestones: as detailed elsewhere in the plan and audit proposal.

Step 2 - Information You Hold

You should document what personal data you hold, where it came from andwho you share it with. You may need to organise an information audit acrossthe organisation or within particular business areas.

The GDPR requires you to maintain records of your processing activities. Itupdates rights for a networked world. For example, if you have inaccuratepersonal data and have shared this with another organisation, you will have totell the other organisation about the inaccuracy so it can correct its ownrecords. You won’t be able to do this unless you know what personal data youhold, where it came from and who you share it with. You should document this.Doing this will also help you to comply with the GDPR’s accountability principle,which requires organisations to be able to show how they comply with the dataprotection principles, for example by having effective policies and procedures inplace.

Actions: Carl Starbuck has previously built data asset register tools in SharePoint and willrevise this approach, building a new tool in the current SharePoint intranet environment tocatalogue current data holdings, with additional fields to include the lawful basis forprocessing (see below). A timetable of corporate department meetings will be scheduled,


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with CS visiting appropriately senior department heads to catalogue departmental personal/ sensitive data holdings.

Key Milestones:

Build asset register tool in SharePoint – Carl Starbuck – by 31st December 2017 Meet department heads & populate asset register – Carl Starbuck – by 31st January

2017, to include:-

o Finance (lease cars, patient affairs)o Workforce / HRo Communicationso FT Membershipo Procuremento PALSo Carers Team (potentially children’s data)o Complaints & Claimso Information Governanceo Medical Recordso ICTo Occupational Healtho Corporate Governanceo CAMHS (children’s data)

Step 3 - Communicating privacy information

You should review your current privacy notices and put a plan in place formaking any necessary changes in time for GDPR implementation.

When you collect personal data you currently have to give people certaininformation, such as your identity and how you intend to use their information.This is usually done through a privacy notice. Under the GDPR there are someadditional things you will have to tell people. For example, you will need toexplain your lawful basis for processing the data, your data retention periodsand that individuals have a right to complain to the ICO if they think there is aproblem with the way you are handling their data. The GDPR requires theinformation to be provided in concise, easy to understand and clear language.

The ICO’s Privacy notices code of practice reflects the new requirementsof the GDPR.

Actions: Carl Starbuck to review existing privacy notice and patient-facing InformationGovernance leaflets and revise accordingly in readiness for timely go-live. Have the PNreviewed by our Learning Disabilities teams, to ensure “easy read” approach (wherepossible) and to create a symbolised version. To publish the new privacy notice via the


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public facing website, and to re-advertise the revised leaflets Trustwide. Privacy Notice toalign to ICO guidance: https://ico.org.uk/for-organisations/guide-to-data-protection/privacy-notices-transparency-and-control/privacy-notices-under-the-eu-general-data-protection-regulation/

Key Milestones:

Refresh privacy notice text and patient-facing leaflets – Carl Starbuck – by 31st

January 2018. Have the content reviewed by Learning Disabilities teams for “easy read” check and

symbolised version creation – Carl Starbuck – by 28th February 2018. Publish and advertise the above – Carl Starbuck – by 11th May 2018. (2 weeks lead

of GDPR go-live). To maintain a watching brief on DoH / NHS policy releases aligned to GDPR and

echo these in privacy notices as necessary on an ongoing basis.

Step 4 - Individuals’ rights

You should check your procedures to ensure they cover all the rights individualshave, including how you would delete personal data or provide dataelectronically and in a commonly used format.

The GDPR includes the following rights for individuals:

the right to be informed; the right of access; the right to rectification; the right to erasure; the right to restrict processing; the right to data portability; the right to object; and the right not to be subject to automated decision-making including

profiling.

On the whole, the rights individuals will enjoy under the GDPR are the same asthose under the DPA but with some significant enhancements. If you are gearedup to give individuals their rights now, then the transition to the GDPR shouldbe relatively easy. This is a good time to check your procedures and to workout how you would react if someone asks to have their personal data deleted,for example. Would your systems help you to locate and delete the data? Whowill make the decisions about deletion?

The right to data portability is new. It only applies:

to personal data an individual has provided to a controller;


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where the processing is based on the individual’s consent or for theperformance of a contract; and

when processing is carried out by automated means.

You should consider whether you need to revise your procedures and make anychanges. You will need to provide the personal data in a structured commonlyused and machine readable form and provide the information free of charge.

Commentary: It is notable that these requirements are either met by current processes, ornot applicable. We will however be required to make changes to SAR processing, to reflectthe new statutory time for compliance (30 days) and end SAR charging for all requestsexcept those deemed manifestly unfounded or excessive.

Actions: Carl Starbuck to assess the relevance & implications of the revised subject rights,review existing IG-related policy & procedure and revise accordingly in readiness for timelygo-live. To publish any revised policy & procedure via the intranet & public facing website,and to re-advertise revised policy & procedure as necessary. Alignment with expectedrevisions to NHS policy (Records Management Code of Practice; Confidentiality Code etc.)to be monitored and echoed in local policy & procedure. Publish data subject rights as partof the Privacy Notice.

Key Milestones:

Refresh relevant policy & procedure – Carl Starbuck – by 30th April 2018. Publish and advertise the above – Carl Starbuck – by 11th May 2018. (2 weeks lead

of GDPR go-live). As Step 3 re. Privacy Notice.

Step 5 - Subject access requests

You should update your procedures and plan how you will handle requeststo take account of the new rules:

In most cases you will not be able to charge for complying with arequest.

You will have a month to comply, rather than the current 40 days. You can refuse or charge for requests that are manifestly unfounded

or excessive. If you refuse a request, you must tell the individual why and that they

have the right to complain to the supervisory authority and to a judicialremedy. You must do this without undue delay and at the latest, withinone month.

If your organisation handles a large number of access requests, considerthe logistical implications of having to deal with requests more quickly.


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You could consider whether it is feasible or desirable to develop systemsthat allow individuals to access their information easily online.

Commentary: Current performance monitoring via monthly reporting to the IG Groupshows that only ~5% of current medical records SAR throughput would be outside therevised 30 day target for GDPR. Charging is currently restricted to solicitor requests only.Workforce / HR report less favourable performance at recent advisory session at IG Group.

Actions: To revise policy to align to new timeframe and remove all charging unlessrequests are manifestly unfounded or excessive. Notable that when frequency ofrequesting is a factor, the offer will be made to provide only new content since the lastrequest. Further engagement with Workforce / HR to improve compliance via provision of amonitoring tool & education.

Key Milestones:

Revision of IG-0008 & associated forms – Carl Starbuck – by 30th April 2018 Publish and advertise the above – Carl Starbuck – by 11th May 2018. (2 weeks lead

of GDPR go-live) Education of Medical Records team – Carl Starbuck – by 11th May 2018. (2 weeks

lead of GDPR go-live) Engagement & Education with Workforce / HR team – Carl Starbuck – booked for

16th November 2018 Provision of monitoring tool for Workforce / HR team – Carl Starbuck – to discuss at

meeting above for use ASAP.

Step 6 - Lawful basis for processing personal data

You should identify the lawful basis for your processing activity in the GDPR,document it and update your privacy notice to explain it.

Many organisations will not have thought about their lawful basis for processingpersonal data. Under the current law this does not have many practicalimplications. However, this will be different under the GDPR because someindividuals’ rights will be modified depending on your lawful basis for processingtheir personal data. The most obvious example is that people will have astronger right to have their data deleted where you use consent as your lawfulbasis for processing.

You will also have to explain your lawful basis for processing personal data inyour privacy notice and when you answer a subject access request. The lawfulbases in the GDPR are broadly the same as the conditions for processing in theDPA. It should be possible to review the types of processing activities you carryout and to identify your lawful basis for doing so. You should document your


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lawful bases in order to help you comply with the GDPR’s ‘accountability’requirements.

Commentary: This will be met by Steps 2 & 3. The lawful basis for processing will bedocumented as part of the data asset cataloguing exercise and communicated via therevised Privacy Notice.

Actions: As Steps 2 & 3.

Key Milestones: As Steps 2 & 3.

Step 7 – Consent

You should review how you seek, record and manage consent and whether youneed to make any changes. Refresh existing consents now if they don’t meetthe GDPR standard.

You should read the detailed guidance the ICO has published on consent underthe GDPR, and use our consent checklist to review your practices. Consentmust be freely given, specific, informed and unambiguous. There must be apositive opt-in – consent cannot be inferred from silence, pre-ticked boxes orinactivity. It must also be separate from other terms and conditions, and youwill need to have simple ways for people to withdraw consent. Public authoritiesand employers will need to take particular care. Consent has to be verifiableand individuals generally have more rights where you rely on consent toprocess their data.

You are not required to automatically ‘repaper’ or refresh all existing DPAconsents in preparation for the GDPR. But if you rely on individuals’ consent toprocess their data, make sure it will meet the GDPR standard on being specific,granular, clear, prominent, opt-in, properly documented and easily withdrawn.If not, alter your consent mechanisms and seek fresh GDPR-compliant consent,or find an alternative to consent.

Commentary: This will be met by Step 2. The lawful basis for processing will bedocumented as part of the data asset cataloguing exercise and where this is established asconsent-based processing advice will be provided to ensure that consent processes arealigned to GDPR’s standards.

At the time of writing the ICO are analysing feedback received and this will feed into thefinal version of their consent guidance. However this cannot be finalised until the Article 29Working Party of European Data Protection Authorities (WP29), of which the ICO is amember, has agreed its Europe-wide consent guidelines. The WP29 consent guidelinesare due to be published later in 2017 and the latest timetable is for this to be agreed andadopted in December 2017.


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Actions: As Step 2, with additional investigations and advice on consent gathering andalignment of forms & customer facing content etc. with ICO guidance.

Key Milestones: As Step 2.

Step 8 – Children

You should start thinking now about whether you need to put systems in placeto verify individuals’ ages and to obtain parental or guardian consent for anydata processing activity.

For the first time, the GDPR will bring in special protection for children’spersonal data, particularly in the context of commercial internet services suchas social networking. If your organisation offers online services (‘informationsociety services’) to children and relies on consent to collect information aboutthem, then you may need a parent or guardian’s consent in order to processtheir personal data lawfully. The GDPR sets the age when a child can give theirown consent to this processing at 16 (although this may be lowered to aminimum of 13 in the UK). If a child is younger then you will need to getconsent from a person holding ‘parental responsibility’.

This could have significant implications if your organisation offers onlineservices to children and collects their personal data. Remember that consenthas to be verifiable and that when collecting children’s data your privacy noticemust be written in language that children will understand.

Commentary: Restricted in the main to our CAMHS service. Possibly an issue in Carers(e.g. if we have records of any “Child Carers”). DoB already routinely record in CAMHSrecords.

Actions: Meetings to be timetabled with appropriate service leads to educate thoseappropriate of the need to recognise a child’s right to self-determination in regard toprocessing of their personal data, and the age demarcation of child / parent-guardianresponsibility. To ensure that teams are aware, particularly in e.g. Subject AccessRequests.

Key Milestones: As Step 2.

Step 9 – Data Breaches

You should make sure you have the right procedures in place to detect, reportand investigate a personal data breach.


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Some organisations are already required to notify the ICO (and possibly someother bodies) when they suffer a personal data breach. The GDPR introduces aduty on all organisations to report certain types of data breach to the ICO, andin some cases, to individuals. You only have to notify the ICO of a breach whereit is likely to result in a risk to the rights and freedoms of individuals – if, forexample, it could result in discrimination, damage to reputation, financial loss,loss of confidentiality or any other significant economic or social disadvantage.

Where a breach is likely to result in a high risk to the rights and freedoms ofindividuals, you will also have to notify those concerned directly in most cases.

You should put procedures in place to effectively detect, report and investigatea personal data breach. You may wish to assess the types of personal data youhold and document where you would be required to notify the ICO or affectedindividuals if a breach occurred. Larger organisations will need to developpolicies and procedures for managing data breaches. Failure to report a breachwhen required to do so could result in a fine, as well as a fine for the breachitself.

Commentary: Already business-as-usual via the NHS Digital IG Toolkit breach reportingmechanism. Data subjects routinely informed under Duty of Candour requirements. Nofurther action required.

Step 10 – Data Protection by Design and Data Protection Impact Assessments

It has always been good practice to adopt a privacy by design approach and tocarry out a Privacy Impact Assessment (PIA) as part of this. However, theGDPR makes privacy by design an express legal requirement, under the term‘data protection by design and by default’. It also makes PIAs – referred to as‘Data Protection Impact Assessments’ or DPIAs – mandatory in certaincircumstances.

A DPIA is required in situations where data processing is likely to result in highrisk to individuals, for example:

where a new technology is being deployed; where a profiling operation is likely to significantly affect individuals; or where there is processing on a large scale of the special categories of

data.

If a DPIA indicates that the data processing is high risk, and you cannotsufficiently address those risks, you will be required to consult the ICO to seekits opinion as to whether the processing operation complies with the GDPR.


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You should therefore start to assess the situations where it will be necessary toconduct a DPIA. Who will do it? Who else needs to be involved? Will the processbe run centrally or locally?

You should also familiarise yourself now with the guidance the ICO hasproduced on PIAs as well as guidance from the Article 29 Working Party, andwork out how to implement them in your organisation. This guidance showshow PIAs can link to other organisational processes such as risk managementand project management.

Commentary: Already business-as-usual as stipulated in the NHS Digital IG Toolkitrequirement #210, evidenced annually. No further action required.

Step 11 – Data Protection Officers

You should designate someone to take responsibility for data protectioncompliance and assess where this role will sit within your organisation’sstructure and governance arrangements.

You should consider whether you are required to formally designate a DataProtection Officer (DPO). You must designate a DPO if you are:

a public authority (except for courts acting in their judicial capacity); an organisation that carries out the regular and systematic monitoring of

individuals on a large scale; or an organisation that carries out the large scale processing of special

categories of data, such as health records, or information about criminalconvictions. The Article 29 Working Party has produced guidance fororganisations on the designation, position and tasks of DPOs.

It is most important that someone in your organisation, or an external dataprotection advisor, takes proper responsibility for your data protectioncompliance and has the knowledge, support and authority to carry out their roleeffectively.

Commentary: With the IG function being very much a “mature product” within the Trust,the Information & Knowledge Manager & the IG team already have a “voice” within theorganisation and the backing of the Board in their activities. Nevertheless the cementing ofthe required reporting lines and formal adoption of the role within the IG team needs to beformalised and documented, via a refresh of job description documentation and relevantpolicy / procedure. Appropriate training will be undertaken by the IG team, once coursesreflecting the revised & finalised legislative framework is known and the courses availablehave some standing. A watching brief on NHS policy changes echoing the new legislationwill be necessary given the ongoing embedding of the law after go-live. Procure areplacement reference book in Kindle app compatible format.


Page 13 of 14

Actions: Refresh job description documentation using NHS exemplar documents, aligningto the Article 29 Working Party content & seek ratification via the CIO. Research &undertake appropriate training for the IG team. Procure replacement reference book.Engagement with local IG fora for peer support, advice, and sharing best practice &knowledge.

Key Milestones:

Refresh job description documentation & ratify – Carl Starbuck – by 25th May 2017. Research & undertake appropriate formal training for the IG team – Carl Starbuck /

Anne-Marie Field – In 12 months ahead, when appropriate opportunities arise. Procure replacement reference book in Kindle form for desktop app (Data

Protection: A Practical Guide to UK and EU Law) – by 31st March 2018. Continue / renew engagement with local IG fora (ongoing), including

o Leeds Information Governance Steering Groupo Yorkshire & Humber Information Governance Groupo NYHDIF IG Sub-Group / SIGN

Maintain a watching brief for other networking, WebEx, or other educationalopportunities aligned to GDPR.

Step 12 – International

If your organisation operates in more than one EU member state, you shoulddetermine your lead data protection supervisory authority and document this.

The lead authority is the supervisory authority in the state where your mainestablishment is. Your main establishment is the location where your centraladministration in the EU is or else the location where decisions about thepurposes and means of processing are taken and implemented.

This is only relevant where you carry out cross-border processing – i.e. youhave establishments in more than one EU member state or you have a singleestablishment in the EU that carries out processing which substantially affectsindividuals in other EU states.

If this applies to your organisation, you should map out where yourorganisation makes its most significant decisions about its processing activities.This will help to determine your ‘main establishment’ and therefore your leadsupervisory authority.

The Article 29 Working party has produced guidance on identifying a controlleror processor’s lead supervisory authority.


Page 14 of 14

Commentary: As the Trust has its head office in Leeds, UK, and operates solely inEngland and processes personal / sensitive data exclusively in the UK, there is no cross-border processing or processing actions that significantly affect citizens in other memberstates. Processing is therefore beholden to the English enactment of GDPR, and thusrecognises the Information Commissioner’s Office (England) as its supervisory authority.Our ongoing registration with the ICO as a Data Controller will be maintained. No furtheraction required.

Audit Yorkshire - 1

PRIVATE AND CONFIDENTIAL

To: Dawn Hanwell , Chief Financial Officer and Deputy Chief

Executive (SIRO) Claire Kenwood, Medical Director (Caldicott Guardian) Bill Fawcett, Chief Information Officer Carl Starbuck (Information and Knowledge Manager)

From: Susan Hall, Information Governance Specialist Lead

Date: 4 December 2017

Subject: GDPR Readiness

Introduction

The EU General Data Protection Regulation (GDPR) will apply in the UK from 25 May 2018. The government has confirmed that the UK’s decision to leave the EU will not affect the commencement of the GDPR. The Regulation forms the basis of the Data Protection Bill, which is currently going through Parliament and will ensure continuity after Brexit. The benefits of compliance are to respect the law and data subjects’ rights, to mitigate risk appropriately and have a robust defence in the event of any breach. The risks associated with non-compliance include reputational harm to the Trust and regulatory action with financial penalties of up to £19m. Objective Audit Yorkshire has been engaged to provide assurance that the Trust has, or is putting in place, adequate measures to ensure compliance with the GDPR within the required timescales. The approach agreed was to undertake a readiness review in three stages, to reflect the required pace of progress and anticipated changes to the legal framework. The first deliverable was an assurance statement based on the initial project plan, followed by a follow-up report in January 2018, and a final update for inclusion in the Head of Audit Opinion statement in March 2018. This memorandum provides the first Assurance Statement. Audit work performed

The initial project plan was reviewed against the Information Commissioner’s ‘Twelve Steps’ document and subsequent published guidance. Evidence of progress against the first step, Awareness, was provided in the form of a presentation made in October 2017 to the Trust’s IG Group. This was used as the basis for a subsequent Q&A session with the Workforce and Human Resources teams.

Audit Yorkshire - 2

Findings The required GDPR awareness campaign is already under way and suitably targeted at the Trust’s Senior Management Team and principal stakeholders. The Key Milestones identified in the action plan set an appropriate trajectory towards implementation within the statutory timescale.

The action plan acknowledges the need to keep a ‘watching brief’ on emerging guidance from the Article 29 Working Party and from NHS Digital, as well as the derogations likely to be exercised by the UK in the forthcoming Data Protection Act.

Conclusion

In view of the above, the conclusion of the review is to offer Significant Assurance that the action plan is fit for purpose, and adherence to the plan is likely to satisfy the requirement, from May 2018, to demonstrate compliance with the Regulation.

Recommendation

None required.

Template V2 – November 2017


PAPER TITLE: Approval of the Standing Financial Instructions





Gerard Enright, Financial Controller



EXECUTIVE SUMMARYStanding Financial Instructions (SFIs) detail the financial responsibilities, policies andprocedures adopted by the Trust. They are designed to ensure that financial transactionsare carried out in accordance with the law and with Government policy in order to achieveprobity, accuracy, economy, efficiency and effectiveness.

The SFIs have been reviewed by subject matter experts including Information Technology,Procurement, Corporate Governance, Internal Audit and Finance, with amendments madeto reflect the regulatory structure of Foundation Trusts, the organisational structure of theTrust and updates or changes in legislation, eg Health and Social Care Act 2012 and theGeneral Data Protection Regulations (GDPR).

The most significant change to the SFIs is in relation to how levels of spend are calculated inrelation to tender and quotation limits. In the past these were based on an annual spend of£10k or £50k respectively and this was included in the Trust’s SFIs. However, best practice(in operation at the Trust) and EU legislation considers spend over the term of theagreement and the SFIs have now been updated to reflect this.

Do the recommendations in this paper have anyimpact upon the requirements of the protectedgroups identified by the Equality Act?

State below‘Yes’ or ‘No’

If yes please set out what action has beentaken to address this in your paper

No

RECOMMENDATION

The Board of Directors are asked to consider the amendments and ratify the updatedStanding Financial Instructions and/or feedback any comments.

AGENDAITEM

15.

STANDING FINANCIALINSTRUCTIONS

Director Responsible: Chief Financial OfficerDepartment: FinanceDate Issued: April 2018Review Date: March 2021Ratified By: Board of Directors

Leeds and York Partnership NHS Foundation Trust – Standing Financial Instructions – 2018

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CONTENTS

1. INTRODUCTION

2. AUDIT

3. ALLOCATIONS, BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROLAND MONITORING

4. ANNUAL ACCOUNTS, REPORTS AND PLANS

5. BANK AND GOVERNMENT BANKING SERVICE (GBS) ACCOUNTS

6. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES ANDOTHER NEGOTIABLE INSTRUMENTS

7. FOUNDATION TRUST CONTRACTS

8. TENDERING AND CONTRACTING PROCEDURES

9. TERMS OF SERVICE, ALLOWANCES AND PAYMENT OF DIRECTORS ANDEMPLOYEES

10. NON-PAY EXPENDITURE

11. EXTERNAL BORROWING AND INVESTMENTS

12. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERSAND SECURITY OF ASSETS

13. STORES AND RECEIPT OF GOODS

14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

15. INFORMATION TECHNOLOGY

16. PATIENTS' PROPERTY

17. FUNDS HELD ON TRUST (CHARITABLE FUNDS)

18. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OFBUSINESS CONDUCT (see overlap with SO (Directors) No. 9)

19. RETENTION OF RECORDS

20. RISK MANAGEMENT AND INSURANCE


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FOREWORD

1. INTRODUCTION

1.1 Requirement to have Standing Financial Instructions (SFIs)

1.1.1 Provider Licence for the Foundation Trusts require compliance with the principles ofbest practice applicable to corporate governance within the NHS / Health Sector

1.1.2 The Code of Conduct and Accountability in the NHS issued by the Department ofHealth requires that each NHS organisation shall have Standing FinancialInstructions.

1.1.3 Status of SFIs - These SFIs are issued in accordance with the Code.

1.1.4 These Standing Financial Instructions detail the financial responsibilities, policiesand procedures adopted by the Foundation Trust. They are designed to ensurethat its financial transactions are carried out in accordance with the law and withGovernment policy in order to achieve probity, accuracy, economy, efficiency andeffectiveness. They should be used in conjunction with the Reservation of Powersto the Board of Directors and Council of Governors and Schedule ofDecision/Duties Delegated by the Board of Directors.

1.1.5 Non Compliance with SFIs - Should any difficulties arise regarding the interpretationor application of any of the Standing Financial Instructions then the advice of theChief Financial Officer MUST BE SOUGHT BEFORE ACTING.

1.1.6 The failure to comply with Standing Financial Instructions is regarded as adisciplinary matter that could result in dismissal.

1.1.7 Overriding Standing Financial Instructions – If for any reason these StandingFinancial Instructions are not complied with, full details of the non-compliance andany justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Audit Committee forreferring action. All members of the Board of Directors and staff have a duty todisclose any non-compliance with these Standing Financial Instructions to the ChiefFinancial Officer as soon as possible.


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1.2 Terminology

1.2.1 Unless the contrary intention appears or the context otherwise requires, words orexpressions contained in the SFIs bear the same meaning as the Health and SocialCare Act 2012 and the constitution. References in the SFIs to legislation include allamendments, replacements, or re-enactments made.

1.2.2 Headings are for ease of reference only and are not to affect interpretation. Wordsimporting the masculine gender only shall include the feminine gender; wordsimporting the singular shall include the plural and vice-versa.

1.2.3 Wherever the term "employee" is used and where the context permits it shall bedeemed to include employees of third parties contracted to the Foundation Trustwhen acting on behalf of the Foundation Trust. These shall include nursing, medicalstaff and consultants practising on the Foundation Trust premises.

Wherever the title Chief Executive, Chief Financial Officer, or other nominatedofficer is used in these instructions, it shall be deemed to include such otherdirectors or employees who have been duly authorised to represent them.

DefinitionsThe Act The Health and Social Care Act 2012

Accounting Officer Shall be the Officer responsible and accountable forfunds entrusted to the Foundation Trust in accordancewith the NHS Foundation Trust Accounting OfficerMemorandum. He shall be responsible for ensuringthe proper stewardship of public funds and assets. TheHealth and Social Care Act 2012 designates the ChiefExecutive of the NHS Foundation Trust as theAccounting Officer.

AnnualFinancialStatements

Mean the annual financial accounts prepared inaccordance with the requirements of NHSImprovement.

Authorisation Means an authorisation given by NHS Improvement.Budget Holder Means the director or employee with delegated

authority to manage finances (Income andExpenditure) for a specific area of the organisation.

Budget Manager Means the officer who has daily operationalresponsibility for the management of the budget.

Board of Directors Means the Board of Directors as constituted inaccordance with the constitution.

Budget Means a resource, expressed in financial or manpowerterms, proposed by the Board of Directors for thepurpose of carrying out, for a specific period, any or allof the functions of the Foundation Trust.

Charity Means the Charitable funds, gifts, donations and


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endowments made under the relevant charitieslegislation and held on trust for purposes relating tothe Trust that are administered by the Board ofDirectors acting as Trustee.

Chair of the Board ofDirectors

Is the person appointed by the Council of Governors tolead the Board and to ensure that it successfullydischarges its overall responsibility for the FoundationTrust as a whole. The expression “the Chair of theFoundation Trust” shall be deemed to include theDeputy Chair of the Foundation Trust if the Chair isabsent from the meeting or is otherwise unavailable.

Chief Executive Shall mean the Chief Officer of the Foundation Trust.Chief Financial Officer Shall mean the Chief Finance officer of the Foundation

Trust.Committee A committee or sub-committee created and appointed

by the Foundation Trust.Code of Conduct ofAccountability in theNHS

Describes the three crucial public service values(Accountability, Probity and Openness), which mustunderpin the work of the health service.

Constitution The constitution of the Foundation Trust that describesthe type of organisation, its primary purpose,governance arrangements and membership.

Council of Governors Means the Council of Governors as constituted in theconstitution, which has the same meaning as thecouncil of governors in the Health and Social Care Act2012.

Director Means a member of the Board of Directors.Executive Director Means a Director who is an officer and member of the

Board of Directors.External Auditor Means the person appointed by the Council of

Governors to audit the accounts of the FoundationTrust, who is called the auditor in the Health andSocial Care Act 2012.

Financial Procedures Detailed financial requirements regarding theapplication of Standing Financial Instructions

Financial Year Means a period beginning with the date on which theFoundation Trust is authorised and ending with thenext 31 March; and each successive period of twelvemonths beginning with 1 April.

Funds held on Trust Shall mean those funds which the Foundation Trustholds at its date of incorporation, receives ondistribution by statutory instrument, or choosessubsequently to accept under powers derived underSchedule 4 Part 1 paragraph 10 of the Health andSocial Care Act 2012. Such funds may or may not becharitable.

Foundation Trust The Leeds and York Partnership NHS FoundationTrust.


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Legal Adviser Means the properly qualified person appointed by theFoundation Trust to provide legal advice.

Member Means a member of the Foundation Trust.

NHS Improvement Means the independent regulator for the purposes ofPart 2 of the Health and Social Care Act 2012.

Non-Executive Director Means a Director who is not an officer of theFoundation Trust and is not to be treated as an officerby virtue of the Constitution.

Officer Means an employee of the Foundation Trust.Partner Means, in relation to another person, a member of the

same household living together as a family unit.Property Is land, buildings and equipment owned or leased by

the Foundation Trust.Protected Property(Assets)

The property (land and buildings) needed for thepurposes of providing any of the mandatory(designated) goods and services and mandatorytraining and education.

Provider Licence The document issued by NHS Improvement whichauthorises an organisation to provide health care.

Secretary Means the Trust Board Secretary of the FoundationTrust or any other person appointed to perform theduties of the Secretary, including a joint, assistant ordeputy secretary.

Standing FinancialInstructions (SFIs)

Regulate the conduct of the Trust’s financial matters.

Standing Orders (SOs) The constitution incorporates the Standing Orders andregulates the business conduct of the Board ofDirectors and Council of Governors.

1.3 Responsibilities and delegation

1.3.1 The Trust Board

The Board of Directors exercises financial supervision and control by:

(a) formulating the financial strategy;

(b) requiring the submission and approval of plans;

(c) defining and approving essential features in respect of importantprocedures and financial systems (including the need to obtain value formoney) and by ensuring appropriate audit provision; and

(d) defining specific responsibilities placed on directors of the Board andemployees as indicated in the Schedule of Decision/Duties Delegated by


6

the Board of Directors document.

1.3.2 The Board of Directors has resolved that certain powers and decisions may only beexercised by the Board of Directors in formal session. These are set out in the“Reservation of Powers to the Board of Directors and Council of Governors andSchedule of Decision/Duties Delegated by the Board of Directors” document. Allother powers have been delegated to such other officers and committees as theFoundation Trust has established.

1.3.3 The Chief Executive and Chief Financial Officer

The Chief Executive and Chief Financial Officer will, as far as possible, delegatetheir detailed responsibilities, but they remain accountable for financial control.

The Chief Executive is ultimately accountable to the Board of Directors and asAccounting Officer, to the Secretary of State, for ensuring that the Board meets itsobligation to perform its functions within the available financial resources. TheChief Executive has overall executive responsibility for the Foundation Trust’sactivities, is responsible to the Chair and the Board of Directors for ensuring that itsfinancial obligations and targets are met and has overall responsibility for theFoundation Trust’s system of internal control.

1.3.4 It is a duty of the Chief Executive to ensure that directors of the Board, employeesand all new appointees are notified of and put in a position to understand theirresponsibilities within these Instructions.

1.3.5 The Chief Financial Officer

The Chief Financial Officer is responsible for:

(a) implementing the Foundation Trust’s financial policies and for co-coordinating any corrective action necessary to further these policies; (theSFIs themselves do not provide detailed procedural advice. Thesestatements should therefore be read in conjunction with the detaileddepartmental and financial procedure notes);

(b) maintaining an effective system of internal financial control includingensuring that detailed financial procedures and systems incorporating theprinciples of separation of duties and internal checks are prepared,documented and maintained to supplement these instructions;

(c) ensuring that sufficient records are maintained to show and explain theFoundation Trust’s transactions in order to disclose, with reasonableaccuracy, the financial position of the Foundation Trust at any time;

(d) Without prejudice to any other functions of the Foundation Trust, andemployees of the Foundation Trust, the duties of the Chief Financial Officerinclude:


7

(i) the provision of financial advice to other members of the Board ofDirectors, Council of Governors and employees;

(ii) the design, implementation and supervision of systems of internalfinancial control;

(iii) the preparation and maintenance of such accounts, certificates,estimates records and reports as the Foundation Trust may requirefor the purpose of carrying out its statutory duties.

1.3.6 Board of Directors and Employees

All directors of the Board and employees, severally and collectively, areresponsible for:

(i) the security of the property of the Foundation Trust;

(ii) avoiding loss;

(iii) exercising economy and efficiency in the use of resources;

(iv) conforming with the requirements of Constitution, Standing FinancialInstructions, Financial Procedures and the Reservation of Powers to theBoard of Directors and Council of Governors and Schedule ofDecisions/Duties Delegated by the Board of Directors.

1.3.7 Contractors and their employees

Any contractor or employee of a contractor who is empowered by the FoundationTrust to commit the Foundation Trust to expenditure or who is authorised to obtainincome shall be covered by these instructions. It is the responsibility of the ChiefExecutive to ensure that such persons are made aware of this

1.3.8 For all directors of the Board and any employees who carry out a financial function,the form in which financial records are kept and the manner in which members ofthe Board and employees discharge their duties must be to the satisfaction of theChief Financial Officer.


8

2. AUDIT

2.1 Audit Committee

2.1.1. In accordance with the Constitution, the Board of Directors shall formally establish acommittee of at least three Non-Executive Directors (the Audit Committee) withclearly defined terms of reference. This committee will provide an independent andobjective view of internal control by amongst other things:

(a) overseeing Internal and External Audit services;

(b) review and report to the Board on the annual financial statements beforesubmission to the Board with a recommendation as to the adoption of thefinancial statements.

(c) review the establishment and maintenance of an effective system ofinternal control, across the whole of the organisation’s activities(both clinical and non-clinical), that supports the achievement of theorganisation’s objectives;

(d) monitoring compliance with the Constitution and Standing FinancialInstructions;

(e) reviewing schedules of losses and special payments and makingrecommendations to the Board of Directors;

(f) reviewing the arrangements in place to support the Board AssuranceFramework process and advising the Board of Directors accordingly.

2.1.2 Where the Audit Committee considers there is evidence of ultra vires transactions,evidence of improper acts, or if there are other important matters that theCommittee wishes to raise, the Chair of the Audit Committee should raise thematter at a full meeting of the Board of Directors. Exceptionally, the matter mayneed to be referred outside the Foundation Trust to an appropriate organisation.

2.1.3 It is the responsibility of the Chief Financial Officer to ensure an adequate InternalAudit service is provided and the Audit Committee shall monitor arrangements andbe involved in the selection process when/if an Internal Audit service provider ischanged.

2.2 Chief Financial Officer

2.2.1 The Chief Financial Officer is responsible for:

(a) ensuring there are arrangements to review, evaluate and report on theeffectiveness of internal control including the establishment of an effectiveInternal Audit function;


9

(b) ensuring that the Internal Audit is adequate and meets mandatory auditstandards;

(c) deciding at what stage to involve the police in cases of misappropriation offunds and other financial irregularities not involving fraud or corruption;

(d) ensuring that an annual internal audit report is prepared for theconsideration of the Audit Committee. The report must cover:

(i) a clear opinion on the effectiveness of internal control inaccordance with current assurance framework guidance issued bythe Department of Health including for example compliance withcontrol criteria and standards;

(ii) major internal control weaknesses discovered;

(iii) progress against plan over the previous year;

(e) ensuring the following plans are submitted for consideration of the AuditCommittee;

(i) at least every three years a strategic plan covering three years;

(ii) annually a detailed plan for the coming year.

(f) monitoring and reporting on the progress on the implementation of internalaudit recommendations.

2.2.2 The Chief Financial Officer or designated auditors are entitled without necessarilygiving prior notice to require and receive:

(a) access to all records, documents and correspondence relating to anyfinancial or other relevant transactions, including documents of aconfidential nature;

(b) access at all reasonable times to any land, premises, members of theBoard of Directors and Council of Governors or employee of the FoundationTrust;

(c) the production of any cash, stores or other property of the Foundation Trustunder a director of the Board of Directors and an employee's control; and

(d) explanations concerning any matter under investigation.


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2.3 Internal Audit

2.3.1 Internal Audit will review, appraise and report upon:

(a) the extent of compliance with and the effect of relevant established policies,plans and procedures;

(b) the adequacy and application of financial and other related managementcontrols;

(c) the suitability of financial and other related management data;

(d) the extent to which the Foundation Trust’s assets and interests areaccounted for and safeguarded from loss of any kind, arising from:

(i) fraud and other offences;

(ii) waste, extravagance, inefficient administration;

(iii) poor value for money or other cause;

2.3.2 Whenever any matter arises which involves, or is thought to involve, Trust propertyor any suspected irregularity in the exercise of any function of a pecuniary nature,the Chief Financial Officer must be notified immediately. Where fraud is suspectedthe Chief Financial officer and / or Local Counter Fraud Specialist must becontacted and the relevant financial procedures must be followed.

2.3.3 The Internal Audit representative will attend Audit Committee meetings and has aright of access to all Audit Committee members, the Chair and Chief Executive ofthe Foundation Trust.

2.3.4 The reporting system for internal audit shall be agreed between the Chief FinancialOfficer, the Audit Committee and the Internal Audit representative. The agreementshall be in writing and shall comply with the guidance on reporting contained inInternal Audit Standards. The reporting system shall be reviewed at least everythree years.

2.3.5 Managers in receipt of audit reports referred to them, have a duty to takeappropriate remedial action within the agreed time-scales specified within thereport. The Chief Financial Officer shall identify a formal review process to monitorthe extent of compliance with audit recommendations. Where appropriate remedialaction has failed to take place within a reasonable period, the matter shall bereported to the Audit Committee.


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2.4 Financial Audit (External Audit)

2.4.1 2.4.2 Duties

The Foundation Trust is to have an External Auditor and is to provide the ExternalAuditor with every facility and all information which he may reasonably require forthe purposes of his functions under Part 2 of the Health and Social Care Act 2012.

The External Auditor is to carry out their duties in accordance with Schedule 10 ofthe Health and Social Care Act 2012 and should comply with NHS Improvement’sAudit Code.

2.4.2 Appointment of External Auditor

The External Auditor is appointed by the Council of Governors followingrecommendation from the Audit Committee.

The Council of Governors at a General Meeting shall appoint or remove theFoundation Trust’s External Auditor.

The Board of Directors may resolve that External Auditors be appointed to reviewand publish a report on any other aspect of the Foundation Trust’s performance.Any such auditors are to be appointed by the Council of Governors.

2.4.3 The Foundation Trust shall comply with the Audit Code.

2.4.4 The Foundation Trust shall implement a procedure for considering and approvingany additional services to be provided by the auditor.

2.4.5 Liaison with Internal Audit

The External Auditor will liaise with the Internal Audit function in order to obtain asufficient understanding of internal audit activities to assist in planning the audit anddeveloping an effective audit approach.

2.4.6 Access to Documents

The External Auditor of the Foundation Trust has a right of access at all reasonabletimes to every document, to which they are legally entitled, relating to theFoundation Trust which appears to them necessary for the purpose of theirfunctions under Part 2 of the Health and Social Care Act 2012.

2.4.7 Public Interest Report

In the event of the External Auditor issuing a Public Interest Report the FoundationTrust shall:

(a) Send the public interest report to the Council of Governors and the Board ofDirectors:


12

(i) At once if it is an immediate report; or(ii) Not later than 14 days after conclusion of the audit.

(b) Forward a report to NHS Improvement within 30 days (or such shorterperiod as NHS Improvement may specify) of the report being issued. Thereport shall include details of the Foundation Trust’s response to the issuesraised within the Public Interest Report.

2.5 Fraud and Corruption

2.5.1 The Chief Executive and Chief Financial Officer shall monitor and ensurecompliance with all relevant laws, codes and contractual obligations governing theconduct of countering fraud and corruption.

2.5.2 The Trust shall nominate a suitable person to carry out the duties of the LocalCounter Fraud Specialist (LCFS) in accordance with relevant Counter FraudStandards for Providers.

2.5.3 The LCFS shall report to the Chief Financial Officer and shall work with staff at theNHS Counter Fraud Authority in accordance with the NHS Anti-Crime Manual.

2.5.4 The Local Counter Fraud Specialist will provide a written report to the AuditCommittee, at least annually, on counter fraud work within the Foundation Trust.

2.6 Security Management

2.6.1 The Foundation Trust shall promote and protect the security of people engaged inactivities for the purposes of the health service functions of that body, service users,its property and its information. This shall be in accordance with Directions issuedby the Secretary of State for Health on NHS security management and havingregard to any other reasonable guidance or advice issued by NHS Protect.

2.6.2 The Foundation Trust Chief Executive and designated Director will monitor andensure compliance with Directions.

2.6.3 The Foundation Trust shall nominate and appoint a suitable person to carry out theduties of the Local Security Management Specialist (LSMS).

2.6.4 The Foundation Trust shall designate a Non-Executive Director to be responsible tothe Board for NHS security management.

2.6.5 The Chief Executive has overall responsibility for controlling and co-ordinatingsecurity. There are nominated Executive and Non–Executive Directors, inaccordance with statutory requirements and key tasks are delegated to the Directorwith responsibility for Security Management and the appointed Local SecurityManagement Specialist (LSMS).


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3. ALLOCATIONS, BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROLAND MONITORING

3.1 Preparation and Approval of Business Plans and Budgets

3.1.1 The Chief Executive will compile and submit to the Board a Business Plan thattakes into account financial targets and forecast limits of available resources. TheBusiness Plan will contain:

(a) a statement of the significant assumptions on which business planning isbased;

(b) details of major changes in workload, delivery of services or resourcesrequired to achieve the business plan.

3.1.2 Prior to the start of the financial year the Chief Financial Officer will, on behalf of theChief Executive, prepare and submit budgets for approval by the Board. Suchbudgets will:

(a) be in accordance with the aims and objectives set out in the FoundationTrust’s Annual Business Plan and the commissioners’ local delivery plans;

(b) accord with workload, manpower and activity (where appropriate) plans;

(c) be produced following discussion with appropriate budget holders;

(d) be prepared within the limits of overall plans and available funds;

(e) identify potential risks;

(f) be based on reasonable and realistic assumptions; and

3.1.3 The Chief Financial Officer shall monitor financial performance against budget andbusiness plan, periodically review them and report to the Board and Finance andBusiness Committee. Any significant variances should be reported by the ChiefFinancial Officer to the Board of Directors as soon as possible, who shall beadvised of action to be taken in respect of such variances.

3.1.4 All budget holders must provide information as required by the Chief FinancialOfficer to enable budgets to be compiled.

3.1.5 All budget holders will sign up to their allocated budgets at the commencement ofeach financial year.

3.1.6 The Chief Financial Officer has a responsibility to ensure that adequate training isdelivered on an on-going basis to budget holders to help them managesuccessfully.


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3.2 Budgetary Delegation

3.2.1 The Chief Executive may delegate the management of a budget to permit theperformance of a defined range of activities. This delegation is set out and budgetholders confirm in writing, accompanied by a clear definition of:

(a) the amount of the budget;

(b) the purpose(s) of each budget heading;

(c) individual and group responsibilities;

(d) authority to exercise virement;

(e) achievement of planned levels of service;

(f) the provision of regular reports.

3.2.2 The Chief Executive and delegated budget holders must not exceed the budgetarytotal or virement limits set by the Board.

3.2.3 Non-recurring funds should not be used to finance recurrent activities

3.3 Budgetary Control and Reporting

3.3.1 The Chief Financial Officer will devise and maintain systems of budgetary control.These will include:

(a) regular financial reports to the Board of Directors in a form approved by theBoard of Directors containing:

(i) Statement of Comprehensive Income;

(ii) Statement of Financial Position, including movements in working capital;

(iii) Risk Ratings, including analysis of liquidity and capital service coverpositions;

(iv) Cost Improvement Plans and Revenue Generation schemesperformance against plan;

(v) Cash Flow statement showing movements in cash and capital anddetailing of performance in respect of the Prudential Borrowing Code;

(vi) capital project spend and forecast spending against plan;

(vii) explanations of any material variances from plan;


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(viii) details of any corrective action where necessary and the ChiefExecutive's and/or Chief Financial Officer's view of whether such actionsare sufficient to correct the situation;

(b) monthly service reports for each service directorate, including costs,income and activity

(c) the issue of timely, accurate and comprehensible advice and financialreports to each budget holder, covering the areas for which they areresponsible;

(d) investigation and reporting of variances from financial, activity / workloadand manpower budgets;

(e) monitoring of management action to correct variances;

(f) arrangements for the authorisation of budget transfers;

(g) advising the Chief Executive and Foundation Trust Board of Directors of theconsequences of changes in policy, pay awards and other events andtrends affecting budgets and shall advise on the economic and financialimpact of future plans and projects;

(h) review of the bases and assumptions used to prepare budgets; and

(i) regular monitoring meetings with the Chief Financial Officer, budgetmanagers and relevant Director(s) of the service.

In the performance of these duties the Chief Financial Officer will have access to allbudget holders and budget managers on budgetary matters and shall be providedwith such financial and statistical information as is necessary.

3.3.2 Each budget manager is responsible for ensuring that budgets are managed withinresources, both in terms of manpower and finance. Any requirement to transferbudgets must comply with the virement process:

(a) officers shall not exceed the budget limit set;

(b) the amount provided in the approved budget is not used in whole or in partfor any purpose other than that specifically authorised subject to the rules ofvirement; and

(c) no permanent employees are appointed without the approval of the ChiefExecutive other than those provided for within the available resources andmanpower establishment as approved by the Board of Directors.

3.3.3 The Chief Executive is responsible for ensuring the best possible use of resources,both manpower and finances and for delivering value for money at all times.


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3.3.4 The Chief Executive is responsible for identifying and implementing costimprovement plans and revenue generation initiatives in accordance with therequirements of the Annual Business Plan.

3.4 Capital Expenditure

The general rules applying to delegation and reporting shall also apply to capitalexpenditure.

3.5 Monitoring Returns

3.5.1 The Board of Directors are responsible for ensuring that the appropriate monitoringforms are submitted to NHS Improvement the Independent Regulator, at suchfrequency as is required.


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4. ANNUAL ACCOUNTS, REPORTS AND PLANS

4.1 Accounts

4.1.1 The Foundation Trust is to keep accounts in such form as NHS Improvement may,with the approval of the Treasury direct. The accounts are to be audited by theFoundation Trust’s External Auditor. The following documents will be madeavailable to the Comptroller and Auditor General for examination by request:

(a) the accounts;

(b) any records relating to them; and

(c) any report of the External Auditor on them.

4.1.2 The Accounting Officer, via the Chief Financial Officer, shall ensure that theFoundation Trust prepares in respect of each financial year annual accounts insuch form as NHS Improvement may with the approval of the Treasury direct. Inpreparing its annual accounts, the Foundation Trust is to comply with any directionsgiven by NHS Improvement with the approval of the Treasury as to:

(a) the methods and principles according to which the accounts are to beprepared;

(b) the information to be given in the accounts;

and shall be responsible for the functions of the Foundation Trust as set out inParagraph 25 of Schedule 7 of the Health and Social Care Act 2012.

4.1.3 The annual accounts and any report of the External Auditor on them are to bepresented to the Council of Governors at a General Public Meeting and madeavailable to the public.

4.1.4 The Accounting Officer shall ensure the Foundation Trust:

(a) sends copies of the final annual accounts and any report of the ExternalAuditor to NHS Improvement and once it has done so

(b) lay a copy of those documents before Parliament.

4.1.5 Responsibility for complying with the requirements relating to the form, preparationand presentation of the accounts shall be delegated to the Accounting Officer.


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4.2 Annual Report

4.2.1 The Accounting Officer shall ensure that the Foundation Trust prepares annualreports in accordance with the accounting policies and guidance given by NHSImprovement and sends these to NHS Improvement.

4.2.2 The Foundation Trust is to comply with any decision NHS Improvement makes asto:

(a) the form of the reports/returns;

(b) when the reports are to be sent to them;

(c) the periods to which the reports are to relate.

4.3 Annual Plans

4.3.1 The Foundation Trust is to give information as to its forward planning in respect ofeach financial year to NHS Improvement. The document containing this informationis to be prepared by the Directors, and in preparing the document, the Board ofDirectors must have regard to the views of the Council of Governors.

4.3.2 The Foundation Trust is required to provide the following types of information toNHS Improvement:

(a) annual submissions: plans, statutory reporting requirements of theFoundation Trust, and other annual requirements specified in the licence,as required by NHS Improvement;

(b) in-year submissions: financial and service performance information issubmitted on a monthly/quarterly basis;

(a) exception reports: other information that may have material implicationsfor the Foundation Trust’s compliance, but which is not routinely requestedby NHS Improvement. These may relate to any in-year identified concernsrelevant to the Foundation Trust’s governance of quality (and therefore tothe Trust’s compliance with its licence);

(c) other information/ad-hoc reports: following up specific issues identifiedas part of the annual planning process or in-year. This includes periodicreviews of the Foundation Trust’s governance, where external reviewscovering areas of governance have been conducted.


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5. BANK AND GOVERNMENT BANKING SERVICE (GBS) ACCOUNTS

5.1 General

5.1.1 The Chief Financial Officer is responsible for managing the Foundation Trust’sbanking arrangements and for advising the Foundation Trust on the provision ofbanking services and operation of accounts.

5.1.2 The Board of Directors shall approve the banking arrangements.

5.2 Bank and GBS Accounts


(a) commercial bank accounts and Government Banking Service (GBS) accounts;

(b) establishing separate bank accounts for the Foundation Trust’s non-exchequer funds;

(c) ensuring payments made from bank or GBS accounts do not exceed theamount credited to the account except where arrangements have been made;

(d) reporting to the Board of Directors all arrangements made with the FoundationTrust’s bankers for accounts to be overdrawn when utilising a working capitalfacility.

All accounts should be held in the name of the Foundation Trust. No officer otherthan the Chief Financial Officer shall open any account in the name of theFoundation Trust, or for the purpose of furthering Foundation Trust activities, or anyFunds held on Trust Accounts.

5.3 Banking Procedures

5.3.1 The Chief Financial Officer will prepare detailed instructions on the operation ofbank and GBS accounts which must include:

(a) the conditions under which each bank and GBS account is to be operated;

(b) the limit to be applied to any overdraft;

(c) those authorised to sign cheques or other orders drawn on the FoundationTrust’s accounts.

5.3.2 The Chief Financial Officer must advise the Foundation Trust’s bankers in writing ofthe conditions under which each account will be operated.


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5.3.3 The Chief Financial Officer shall approve security procedures for any chequesissued without a hand-written signature e.g. lithographed. Manually producedcheques shall be signed by the authorised officer(s) in accordance with the bankmandate.

All cheques shall be treated as controlled stationery, in the charge of a dulydesignated officer controlling their issue.

5.4 Tendering and Review

5.4.1 The Chief Financial Officer will review the commercial banking arrangements of theFoundation Trust at regular intervals to ensure they reflect best practice andrepresent best value for money by periodically seeking competitive tenders for theFoundation Trust’s commercial banking business.

5.4.2 Competitive tenders should be sought at least every five years. The results of thetendering exercise should be reported to the Board of Directors. This review is notnecessary for GBS accounts.


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6. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES ANDOTHER NEGOTIABLE INSTRUMENTS

6.1 Income Systems

6.1.1 The Chief Financial Officer is responsible for designing, maintaining and ensuringcompliance with systems for the proper recording, invoicing, collection and codingof all monies due.

6.1.2 All such systems shall incorporate, where practicable, in full the principles ofinternal check and separation of duties.

6.1.3 The Chief Financial Officer is also responsible for the prompt banking of all moniesreceived.

6.2 Fees and Charges

6.2.1 The Chief Financial Officer is responsible for approving and regularly reviewing thelevel of all fees and charges other than those determined by the Department ofHealth or by Statute. Independent professional advice on matters of valuation shallbe taken as necessary. Where sponsorship income (including items in kind such assubsidised goods or loans of equipment) is considered the guidance in theDepartment of Health’s Commercial Sponsorship – Ethical standards in the NHSshall be followed.

6.2.2 All employees must inform the Chief Financial Officer promptly of money duearising from transactions which they initiate/deal with, including all contracts,leases, tenancy agreements, private patient undertakings and other transactions.

6.3 Debt Recovery

6.3.1 The Chief Financial Officer is responsible for the appropriate recovery action on alloutstanding debts, including formal follow up procedure for all debtor accounts.Overpayments should be detected (or preferably prevented) and recovery initiated.

6.3.2 Income not received should be dealt with in accordance with losses procedures.

6.3.3 Overpayments should be detected (or preferably prevented) and recovery initiated.

6.4 Security Of Cash, Cheques and Other Negotiable Instruments


(a) approving the form of all receipt books, agreement forms, or other means ofofficially acknowledging or recording monies received or receivable;

(b) ordering and securely controlling any such bulk stationery stocks;


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(c) the provision of adequate facilities and systems for employees whoseduties include collecting and holding cash, including the provision of safesor lockable cash boxes, the procedures for keys, and for coin operatedmachines; and

6.4.2 Official money shall not under any circumstances be used for the encashment ofprivate cheques or IOUs.

6.4.3 All cheques, postal orders, cash etc., shall be banked intact. Disbursements shallnot be made from cash received, except under arrangements approved by theChief Financial Officer.

6.4.4 The holders of safe keys shall not accept unofficial funds for depositing in theirsafes unless such deposits are in special sealed envelopes or locked containers. Itshall be made clear to the depositors that the Foundation Trust is not to be heldliable for any loss, and written indemnities must be obtained from the organisationor individuals absolving the Foundation Trust from responsibility for any loss.

6.4.5 Any loss or shortfall of cash, cheques or other negotiable instruments, howeveroccasioned, shall be monitored and recorded within the Finance Department. Anysignificant trends should be reported to the Chief Financial Officer and InternalAudit via the incident reporting system. Where there is prima facie evidence offraud or corruption this should follow the form of the Foundation Trust’s CounterFraud procedure. Where there is no evidence of fraud or corruption the loss shouldbe dealt with in line with the Foundation Trust’s Losses and Special PaymentsProcedures.


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7. FOUNDATION TRUST CONTRACTS

7.1 The Board of Directors of the Foundation Trust shall regularly review and shall at alltimes maintain and ensure the capacity and capability of the Foundation Trust toprovide the mandatory goods and services as per the Provider Licence.

7.2 The Chief Executive, as the Accounting Officer, is responsible for ensuring theFoundation Trust enters into suitable Foundation Trust Contracts (FTC) withcommissioners for the provision of NHS services. The Foundation Trust will followthe priorities contained within the schedules of the contract, and wherever possible,be based upon integrated care pathways to reflect expected patient experience. Indischarging this responsibility, the Chief Executive should take into account:

(a) the standards of service quality expected;

(b) the relevant national service framework (if any);

(c) the provision of reliable information on cost and volume of services;

(d) the NHS Operating Framework;

(e) that contracts build where appropriate on existing partnershiparrangements;

(f) that contracts are based on integrated care pathways.

7.3 The Chief Executive is to ensure that the Foundation Trust works with all partneragencies involved in both the delivery and the commissioning of the servicerequired.

7.4 The Chief Executive, as the Accounting Officer, will need to ensure that regularreports are provided to the Board of Directors detailing actual and forecast incomefrom the FTCs. All parties involved in an FTC should agree a common activitycurrency for application across the ranges of services included in the contract.

7.5 Non Commercial Contracts

7.5.1 Where the Trust enters into a relationship with another organisation for the supplyor receipt of other services – clinical or non-clinical, the responsible officer shouldensure that an appropriate non-commercial contract is present and signed by bothparties. This should incorporate:

(a) A description of the service and indicative activity levels;

(b) The term of the agreement;

(c) The value of the agreement;


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(d) The lead officers;

(e) Performance and dispute resolution procedures;

(f) Risk management and clinical governance arrangements.

7.5.2 Non-commercial contracts should be reviewed and agreed on an annual basis or asdetermined by the term of the agreement so as to ensure value for money and tominimise the potential loss of income.

7.6 Partnership Agreements

When the Foundation Trust proposes to enter into a partnership arrangement topool funds as outlined in section 75 of the Health and Social Care Act 2012, thefollowing procedures shall apply:

(a) The Chief Executive shall demonstrate that the aim of the partnershiparrangement is to improve services for users by raising standards andimproving the quality and responsiveness of services;

(b) The Chief Executive and partner organisations will jointly set out a writtenpartnership agreement as identified in the Regulations;

(d) The written partnership agreement must be specifically agreed by theBoard of Directors.

7.7 Private Health Care

7.7.1 The Foundation Trust may seek private patient income, subject to the condition thatit is not at the expense of NHS patients, to a value of 1.5% of patient relatedactivity.


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8. TENDERING AND CONTRACTING PROCEDURES

8.1 Duty to comply with Standing Financial Instructions

8.1.1 The procedure for making all contracts by or on behalf of the Foundation Trust shallcomply with these Standing Financial Instructions.

8.2 EU Directives Governing Public Procurement

8.2.1 Directives by the Council of the European Union (EU) promulgated by theDepartment of Health (DH) prescribing procedures for awarding all forms ofcontracts shall have effect as if incorporated in these Standing FinancialInstructions.

8.2.2 The Foundation Trust shall comply as far as is practicable with the requirements ofNHS Improvement guidance” in respect of capital investment and estate andproperty transactions. In the case of management consultancy contracts the Trustshall comply as far as is practicable with Department of Health guidance "TheProcurement and Management of Consultants within the NHS" (adopted as aseparate guidance document by the Trust).

8.3 Formal Competitive Tendering

8.3.1 General Applicability

The Foundation Trust shall ensure that competitive tenders are invited for:

the supply of goods, materials and manufactured articles; the rendering of services including all forms of management consultancy

services (other than specialised services sought from or provided by theDH);

For the design, construction and maintenance of building and engineeringworks (including construction and maintenance of grounds and gardens);and disposals;

Where the Foundation Trust elects to invite tenders for the supply of healthcareservices these Standing Financial Instructions shall apply as far as they areapplicable to the tendering procedure.

NHS Supply Chain is the preferred procurement route of all goods for the Trust; ifgoods are not available via this method then the decision to use alternative sourcesmust be documented. Where tenders or quotations are not required, becauseexpenditure is below the levels defined in the Reservation of Powers to the Board ofDirectors and Council of Governors and Schedule of Decisions/Duties Delegated bythe Board of Directors, the Foundation Trust shall procure goods and services inaccordance with procurement procedures approved by the Chief Financial Officer;


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8.3.2 Exceptions and instances where formal tendering need not be applied

Formal tendering procedures need not be applied where:

(a) the estimated expenditure or income does not, or is not reasonably expectedto, exceed £50,000 over the length of the contract (cumulative value); publicadvertisement will be carried out, however, where required, in compliancewith EU legislation.

(b) the requirement is ordered under existing contracts.

8.3.3 Formal tendering and quotation procedures may be waived by officers to whompowers have been delegated by the Chief Executive:

(a) in very exceptional circumstances where the Chief Executive decides thatformal tendering procedures would not be practicable or the estimatedexpenditure or income would not warrant formal tendering procedures, andthe circumstances are detailed in an appropriate Foundation Trust record;

(b) where the requirement is covered by an existing contract;

(c) here CPC or other applicable framework agreements are in place and havebeen approved by the Board of Directors;

(d) where a consortium arrangement is in place and a lead organisation hasbeen appointed to carry out tendering activity on behalf of the consortiummembers;

(e) where the timescale genuinely precludes competitive tendering but failure toplan the work properly would not be regarded as a justification for a singletender;

(f) where specialist expertise is required and there is clear and convincingevidence readily at hand that it is available form only one source;

(g) when the task is essential to complete the project, and arises as aconsequence of a recently completed assignment and engaging differentparties for the new task would be inappropriate;

(h) there is a clear benefit to be gained from maintaining continuity with an earlierproject. However in such cases the benefits of such continuity must outweighany potential financial advantage to be gained by competitive tendering;

(i) for the provision of legal advice and services providing that any legal firm orpartnership commissioned by the Foundation Trust is regulated by the LawSociety for England and Wales for the conduct of their business (or by theStandards Board for England and Wales in relation to the obtaining of


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Counsel’s opinion) and are generally recognised as having sufficientexpertise in the area of work for which they are commissioned.

The Chief Financial Officer will ensure that any fees paid are reasonable andwithin commonly accepted rates for the costing of such work.

(j) the goods or materials to be supplied consist of repairs to parts for existingequipment or extensions thereto which, for practical reasons, must be fromthe same manufacturer;

(k) a Framework Agreement has been established by other public sectorbodies, including the Department of Health, and the Head of Procurementhas assessed its appropriateness to the Foundation Trust prior to utilisation;

(l) where the market place has a limited number of suppliers below theminimum number required for quotation or tender exercises. (The type ofresearch and evidence carried out must be documented on the waiversubmission);

(m) Where an extension to an existing contract can be evidenced to be moreeffective to the Trust than the alternative of a competitive exercise at thattime. Initial approval by the Head of Procurement will be report to the AuditCommittee via the Chief Financial Officer. This extension period must notbreach EU thresholds; and/or

(n) Where the Head of Procurement can evidence that cost efficiency can berealised by the Trust through negotiation and or mini competition carried outby the Procurement Department. A comparison of at least the current andproposed supplier must be evidenced. Initial approval by the Head ofProcurement will be reported to the Audit Committee via the Chief FinancialOfficer.

8.3.4 The waiver process should not be used to avoid competition or for administrativeconvenience or to award further work to a consultant originally appointed through acompetitive procedure. A Single Quotation or Tender Waiver form must becompleted and approved in advance for any procurement in excess of £10,000 thathas not followed the correct procurement procedure.

8.3.5 Where it is decided that competitive tendering or quotations is not applicable andshould be waived the reasons should be documented in an appropriate FoundationTrust record and reported by the Chief Financial Officer to the Audit Committee in aformal meeting.

8.3.6 Fair and Adequate Competition

The Board of Directors shall ensure that an electronic system is in place to allowcomplete transparency of contract opportunities; this system should populate thegovernment’s contract finder portal.


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Over EU threshold tender opportunities advertised should be subject to adequatepre-qualification criteria to ensure that appropriate suppliers are involved with theprocess.

The annual declaration of interests update will consider the need for all staffinvolved in the management and processing of tenders to be included the process.

8.3.7 Building and Engineering Construction Works

Competitive Tendering cannot be waived for building and engineering constructionworks and maintenance without Departmental of Health approval.

8.3.8 Items which subsequently breach thresholds after original approval

Items estimated to be below the limits set in this Standing Financial Instruction forwhich formal tendering procedures are not used which subsequently prove to havea value above such limits shall be reported to the Chief Executive, and be recordedin an appropriate Foundation Trust record.

8.4 Contracting/Tendering Process

All tender processes shall be undertaken via the Procurement team utilising theTrusts E-Tendering system. Where an alternative tender process is considered thismust be approved by the Chief Financial Officer and the tender process belowmust still be followed with the exception that tenders may be receipted andacknowledged by a third party but must be opened in line with the process in 8.4.3below.

8.4.1 Invitation to tender

(i) All invitations to tender shall state the date and time as being the latest timefor the receipt of tenders.

(ii) All invitations to tender shall state that no tender will be accepted unless:

(a) submitted vie the Trust e-tendering portal that the opportunity wasadvertised on. No paper responses will be accepted.

(b) submissions meet the formal Trust procedure that has been laid downfor e-tendering;

(iii) Every tender for goods, materials, services or disposals shall embody suchof the NHS Standard Contract Conditions as are applicable;

(iv) Every tender for building or engineering works (except for maintenancework, when ESTATECODE guidance shall be followed) shall embody or bein the terms of the current edition of one of the Joint Contracts TribunalStandard Forms of Building Contract or Department of the Environment


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(GC/Wks) Standard forms of contract amended to comply with legislationor, when the content of the work is primarily engineering, the GeneralConditions of Contract recommended by the Institution of Mechanical andElectrical Engineers and the Association of Consulting Engineers (Form A),or (in the case of civil engineering work) the General Conditions of Contractrecommended by the Institute of Civil Engineers, the Association ofConsulting Engineers and the Federation of Civil Engineering Contractors.These documents shall be modified and/or amplified to accord withDepartment of Health guidance and, in minor respects, to cover specialfeatures of individual projects.

8.4.2 Receipt, safe custody and opening of tenders

The Trust e-Tendering portal will record all responses to ITT documents that aresubmitted. The opening of tender responses will be carried out within the portal bythe buyer responsible for the tender process. The system will capture informationabout who is involved with the electronic opening of Tenders.

The date and time of the opening process will be captured in the e-Tenderingsystem.

8.4.3 Admissibility

(i) If for any reason the designated officers are of the opinion that the tendersreceived are not strictly competitive (for example, because their numbersare insufficient or any are amended, incomplete or qualified) no contractshall be awarded without the approval of the Chief Executive.

(ii) Where only one tender is sought and/or received, the Chief Executive andChief Financial Officer shall, as far practicable, ensure that the price to bepaid is fair and reasonable and will ensure value for money for theFoundation Trust.

8.4.4 Late tenders

(i) Tenders received after the due time and date, but prior to the opening of theother tenders, may be considered only if the Chief Executive or their nominatedofficer decides that there are exceptional circumstances i.e. despatched in goodtime but delayed through no fault of the tenderer. This would require theresponsible buyer to amend the deadline for receipt of tenders on the e-Tendering portal and should allow all bidders the opportunity to resubmit theirown bid.Note: this can only be done if the opening ceremony has not yet takenplace.

(ii) under no circumstances should a tender submission be allowed after theopening ceremony.


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8.4.5 Acceptance of formal tenders

(i) Any discussions with a tenderer which are deemed necessary to clarifytechnical aspects of their tender before the award of a contract will notdisqualify the tender. These discussions should take place through the e-Tendering portal and any questions and subsequent answers are recorded andshared with all interested parties.Note: no correspondence should be entered into outside of the e-Tendering portal.

(ii) An award criteria should be prepared alongside the specification to be issuedwith the ITT. This will consider all aspects of the contract on offer, Price willalways be a component of this evaluation.

It is accepted that for professional services such as management consultancy,the lowest price does not always represent the best value for money. Otherfactors affecting the success of a project include inter alia;

(a) experience and qualifications of team members;

(b) understanding of client’s needs;

(c) feasibility and credibility of proposed approach;

(d) ability to complete the project on time.

Where other factors are taken into account in selecting a tenderer, these mustbe clearly recorded and documented in the contract file, and the reason(s) fornot accepting the lowest tender clearly stated.

(iii) No tender shall be accepted which will commit expenditure in excess of thatwhich has been allocated by the Foundation Trust and which is not inaccordance with these Instructions except with the authorisation of the ChiefExecutive.

(iv) The use of these procedures must demonstrate that the award of the contractwas:

(a) not in excess of the going market rate/price current at the time the contractwas awarded;

(b) that best value for money was achieved.

(c) All tenders should be treated as confidential and should be retainedin line with the retention of records financial procedure and be madeavailable for inspection to comply with the Freedom of Information Act.


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8.4.6 Tender reports to the Board of Directors

Reports to the Board of Directors will be made on an exceptional circumstancebasis only.

8.4.7 The Trust should ensure that firms submitting tenders follow industry good practiceand as a minimum:

(a) All suppliers should work to the Foundation Trust’s terms and conditions ofcontract.

(b) The Trust should confirm that firms tendering for work shall ensure thatwhen engaging, training, promoting or dismissing employees or in anyconditions of employment, shall not discriminate against any personbecause of colour, race, ethnic or national origins, religion or sex, and willcomply with the provisions of the Equal Pay Act 1970, the SexDiscrimination Act 1975, the Race Relations Act 1976, the DisabledPersons (Employment) Act 1944, the Disability Discrimination Acts of 1995and 2005 and the Equality Act 2005 and any amending and/or relatedlegislation.

(c) Firms shall conform at least with the requirements of the Health and Safetyat Work Act and any amending and/or other related legislation concernedwith the health, safety and welfare of workers and other persons, and to anyrelevant British Standard Code of Practice issued by the British StandardInstitution. Firms must provide to the appropriate manager a copy of itssafety policy and evidence of the safety of plant and equipment, whenrequested.

(d) The Chief Financial Officer may make or institute any enquiries they deemappropriate concerning the financial standing and financial suitability ofapproved contractors.

(e) The Director with lead responsibility for clinical governance may make suchenquiries as is felt appropriate to be satisfied as to their technical / medicalcompetence.

8.4.8 Quotation

General position re quotations

Quotations are required where formal tendering procedures are:

(a) not applied;


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(b) not required and where the intended expenditure or income exceeds£10,000;

(c) reasonably expected to exceed the limit defined in the Reservation ofPowers to the Board of Directors and the Council of Governors andSchedule of Decisions/Duties Delegated by the Board of Directors(excluding vat irrespective of recovery arrangements).

8.4.9 Competitive Quotations

(a) Where quotations are required they should be advertised on the e-Tenderportal. The invitations to quote should be based on specifications or terms ofreference prepared by, or on behalf of, the Board of Directors;

(b) Quotations should be received through the e-tendering Portal. Nocorrespondence should be entered into outside of the agreed route.

(c) All quotations should be treated as confidential, unless a Purchase Order israised following the quotation process. This information will then become partof the freedom of Information act. All information should be retained on the e-tendering portal.

(d) The Head of Procurement or a nominated officer should evaluate theresponses based upon the award criteria issued with the ITQ. Price will be aconsideration but not the only factor in deciding which response offers thebest value.

(e) For the purposes of this section where there is a Framework Agreement inplace that has been established for use by Public Sector bodies the pricecontained therein may be used in lieu of a quotation(s).

8.4.10 Non-Competitive Quotations

Non-competitive quotations in writing may be obtained in the followingcircumstances:

(a) the supply of proprietary or other goods of a special character and therendering of services of a special character, for which it is not, in the opinionof the responsible officer, possible or desirable to obtain competitivequotations;

(b) the supply of goods or manufactured articles of any kind which are requiredquickly and are not obtainable under existing contracts;

(c) miscellaneous services, supplies and disposals;

(d) where the goods or services are for building and engineering maintenancethe responsible works manager must certify that the first two conditions ofthis SFI (i.e. (i) and (ii) of this SFI) apply.

(e) when a written quotation has been received, this must be included when


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raising a requisition for the goods or services quoted. The subsequentPurchase Order should refer to the written quotation to prevent anydiscrepancy with invoicing.

8.4.11 Quotations to be within Financial Limits

No quotation shall be accepted which will commit expenditure in excess of thatwhich has been allocated by the Foundation Trust and which is not in accordancewith Standing Financial Instructions except with the authorisation of either theChief Executive or Chief Financial Officer.

8.4.12 Authorisation of Tenders and Competitive Quotations

Providing all the conditions and circumstances set out in these Standing FinancialInstructions have been fully complied with, formal authorisation and awarding of acontract may be decided by the staff as defined in the Reservation of Powers tothe Board of Directors and the Council of Governors and Schedule ofDecisions/Duties Delegated by the Board of Directors. These levels ofauthorisation may be varied or changed. Formal authorisation must be put inwriting. In the case of authorisation by the Board of Directors this shall berecorded in their minutes.

8.5. Private Finance for capital procurement (see overlap with SFI No. 12.8)

8.5.1 The Foundation Trust should normally test for PFI when considering significantcapital procurement. When the Foundation Trust proposes to use finance which isto be provided by the private sector the following should apply:

(a) The Chief Financial Officer/Chief Executive shall demonstrate that the useof private finance represents value for money and genuinely transferssignificant risk to the private sector.

(b) The business case must be referred to the DOH Private Finance Unit (PFU),as appropriate (for example if a ‘Deed of Safeguard’ is required), for approvalor treated as per current guidelines. The Foundation Trust must follow theguidance contained in the NHS Improvement “Significant Investment”guidance. Any investment over a certain size must be reported to NHSImprovement who will assess the impact on our risk rating, which mayultimately preclude the Foundation Trust from progressing with PFI.

(c) The proposal must be specifically agreed by the Foundation Trust Board ofDirectors in the light of such professional advice as should reasonably besought in particular with regard to vires.

(d) The selection of a contractor/finance company must be on the basis ofcompetitive tendering or quotations.


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8.6 Compliance requirements for all contracts

The Board of Directors may only enter into contracts on behalf of the FoundationTrust within its Provider Licence and shall comply with:

(a) the Foundation Trust’s Standing Orders and Standing FinancialInstructions;

(b) EU Directives and other statutory provisions;

(c) any relevant directions including the Capital Investment Manual,ESTATECODE and guidance on the Procurement and Management ofConsultants;

(d) such of the NHS standard contract conditions as are applicable.

(e) contracts with Foundation Trusts must be in a form compliant withappropriate NHS guidance;

(f) where appropriate contracts shall be in or embody the same terms andconditions of contract as was the basis on which tenders or quotations wereinvited;

(g) In all contracts made by the Foundation Trust, the Board of Directors shallendeavour to obtain best value for money by use of all systems in place.The Chief Executive shall nominate an officer who shall oversee andmanage each contract on behalf of the Foundation Trust.

8.7 Personnel and Agency or Temporary Staff Contracts

The Chief Executive shall nominate officers with delegated authority to enter intocontracts for the employment of other officers, to authorise re-grading of staff, andenter into contracts for the employment of agency staff or temporary staff servicecontracts.

8.8 Disposals

Competitive Tendering or Quotation procedures shall not apply to the disposal of:

(a) any matter in respect of which a fair price can be obtained only bynegotiation or sale by auction as determined (or pre-determined in areserve) by the Chief Executive or his nominated officer;

(b) obsolete or condemned articles and stores, which may be disposed of inaccordance with the policy of the Foundation Trust;

(c) items to be disposed of with an estimated sale value of less than £10,000,this figure to be reviewed on a periodic basis;


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(d) items arising from works of construction, demolition or site clearance, whichshould be dealt with in accordance with the relevant contract;

8.9 In-house Services

8.9.1 The Chief Executive shall be responsible for ensuring that best value for money canbe demonstrated for all services provided on an in-house basis. The FoundationTrust may also determine from time to time that in-house services should be markettested by competitive tendering.

8.9.2 In all cases where the Board of Directors determines that in-house services shouldbe subject to competitive tendering the following groups shall be set up:

(a) Specification group, comprising the Chief Executive or nominatedofficer/s and specialist(s);

(b) In-house tender group, comprising a nominee of the ChiefExecutive, representative(s) of the in-house team and technical support;

(c) Evaluation team, comprising normally a specialist officer, a suppliesofficer and a Chief Financial Officer representative. For services having alikely annual expenditure exceeding £500,000, a non-executive should be amember of the evaluation team.

8.9.3 All groups should work independently of each other and individual officers may be amember of more than one group but no member of the in-house tender group mayparticipate in the evaluation of tenders.

8.9.4 The evaluation team shall make recommendations to the Board of Directors.

8.9.5 The Chief Executive shall nominate an officer to oversee and manage the contracton behalf of the Foundation Trust.

8.9.6 Applicability of SFIs on Tendering and Contracting to funds held in FoundationTrust (see overlap with SFI No. 17)

These Instructions shall not only apply to expenditure from Exchequer funds butalso to works, services and goods purchased from the Foundation Trust’s fundsand private resources.

8.9.7 Cancellation of Contracts

Except where specific provision is made in model Forms of Contracts or standardSchedules of Conditions approved for use within the National Health Service, thereshall be inserted in every written contract a clause empowering the FoundationTrust to cancel the contract and to recover from the contractor the amount of anyloss resulting from such cancellation:


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if the contractor shall have offered, or given or agreed to give, any personany gift (exceeding £25) or consideration of any kind as an inducement orreward for doing or forbearing to do or for having done or forborne to do anyaction in relation to the obtaining or execution of the contract of any othercontract with the Foundation Trust;

or for showing or forbearing to show favour or disfavour to any person inrelation to the contracts or any other contract with the Foundation Trust;

or if the like acts shall have been done by any person employed by him oracting on his behalf (whether with or without the knowledge of thecontractor);

or if in relation to any contract with the Foundation Trust the contractor orany person employed by him/her or acting on his/her behalf shall havecommitted any offence under the Bribery Act 2010.

8.9.8 Determination of Contracts for Failure to Deliver Goods or Material

There shall be inserted in every written contract for the supply of goods or materialsa clause to secure that, should the contractor fail to deliver the goods or materialsor any portion thereof within the time or times specified in the contract, theFoundation Trust may without prejudice cancel the contract either wholly or to theextent of such default and purchase other goods, or material of similar descriptionto make good (a) such default, or (b) in the event of the contract being whollycancelled the goods or material remaining to be delivered. The clause shall furthersecure that the amount by which the cost of so purchasing other goods or materialsexceeds the amount which would have been payable to the contractor in respect ofthe goods or materials shall be recoverable from the contractor.

8.9.9 Contractors Involving Funds Held on Foundation Trust – shall do so individually to aspecific named fund. Such contracts involving charitable funds shall comply withthe requirements of the Charities Act.


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9. TERMS OF SERVICE, ALLOWANCES AND PAYMENT OF DIRECTORS ANDEMPLOYEES

9.1 Remuneration and Terms of Service (see overlap with SO (Directors) No. 5)

9.1.1 In accordance with the Trust’s Constitution (Annex 8 SO 5.1.1) the Board ofDirectors shall establish a Remuneration Committee, with clearly defined terms ofreference, specifying which posts fall within its area of responsibility, itscomposition, and the arrangements for reporting.

9.1.2 The Committee will:

(a) advise the Board of Directors about appropriate remuneration and terms ofservice for the Chief Executive and other executive directors:

(i) all aspects of salary (including any performance-relatedelements/bonuses);

(ii) provisions for other benefits;(iii) arrangements for termination of employment and other contractual

terms;

(b) make such recommendations to the Board of Directors on the remunerationand terms of service of executive directors of the Board of Directors toensure they are fairly rewarded for their individual contribution to theFoundation Trust - having proper regard to the Foundation Trust'scircumstances and performance and to the provisions of any nationalarrangements for such members and staff where appropriate;

(c) monitor and evaluate the performance of individual executive directors; and

(d) advise on and oversee appropriate contractual arrangements for such staffincluding the proper calculation and scrutiny of termination payments takingaccount of such national guidance as is appropriate.

9.1.3 The Committee shall report in writing to the Board of Directors the basis for itsrecommendations. The Board of Directors shall use the report as the basis fortheir decisions, but remain accountable for taking decisions on the remunerationand terms of service of executive directors. Minutes of the Board of Directorsmeetings should record such decisions.

9.1.4 The Board of Directors will consider and need to approve proposals presented bythe Chief Executive for setting of remuneration and conditions of service for thoseemployees and officers not covered by the Committee.

9.1.5 The Foundation Trust will pay allowances to the Chair and Non-ExecutiveDirectors of the Board of Directors in accordance with the level of remunerationand terms and conditions agreed by the Council of Governors.


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9.2 Funded Establishment

9.2.1 The workforce plans incorporated within the annual budget will form the fundedestablishment.

9.2.2 Amendments to funded establishments may only be varied with the authority of theChief Financial Officer or nominated Finance representative. Such amendments willbe recorded on the appropriate establishment control forms.

9.3 Staff Appointments

9.3.1 No directors of the Foundation Trust Board of Directors or staff may engage, re-engage or re-grade employees, either on a permanent or temporary nature, or hireagency staff, or agree to changes in any aspect of remuneration:

(a) unless authorised / delegated to do so by the Chief Executive; and

(b) within the limit of their approved budget and funded establishment.

9.3.2 The Board of Directors will approve procedures presented by the Chief Executivefor the determination of commencing pay rates, condition of service, etc., foremployees.

9.4 Processing Payroll


(a) specifying timetables for submission of properly authorised time recordsand other notifications;

(b) the final determination of pay and allowances; including verification that therates of pay and relevant conditions of service are in accordance withcurrent agreements;

(c) making payment on agreed dates; and

(d) agreeing method of payment.

9.4.2 The Chief Financial Officer will, via a contract with the payroll provider, issueinstructions regarding;

(a) verification and documentation of data;

(b) the timetable for receipt and preparation of payroll data and the payment ofemployees and allowances;

(c) maintenance of subsidiary records for pensions, income tax, nationalinsurance and other authorised deductions from pay;


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(d) security and confidentiality of payroll information;

(e) checks to be applied to completed payroll before and after payment;

(f) authority to release payroll data under the provisions of the Data ProtectionAct and Freedom of Information Act;

(g) methods of payment available to various categories of employee andofficers;

(h) procedures for payment by cheque, bank credit, or cash to employees anddirectors;

(i) procedures for the recall of cheques and bank credits;

(j) pay advances and their recovery;

(k) maintenance of regular and independent reconciliation of pay controlaccounts;

(l) separation of duties of preparing records and handling cash;

(m) a system to ensure the recovery from those leaving the employment of theFoundation Trust of sums of money and property due by them to theFoundation Trust.

9.4.3 Appropriately nominated managers have delegated responsibility for:

(a) submitting time records and other notifications in accordance with agreedtimetables;

(b) completing time records and other notifications in accordance with the ChiefFinancial Officer’s instructions and in the form prescribed by the ChiefFinancial Officer;

(c) submitting termination forms in the prescribed form immediately uponknowing the effective date of an employee's or officer’s resignation,termination or retirement. Where an employee fails to report for duty or tofulfil obligations in circumstances that suggest they have left without notice,Payroll and Human Resources must be informed immediately.

9.4.4 Regardless of the arrangements for providing the payroll service, the ChiefFinancial Officer shall ensure that the chosen method is supported by appropriate(contracted) terms and conditions, adequate internal controls and audit reviewprocedures and that suitable arrangements are made for the collection of payrolldeductions and payment of these to appropriate bodies.


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9.5 Contracts of employment

9.5.1 The Board of Directors shall delegate responsibility to an officer for:

(a) ensuring that all employees are issued with a Contract of Employment in aform approved by the Board of Directors and which complies withemployment and Health & Safety legislation;

(b) dealing with variations to, or termination of, contracts of employment.


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10. NON-PAY EXPENDITURE

10.1 Delegation of Authority

10.1.1 The Board of Directors will approve the level of non-pay expenditure on an annualbasis and the Chief Executive will determine the level of delegation to budgetmanagers.

10.1.2 The Chief Executive will set out:

(a) the list of managers who are authorised to place requisitions for the supplyof goods and services which should be updated and reviewed on an on-going basis and annually by the Finance/Supplies Department;

(b) the maximum level of each requisition and the system for authorisationabove that level.

10.1.3 The Chief Executive shall set out procedures on the seeking of professional adviceregarding the supply of goods and services.

10.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services(see overlap with Standing Financial Instruction No. 13)

10.2.1 Requisitioning

The requisitioner, in choosing the item to be supplied (or the service to beperformed) shall always obtain the best value for money for the Foundation Trust.In so doing, the advice of the Foundation Trust’s adviser on supply shall be sought.Where this advice is not acceptable to the requisitioner, the Chief Financial Officer(and/or the Chief Executive) shall be consulted.

10.2.2 System of Payment and Payment Verification

The requisitioner, in choosing the item to be supplied (or the service to beperformed) shall always obtain the best value for money for the Foundation Trust.In so doing, the advice of the Head of Procurement shall be sought. Where thisadvice is not acceptable to the requisitioner, the Chief Financial Officer (and/or theChief Executive) shall be consulted.

The Chief Financial Officer shall be responsible for the prompt payment of accountsand claims in accordance with the Better Payment Practice Code (BPPC).Employees are responsible for processing invoices in a timely manner. Payment ofcontract invoices shall be in accordance with contract terms, or otherwise, inaccordance with national guidance.


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10.2.3 The Chief Financial Officer will:

(a) advise the Board of Directors regarding the setting of thresholds abovewhich quotations (competitive or otherwise) or formal tenders must beobtained; and, once approved, the thresholds should be incorporated inStanding Financial Instructions and regularly reviewed;

(b) prepare procedural instructions or guidance within the managedprocurement framework on the obtaining of goods, works and servicesincorporating the thresholds;

(c) be responsible for the prompt payment of all properly authorised accountsand claims;

(d) be responsible for designing and maintaining a system of verification,recording and payment of all amounts payable. This may includeinteraction with the Foundation Trust’s payment service provider. Thesystem shall provide for:

(i) A list of Board directors/employees (including specimens of theirsignatures) authorised to certify invoices.

(ii) Certification that:

- goods have been duly received, examined and are inaccordance with specification and the prices are correct;

- work done or services rendered have been satisfactorily carriedout in accordance with the order, and, where applicable, thematerials used are of the requisite standard and the charges arecorrect;

- in the case of contracts based on the measurement of time,materials or expenses, the time charged is in accordance withthe time sheets, the rates of labour are in accordance with theappropriate rates, the materials have been checked as regardsquantity, quality, and price and the charges for the use ofvehicles, plant and machinery have been examined;

- where appropriate, the expenditure is in accordance withregulations and all necessary authorisations have been obtained;

- the account is arithmetically correct;

- the account is in order for payment.

(iii) A timetable and system for submission to the Chief Financial Officer of


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accounts for payment; provision shall be made for the earlysubmission of accounts subject to cash discounts or otherwiserequiring early payment.

(iv) Instructions to employees regarding the handling and payment ofaccounts within the Finance Department.

(e) be responsible for ensuring that payment for goods and services is onlymade once the goods and services are received. The only exceptions areset out in SFI No. 10.2.4 below.

10.2.4 Prepayments

Prepayments outside of normal commercial arrangements for example fullycomprehensive maintenance contracts, rental, insurance, are only permitted whereexceptional circumstances apply. In such instances:

(a) prepayments are only permitted where the financial advantages outweighthe disadvantages (i.e. cash flows must be discounted to NPV);

(b) The appropriate officer must provide, in the form of a written report, a casesetting out all relevant circumstances of the purchase. The report must setout the effects on the Foundation Trust if the supplier is at some time duringthe course of the prepayment agreement unable to meet his commitments;

(c) the Chief Financial Officer will need to be satisfied with the proposedarrangements before contractual arrangements proceed (taking intoaccount the EU public procurement rules where the contract is above astipulated financial threshold);

(d) the budget holder is responsible for ensuring that all items due under aprepayment contract are received and they must immediately inform theappropriate Director or Chief Executive if problems are encountered.

10.2.5 Official Orders

Official Orders must:

(a) be consecutively numbered;

(b) be in a form approved by the Chief Financial Officer;

(c) state the Foundation Trust’s terms and conditions of trade;

(d) only be issued to / accessed on-line by, and used by, those duly authorisedby the Chief Executive.


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The use of confirmation orders should be avoided wherever possible and shouldnot be considered an official order. It is accepted that on occasion a confirmationorder may be used in response to the immediacy of the requirement but this mustbe superseded by a Purchase Order as soon as is practically possible. Where thereis a need to use confirmation orders for a specific requirement on a regular basisthen the procurement process must be reviewed and consideration given to theapplication of a schedule of rates or a tender process to gain comfort over value formoney. The use of confirmation orders will be monitored and reviewed monthly.

10.2.6 Duties of Managers and Officers

Managers and officers must ensure that they comply fully with the guidance andlimits specified by the Chief Financial Officer and that:

(a) all contracts (except as otherwise provided for in the Schedule ofDecision/Duties Delegated by the Board of Directors), leases, tenancyagreements and other commitments which may result in a liability arenotified to the Chief Financial Officer in advance of any commitment beingmade;

(b) contracts above specified thresholds are advertised and awarded inaccordance with EU rules on public procurement; and comply with theWhite Paper on Standards, Quality and International Competitiveness(CMND 8621);

(c) where consultancy advice is being obtained, the procurement of suchadvice must be in accordance with guidance issued by the Department ofHealth (The Procurement and Management of Consultants in the NHS asadopted by the Trust:

(d) no order shall be issued for any item or items to any firm which has madean offer of gifts, reward or benefit to directors or employees, other than:

(i) isolated gifts of a trivial character or inexpensive seasonal gifts, suchas calendars;

(ii) conventional hospitality, such as lunches in the course of workingvisits;

(This provision needs to be read in conjunction with the Trust’s Bribery andCorruption policy and in accordance with Standing Order Annex 8 No. 9and the principles outlined in the national guidance contained in HSG 93(5)“Standards of Business Conduct for NHS Staff”);

(e) no requisition/order is placed for any item or items for which there is nobudget provision unless authorised by the Chief Financial Officer on behalfof the Chief Executive;


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(f) all goods, services, or works are ordered either on an official order orotherwise in line with approved systems within the managed procurementframework;

(g) verbal orders must only be issued very exceptionally - by an employeedesignated by the Chief Executive and only in cases of emergency orurgent necessity. These must be confirmed by an official order and clearlymarked "Confirmation Order";

(h) orders are not split or otherwise placed in a manner devised so as to avoidthe financial thresholds;

(i) goods are not taken on trial or loan in circumstances that could commit theFoundation Trust to a future uncompetitive purchase;

(j) changes to the list of employees and officers authorised to certify invoicesare notified to the Chief Financial Officer;

(k) purchases from petty cash are restricted in value and by type of purchasein accordance with instructions issued by the Chief Financial Officer;

(l) petty cash records are maintained in a form as determined by the ChiefFinancial Officer;

(m) orders are not required to be raised for certain exempt areas under themanagement procurement guidelines (e.g. utility bills, NHS Recharges;audit fees and ad hoc services). Payments must be authorised inaccordance with the delegated limits set for non-pay.

10.2.7 The Chief Financial Officer shall ensure that the arrangements for financial controland financial audit of building and engineering contracts and property transactionscomply with the relevant guidance, eg ESTATECODE. The technical audit of thesecontracts shall be the responsibility of the relevant Director.

Under no circumstances should goods be ordered through the Foundation Trust forpersonal or private use.

10.2.8 Joint Finance Arrangements with Local Authorities and Voluntary Bodies

Payments to local authorities and voluntary organisations made under the powersof section 75 of the Health and Social Care Act 2012 shall comply with procedureslaid down by the Chief Financial Officer which shall be in accordance with theseActs.


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11. EXTERNAL BORROWING AND INVESTMENTS

11.1 Public Dividend Capital

11.1.1 On authorisation as a Foundation Trust the Public Dividend Capital heldimmediately prior to authorisation continues to be held on the same conditions.

11.1.2 Additional Public Dividend Capital may be made available on such terms theSecretary of State (with the consent of the Treasury) decides.

11.1.3 Draw down of Public Dividend Capital should be authorised in accordance with themandate held by the Department of Health, and is subject to approval by theSecretary of State.

11.1.4 The Foundation Trust shall be required to pay annually to the Department of Healtha dividend on its Public Dividend Capital at a rate to be determined from time totime, by the Secretary of State.

11.2 Commercial Borrowing and Investment

11.2.1 The Foundation Trust may borrow money from any commercial source for thepurposes of or in connection with its functions.

11.2.2 The Board of Directors must be made aware by the Chief Financial Officer of anyutilisation of a working capital facility at the next appropriate Board of Directorsmeeting.

11.2.3 All long-term borrowing must be consistent with the plans outlined in the currentannual plans and be approved by the Foundation Trust Board of Directors.

11.2.4 The Foundation Trust may invest money (other than money held by it as charitabletrustee) for the purposes of or in connection with its functions. Such investmentmay include forming, or participating in forming, or otherwise acquiring membershipof bodies corporate and/or participating in a joint venture(s).

11.2.5 The Foundation Trust may also give financial assistance (whether by way of loan,guarantee or otherwise) to any person for the purposes of or in connection with itsfunctions.

11.3 Investment of Temporary Cash Surpluses

11.3.1 Temporary cash surpluses must be held only in such public and private sectorinvestments in accordance with the appropriate policy.

11.3.2 The Finance and Performance Committee is responsible for establishing andmonitoring an appropriate investment strategy and policy.

11.3.3 The Chief Financial Officer is responsible for advising the committee on


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investments and shall report periodically concerning the performance ofinvestments held.

11.3.4 The Chief Financial Officer will prepare detailed procedural instructions oninvestment operations and on the records to be maintained. The Foundation Trust’sTreasury Management policy will incorporate guidance from NHS Improvement asappropriate.


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12. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERSAND SECURITY OF ASSETS

12.1 Capital Investment

The Chief Executive:

(a) shall ensure that there is an adequate appraisal and approval process inplace for determining capital expenditure priorities and the effect of eachproposal upon business plans;

(b) is responsible for the management of all stages of capital schemes and forensuring that schemes are delivered on time and to cost;

(c) shall ensure that the capital investment is not undertaken without theavailability of resources to finance all revenue consequences, including capitalcharges.

12.2 For every major capital expenditure proposal the Chief Executive shall ensure (inaccordance with the limits outlined in the scheme of delegation):

(a) that a business case is produced setting out:

(i) an option appraisal of potential benefits compared with known costs todetermine the option with the highest ratio of benefits to costs; and

(ii) the involvement of appropriate Foundation Trust personnel and externalagencies; and

(iii) appropriate project management and control arrangements; and

(b) that the Chief Financial Officer has certified professionally to the costs andrevenue consequences detailed in the business case.

12.3 For capital schemes where the contracts stipulate stage payments, the ChiefExecutive will issue procedures for their management, incorporating therecommendations of ESTATECODE and other relevant guidance.

12.4 The Chief Financial Officer shall assess on an annual basis the requirement for theoperation of the construction industry tax deduction scheme in accordance withInland Revenue guidance.

12.5 The Chief Financial Officer shall issue procedures for the regular reporting ofexpenditure and commitment against authorised expenditure.

12.6 The approval of a capital programme shall not constitute approval for expenditureon any scheme.


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The Chief Executive shall issue to the manager responsible for any scheme:

(a) specific authority to commit expenditure;

(b) authority to proceed to tender;

(c) approval to accept a successful tender.

The Chief Executive will issue a scheme of delegation for capital investmentmanagement in accordance with NHS Improvement guidance and the FoundationTrust’s Standing Orders.

12.7 The Chief Financial Officer shall issue procedures governing the financialmanagement, including variations to contract, of capital investment projects andvaluation for accounting purposes.

12.8 Private Finance

The Foundation Trust should normally test PFI when considering capitalprocurement of a significant level. The process should be as described in SFI 8.5.

Any finance or operating lease entered into must be agreed by the Chief FinancialOfficer.

12.9 Asset Registers

12.9.1 The Chief Executive is responsible for the maintenance of registers of assets,taking account of the advice of the Chief Financial Officer concerning the form ofany register and the method of updating, and arranging for a physical check ofassets against the asset register to be conducted once a year.

12.9.2 The Foundation Trust shall maintain an Asset Register recording non-currentassets to enable financial reporting in accordance with the requirements ofInternational Financial Reporting Standards (IFRS). Guidance on the interpretationsof the above is contained in the Department of Health Group Accounting Manual(DH GAM) and the FT Annual Reporting Manual (FT ARM).

12.9.3 Additions to the non-current asset register must be clearly identified to anappropriate scheme manager and be validated by reference to:

(a) properly authorised and approved agreements, architect's certificates,supplier's invoices and other documentary evidence in respect of purchasesfrom third parties;

(b) stores, requisitions and wages records for own materials and labour includingappropriate overheads;

(c) lease agreements in respect of assets held under a finance lease andcapitalised.


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12.9.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their valuemust be removed from the accounting records and each disposal must be validatedby reference to authorisation documents and invoices (where appropriate).

12.9.5 The Chief Financial Officer shall approve procedures for reconciling balances onnon-current assets accounts in ledgers against balances on non-current assetregisters.

12.9.6 The value of each asset shall be accounted for as per International Financialreporting standards using Modern Equivalent Asset Values as appropriate, theDepartment of Health Group Accounting Manual and the Foundation Trust AnnualReporting Manual (FT ARM) issued by NHS Improvement.

12.9.7 The Chief Financial Officer of the Foundation Trust shall calculate and pay capitalcharges as specified by the Department of Health.

12.10 Protected Property

12.10.1 A register of Protected Property is required to be maintained in accordance withrequirements issued by NHS Improvement. The property referred to in CoS2Condition 5 of the Provider Licence, which is to be protected, is limited to land andbuildings owned or leased by the Foundation Trust (assets such as equipment,financial assets, cash or intellectual property will not be regarded as protectedassets).

12.10.2 Protected property may not be disposed of without the approval of NHSImprovement

12.10.3 The Foundation Trust is required to notify relevant bodies of the publication date oftheir plans to allow them to lodge any objections. Twenty-one days is allowedbefore the plans are then approved.

12.10.4 During the year when the proposed changes are made the Asset Register must beupdated accordingly. The relevant bodies should then be notified that an updatedAsset Register is available.

12.11 Security of Assets

12.11.1 The overall control of non-current assets is the responsibility of the Chief Executiveadvised by the Chief Financial Officer.

12.11.2 Asset control procedures (including non-current assets, cash, cheques andnegotiable instruments, and also including donated assets) must be approved bythe Chief Financial Officer. This procedure shall make provision for:

(a) recording managerial responsibility for each asset;

(b) identification of additions and disposals;


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(c) identification of all repairs and maintenance expenses which enhance thevalue of the assets;

(d) physical security of assets;

(e) periodic verification of the existence of, condition of, and title to, assetsrecorded;

(f) identification and reporting of all costs associated with the retention of anasset;

(g) reporting, recording and safekeeping of cash, cheques, and negotiableinstruments.

12.11.3 All significant discrepancies revealed by verification of physical assets to non-current asset register shall be notified to the Chief Financial Officer.

12.11.4 Whilst each Board Director and employee has a responsibility for the security ofproperty of the Foundation Trust, it is the responsibility of Board Directors andsenior employees in all disciplines to apply such appropriate routine securitypractices in relation to NHS property as may be determined by the Board ofDirectors. Any breach of agreed security practices must be reported in accordancewith agreed procedures.

12.11.5 Any damage to the Foundation Trust’s premises, vehicles and equipment, or anyloss of equipment, stores or supplies must be reported by Board members andemployees in accordance with the procedure for reporting losses.

12.11.6 Where practical, assets should be marked as Foundation Trust property.


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13. STORES AND RECEIPT OF GOODS

13.1 General position

Stocks are defined as those goods normally utilised in day to day activity, but whichat a given point in time have not been used or consumed. There are two broadtypes of store:-

(a) Controlled stores - specific areas designated for the holding and control ofgoods;

(b) Wards & departments - goods required for immediate usage to supportoperational services.

13.1.1 Stores, defined above (for immediate use) should be:

(a) kept to a minimum;

(b) subject to annual stock take or perpetual inventory procedures; and

(c) valued at the lower of cost and net realisable value.

13.2 Control of Stores, Stocktaking

13.2.1 Subject to the responsibility of the Chief Financial Officer for the systems of control,overall responsibility for the control of stores shall be delegated to an employee bythe Chief Executive. The day-to-day responsibility may be delegated todepartmental employees and stores managers/keepers, subject to such delegationbeing entered in a record available to the Chief Financial Officer. The control ofany Pharmaceutical stocks shall be the responsibility of a designatedPharmaceutical Officer; the control of any fuel oil and coal of a designated estatesmanager.

13.2.2 The responsibility for security arrangements and the custody of keys for any storesand locations shall be clearly defined in writing by the designatedmanager/Pharmaceutical Officer. Wherever practicable, stocks should be markedas National Health Service property.

13.2.3 The Chief Financial Officer shall set out procedures and systems to regulate thestores including records for receipt of goods, issues from and returns to stores, andlosses.

13.2.4 Stocktaking arrangements shall be agreed with the Chief Financial Officer andthere shall be a physical check, the extent of which shall be determined by theChief Financial Officer, at least once a year.

13.2.5 Where a complete system of stores control is not justified, alternative arrangementsshall require the approval of the Chief Financial Officer.


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13.2.6 The designated Manager/Pharmaceutical Officer shall be responsible for a systemapproved by the Chief Financial Officer for a review of slow moving and obsoleteitems and for condemnation, disposal, and replacement of all unserviceablearticles. The designated Officer shall report to the Chief Financial Officer anyevidence of significant overstocking and of any negligence or malpractice (see alsooverlap with SFI No. 14 Disposals and Condemnations, Losses and SpecialPayments). Procedures for the disposal of obsolete stock shall follow theprocedures set out for disposal of all surplus and obsolete goods.

13.3 Goods supplied by NHS Supply Chain

For goods supplied via the central warehouses, the Chief Executive shall identifythose authorised to requisition and accept goods from the store. The authorisedperson shall check receipt against the delivery note before forwarding this to theChief Financial Officer who shall satisfy himself that the goods have been receivedbefore accepting the recharge. This will be achieved through sample checking andtolerance levels. The Finance Department will make payment on receipt of aninvoice. This may also apply for high-level low volume items such as stationery.

13.4 Issue of Stocks

The issue of stocks shall be supplied by an authorised requisition note and a receiptfor the stock issued shall be returned to the designated officer. Where a ‘toppingup’ system is used, a record shall be maintained as approved by the Chief FinancialOfficer. Regular comparisons shall be made of the quantities issued towards/departments etc. and explanations recorded of significant variations.

All transfers and returns shall be recorded on forms/systems provided for thepurpose and approved by the Chief Financial Officer.


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14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

14.1 Disposals and Condemnations

14.1.1 Procedures

The Chief Financial Officer must prepare detailed procedures for the disposal ofassets including condemnations, and ensure that these are notified to managers.Material disposals will be defined annually with reference to the Trust’s capital planand replacement program. Responsibility for the approval of material disposals willrest with the Chief Financial Officer.

14.1.2 When it is decided to dispose of a Foundation Trust asset, the head of departmentor authorised deputy will determine and advise the relevant persons of theestimated market value of the item, taking account of professional advice whereappropriate. The relevant person shall be:

(a) non-current assets: Estates Strategy Steering Group (noting the limitspertaining to protected assets);

(b) office equipment (furniture, fixture and fittings): Head of Procurement;

(c) IT equipment: Head of I M & T.

14.1.3 All unserviceable articles shall be:

(a) condemned or otherwise disposed of by an employee authorised for thatpurpose by the Chief Financial Officer;

(b) recorded by the Condemning Officer in a form approved by the ChiefFinancial Officer which will indicate whether the articles are to beconverted, destroyed or otherwise disposed of. All entries shall beconfirmed by the countersignature of a second employee authorised for thepurpose by the Chief Financial Officer.

14.1.4 The Condemning Officer shall satisfy himself as to whether or not there is evidenceof negligence in use and shall report any such evidence to the Chief FinancialOfficer who will take the appropriate action.

14.2 Losses and Special Payments

14.2.1 Procedures

The Chief Financial Officer must prepare procedural instructions on the recording ofand accounting for condemnations, losses, and special payments. Referenceshould be made to the Counter Fraud procedures regarding the action to be takenboth by persons identifying a suspected fraud and those persons responsible forinvestigating it.


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14.2.2 Any employee or officer discovering or suspecting a loss of any kind must eitherimmediately inform their head of department, who must immediately inform theChief Executive and the Chief Financial Officer or inform an officer charged withresponsibility for responding to concerns involving loss or fraud, confidentiality.This officer will then appropriately inform the Chief Financial Officer and/or ChiefExecutive.

Where a criminal offence is suspected, the Chief Financial Officer must immediatelyinform the police if theft or arson is involved. In cases of fraud and corruption or ofanomalies which may indicate fraud or corruption, the Chief Financial Officer mustinform the relevant Local Counter Fraud Specialist (LCFS).

The Chief Financial Officer will liaise appropriately with the LCFS, the NHSCounter Fraud Authority and the External Auditor regarding all frauds.

14.2.3 For losses apparently caused by theft, arson, neglect of duty or gross carelessness,except if trivial, the Chief Financial Officer must immediately notify:

(a) the Board of Directors; and

(b) the External Auditor; and

(c) NHS Protect.

14.2.4 The Board of Directors shall approve the writing-off of all losses and specialpayments in accordance with the Reservation of Powers to the Board of Directorsand Council of Governors and Schedule of Decisions/Duties Delegated by theBoard of Directors.

14.2.5 The Chief Financial Officer shall be authorised to take any necessary steps tosafeguard the Foundation Trust’s interests in bankruptcies and companyliquidations.

14.2.6 For any loss, the Chief Financial Officer should consider whether any insuranceclaim can be made.

14.2.7 The Chief Financial Officer shall maintain a Losses and Special Payments Registerin which write-off action is recorded.

14.2.8 No special payments exceeding delegated limits (£500,000 and above) shall bemade without the prior approval of the Board of Directors.

14.2.9 All losses and special payments must be reported to the Audit Committee asscheduled by that committee.


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15. INFORMATION TECHNOLOGY

15.1 Responsibilities and duties of the Chief Financial Officer

15.1.1 The Chief Financial Officer, who is responsible for the accuracy and security of thecomputerised financial data of the Foundation Trust, shall, in conjunction withInformation and Knowledge Services Department:

(a) devise and implement any necessary procedures to ensure adequate(reasonable) protection of the Foundation Trust’s data. This includesprograms and computer hardware for which the Director is responsible fromaccidental or intentional disclosure to unauthorised persons, deletion ormodification, theft or damage, having due regard for the UK enactment ofthe General Data Protection Regulation (GDPR), the Computer Misuse Act1990 and Freedom of Information Act 2000;

(b) ensure that adequate (reasonable) controls exist over data entry,processing, storage, transmission, output and final destruction to ensuresecurity, privacy, accuracy, completeness, and timeliness of the data, aswell as the efficient and effective operation of the system;

(c) ensure that adequate controls exist such that the computer operation isseparated from development, maintenance and amendment;

(d) ensure that adequate controls exist to maintain the security, privacy,accuracy and completeness of financial data sent via transmissionnetworks;

(e) ensure that an adequate management (audit) trail exists through thecomputerised system and that such computer audit reviews as the Directormay consider necessary are being carried out.

15.1.2 The Chief Financial Officer shall need to ensure that new financial systems andamendments to current financial systems are developed in a controlled manner andthoroughly tested prior to implementation. Where this is undertaken by anotherorganisation, assurances of adequacy must be obtained from them prior toimplementation. This may be through the use of mutually agreed test services andin conjunction with ICT where necessary.

15.1.3 The Director responsible for information technology shall publish and maintain aFreedom of Information (FOI) Publication Scheme, or adopt a model PublicationScheme approved by the Information Commissioner. A Publication Scheme is acomplete guide to the information routinely published by a public authority. Itdescribes the classes or types of information about our Foundation Trust that wemake publicly available.


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15.2 Responsibilities and duties of other Directors and Officers in relation to computersystems of a general application

15.2.1 In the case of computer systems which are proposed for general applications (i.e.normally those applications which the majority of the NHS in the Region wishes tosponsor jointly) all responsible directors and employees will send to the ChiefFinancial Officer:

(a) details of the outline design of the system;

(b) in the case of packages acquired either from a commercial organisation,from the NHS, or from another public sector organisation, the operationalrequirement.

15.3 Contracts for Computer Services with other health bodies or outside agencies

The Chief Financial Officer shall ensure that contracts for computer services forfinancial applications with another health organisation or any other agency shallclearly define the responsibility of all parties for the security, privacy, accuracy,completeness, and timeliness of data during processing, transmission and storage.The contract should also ensure rights of access for audit purposes.

Where personal data is processed on the Foundation Trust’s behalf by anotherorganisation, this must be reflected in the Foundation Trust’s registration with theInformation Commissioner and the Chief Financial Officer shall periodically seekassurances that adequate controls are in operation.

15.4 Risk Assessment

The Senior Information Risk Officer (SIRO) shall ensure that risks to the FoundationTrust arising from the use of IT are effectively identified, considered andappropriate action taken to mitigate or control the risk. This shall include thepreparation and testing of appropriate disaster recovery plans.

15.5 Requirements for Computer Systems which have an impact on corporate financialsystems

Where computer systems have an impact on corporate financial systems the ChiefFinancial Officer shall need to be satisfied that:

(a) systems acquisition, development and maintenance are in line withcorporate policies such as an Information Technology Strategy;

(b) data produced for use with financial systems is adequate, accurate,complete and timely, and that a management (audit) trail exists;

(c) Chief Financial Officer staff have access to such data;(d) Such computer audit reviews as are considered necessary are being

carried out.


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16. PATIENTS' PROPERTY

16.1 The Foundation Trust has a responsibility to provide safe custody for money andother personal property (hereafter referred to as "property") handed in by patients,in the possession of unconscious or confused patients, or found in the possessionof patients dying in hospital or dead on arrival.

Personal property shall mean all personal valuables such as electrical goods,furniture, allowance order books, bank/building society books, credit cards, andjewellery.

16.1.1 Personal property of patients unable to manage will not automatically be placed insafe custody but it is important for staff to acknowledge that they have a duty tosafeguard the property of those who are unable to manage their affairs while inhospital. (This will include those admitted who are confused but it is unlikely thatunconscious, dying or deceased patients will be admitted to a Leeds and YorkPartnership NHS FT Unit/Ward.)

16.2 The Chief Executive is responsible for ensuring that patients or their guardians, asappropriate, are informed before or at admission by:

- notices and information booklets; (notices are subject to sensitivityguidance)

- hospital admission documentation and property records- the oral advice of administrative and nursing staff responsible for

admissions

The Foundation Trust will not accept responsibility or liability for patients' propertybrought into Health Service premises, unless it is handed in for safe custody and acopy of an official patients' property record is obtained as a receipt.

16.3 The Chief Financial Officer must provide detailed written instructions on thecollection, custody, investment, recording, safekeeping and disposal of patients'property (including instructions on the disposal of the property of deceased patientsand of patients transferred to other premises) for all staff whose duty is toadminister, in any way, the property of patients. Due care should be exercised inthe management of a patient's money in order to maximise the benefits to thepatient.

16.4 A patient’s property record, in a form determined by the Chief Financial Officer,shall be completed in respect of the following:

(a) property handed in for safe custody by any patient (or guardian asappropriate); and

(b) property taken into safe custody having been found in the possessions of:

- mentally disordered patients

- confused and/or disorientated patients


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- unconscious patients

- patients dying in hospital

- patients found dead on arrival at hospital

(c) A record shall be completed in respect of all persons in category b,including a nil return if no property is taken into safe custody.

16.5 Where Department of Health instructions require the opening of separate accountsfor patients' moneys, these shall be opened and operated under arrangementsagreed by the Chief Financial Officer.

16.6 In all cases where property of a deceased patient is of a total value in excess of£5,000 (or such other amount as may be prescribed by any amendment to theAdministration of Estates, Small Payments, Act 1965), the production of Probate orLetters of Administration shall be required before any of the property is released.Where the total value of property is £5,000 or less, forms of indemnity shall beobtained.

16.7 Staff should be informed, on appointment, by the appropriate departmental orsenior manager of their responsibilities and duties for the administration of theproperty of patients.

16.8 Where patients' property or income is received for specific purposes and held forsafekeeping the property or income shall be used only for that purpose, unless anyvariation is approved by the donor or patient in writing.


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17. FUNDS HELD ON TRUST (CHARITABLE FUNDS)

17.1 Corporate Trustee

17.1.1 Standing Order Annex 8 No. 2.3 outlines the Foundation Trust’s responsibilities asa corporate trustee for the management of funds it holds on trust.

17.1.2 The discharge of the Foundation Trust’s corporate trustee responsibilities are distinctfrom its responsibilities for exchequer funds and may not necessarily be dischargedin the same manner, but there must still be adherence to the overriding generalprinciples of financial regularity, prudence and propriety. Trustee responsibilitiescover both charitable and non-charitable purposes.

17.1.3 The Chief Financial Officer shall ensure that each trust fund which the FoundationTrust is responsible for managing is managed appropriately with regard to itspurpose and to its requirements.

17.2 Accountability to Charity Commission and Secretary of State for Health

17.2.1 The trustee responsibilities must be discharged separately and full recognitiongiven to the Foundation Trust’s dual accountabilities to the Charity Commission forcharitable funds held on trust and to the Secretary of State for all funds held ontrust.

17.2.2 The Reservation of Powers to the Board of Directors and the Council of Governorsand the Schedule of Decisions/Duties Delegated by the Board of Directors makeclear where decisions regarding the exercise of discretion regarding the disposaland use of the funds are to be taken and by whom. All Foundation Trust Boarddirectors and Foundation Trust officers must take account of that guidance beforetaking action.

17.3 Applicability of Standing Financial Instructions to funds held on trust

17.3.1 In so far as it is possible to do so, most of the sections of these Standing FinancialInstructions will apply to the management of funds held on trust.

17.3.2 The over-riding principle is that the integrity of each trust fund must be maintainedwith statutory and trust fund obligations met. Materiality must be assessedseparately from Exchequer activities and funds.

17.4 Reporting

17.4.1 The Chief Financial Officer shall ensure that regular reports are made to the Boardof Trustees with regard to, inter alia, the receipt of funds, investments andexpenditure.

17.4.2 The Chief Financial Officer shall prepare annual accounts in the required manner,which shall be submitted, to the Board of Trustees acting on behalf of the corporatetrustee within agreed timescales.


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17.4.3 The Chief Financial Officer shall prepare an annual trustees’ report and therequired returns to the Charity Commission for adoption by the Charitable FundsCommittee.

17.5 Accounting and Audit

17.5.1 As Corporate Trustee arrangements must be made to ensure that a financialauditor is appointed to provide an independent audit review of the accounts inaccordance with the Charity Commission legislation.

17.5.2 The Chief Financial Officer shall maintain all financial records to enable theproduction of reports as above and to the satisfaction of internal audit and thefinancial auditor.

17.5.3 Distribution of investment income to the charitable funds and the recovery ofadministration costs shall be performed on a basis determined by the ChiefFinancial Officer.

17.5.4 The Chief Financial Officer shall ensure that the records, accounts and returnsreceive adequate scrutiny by internal audit during the year. He/she will liaise withthe financial auditor and provide them with all necessary information, as required bythe current legislation governing the administration of charities

17.5.5 The Board of Trustees shall be advised by the Chief Financial Officer on theoutcome of the annual audit.


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18. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OFBUSINESS CONDUCT (see overlap with SO Annex 8 No. 9)

The Chief Executive via the Chief Financial Officer shall ensure that all staff aremade aware of the Foundation Trust policy on acceptance of gifts and otherbenefits in kind by staff. This policy follows the guidance contained in theDepartment of Health circular HSG (93) 5 ‘Standards of Business Conduct for NHSStaff’ and is also deemed to be an integral part of the Standing Orders andStanding Financial Instructions

The Foundation Trusts Hospitality, Sponsorship and Gifts Policy and Procedureshould be followed at all times and consideration should also be given to the TrustsBribery and Corruption policy in this area.


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19. RETENTION OF RECORDS

19.1 Context

All NHS records are public records under the terms of the Public Records Act 1958section 3 (1) – (2). The Secretary of State for Health and all NHS organisationshave a duty under this Act to make arrangements for the safe keeping and eventualdisposal of all types of records. In addition, the requirements of the General DataProtection Regulation (GDPR) and the Freedom of Information Act 2000 must beachieved.

19.2 Accountability

The Chief Executive and senior managers are personally accountable for recordsmanagement within the organisation. Additionally, the organisation is required totake positive ownership of, and responsibility for, the records legacy of predecessororganisations and/or obsolete services. Under the Public Records Act all NHSemployees are responsible for any records that they create or use in the course oftheir duties. Thus any records created by an employee of the NHS are publicrecords and may be subject to both legal and professional obligations.

The Chief Executive shall be responsible for maintaining archives for all documentsrequired to be retained under the direction contained in Department of Healthguidance; Records Management Code of Practice.

19.3 Types of Record Covered by The Code of Practice

The guidelines apply to NHS records of all types (including records of NHS patientstreated on behalf of the NHS in the private healthcare sector) regardless of themedia on which they are held:

Patient health records (electronic or paper based) Records of private patients seen on NHS premises; Accident and emergency, birth and all other registers; Corporate and Administrative records (including e.g. personnel, estates,

financial and accounting records, notes associated with complaint-handling);

X-ray and imaging reports, output and other images; Photographs, slides and other images; Microform (i.e. fiche / film) Audio and video tapes, cassettes, CD-ROM etc. Emails; Computerised records; Scanned records;


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Text messages (both out-going from the NHS and in-coming responsesfrom the patient)

19.4 The records held in archives shall be capable of retrieval by authorised persons.

19.5 Records held in accordance with latest Department of Health guidance “RecordsManagement Code of Practice” shall only be destroyed at the express instigation ofthe Chief Executive, or designated officer, in line with DH guidelines. Details shallbe maintained of records so destroyed.


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20. RISK MANAGEMENT AND INSURANCE

20.1 Programme of Risk Management

The Chief Executive shall ensure that the Foundation Trust has a programme ofrisk management, in accordance with current Department of Health assuranceframework requirements, which must be approved and monitored by the Board ofDirectors.

The programme of risk management shall include:

(a) a process for identifying and quantifying risks and potential liabilities;

(b) engendering among all levels of staff a positive attitude towards the controlof risk;

(c) management processes to ensure all significant risks and potential liabilitiesare addressed including effective systems of internal control, cost effectiveinsurance cover, and decisions on the acceptable level of retained risk;

(d) contingency plans to offset the impact of adverse events;

(e) audit arrangements including; internal audit, clinical audit, health and safetyreview;

(f) a clear indication of which risks shall be insured;

(g) arrangements to review the risk management programme.

The existence, integration and evaluation of the above elements will assist inproviding a basis to make a Statement on the effectiveness of Internal Controlwithin the Annual Report and Accounts as required by current Department of Healthguidance.

20.2 Insurance

The Board of Directors shall decide if the Foundation Trust will insure through therisk pooling schemes administered by the NHS Litigation Authority, obtaincommercial insurance or self-insure for some or all of the risks covered by the riskpooling schemes. If the Board of Directors decides not to use the risk poolingschemes for any of the risk areas (clinical, property and employers/public liability)covered by the schemes this decision shall be reviewed annually by the Board ofDirectors.

20.3 Arrangements to be followed by the Board of Directors in agreeing Insurance cover

Where the Board of Directors decides to use the risk pooling schemes administered


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by the NHS Litigation Authority, the Medical Director shall ensure that thearrangements entered into are appropriate and complementary to the riskmanagement programme. The Medical Director shall also ensure that documentedprocedures cover these arrangements.

Where the Board of Directors decides not to use the risk pooling schemesadministered by the NHS Litigation Authority or obtain commercial insurance forone or other of the risks covered by the schemes, the Medical Director shall ensurethat the Board of Directors is informed of the nature and extent of the risks that areself-insured as a result of this decision. The Chief Executive will draw up formaldocumented procedures for the management of any claims arising from thirdparties and payments in respect of losses which will not be reimbursed.

All the risk pooling schemes require Scheme members to make some contributionto the settlement of claims (the ‘deductible’). The Chief Executive should ensuredocumented procedures also cover the management of claims and paymentsbelow the deductible in each case.

20.4 Insurance arrangements with commercial insurers

As a Foundation Trust, the Board of Directors need to consider the adequacy ofinsurance cover recognising the Public Benefit Corporation status. FoundationTrusts may decide to enter into top-up commercial insurance arrangements, forexample

Directors and Officers Liability Property Damage Private Finance Initiatives (as may be required by consortium members) Motor vehicle insurance (including third party liability) Business interruption (Increased Cost of Working and Loss of Income) Income generation activities (if different from business activities already

covered) Other as agreed by the Board of Directors

20.5 Compensation Claims

20.5.1 The Foundation Trust is committed to effective and timely investigation andresponse to any claim which includes allegations of clinical negligence, employeeand other compensation claims. The Foundation Trust will follow the requirementsand note the recommendations of the Department of Health, and the NHS LitigationAuthority (NHSLA) in the management of claims. Every member of staff is expectedto co-operate fully, as required, in assessment and management of each claim.

20.5.2 The Foundation Trust will seek to reduce the incidence and adverse impact ofclinical negligence, employee and other litigation by:-

- Adopting prudent risk management strategies including continuous review.- Implementing in full the NHS Complaints Procedure and the Ombudsman’s

Principles, thus providing an alternative remedy for some potential litigants.


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- Adopting a systematic approach to claims handling in line with the bestcurrent and cost effective practice.

- Following guidance issued by the NHSLA relating to clinical negligence.- Achieving the Standards for Better Health.- Implementing an effective system of Clinical Governance (including the

review of serious untoward incidents)

20.5.3 The Chief Executive is responsible for managing clinical negligence: for managingthe claims process and informing the Foundation Trust Board of Directors of anymajor developments on claims related issues.


PAPER TITLE: IG Toolkit – Board approval prior to submission





Carl Starbuck, Information and Knowledge Manager



EXECUTIVE SUMMARY

The IG Toolkit is a DoH Policy delivery vehicle that NHS Digital is commissioned to developand maintain. It draws together the legal rules and central guidance set out by DoH policyand presents them in in a single standard as a set of information governance requirements.The organisations in scope of this are required to carry out self-assessments of theircompliance against the IG requirements.

All requirements must meet a minimum reporting level of 2 or above. The failure to achievea level 2 result, for any single requirement, results in an ‘Unsatisfactory’ rating for the entireToolkit submission. It should be noted that even if the Trust improved every score to 3 theoverall assessment would still be classed as satisfactory.

A selection of 10 requirements was selected to undergo Audit scrutiny in early March. This isreduced from 15 in previous years, as the IG Toolkit standards were unchanged from theprevious reporting year, with the Toolkit itself to be radically redesigned and relaunched for2018-2019 as the “Data Security and Protection Toolkit”, to deliver the recommendations ofthe National Data Guardian report and GDPR.

Our draft position is that we are once again “Satisfactory”, with all relevant requirementsachieving or exceeding Level 2.




AGENDAITEM

16.

2Template V1 – July 2017

RECOMMENDATION

The Board of Directors is asked to:-

Confirm agreement with the final scoring of the NHS Digital IG Toolkit.

Approve publication of the results in line with national deadline of 31 March.

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29 March 2018

IG Toolkit – Board approval prior to submission

1 Executive Summary

The IG Toolkit is a DoH Policy delivery vehicle that NHS Digital is commissioned to develop

and maintain. It draws together the legal rules and central guidance set out by DoH policy

and presents them in in a single standard as a set of information governance requirements.

The organisations in scope of this are required to carry out self-assessments of their

compliance against the IG requirements.

All requirements must meet a minimum reporting level of 2 or above. The failure to achieve

a level 2 result, for any single requirement, results in an ‘Unsatisfactory’ rating for the entire

Toolkit submission.

A selection of 10 requirements was selected to undergo Audit scrutiny in early March. This

is reduced from 15 in previous years, as the IG Toolkit standards were unchanged from the

previous reporting year, with the Toolkit itself to be radically redesigned and relaunched for

2018-2019 as the “Data Security and Protection Toolkit”, to deliver the recommendations of

the National Data Guardian report and GDPR.

Our draft position is that we are once again “Satisfactory”, with all relevant requirements

achieving or exceeding Level 2.

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2 Compliance with the Information Governance Toolkit

The table below presents our final scoring against v14.1 of the NHS Digital IG Toolkit for2017-2018. Hyperlinks to the definitions of the standards are provided for information. Thestandards selected for audit are indicated.

Requirement Description Definition Score To Audit?

101There is an adequate Information Governance ManagementFramework to support the current and evolving InformationGovernance agenda.

101 - Definition 3

105There are approved and comprehensive InformationGovernance Policies with associated strategies and/orimprovement plans.

105 - Definition 3

110Formal contractual arrangements that include compliance withinformation governance requirements, are in place with allcontractors and support organisations.

110 - Definition 2

111Employment contracts which include compliance withinformation governance standards are in place for allindividuals carrying out work on behalf of the organisation.

111 - Definition 2

112 Information Governance awareness and mandatory trainingprocedures are in place and all staff are appropriately trained.

112 - Definition 2

200The Information Governance agenda is supported by adequateconfidentiality and data protection skills, knowledge andexperience which meet the organisation’s assessed needs.

200 - Definition 3

201

The organisation ensures that arrangements are in place tosupport and promote information sharing for coordinated andintegrated care, and staff are provided with clear guidance onsharing information for care in an effective, secure and safemanner.

201 - Definition 2

202Confidential personal information is only shared and used in alawful manner and objections to the disclosure or use of thisinformation are appropriately respected.

202 - Definition 2

203

Patients, service users and the public understand how personalinformation is used and shared for both direct and non-directcare, and are fully informed of their rights in relation to suchuse.

203 - Definition 3

205There are appropriate procedures for recognising andresponding to individuals’ requests for access to their personaldata.

205 - Definition 2

206

Staff access to confidential personal information is monitoredand audited. Where care records are held electronically, audittrail details about access to a record can be made available tothe individual concerned on request.

206 - Definition 3

207Where required, protocols governing the routine sharing ofpersonal information have been agreed with otherorganisations.

207 - Definition 2

209All person identifiable data processed outside of the UKcomplies with the Data Protection Act 1998 and Department ofHealth guidelines.

209 - Definition NR

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210

All new processes, services, information systems & otherrelevant information assets are developed & implemented in asecure & structured manner & comply with IG securityaccreditation, information quality & confidentiality & dataprotection requirements.

210 - Definition 2

300The Information Governance agenda is supported by adequateinformation security skills, knowledge and experience whichmeet the organisation’s assessed needs.

300 - Definition 3

301A formal information security risk assessment andmanagement programme for key Information Assets has beendocumented, implemented and reviewed.

301 - Definition 2

302There are documented information security incident / eventreporting and management procedures that are accessible toall staff.

302 - Definition 3

303There are established business processes and procedures thatsatisfy the organisation’s obligations as a RegistrationAuthority.

303 - Definition 2

304Monitoring and enforcement processes are in place to ensureNHS national application Smartcard users comply with theterms and conditions of use.

304 - Definition 2

305

Operating and application information systems (under theorganisation’s control) support appropriate access controlfunctionality and documented and managed access rights arein place for all users of these systems.

305 - Definition 2

307An effectively supported Senior Information Risk Owner takesownership of the organisation’s information risk policy andinformation risk management strategy.

307 - Definition 3

308

All transfers of hardcopy and digital person identifiable andsensitive information have been identified, mapped and riskassessed; technical and organisational measures adequatelysecure these transfers.

308 - Definition 2

309

Business continuity plans are up to date and tested for allcritical information assets (data processing facilities,communications services and data) and service - specificmeasures are in place.

309 - Definition 2

310Procedures are in place to prevent information processingbeing interrupted or disrupted through equipment failure,environmental hazard or human error.

310 - Definition 2

311Information Assets with computer components are capable ofthe rapid detection, isolation and removal of malicious codeand unauthorised mobile code.

311 - Definition 2

313Policy and procedures are in place to ensure that InformationCommunication Technology (ICT) networks operate securely.

313 - Definition 2

314Policy and procedures ensure that mobile computing andteleworking are secure.

314 - Definition 2

323All information assets that hold, or are, personal data areprotected by appropriate organisational and technicalmeasures.

323 - Definition 2

324The confidentiality of service user information is protectedthrough use of pseudonymisation and anonymisationtechniques where appropriate.

324 - Definition 2

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400The Information Governance agenda is supported by adequateinformation quality and records management skills, knowledgeand experience.

400 - Definition 3

401There is consistent and comprehensive use of the NHS Numberin line with National Patient Safety Agency requirements.

401 - Definition 3

402Procedures are in place to ensure the accuracy of service userinformation on all systems and /or records that support theprovision of care.

402 - Definition 2

404A multi-professional audit of clinical records across allspecialties has been undertaken.

404 - Definition 2

406Procedures are in place for monitoring the availability of paperhealth/care records and tracing missing records.

406 - Definition 3

501National data definitions, standards, values and data qualitychecks are incorporated within key systems and localdocumentation is updated as standards develop.

501 - Definition 2

502External data quality reports are used for monitoring andimproving data quality.

502 - Definition 2

504

Documented procedures are in place for using both local andnational benchmarking to identify data quality issues andanalyse trends in information over time, ensuring that largechanges are investigated and explained.

504 - Definition 2

506A documented procedure and a regular audit cycle foraccuracy checks on service user data is in place.

506 - Definition 2

507The secondary uses data quality assurance checks have beencompleted.

507 - Definition 3

508Clinical/care staff are involved in quality checking informationderived from the recording of clinical/care activity.

508 - Definition 3

514An audit of clinical coding, based on national standards, hasbeen undertaken by a Clinical Classifications Service (CCS)approved clinical coding auditor within the last 12 months.

514 - Definition 3

516Training programmes for clinical coding staff entering codedclinical data are comprehensive and conform to nationalclinical coding standards.

516 - Definition 2

601Documented and implemented procedures are in place for theeffective management of corporate records.

601 - Definition 2

603Documented and publicly available procedures are in place toensure compliance with the Freedom of Information Act 2000.

603 - Definition 3

604As part of the information lifecycle management strategy, anaudit of corporate records has been undertaken.

604 - Definition 2

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3 Conclusion

This concludes the presentation of our final scoring for the NHS Digital IG Toolkit v14.1 –

2017-2018.

An overall “Satisfactory” result is achieved, with all relevant requirements achieving or

exceeding Level 2.

4 Recommendation

That the Board approves the final scoring of the NHS Digital IG Toolkit and signs off our

final position.

As this is the last working day before Easter, Carl Starbuck – Information & Knowledge

Manager should be notified on the day so that the Trust’s final Toolkit results can be

published online, in time for the annual deadline of 31 March.

Carl StarbuckInformation & Knowledge Manager19 March 2018

Template V2 – November 2017

LEEDS AND YORK PARTNERSHIP NHSFOUNDATION TRUST


PAPER TITLE: Approval of the Terms of Reference for the Strategic Investmentand Development Committee



Sue Proctor, Chair of the Trust


Cath Hill, Head of Corporate Governance



EXECUTIVE SUMMARY

The Board will recall that as part of the review against the NHS Improvement Well-ledFramework it was agreed that the Board would put in place a Board sub-committee whoseduties are to consider, and where required, agree major investment / development /business opportunities where these require Board level scrutiny and approval.

Attached to this paper are the Terms of Reference for the Strategic Investment andDevelopment Committee. These have been sent to the Chair, Chief Executive and ChiefFinancial Officer for comment and are presented to the Board for approval.

Do the recommendations in this paper have anyimpact upon the requirements of the protectedgroups identified by the Equality Act?

State below‘Yes’ or ‘No’ If yes please set out what action has been

taken to address this in your paperNo

RECOMMENDATION

The Board is asked to approve the Terms of Reference for the Strategic Investment andDevelopment Committee.

AGENDAITEM

17

Template V2 – February 2018

STRATEGIC INVESTMENT AND DEVELOPMENT COMMITTEE

Terms of Reference(To be approved by the Board 29 March 2018)

1 NAME OF GROUP / COMMITTEE

Strategic Investment and Development Committee

2 COMPOSITION OF THE GROUP / COMMITTEE

Members: full rights

Title Role in the group / committee

Chair of the Trust Chair of the committeeChief Executive MemberChief Financial Officer and DeputyChair of the Trust

Member

Medical Director MemberDirector of Nursing MemberChief Operating Officer MemberDirector of Workforce Development MemberNon-executive Director and DeputyChair of the Trust

Deputy Chair of the committee

5 other non-executive directors Members

In attendance: in an advisory capacity

Title Role in the group / committee Attendance guide

Head of CorporateGovernance

Secretariat and advisor to thecommittee

Every meeting

In addition to anyone listed above as a member, at the discretion of the Chair, thecommittee may also request individuals to attend on an ad-hoc basis to provideadvice and support for specific items from its work plan when these are discussedin the meetings.

3 QUORACY

Number: No business shall be transacted at a meeting of the committee unless atleast one third of the whole number of the members is present including at leastone executive director and one non-executive director.

2Template V2 – February 2018

Deputies: Where, exceptionally, a director is absent from a meeting they may notnormally send a deputy in their place (with the exception of the Chief Executivewhose deputy is an executive director). However, attendance to cover absenceswill be at the discretion of the Chair and will be agreed in order to ensure thecommittee has access to appropriate advice and information. In thesecircumstances the deputy attending will not have any voting rights and will berecorded as ‘in attendance’. Where there are formal acting up arrangements inplace the person acting-up may attend and will assume the voting rights of thedirector they are acting up for. They will be recorded as a member of thecommittee.

Non-quorate meeting: Non-quorate meetings may go ahead unless the Chairdecides not to proceed. Any decisions made by the non-quorate meeting must bereviewed at the next quorate meeting.

Alternate chair: Should the Chair of the Trust be unable to attend, the meeting willbe chaired by the Deputy Chair of the Trust. If the Deputy Chair of the Trust is notavailable then the meeting shall be chaired by one of the other non-executivedirectors

4 MEETINGS OF THE COMMITTEE

Frequency: The committee shall meet as required or at least annually.

Urgent meeting: Any member of the committee may request an urgent meeting.The Chair will normally agree to call an urgent meeting to discuss the specificmatter, unless the opportunity exists to discuss the matter in a more expedientmanner.

Minutes: The Trust Board Secretary (or in their absence the Deputy Trust BoardSecretary) shall provide secretariat support which will include being in attendance,writing and circulating the minutes, ideally one week after the meeting. Minutesshall be provided to the next meeting of the committee and actions will becirculated to action leads following the drafting of the minutes.

5 AUTHORITY

Establishment: The Board of Directors has established the Strategic Investmentand Development Committee as a formal sub-committee of the Board.

Powers: Because the committee consists of all members of the Board and requires thesame level of quoracy as the Board of Directors, it has delegated authority to thecommittee to make decisions and approve investment / development opportunities onits behalf in relation to the duties set out in the section below. For clarity any decisionor investment / development opportunity approved by the committee will not need to bereferred to the Board for final sign off. However, a report will be made to the Board ofDirectors of the business transacted and the decisions taken by the committee so thiscan be recorded in the Board’s minutes.


Cessation: As this is a sub-committee of the Board of Directors, it shall be adecision of the Board of Directors that can formally dissolve the committee shouldthis be necessary.

6 ROLE OF THE COMMITTEE

6.1 Purpose of the Committee

The purpose of the committee is to consider and where required agreemajor investment / development / business opportunities where theserequire Board level scrutiny and approval.

ObjectiveHow the group / committee will meet thisobjective

We use our resourcesto deliver effectiveand sustainableservices

The committee will consider in detail anyinvestment / development / business opportunitiesto make sure these meet the Board’s duty toensure financial stability and best use ofresources to support the delivery of high qualitycare.

6.2 Guiding principles for members (and attendees) when carrying out theduties of the group / committee

In carrying out their duties, members of the committee and any attendees ofthe committee must ensure that they act in accordance with the values ofthe Trust, which are:

We have integrity We are caring We keep it simple.

6.3 Duties of the group / committee

The committee will consider, and where required approve, major investment/ development / business opportunities where these meet the followingcriteria:

Over the financial limit reserved to the Board (i.e. over £1m formainstream Trust business or over £500k for WYMHS CollaborativeProgramme priorities),

Complex, novel or contentious developments or initiatives whichmay be under the limit reserved to the Board but are recommendedfor Board level consideration.

Major investment / development / business opportunities will include:


Board of Directors

Major procurement and tender opportunities Business cases Contracts (clinical and non-clinical) Variations to contracts Major capital investments / divestments Major commercial arrangements including leases.

7 RELATIONSHIP WITH OTHER COMMITTEES

The work of the Finance and Performance (F&P) Committee, in particular, willhave some points of similarity with the duties of the Strategic Investment andDevelopment Committee. In relation to matters of finance and service delivery theF&P Committee will consider performance against planned, regulatory andcontractual targets and measures (including any trajectories) in detail. Thesemeasures against performance may be impacted by potential investment /development / business opportunities, which the Strategic Investment andDevelopment Committee will consider in detail.

The Strategic Investment and Development Committee will also take account ofinformation about performance, service quality and delivery from the work of otherBoard sub-committees and will do this through its membership and the reports itreceives.

The Board of Directors as the ‘parent’ group will receive reports from the Chair ofthe Strategic Investment and Development Committee in relation to the work it hasundertaken and the decisions it has made. An annual report of the work of thecommittee will also be made to the Board of Directors in line with all other Boardsub-committees.

8 DUTIES OF THE CHAIR

The Chair of the committee shall be responsible for:

Agreeing the agenda Directing the meeting ensuring it operates in accordance with the Trust’s

values

AuditCommittee

Finance andPerformanceCommittee

QualityCommittee

StrategicInvestment

andDevelopmentCommittee

NominationsCommittee

RemunerationCommittee

MentalHealth

LegislationCommittee


Giving direction to the minute taker Ensuring everyone at the meeting has a reasonable chance to contribute to

the discussion Ensuring discussions are productive, and when they are not productive they

are efficiently brought to a conclusion Deciding when it is beneficial to vote on a motion or decision Checking the minutes Ensuring sufficient information is presented to the Board of Directors in

respect of the work of the committee Ensuring the Chair’s report is submitted to the ‘parent’ committee, i.e. the

Board of Directors at the first opportunity.

It will be the responsibility of the Chair of the committee to ensure that it carriesout an assessment of effectiveness annually, and ensure the outcome is reportedto the Board of Directors along with any remedial action to address weaknesses.The Chair will also be responsible for ensuring that the actions to address anyareas of weakness are completed.

In the event of there being a dispute between any group / committees in themeeting structure it will be for the Chairs of those groups / committees to ensurethere is an agreed process for resolution; that the dispute is reported to the groups/ committees concerned and brought to the attention of the Board of Directors; andthat when a resolution is proposed that the outcome is reported back to the allgroups / committees concerned for agreement.

9 REVIEW OF THE TERMS OF REFERENCE

The terms of reference shall be reviewed in by the committee at least annually,and be presented to the Board of Directors for ratification, where there has been achange.

JuT29Mar/13CEW/14CHTemplate V1 – July 2017

LEEDS AND YORK PARTNERSHIP NHSFOUNDATION TRUST


PAPER TITLE: Mental Health Legislation Committee Terms of Reference



Sue White, Mental Health Legislation Committee Chair, NED


Sarah Layton, Mental Health Legislation Team Leader



EXECUTIVE SUMMARYThe Terms of Reference are presented for approval. The format has been updated to reflectthe Trust template for Committee terms of reference. There are no other major changes.The Terms of Reference were reviewed and agreed by the MHLC at the meeting held 8February 2018.




RECOMMENDATIONThe Bards is asked to approve the MHL Committees Terms of Reference.

AGENDAITEM

18

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JuT29Mar/13CEW/14CHJuT29Mar/13/

Mental Health Legislation Committee

Terms of Reference

To be approved by the Board of Directors – 29 March 18

1 NAME OF GROUP / COMMITTEE

The name of this committee is the Mental Health Legislation Committee.

2 COMPOSITION OF THE GROUP / COMMITTEE

The members of the committee and those who are required to attend are shownbelow together with their role in the operation of the committee.

Members: full rights

Title Role in the group / committee

Non-executive Director Committee ChairNon-executive Director Deputy ChairDirector of Nursing CQC Nominated IndividualDeputy Chief OperatingOfficer

Linkage to Care Services, Chair of the MHLOperational Steering Group

Attendees:

Title Role in the group / committee Attendance guide

Associate MedicalDirector for MentalHealth Legislation

Advisory and technical expertise Every meeting

ASC representatives(for Leeds,)

Linkage to social workers Every meeting

Head of CorporateGovernance

Linkage to Board and other sub-committees

As required

Mental Health ClinicalDevelopment Manager

Advisory and technical expertise Every meeting

Associate Director careservices

Linkage to care services As required

MHA managers’nominated individual

MHAM’s perspective, experience andconcerns

Every meeting

Governor Observer with opportunity tocontribute to discussions

Every Meeting

2

JuT29Mar/13/JuT29Mar/13CEW/14CH

In addition to anyone listed above as a member, at the discretion of the chair of thecommittee the committee may also request individuals to attend on an ad-hocbasis to provide advice and support for specific items from its work plan whenthese are discussed in the meetings.

3 QUORACY

Number: The minimum number of members for a meeting to be quorate is 3. Thismust include the Chair / Deputy Chair of the meeting plus the director of nursing.Attendees do not count towards quoracy. If the chair is unable to attend themeeting, and if otherwise quorate, the meeting will be chaired by the Deputy Chair.

Deputies: Where appropriate members may nominate deputies to represent themat a meeting. Deputies do not count towards the calculation of whether themeeting is quorate except if the deputy is representing the member under formal“acting up” arrangements. In this case the deputy will be deemed a full member ofthe group / committee.

It may also be appropriate for attendees to nominate a deputy to attend in theirabsence.

A schedule of deputies, attached at appendix 1, should be reviewed at leastannually to ensure adequate cover exists.

Non-quorate meeting: Non-quorate meetings may go ahead unless the chairdecides not to proceed. Any decisions made by the non-quorate meeting must bereviewed at the next quorate meeting.

Alternate chair: The unique character of Board sub-committees is that they arenon-executive director chaired. The Mental Health Legislation Committee has twonon-executive director members hence the role of the chair will automatically fall tothe other non-executive director if the chair is unable to attend.

4 MEETINGS OF THE COMMITTEE

Frequency: The Mental Health Legislation Committee will normally meet everythree months or as agreed by the Committee.

Urgent meeting: Any member of the group / committee member may request anurgent meeting. The chair will normally agree to call an urgent meeting to discussthe specific matter, unless the opportunity exists to discuss the matter in a moreexpedient manner.

Minutes: Draft minutes will be sent to the Chair for review and approval withinseven working dates of the meeting by the MHL Team Leader.

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5 AUTHORITY

Establishment: The Mental Health Legislation Committee is a sub-committee of theBoard of Directors and has been formally established by the Board of Directors.

Powers: The MHL Committees powers are detailed in the Trust’s Scheme ofDelegation. The Mental Health Legislation Committee has delegated authority tooversee the management and administration of the Mental Health Act 1983, theMental Capacity Act 2005 and the Deprivation of Liberty Safeguards. TheCommittee is authorised by the Board to investigate and seek assurance on anyactivity within its terms of reference.

Cessation: The MHL Committee is a standing committee in that its responsibilitiesand purpose are not time limited. However, the committee has a responsibility toreview its effectiveness annually and on the basis of this review and if agreed by amajority of members the Chair of the committee may seek Board authority to endthe Mental Health Legislation Committee’s operation.

In addition, the Trust should periodically review its governance structure forcontinuing effectiveness and as a result of such a review the Board may seek thewinding up of the Mental Health Legislation Committee.

This committee is implemented as a part of the 2013 governance review

ROLE OF THE COMMITTEE

6.1 Purpose of the Committee

Objective How the group / committee will meet this objective

Governanceandcompliance

The MHL Committee provides assurance to the Boardregarding compliance with all aspects of the Mental Health Act1983 and subsequent amendments and on compliance with allaspects of mental health legislation including, but not limited tothe Mental Capacity Act 2005 and Deprivation of LibertySafeguards.

6.2 Guiding principles for members (and attendees) when carrying out theduties of the group / committee

In carrying out their duties members of the group / committee and anyattendees of the group / committee must ensure that they act in accordancewith the values of the Trust, which are:

We have integrity We are caring We keep it simple.

4


6.3 Duties of the group / committee

The MHL Committee has the following duties: Mental health legislation

o The Committee will monitor and review the adequacy of theTrust’s processes for administering the Mental Health Act 1983and subsequent amendments and on compliance with allaspects of mental health legislation including the MentalCapacity Act 2005 and the Deprivation of Liberty Safeguards.

o Formally submit an annual report on its activities and findings tothe Board of Directors.

o Consider and make recommendations on other issues andconcerns in order to ensure compliance with the relevant mentalhealth legislation and to promote best practice by adherence tothe codes of practice.

o Review the findings of other relevant reports functions, bothinternal and external to the organisation, and consider theimplications for the governance of the organisation

Mental Health Act Managers’ Forum

o The Mental Health Legislation Committee will ensure that theMental Health Act Managers’ Forum is supported to shareexperience, promote shared learning and raise concerns, whereappropriate both amongst themselves and, with the Trust Boardand management

o The Mental Health Legislation Committee will act as arbiter ofany disputes in the work of Mental Health Act Managers arisingeither through the Mental Health Act Managers Forum or fromindividuals

Performance and regulatory compliance

o Will receive assurance from the MHL Operational Steering Group

regarding the flow of Mental Health Act inspection reports and

related Provider Action Statements.

o Wil receive assurance from the MHAMs Forum regarding

training, learning and development.

o To provide relevant assurance to the Board as to evidence of

compliance with the Care Quality Commission registration and

commissioning requirements related to Mental Health Act.

5


Training, clinical development and guidance

o To monitor and recommend action to ensure there are adequatestaff members/skill mix trained in the application of mentalhealth legislation and there is sufficient training provided tomaintain the required competency levels within clinical teams.

o To oversee the development and implementation of goodclinical practice guidelines and effective administrativeprocedures in regard to the Mental Health Act and MentalCapacity Act 2005 and the Deprivation of Liberty Safeguardsand advise on any other matters pertinent to MCA within theTrust

Assurance

o To ensure adequate quality control arrangements are in placeto enable:

Annual Mental Health Act report Continuous monitoring arrangements Agreed board reporting process

o To ensure there is an agreed programme of clinical audit andmechanisms for following up actions arising

o Receive the Board Assurance Framework and ensure thatsufficient assurance is being received by the committee inrespect of those strategic risks where it is listed as anassurance receiver

o Receive the quarterly documentation audit to be assured of thefindings, how these will be addressed and progress withactions.

User and carer involvement

o To ensure there is a mechanism for service users, carers andother groups with an interest to contribute to discussions andagreement on proper use of the relevant legislation, withparticular regard to the experience of compulsory detention andits therapeutic impact

o Consider any feedback received from service user surveys.

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7 RELATIONSHIP WITH OTHER GROUPS AND COMMITTEES

Board of Directors

AuditCommittee

NominationsCommittee

MentalHealth

LegislationCommittee

QualityCommittee

Finance &PerformanceCommittee

StrategicInvestment &DevelopmentCommittee

RemunerationCommittee

MentalHealth

OperationalSteeringGroup

7


8 DUTIES OF THE CHAIRPERSON

The chair of the group / committee shall be responsible for:

Agreeing the agenda Directing the meeting ensuring it operates in accordance with the Trust’s

values Giving direction to the minute taker Ensuring everyone at the meeting has a reasonable chance to contribute to

the discussion Ensuring discussions are productive, and when they are not productive they

are efficiently brought to a conclusion Deciding when it is beneficial to vote on a motion or decision Checking the minutes Ensuring sufficient information is presented to the Trust Board of Directors

in respect of the work of the group / committee.

It will be the responsibility of the chair of the committee to ensure that it (or anygroup that reports to it) carries out an assessment of effectiveness annually, andensure the outcome is reported to the Trust Board along with any remedial actionto address weaknesses. The chair will also be responsible for ensuring that theactions to address any areas of weakness are completed.

In the event of there being a dispute between any committees in the meetingstructure it will be for the chairs of those committees to ensure there is an agreedprocess for resolution; that the dispute is reported to the committees concernedand brought to the attention of the Board of Directors; and that when a resolutionis proposed that the outcome is reported back to all the committees concerned foragreement.

9 REVIEW OF THE TERMS OF REFERENCE AND EFFECTIVENESS

The terms of reference shall be reviewed by the committee at least annually, andbe presented to the Board of Directors for ratification, where there has been achange.

In addition to this the chair must ensure the committee carries out an annualassessment of how effectively it is carrying out its duties and make a report to theBoard of Directors including any recommendations for improvement.

8


Appendix 1Schedule of deputies

It may not be necessary or appropriate for all members (or attendees) to have a deputyattend in their absence. If this is the case please state below “no deputy required”.

Full member (by job title) Deputy (by job title)

Non-executive Director (Chair) Non-executive Director second memberNon-executive Director NoneDirector of Nursing Executive Director (ideally with knowledge and

experience of MHL)Deputy Chief Operating Officer Associate Director

Attendee (by job title) Deputy (by job title)

Associate Medical Director for Mental HealthLegislation

No deputy available to attend this Committee

ASC representative (for Leeds,)Head of Corporate Governance Governance OfficerMental Health Clinical DevelopmentManager

Mental Health Legislation Team Leader / LawAdvisor

Associate Director care services Another Associate DirectorMHA managers’ nominated individual Another MHA ManagerGovernor

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Glossary of Terms

In the table below are some of the acronyms used in the course of a Board meeting

Acronym / Term Full title Meaning

AHP Allied HealthProfessionals

Allied Health is a term used todescribe the broad range of healthprofessionals who are not doctors,dentists or nurses.

ASC Adult Social Care Providing Social Care and support foradults.

BAF Board AssuranceFramework

A document which is to assure theBoard that the risks to achievingour strategic objectives are beingeffectively controlled and that anygaps in either controls orassurances are being addressed.

CAMHS Child and AdolescentMental Health Services

The services we provide to ourservice users who are under theage of 18.

CGAS Child Global AssessmentScale

A numeric scale used by mentalhealth clinicians to rate thegeneral functioning of youthsunder the age of 18

CCG Clinical CommissioningGroup

An NHS statutory body whichpurchases services for a specificgeographical area. (CCGspurchase services from providersand this Trust is a provider ofmental health and learningdisability services)

CIP Cost ImprovementProgramme

Cost reduction schemes designedto increase efficiency/ or reduceexpenditure thereby achievingvalue for money and the bestquality for patients

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CMHT Community Mental HealthTeam

Teams of our staff who care forour service users in thecommunity and in their ownhomes.

Control Total Set by NHS Improvement withindividual trusts. These representthe minimum level of financialperformance required for the year,against which the boards,governing bodies and chiefexecutives of organisations will beheld directly accountable.

CPA Care Programme Approach The Care Programme Approach(CPA) is a way that services areassessed, planned, co-ordinatedand reviewed for someone withmental health problems or a rangeof related complex needs. Youmight be offered CPA support ifyou: are diagnosed as having asevere mental disorder.

CQC Care Quality Commission The Trust’s regulator in relation tothe quality of services.

CAS Crisis Assessment Unit The Leeds Crisis AssessmentService (CAS) is a city-wide acutemental health service. It offersassessment to people 18 yearsand over who are experiencingacute mental health problems thatmay pose a risk to themselvesand/or others, who require anassessment that day or within thenext 72 hours.

CTM Clinical Team Manager The Clinical Team Manager isresponsible for the dailyadministrative and overall operationsof the assigned clinical teams.

DBS Disclosure and BaringService

A service which will check ifanyone has any convictions andprovide a report on this

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DToCs Delayed Transfers of Care Service users who are delayed inbeing discharged from our servicebecause there isn’t an appropriateplace for them to go to.

EMI Unit Elderly Mentally Infirm Is a secure unit for the ElderlyMentally Infirm

First Care An electronic system for reportingand monitoring sickness. Thesystem is used by both staff andmanagers

I&E Income and Expenditure A record showing the amounts ofmoney coming into and going outof an organization, during aparticular period of time

iLearn An electronic system where staffand managers monitor and recordtraining and supervision.

KLoEs Key Lines of Enquiry The individual standards that theCare Quality Commission willmeasure the Trust against duringan inspection.

LADS Leeds Autism DiagnosisService

The Leeds Autism Diagnostic Service(LADS) provides assessment anddiagnosis of people of all intellectualability who may have autism who livein Leeds.

LCG Leeds Care Group The care services directoratewithin the Trust which managesthe mental health services inLeeds

LTHT Leeds Teaching HospitalsNHS Trust

An NHS organisation providingacute care for people in Leeds

LCH Leeds CommunityHealthcare NHS Trust

An NHS organisation providingcommunity-based healthcareservices to people in Leeds (thisdoes not include communitymental health care which Leedsand York Partnership NHSFoundation Trust provides)

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MDT Multi-disciplinary Team A multidisciplinary team is a groupof health care workers who aremembers of different disciplines(professions e.g. Psychiatrists,Social Workers, etc.), eachproviding specific services to thepatient

MSK Musculoskeletal Conditions relating to muscles,ligaments and tendons, and bones

Never event Never Events Never events are serious, largelypreventable patient safety incidentsthat should not occur if the availablepreventative measures have beenimplemented.

NHSI NHS Improvement The Trust’s regulator in relation tofinances and governance.

OD OrganisationalDevelopment

A systematic approach toimprovingorganisational effectiveness

OPEL Operational PressuresEscalation Level

National framework set by NHSEngland that includes a singlenational system to improvemanagement of system-wideescalation, encourage widercooperation, and make regionaland national oversight moreeffective.

OAPs Out of Area Placements Our service users who have to beplaced in care beds which are inanother geographical area and notin one of our units.

PFI Private Finance Initiatives A method of providing funds formajor capital investmentswhere private firms are contractedto complete and manage publicprojects

PICU Psychiatric Intensive CareUnit

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Q1, Q2, Q3, Q4 Quarter 1, Quarter 2,Quarter 3 Quarter 4

Divisions of a financial yearnormally Quarter 1 – 1 April to 30 June Quarter 2 – 1 July to 30

September Quarter 3 – 1 October to 31

December Quarter 4 – 1 January to 31

March

S136 Section 136 Section 136 is an emergency powerwhich allows you to be taken to aplace of safety from a public place, ifa police officer considers that you aresuffering from mental illness and inneed of immediate care.

SI Serious Incident Serious Incident RequiringInvestigation.

SOF Single OversightFramework

The targets that NHSImprovement says we have toreport against to show how wellwe are meeting them.

SS&LD Specialist Services andLearning Disability

The care services directoratewithin the Trust which managesthe specialist mental health andlearning disability services

STF Sustainability andTransformation Fund

Money which is given to the Trustis it achieves its control total.

Tier 4 CAMHS Tier 4 Child AdolescentMental Health Service

Child and Adolescent MentalHealth Tier 4 Children’s Servicesdeliver specialist in-patient andday-patient care to children whoare suffering from severe and/orcomplex mental health conditionswho cannot be adequately treatedby community CAMH Services.

TRAC The electronic system formanaging the process forrecruiting staff. A tool to be usedby applicants, managers and HR

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Triangle of care - The 'Triangle of Care' is a workingcollaboration, or ‘therapeuticalliance’ between the service user,professional and carer thatpromotes safety, supportsrecovery and sustains well-being.

Below is a link to the NHS Confederation Acronym Buster which might also provide help

http://www.nhsconfed.org/acronym-buster?l=A