sept meeting of the board of directors held in public at 10.30am … · board of directors part 1...

Board of Directors Part 1 Meeting 30 March 2016 DRAFT v007

SEPT

Meeting of the Board of Directors held in Public at 10.30am on

Wednesday 30 March 2016

TR1, The Lodge, Runwell Chase, Wickford SS11 7XX

Our Vision

“Providing services that are in tune with you”

PART ONE – MEETING HELD IN PUBLIC

AGENDA

1 APOLOGIES FOR ABSENCE CL (verbal)

2 DECLARATIONS OF INTEREST LC (verbal)

PRESENTATION: STAFF SURVEY RESULTS

CHARLES BOSHER, CONSULTANT, QUALITY HEALTH

3 MINUTES OF THE LAST MEETING HELD ON 24 FEBRUARY 2016 (attached)

4 ACTION LOG (attached)

5 QUALITY AND OPERATIONAL PERFORMANCE

(a) Assurance Report from Performance & Finance Scrutiny Committee

SM/MM (attached)

(b) Quality Report AB (attached)

(c) Safer Staffing Report AB (attached)

(d)

6 ASSURANCE, RISK AND SYSTEMS OF INTERNAL CONTROL

(a) Board Assurance Framework NL (attached)

(b)

Sub-Committees

(i) Quality Committee

(ii) Investment Committee

(iii) Audit Committee

LC

LC

JW

(attached)

(attached)

(attached)

7 STRATEGIC INITIATIVES

(a) SEPT/NEP Merger Proposals Update NL (attached)

(b) Operational Plan 2016/17 Update NL (attached)

(c) Essex Success Regime SM (attached)

Board of Directors Part 1 Meeting 30 March 2016 DRAFT v007

8 REGULATION AND COMPLIANCE

(a) CQC Inspection Visit Update SM (attached)

(b) Legal & Policy Updates NL (attached)

(c) CQC Intelligence Monitoring Report SM (attached)

(d) Views of Governors and Members Report LC (attached)

9 OTHER REPORTS

(a) Use of Corporate Seal SM (verbal)

(b) Correspondence circulated to Board members since the last meeting

LC (verbal)

(c) New Risks identified that require adding to the Risk Register or any items that need removing

All (verbal)

10 ANY OTHER BUSINESS

11 DATE AND TIME OF NEXT BOARD OF DIRECTORS MEETING

Wednesday, 27 April 2016 at The Lodge, Runwell Chase, Wickford, Essex, SS11 7XX

12 ‘QUESTION THE DIRECTORS‘ SESSION

There will be a 15 minute session for members of the public to ask questions of the Board of Directors.

13 RESOLUTION

To exclude members of the Public and Press

Lorraine Cabel Chair

SEPT: Board of Directors Meeting Part 1 Minutes 24 February 2016

Signed ………………………………………………. Date …………………...............

In the Chair, Board of Directors Meeting Page 1 of 13

SEPT MINUTES OF PUBLIC BOARD OF DIRECTORS

PART 1 held on Wednesday 24 February 2016

at The Lodge, Runwell Chase, Wickford SS11 7XX

Members present: Lorraine Cabel (Chair) Chair Sally Morris (CEO) Chief Executive Andy Brogan (AB) Executive Director Mental Health & Executive Nurse Steve Cotter (SCt) Non-Executive Director Steve Currell (SCl) Non-Executive Director Alison Davis (AD) Non-Executive Director Nigel Leonard (NL) Executive Director Corporate Governance Mark Madden (CFO) Executive Chief Finance Director Malcolm McCann (MMc) Executive Director Community Health Services & Partnerships Mary-Ann Munford (MAM) Non-Executive Director Janet Wood (JW) Non-Executive Director In attendance: Brian Arney (BA) Public Governor Penny Calder (PC) Occupational Therapist, SEPT Suzanne Deighton (SD) Local Security Management Specialist, SEPT Joy Das (JD) Service User & Carer Governor Joanna Eley (JE) Clinical Lead Health Visiting, SEPT Max Forrest (MF) Associate Director Communications, SEPT Chris Jennings (CJ) Compliance Officer, SEPT John Jones (JJ) Public Governor Cathy Lilley (CL) Acting Trust Secretary [Minute Taker] Kresh Ramanah (KR) Public Governor Tracy Reed (TR) Education Facilitator End of Life Care, SEPT & Staff Governor Elaine Taylor (ET) Associate Director Safeguarding, SEPT Lucia Vambe (LV) Community Psychiatric Nurse, SEPT Andy Ward (AW) Matron, SEPT David Watts (DW) Public Governor Amanda Whitman (AW) Clinical Effectiveness Manager, SEPT The Chair welcomed members of the public, staff and Governors to the meeting and reminded members of the Trust’s vision: providing services in tune with you.

029/16 APOLOGIES FOR ABSENCE

Apologies for absence were received from: Randolph Charles (RC) Non-Executive Director Dr Milind Karale (MK) Executive Medical Director

030/16 DECLARATIONS OF INTEREST


Signed ………………………………………………. Date …………………...............


None.

031/16 PRESENTATION: QUALITY ACADEMY

The Board received a presentation from Andy Brogan, Executive Director Mental Health & Executive Nurse, on the progress of the Trust’s Quality Academy which he described as ‘a mechanism to capture and sustain the commitment and enthusiasm of our workforce’. It will have an organisation-wide focus on high quality care, clear aligned objectives at every level from top team to front line, employee engagement throughout with team and inter-team working and clear leadership from the front line. The aim is to recruit as many staff as possible from all departments across the organisation at all levels and in all roles to be Quality Champions. AB confirmed that the work to date has included the development of a training programme, the establishment of a programme board, identification of initial projects and clear links with the Trust’s transformation agenda. Progress reports on the Quality Academy will be reported in upcoming editions of Quality Matters and through the Quality Committee. On behalf of the Board, the Chair thanked AB for the update on this exciting development which coincided with the timely announcement of the establishment of an Improvement Faculty by NHS Improvement and looked forward to receiving further updates on the projects and the Academy.

032/16 MINUTES OF THE MEETING HELD ON 27 JANUARY 2016

The minutes were agreed to be a correct record.

033/16 ACTION LOG

The Board reviewed the action log and noted:

Nov 237/15: an analysis of the number of staffing vacancies and/or use of bank/agency staff on Fuji Ward had not identified any meaningful correlation with the number of restraints experienced on the ward.

The Board noted the updates on the action log.

034/17 FINANCE & PERFORMANCE COMMITTEE ASSURANCE REPORT

As Chair of the Committee, JW provided assurance that a full and robust debate and scrutiny had taken place on 18 February 2016 on all performance issues and that mitigating actions and monitoring processes had been requested where appropriate. JW highlighted that the Committee had reviewed the Trust’s Governance Development Plan which identified the key priorities and high level actions that will support in delivering effective governance arrangements. It was agreed that the plan would provide more clarity regarding merger governance and that an additional priority for 2016/17 would be included in respect of utilising more proactively benchmarking


Signed ………………………………………………. Date …………………...............


information to understand Trust performance and opportunities for improvement or transformation. Performance The CEO stated that the Committee reviews and monitors the financial, operational and organisational performance of the Trust, and assurance was provided to the Non-Executive Directors (NEDs) that action was being taken to mitigate risks where necessary. During January there had been three Serious Incidents (SIs) reported in mental health services bringing the total year to date figure to 47 compared to 42 for 2014/15. Assurance was provided that a number of independent reviews had been undertaken but no trends had been identified, and that recommendations from the reviews were being implemented. The Board noted that a Mortality Review Group would be established following a request by the Quality Committee for a further consideration of the results from the various independent reviews to be taken forward in conjunction with the actions arising from the Southern Health Report review. There were three performance hotspots (vacancy rates, percentage of people entering IAPT treatment and the percentage of users on CPA with a crisis plan in place) out of a total of 87 key performance metrics and the Key Performance Indicators (KPIs) identified in CCG contracts, and the Board was pleased to note that none of the hotspots relate to national compliance indicators. The CEO highlighted the emerging risks discussed which included restraints, sickness absence, local target turnover, submission of the new Mental Health Services Data Set (MHSDS) and the number of consultant appointments cancelled. In addition, it was not expected that the Trust would be able to confirm compliance with the new access and waiting time standards for Early Intervention of Psychosis (EIP) performance standard as the funding/service re-design has not yet been agreed and it is therefore unlikely that the Trust will start delivering a compliant service from 1 April 2016. Consideration is being given to including this issue on the Trust’s risk register as appropriate. SCo asked about the remit of the Mortality Review Group and how this extended beyond the Trust’s current SI review processes. The CEO explained that this Group would review all deaths associated with Trust’s services to help identify and understand where and why the deaths occurred, and to identify trends. Retrospective reviews would not be undertaken as there had already been a number of internal and independent reviews. MAM noted that there had been a slight improvement in the vacancy rate during the year and asked if the reasons for staff leaving were known. The CEO confirmed that detailed reports are now reviewed regularly by the Executive Operational Sub-Committee (EOSC) and HR. Finance The CFO advised that the Trust’s financial position at January 2016 was an operating surplus of £1.58m which was ahead of revised plan. There was a year to date deficit of £3,085k on the Trust’s Cost Improvement Programme (CIPs) with a year-end deficit


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forecast of £3,851k and a recurrent net deficit of £4,502k but this assumes that a further £926k of schemes remain deliverable. The Board noted that the NEDs at the Finance & Performance Committee had sought assurance from Executive Directors in respect of action being taken to mitigate the recurrent CIP deficit. The continued deterioration of the adverse variance in Specialist Services of £1,190k from £1,165k in the previous month was highlighted. As previously reported, the reasons for the variance include above establishment pay costs in Learning Disability in (LD) patient service, unachieved CIPs and the impact of bed-watch, observations and escorted leave costs at Bedford Prison, and the underachievement against the income target at Robin Pinto and Wood Lea Clinics. There also continued to be a deterioration of the adverse variance in Operational Services (South Essex Mental Health) where the continued use of bank and agency staff significantly contributed to the deterioration. The overall position for Community Services was a cumulative actual of £76.7m against a budget of £78.1m resulting in a net favourable variance of £1.4m. The Board was pleased to note that the Trust’s financial sustainability risk rating was at 4 which demonstrated the strong financial health of the Trust, and that working capital and cash balances remained strong and above plan. The Board noted that following a request by Monitor, the Trust has agreed a reduced capital spend which will improve the Trust’s forecast year end surplus/deficit and cash positions to a £1.4m revenue benefit for 2015/16. The Board discussed the resource implications to be able to meet the new targets and developments and noted the importance of the current contracting negotiations with commissioners to ensure that realistic expectations were being agreed. The Board noted the performance and finance report and confirmed acceptance of assurance provided.

035/16 QUALITY REPORT

AB presented the report which focused on aspects of care relating to three key categories: safety, experience and improvement, and highlighted that there was a small increase to 98.68% of patients did not experience any of the four harms covering pressure ulcers, falls, blood clots and urine infections for those patients who have a urinary catheter in place. The Board was pleased the Trust consistently continue to achieve a high rate against the national ambition of 95%. AB highlighted the continued progress with the Sign Up to Safety work streams. The projected outturn for avoidable pressure ulcers was 19 which is less than the previous year although the ambition remains at zero. There continued to be a reduction in the number of falls compared to the previous year with 13 year to date compared to 24 in 2014/15 and there has been one avoidable fall during 2015/16. A comprehensive audit which included impact of environment, care planning and risk assessments had been undertaken across all older people’s inpatient and rehabilitation units, and the results were currently being analysed. In addition work was being undertaken with the Medicines Management Committee to identify, from an evidence base, those drugs which may have a propensity to contribute to falls.


Signed ………………………………………………. Date …………………...............


The Board was pleased to note that 95% of the 843 responses for the Friends and Family Test in January would positively recommend the Trust across all services. Following a question by SCo, AB confirmed that the respondents may vary from month to month as this is dependent on those patients accessing services in the month in question. JW acknowledged the significant progress being made through the Sign Up to Safety work streams and asked if there were plans to include additional work streams. AB advised that the work streams reflected the six quality priorities including in the Trust’s quality strategy and it was therefore unlikely at this stage that an additional work stream would be developed. Led by the Chair, the Board discussed the importance of a system-wide multi agency group to lead on SI prevention. The Board received and discussed the report, and confirmed acceptance of assurance provided.

036/16 SAFER STAFFING REPORT

AB presented the Safer Staffing report for nursing, midwifery and care staff that contained details and a summary of planned and actual staffing on a shift-by-shift basis as part of the Hard Truths commitment. He highlighted that the majority of wards in LD, Secure Services and Community Health Services were above 95%. The Board noted the increase in the number of hotspots and emerging risks relating to fill rates but was assured that there were no concerns with regards to the safety and quality of care on the wards and that mitigating actions were in place. The Board noted that whilst recruitment was being undertaken, site managers on wards were being utilised to provide support alongside ward managers and matrons to ensure wards remained safe. MAM enquired as to mechanisms which provide assurance that the quality of care provided to patients is of a high standard. JW advised that the Finance & Performance Committee was reviewing the benchmarking data, proxy indicators and how information across the Trust could be triangulated. The Board approved the report.

037/16 BOARD ASSURANCE FRAMEWORK (BAF)

NL presented the Board Assurance (BAF) report and reminded the Board that the BAF was a living document which was subject to changes, which provided a comprehensive method for the effective management of the potential risks that may prevent achievement of the key aims agreed by the Board. The Board noted the review, challenge and approval of individual action plans by the EOSC for risks detailed on the BAF and approved the following risk to be escalated to the BAF:


Signed ………………………………………………. Date …………………...............


As a result of regulatory actions or Governors failing to approve the merger proposal, there is a risk that the merger will not be completed by April 2017 resulting in the benefits identified in the merger proposal (clinical and patient, commissioner and financial benefits) not being delivered.

The Board reviewed the BAF ratings and:

1 Approved the BAF at 16 Februar 2015 2 Agreed the recommendations as detailed in table 1 – BAF overview 3 Approved the escalation to the BAF of the following risk:

As a result of regulatory actions or Governors failing to approve the merger proposal, there is a risk that the merger will not be completed by April 2017 resulting in the benefits identified in the merger proposal (clinical and patient, commissioner and financial benefits) not being delivered.

4 Did not identify any potential risks to be escalated to the Corporate Risk Register and/or BAF.

038/16 SUB-COMMITTEES

(i) Quality Committee The Chair presented the report of the meeting held on 11 February 2016. She provided assurance that robust discussions were held on a number of issues some of which had already been covered by the Board as separate agenda items including the Quality and Safer Staffing reports. The Chair highlighted:

the case study covering a patient supported by the Trust’s Learning Disability Therapy Team that demonstrated the positive difference technology made on the patient’s quality of life and how this helped with her recovery

the excellent work being undertaken to achieve the national ambition to reduce pressure ulcers. She highlighted that an informative report had been presented by the Specialist Nursing Services manager and Tissue Viability Nurse who demonstrated how work had resulted in a reduction in the number of avoidable pressures within the Trust

the Committee was assured that there were no concerns to safety and the quality of care on wards with regards to the hotspots identified in terms of safer staffing

that all Board Directors have signed their Fit & Proper Persons declarations and passed the relative tests

that assurance was provided that appropriate actions were being taken to address the issues identified following the limited assurance received following an internal audit of clinical handovers

the Committee had requested further consideration be undertaken for the escalation of a risk to the CRR in relation to the criteria for determining the seriousness of risk in relation to the bed capacity and Rapid Response.

In response to a question by SCo, assurance was provided that the Trust was proactively reviewing ways of using technology to improve the quality of patient


Signed ………………………………………………. Date …………………...............


care/service provision through its own internal digital technology review group as well as working external bodies, including the Health & Wellbeing Academy and ARU. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of risks and action identified. (ii) Audit Committee JW presented the report of the meeting held on 28 January 2016 and provided assurance that the duties of the Committee which include governance, risk management and internal control had been appropriately complied with. JW pointed out that the Committee had focused on reviewing in detail the twelve internal audit final reports and in response to a question by AD, provided assurance at appropriate actions were in place in respect of the five reports which had received limited assurance. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of risks and action identified. (iii) Mental Health & Safeguarding Committee SCu presented the report of the meeting held on 12 February 2016 which focused on safeguarding, the CQC MHA Audit Report, Associate Hospital Managers (AHMs) and CQC. LC asked for an update on the concerns raised by AHMs in relation to detained patients not being able to finish their psychology sessions in the community if discharged. SCu confirmed that assurance has been provided that this was being reviewed. He advised that future reports would include a summary of actions including progress and outcomes. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of risks and action identified.

039/16 ESSEX SUCCESS REGIME UPDATE

The CEO presented the report from Monitor, Trust Development Authority (TDA) and NHS England on the progress with the Essex Success Regime which had been issued on 22 January 2016. The report also included a summary of the challenges which will need to be tackled, overview of aims and next steps. The Board received and noted the report.

040/16 SEPT/NEP MERGER PROPOSALS UPDATE

NL presented an update report on the progress of the SEPT/North Essex Partnership University NHS FT (NEP) merger proposals. He reminded the Board that the Outline Business Case (OBC) had been submitted to Monitor on 8 January and that a risk relating to the merger had been approved for inclusion on the BAF.


Signed ………………………………………………. Date …………………...............


Meetings between Monitor’s review team and members of the Strategic Alliance Working Group and Project Team were held during week commencing 15 February, and in addition, Monitor had spoken with lead commissioners. Prior to the formal feedback meeting on 11 March, Monitor shared some initial headline informal feedback and guidance, which included the importance of undertaking thorough due diligence processes particularly for clinical due diligence and having clarity about the full benefits of the merger. NL confirmed that written feedback will be provided after the meeting on 11 March and that regular update reports on the merger will be provided at both Boards’ meetings. The Board received and noted the progress report.

041/16 BOARD OF DIRECTORS ANNUAL SELF-ASSESSMENT 2016

The Chair presented the update action plan following the Board’s self-assessment undertaken during 2015 and highlighted the excellent progress made. The Chair outlined the proposal for the Board to undertake an internal self-assessment for 2016 rather than an external assessment as originally planned. The Board unanimously agreed to this taking account of the report from the CQC following the Trust’s comprehensive inspection that rated the Trust overall as ‘good’ including ‘good’ for well-led, the governance due diligence which will take place during the merger with NEP process and that the next external independent review is not actually due until 2017/18, The Board also agreed the timeframe for the self-assessment and to follow the same internal self-assessment framework and questions used in 2015. The Board:

1 Received and noted the report 2 Agreed the Board’s self-assessment review for 2016 would be undertaken

internally following the same framework as used for 2015 3 Agreed the timeframe for the 2016 internal self-assessment.

042/16 THE FIVE-YEAR FORWARD VIEW FOR MENTAL HEALTH (5YFV)

The Board received a report from the CEO on the Five-Year Forward View for Mental Health: a report from the independent Mental Health Taskforce to the NHS in England which sets out a number of priority areas for action, including the improvement of crisis care and physical health outcomes, and the need to invest an additional £1bn by 2020/21 to generate significant savings, building on the £280m investment each year already committed to drive improvements for children and young people. The CEO highlighted the implications of this report, the new system-wide Sustainability & Transformation Plans (STPs) and the future commissioning intentions will have on the Trust which is well place to respond to these priorities. However, she pointed out that funding variations as well as differing demands in each locality may lead to variations in the range of service developments requested by commissioners.


Signed ………………………………………………. Date …………………...............


The Trust was anticipating additional stretch targets for mental health provision and physical health over the planning period to 2021. The Board received and discussed the report, and noted the implications on the Trust’s operational plan and objectives for 2016/17.

043/16 IMPLEMENTING THE FORWARD VIEW: SUPPORTING PROVIDERS TO DELIVER

NL presented the report on the newly published guidance on Implementing the Forward View: supporting providers to deliver which had been issued by NHS Improvement (formerly Monitor). The Board noted that in response to the 5YFV the Government has pledged an additional £8.4bn of real-term investment in the NHS by 2020 which is heavily weighted to earlier years of the spending period. The intention is to give NHS service providers a window of opportunity in which to invest in lasting improvements in the quality and efficiency of care to sustain higher standards as funding growth slows. The 5YFV identifies a number of development areas for the period to 2021 including a focus on transformation covering quality, access, finance, sustainability, workforce and leadership, technology and research. NHS Improvement will support providers through a new oversight model, developing the right relationships, autonomy for successful FTs and evidence-based improvement approaches. The Board noted the challenges facing providers through to 2020 which includes delivering patient care of outstanding quality, meeting NHS Constitution access standards, returning to financial balance and eliminating unwarranted variation across all these areas, whilst at the same time making the transformation needed to ensure long-term sustainability. NL advised that the Trust ha\s been working towards the areas of transformation identified in the 5YFV as demonstrated through our strategic priorities, corporate aims and transformational programmes. He assured the Board that a number of initiatives identified are already well under way and that the Trust is well placed to meet the challenges identified by the target date of 2021. In addition, the Trust’s strategies and frameworks will be revisited to ensure they are fit for purpose and the Operational Plan for 2016/17 will be changed to reflect the new guidance. The Board received and discussed the report, noting the implications of the new guidance on the Trust’s Operational Plan for 2016/17.

044/16 LEGAL & POLICY UPDATES

NL introduced the Legal & Policy update report highlighting the number of reports and guidance from the centre that support the drive for transformation and change, as well as intervention from Monitor (NHS Improvement) to move troubled Trusts into turnaround.


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Referring to 2.11 of the report relating to Monitor’s investigation into NEP because of concerns over the quality of services and state of finances, SCu asked if the Trust would be undertaking its own due diligence as part of the merger process. The CEO provided assurance that this would be the case. In addition, in the spirit of openness and transparency it was hoped that any findings would be shared. The Board received and noted the report.

045/16 USE OF CORPORATE SEAL

The Board noted that the corporate seal had been used on one occasion since the last meeting:

17 February 2016: lease in respect of 30-31 Pickwick Close, Laindon.

04616 CORRESPONDENCE TO THE BOARD SINCE THE LAST MEETING

None.

047/16 NEW RISKS IDENTIFIED THAT REQUIRE ADDING TO THE TRUST RISK REGISTER OR REMOVED FROM THE REGISTER

The Board noted there were no new risks identified.

048/16 BOARD OF DIRECTOR SCHEDULE OF BUSINESS 2016/17

NL presented the Board of Directors 2016/17 meetings schedule of business which details the essential business items to be considered but does not preclude the Board from considering any other issues it wishes to discuss or to vary the schedule. The Board received and approved its schedule of business for its meetings for 2016/17.

049/16 ANY OTHER BUSINESS

Freedom to Speak Up Principal Guardian Election Results The CEO announced the results of the Trust’s Freedom to Speak Up Principal Guardian, appointed through an election process that was voted for by all members of staff across the Trust (substantive, bank, agency and contracted). She expressed her personal pleasure with the level of interest in both the Principal and Local Guardian roles. The CEO stated that high on the Board’s agenda is the Trust’s approach to clinical safety, and openness and transparency and highlighted that the Trust already has in place a number of mechanisms to enable staff to raise issues (I’m Worried facility on the intranet, the Whistle-blowing Policy, etc).


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There were six nominees for the Principal Guardian role and the CEO confirmed that Suzanne Deighton had been elected as the Trust’s Principal Guardian with effect from 1 April 2016 for one year with 34.7% of the vote. The other candidates were:

Kathy Swearingen (16.8% of the vote)

Penny Calder (15%)

Jo Eley (13.95%)

Dean Hall (10.6%)

Amanda Whitman (8.8%). The CEO took the opportunity of thanking all the nominees for putting themselves forward and was pleased to confirm that they have all agreed to become a Local Guardian demonstrating their commitment to the Freedom to Speak Up initiative.

050/16 DATE AND TIME OF NEXT MEETING

The next meeting will take place on place on Wednesday 30 March 2016 at 10:30 at The Lodge, Runwell Chase, Wickford SS11 7XX.

051/16 RESOLUTION TO EXCLUDE MEMBERS OF THE PUBLIC & PRESS

In accordance with provision 14.20.2 of the Constitution and paragraph 18E of Schedule 7 of the NHS Act 2006, the Board of Directors resolves to exclude members of the public from Part 2 of this meeting having regard to commercial sensitivity and/or confidentiality and/or personal information and/or legal professional privilege in relation to the business to be discussed. The Board noted and agreed the resolution.

052/16 STAFF RECOGNITION SCHEME

The Chair and CEO were delighted to present certificates to:

Individual ‘In Tune’ Awards - Sue Davis, PA to Clinical Nurse Specialist, Secure Services - Olgah Gopo, Staff Nurse Aurora Ward - Hannah Mould, Business Administration Support Office, Chair’s Office - Karen Turner, IT Service Desk Engineer - Karen Waldock, Disability Resource Centre, Bedfordshire

Team ‘In Tune’ Awards - Alpine and Lagoon Wards, Brockfield House - Maple Ward, Rochford Hospital

Long Service Awards - Judith Hurry, Head of Universal Children’s Services – 38 years - Anne Moss, Thurrock Memory Service – 34 years - Tracy Reed, Education Facilitator for End of Life Care – 35 years - John Webb, Primary Care Therapist – 41 years.


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The Staff Recognition Awards are the official way for the Board, colleagues, patients and carers, to recognise those who demonstrate, above and beyond, their commitment to delivering excellent service. The Staff Recognition Scheme promotes the Trust’s vision - ‘Providing services that are in tune with you’ and values - Positive, Welcoming, Respectful, Involving, Accountable, Kind. These awards are a positive way of the Board remaining ‘in touch’ with front line staff.

053/16 MEMBERS OF THE PUBLIC/STAFF/GOVERNORS QUESTIONS

Questions from member of the Public, Staff and Governors are detailed in Appendix 1. The meeting closed at 12:40.


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Appendix 1: Governors/Public Query Tracker (Item 053/16)

Governor /Member of Public

Query Assurance provided by the Trust Actions

JJ Finance & Performance Committee 3.5 page 7: asked for more clarity regarding the non-payment of some NHS Property Services invoices

MM advised that a detailed property by property review of the schedule (amounting to £8m) was being undertaken as there are concerns that the records do not accurately reflect the occupancy of buildings

-

JJ Safer Staffing Report: queried if the number of beds at Robin Pinto and Woodlea are accurate – currently shown as 14 and 8 respectively

AB to confirm correct figures Subsequent to meeting AB confirmed that the reported figures were correct and had been changed to reflect the number of commissioned beds rather than the number of beds being utilised

JD Asked when the merger was expected to be finalised

CEO advised that based on the current timeframe this was expected to be 1 April 2017 but was subject to various key milestones in the project plan including the submission of the FBC and review by Monitor

-

BA Enquired as to the number of patients who were surveyed in relation safety thermometer audit and the percentage compared to the number of patients treated within the same timeframe

AB confirmed that for February 2050 patients were surveyed out of approximately 15,000 contacts during the month

-

BA Enquired as to how relevant the number of patients surveyed in the Friends & Family Test is in relation to the total number of patients treated

- AB to review and advise BA

Agenda Item 4 Board of Directors Part 1 Meeting

30 March 2016

Board of Directors Meeting Part 1 30 March 2016 Page 1 of 2

SEPT Board of Directors Meeting: Action Log (following Part 1 meeting held on 24 February 2016)

Lead Initials Lead Initials Lead Initials

Andy Brogan AB Alison Davis AD Sally Morris SM

Lorraine Cabel LC Milind Karale MK Mary-Ann Munford MAM

Randolph Charles RC Nigel Leonard NL Janet Wood JW

Steve Cotter SCt Malcolm McCann MMc

Steve Currell SCl Mark Madden MM Cathy Lilley CL

Minutes

Ref

Action Owner Dead-line

Outcome Status

Comp/Open

RAG rating

June

137/15

Workforce Race Equality Standard (WRES): Progress report to be presented at April 2016 Board meeting

AB Apr 16 Open

May

113/15

Complaints Annual Report: Future reports to include a range of patient stories (including challenging stories) and learning.

NL May 16 Need to build in process for report to be presented to Quality Committee prior to Board. Deadline extended to May 16

Open

May 15

113/15

Complaints Annual Report: Triangulation of information collected during 2015/16 to include staff views

Jan

010/15

Customer Services Framework: Combine with a review of the Patient and Carer Experience Strategy.

NL May 16 Quality Committee agreed this is one of the frameworks which underpins and links into the Quality Strategy. Framework to be presented at May 16 mtg

Open

Nov 237/15

Quality Report: Review number of staffing vacancies and/or use of bank/agency staff on wards with the number of restraints on those wards to see if there is any correlation (ref Fuji Ward)

AB Feb 16 Analysis of the number of staffing vacancies and/or use of bank/agency staff on Fuji Ward had not identified any meaningful correlation with the number of restraints experienced on the ward

Comp

Sept Board Self-Assessment 2015: Progress on evaluation NL Feb 16 Included as agenda item in part 1 February Board Comp

Requires immediate attention /overdue for action

New action or required next meeting

Action Completed

Future Actions

Agenda Item 4 Board of Directors Part 1 Meeting

30 March 2016

Board of Directors Meeting Part 1 30 March 2016 Page 2 of 2

Minutes

Ref

Action Owner Dead-line

Outcome Status

Comp/Open

RAG rating

193/15 action plan to be presented in Feb 2016 meeting: good progress noted

Sept 193/15

Board Self-Assessment: Timetable for the full independent assessment to be reviewed and proposal presented in Feb 2016

SM/LC Feb 16 Included as agenda item in part 1 February Board meeting: framework and timetable agreed

Comp

of 2

Agenda Item No: 5a

SUMMARY REPORT BOARD OF DIRECTORS MEETING PART 1

30 March 2016

Report title: Assurance Report from the Finance & Performance Committee

Lead: Janet Wood Non Executive Director

Report Author(s): Faye Swanson Director of Compliance & Assurance

Report discussed previously at: Content discussed at Finance & Performance Committee – 24.03.2016

Level of Assurance: The content of this report has been considered by the Finance & Performance Committee.

Level 1

Level 2

Level 3

Purpose of the Report

This report is provided by the Chair of the Finance and Performance Committee to provide assurance to the Board of Directors that the performance (operational and financial) of the Trust as at Month 11 – February 2016 was subject to appropriate and robust scrutiny.

Approval

Discussion

Information

Recommendations / Action Required

Based on the information provided the Board of Directors is asked to:

Confirm acceptance of the assurance provided

Request any further action / assurance

Summary of Key Issues

The committee considered:

Quality and Performance as at Month 11 – February 2016

Financial performance as at Month 11 – February 2016

Executive Operational Sub Committee Part One Minutes

Policies and procedures requiring approval

Outcome of the self assessment phase of the efficacy review of the committee

Relationship to Trust Strategic Priorities

SP 1: Quality Services

SP 2: Quality Leadership & Workforce

SP 3: Sustainability of Service Provision

SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness

Relationship to the Board Assurance Framework

Are any existing risks in the Board Assurance Framework affected?

Yes

If yes, insert relevant risk

Learning from Serious Incidents – BAF#13060607 Compliance with CQC standards – BAF#14033001 Vacancy Fill Rates – BAF#15042101 30% Slippage CIP – BAF#15042103 Delivery of the transformation programme – BAF#15042105

Do you recommend a new entry to the Board Assurance Framework is made as a result of this report?

No

of 2

Corporate Impact Assessment OR Board Statements: Assurance(s) against:

Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives

Data Quality Issues Involvement of Service Users/ Healthwatch N/A

Communication and Consultation with stakeholders required N/A

Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £

X

Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity X

Equality Impact Assessment (EIA) Completed? No If yes, EIA Score N/A

Acronyms / Terms used in the report

FPC Finance & Performance Committee

KPI Key Performance Indicators

CEO Chief Executive Officer

NEDs Non Executive Directors

YTD Year to Date

MH Mental Health

EOSC Executive Operational Sub Committee

CQC Care Quality Commission

CCG Clinical Commissioning Group

SI Serious Incident

RCA Root Cause Analysis

CAMHS Child and Adolescent Mental Health Services

AWOL Absent Without Leave

LD Learning Disabilities

SE South East

DH Department of Health

HSCIC Health and Social Care Information Centre

NICE National Institute for Health and Care Excellence

NHS National Health Service

IAPT Improving Access to Psychological Therapies

PbR Payment by Results

EIP Early Intervention Plan

CQUIN Commissioning of Quality and Innovation

MHSDS Mental Health Data Set

CFO Chief Finance Officer

CIP Cost Improvement Programme

Supporting Documents &/or Further Reading

None

Lead

Janet Wood, Non Executive Director

Assurance Report From Finance and Performance Committee

1

Agenda Item 5a Board of Directors Meeting

30 March 2016

SEPT

ASSURANCE REPORT FROM THE FINANCE AND PERFORMANCE COMMITTEE (Part 1)

PURPOSE OF REPORT

This report is provided by the Chair of the Finance and Performance Committee to provide assurance to Board members that the performance (operational and financial) and governance arrangements of the Trust as at Month 11 - February 2016 was subject to appropriate and robust scrutiny.

ASSURANCE REPORT

The committee met on 24 March 2016 and considered the performance and governance arrangements of the Trust as at Month 11 - February 2016. The Finance and Performance Committee (FPC) is constituted as a standing committee of the Board of Directors. The Board of Directors has delegated responsibility to this committee for the oversight and monitoring of the Trust’s financial, operational and organisational performance in accordance with the relevant legislation, national guidance, Monitor’s Code of Governance and current best practice. The committee is required to ensure that risks associated with the performance and governance arrangements of the Trust are brought to the attention of the Board of Directors and/ or to provide assurance that these are being managed appropriately by the Executive Directors. The committee will be responsible for ensuring the Executive Directors of the Trust are held to account for the reported performance and any actions to address issues/ risks that may be identified by its members.

1.0 Actions arising from previous meetings

1.1 Action Log

An action log is in place and this was reviewed. Two actions were due for completion in March 2016.

Outcome of Self Assessment of Effectiveness of Committee A report was provided confirming that the self assessment phase of the efficacy review had been completed. Three key areas for further consideration have been identified:

Potential duplication of KPIs covered by Quality Committee

Variation in content of assurance report to the Board by the committee compared to other standing committees

Membership overlap/ duplication Recommendations will be developed and presented to the Board of Directors in April 2016.

Timetable for Mobius project to take forward the separate crisis plan and linking DATIX to Mobius in relation to restraints It was confirmed that the separate crisis plan will be developed at the earliest by the end of June. Although scoping of the potential to link Datix to Mobius is underway, no timescale has yet been identified. An update is to be provided in 3 months.


2

2.0 Quality and Performance

The deputy CEO presented the Quality and Performance report for Month 11 - February 2016. The performance of the Trust was discussed and assurance was sought by the Non-Executive Director members from the deputy CEO and Executive Directors that action was being taken to mitigate risks where necessary. NEDs also took the opportunity to understand the context for reported performance and the systems and processes in place to support service delivery and implementation of action. A summary of discussions and key actions agreed (as appropriate) is set out below.

2.1 Serious Incidents

Mental Health During February 2016 there were 11 Serious Incidents reported in Mental Health Services (3 reported in January):

5 Unexpected Deaths

1 Assault on a family member

2 Serious self-harm behaviours

1 Adverse media coverage

1 Outbreak of Infection

1 Self-harm meeting Criterion 9 for Specialist Services YTD there have been 58 Serious Incidents compared to 42 for 2014/15. So far this year there have been 28 Unexpected deaths in Essex MH – almost double the figure reported in 2014/15 (16). There have been 6 Serious Accidents / Injuries reported in Specialist Services compared to only two for the whole of 2014/15. The committee was advised that Monitor has contacted the Executive Director of Clinical Governance & Quality to seek assurance in respect of action being taken to respond to the increased number of unexpected deaths as this has been identified as a potential quality concern through the Quality Surveillance process. Non Executive Directors sought assurance on the action being taken in the Trust to understand the reasons for the increased trend and learn from incidents that have occurred. The chair of the committee confirmed that the Quality Committee received a detailed report on action being taken within the Sign Up To Safety workstream relating to suicide prevention at it’s meeting 17 March 2016. The workstream has included development of new processes to review all deaths by suicide in order to determine if any of these deaths could have been avoided. The deputy CEO assured the committee that the Trust is committed to achieving its ambition of zero avoidable suicides by 2017 and has prioritised suicide reduction through its sign up to safety campaign. A comprehensive forward looking action plan has been developed to deliver transformational change to how staff assess and plan for safety within services, supported by the plan to commission specific suicide prevention training for all staff, underpinned by a cultural review of the organisations’ understanding and attitudes towards suicide prevention. In addition a new mortality review group has been established to consider the findings of the Southern Health investigation and take forward action as necessary within the Trust. Community Health Services There were no new incidents in February.


3

2.2 Hotspots

The deputy CEO advised that two performance hotspots had been identified by the EOSC for bringing to the attention of the committee out of a total of 87 key performance metrics and contract reports.

2.2.1 Indicator: IAPT Entering Treatment

The cumulative target is for 13.75% of the target population to have entered treatment during April to February. Performance by CCG is as follows:

Basildon & Brentwood CCG : 13.46%

Castlepoint & Rochford CCG : 12.94%

Southend CCG : 15.10%

Thurrock CCG : 12.33% Remedial Action Plans are in place for Basildon & Brentwood CCG and CastlePoint & Rochford CCG to ensure the 15% trajectory is achieved by March 2016. The CCGs are provided with weekly updates regarding the performance. Fortnightly meetings are taking place with the Commissioners to monitor the actions. The committee was reminded that an IAPT capacity check has identified the service in South Essex is under-funded by £770,000 if it is to reach the 15% access target and that the current level of funding enables the Trust to achieve only 9.5% access. Contract negotiations are underway to either agree that the target to be achieved in 16/17 should be circa 9.8% based on the current level of funding or to agree the level of funding and service model required to deliver the target of 15%.

2.2.2 Indicator: % Users on CPA with a Crisis Plan in Place

This indicator was introduced part year as a result of the introduction into the contract with South Essex CCGs of a suite of PBR related indicators. In December 2015 and January 2016 performance, 71% against the target of 95%, was reported based on an assumption that if there was a care plan in place there would be a crisis plan, because the crisis plan was integrated into the care plan. Separately, as a result of the CQC Intelligence Monitoring data (published 25th February 2016) it was identified that the MHMDS held by HSCIC recorded that 0% of discharged patients had a crisis plan and that this is identified by the CQC as posing an elevated risk. It was identified that the reason why the MHMDS records 0% is because there are 5 criteria required to be met in all crisis plans and data fields for each of these. (contact details; patient history, previous anti-depressants and psychotherapies; signs predicting relapse and instructions for care if a future relapse occurs). As the Trust’s crisis plan is incorporated into the care plan the data fields cannot be automatically populated. It was noted that it appears that many trusts failed to meet this reporting requirement (actual numbers are being analysed to support this perception). The EOSC agreed in February that a separate crisis plan should be created to explicitly meet the 5 criteria and to provide patients with better clarity about this part of the care plan in place for them. The committee was advised that in taking forward action to address this issue it has been confirmed that both inpatient and community care plans are designed to incorporate the 5 criteria. However there is no absolute assurance available that this is the case at this time. As a result the EOSC had recommended that performance is reported as 0% at this time. The committee acknowledged the risk associated with this but accepted that data integrity was equally important.


4

The committee was provided with assurance that action is underway to create a separate crisis plan (as part of the care plan) that automatically populates the required data fields but that this will be completed at the earliest in June 2016. The committee requested that action is taken to provide operational assurance of crisis plan content in the interim and to triangulate SI RCA findings in respect of crisis plan formulation. It was noted that in addition to concern regarding the performance in respect of crisis plans, the number of patients with a care plan reported as 76.7% is also being investigated as although this is not a Trust KPI it should be much higher. A list of patients without care plans recorded has been forwarded to the Director of Mental Health for validation.

2.3 Update on Last Month’s Hotspots

Indicator: Vacancy Rates The committee was pleased to note that the vacancy rate across the Trust has fallen to 10.2% (benchmark target is 10%), the lowest monthly rate reported since vacancy rates were included in the performance report almost two years ago. During this period there were 61 new starters and there were 32 leavers. The committee was advised that for Registered Nursing staff, the vacancy rate remains above target at 12.3%, however this rate has been steadily decreasing. In February there was a decrease of 12.3 wte vacancies but also a reduction of 16.7 wte funded establishment. There are though still 180 wte registered nursing vacancies overall.

2.4 Emerging Risks

2.4.1 Indicator: % users assigned to a cluster (Mental Health)

The committee noted that as part of the PbR CQUIN scheme the Trust is required to reach a target of 95% of all patients assigned to a PbR cluster by the end of March 2016. The target was increased from 90% in Q3. The February performance is 91.1% (1024 patients not clustered). This was identified as an emerging risk in February when performance as at the end of January was 91.3%. The CFO advised that action continues to be taken to achieve the target and there is reasonable confidence that it will be achieved.

2.4.2 Indicator: % within Cluster Review Periods (Mental Health)

The committee noted that as part of the PbR CQUIN scheme the Trust is also required to reach a target of 90% of all patients having their PbR cluster reviewed within the defined review periods by March 2016. The target was increased from 75% in Q3. The February performance is 85.8% - which is an increase on the January figure of 78.8%. This was identified as an emerging risk in February based on the January position. The CFO advised that action continues to be taken to achieve the target and there is reasonable confidence that it will be achieved.

2.4.3 Indicator: Early Intervention Service – First episode of psychosis treated within 2 weeks of referral.

The committee had previously been advised that from 1 April 2016 the new Monitor indicator regarding the access and waiting time standard for Early Intervention in Psychosis (EIP) will be reported. Foundation Trusts will be required to start reporting their performance in Q4. The Trust has advised the CCGs of additional investment required to deliver the new targets. This is part of contract negotiations. Regardless of the outcome there is a risk that the Trust will not meet targets in Q1 2016/17 if the expectation is that both parts of the target (access and NICE compliance) are required to be reported in Q1 due to the need to recruit staff.


5

2.4.4 Indicator: Local Target Turnover

The 12 month rolling turnover rate has fallen to 14.6% from 15.2% last month, remaining above the benchmark rate of 8.4%.

2.4.5 Indicator: Consultant Appointments cancelled by Service

During February 6.5% (January 8.4%) of appointments were cancelled by the service compared to the contracted target of 3.0%. This equates to 131 cancelled appointments out of a total of 2007 booked appointments. The main reasons for the cancellation of the clinics were the junior doctor’s strike and no locum cover available.

2.4.6 Indicator: South East Essex Community Health Services - Continence Service - % of people that have been prescribed continence products for 12 months or more that have had an annual review

The target within the contract is 95%, the February performance was 73.8%. The committee had previously been advised that concerns about this level of performance have been raised by the Commissioners and escalated to the Contract Management Meeting to agree that a contract query is raised. It has not yet been received.

2.4.7 Data and Performance Recording and Reporting

The committee was advised of risks associated with the Trust’s ability to collect and report new data fields associated with the Mental Health Minimum Data Set and Specialist Services Commissioning dataset. It was acknowledged that failure to meet these requirements could result in contract queries and/ or penalties, but it was confirmed that action is being taken to address the majority of the identified gaps by the end of September 2016.

2.5 Other Information

Progress with the outpatients project was reported and it was noted that there had been a small decrease in the numbers of patients not seen for 12 months. The committee was satisfied that action continues to be taken forward as agreed and the committee was advised that a detailed report on progress will be presented in April. Data identifying increased demand for acute adult admission beds was provided. Action being taken to manage pressure on beds was confirmed by the deputy CEO. An increase in reported restraint incidents was noted in Poplar Ward (CAMHs). This was confirmed to relate to three particularly challenging patients; two of whom have since been transferred out of the ward. Non Executive Directors noted that the number of incidents successfully de-escalated continues to be high. The committee sought assurance from the deputy CEO in respect of the investigation taking place following the AWOL incident of a patient who had travelled to Italy and for further information about action taken to address a physical security issue identified following a separate AWOL incident.

2.7 Contract Exceptions Summary

The committee was assured by Executive Directors that other performance issues, as identified in the contract monitoring reports presented to the EOSC were being handled as part of day to day management of the service and that escalation was not required to the FPC.


6

2.8 Monitor Compliance Targets

As at the end of Month 11 all of the KPIs in the Risk Assessment Framework issued by Monitor as proxy measures of quality have been achieved and detailed performance is set out in the National Regulation section.

2.10 Quality and Safety Information

Performance in respect of 87 key quality and safety measures in total was presented to the committee. No further action was requested in respect of reported performance.

3.0 Finance

The committee received a report on financial performance presented by the Chief Finance Officer. He confirmed that the content of the report had previously been considered by the EOSC which had provided an opportunity for more of the Trust’s senior leaders to be involved in the discussion of the organisations performance. The financial performance of the Trust was discussed and assurance was sought by the NED members from the CEO and Executive Directors that action was being taken to mitigate risks where necessary. NEDs also took the opportunity to understand the context for reported performance.

3.1 Overview

The CFO presented a summary of performance for Month 11 - February 2016 to the committee as follows:

Forecast YTD Position

Annual Plan

2015/16

Revised Plan

Actual Revised Plan

Actual

Operating (Surplus)/Deficit £000

£0k

£0k

(£128k)

(£1,242k)

(£2,022k)

Capital Expenditure £7,040k £7,040k £2,542k £4,476k £1,495k

Cash Balance £40,557k £37,247k £44,866K £41,013k £45,882k

FSSR Rating 4 3 4 3 4

The Trust’s Continuing Operating position, excluding Impairments and Technical Adjustments is a surplus of £2m, which is £780k above the current revised plan. The surplus reported in month 10 was £1,582k, an improvement of £440k on year to date. This improvement is mainly attributable to the net effect of contract variation income.

3.2. Hotspots and Emerging Risks

The committee was advised of and discussed the following four items reported this month:

1. Cost Improvement Plan (CIPs) – Year end forecast deficit of £3.3m (£3.8m in month 10) and £4.5m recurrent net deficit against 15/16 plan. The Trust is reporting a year to date deficit of £3,001k on its cost improvement programme, with the year-end deficit forecast to be £3,276k. On a recurrent basis, the Trust is reporting a net deficit of £4,460k but this assumes that a further £356k of schemes remain deliverable.

2. Specialist Services (Mental Health - Forensic, LD & Prison) – The overall adverse variance is £1,099k; the position has improved from an adverse variance of £1,190k reported in month 10 and £1,165k reported in month 9. The reasons for the variance are the same as previously reported, that is, above establishment pay costs in LD inpatient service (Byron Court) - £155k, an unachieved CIP of £566k, also the impact of bed-watch, observations and


7

escorted leave costs at Bedford Prison and underachievement against the income target at Robin Pinto and Wood Lea Clinic - £622k, off-set by additional activity income in Essex Forensic.

3. Operational Services – (SE Mental Health) reports an adverse variance of £2,845k. The

position continues to deteriorate from month 10 figure of £2,318k and month 9 figures of £2,199m. A significant part of the adverse variance relates to the continuing use of Bank & Agency staff. Other factors include:

Bank and agency staff costs within the inpatient wards, particularly in Hadleigh, Grangewaters and Cedar Wards and Assessment Unit. However, this adverse run rate continues to improve monthly over the last 5 months.

Disputed invoiced income relating to additional / non-block beds at Hadleigh Ward and consequent provision for potential income claw-back.

Underachievement of CIP target of £1,238k.

The psychology IAPT is an adverse variance of £136k, partly offset by staff vacancies within other areas.

4. Operational Services (Community Health Service) – The overall position for Community

Services is a cumulative actual of £84m against a budget of £85.9m, resulting in a net favourable variance of £1.9m (2.2%). The main reason for the favourable variance is the same as previously reported, namely; vacant posts not back filled by bank or agency staff.

A discussion took place regarding the financial plan and risks for 2016/17. It was confirmed that this is to be discussed in more detail at the Board Development Session taking place on 24 March 2016, the outcome of which will be set out in the final Operational Plan 2016/17 to be presented to the Board and Monitor by 11 April 2016. The CFO advised the committee that a new control target for agency staffing has been received from Monitor for 2016/17 which is £5.5m less than the plan for 2015/16. This will be extremely challenging and will potentially require the introduction of greater controls but balancing operational demands with the need to meet the target will still need to happen.

3.3 Financial Sustainability Risk Rating

The CFO advised that as at the end of month 11, the Trust has achieved a financial sustainability risk rating of 4, versus the planned risk rating of 3. This result demonstrates the Trust is in strong financial health.

3.4 Capital Expenditure

The CFO advised that as at end of Month 11, the net capital programme recorded a net variance of £2,252k against plan. This is in line with the reforecast capital plan submitted to monitor at month 11. As previously reported, the CFO advised that Monitor had previously asked the Trust to consider whether a further underspend on the capital programme would be possible during 2015/16. Discussion between Monitor and DH on this subject had concluded, but may be re-initiated in light of the national NHS shortfall. The (current) agreed reduced capital spend and subsequent adjustments will improve the Trust’s forecast year end surplus /deficit and cash positions. The forecast revenue benefit for 2015/16 is £1.4m.

3.5 Cash and Working Capital

The CFO confirmed that against the revised plan, the Trust is reporting actual YTD cash of £45,882k at the end of month 11 compared to plan of £41,013. The increase in cash is mainly due to lower capital spend than planned as reflected in note 4.1.1 above and non-payment of some NHS Property Services invoices where the invoice values are being disputed.


8

4.0 Sub-Committee Reports

4.1 Executive Operational Sub-Committee

The committee considered four sets of Part 1 minutes of the Executive Operational Sub Committee:

9 February 2016

16 February 2016

23 February 2016

1 March 2016

8 March 2016

No further information or action was requested by committee members.

5.0 Approval of Policies

The following policy and procedure was approved by the committee on behalf of the Board of Directors:

Mobile Phone Policy The committee approved extension of the Resolution of Salary Overpayments and Underpayments Policy (HR50) until October 2016.

6.0 Summary

The committee members were assured by the information provided and the actions that are being taken. No further hotspots, actions or matters for escalation were identified.

RECOMMENDATION & ACTION REQUIRED

The Board of Directors is recommended to:

Confirm acceptance of the assurance provided

Request any further action / assurance Report prepared by: Faye Swanson Director of Compliance & Assurance On behalf of: Janet Wood, Non Executive Director / Chair of the Finance and Performance Committee

1

Agenda Item No: 5b

SUMMARY REPORT

BOARD OF DIRECTORS PART I

30th March 2016

Report title: Quality Report

Executive Lead: Andy Brogan, Executive Director Mental Health, Executive Nurse

Report Author(s): Sarah Browne, Deputy Director of Nursing

Report discussed previously at:

Level of Assurance:

Level 1

2

3


To provide the Quality Committee with monthly quality report Approval

Discussion

Information


1. Discuss the content of this report 2. Note the issues identified 3. Recommend any further actions as required


The key issues:

98.78% harm free care

Update on Sign up to Safety campaign

Update on serious incidents reported

98% of all respondents would positively recommend the Trust across all services








No



No

2



Data Quality Issues

Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required


Governance Implications

Impact on Patient Safety /Quality Impact on Equality & Diversity

Equality Impact Assessment (EIA) Completed?

No


SI Serious Incident


Beds Bedfordshire

SEECHS South East Essex Community Health Services

WECHS West Essex Community Health Services

CMHT Community Mental Health Team

MH Mental Health

COD Cause of Death



NA

Executive Lead

Andy Brogan Executive Director Mental Health, Executive Nurse

Quality Report

3

Agenda Item: 5b

Board of Directors 30th March 2016

SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

QUALITY REPORT

1.0 PURPOSE OF REPORT

The purpose of this report is to provide the Board of Directors with a quality report giving an overview on aspects of care relating to three key categories: safety, experience and improvement. The report also signposts towards additional information about the trust's performance within these categories as part of our on-going commitment to being open and honest

2.0 SAFETY

Safety Thermometer On one day each month we check to see how many of our patients suffered four types of harm whilst in our care covering pressure ulcers, falls, blood clots and urine infections for those patients who have a urinary catheter in place. This is called the Safety Thermometer and is a national monthly audit. The national ambition is to attain 95% harm free care. The score below shows the percentage of patients who did not experience any new harms in our care.

98.78% of patients did not experience any of the four harms in our Trust.

Out of 1971 patients surveyed, 24 patients were identified as having one of the four harms.

18 patients within community health services o 9 pressure ulcers o 7 falls o 2 VTE (Blood clots)

6 patients within community health services o 4 falls o 2 VTE

For more information, including a breakdown by category, please visit http://www.safetythermometer.nhs.uk

Sign up to Safety We have signed up to ‘Sign up to Safety’ which is a national safety campaign that was launched in June 2014 with the mission to strengthen patient safety in the NHS and make it the safest healthcare system in the world. Each of the work streams have two year action plans going forward which will feed into an overarching Safety Framework covering:-

Early detection of deteriorating patient

Avoidable pressure ulcers

Avoidable falls

Avoidable unexpected deaths

Reduction in use of restraint

Reduction in omitted doses of medication The report details work in progress covering each of these areas.

http://www.safetythermometer.nhs.uk/

Quality Report

4

Early detection of deteriorating patient The rollout of the MEWS system, where an overall score is calculated for a patient based on six physical vital signs continues. The aim of the score is to standardise assessment of the severity of acute physical illness so that patients who are deteriorating physically or at risk of deteriorating can be identified and managed consistently. A re-audit on compliance with MEWS has been undertaken. The audit focused on a number of standards as follows:

Frequency of vital signs to be undertaken

Whether vital signs have been measured within 12 hours of admission and reviewed as a minimum on a weekly basis;

Whether a MEWS score has been calculated, and, if the score is raised, whether this has been escalated appropriately.

The audit involved speaking with staff, reviewing the accuracy and completeness of MEWs charts in the past 14 days and examining patient records where a MEWs score was found to be elevated, requiring escalation to an appropriate clinician. Figure 1 illustrates the number of patients with a MEWS score greater than 3 (which is a trigger to ensure that appropriate interventions and management are considered at the earliest opportunity). These results have been raised with service leads and further training has been arranged both on a 1:1 coaching basis and as part of workshops on physical health.

Pressure Ulcers Pressure Ulcers are localised injuries to the skin and/or underlying tissue as a result of pressure. They can be classed into four grades, 1 is the least severe and is rated as Low Harm according to the National Reporting and Learning System. Grades 2 and 3 are rated Moderate Harm and Grade 4, which is rated as Severe Harm.

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Patients escalated as per MEWS chart

No of patients with MEWS > 3

No patients escalated

Quality Report

5

Pressure Ulcer Grade

2014/15 February PUs Year to date Apr – Feb 16

Projected Outturn

Grade 1 17 1 14 15

Grade 2 1043 110 1072 1182

Grade 3 512 41 433 474

Grade 4 20 - 19 41

With all grade 3 and 4 pressure ulcers a root cause analysis is undertaken to identify how the pressure ulcer occurred and if found to be avoidable. The majority of pressure ulcers reported are within the community nursing teams across the trust who are supporting patients within their own homes but are not receiving 24 hour nursing support. The table below details the number of avoidable pressure ulcers to date this year in comparison to last year.

Falls This measure includes all falls which were classified as Patient Safety Incidents (those falls which adversely affected patients). Falls relating to staff members/visitors/contractors/others are not included in these figures.

An audit has been undertaken across all older people’s inpatient and rehabilitation units during the months of November and December. The audit examines the extent to which staff are complying with Trust policy, NICE guidance and other patient safety guidance on the prevention and management of falls in hospital.

To assess the extent to which SEPT complies with evidence based standards via the Royal College of Physicians Falls and Fragility Fracture Audit Programme Spring 2015 at an Organisational Level.

To assess the extent to which SEPT older people inpatient and rehabilitation units are complying with Trust policy on slips, trips and falls, including carrying out falls risk assessments (FRATs)

To assess the risk of falls related to the physical environment in SEPT older people inpatient and rehabilitation units in relation to falls and make recommendations for improvements. This will include an assessment of how “dementia friendly” the physical environment is.

To make recommendations for improvements to falls prevention practice that can be progressed by the Trust’s Falls Group. This will include any recommendations for improvements to the Trusts’ falls risk assessment tool and slips, trips and falls policy.

Early findings suggest that there are some areas of good practice including:

Avoidable Pressure Ulcers

2014/15 Feb 16 Year to

Date

Projected Outturn

Grade 3 20 0 14 17

Grade 4 3 0 1 2

RCA in progress 0 51 39 0

Severity 2014/15 February Year to date Apr – Feb 16

Projected Outturn

No Harm 1271 54 728 782

Low Harm 373 28 353 381

Moderate Harm 24 - 19 19

Severe Harm 21 - 4 4

Death - - - -

Quality Report

6

Falls guidance which references NICE recommendations;

The Trust Falls Risk Assessment Tool (FRAT) includes recommended multifactorial assessments;

There is a trust post falls protocol in place;

The Trust wide Falls Group is comprises a number of professionals including nursing, therapy, pharmacy and medicine.

Areas to address include:

An absence of Trust guidance on delirium and dementia;

The number of Falls Risk Assessment Tools in use across inpatient areas;

Variable completion of the FRAT and within the expected time;

An absence of a standard continence assessment for the Trust.

Work is underway to address gaps and will be reported to the committee on a monthly basis. All severe harm falls are subject to a root cause analysis to identify how the fall occurred. This is scrutinised by the Falls Group. The table below details the number of falls to date this year in comparison to last year. All repeat and are followed up where issues are identified. The table below provides detail on the number of severe harm falls to date this year in comparison to last year. Serious Incidents A Serious Incident is an incident that meets nationally defined criteria as listed in the National Serious Incident Framework. These include:

Unexpected or avoidable death of patients, staff, visitors or members of the public

Serious harm to patients, staff visitors or members of the public where the outcome requires life-saving intervention, major surgical/medical intervention or permanent harm

A scenario that prevents provision of healthcare services

Allegations of abuse

Adverse media coverage

One of the core set of ‘Never Events’

Information governance breaches meeting the ICO Toolkit criteria The table below lists the number and types of Serious Incidents reported between 1st and 29th February 2016.

Type Number

Unexpected death in the community 5

Serious Assault 1

Serious Self Harm 2

Adverse Media Coverage 1

Outbreak of Infection 1

Self-harm meeting Criterion 9 for Specialist Services 1

Fall 2014/15

Feb 16 Year to

Date

Projected Outturn

Avoidable 5 0 2 2

Unavoidable 19 0 11 13

RCA in progress 0 0 0 0

Total 24 0 13 15

Quality Report

7

Restraint The Restrictive Practice (RP) work stream has benefitted from a productive leads meeting where actions were agreed to strengthen the agenda with senior management sign up. All leads are now required to provide a monthly Restrictive Practice Report to their Quality& Safety local meeting with assurances of work undertaken to reduce restraints and restrictive practices as well as data outlining patterns. Reports will be shared within the leads meetings. The group is now taking forward the existing next 90 day action plan into a two year action plan with particular focus on measuring the reduction of restraints and prone restraints; however join working is planned to work with other work stream on reviewing the self-harm policy review, pharmacological impact and blanket rules and interface between restraint as a result of self-harm Maple (382), Poplar (Essex) (192), Fuji (125), Hadleigh Unit (99) and Lagoon (98) are the top 5 highest reporting areas for restraint interventions for 2015/16. For the month of February the three top reporting areas for restraints are Poplar (Essex) (78), Maple Ward (27) and Hadleigh Unit (15). The restraint data is monitored on a weekly and monthly basis.

Omitted Doses of Medicines The working group continues to allow a broad ranging discussion about the themes raised in the workshops held earlier and linked to the rolling 90 day action plan, including promoting self-administration as part of re-ablement in community health services, and ensuing that facilities are available in mental health services to allow the blood tests required for administration of some high risk medicines. These will be explored further in future meetings. Main area of work in progress at present is repeating the full inpatient audit of omitted doses. Data has been collected on more than 36,000 doses due for administration and is in presently being analaysed.

17 18

7 8

15

57

84

54

49

29

34

27

16 15

4 5 5 7

16

23

3

11

25

78

7 11

15 11 11

9 11

17

8

15 11

6

0

10

20

30

40

50

60

70

80

90

2015 03 2015 04 2015 05 2015 06 2015 07 2015 08 2015 09 2015 10 2015 11 2015 12 2016 01 2016 02

Trustwide Restrictive Practice Incidents by Team Name (Top 3 and Month)

Maple Ward Poplar Ward (Essex) Fuji

Quality Report

8

Avoidable Unexpected Deaths (Suicide Prevention) The Suicide Prevention work stream two year action plan has now been reviewed and signed off by the sign up to safety project group. This action plan draws on lessons learned from both national and local investigations to deliver and ambitious set of actions to both reduce and prevent serious harm and suicide within mental health services in Essex. This action plan has been shared with operational services and leads and will be overseen by the work stream suicide prevention group. Work is concluded on a baseline audit to determine how services respond to serious self-harm attempts in keeping with NICE Guidance and a draft report on the findings has now been shared with the project group and recommendations are currently being developed in response to the findings of this audit. Work has now commenced on the roll out of the Anglia Ruskin Serious Incident cultural evaluation. A survey monkey questionnaire will shortly be sent to all staff to complete with a cross section of staff being selected to participate in more in-depth interviews in order to understand the impact and efficacy of the current SI Learning process and culture within the organization. Interview dates have been identified and work is currently in progress to communicate the project to all staff using existing communication methods.

3.0 EXPERIENCE

Friends and Family Test

In February approximately 98% of the 716 responses would positively recommend the Trust across all services.

Since 2012, SEPT has been using the NHS Friends and Family Test (FFT) as one way of measuring the experience of people who use our services. The FFT question asks “How likely are you to recommend our service to friends and family if they needed similar care or treatment?” Respondents answer on a scale of ‘Extremely Likely’ to ‘Extremely Unlikely’.

Total number of responses 716

Number of positive responses 703

Number of negative responses 5

Number of neutral responses 8

Percentage who would recommend 98%

Percentage who would not recommend 1%

Percentage who were neutral 1%

Quality Report

9

4.0 IMPROVEMENT

Learning Lessons Falls: RCAs being reviewed within multidisciplinary falls group to identify themes or

areas for further training. Further equipment being purchased to support reducing risk of falls.

Pressure Ulcers: Staff have been provided with further education and training around the use of risk assessments and ordering/recommending appropriate equipment. Mandatory training now in place.

Unexpected Deaths: Review of risk assessments and suicide prevention training being taken forward for staff.

‘Sign up to Safety’ rolling 90 day action plans in place to ensure continuation of work. Contact has been made with a number of other Sign up to Safety campaign trusts who have workstreams addressing similar areas of work to share ideas.

Restrictive Practice: Risk reduction plans being taken forward within all ward areas.

5.0 RECOMMENDATIONS

It is recommended that the Board of Directors: 1. Note the contents of this report 2. Identify any further work required to be taken forward.

6.0 ACTION REQUIRED

The Board of Directors is asked to: 1. Approve the report

Report prepared by Sarah Browne Deputy Director of Nursing

On behalf of


1

Agenda Item No: 5c

SUMMARY REPORT

BOARD OF DIRECTORS PART I

30th March 2016

Report title: Safer Staffing Report

Executive Lead: Andy Brogan, Executive Director Clinical Governance & Quality

Report Author(s): Sarah Browne, Deputy Director of Nursing


Level of Assurance:

Level 1

2

3


To provide the Board of Directors with the monthly safer staffing report

Approval

Discussion

Information


1. Note the contents of this report 2. Identify any further work required to be taken forward.


The key issues:

Monthly shift by shift information required as part of the delivery of the Hard Truths commitments

Active recruitment is ongoing

Twice daily teleconference call in continue covering South Essex Mental Health Services

Hot spots and emerging risks for fill rates are outlined but no safety concerns have been identified








Yes


If fill rates are not achieved for safer staffing there is a safety and reputational risk for the Trust

Do you recommend a new entry to No

2

the Board Assurance Framework is made as a result of this report?



Data Quality Issues

Involvement of Service Users/ Healthwatch

Communication and Consultation with stakeholders required

Service Impact/Health Improvement Gains

Financial Implications Capital £ Revenue £ Non Recurrent £


Impact on Patient Safety /Quality

Impact on Equality & Diversity


No


SI Serious Incident


Beds Bedfordshire

SEECHS South East Essex Community Health Services

WECHS West Essex Community Health Services

CMHT Community Mental Health Team

MH Mental Health

COD Cause of Death



NA

Executive Lead


Monthly Shift By Shift Staffing Report

3

Agenda Item 5c

Board of Directors 30th March 2016


MONTHLY SHIFT BY SHIFT STAFFING REPORT


The purpose of this report is to provide the Board of Directors with the monthly shift by shift information required to be presented as part of the delivery of the Hard Truths commitments associated with publishing staffing data regarding nursing, midwifery and care staff.

2.0 OVERVIEW

A monthly report to Board containing details and summary of planned and actual staffing on a shift-by-shift basis is part of the Hard Truths commitments. As discussed in previous reports, the information returned to the central collection captures the identified staffing required for each shift in relation to the number of patients on the ward and the dependency of the patients, allowing flexing of the staffing required. This information continues to be reviewed on a weekly basis via teleconference call with lead nurses and senior managers to identify any hotspots from the previous week, any mitigations and actions taken to ensure safe staffing as well as discuss any concerns for the following week. Twice daily teleconference calls continue for South Essex Mental Health Inpatient areas led by senior managers (Director or Associate Director of Mental Health) with matrons of the wards to review each ward. The purpose of this call is to identify staffing on the wards, reviewing use of agency and bank staff as well as the dependency of the ward to enable identification of any areas of concern and to move staff if required to support wards. The call also looks forward to shifts to ensure appropriate night cover and weekend cover with a clear process for escalation if required. A SitRep is circulated to the Chief Executive and senior staff identified above. The following section details the dashboard covering each ward reported via Unify alongside agreed quality indicators. This information is reported through the safer staffing database on the intranet covering all ward areas across the trust to enable review by managers as live reporting as well as detail further information covering, bank and agency usage as well as the level of observations required. Further information is also available within the intranet section to record if bank staff are permanent staff and whether bank and agency staff are known to the wards. The report considers the fill rate on the revised staffing levels following the board reviews. As discussed over the past months Essex Mental Health Services have been showing a lower than expected fill rate within some of the wards although this has improved from earlier in the year. The report also details the percentage of bank and agency staff known to the ward areas, detailing that the staff are generally known to the units. Committee members can be reassured that through the twice daily teleconference calls and monitoring of incidents there have been no safety concerns identified on these wards, and the site manager and matrons have supported wards when required to cover, whilst active recruitment is underway


4

The Trust continues to advertise vacancies actively including Nursing Times, Irish Nursing Times, NHS Jobs, along with social media sites such as Facebook and Twitter. We plan to continue to attend recruitment fairs as well as continue to take forward the active recruitment campaign. A number of further workstreams are also in place to review staffing including reducing agency staffing as well as monitoring and review of vacancies. The individual report and dashboard now identifies hot spots and emerging risks as discussed at October’s Quality Committee with assurance given regarding safety throughout the report. The following two pages contain the dashboards for both January and February to allow comparison of data.


5

3.0 DASHBOARD

Day Night

WARD NAME Location

NO OF

BEDS

OPEN

Occupancy

Rate

(including

leave days)

STAFF

(WTE

Contrac

ted)

Vacanc

y Rate

FILL

RATE

Register

ed

FILL

RATE

Unregist

ered

FILL

RATE

Register

ed

FILL

RATE

Unregist

ered

%

Appraised

in previous

12 months

% Bank

Use

% Bank

Staff

Used

Perman

ent or

Known

%

Agency

Use

%

Agency

Used

Known

FALLS

Moderat

e &

Severe

PRESS

URE

ULCER

S

HCAIsSicknes

s Rate

Long

Term

Sicknes

s Rate

TARGET: >90% >90% >90% >90%

ESSEX MENTAL HEALTH INPATIENT SERVICES

Basildon MHAU Basildon 20 98.1% 26.3 -15.2% 89.70% 100.0% 98.4% 101.1% 81.8% 36.7% 98.4% 7.9% 74.4% 0 0 0 13.2% 6.8%

Beech Rochford 24 106.0% 21.8 10.9% 92.6% 97.5% 96.6% 93.9% 100.0% 46.9% 92.7% 5.6% 54.5% 0 0 0 1.6% 0.0%

Cedar Ward Rochford 24 121.0% 17.9 18.8% 93.4% 95.6% 87.9% 101.0% 100.0% 54.4% 84.7% 11.0% 74.1% 0 0 0 13.4% 10.7%

Clifton Lodge Westcliff 35 76.3% 28.2 20.7% 90.3% 97.5% 69.0% 109.1% 91.7% 42.0% 105.5% 15.6% 93.4% 0 0 0 9.1% 4.6%

Gloucester Basildon 25 138.2% 18.2 12.8% 95.9% 99.3% 100.0% 100.0% 100.0% 32.6% 88.1% 1.0% 100.0% 0 0 0 1.5% 0.0%

Grangewater Basildon 28 83.9% 24.1 -1.4% 95.1% 97.9% 89.7% 100.9% 88.9% 47.9% 95.9% 8.6% 72.9% 0 0 0 11.2% 7.5%

Hadleigh Unit Basildon 20 120.9% 22.2 19.2% 100.9% 98.4% 98.3% 98.3% 93.3% 39.3% 110.1% 4.3% 100.0% 0 0 0 10.4% 6.8%

Maple Rochford 24 93.5% 19.7 22.4% 100.9% 93.8% 63.8% 100.0% 81.3% 49.3% 99.3% 6.4% 63.9% 0 0 0 6.4% 5.1%

Mayfield Rochford 24 45.0% 22.7 9.7% 93.8% 100.7% 96.5% 102.3% 100.0% 53.4% 101.7% 1.6% 88.9% 0 0 0 2.8% 0.0%

Meadowview Thurrock 24 108.9% 23.2 5.0% 100.9% 97.0% 96.6% 101.7% 90.5% 30.9% 97.0% 0.7% 66.7% 0 0 0 6.8% 0.1%

Mountnessing Ct Mountnessing 22 76.5% 23.5 15.4% 87.2% 105.4% 94.8% 103.4% 100.0% 40.2% 102.6% 2.7% 69.2% 0 0 0 10.9% 0.0%

Rawreth Court Rayleigh 35 62.1% 32.0 7.2% 87.7% 98.7% 100.0% 100.0% 97.1% 19.7% 119.9% 7.7% 89.1% 0 0 0 7.4% 0.0%

Poplar Adolescent Unit Rochford 13 105.0% 22.9 15.4% 100.0% 96.1% 100.0% 97.9% 94.7% 54.0% 103.2% 6.3% 27.9% 0 0 0 2.0% 0.0%

FORENSIC SERVICES

Alpine Brockfield 13 99.5% 18.6 12.3% 95.7% 105.7% 94.8% 101.5% 100.0% 47.7% 99.5% 0.0% - 0 0 0 5.1% 0.0%

Aurora Brockfield 12 108.3% 12.9 8.1% 101.7% 104.1% 103.4% 96.6% 91.7% 32.7% 95.0% 0.0% - 0 0 0 4.1% 0.0%

Causeway Brockfield 16 100.0% 23.8 3.8% 81.0% 103.2% 96.7% 101.0% 93.3% 44.2% 100.5% 2.6% 90.9% 0 0 0 23.7% 13.1%

Dune Brockfield 15 100.0% 18.2 4.8% 98.3% 99.1% 100.0% 100.0% 100.0% 23.9% 96.1% 0.6% 0.0% 0 0 0 2.8% 0.0%

Forest Brockfield 15 99.3% 15.9 9.5% 96.6% 109.4% 100.0% 98.3% 92.9% 32.6% 100.0% 0.0% - 0 0 0 14.6% 6.5%

Fuji Brockfield 12 96.8% 26.2 16.5% 99.2% 95.3% 93.1% 101.7% 87.5% 43.9% 104.0% 0.0% - 0 0 0 4.7% 0.0%

Lagoon Brockfield 15 98.6% 16.4 27.5% 93.1% 104.4% 98.3% 100.9% 92.9% 65.5% 99.7% 0.6% 0.0% 0 0 0 3.0% 0.0%

Robin Pinto Unit Luton 14 110.8% 18.9 5.5% 101.3% 101.4% 100.0% 100.0% 94.4% 21.6% 101.4% 0.6% 0.0% 0 0 0 17.1% 15.8%

Woodlea Clinic Bedford 8 125.0% 13.2 35.9% 100.0% 98.9% 100.0% 100.0% 90.0% 30.3% 96.9% 40.8% 97.7% 0 0 0 19.9% 15.2%

LEARNING DISABILITY SERVICES

Heath Close Billericay 7 153.1% 23.9 -9.2% 99.1% 92.9% 97.9% 100.0% 95.2% 62.0% 90.5% 3.3% 48.0% 0 0 0 11.4% 2.9%

COMMUNITY HEALTH SERVICESCumberlege IC Centre Rayleigh 22 99.2% 18.1 13.9% 95.7% 99.3% 100.0% 105.2% 95.5% 21.1% 19.2% 14.7% 8.7% 0 0 0 2.6% 0.0%

Avocet Saffron Walden 19 88.0% 0.0 1.4% 100.0% 99.4% 96.6% 94.6% 92.9% 0.8% 100.0% 11.3% 17.8% 0 0 0 3.4% 0.0%

Beech St Margarets

Epping12 90% 24.9 5.8% 100.0% 99.6% 100.0% 100.0% 85.7% 1.1% 0.0% 3.1% 0.0% 0 0 0 1.3% 0.0%

Plane St Margarets

Epping

22 90% 26.7 13.4% 100.0% 100.0% 100.0% 100.0% 84.0% 1.7% 0.0% 8.5% 0.0% 0 0 0 4.4% 0.0%

Poplar St Margarets

Epping

22 91% 27.7 2.7% 100.0% 100.0% 100.0% 100.0% 83.3% 2.2% 0.0% 7.2% 0.0% 0 0 0 17.3% 10.6%

The Archer Unit Bedford 20 91.2% 26.8 -18.8% 99.1% 99.6% 100.0% 100.0% 100.0% 0.6% 66.7% 14.9% 20.3% 0 0 0 7.8% 2.1%

TRUST INPATIENT

TOTAL562 90.3% 30.7 9.4% 95.9% 98.8% 94.6% 100.6% 0.0% 35.7% 96.6% 6.4% 57.3% 0 0 0 8.2% 3.5%

CAMHS SERVICES

February


6

Day Night

WARD NAME Location

NO OF

BEDS

OPEN

Occupancy

Rate

(including

leave days)

STAFF (WTE

Contracted)

Vacancy

Rate

FILL RATE

Registered

FILL RATE

Unregistered

FILL RATE

Registered

FILL RATE

Unregistered

% Appraised

in previous

12 months

% Bank Use

% Bank Staff

Used

Permanent

or Known

% Agency

Use

% Agency

Used Known

FALLS

Moderate &

Severe

PRESSURE

ULCERSHCAIs

Sickness

Rate

Long

Term

Sickness

Rate

TARGET: >90% >90% >90% >90%

ESSEX MENTAL HEALTH INPATIENT SERVICES

Basildon MHAU Basildon 20 101.8% 27.3 -19.6% 93.55% 104.1% 97.2% 103.0% 80.0% 36.4% 110.0% 2.7% 33.3% 0 0 0 7.6% 2.9%

Beech (Rochford) Rochford 24 99.2% 19.8 19.1% 96.1% 96.5% 88.7% 101.9% 78.6% 43.2% 82.1% 6.0% 62.9% 0 0 0 0.7% 0.0%

Cedar Ward Essex Rochford 24 113.3% 19.9 9.7% 94.0% 94.5% 89.7% 100.7% 100.0% 54.2% 95.8% 12.9% 74.4% 0 0 0 13.7% 10.2%

Clifton Lodge Westcliff 35 81.3% 29.0 18.4% 90.3% 100.7% 75.8% 105.1% 92.0% 50.6% 100.0% 8.5% 90.5% 0 0 0 7.1% 3.4%

Gloucester Basildon 25 130.3% 20.2 3.3% 98.0% 100.0% 100.0% 100.0% 88.2% 28.1% 89.1% 0.9% 650.0% 0 0 0 1.1% 0.0%

Grangewater Basildon 28 83.4% 23.1 2.8% 94.5% 107.1% 98.4% 102.6% 93.3% 43.6% 94.6% 10.4% 80.6% 0 0 0 10.3% 3.4%

Hadleigh Unit Basildon 20 112.6% 23.2 15.5% 96.8% 100.3% 93.5% 102.6% 87.5% 43.1% 114.1% 3.6% 87.0% 0 0 0 10.4% 7.8%

Maple Rochford 24 95.6% 19.7 22.4% 93.5% 99.1% 87.8% 100.9% 68.8% 55.1% 95.2% 5.4% 78.8% 0 0 0 10.3% 5.1%

Mayfield Rochford 24 49.9% 22.7 9.7% 96.7% 100.6% 91.7% 104.1% 100.0% 44.5% 98.9% 0.5% 100.0% 0 0 0 3.9% 0.0%

Meadowview Thurrock 24 118.5% 22.2 9.1% 100.8% 98.7% 98.3% 100.0% 94.7% 36.1% 103.5% 2.5% 16.7% 0 0 0 12.6% 8.4%

Mountnessing Ct Mountnessing 22 81.8% 23.5 15.4% 89.2% 99.3% 98.4% 100.0% 100.0% 40.5% 99.5% 3.1% 68.8% 0 0 0 9.9% 4.7%

Rawreth Court Rayleigh 35 43.1% 32.2 6.6% 90.3% 96.5% 100.0% 98.2% 97.1% 14.4% 86.4% 4.5% 36.0% 0 0 0 7.5% 2.4%

CAMHS SERVICES

Poplar Adolescent Unit Rochford 13 102.5% 21.9 19.1% 97.5% 101.7% 100.0% 100.0% 94.7% 50.9% 98.7% 7.7% 97.9% 0 0 0 2.1% 0.0%

FORENSIC SERVICES

Alpine Brockfield 13 86.6% 14.6 31.2% 98.4% 106.6% 98.3% 126.3% 100.0% 65.5% 101.7% 0.0% - 0 0 0 6.0% 0.0%

Aurora Brockfield 12 108.3% 11.9 15.3% 103.2% 102.2% 100.0% 108.1% 91.7% 37.1% 100.0% 0.4% 100.0% 0 0 0 11.1% 0.0%

Causeway Brockfield 16 92.3% 19.5 21.2% 88.2% 99.5% 102.9% 105.0% 93.8% 42.7% 99.5% 1.1% 40.0% 0 0 0 17.2% 4.5%

Dune Brockfield 15 96.6% 18.2 4.8% 99.2% 96.0% 100.0% 100.0% 100.0% 23.6% 97.5% 0.0% - 0 0 0 11.2% 5.5%

Forest Brockfield 15 97.6% 16.1 8.4% 97.6% 106.2% 100.0% 98.4% 93.3% 29.8% 98.8% 0.4% 0.0% 0 0 0 7.9% 6.4%

Fuji Brockfield 12 105.1% 24.7 21.3% 97.6% 99.2% 96.8% 100.7% 86.7% 41.5% 101.2% 0.2% 0.0% 0 0 0 4.2% 0.9%

Lagoon Brockfield 15 98.7% 17.4 23.1% 97.6% 105.6% 98.4% 122.3% 85.7% 56.5% 100.0% 0.2% 100.0% 0 0 0 0.2% 0.0%

Robin Pinto Unit Luton 14 112.7% 20.9 -4.5% 102.4% 100.0% 100.0% 100.0% 94.7% 29.1% 93.0% 33.2% 92.6% 0 0 0 17.9% 14.2%

Woodlea Clinic Bedford 8 125.0% 13.2 35.9% 100.0% 99.4% 105.7% 96.7% 81.8% 24.1% 98.9% 0.5% 100.0% 0 0 0 16.9% 15.2%

LEARNING DISABILITY SERVICES

Heath Close Billericay 7 174.7% 22.3 -1.9% 100.0% 93.8% 108.8% 103.2% 95.2% 41.9% 86.6% 1.3% 42.9% 0 0 0 12.9% 9.9%

COMMUNITY HEALTH SERVICES

Cumberlege IC Centre Rayleigh 22 98.5% 24.9 13.9% 96.0% 100.0% 100.0% 101.6% 95.5% 18.0% 30.2% 13.8% 13.6% 0 0 0 2.5% 0.0%

Avocet Saffron Walden 19 88.0% 27.2 -0.4% 103.1% 97.4% 101.6% 87.1% 93.1% 0.5% 100.0% 9.0% 41.0% 0 0 0 1.5% 1.5%

Beech (St Margarets) St Margarets Epping 12 91.0% 28.9 1.7% 100.0% 100.0% 100.0% 100.0% 86.4% 1.2% 0.0% 3.6% 0.0% 0 0 0 3.6% 0.0%

Plane St Margarets Epping 22 90.0% 26.8 13.4% 98.4% 100.0% 100.0% 100.0% 80.0% 0.2% 0.0% 6.3% 0.0% 0 0 0 4.9% 0.0%

Poplar St Margarets Epping 22 91.0% 30.1 4.8% 98.4% 99.6% 100.0% 100.0% 84.0% 1.6% 0.0% 11.2% 0.0% 0 0 0 15.0% 8.7%

The Archer Unit Bedford 20 104.8% 37.2 -19.1% 100.0% 100.0% 100.0% 100.0% 100.0% 0.2% 100.0% 7.8% 38.5% 0 0 0 4.1% 0.1%

TRUST INPATIENT

TOTAL562 78.5% 658.5 13.2% 96.7% 99.9% 96.8% 102.9% 91.1% 35.1% 96.8% 5.3% 61.8% 4 0 0 7.8% 3.7%

January


7

4.0 HOTSPOTS

The dashboard above shows that the majority of wards in Learning Disability, Secure Services and Community Health Services are above 95%. As discussed in previous months, a recruitment campaign is continuous and being monitored through a number of workstreams. Last month two wards were identified as hot spots (Clifton and Avocet), whilst 4 were emerging risks (Maple, Beech, Mountnessing and Causeway). One ward has remained as a hotspot for second registered on night shifts:-

Clifton Lodge (second qualified for night shift)

Two wards identified as an emerging risk last month have moved to hot spot:-

Maple (second qualified for night shift)

Causeway ( influenza outbreak with staff sickness) One ward has remained as potential emerging risk:-

Mountnessing Two further wards have been identified as potential emerging risk:-

Cedar

Rawreth During this time on the wards whilst recruitment is ongoing, site managers are being utilised to support wards alongside the ward managers and matrons to ensure the wards are safe as discussed through the monitoring at the twice daily teleconference calls and SitRep. A local

recruitment drive in the Southend area is being taken forward to see if this can help with Clifton Lodge. This information is also being triangulated with the Quality Dashboard and CQC compliance information. Three wards have been identified through the CQC compliance as hotspots

Maple

Hadleigh

Grangewaters Only one ward is reflected in both areas – Maple where we are aware that the dependency of patients has increased and further work is being taken forward to support the ward. Grangewaters, whilst not being highlighted as a potential hot spot for planned and actual staffing further work is in progress with operational staff to look patient dependency and required staffing numbers. Within all the other wards

highlighted as hotspots, there have been no significant concerns in regards to the safety and quality of care on the ward when reviewing clinical incidents and safeguarding reports.

5.0 RECOMMENDATIONS

It is recommended that the Board of Directors:

1. Note the contents of this report 2. Identify any further work required to be taken forward.

6.0 ACTION REQUIRED

The Board of Directors is asked to:

1. Approve report


8

Report prepared by Sarah Browne Deputy Director of Nursing

On behalf of

Andy Brogan Executive Director of Mental Health and Executive Nurse

1

Agenda Item No: 6a

SUMMARY REPORT

BOARD OF DIRECTORS 30th March 2016

Report title: Board Assurance Framework 2015-16 Update Report

Executive Lead: Nigel Leonard Executive Director of Corporate Governance

Report Author(s): Joanne Sims Head of Assurance

Report discussed previously at: Executive Operational Sub Committee on the 22nd March 2015.

Level of Assurance: Different levels of assurance apply to each risk on the 2015-16 Board Assurance Framework (BAF). Internal Audit provided full assurance in respect of the controls in place as a result of its review of the Assurance and Risk Management arrangements undertaken in March 2016.

Level 1

2

3


This report presents the Board of Directors with the Board Assurance Framework 2015 –16 as at the 22nd March 2016 for discussion, update and approval.

Approval

Discussion

Information


1. Review and approve the Board Assurance Framework as at 22nd March 2016 detailed at

appendix 1 and identify any further updates and / or changes required.

2. Agree recommendations made by the Executive Operational Sub Committee and the

Chief Executive Officer (CEO) as detailed in table 1.

3. Note the review of the 2015-16 Corporate Risk Register (CRR) risks as at the 22nd March 2016.

4. Note the positive assurance provided by the Internal Audit review of the Assurance

Framework and Risk Management arrangements. 5. Identify new potential risks to be escalated to the CRR or BAF.


Updates to the Board Assurance Framework received as at 22nd March 2016 are detailed in Table 1.

Action plans for supporting the risks detailed on the BAF were approved by the EOSC on the 22nd March 2016.

The EOSC received and approved the Corporate Risk Register on the 22nd March 2016.

2

The annual Internal Audit review of the Assurance Framework and Risk Management arrangements was completed in March 2016; Full Assurance on the controls in place was provided.







Yes


All risks identified on the BAF.


No



Data Quality Issues









No If yes, EIA Score



CRR Corporate risk register

BAF Board Assurance Framework

EOSC Executive Operational Subcommittee



Appendix 1 The Board Assurance Framework 2015-16 as at the 22nd March 2016

Executive Lead

Nigel Leonard Executive Director of Corporate Governance

1

Agenda item 6a Board of Directors Meeting

30th March 2016

SEPT

BOARD ASSURANCE FRAMEWORK 2015-16 UPDATE REPORT

PURPOSE OF THE REPORT

This report presents the Board of Directors with the Board Assurance Framework 2015-16 as at the 22nd March 2016 for discussion, update and approval.

MARCH 2016 UPDATE

1. Introduction The Board Assurance Framework provides a comprehensive method for the effective management of the potential risks that may prevent achievement of the key aims agreed by the Board of Directors. The Board Assurance Framework (BAF) 2015-16 was last reviewed by the Board of Directors on the 24th February 2016 and the Executive Operational Subcommittee (EOSC) on the 22nd March 2016. Updates and recommendations from the EOSC, Executive Directors, Directors, and Senior Managers to the March 2016 Board Assurance Framework are summarised in Table 1 as at the 22nd March 2016. The Board Assurance Framework as at 22nd March 2016 is attached in full at Appendix 1 for review, challenge and approval. Table 1 – BAF Overview at the 22nd March 2016

No. Real Risk Exec Lead

Overview Update Risk scoring status

Aim 1 Safe Care

R1 If learning from incidents is not embedded quality and patient safety may not be maintained or improved. The Francis report has re-emphasised the risk to patient safety if learning from SI's are not implemented.

MMc, AB

Reviewed by the Deputy Director of Nursing and Head of Organisational Resilience and Business Continuity (11/3/16). All actions on the BAF action plan are rated green.

Current risk scoring 4 x 3 = 12 Risk scoring remains unchanged.

R2 If care is not clearly documented detailing person centred care in line with risk and needs assessments this may impact on the identification of individual clinical need and a high quality of outcome may not be achieved.

AB , MMc

Reviewed by the Deputy Director of Nursing and Head of Organisational Resilience and Business Continuity (11/3/16) and Head of Compliance (15/3/16). CQC actions and timescales agreed and presented to the Quality Committee January 16.

Current risk scoring 4 x 3 =12 Risk scoring remains unchanged.

2



R3 If services fall short of the standards required to remain compliant with the Health and Social Care Act there is the potential for CQC enforcement action or in extreme cases closure of services.

NL Reviewed by the Director of Compliance and Assurance. BAF Action plan updated 15/3/16. Work continues to implement learning workstreams. CQC actions and timescales agreed and presented to the Quality Committee January 16. Review of internal compliance system complete and programme for 2016/17 agreed by the Executive Team.

Current risk scoring 4 x 3 =12 Risk scoring remains unchanged

R4 If record keeping standards are not in line with Trust policy quality of care may be compromised.

MMc, AB

Reviewed by the Deputy Director of Nursing and Head of Organisational Resilience and Business Continuity (11/3/16) and Head of Compliance (15/3/16). CQC actions and timescales agreed and presented to the Quality Committee January 16.

Current risk scoring 4 x 4 = 16 Risk scoring remains unchanged

Aim 5 Right Staff, Right Skills, Right Place

R7 If there is a high reliance on Bank and Agency staff as a result of vacancies and sickness this will impact on the quality and continuity of SEPT services

NL Reviewed by Assistant Director of Human Resources (9/3/16). Actions continue to be implemented in line with the BAF action plan. 19 areas rated green on the BAF action plan, 1 area remains amber. Sickness advisors in post to support line managers in addressing absences across the Trust. Full centralisation of bank/agency bookings from the 1st April 2016. SLAs in place with agencies to ensure workers engaged have full pre-employment checks and training requirements.

Current risk scoring 4 x 4 =16 Risk scoring remains unchanged

Aim 7 Financially Sound

R10 30% slippage on a £12.3 million CIP programme anticipated.

MM Reviewed by the Deputy Chief Finance Officer (17/3/16). Little additional opportunity for the rest of year and focus is now on 16/17. Additional resource brought in for 3 months to

Current risk scoring 4 x 4 = 16 Risk scoring remains unchanged

3



support CIP programme.

Aim 8 Clear Strategy for Securing Our Success

R13 NEP / SEPT Merger - As a result of regulatory actions or Governors failing to approve the merger proposal there is a risk that the merger will not be completed by April 2017, resulting in the benefits identified in the merger proposal (clinical and patient benefits, commissioner benefits and financial benefits) not being delivered.

NL Reviewed by the interim project manager. (17/3/16). BAF action plan developed. Risk to be reassessed by the board following feedback from Monitor due March 16 with the potential to change the risk description and mitigating actions.

Current risk scoring 4 x 3 =12 New risk approved for escalation by the Board of Directors February 16.

Priority 4 – Innovation and transformation

R12 If the scale, scope and speed associated with delivering the Trust’s Transformation programme is not managed appropriately there may be an impact on the quality of existing service provision and the Trust financial position.

MM Reviewed by the Head of Business Transformation (15/3/15). Action plans continue to be implemented. However 9 areas rated red, 1 area rated amber and 4 areas rated green.

Current risk rating 5 x 4 = 20 Risk scoring remains unchanged

2. Corporate Risk Register (CRR) One new risk has been escalated to the Corporate Risk Register following discussion at the Finance and Performance Committee in February 2016 and risk assessment undertaken by the Director of Compliance and Assurance as follows;

If additional funding (new or transfer from existing services) is not identified the Trust

may not be able to meet the new targets for early intervention in psychosis.

Negotiations are underway with commissioners as part of 16/17 contract negotiations.

Potential to identify sliding scale of investment to deliver 50% target (16/17 requirement) is

being considered.

The EOSC last received and considered the CRR in full on the 22nd March 2016 agreed to close the following three risks:

If landlords of leased properties do not provide assurance that fire risk assessments have been completed, the trust may breach fire safety requirements, leaving staff and patients at risk and the trust may not be compliant with the trusts own policy.

If the trust does not have business continuity systems in place to manage the impact of any potential industrial action by junior doctors safe care may not be delivered to service users.

There is a financial and reputational risk if the trust is unable to maximise the chance of achievement of the Trusts 2015/16 CQUIN Indicators.

4

3. Directorate risk registers Directorate risk registers have now been reviewed against all corporate aims and directorate objectives for 2015-16. 4. Hot spots from the Quality and Performance Report The Finance and Performance Committee considered the hotspots identified within the February 2016 Quality and Performance Report on the 23rd March 2016. No hotspots were identified for escalation to the BAF or CRR. 5. Internal Audit Review of the Board Assurance Framework and Risk

Management Arrangements Internal Audit undertook the annual review of the BAF and Risk Management arrangements during March 2016. The final report has now been received providing Full Assurance on the controls in place. No recommendations for improvement were made. The Risk Management and Assurance Framework is now undergoing its annual review and will be updated to include a number of new key developments to strengthen existing arrangements. Feedback received from the January 16 Finance and Performance Committee meeting will also be incorporated. Potential new developments include:

Review of escalation thresholds to the BAF and CRR

Potential to define the trusts risk appetite for service redesign and new business opportunities

Updating the risk assessment template

RECOMMENDATIONS

The Board of Directors is recommended to: 1. Review and approve the Board Assurance Framework as at 22nd March 2016 detailed at

appendix 1 and identify any further updates and / or changes required.

2. Agree recommendations made by Executive Operational Sub Committee and the Chief

Executive Officer (CEO) as detailed in table 1.

3. Note the review of the 2015-16 Corporate Risk Register (CRR) risks as at the 22nd March

2016.

4. Note the positive assurance provided by the Internal Audit review of the Assurance

Framework and Risk Management arrangements.

5. Identify new potential risks to be escalated to the CRR or BAF.

Prepared by: Joanne Sims, Head of Assurance On behalf of: Nigel Leonard, Executive Director of Corporate Governance

APPENDIX 1 Appendix 1 - Agenda Item Board of Directors Meeting March 16

Links to -

I L RR I L RR Q1 Q2 Q3 Q4 I L RR

Gap in

Control

Assurance Gap in

Assurance

Date

reviewed

Risk

Category

Lead Directorate

Objective/

High Level

Actions/

Source

ControlInitial

Risk

Rating

Current

Risk Score

Direction of risk Post

Mitigation

target risk

scoring

Potential Risk Is the level of

risk

acceptable post

mitigation ?

SEPT Board Assurance Framework 2015-16 At March 16

Assumption

Strategic Priority 1: Quality Services

The NHS is the only healthcare system in the world with a definition of quality enshrined in legislation. An organisation delivering high quality care will be offering care that is clinically effective, safe and delivering as positive experience as possible for patients. We believe that SEPT is

such an organisation; our main driver is to improve the health of the communities that we serve. We are realistic that less funding may mean that some of our high standards may have to be re-defined to be affordable but we are absolutely certain that we will not compromise safety as a

result.

Aim 1 : Safe care

Lead Director Executive Director of Clinical Governance & Quality

Medical Director

Corporate Governance Statement, CQC Quality and Safety

Standards, Quality Governance Framework , Annual

Governance Statement . Operational Plan

Mitigating actions Target

Comp

Date

↔4 ↓↔↔4Carried forward

from the BAF

14-15

REF-

BAF13060607

Learning from SI's will continue to

inform Patient Safety Work streams

and Quality Improvement Programme.

Process for escalation point for carers

agreed and launched. Internal and

external review of serious incidents to

identify trends and themes and learning

across the Trust. Learning summary

on Intranet for all staff to access,

however the profile needs to be raised

with regular updates in Trust Today &

Weekly briefs. Lessons Learnt element

to be reviewed every 3 months as a

minimum or as new learning is

identified. SI Team & Consultant Nurse

to run regular audits to ensure learning

embedded following completion of

action plan.

Trends & Themes to be reviewed by

Risk Team / Clinical Gov and included

within Datix once Datix upgrade

completed at end of Oct. Change in

target completion date to end of Nov to

reflect Datix upgrade. Datix upgrade

now complete as at end of Nov and

trends & Themes to be reported

through Clinical Governance

Committee.

The Trust will

ensure learning

from serious

incidents is

embedded and

facilitates

improvements in

quality and safety

If learning from

incidents is not

embedded quality

and patient safety

may not be

maintained or

improved. The

Francis report has

re-emphasised the

risk to patient safety

if learning from SI's

are not

implemented.

Patient

Safety

Reputation

Compliance

Andy

Brogan /

Malcolm

McCann

SI reporting and

learning reports

presented to

relevant Groups

and Committees

in line with

clinical

governance

processes.

Quality report

presented to

Board, Quality

Committee &

Clinical

Governance

Committee.

Review of

Suicides

(including

benchmarking

information

undertaken and

action plans

developed.

Evidence of

implementation

of SI learning

held in SI office

provided by

Ops.Following

the completion

of 3 independent

reviews no

common themes

have been

identified.

Analysis of SI’s

from April

onwards

undertaken by

the Medical

Director looking

at clinical care.

Completion of

actions plans

developed from

2 reviews

commissioned

to take

recommendatio

ns forward

Mar-16Jul-15 4 2 8 Risk will be

required to be

monitored on an

on going basis.

Recommendation

to increase risk

scoring at Feb 15

due to the rise in

SIs agreed ,

increase of

current risk

scoring from 12 to

16 . Discussed by

EOSC Dec 15

recommendation

to be made to the

Board of Directors

to reduce risk

scoring to 4 x 3

=12. Risk remains

on the BAF.

SI reporting and learning

reports presented to

relevant Groups and

Committees in accordance

with clinical governance

processes. Assurance

report presented to Board,

Quality Committee &

Clinical Gov Committee.

Template developed for

cascade learning to be

rolled out. Clinical Risk

training. Incident

Reporting Policy and

Procedure. Learning

Lessons Oversight

Committee established

and terms of reference

agreed. Each SI

investigation and report

demonstrates RCA

methodology. Robust

process in place for

sharing learning with team

and wider trust including ,

Learning Lessons Review

Group (LLRG) reviewed,

staff learning events,

audits arising from SI

recommendations.

Reflections to take place

after significant issues as

part of any rapid response

process. Quality Strategy

and implementation plan.

Sign up for Safety. Safety

Thermometer

No gaps currently

identified. All

actions rated

green on BAF

action plan

123416

March 16 1



Care planning and

delivery of care will

be personalised

and centred

around the patient

If care is not clearly

documented

detailing person

centred care in line

with risk and needs

assessments this

may impact on the

identification of

individual clinical

need and a high

quality of outcome

may not be

achieved

Patient

Safety

Compliance

Andy

Brogan /

Malcolm

McCann

4 3 12 4 3 12 ↔ ↔ ↔ ↔ Re review of Trust CPA policy and

undertaken and approved.

Record keeping identified as a learning

stream and will be monitored by Care

Planning Advisory Group.

Development of sustainable care

planning training programme to be

undertaken. Training to be reviewed

and to include any further learning from

CQC feedback and changes to

electronic record system.

Project started to review different audit

tools used and develop one universal /

set of core questions for all tools.

Drafted new standard audit tools. Tools

being trialled .

Once tools agreed, system will be

developed. Training being reviewed,

but need to include any further learning

from CQC feedback and changes to

electronic record system

Mar-16 4 1 4 Risk will be

required to be

monitored on an

on going basis

Care planning advisory

group. Principles of

personalised care

planning in place and

circulated to inpatient

(face to face session) and

community teams.

Effectiveness monitored

by range of committees.

Care Planning Advisory

Group now taking forward

care planning and record

keeping.

Internal compliance

checks for monitoring

quality. Clinical Audit

programme in place. Spot

checks undertaken as part

of supervision.

Complaints reviewed and

monitored in relation to

personalised care and

actioned. Care planning /

Quality of Records BAF

risk action plan.

Areas

outstanding on

the associate

Joint Learning

from CQC

inspection to be

fully implemented

Reporting to CG

Committee and

SMTs.

MDT

implemented in

all Essex

inpatient wards.

Peer reviews

undertaken

within

Bedfordshire

CHS. Care

planning

advisory group.

Quality

Committee

approved CQC

action plans

January 2016.

Areas

outstanding on

the associate

BAF risk action

plan . Learning

from CQC

inspection to

fully

implemented

Mar-16Carried forward

from the BAF

14-15

REF-

BAF13062001

Initial

Risk

Rating

Is the level of

risk

acceptable post

mitigation ?

Directorate

Objective/

High Level

Actions/

Source

Assumption Potential Risk Risk

Category

Lead Gap in

Control

Current

Risk Score


Comp

Date

Post

Mitigation

target risk

scoring

Assurance Gap in

Assurance

Date

reviewed

Direction of risk Control

March 16 2



The trust will

remain compliant

with the CQC

standards in all

services at all

times

If services fall short

of the standards

required to remain

compliant with the

Health and Social

Care Act there is

the potential for

CQC enforcement

action or in extreme

cases closure of

services. (risk ref

BAF14033001)

Safety

Compliance

Reputation

Nigel

Leonard

4 3 12 4 3 12 ↔ ↔ ↔ ↔ Participation in all CQC consultations.

Development of local portfolios for all

wards / teams and uploaded to the

intranet.

• Reflection workshops held for all

operational services and learning

opportunities identified which have

been shared with executive directors to

take forward as appropriate.

• Action required mapped to task and

finish group workplans and refreshed

following receipt of final report.

Changes to some task and finish group

titles and remits required and

establishment of new task and finish

groups

Individual Core Service Action Plans

developed linked to CQC task and

finish groups to ensure operational

ownership of actions as well as

trustwide consistent response.

Mar-16 4 2 8 • Compliance team

intelligence monitoring

programme

• MHA spot checking

programme.

• MHA intelligence system

• MHA hospital managers

undertake reviews of

section reviews.

MH and Safeguarding

Standing Committee

established

• Quality committee

established includes

responsibility for CQC

compliance. CQC

Comprehensive inspection

undertaken and

responded to.

Action plan developed

and submitted to CQC

following inspection.

Learning workstreams

identified and supported

by a range of specialist

task and finish groups.

Internal CQC compliance

systems agreed by EOSC.

Review of internal

Areas identified

for action

following CQC

MHA visits. CQC

and BAF action

plans being

implemented but

not fully

completed at this

stage. BAF risk

action plan - 10

areas rated

green, 10 areas

rated amber and

ongoing.

Final Report

received from

CQC providing

positive

assurance - trust

overall rating

GOOD. Internal

Audit review of

CQC process 13-

14 full

assurance. An

extraordinary

meeting has

taken place of

the Mental

Health Act and

Safeguarding

Committee to

agree the

actions

developed

following 5 CQC

MHA visit

reports.

Action plan

following CQC

inspection in

2014 closed

internally but

not yet closed

by CQC re

Bedford Prison.

CQC are

undertaking a

table top

review.

Individual core

action plans to

be audited

internally June

16

Mar-16

Directorate

Objective/

High Level

Actions/

Source


Category

Lead Initial

Risk

Rating

Date

reviewed

Current

Risk Score

Direction of risk Mitigating actions Target

Comp

Date

Post

Mitigation

target risk

Is the level of

risk

acceptable post

mitigation ?

Control Gap in

Control

Assurance Gap in

Assurance

Identified from

the Operational

plan and

carried forward

from the BAF

14-15

REF -

BAF14033001

March 16 3



Care planning advisory

group in place reporting to

Clinical Governance

Group

• Records management

policy and procedures /

Staff should be operating

under professional

standards.

Record keeping identified

as a learning stream

following CQC Inspection

and will be monitored by

Care Planning Advisory

Group

• Internal CQC spot

checks.

•Quality of Records / CPA

BAF action plan.

•Areas of learning from SI

investigations taken

forward.

Clinical Audits reported

through Clinical

Governance routes and

SMTs

No - This remains

a priority for the

Trust .

Recommendation

made to increase

risk scoring to

4 x 4 =16 to

reflect recent

CQC MH Act

visits and recent

and internal

compliance visits

June 15.

12

Gap in

Control

Assurance

Areas

outstanding on

the associate

Joint BAF risk

action plan - 4

areas rated

green, 6 areas

remain open due

for completion

March and July

16, Learning

from CQC

inspection to be

fully implemented

Date

reviewed

Current

Risk Score

ControlAssumption Potential Risk Risk

Category


Comp

Date

Post

Mitigation

target risk

scoring

Lead Is the level of

risk

acceptable post

mitigation ?

3↔

Directorate

Objective/

High Level

Actions/

Source

Initial

Risk

Rating

Identified from

the Operational

plan and

carried forward

from the 14-15

BAF

REF -

BAF14033003

Records are

maintained in line

with Trust Policy

and procedure

Gap in

Assurance

16 ↑ Mar-16Trends

identified from

SI analysis.

CQC

Inspection

Basildon MHU -

Moderate

concern. CQC

MH Act visits

and recent and

internal

compliance

visits identified

gap in

assurance.

Internal Audits

scopes to

request focus on

records where

possible. Care

Planning

Advisory Group

oversee

monitoring. CQC

actions and

timescales

approved by the

Quality

Committee.

If record keeping

standards are not in

line with Trust

policy quality of

care may be

compromised;

Safety

Compliance

Andy

Brogan /

Malcolm

McCann

4 ↔ ↔ • Spot checks undertaken by ward

managers as part of supervision

• Continued drive to deliver

improvements through supervision and

staff bulletin.

•Learning from CQC Inspection to be

actioned and implemented. Record

keeping identified as a learning stream

and will be monitored by care planning

advisory group.

Enhanced . Drafted new standard audit

tools.

Tools being trialled .

Once tools agreed, system will be

developed

Mar-16 43 12 4 4

March 16 4


Links to -


Substantive posts

are recruited too

If there is a high

reliance on Bank

and Agency staff as

a result of

vacancies and

sickness this will

impact on the

quality and

continuity of SEPT

services

Safety

Compliance

Reputation

Nigel

Leonard

4 3 12 4 4 16 ↑ ↔ ↔ Full revision of vacancies and

recruitment drive within all Operational

areas, which includes national

advertising, attendance at University

Recruitment Fairs, open-ended

adverts. Sickness workshops in place

to consider means of reducing sickness

rates. Meetings arranged to discuss

and identify on-going recruitment

initiatives and ways to attract staff to

the Trust . Additional HR resource

identified to concentrate on hard to fill

vacancies and actions being taken

forward include recruitment and

induction mandatory workshops,

candidate packs, feedback

questionnaires for new starters.

Sickness workshops to consider means

of reducing sickness - E learning

module on OLM for managers. Areas of

concern being identified and sessions

to be provided to managers.

Develop and implement Service Level

Agreements with the specified

approved agencies for Nursing staff

that have been selected.

July 2015

and On-

going

4 2 8 Sickness reports to Board,

ET & Directorate SMTs.

OLM training for

managers.

Sickness Absence Polices

and procedures.

Recruitment and retention

Policies and Procedures.

Analysis to be undertaken

of staff anticipated to retire

and proactive recruitment

to take place against

identified numbers. The

trust has increased the

number of support workers

on the bank by 50+

workers. Recruitment and

operational services

attended ARU recruitment

fair on 7th September with

the intention to recruit 2nd

year students for posts

with the Trust in

September 2016.

Sickness Advisors in post

to support Line Managers

in addressing absences

across the Trust

Full Centralisation of

Hotspots

identified in Safer

Staffing Reports.

Recruitment

initiatives

continue as per

the BAF Risk

action plan. 1

areas remain as

rated amber on

the BAF action

plan. 19 areas

rated green on

BAF action plan

Sickness and

Bank & Agency

levels reports

presented to

relevant Groups

and Committees

in accordance

with HR

processes.

Assurance

report presented

to Board, ET &

Quality group. •

Trust has been

successful in

filling a majority

of its Nursing

vacancies as per

the BAF action

plan

Hotspots

identified in

Safer Staffing

Reports.

Recruitment

initiatives

continue as per

the BAF Risk

action plan.

Some key

posts remain

challenging to

recruit too.

Mar-16↔

AssuranceLead Post

Mitigation

target risk

scoring

Target

Comp

Date

Gap in

Assurance

Directorate

Objective/

High Level

Actions/

Source


Category

Control Gap in

Control

Initial

Risk

Rating

Current

Risk Score

Direction of risk Mitigating actions Is the level of

risk

acceptable post

mitigation ?

Date

reviewed

Identified Mar

15 Board

development

Session new

Quality Risk

REF -

BAF15042102

Strategic Priority 2: Quality Leadership and Workforce

We will only be able to achieve our strategic vision if we have the best staff and an organisational culture that supports staff in delivering the best quality services. Excellent leadership at all levels, clinically and managerially is key to delivering the other three strategic priorities. It’s not

just about the numbers of staff and the competencies they have; we want our staff to have shared values and belief systems that engender trust from our patients and their carers.

Aim 5 : Right staff, Right skills, Right Place

Lead Director Executive Director of Clinical Governance and Quality Corporate Governance Statement, CQC Quality and Safety


Governance Statement

March 16 5


March 16 6


March 16 7


Links to -


Category

Lead Mitigating actions Target

Comp

Date

Control Gap in

Control

Assurance Gap in

Assurance

Date

reviewed


The Trust CIP

programme of

identified schemes

is delivered in full

across the

planning period

and the year-on-

year financial plan

is to breakeven,

maintaining a

minimum

Continuity of

Service Risk

Rating of 3.

30% slippage on a

£12.3 million CIP

programme

anticipated.

Finance Mark

Madden

4 4 16 4 4 16 ↔ ↔ ↔ ↔ Implementation of the Financial Plan

and potential to review each quarter

with updates and

recommendations/revisions if required.

All Executive Directors have been

asked to update and refresh CIP plans

to identify new savings opportunities

(ongoing process). Little additional

opportunity for rest of year and focus is

now on 16/17.Additional resource

brought in for 3 months to support CIP

programme

Mar-16 4 2 8 Financial Plan and

monitoring arrangements.

CIP programme and

plans. PMO . Updated

plans for mental health

services identified which

now need to be worked up

into detailed plans.

Financial Plan

does not identify

schemes for full

value of CIP,

residual gaps still

exist, subject to

further review.

There is a

widening gap in

terms of MH

inpatient CIPs

and no plan for

delivery agreed

Reporting to ET

and Finance

and

Performance

Committee.

Hotspots

reported to

Board.

QIAs are not

100%

complete.

£3.3m deficit

anticipated at

year end is an

improvement

from

M10.Recurrent

deficit remains

at £4.5m

Mar-16

Post

Mitigation

target risk

scoring

Directorate

Objective/

High Level

Actions/

Source

Initial Risk

Rating

Financial plan

15-16

REF -

BAF15042103

Direction of risk Is the level of

risk

acceptable post

mitigation ?

Current

Risk Score

Lead Director Corporate Governance Statement, CQC Quality and Safety



Strategic Priority 3: Sustainability of Service Provision

We want SEPT to be a provider of health and social care services going forward and therefore ensuring that we remain viable is a key priority. However, we recognise that sustainability of strong health and social care economies is as important and therefore our strategy will be

developed and delivered in partnership with our CCG and local authority colleagues and will prioritise the benefits to patients not organisations.

Aim 7 : Financially sound

Chief Finance Officer

March 16 8



The trust will be

able to deliver the

transformation

programme

If the scale, scope

and speed

associated with

delivering the

Trust’s

Transformation

programme is not

managed

appropriately there

may be an impact

on the quality of

existing service

provision and the

Trusts financial

position.

Safety

Finance

Reputation

Compliance

Mark

Madden

and all

Executive

Directors

5 4 20 5 4 20 ↔ ↔ ↔ ↔ Most programmes properly scoped,

supported and managed. Investment

to be made available to ensure delivery

. QIAs have been requested from all

Executive Directors for all schemes.

Workshops have been held to revise

the estates rationalisation plan and this

will now be presented to ET as a matter

of urgency. Current transformational

schemes recurrent FY deliver only

£4.2m against £9.45m target.

Mar-16 5 2 10 PMO established.

Executive Director lead

and operational project

lead for each scheme in

place, with PMO support.

Transformation Steering

Group (TSG) meetings

held monthly. Terms of

Reference reviewed

earlier in 2015/16. All

Executive Directors are

invited and expected to

attend and provide

updates on relevant

projects within each

programme. Meetings are

now chaired by the Chief

Executive to emphasise

the importance of

monitoring the delivery of

the Transformation

Programme. Minutes and

an action log are taken /

updated at each meeting

and circulated to allow

people time to undertake

any relevant actions prior

to the deadline.

Plans not

currently fully

scoped and

implemented.

BAF action plan

in place, 9 areas

rated red, 1 areas

rated amber and

4 areas rated

green. Current

transformational

schemes

recurrent FY

deliver only

£4.2m against

£9.45m target.

Quarterly

reporting to

Finance and

Performance

Report.

Transitional

Steering Group

monitoring.

Plans not

currently fully

scoped and

implemented.

Major gap in

inpatient

mental health

transformation

programme.

Estates

rationalisation

and reduced

savings on

workforce

redesign not

abating.

Mar-16

Links to -


No gaps

currently

identified but

note that much

of the external

engagement

work only starts

in April 2016.

Mar-162 8 Given the

complexity and

scale of this

transaction a

rating of 8 is

acceptable

Project plan monitored by

proposed Project Board;

regular reports to

Executive Management

Teams, Board of Directors

and Council of Governors;

FBC has to be signed off

by independent external

opinion and by Medical

Directors regarding

benefits plan, financial

status and clinical quality;

external regulatory

oversight of the whole

transaction is the single

biggest control - Monitor

will assess the FBC and

give the transaction a risk

rating and this will inform

the vote of the Governors;

newly merged

organisation will be

authorised and licenced by

Monitor and the Care

Quality Commission as all

other NHS Foundation

Trusts are.

No gaps currently

identified but

note that some

controls for

delivering the

project such as

procurement of

external support

has not yet

commenced and

will not be in

place until mid

May.

Monitoring

through

proposed

Project Board,

Exec Teams,

Board and

Governor

meetings.

Additional

scrutiny

provided by

Investment

Committee that

receives an

update on

project progress

at each meeting;

additional

meetings

scheduled

where needed.

External

independent

reviews as part

of the FBC.

Engagement

with HOSC,

healthwatch and

other key

stakeholders

↔ i. Regulatory risk: Monitor reviewed

the Strategic Options Case and made

suggestions for further work at Outline

Business Case (OBC) stage; OBC

submitted to Monitor on 08.01.16 and

review being undertaken throughout

Feb 2016 - this will lead to analysis of

strengths and weaknesses of business

case that need to be addressed in the

Full Business Case to secure an

acceptable transaction risk rating.

17.03.16 - OBC review completed; no

material issues identified by Monitor but

a number of areas to focus on including

due diligence exercise, organisational

development and continuing current

service delivery. Governance of

merger project has been reviewed and

reflected in Heads of Agreement

proposed to both Trust Board of

Directors in March 2016. Creation of

Project Board to take over merger

work; disband Strategic Alliance

Working Group.

ii. Regulatory risk: Monitor have

received competition analysis from

Trusts and are reviewing this as to

whether a referral to the CMA is

Apr-16 44 20 4 3 1230 January

2016 Board

Meeting

BAF16032401

The merger

proposal is

approved by the

CMA and Monitor

as regulatory

bodies, has

necessary

stakeholder

support and is

approved by a

majority vote of

both Council of

Governors

As a result of

regulatory actions

or Governors failing

to approve the

merger proposal

there is a risk that

the merger will not

be completed by

April 2017, or at all,

resulting in the

benefits identified in

the merger

proposal (clinical

and patient

benefits,

commissioner

benefits and

financial benefits)

not being delivered.

Patient

Safety

Reputation

Compliance

Nigel

Leonard

5

Assurance Gap in

Assurance

Post

Mitigation

target risk

scoring

Directorate

Objective/

High Level

Actions/

Source

Assumption Potential Risk

Reassessed for

15-16

REF-

BAF15042105

ControlRisk

Category

Lead Initial

Risk

Rating

Current

Risk Score

Is the level of

risk

acceptable post

mitigation ?

Gap in

Control

Gap in

Assurance

Date

reviewed


Comp

Date

Control Gap in

Control

Assurance

Aim 8 Clear Strategy for Securing Our Success

Lead Director Executive Director of Corporate Governance Corporate Governance Statement, CQC Quality and Safety




Comp

Date

Date

reviewed

Directorate

Objective/

High Level

Actions/

Source

Initial

Risk

Rating

Current

Risk Score

Direction of risk Post

Mitigation

target risk

scoring

Is the level of

risk

acceptable post

mitigation ?


Category

Lead

March 16 9


No gaps

currently

identified but

note that much

of the external

engagement

work only starts

in April 2016.

Mar-162 8 Given the

complexity and

scale of this

transaction a

rating of 8 is

acceptable

Project plan monitored by

proposed Project Board;

regular reports to

Executive Management

Teams, Board of Directors

and Council of Governors;

FBC has to be signed off

by independent external

opinion and by Medical

Directors regarding

benefits plan, financial

status and clinical quality;

external regulatory

oversight of the whole

transaction is the single

biggest control - Monitor

will assess the FBC and

give the transaction a risk

rating and this will inform

the vote of the Governors;

newly merged

organisation will be

authorised and licenced by

Monitor and the Care

Quality Commission as all

other NHS Foundation

Trusts are.

No gaps currently

identified but

note that some

controls for

delivering the

project such as

procurement of

external support

has not yet

commenced and

will not be in

place until mid

May.

Monitoring

through

proposed

Project Board,

Exec Teams,

Board and

Governor

meetings.

Additional

scrutiny

provided by

Investment

Committee that

receives an

update on

project progress

at each meeting;

additional

meetings

scheduled

where needed.

External

independent

reviews as part

of the FBC.

Engagement

with HOSC,

healthwatch and

other key

stakeholders

↔ i. Regulatory risk: Monitor reviewed

the Strategic Options Case and made

suggestions for further work at Outline

Business Case (OBC) stage; OBC

submitted to Monitor on 08.01.16 and

review being undertaken throughout

Feb 2016 - this will lead to analysis of

strengths and weaknesses of business

case that need to be addressed in the

Full Business Case to secure an

acceptable transaction risk rating.

17.03.16 - OBC review completed; no

material issues identified by Monitor but

a number of areas to focus on including

due diligence exercise, organisational

development and continuing current

service delivery. Governance of

merger project has been reviewed and

reflected in Heads of Agreement

proposed to both Trust Board of

Directors in March 2016. Creation of

Project Board to take over merger

work; disband Strategic Alliance

Working Group.

ii. Regulatory risk: Monitor have

received competition analysis from

Trusts and are reviewing this as to

whether a referral to the CMA is

Apr-16 44 20 4 3 1230 January

2016 Board

Meeting

BAF16032401

The merger

proposal is

approved by the

CMA and Monitor

as regulatory

bodies, has

necessary

stakeholder

support and is

approved by a

majority vote of

both Council of

Governors

As a result of

regulatory actions

or Governors failing

to approve the

merger proposal

there is a risk that

the merger will not

be completed by

April 2017, or at all,

resulting in the

benefits identified in

the merger

proposal (clinical

and patient

benefits,

commissioner

benefits and

financial benefits)

not being delivered.

Patient

Safety

Reputation

Compliance

Nigel

Leonard

5

RISK RATING

Impact

Lik

elih

oo

d

1 2 3 4 5

1 Low 1

Low 2

Low 3

Medium 4

Medium 5

2 Low 2

Medium 4

Medium 6

Medium 8

High 10

3 Low 3

Medium 6

Medium 9

High 12

High 15

4 Medium 4

Medium 8

High 12

High 16

Extreme 20

5 Medium 5

High 10

High 15

Extreme 20

Extreme 25

March 16 10

1

Agenda Item No: 6(b)(i)

SUMMARY REPORT

BOARD OF DIRECTORS MEETING PART 1

30 March 2016

Report title: Board of Directors Quality Committee Assurance Report Non-Executive Lead: Lorraine Cabel, Chair

Executive Lead: Andy Brogan, Executive Nurse & Executive Director Mental Health

Report Author(s): Cathy Lilley, Acting Trust Secretary & Business Administration Manager (Chair’s Office)

Report discussed previously at: Quality Committee meetings held on 17 March 2016

Level of Assurance:

Level 1

2

3


To provide assurance to the Board that the Quality Committee is discharging its terms of reference and delegated responsibilities effectively, and that the risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively.

Approval

Discussion

Information


1 To note the contents of the report 2 To confirm acceptance of assurance given in respect of risks and actions identified 3 To request further action/information as required 4 To note that no significant risks or hotspots were identified for escalation to the Board of

Directors.


Summary of report:

Patient story that demonstrated the positive outcome for patients in West Essex community health services who having received support from the Rapid Response Team were able to stay in their own homes, preventing an acute hospital admission

Reviewed Quality Report and in particular noted the work being undertaken to embed the use of the MEWS system in wards and the continued reduction in the number of falls

Detailed report on the Suicide Prevention work stream to reduce avoidable suicides in the Trust’s mental health services and achieve the ambition to have zero avoidable suicides by 2017

Hotspots identified with regards to safer staffing but assurance of no concerns relating to safety and quality of care on wards; assurance provided that mitigating actions were in place

Update on the implementation of the Quality Academy

Continued progress on the action plan following the CQC comprehensive inspection visit

Update on the third CQC MH Intelligence Monitoring Report for Trusts due to be published in February 2016

Assurance that there are no significant concerns following the internal CQC monitoring

Positive CQC MHA focused visit to Mayfield Ward

Committee effectiveness review feedback and next steps

Corporate governance statement update including actions and self-assessment evidence

Feedback following the Deanery Visit

Approval of policies including review extensions

Update on internal audit programme 2016/17

Update on the limited assurance received on clinical audit and actions being taken

Progress with the submission of the IG Toolkit due on 31 March 2016

2

Received assurance reports from its sub-committees

There were no significant risks or hotspots for escalation to the Board of Directors.








Yes

If yes, insert relevant risk Following risks already included on the BAF: 1 Learning from SIs embedded and facilitates improvements

in quality and safety 2 Trust will remain compliant with CQC standards in all

services at all times 3 Fill rates achieved and maintained in all services 4 Substantive posts are recruited to 5 Resources in place to meet staffing establishments


No



Data Quality Issues




Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity

Equality Impact Assessment (EIA) Completed? No If yes, EIA Score

Acronyms / Terms used in the Report

CQC Care Quality Commission SI Serious Incidents

SUTS Sign Up To Safety (Campaign) MHA Mental Health Act

CQUIN Commissioning for Quality & Innovation


Yes – main report

Non-Executive Lead

Lorraine Cabel , Chair of the Trust and Chair of the Quality Committee

Board of Directors

Board of Directors Part 1 30 March 2016 Page 1 of 5

Agenda Item 6(b)(i) Board of Directors Meeting Part 1

30 March 2016

SEPT

BOARD OF DIRECTORS QUALITY COMMITTEE ASSURANCE REPORT

1 Purpose of Report

This report is provided to the Board of Directors by the Chair of the Board of Directors Quality Committee. As an integral part of the Trust’s agreed assurance system, the report is designed to provide assurance to the Board that:

risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively. This is an integral part of the Trust’s agreed assurance system

the Committee is discharging its terms of reference and delegated responsibilities effectively.

2 Executive Summary

2.1 Minutes of meetings held on 11 February 2016 These were approved on 17 March 2016 and are available in full to Board members via the Chair’s Office or on the intranet. 2.2 Summary of discussions and issues identified as well as assurances provided at the meeting held on 17 March 2016: 2.2.1 Patient Stories: The Committee was presented with two case studies of West

Essex community health services patients who received support from the Rapid Response Team resulting in both patients being able to stay in their own homes and prevent an acute hospital admission. The Committee noted the critical role the Reablement Team which focuses on personal care and felt the case studies demonstrated the cultural move towards facilitating patients to maintain their independence. The Committee asked that consideration be given to an outcome reporting mechanism for CCGs.

2.2.2 Quality Report: A detailed report on quality was presented providing an

update on areas of work within the quality strategy aligned to the Sign Up To Safety campaign (SUTS).

98.78% of patients did not experience any of the four harms in the Trust and the Committee was pleased that the Trust was continuing to achieve a high rate against the national ambition of 95%. The Committee were reminded that the score was based at a point in time of those patients on the case load at that time. Of those patients who did experience one of the four harms, these would have been ‘low’ harms and in the main would have been unavoidable.

Board of Directors


The Committee noted that actions, including additional training, were being taken to ensure the MEWS system was embedded in wards. In addition, the Committee was pleased with the continued reduction in the number of falls with 13 year to date compared to 24 in 2014/15, particularly taking account of the acuity of patients. The Committee requested that future reports included a monthly trajectory table/summary for restrictive practices in line with the reports on pressure ulcers and falls.

2.2.3 Quality Priority – Suicide Prevention: Chris Bradley-Rushe presented a

detailed report on the work being undertaken within the Suicide Prevention work stream in support of the suicide prevention strategy to reduce avoidable suicides in the Trust’s mental health services and to achieve the Trust’s ambition to have zero avoidable suicides by 2017. A two-year forward plan has been developed to enable progress to be monitored and to maintain momentum. The overarching action plan incorporates any outstanding actions from the previous suicide strategy action plan. The Committee noted the actions undertaken to date including the appointment of Anglia Ruskin University to undertake a review of the current culture and effectiveness of the SI process and learning mechanisms within the Trust following an SI resulting in a death by suicide. It was felt that this evaluation was timely in the light of the independent inquiry into deaths at Southern Health NHS FT. The two-year action plan was approved.

2.2.4 Safer Staffing Report: The report highlighted that the majority of wards in

Learning Disability, Secure Services and Community Health Services were above 95%. Assurance was provided that whilst recruitment is being undertaken, site managers on wards are being utilised to support wards alongside ward managers and matrons to ensure the wards are safe; there were no significant concerns with regards to the safety and quality of care on the ward when reviewing clinical incidents and safeguarding reports. The Committee discussed the actions being taken to address the hotspots and were sighted on the potential emerging risks. The Committee noted that new guidance from Monitor would require more triangulation of information. The Trust had adopted this approach when undertaking the establishment review.

2.2.5 Quality Academy Update: An update on the implementation of the Quality

Academy was provided which included the pathway to developing the Academy, governance arrangements, the appointment and role of Quality Champions, success/outcome measures and funding requirements. The Committee was pleased to see the progress of the Academy which will act as a catalyst to improve quality across the Trust.

2.2.6 CQC The Committee was pleased with the pace and progress of the CQC action plan (following the Trust’s comprehensive inspection), however, noted there were four actions which had breached their timescale, and having considered the reasons for the breach approved extensions to the timescales.

Board of Directors


As originally discussed in the previous meeting, the CQC had published in February 2016 its third intelligence monitoring report for mental health services. The Trust’s monitoring report contains 73 indicators some of which are broken down into multiple parts which is an increase of 9 from the last report published in June 2015. The report highlights two areas of elevated risk and four areas of risk for the Trust. The Committee was assured that actions were being taken to address concerns. The Committee was apprised of the CQC’s consultation on its five year strategy 2016 to 2021 – Shaping the Future which aims to help the CQC become more efficient and effective so it can stay relevant and sustainable for the future. In addition, the Committee was provided with recent guidance from the CQC for inspection teams. The Committee noted that internal CQC monitoring has continued and was assured that there were no significant concerns. An update was also provided on the CQC MHA focused visit to Mayfield Ward which was a very positive visit with only one issue raised. In addition, the Committee was advised that the MHA Office had undertaken 18 audits as part of its annual schedule to ensure compliance with the Mental Health Act 1983, the Code of Practice and Trust policies, and no significant issues were raised.

2.2.7 Committee Effectiveness Review: Positive feedback had been received

from members and non-members of the Committee. The Committee noted that the Chair of the Committee will be meeting with non-member colleagues who selected the neither agree nor disagree scoring in the online survey relating to timeliness, content, risks and assurance to understand the reasons for the scoring and what actions can be taken to address any issues or concerns. A summary report covering all of the Board’s standing committees’ effectiveness reviews will be presented to the April Board of Directors meeting which will include any recommendations for change/improvement and also the development of an action plan. An update report will be provided at the next Nominations Committee meeting.

2.2.8 Corporate Governance Statement: A report on the current position and

actions planned to meet Monitor’s self-certification requirements for 2016/17 in respect of the Corporate Governance Statement was considered. The Committee agreed to provide comments outside of the meeting on the self-assessment evidence, specifically in relation to quality.

2.2.9 External Accreditations/Inspections: The final draft report following the

Deanery Visit was presented on 25 February. The Trust challenged a number of areas which were acknowledged by the Deanery. The final report is awaited.

2.2.10 Internal Audit Programme 2016/17: The Committee agreed that internal

audit on patient and staff safety issues should be included in the internal audit programme for 2016/17 and requested that a clear brief is provided.

Board of Directors


2.2.11 Clinical Audit – Clinical Handovers Action Plan: An update on the actions being taken forward following the limited assurance on internal audit of clinical handovers, as reported at the Committee meeting in February, was provided. The Committee noted that the Audit Committee had met on 16 March and were assured of the actions being taken to address the issues and an update report would be provided in a year’s time.

2.2.12 HSCIC Information Governance Toolkit: The submission of the IG Toolkit

will take place on 31 March 2016. The external auditors have recommended a submission of Level 2 which is the required level set by HSCIC, Monitor and the CQC. A report from the external auditors confirms compliance at level 2 and also identifies a further 25 recommendations that would improve the Trust’s position. The outcome of last year’s audit highlighted 55 recommendations of which 23 were identified as ‘red’ compared to this year where there were no ‘red’ recommendations.

The Committee was pleased to note the improvement in the quality of evidence produced for the Toolkit submission and that of the 55 actions identified in 2015 no further action was identified following the re-audit this year.

2.2.13 Policies: The Committee approved the following policies and procedures:

Information Governance Policy and Associated Procedures (CP50)

Information Risk Policy and Procedure (CP57)

Data Protection Act 1998 & Confidentiality Policy and Associated Procedures (CP59)

Information Sharing & Consent Policy and Procedure (CP60)

Freedom of Information Act 2000 Policy and Procedure (CP25)

Smokefree Policy and Procedure (CP32)

Use of Seclusion and Long Term Segregation Policy and Procedure (CLP41)

The Committee agreed an extension to the Referral to Treatment Access Procedure (CLPG69) to May 2016.

2.2.14 Sub-Committees: Assurance reports were received from the following:

Learning Oversight Physical Health Sub-Committee: The Committee was pleased to note the full achievement of Q4 milestones for the Physical Health CQUIN. There were no new hotspots.

Patient Experience & Carer Steering Group: There were no new hotspots. 2.3 Risks/hotspots No significant risks or hotspots were identified for escalation to the Board of Directors.

Board of Directors


3 Action Required

The Board of Directors is asked to:

1 Note the contents of this report 2 Confirm acceptance of assurance given in respect of risks and action

identified 3 Request further action/information as required.

Report prepared by Cathy Lilley, Acting Trust Secretary On behalf of:

Lorraine Cabel Trust Chair Chair of the Quality Committee 30 March 2016

Investment and Planning Committee

Brd Rpts/Secs SEPT 1

Agenda Item No: 6b (ii)

SUMMARY REPORT


30 March 2016

Report title: Investment & Planning Committee

Executive Lead: Lorraine Cabel

Report Author(s):


Level of Assurance: 1

Purpose of the Report This report is provided to the Board of Directors by the Chairman of the Investment and Planning Committee. It is designed to provide assurance to the Board of Directors that risks that may affect the achievement of the organisations objectives are being managed effectively.

Approval

Discussion

Information


1. Note the summary of the meeting held on 14 March 2016 2. Confirm acceptance of assurance given in respect of risk and the action identified. 3. Request further action/information as required.

Summary of Key Issues The key issues:

Review of Successful/Unsuccessful Tenders

Lessons Learnt re Kent

Service Disaggregation and Mobilisation Update

Capital Project Programme Board Assurance

Sustainable Development and Caron Management

Treasury Management

Committee Efficacy Review

SEPT/NEP Merger Timetable Annual Plan Timetable 2016/17








No





No



Data Quality Issues N/A

Involvement of Service Users/ Healthwatch N/A

Communication and Consultation with stakeholders required N/A

Service Impact/Health Improvement Gains N/A



Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed?

Yes / No If yes, EIA Score


ERIC

Estates Return Information Collection


Executive Lead

Lorraine Cabel, Chair



Agenda Item No: 6b (ii)

Board of Directors Meeting: 30.3.16


INVESTMENT AND PLANNING COMMITTEE

PURPOSE OF REPORT

This report is provided to the Board of Directors by the Chairman of the Investment and Planning Committee. It is designed to provide assurance to the Board of Directors that risks that may affect the achievement of the organisations objectives are being managed effectively.

EXECUTIVE SUMMARY

Investment & Planning Committee Meeting 14 March 2016 The Investment and Planning Committee met on the 14 March 2016 and approved the minutes of the meeting held on the 19 January 2016. At the meeting held on 14 March 2016 the following matters were discussed:

1. Review of successful/unsuccessful tenders – There are no successful tenders to report this month. There are 8 tenders in progress. The key tenders in progress are:

Essex Wide 0-19 Children Services

IAPT Brent CCG

IAPT Medway CCG

Early Supported Discharge Stroke Service – this tender is in partnership with Southend Hospital

Unsuccessful Tenders The Trust was unsuccessful in the Soft FM Lot 8 & 17 Cleaning Domestic tender.

This loss will result in a significant cost pressure.

2. Lessons Learnt – A paper was presented highlighting the lessons learnt with regard to the unsuccessful Adult Community Services Kent bid. The bid had identified several factors that could have influenced the outcome. This served to reduce the overall score for the Trust reducing the quality of our submission and our competitiveness.



3. Services Disaggregation/Mobilisation Update –

Thurrock IAPT – The contract for this service will transfer to South Staffordshire and Shropshire NHS FT on the 1 April 2016.

HMP Bedford – Healthcare services to HMP Bedford, currently provided by

SEPT, are transferring to Northamptonshire Healthcare NHS FT.

Southend Falls service – This service will transfer to NELFT further to a recent

tender process.

Essex Sexual Health Service – BTUH has since withdrawn from the

consortium and negotiations are being undertaken to transfer this part of the

contract to Colchester University NHS FT.

Primary Care Services to Care Homes – Southend (Pilot) – The Trust is

preferred bidder for the provision of services for a one year period and is in the

process of agreeing a letter, pre contract. .

Capital Project Programme Board – The Capital Project Programme Board Assurance report was presented to the Investment and Planning Committee. The Committee was updated on a number of capital bids and received appropriate assurance of the effectiveness of business transacted. No hot spots were reported.

4. Sustainable Development and Carbon Management The Good Corporate Citizen scores have now been published and there has been a significant improvement on the previous year’s score. However, further investment would be required to improve the Trust’s Corporate Citizen Score in 2016/17. Stakeholder workshops are being arranged to identify carbon hotspots to encourage a reduction of carbon waste throughout the Trust. The ERIC return has been submitted. The Trust’s carbon emissions have reduced significantly over the past ten years. The results are to be published within Trust Today as a “Good News Story”.

5. Treasury Management

An update was received on the current investment performance. The balance as at the end of January 2016 is £43.7million and year to date the Trust has received interest totalling £134K.

6. Committee Efficacy Review - Positive feedback was received from members and non members of the committee. A summary report covering all of the Board’s standing committees effectiveness reviews will be presented to the April Board of Directors meeting. A further update report will be provided at the next Investment and Planning Committee meeting in April.

7. Merger Timeline and Update Report OBC – Monitor’s review of the OBC completed on the 11 March with an Executive Challenge session. Heads of Agreement - Draft Heads of Agreement has been drafted to clarify a number of points that did not have a common understanding. It was noted that the final Heads of Agreement will be drafted by a legal firm and that SEPT and NEP would share the costs.



Competition Considerations – Monitor has advised that on the basis of the information they have asked for and received and in discussion with commissioners they do not perceive there to be a significant competition concerns with the merger. SEPT and NEP Boards will need to discuss Monitor’s view and decide on their approach at their March meetings.

8. Annual Planning Timetable 2016/17 The Monitor timetable and the Annual Planning Timetable for 2016/17 was discussed and approved. It was noted that an extraordinary Investment and Planning Committee would be held in early April to review the detail of the Final Operational Plan prior to submission to Monitor. An Extraordinary Investment and Planning Committee is to be arranged in October 2016 to consider further information requests from Monitor and Trust responses.

Management of Risk This committee is not responsible for managing any of the Trusts’ significant risks (as identified in the Board Assurance Framework). New Risks There are no new risks that the committee has identified that require adding to the Trusts’ Assurance Framework nor bringing to the attention of the Board of Directors.

ACTION REQUIRED

The Board of Directors are asked to:

1. Note the summary of the meeting held 14 March 2016..

2. Confirm acceptance of assurance given in respect of risk and the action identified.

3. Request further action/information as required. Lorraine Cabel Chair of Investment and Planning Committee

Assurance Report – Audit Committee


Agenda Item No: 6b (iii)

SUMMARY REPORT

BOARD OF DIRECTORS MEETING

PART 1

30 March 2016

Report title: Board of Directors Audit Committee Assurance Report

Executive Lead: Janet Wood, Chair

Report Author(s): Carol Riley, Audit Committee Secretary


Assurance reports provided to the Board following Audit Committee meetings.



To provide assurance to the Board that the duties of the Audit Committee, which include Governance, Risk Management and Internal Control, have been appropriately complied with.

Approval

Discussion

Information


1. To note the contents of the report 2. To confirm acceptance of assurance given in respect of risks and actions identified 3. To request further action/information as required.


The key issues discussed at the meeting held on the 16 March 2016.

Internal Audit and LCFS

External Auditors

Extension of Review Date of SFIs and Detailed Scheme of Delegation

Workplan 2016/17

Impaired Debts Write Offs

Asset Verifications/Statement of Financial Position Write Offs

Waiver of Standing Orders

Committee Efficacy Review

Non Consolidation of Charity Accounts with Trust Accounts

Audit Committee Chairs Activity










No



No



Data Quality Issues





N/A





No If yes, EIA Score No



ECFO Executive Chief Finance Officer


Executive Lead

Janet Wood Audit Committee Chair



Agenda Item: 6b (iii) Board of Directors

Meeting: 30.3.16

SEPT

ASSURANCE REPORT FROM THE AUDIT COMMITTEE CHAIR PART ONE


This report is provided by the Chair of the Audit Committee, a sub-committee of the Board of Directors to provide assurance to Board members that the duties of the Audit Committee which include Governance, Risk Management and Internal Control have been appropriately complied with.

2.0 EXECUTIVE SUMMARY

Audit Committee meeting 16 March 2016 The Audit Committee met on the 16 March 2016 and approved the minutes of the meeting held on 29 January 2016. These minutes are available to Board members on request. At the meeting held on 16 March 2016 the following matters were discussed:

1. Internal Audit and LCFS

Internal Audit: 3 final reports had been issued since the meeting held in January 2016. It was noted that two of the reports had received substantial assurance. However, the Data Quality – Cancelled Clinics/Appointments report received limited assurance as the outpatient processes could be improved. LCFS: Members received an update on LCFS work. It was noted that there had been four new referrals since the last meeting held in January 2016. Two remain under consideration and two will not be progressed to formal investigation. One of these has been passed to the LSMS for investigation as it related to theft. Draft Audit Plan 2016/17: The draft Audit Plan has been circulated to managers and is awaiting feedback. The report will also be discussed the Quality Committee and the Executive Operational Committee in March. Members approved the report subject to changes by the Executive Operational Committee and the Quality Committee.



LCFS Workplan 2016/17: The workplan was approved by members. Draft Head of Internal Audit Opinion 2015/16: The draft was presented Two or three audits are still in progress but that this should have no impact on the audit opinion.

2. Report from Ernst & Young (External Auditors)

Audit Progress Report The planned interim audit work was carried out relating to the following:

Walkthroughs of significant classes of transactions

Bedfordshire and Luton demerger work – Asset and LGPS transfers

Quality accounts walkthroughs

Early income and expenditure substantive testing based on month 9 There were no findings to report to management.

3. Extension of Review Date of SFIs and Detailed Scheme of Delegation

Members approved the extension of the above policies until September 2016 which will bring the above policies in line with the review of the Standing Orders and Constitution.

4. Workplan 2016/17: The workplan was approved subject to the terms of reference column being completed.

5. Impaired Debts Write Offs: The Committee noted the write off of impaired

debts which total £674.09. It was noted that these relate to Staff debts, Trade debts, and Dental Patient debts.

6. Asset Verifications/Statement of Financial Position Write Offs: The Committee noted the write off of fixed assets that are unable to be verified and the write off of irreconcilable ledger balances.

7. Waiver of Standing Orders: The Committee noted that the standing orders for competitive quotations were waived on one occasion to the value of £6,137.72.

8. Committee Efficacy Review: Positive feedback was received from members of the committee. A summary report covering all of the Board’s standing committees effectiveness reviews will be presented to the April Board of Directors meeting.

9. Non Consolidation of Charity Accounts with Trust Accounts: The

Committee approved the non-consolidation of the Charitable Funds accounts into the Trust’s main accounts for 2015/16.



10. Audit Committee Chairs Activity: The Audit Committee chair reported that

she had met with Carol Riley and Clare Barley with regard to the Workplan and Committee Efficacy report. Private meetings were also held with the internal and external auditors.

3.0 MANAGEMENT OF RISK

The Audit Committee is not responsible for managing any of the Trust’s significant risks (as identified in the Board Assurance Framework).

4.0 NEW RISKS

There are no new risks that the Audit Committee has identified that require adding to the Trusts’ Assurance Framework, nor bringing to the attention of the Board of Directors.

5.0 ACTION REQUIRED

The Board of Directors are asked to:

1. Note the summary of the meeting held on 14 March 2016

2. Confirm acceptance of assurance given in respect of risk

3. Request further action/information as required.

Janet Wood Non Executive Director Chair of Audit Committee

1

Agenda Item No: 7a

SUMMARY REPORT


30 March 2016

Report title: Merger with North Essex Partnership University NHSFT: progress report

Executive Lead: Nigel Leonard, Executive Director Corporate Governance

Report Author(s): Tom Wilson, Interim Project Manager

Report discussed previously at: SEPT / NEPT Strategic Alliance Working Group

Level of Assurance:

Level 1

2

3


This paper updates the Board on the work to pursue a merger with South Essex Partnership University NHS Foundation Trust (SEPT) following the review of the Outline Business Case by Monitor in February 2016.

Approval

Discussion

Information


1. Note the feedback from Monitor’s Provider Appraisal Directorate on the Outline Business Case.

2. Note that a Heads of Agreement document will be discussed and agreed at Part II of the Board to detail the creation of a Project Board to progress the merger work.

3. Agree the recommendation not to notify the Competition & Markets Authority of the proposed

merger with South Essex Partnership University NHSFT.


Outline Business Case review The Outline Business Case (OBC) for the merger was submitted to Monitor on 8th January 2016; the formal review of the OBC by Monitor’s Provider Appraisal Division began in February and finished with an Executive Challenge session on 11 March 2016. Formal feedback was on 21st March 2016. A number of areas for further work and advice were notified but no material problems were raised during the review with Monitor to prevent the project moving to Stage 3 and presentation of a Full Business Case to merge in September 2016. Heads of Agreement During the review process the Project Team were prompted to consider the proposed governance of the merger and a number of other areas for consideration such as balancing such a significant transaction with daily operational requirements. A number of guiding principles have been established and set down formally in a non-legally binding Heads of Agreement document that each Trust will sign following approval from their Board and legal drafting of the document Most importantly the Heads detail the Terms of Reference of the Project Board. It is proposed that the Project Board should become a working group of this Board and of the NEP Trust Board with

2

delegated authority and budgetary responsibilities as outlined in the Terms of Reference. The Trust Board is asked to approve these Terms of Reference. As a result of this change the Strategic Alliance Working Group (SAWG) will be disbanded. The Heads of Agreement will be considered in full at the Board’s Part II private session due to its commercially sensitive nature. Competition Decision As well as the OBC a revised Competition Analysis was submitted to Monitor’s Co-Operation & Competition Directorate on 8th January 2016. This was reviewed jointly with the Monitor team during January and February, including discussions with commissioners and other stakeholders. Monitor has advised that on the basis of the information they asked for and received, and in discussion with commissioners, that they do not perceive there to be significant competition concerns with the merger. It is important to note that the Monitor team do not use the same methodology as a team from the Competition & Markets Authority (CMA) would. The Project Team have reviewed this advice and, considering the fact that the CMA still have the ability to review the transaction if they wish, believe that it would be disproportionate to notify the transaction to the CMA and incur the £120,000 fee. Both Trust Boards are therefore recommended to approve the decision not to notify the CMA with regard to the merger.








Yes

If yes, insert relevant risk As a result of regulatory actions or Governors failing to approve the merger proposal there is a risk that the merger will not be completed by April 2017, or at all, resulting in the benefits identified in the merger proposal (clinical and patient benefits, commissioner benefits and financial benefits) not being delivered


No the existing BAF entry has been updated to reflect the current situation.



Data Quality Issues Involvement of Service Users/Healthwatch Communication and Consultation with stakeholders required

Service Impact/Health Improvement Gains Financial Implications Capital £ TBC

3

Revenue £ Non Recurrent £


Impact on Patient Safety /Quality Impact on Equality & Diversity



The Board should note that a formal Equality Impact Assessment (EIA) of the merger will be commenced in late April/May with stakeholder groups identified across both Trusts. The EIA will form an important part of the FBC scheduled to be presented to each Trust Board for approval in September 2016.

TBC


CMA Competition & Markets Authority

FBC Full Business Case

NEP North Essex Partnership University NHS Foundation Trust

OBC Outline Business Case

SOC Strategic Outline Case

SAWG Strategic Alliance Working Group


None

Executive Lead

Nigel Leonard Executive Director Corporate Governance

4

Merger with North Essex Partnership University NHS Foundation Trust.

Outline Business Case Review

1. The Outline Business Case (OBC) for the merger was submitted to Monitor on 8th

January 2016 as was reported to the January Board. The formal review of the

OBC by Monitor’s Provider Appraisal Division began in February and finished

with an Executive Challenge Session on 11 March 2016. Formal feedback was

received on 21st March 2016.

2. The review process with Monitor has been very helpful in offering advice to the

Project Team in a number of areas. The review covers four broad areas:

a. Strategic rationale – the focus of the review was to ensure that any changes

since the Strategic Options Case recommended merger in September 2015

have been captured. The review considered the fact that the Strategic

Review of Mental Health Services had formally reported in November 2015

and received the full support of the commissioners and providers. The

review included discussions with the lead Essex CCGs who commission

mental health services to ensure that the merger itself had their support.

Changes to the NHS planning guidance and developments in the Essex

success regime were also considered.

The conclusion of the review was that the strategic rationale for a merger

remains valid but that there is a need for the Full Business Case (FBC) to

give greater clarity and certainty over the commissioning changes

recommended by the Strategic Review.

b. Finances – Monitor’s review team thoroughly tested the Long Term Financial

Model (LTFM) submitted with the OBC and sought to understand in more

detail a number of the financial assumptions that had been made and to

consider “downside risk” – that is to model what would happen if the financial

position of either NEP or SEPT were to deteriorate before the merger or if

some of the positive savings assumptions of the merger did not happen.

Areas for review and consideration by the Project Team will be progressed

with Monitor as the LTFM is developed.

The formal feedback has confirmed the need for greater clarity over merger-

specific benefits compared to the cost savings that could be achieved in any

case – this has always been noted in the project’s risk register and will be

addressed as the LTFM is developed for the FBC.

c. Quality – at the OBC stage the plans for quality improvements are less of a

consideration: this is essential to the FBC and is where the external review

of the business case and Medical Director sign off are important.

5

Nonetheless the review did consider how the position of the merger project

had changed since the publication of NEP’s Care Quality Commission

(CQC) report in January 2016. As the OBC suggested, if anything the rating

of “requires improvement” actually strengthens the case for merger:

irrespective of merger SEPT are, and would have been asked to support

NEP’s CQC action plan and a formal merger will serve only to strengthen

and increase the pace of such co-operation.

Unsurprisingly, the formal feedback from Monitor has reminded both Trust

Boards of the necessity to manage operational capacity to ensure delivery of

both improvements in CQC action plans and relevant support, and the

merger transaction.

d. Transaction execution: the review considered the capacity and capability of

both organisations to undertake such a significant transaction. The Project

Team felt, during the review process, that the level of resources devoted to

the merger work needed to take a step forward and that some additional

governance of the transaction was required. This is discussed at the Heads

of Agreement section below.

It should be noted that the review process has also led to an offer of closer

engagement with Monitor to ensure that the governance processes of

moving from two Trust Boards, through a transition to a single substantive

Board is managed carefully and within the relevant guidance and rules.

The review process and formal feedback also highlighted the need to

undertake a rigorous process of due diligence and the significant work that

needs to be contained in the merger organisational development plan. All

involved agree that the greatest risk to the merger is not the actual

regulatory transaction but a failure to fully address organisational and

cultural differences meaning the benefits of merger are not fully realised.

3. Monitor’s formal written feedback will be reviewed in the Board’s Part II private

session.

4. The Challenge Session and formal feedback did not however highlight any

material issues that stop the work progressing to Stage 3 FBC. It is intended that

this business case will be received at the September 2016 Board meeting.

5. Two further clinical workshops were held in early March to refine the approach to

benefits realisation and this helped start the formal process of clinical due

diligence. A procurement process will commence shortly to select the necessary

external support for the merger transaction – legal, audit and advisory. This is

being run under SEPT’s procurement processes but with equal decision making

with NEP teams. Appointments are expected to be confirmed by the end of April.

6

Heads of Agreement

6. During the review process the Project Team were prompted to consider the

proposed governance of the merger and a number of other areas for

consideration such as balancing such a significant transaction with daily

operational requirements. A number of guiding principles have been established

and set down formally in a non-legally binding Heads of Agreement document

that each Trust will sign following approval from their Board and legal drafting of

the document.

7. A revised governance proposal for the project will be considered in full at Part II

of the meeting but the key point to note is that a Project Board will be created to

progress the merger. The Project Board will be a working group of both NEP and

SEPT’s Trust Boards.

8. It is important to stress that the Project Board cannot take decisions – these will

still be the preserve of the Trust Board. The Full Business Case for merger, for

example, will be presented to each Trust Board for approval before it is submitted

to Monitor for a risk rating. The Project Board will ensure the work is progressed

and will make a recommendation to the Trust Board. The creation of the Project

Board does not pre-determine the merger as the FBC can still be rejected by

either Trust Board, or by a vote of Governors as a result of Monitor’s risk rating.

9. The Heads of Agreement propose the Terms of Reference of the Project Board

and by default remove formal meetings of the Strategic Alliance Working Group

(SAWG). The SAWG has previously been the forum where cooperation and

collaboration between the two Trusts could be discussed but was not structured

properly to take on the governance required by such a significant transaction as

merger. The SAWG therefore will be disbanded.

10. As part of the FBC review process Monitor requests a Board to Board meeting

and this will be held with the Project Board representing both organisations rather

than with both Trust Boards. However, it is a guiding principle that membership

of the Project Board does not pre-determine membership of the merged

organisation’s Board for either Executive or Non-Executive roles. Substantive

Executive Director Board appointments will be made in line with good HR

practice and organisational change policies; Non-Executive Director Board

appointments will need to be made in line with the new organisation’s constitution

and Governor and Board Nominations Committees.

11. In addition, the Heads of Agreement confirm both organisations’ commitment to

sharing the costs of the transaction equally and to ensuring that material

operational and investment decisions taken in the phase leading to merger will

only be made after consultation with the other party.

7

Competition Considerations

12. As well as the OBC a revised Competition Analysis was submitted to Monitor’s

Co-Operation & Competition Directorate on 8th January 2016. This was reviewed

jointly with the Monitor team during January and February, including discussions

with commissioners and other stakeholders. Monitor has advised that on the

basis of the information they asked for and received, and in discussion with

commissioners, that they do not perceive there to be significant competition

concerns with the merger.

13. It is important to note that the Monitor team does not use the same methodology

as a team from the Competition & Markets Authority (CMA) would. The CMA

take advice from Monitor and its review but is not bound by this advice.

14. It is also important that in public discussions about the merger there is a very

clear distinction maintained between a decision not to notify and the transaction

receiving regulatory clearance from the CMA: as no notification has been made

the merger does not have regulatory clearance and there remains a residual risk

that the CMA may choose to review the transaction of its own accord for instance

following a formal complaint being received from a third party. The project team

believes this risk to be small and remain confident that any review would

complete at Phase I. Such a review would not throw out the timetable for merger

by April 2017 but would incur a £120,000 fee and of course the opportunity cost

of time and resource required in cooperating with the CMA review.

15. The Project Team have reviewed Monitor’s advice and, considering the fact that

the CMA still have the ability to review the transaction if they wish, believe that it

would be disproportionate to notify the transaction to the CMA and incur the

£120,000 fee. The Board is therefore recommended to approve the decision not

to notify the CMA with regard to the merger.

1

Agenda Item No: 7b

SUMMARY REPORT

BOARD OF DIRECTOR MEETING Part 1

30 March 2016

Report title: Operational Plan

Executive Lead: Nigel Leonard

Report Author(s): Gill Brice, Associate Director of Planning


Level of Assurance:

Level 1

2

3


The purpose of this report is to provide the Trust Board of Directors with an update regarding the Trust’s Operational Plan 2016/17 which is due for submission on 11 April 2016.

Approval

Discussion

Information


The Trust Board is asked to consider and discuss the content of this report.


The Board will recall that the approach SEPT is adopting is to continue with the review of strategic drivers and options for the organisation in the medium term. SEPT’s Board has already dedicated time over the last year to discuss the strategic positioning of the Trust in the medium and long term as part of our joint working with North Essex Partnership University NHS Foundation Trust (NEP). The Outline Business Case (OBC) was submitted to monitor in January 2016. Work will be commencing on the Full Business Case (FBC) taking into consideration the feedback provided from Monitor following their review of the OBC. We continue to be mindful that the planning process will be influenced by the local decisions arising from work on the Essex Success Regime and the Essex Mental Health Review, as well as the need for every health and care system to come together to create a five year Sustainability and Transformation Plan (STP). Since submitting the draft plan to the Board in January 2016 a number of changes have been made in line with planning guidance issued late January 2016. In addition, it is envisaged that further changes will be necessary as contract negotiations have not yet been finalised. Further, Monitor have not published updated information in respect of changes to control totals. As such the Trust awaits further planning guidance in respect of this. It is likely that the guidance produced will result in the Trust making changes to its financial plans. The public version of the Operational Plan is also to be submitted on 11 April 2016. The Operational Plan was discussed at the Board Development Session and in preparation for any further changes an extraordinary meeting of the Investment & Planning Committee has been organised.

2








No


N/A


No



Data Quality Issues Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications:

N/a

Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity No


No If yes, EIA Score N/a


NEP North Essex Partnership University NHS Foundation Trust

OBC Outline Business Case

FBC Full Business Case

STP Sustainability and Transformation Plan


None

Executive Lead


1

Agenda Item No: 7c

SUMMARY REPORT

BOARD OF DIRECTORS

30 March 2016

Report title: Essex Success Regime

Executive Lead: Sally Morris

Report Author(s):


Level of Assurance:

Level 1

2

3

Purpose of the Report During March and April, partners in the Mid and South Essex Success Regime are asked to hold discussions with their Boards and governing bodies, ideally in public, and to respond to the programme office with feedback. The programme will benefit from the overall views of each board and any specific views and comments on aspects of the plan. This paper provides a summary of the Success Regime operational briefing that was published on 1 March and invites views.

Approval

Discussion

Information


The Board is asked to Support senior staff and communications leads in facilitating wider discussions with staff and local stakeholders;

Consider and comment on the operational briefing for the Success Regime attached at appendix 1;

and make arrangements to submit feedback by 2 May 2016 to: [email protected]

Summary of Key Issues The Success Regime gives the opportunity to realise the full potential of the workforce, achieve financial balance by 2018/19 and provide the best of modern health and care for local people.

mailto:[email protected]

2

Six priority areas in which to accelerate change to sustain local services and improve care which are included in the attached paper.








No



No



Data Quality Issues










Executive Lead

Sally Morris Chief Executive

3

Mid and South Essex Success Regime

A programme to sustain services and improve care

Purpose

1. During March and April, partners in the Mid and South Essex Success Regime are asked to hold discussions with their boards and governing bodies, ideally in public, and to respond to the programme office with feedback. The programme will benefit from the overall views of each board and any specific views and comments on aspects of the plan.

2. This paper provides a summary of the Success Regime operational briefing that was

published on 1 March and invites views. The full briefing is attached at appendix 1.

Headline summary

3. The plan 3.1. The Success Regime gives us the opportunity to realise the full potential of our

workforce, achieve financial balance by 2018/19 and provide the best of modern health and care for local people.

3.2. We have identified six priority areas in which to accelerate change to sustain local services and improve care. These are summarised below:

1. Address clinical and financial sustainability of local hospitals by: o Increasing collaboration and service redesign across three sites o Sharing back office and clinical support services.

2. Accelerate plans for changes in urgent and emergency care, in line with national recommendations e.g.:

o Doing more to help people avoid problems and get the right help o Developing same day services and urgent care in communities, to

reduce unnecessary visits and admissions to hospital o Designating hospital sites for specialist emergency care.

3. Join up community-based services – GPs, primary, community, mental health and social care – around defined localities or hubs.

4

4. Simplify commissioning, reduce workload and bureaucracy e.g.:

o Reduce the number of contracts from around 300 to around 50 o Commission services on a wider scale e.g. with one lead provider where

several may be involved o Agree a consistent and common offer to focus on priorities and identify

limits of NHS funding.

5. Develop a flexible workforce that can work across organisations and geographical boundaries.

6. Improve information, IT and shared access to care records.

4. Why we are doing this 4.1. We need to keep up with increasing demands and the pace of change of modern

health and care so that we can do more for people now and in the future.

4.2. If we did not accelerate change, the current £94 million NHS deficit in mid and south Essex could rise to over £216 million by 2018/19. We would not be able to meet year on year growing demands.

4.3. Our aim is to get the system back into balance by 2018/19 and deliver the best joined up and personalised care for patients.

5. The approach 5.1. Change will be led by clinicians, with the involvement of service users, staff and

local people.

5.2. The Success Regime provides programme structure, rigour and support, including a financial bridge during the transition to a balanced position in 2018/19.

5.3. We are keen to involve people at this early stage. There will be more opportunities to help shape options over the summer, and further public consultation on options in the autumn.

Background

6. Areas and services involved

6.1. All health and social care services in mid and south Essex are involved in the programme, including some 183 GP practices, community services, mental health, social care and hospital services.

5

6.2. The Success Regime area will be the footprint for the Sustainability and Transformation Plan that health and care organisations are required to agree by June 2016, as part of implementing the NHS Five Year Forward View.

6.3. The main partner organisations are as follows:

6.4. Clinical commissioning groups (CCGs):

Basildon and Brentwood

Castle Point and Rochford

Mid Essex

Southend

Thurrock

Local authorities:

Essex County Council

Southend-on-sea Borough Council

Thurrock Council

Service providers:

Basildon and Thurrock University Hospitals NHS Foundation Trust (BTUH)

East of England Ambulance Service NHS Trust

Mid Essex Hospital Services NHS Trust

NELFT NHS Foundation Trust

North Essex Partnership University NHS Foundation Trust

Provide

Southend University Hospital NHS Foundation Trust

South Essex Partnership University NHS Foundation Trust

6

7. Success Regime governance 7.1. Each partner organisation in the Success Regime has clinical and leadership

representation at a System Leaders Group (SLG) and a Clinical and Professional Leaders Group (CPLG).

7.2. These representatives have the responsibility for steering the overall programme and keeping their organisations and local networks updated.

7.3. The SLG is chaired by an independent clinical chair, Dr Anita Donley, a consultant from Plymouth Hospitals NHS Trust and clinical vice-president of the Royal College of Physicians.

7.4. The Mid and South Essex Success Regime is accountable to the Regional Directors of three national organisations - NHS England, NHS Trust Development Authority and Monitor.

Examples of potential changes for patients

8. Local health and care 8.1. The range of services provided locally could expand over the next three to five

years, with joined up services based in primary care, multidisciplinary teams and close links with voluntary sector and other public services.

7

8.2. There would be a greater emphasis on supporting people to stay healthy and encouraging individuals to take responsibility for their own health and wellbeing. Greater use of technology would give people online and practical tools to self-manage where possible.

8.3. Vulnerable people, frail people and those identified as at higher risk would have the benefit of a personalised plan and joined up services that can monitor and intervene at an early stage to avoid escalating problems.

8.4. There could be more consultations available locally by involving a wider range of professionals.

8.5. Some routine hospital outpatient services could be available from local health facilities.

9. Care in hospital

9.1. There would continue to be three sites providing core hospital services at Basildon, Chelmsford and Southend.

9.2. Some specialist services could be provided by a designated hospital and, for these services, some patients may have to travel further than their local hospital, as is the case now with cardiothoracic services at Basildon, radiotherapy services at Southend and burns and plastics at Broomfield.

9.3. Such changes would lead to improved clinical staffing levels, potentially shorter waiting times, better quality of care and patient experience and better clinical outcomes for recovery.

10. Urgent and emergency care

10.1. Vulnerable and high-risk patients would have the benefit of joined-up and personalised health and social care and early intervention to avoid emergencies.

10.2. Service developments in localities could offer more urgent care in the community e.g. frailty assessment units, 24/7 mental health crisis support.

10.3. Developments in 111 and ambulance services could offer more online and telephone access to high quality urgent care.

10.4. Most people in need of urgent care could be seen at home, in a local health facility or at the nearest local hospital.

10.5. Under options to be developed by local clinicians, some very serious emergencies could be taken by ambulance to a designated hospital, as is the case now for

8

complex heart problems (e.g. to specialised services in Basildon) and for multiple serious injuries (e.g. to major trauma centres at the Royal London or Addenbrooke’s in Cambridge).

Governance to support collaboration

11. The five CCGs are working together to simplify commissioning and agree “a consistent and common offer”. It has been agreed in principle that a single committee could be the best approach to achieve joint commissioning. CCGs are currently determining terms of reference and operational details.

12. The three acute trusts are developing a group model to extend their current collaboration in both clinical and non-clinical functions across the three sites. This could include building single teams in some specialties, clinical support and back office functions.

13. To support the proposed service improvements, commissioners and acute providers are negotiating block contracts for 2016/17.

Current progress

14. Clare Panniker, chief executive of BTUH, is coordinating workstreams for the acute care changes. Caroline Rassell, accountable officer of Mid Essex CCG is coordinating primary and community workstreams.

15. Leaders are currently being assigned to each workstream and developing the details of project initiation.

16. Next steps and milestones: 1 March Start of discussions and feedback April Launch of workstreams and detailed planning

End May Wider engagement in potential service changes

Sep-Dec Refine options and consult

17. The high level summary of the Success Regime has been widely published with local community groups, representative organisations and in the local press and media. Information is available from web pages hosted by Castle Point and Rochford CCG on behalf of all partners. Please visit: http://castlepointandrochfordccg.nhs.uk/success-regime

Conclusion

18. From 1 March until end of April, we are promoting local discussions and listening to views on the overall plan, whilst putting in place the arrangements for developing options for change.

19. Feedback from discussions in these early stages will inform both the developing options and the working arrangements to speed up the pace of change.

9

20. Boards and other local groups are invited to send their feedback by 2 May to the Success Regime programme office at [email protected]

Recommendation

21. The Board is asked to 21.1. support senior staff and communications leads in facilitating wider discussions

with staff and local stakeholders;

21.2. consider and comment on the operational briefing for the Success Regime attached at appendix 1;

21.3. make arrangements to submit feedback by 2 May 2016 to: [email protected]



1

Agenda Item No: 8a

SUMMARY REPORT

BOARD OF DIRECTORS

30 March 2016

Report title: CQC Inspection Visit Update Executive Lead: Nigel Leonard

Executive Director of Corporate Governance Report Author(s): Nicola Jones, Head of Assurance

Chris Jennings, Compliance Officer Report discussed previously at: Quality Committee



The purpose of this report is to provide the Trust Board of Directors with an update on the CQC Action Plan developed as a result of the CQC Comprehensive Inspection completed in June / July 2015.

Approval Discussion Information


The Board of Directors is asked to: 1. Note the contents of this report

Summary of Key Issues The CQC undertook a Comprehensive Inspection of Trust services in June / July 2015 and published its findings in November 2015. The Trust was rated as “Good” overall. However, the CQC made recommendations (3 Must do and 10 Should do trust recommendations and some additional service specific recommendations) for the Trust to take forward. The Trust developed a robust action plan with timescales for delivering the improvements identified (approved by the Board of Directors in January 2016) and good progress has been made against this action plan. To date, the Trust has completed 49 actions (16 contributing to Must Do recommendations and 33 contributing to Should Do recommendations). There are a number of Task and Finish Groups in place that are taking forward the actions identified. The CEO chairs the CQC Action planning Group and the Quality Committee (chaired by the Trust Chair) is actively monitoring progress on behalf of the Board of Directors. There are currently no actions breaching timescale, however, some completion dates have been extended by the Quality Committee to allow further work to be undertaken to fully implement the action. Implementation of the action plan is monitored by the Trust Quality Committee using the following scorecard:

It is anticipated that the action plan will be completed by the end of May 2016 as envisaged and plans are in place to rigorously audit implementation during June/July 2016. The Board will be provided with an assurance report in September 2016 prior to informing the CQC that actions are complete.

2


SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision




Yes: BAF 15-16 and REF - BAF14033001

If yes, insert relevant risk If services fall short of the standards there is the potential for CQC enforcement action or in extreme cases closure of services


No

Corporate Impact Assessment OR Board Statements: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives

Data Quality Issues Nil

Involvement of Service Users/ Healthwatch N/A Communication and Consultation with stakeholders required N/A Service Impact/Health Improvement Gains Nil


Nil

Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Nil Equality Impact Assessment (EIA) Completed?




Supporting Documents &/or Further Reading None

Executive Lead Nigel Leonard Executive Director of Corporate Governance

1

Agenda Item No: 8b

SUMMARY REPORT


30 March 2016

Report title: Legal & Policy Update

Lead: Nigel Leonard

Report Author(s): Tina Cross

Report discussed previously at: Executive Team

Level of Assurance:

Level 1 2

3


To inform the Board of Directors on recent regulation and compliance guidance issued by Monitor, NHS England, the Care Quality Commission, NHS Development Authority and other relevant bodies.

Approval

Discussion

Information


The Board of Directors is asked to consider and note the content of the report.


Executive Directors will be taking forward any key actions arising from the Legal & Policy Updates and progress updates on these actions will be submitted to the Board of Directors, as appropriate.


SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness



no



no



Data Quality Issues Involvement of Service Users/ Healthwatch

2



Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed?

Yes / No If yes, EIA Score No


As per main report


none

Executive Lead


Trust Secretary’s Report

Trust Secretary: Board Report March 2016 Page 1 of 5

Agenda item 8(b) Board of Directors Meeting: Part 1

30 March 2016

TRUST SECRETARY - LEGAL AND POLICY UPDATES REPORT 1 PURPOSE OF REPORT This report provides an update to the Board of Directors on regulation, compliance guidance and information issued by Monitor, NHS England, Care Quality Commission (CQC), NHS Trust Development Authority (TDA) and any other relevant Authority. A weekly Legal and Policy Update report is received by the Executive Operational Committee to ensure that the Trust is updated in a timely fashion, to enable the Trust to respond to consultations within the required timeframe and for these to be monitored by ET. The report is also circulated to the Senior Management Teams. 2 LEGAL/POLICY UPDATES 2.1 CQC responds to the Bubb report update (22 Feb)

Sir Stephen Bubb has published his 12-month report Time for Change – The Challenge Ahead, looking at the actions taken so far and calling on partners, including CQC, to demonstrate how they are helping to reduce the reliance on hospital-based settings for people with learning disabilities. CQC is a member of the Transforming Care Delivery Board, which was set up to improve services for people with learning disabilities and/or autism by developing community services as an alternative to inpatient care for people who are currently in hospital or who are at risk of being admitted to hospital. For more information: Link

2.2 Independent commission on acute adult psychiatric care publishes final report (19 Feb) The commission on acute adult psychiatric care has published Old problems, new solutions, setting out its findings and recommendations for England. The commission was set up by the Royal College of Psychiatrists and led by Lord Nigel Crisp, in response to widespread concerns about the provision of acute inpatient psychiatric beds and alternatives to admission available for patients. The commission found that access to acute care for severely ill mental health patients is inadequate nationally and, in some cases, potentially dangerous. However, the commission also identified many good services around the country and enormous scope for dramatically improving others. The commission made 12 recommendations that touch on all parts of the mental health system as well as aspects of broader health and social care for people with serious mental illness. For more information: Link

2.3 Improving quality in the English NHS (23 Feb) The King’s Fund has issued a paper that argues that the NHS in England cannot meet the health care needs of the population without a sustained and comprehensive commitment to quality improvement as its principal strategy. Despite a succession of well-meaning policy initiatives over the past two decades, the paper argues that the NHS in England has lacked a coherent approach to improving quality of care. It describes key features of a quality improvement strategy and the role of organisations at different levels in realising it, offering 10 design principles to guide its development. A quality improvement strategy of this kind has never been implemented at such a scale and the challenge in doing so is immense – yet the paper argues that the NHS has no real alternative. For more information: Link



2.4 SEND: guide for health professionals (24 Feb)

DoH has produced a guide for health professionals on the support system for children and young people with special educational needs and disability (SEND). This guide is for:

clinical commissioning groups health professionals local authorities

It explains the duties and responsibilities of health professionals who deal with children and young people with special educational needs and disability (SEND) and their families. This guide should be read alongside the ‘Special education needs and disability code of practice: 0 to 25’. For more information: Link

2.5 Inquiry into maximising NHS non-clinical staff launched (24 Feb) HSJ has launched an inquiry on maximising the contribution of NHS non-clinical staff. The inquiry is calling for examples of good practice, as well as observations and thoughts on how the non-clinical NHS workforce can and will adapt to the demand and resource challenges facing the service over coming years, to help inform evidence-gathering sessions. The challenges of adequately planning the NHS clinical workforce are fairly well researched, but as the service moves to new models of providing care, the importance of the non-clinical workforce is likely to grow. The inquiry, supported by Serco, will seek to investigate the nature of this change. The inquiry’s interim report will be published at the HSJ Value Summit on 24 May and the main report at the HSJ Summit in November.

2.6 Working with Time To Change to build on positive practice in mental health services (25 Feb) A new training pack has been launched to help reduce the stigma and discrimination sometimes experienced by people when using mental health services. NHS England has worked with Time To Change, England’s biggest programme to challenge mental health stigma and discrimination, to develop and fund a project which aims to better understand the dynamics of relationships between people who use services and NHS professionals. Insight from research, focus groups and individual interviews, demonstrated that a high number of people using mental health services felt they experienced stigma and discrimination. This insight helped Time To Change to work with mental health professionals and service users to identify examples of good practice as well as the barriers which can sometimes stand in the way of positive interactions. The resulting training pack focuses on the positive changes which can improve both team culture and working practices. For more information: Link

2.7 Changes in medicines legislation for Dietitians, Orthoptists and Therapeutic Radiographers (26 Feb) Patients under the care of a suitably trained and qualified Dietitian, Orthoptist or Therapeutic Radiographer will shortly be able to access some of their medication without visiting a doctor, thanks to changes in legislation. Following an announcement by George Freeman MP, Minister for Life Sciences, patients will have timely access to the medicines they need and more choice in how they obtain them. The changes to legislation will introduce independent prescribing responsibilities for Therapeutic Radiographers and supplementary prescribing responsibilities for Dietitians. They will also enable Orthoptists to supply and administer medicines under exemptions within Human Medicines Regulations.



Before introducing the changes to their practice, eligible practitioners need to successfully complete a Health and Care Professions Council (HCPC) approved training programme and have this qualification marked against their name on the professional register. Following amendments to the UK-wide legislation, eligible practitioners will be able to undertake training programmes as they are approved by the HCPC over the next 18 months. For more information: Link

2.8 Specialised Services clinical commissioning policies and service specification - 5th Wave and 6th Wave (26 Feb & 04 Mar respectively) NHS England has launched two 30 day public consultations on a number of proposed new products for specialised services, (including service specifications and clinical commissioning policies – 5th wave and 6th wave). These are two of several public consultations on proposed new draft products for specialised services. For more information on the 5th wave: Link For more information on the 6th wave: Link

2.9 New Dementia Envoy appointed (01 Mar) The Prime Minister has appointed David Mayhew as the new Dementia Envoy. The envoy works with countries, corporations and leaders from around the world, sharing expertise and promoting research and support for people with dementia and their carers. Dementia is a high priority for the UK government and internationally. The envoy will play an important role in supporting the 2020 challenge on dementia. David takes over from Dennis Gillings, who was the World Dementia Envoy for 2 years. Dennis helped to launch the £100 million Dementia Discovery Fund and was instrumental in the progress that’s been made since the first G8 summit on dementia was held in 2013. David Mayhew CBE is former Chairman of JP Morgan Cazenove and now Vice Chairman of JP Morgan’s global investment bank. He is also Chairman of Alzheimer’s Research UK and a member of the Wellcome Trust Investment Committee, supporting new breakthroughs in dementia research.

2.10 People not given answers when they complain to NHS, latest ombudsman report reveals (01 Mar) Some people who complain to the NHS are not getting the answers they desperately need meaning they are forced to bring their complaints to the Ombudsman service to get answers. The Parliamentary and Health Service Ombudsman's latest snapshot of cases it has investigated includes cases about grieving parents and partners not being given answers as to why their loved ones died and mistakes not being admitted, which means that much needed service improvements are being delayed. The latest snapshot of cases published details how one family was forced to bring their complaint to the Ombudsman service, after their nine-year-old son died of sepsis after he was wrongly discharged from hospital. For more information: Link

2.11 From NHS Employers: new pay calculator for junior doctors’ pay (02 Mar) NHS Employers has launched a pay calculator for junior doctors showing the breakdown of earnings under the new 2016 contract and the circumstances where pay protection may apply. For more information: Link



2.12 Health Secretary unveils plans for safer 7 day dementia service (06 Mar) A 7 day NHS and helping people live well with the dementia, will help make UK the most dementia friendly society in the world by 2020. Health Secretary Jeremy Hunt has published the dementia implementation plan which will empower people with dementia and their family through improved care and transparency. As part of the government’s aim of building a higher-quality NHS for patients, with safer care throughout the week, the dementia implementation plan will make sure:

for the first time, people with dementia and their families will benefit from greater transparency and will be able to compare the quality of dementia care in their local area

the CQC will include standards of dementia care in their inspections to make sure

services are safer for people with dementia 7 days a week

every person with dementia will receive a personalised care plan As part of plans to raise awareness of health concerns, a new pilot scheme will extend NHS Health Checks. For the first time, NHS Health Checks will include awareness raising, education and discussion of risk reduction for dementia for people aged 40 or older. This is currently only available for over 65s.

For more information: Link

2.13 Bringing together physical and mental health (08 Mar) Until now, most efforts to promote integrated care have focused on bridging the gaps between health and social care or between primary and secondary care. But the NHS five year forward view has highlighted a third dimension – bringing together physical and mental health. A report published by The King’s Fund makes a compelling case for this ‘new frontier’ for integration. It gives service users’ perspectives on what integrated care would look like and highlights 10 areas that offer some of the biggest opportunities for improving quality and controlling costs.


2.14 NHS staff to receive 1% pay rise (08 Mar) Following recommendations from the independent pay review bodies, the NHS Pay Review Body and the Doctors’ and Dentists’ Review Body, the government has accepted a 1% pay rise for doctors, dentists and all NHS staff on Agenda for Change contracts for 2016 to 2017. Delivering a safer 7-day NHS for patients is a government priority. An important part of this is that the NHS has to ensure it has the right staff, in the right place, at the right time to provide high quality services across the week. The NHS already has 32,000 extra clinical staff, including more than 10,700 additional doctors and more than 11,500 additional nurses on its wards since May 2010.


3 RECOMMENDATIONS

The Board of Directors is asked to note the content of this paper.

Report prepared by Tina Cross on behalf of

Nigel Leonard Executive Director Corporate Governance 22 March 2016



APPENDIX: NEWS RELEVANT TO FOUNDATION TRUSTS

1. New Appointed Trusts: There have been no newly appointed Trusts since the last report.

2. Monitor, NHS England, Care Quality Commission (CQC) and NHS Trust Development Authority (TDA) investigations and actions Listed below are recent investigations of Hospitals and Care Homes carried out by the above named authorities to provide the Board with an outline of how these authorities exercise their powers and the measures implemented by the Trusts in response to the various findings. In the last month, these authorities have issued their findings on several investigations that have been carried out within the past year. Of those investigations:

4 Trusts and Care Homes have been rated as Inadequate or Require Improvement

4 have been rated as Outstanding or Caring

2 have been placed into Special Measures, had conditions imposed or have

been closed The following are investigations from Essex and the surrounding area of London and Kent which may be of interest to the Board:

Ebury Court Residential Home in Havering, North East London: rated as Outstanding following a CQC inspection in December 2015

Thames Healthcare Service Limited, Merton, South London: CQC has

taken enforcement action to cancel the provision of services, following serious concerns identified during an inspection in July 2015

1

Agenda Item No: 8c

SUMMARY REPORT

BOARD OF DIRECTORS

30 March 2016

Report title: CQC INTELLIGENCE MONITORING REPORT Executive Lead: Nigel Leonard

Executive Director of Corporate Governance

Report Author(s): Nicola Jones, Head of Assurance Chris Jennings, Compliance Officer

Report discussed previously at: Quality Committee Level of Assurance: 1

Purpose of the Report The purpose of this report is to provide the Trust Board of Directors with details by the CQC Intelligence Monitoring Report for Mental Health Services published on 25th February 2016.

Approval

Discussion Information

Recommendations / Action Required The Quality Committee is asked to:

1. Note the contents of this report


CQC Intelligence Monitoring The CQC published it’s third intelligence monitoring report for mental health services on 25th February 2016. The report highlights two “elevated risks” and 4 “risks” for the Trust. This gives the Trust a risk score of 8, with a proportional risk score of 5.56%. When compared to other organisations the Trust is positioned in the middle 40% of organisations. The published report is attached at Appendix 1. Further details of the intelligence monitoring report, including a further breakdown of the “risks” and “elevated risks” and the action being taken to address the risks identified are also included in the accompanying report.

Relationship to Trust Strategic Priorities SP 1: Quality Services SP 2: Quality Leadership & Workforce

SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness

Relationship to the Board Assurance Framework Are any existing risks in the Board Assurance Framework affected?

Yes: BAF14033001

If yes, insert relevant risk If services fall short of the standards there is the potential for CQC enforcement action or in extreme cases closure of services


No

2



Data Quality Issues Nil Involvement of Service Users/ Healthwatch N/A

Communication and Consultation with stakeholders required N/A Service Impact/Health Improvement Gains Nil Financial Implications Capital £ Revenue £ Non Recurrent £

Nil

Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Nil



Acronyms / Terms used in the report CQC Care Quality Commission

Supporting Documents &/or Further Reading Accompanying report and appendices

Executive Lead


1

Agenda Item 8c Board of Directors

30 March 2016

SEPT

CQC Intelligence Monitoring Accompanying Report

1.0 Purpose

The purpose of this report is to provide the Trust Board of Directors with details of the Intelligence Monitoring Report for Mental Health Services for SEPT published on 25 th February 2016.

2.0 CQC Intelligence Monitoring

The Trust CQC MH Intelligence Monitoring Report was published on 25 th February 2016. This report is the third report for Mental Health services developed by the CQC, with the previous reports published in November 2014 and June 2015. The Trust was given the opportunity to review the report in draft and a number of minor factual inaccuracies were noted and a response was sent to the CQC on the 26 th January 2016. The CQC responded in full to the Trusts queries and provided the Trust with a copy of the final report before publication on the 25 February 2016. This is attached at Appendix 1. The CQC has published individual reports for 56 mental health trusts across the country. The CQC have removed the ‘priority bands for inspection’ from the intelligent monitoring reports. This is because the majority of trusts will have fallen into the ‘recently inspected’ category at the time of publication. The Trust monitoring report contains 73 indicators (some of which are further broken down into multiple parts), which is an increase of 9 from the report published in June 2015. T he indicators have been rated as follows:

67 are rated as No Evidence of Risk (one is listed as “Not Included”). 4 are rated as a Risk

2 are rated as an Elevated Risk This gives the Trust a risk score of 8 with a proportional score of 5.56%. Analysis has been undertaken against other MH Trusts Intelligence Monitoring reports to determine the Trust’s position nationally. When compared to other organisations the Trust is positioned in the middle 40% of organisations (see Appendix 2). For the Trust the following indicators have been listed as an Elevated Risk:

Proportion of discharged patients without a recorded crisis plan

Fully and partially upheld investigations into complaints

For the Trust the following indicators have been listed as a Risk:

Ratio of occupied beds to all nursing staff

Mental Health Act complaints received by CQC as a ratio to MHA activity

Composite indicator to assess bed occupancy

o Occupancy ratio, looking at the average daily number of available and occupied

beds open overnight

2

Composite Indicator: Proportion of Mental Health Act (MHA) and hospital inpatient

episodes closed by the provider

o Proportion of provider closed hospital inpatient episodes

Further analysis has been undertaken of the individual indicators to determine any changes since the previous report. Of the 73 indicators, 61 were previously included in the report published in June 2015. The 61 indicators show no changes for 35 of the indicators and of the remaining 26, 13 show an improvement and 12 have declined. Work is being undertaken to review the 12 indicators which have declined and an action plan will be developed to take action where possible. Further detail of the indicators identified as risks and the action being taken is provided in appendix 3. Prepared by: Nicola Jones Head of Compliance On behalf of: Faye Swanson Nigel Leonard Executive Director of Corporate Governance

http://www.cqc.org.uk/Provider/RWN


Intelligent Monitoring Report

February 2016

Report on

To view the most recent inspection report please visit the link below.


What does this report contain?

Further details of the analysis applied are explained in the accompanying guidance document.

What guidance is available?

We have published a document setting out the definition and full methodology for each indicator. If you have any queries or need more information,

please email [email protected] or use the contact details at www.cqc.org.uk/contact-us

We have used a number of statistical tests to determine where the thresholds of "risk" and "elevated risk" sit for each indicator, based on our judgement of

which statistical tests are most appropriate.Where an indicator has 'no evidence of risk' this refers to where our statistical analysis has not deemed there to

be a risk or elevated risk. For some data sources we have applied a set of rules to the data as the basis for these thresholds - for example concerns raised

by staff to CQC (and validated by CQC) are always flagged in the model.

South Essex Partnership University NHS Foundation Trust RWN

Intelligent Monitoring: Report published on 25 February 2016

CQC has developed a model for monitoring a range of key indicators about Trusts that provide Mental Health services. These indicators relate to the five

key questions we will ask of all services – are they safe, effective, caring, responsive and well-led? The indicators will be used to raise questions about the

quality of care. They will not be used on their own to make judgements. Our judgements will always be based on the result of an inspection, which

will take into account our Intelligent Monitoring analysis alongside local information from the public, the trust and other organisations.

This report presents CQC’s analysis of the key indicators (which we call ‘tier one indicators’) for South Essex Partnership University NHS Foundation Trust.

We have analysed each indicator to identify two possible levels of risk.


To view the most recent inspection report please visit the link below.

Intelligent Monitoring Report Page 2 of 6


http://www.cqc.org.uk/contact-us

RWN South Essex Partnership University NHS Foundation Trust

Overall 4 2 4

2

8

Number of "No Evidence of risk" 67

73

5.56%

144

1

Safety 14Safety Risk21 1

14

Responsiveness 1Responsiveness Risk

Responsiveness 2Responsiveness Risk

Responsiveness 4Responsiveness Elevated risk

Responsiveness 8Responsiveness Elevated risk

441

Well Led 12Well Led Risk1

Safe

Responsive

Well-led

Ratio of occupied beds to all nursing staff - ESR

Composite indicator to assess bed occupancy - MHA Database/KH03

Mental Health Act complaints received by CQC as a ratio to MHA activity - MHA Database/KP90

Fully and partially upheld investigations into complaints - PHSO

Composite Indicator: Proportion of Mental Health Act (MHA) and hospital inpatient episodes closed by the provider - MHLDDS


Trust Summary

Number of 'Risks'

Number of 'Elevated risks'

Overall Risk Score

Number of Applicable Indicators

Proportional Score

Maximum Possible Risk Score

Proportion of care spells where patients are discharged without a recorded crisis plan - MHLDDS

0 1 2 3 4 5 6 7

Overall

Count of 'Risks' and 'Elevated risks'

Risks

Elevated risks



Tier One Indicators

Key Question ID Indicators - Source From To Observed Expected Risk?

MHSAF07C Potential under-reporting of patient safety incidents - NRLS/MHLDDS-HES Bridged 01/11/2014 31/10/2015 0.18 0.10 No evidence of risk

MHSAFE06 Proportion of reported patient safety incidents that are harmful - NRLS 01/11/2014 31/10/2015 0.36 0.38 No evidence of risk

MHSDS_PMIN1Proportion of mortality among mental health inpatients aged 0-74 (death recorded in

ONS) - MHLDDS-HES/ONS01/07/2014 30/06/2015 0.01 0.01 No evidence of risk

MHSDS_PMCT1Proportion of mortality among people in contact with community mental health

services aged 0-74 (death recorded in ONS) - MHLDDS-HES/ONS01/07/2014 30/06/2015 0.01 0.01 No evidence of risk

MHSDS_PMCT2Proportion of mortality among people in contact with community mental health

services aged 0-74 (self-harm or undetermined ONS death) - MHLDDS-HES/ONS01/07/2014 30/06/2015 0.00 0.00 No evidence of risk

MHSAFE63Patients that die following injury or self-harm within 3 days of being admitted to

acute hospital beds - MHLDDS-HES Bridged01/07/2014 30/06/2015 0.00 n/a No evidence of risk

MHSAFE64People that take their own lives within 3 days of discharge from hospital - MHLDDS-

HES Bridged01/07/2014 30/06/2015 0.00 0.16 No evidence of risk

COM_MORT01Composite indicator showing trusts flagging for risk in relation to the number of

deaths of patients detained under the Mental Health Act - MHA database/MHLDDS01/08/2014 31/07/2015 n/a n/a No evidence of risk

MHMORT01Trusts flagging for risk in the number of suicides of patients detained under the

Mental Health Act (all ages) - MHA database/HSCIC KP9001/08/2014 31/07/2015 0.00 n/a No evidence of risk

MHMORT03

Trusts flagging for risk in relation to the number of deaths due to natural causes of

patients detained under the Mental Health Act (people aged under 75) - MHA

database/HSCIC KP90

01/08/2014 31/07/2015 * 1.34 No evidence of risk

NHSSTAFF11 Fairness and effectiveness of incident reporting procedures - NHS Staff Survey 01/09/2014 31/12/2014 0.65 0.63 No evidence of risk

NRLSL08MH Consistency of reporting to the National Reporting and Learning System - NRLS 01/10/2014 31/03/20156 months of

reportingn/a No evidence of risk

COM_CASMHComposite of Central Alerting System (CAS): Dealing with (CAS) safety alerts in a

timely way - CAS01/03/2009 31/10/2015 n/a n/a No evidence of risk

CASMH01A

The number of alerts which CAS stipulated should have been closed by trusts during

the preceding 12 months, but which were still open on the date CQC extracted data

from the CAS system - CAS

01/11/2014 31/10/2015 0 alerts still open n/a No evidence of risk

CASMH01B

The number of alerts which CAS stipulated should have been closed by trusts more

than 12 months before, but which were still open on the date CQC extracted data

from the CAS system - CAS

01/03/2009 31/10/2014 0 alerts still open n/a No evidence of risk

CASMH01CPercentage of CAS alerts with closing dates during the preceding 12 months which

the trust has closed late - CAS01/11/2014 31/10/2015

< 25% of alerts

closed laten/a No evidence of risk

MHRES20 Proportion of discharges from hospital followed up within 7 days - MHLDDS 01/07/2014 30/06/2015 0.62 0.70 No evidence of risk

NHSSTAFF07Proportion of staff receiving health and safety training in last 12 months - NHS Staff

Survey01/09/2014 31/12/2014 0.84 0.73 No evidence of risk

PLACE_MH01PLACE (patient-led assessments of the care environment) score for cleanliness of

environment - PLACE04/02/2015 30/06/2015 1.00 0.98 No evidence of risk

SAFEGUAR01 CQC’s National Customer Service Centre (NCSC) safeguarding concerns - CQC 01/11/2014 31/10/2015 53.00 25.12 No evidence of risk

MHESR01 Proportion of registered nursing staff - ESR 30/09/2015 30/09/2015 0.45 0.53 No evidence of risk

MHESR02 Ratio of occupied beds to all nursing staff - ESR 30/09/2015 30/09/2015 9.44 4.53 Risk

CMHSURA06Being informed: for having been told who is in charge of organising their care and

services - CMH Survey01/09/2014 30/11/2014 7.12 n/a No evidence of risk

CMHSURA38

Help finding support for physical health needs: for those with physical health needs

receiving help or advice with finding support for this, if they needed this - CMH

Survey

01/09/2014 30/11/2014 5.23 n/a No evidence of risk

MHCAR201Proportion of patient records checked that show evidence of a physical health check

on admission where the patient has been in hospital less than a year - MHA Database01/09/2014 31/08/2015 0.94 0.96 No evidence of risk

MHSDS_AE1Proportion of detained mental health inpatients who attend Accident and Emergency

departments - MHLDDS - HES bridged01/07/2014 30/06/2015 0.27 0.21 No evidence of risk

MHSDS_ACS1Proportion of emergency admissions of mental health inpatients for ambulatory care

sensitive conditions - MHLDDS - HES bridged01/07/2014 30/06/2015 0.28 0.35 No evidence of risk

MHCAR202Proportion of wards visited where there were difficulties in arranging GP services for

detained patients - MHA Database01/09/2014 31/08/2015 0.00 0.13 No evidence of risk

MHEFF107Proportion of patient records checked where care plans showed evidence of

discharge planning - MHA Database01/09/2014 31/08/2015 0.43 0.70 No evidence of risk

NAS_PH02Service users who had five individual cardiometabolic health risk factors monitored in

the past 12 months - NAS201/08/2013 30/11/2013 0.33 0.33 No evidence of risk

NAS_PH03 Monitoring of alcohol intake in the past 12 months - NAS2 01/08/2013 30/11/2013 0.70 0.71 No evidence of risk

NAS_PT01 Has cognitive behavioural therapy ever been offered to the service user? - NAS2 01/08/2013 30/11/2013 0.48 0.41 No evidence of risk

NAS_PT02 Has family intervention ever been offered to the service user? - NAS2 01/08/2013 30/11/2013 0.30 0.20 No evidence of risk

PLACE_MH02 PLACE (patient-led assessments of the care environment) score for food - PLACE 04/02/2015 30/06/2015 0.89 0.90 No evidence of risk

NHSSTAFF04 Proportion of staff appraised in last 12 months - NHS Staff Survey 01/09/2014 31/12/2014 0.93 0.87 No evidence of risk

NHSSTAFF05Proportion of staff having well-structured appraisals in last 12 months - NHS Staff

Survey01/09/2014 31/12/2014 0.48 0.41 No evidence of risk

NHSSTAFF06 Proportion of staff receiving support from immediate managers - NHS Staff Survey 01/09/2014 31/12/2014 0.72 0.70 No evidence of risk

MHSAFE51Proportion of patient records checked where the Responsible Clinician has recorded

their assessment of a patient's capacity to consent at first treatment - MHA Database01/09/2014 31/08/2015 0.55 0.67 No evidence of risk

MHCAR19Proportion of wards visited where there is an Independent Mental Health Advocacy

(IMHA) service available - MHA Database01/09/2014 31/08/2015 1.00 1.00 No evidence of risk

Safe

Effective



MHCAR20Proportion of wards visited where detained patients have direct access to the

Independent Mental Health Advocacy (IMHA) service - MHA Database01/09/2014 31/08/2015 0.95 0.95 No evidence of risk

MHEFF106Proportion of patient records checked where there was an approved mental health

practitioner (AMHP) report available - MHA Database01/09/2014 31/08/2015 0.80 0.77 No evidence of risk

MHSAFE52Proportion of patient records checked that show evidence of discussions about rights

on detention - MHA Database01/09/2014 31/08/2015 0.94 0.89 No evidence of risk

CMHSURA18Respect and dignity: for feeling that they were treated with respect and dignity by

NHS mental health services - CMH Survey01/09/2014 30/11/2014 8.39 n/a No evidence of risk

CMHSURA31 Time: for being given enough time to discuss their needs and treatment - CMH Survey 01/09/2014 30/11/2014 7.41 n/a No evidence of risk

PLACE_MH03PLACE (patient-led assessments of the care environment) score for privacy, dignity

and well being - PLACE04/02/2015 30/06/2015 0.93 0.90 No evidence of risk

CMHSURA10Involvement in planning care: for those who have agreed what care and services they

will receive, being involved as much as they would like in agreeing this - CMH Survey01/09/2014 30/11/2014 7.35 n/a No evidence of risk

CMHSURA12

Involvement in care review: for those who had had a formal meeting to discuss how

their care is working, being involved as much as they wanted to be in this discussion -

CMH Survey

01/09/2014 30/11/2014 7.49 n/a No evidence of risk

CMHSURA35Involvement in decisions: for those receiving medicines, being involved as much as

they wanted in decisions about medicines received - CMH Survey01/09/2014 30/11/2014 7.10 n/a No evidence of risk

CMHSURA42Involving family or friends: for NHS mental health services involving family or

someone else close to them as much as they would like - CMH Survey01/09/2014 30/11/2014 7.09 n/a No evidence of risk

NAS_SD01Was the patient provided with written information (or an appropriate alternative)

about the most recent antipsychotic prescribed? - NAS201/08/2013 30/11/2013 0.36 0.36 No evidence of risk

CMHSURA16Support: for the people seen through NHS mental health services helping them

achieve what is important to them - CMH Survey01/09/2014 30/11/2014 5.98 n/a No evidence of risk

COM_BEDS Composite indicator to assess bed occupancy - MHA Database/KH03 01/09/2014 30/09/2015 n/a n/a Risk

MHSAF65aOccupancy ratio, looking at the number of patients allocated to visited wards,

compared with the number of available beds - MHA Database01/09/2014 31/08/2015 0.83 n/a No evidence of risk

MHSAF65cOccupancy ratio, looking at the average daily number of available and occupied

consultant-led beds open overnight - KH0301/10/2014 30/09/2015 0.89 n/a Risk

PLACE_MH04 PLACE (patient-led assessments of the care environment) score for facilities - PLACE 04/02/2015 30/06/2015 0.96 0.92 No evidence of risk

CMHSURA23Contact: for knowing who to contact out of office hours if they have a crisis - CMH

Survey01/09/2014 30/11/2014 6.87 n/a No evidence of risk

CP_MH01Proportion of care spells where patients are discharged without a recorded crisis plan -

MHLDDS01/07/2014 30/06/2015 1.00 0.75 Elevated risk

COM_DtcMH01

Composite indicator using analysis of delayed transfers of care where bed data is

available (DTC46) and where it is not available (DTCMH01) - NHS England Delayed

Transfers of Care/KH03

01/07/2015 30/09/2015 n/a n/a No evidence of risk

DTC46

The ratio of the number of patients whose transfer of care is delayed to the average

daily number of occupied beds open overnight in the quarter, where the delay is

attributable to the NHS or both the NHS and social care - Delayed Transfers of

Care/KH03

01/07/2015 30/09/2015 0.00 0.03 No evidence of risk

DTCMH01Trusts where there is evidence of delayed transfers of care but no bed data available -

Delayed Transfers of Care01/07/2015 30/09/2015 No n/a No evidence of risk

CQC_COM02 Concerns and complaints received by CQC - CQC 01/11/2014 31/10/2015 68.00 42.06 No evidence of risk

PHSOMH01 Fully and partially upheld investigations into complaints - PHSO 01/04/2014 31/03/2015 6.00 1.95 Elevated risk

PROV_COM01 NHS written complaints - HSCIC 01/04/2014 31/03/2015 377.00 278.30 No evidence of risk

MHA_COMP01Mental Health Act complaints received by CQC as a ratio to MHA activity - MHA

Database/KP9001/11/2014 31/10/2015 23.30 n/a Risk

COM_CPEMHComposite Indicator: Proportion of Mental Health Act (MHA) and hospital inpatient

episodes closed by the provider - MHLDDS01/07/2014 30/06/2015 n/a n/a Risk

MHSDS_CPE01Proportion of provider closed episodes of patients detained under the Mental Health

Act (MHA) - MHLDDS01/07/2014 30/06/2015 0.92 n/a No evidence of risk

MHSDS_CPE02 Proportion of provider closed hospital inpatient episodes - MHLDDS 01/07/2014 30/06/2015 0.75 n/a Risk

MONITOR_MH01 Monitor: risk rating for governance - Monitor 17/11/2015 17/11/2015Monitor risk rating:

No evident concernsn/a No evidence of risk

TDA_MH01 NHS Trust Development Authority escalation score - TDA Not included Not included Not included Not included Not included

FLUVACMH01Proportion of Health Care Workers with direct patient care that have been vaccinated

against seasonal influenza - Department of Health01/09/2014 28/02/2015 0.31 0.43 No evidence of risk

MHWEL137 Proportion of days sick in the last 12 months for medical and dental staff - ESR 01/10/2014 30/09/2015 0.02 0.02 No evidence of risk

MHWEL138 Proportion of days sick in the last 12 months for nursing and midwifery staff - ESR 01/10/2014 30/09/2015 0.06 0.05 No evidence of risk

MHWEL139 Proportion of days sick in the last 12 months for other clinical staff - ESR 01/10/2014 30/09/2015 0.05 0.05 No evidence of risk

MHWEL140 Proportion of days sick in the last 12 months for non-clinical staff - ESR 01/10/2014 30/09/2015 0.04 0.04 No evidence of risk

NHSSTAFF16Proportion of staff reporting good communication between senior management and

staff - NHS Staff Survey01/09/2014 31/12/2014 0.35 0.31 No evidence of risk

Effective

Caring

Responsive

Well-led



NHSSTAFF20Proportion of staff feeling pressure to attend work when feeling unwell in the last 3

months - NHS Staff Survey01/09/2014 31/12/2014 0.19 0.21 No evidence of risk

NTS12_MH01 General Medical Council national training survey – trainee's overall satisfaction - GMC 24/03/2015 06/05/2015Within the middle

quartile (Q2/IQR)n/a No evidence of risk

STASURBG01Proportion of staff who would recommend the trust as a place to work or receive

treatment - NHS Staff Survey01/09/2014 31/12/2014 0.65 0.63 No evidence of risk

GMC_MH01 General Medical Council enhanced monitoring - GMC 01/06/2015 30/06/2015 No concerns n/a No evidence of risk

MHRES17 Proportion of wards visited that have community meetings - MHA Database 01/09/2014 31/08/2015 0.84 0.92 No evidence of risk

WBLOW_MH01 Snapshot of whistleblowing alerts received by CQC - CQC 16/11/2015 01/02/2016 0.00 n/a No evidence of risk

COM_CMHS

Composite indicator to assess occurrence of sampling errors or non-submission of

data to the two most recent iterations of the Community Mental Health Survey - CMH

Survey

01/09/2013 30/11/2014 n/a n/a No evidence of risk

CMHS_CURROccurrence of sampling errors or non-submission of data relating to the current

iteration of the Community Mental Health Survey - CMH Survey01/09/2014 30/11/2014

Submission, no

errorsn/a No evidence of risk

CMHS_PREVOccurrence of sampling errors or non-submission of data relating to the previous

iteration of the Community Mental Health Survey - CMH Survey01/09/2013 30/11/2013

Submission, no

errorsn/a No evidence of risk

MONITOR_MH02 Monitor: continuity of service rating - Monitor 17/11/2015 17/11/20154: no evident

concernsn/a No evidence of risk

SYEMH Negative comments submitted to Share Your Experience - CQC 01/10/2014 30/09/2015 10.00 15.00 No evidence of risk

P_OPINIONMH Negative comments submitted to Patient Opinion sources - Patient Opinion 01/08/2014 31/07/2015 0.00 3.86 No evidence of risk

Rounding: All observed values have been rounded to two decimal places. Therefore, numbers that are less than 0.005 may be displayed on this report as '0.00'. The datasheet contains the numbers used to calculate the indicators.

Suppression: We apply a strict statistical disclosure control in accordance with the HES protocol to all published data. This requires that small numbers are suppressed to prevent individuals being identified and to ensure that patient

confidentiality is maintained. An asterisk (*) in the observed column indicates a suppressed value between 1 and 5.

Not applicable or N/A Values: “n/a” is used to mean either that an expected value is not relevant to a specific indicator because the indicator is rules based or the indicator does not have an observed value.

Well-led

Cross cutting


Comparison with other Organisations Appendix 2

Name Risks Comp Elevated Risks Comp Risk Score Comp Prop Score Comp Total Trusts 56 Average Trust Comp

Dudley and Walsall Mental Health Partnership NHS Trust 0 -4 0 -2 0 -8 0.00% -5.56% Total Risks 254 4.5 0.5

Tavistock and Portman NHS Foundation Trust 0 -4 0 -2 0 -8 0.00% -5.56% Total Elevated 75 1.34 -0.66

Dorset Healthcare University NHS Foundation Trust 1 -3 0 -2 1 -7 0.70% -4.86% Total Risk Score 404 7.2 -0.8

North Staffordshire Combined Healthcare NHS Trust 1 -3 0 -2 1 -7 0.70% -4.86% Total Prop Score 297.01% 5.30% -0.26

Rotherham, Doncaster and South Humber NHS Foundation Trust 0 -4 1 -1 2 -6 1.39% -4.17%

Berkshire Healthcare NHS Foundation Trust 3 -1 0 -2 3 -5 2.08% -3.48%

Bradford District Care Trust 3 -1 0 -2 3 -5 2.08% -3.48%

Tees, Esk and Wear Valleys NHS Foundation Trust 3 -1 0 -2 3 -5 2.08% -3.48%

Kent and Medway NHS and Social Care Partnership Trust 3 -1 0 -2 3 -5 2.11% -3.45%

South West London and St George's Mental Health NHS Trust 1 -3 1 -1 3 -5 2.11% -3.45%

Pennine Care NHS Foundation Trust 3 -1 0 -2 3 -5 2.24% -3.32%

East London NHS Foundation Trust 4 0 0 -2 4 -4 2.78% -2.78%

Birmingham and Solihull Mental Health NHS Foundation Trust 4 0 0 -2 4 -4 2.78% -2.78%

Oxleas NHS Foundation Trust 4 0 0 -2 4 -4 2.78% -2.78%

South West Yorkshire Partnership NHS Foundation Trust 4 0 0 -2 4 -4 2.78% -2.78%

Sheffield Health and Social Care NHS Foundation Trust 4 0 0 -2 4 -4 2.82% -2.74%

Lincolnshire Partnership NHS Foundation Trust 4 0 0 -2 4 -4 2.99% -2.57%

North East London NHS Foundation Trust 3 -1 1 -1 5 -3 3.47% -2.09%

2gether NHS Foundation Trust 3 -1 1 1 5 -3 3.47% -2.09%

Black Country Partnership NHS Foundation Trust 5 1 0 -2 5 -3 3.47% -2.09%

Cornwall Partnership NHS Foundation Trust 5 1 0 -2 5 -3 3.47% -2.09%

South London and Maudsley NHS Foundation Trust 3 -1 1 -1 5 -3 3.50% -2.06%

Avon & Wiltshire Mental Health Partnership NHS Trust 3 -1 1 -1 5 -3 3.52% -2.04%

Cambridgeshire and Peterborough NHS Foundation Trust 5 1 0 -2 5 -3 3.52% -2.04%

Leeds and York Partnership NHS Foundation Trust 6 2 0 -2 6 -2 4.17% -1.39%

Oxford Health NHS Foundation Trust 4 0 1 -1 6 -2 4.17% -1.39%

Surrey and Borders Partnership NHS Foundation Trust 4 0 1 -1 6 -2 4.17% -1.39%

Northumberland, Tyne and Wear NHS Foundation Trust 4 0 1 -1 6 -2 4.23% -1.33%

Solent NHS Trust 4 0 1 -1 6 -2 4.23% -1.33%

Worcestershire Health and Care NHS Trust 4 0 1 -1 6 -2 4.35% -1.21%

Humber NHS Foundation Trust 5 1 1 -1 7 -1 4.86% -0.70%

South Staffordshire and Shropshire Healthcare NHS Foundation Trust 7 3 0 -2 7 -1 4.86% -0.70%

Hertfordshire Partnership NHS Foundation Trust 1 -3 3 1 7 -1 4.90% -0.66%

Somerset Partnership NHS Foundation Trust 4 0 1 -1 6 -2 4.92% -0.64%

Barnet, Enfield and Haringey Mental Health NHS Trust 7 3 0 -2 7 -1 4.93% -0.63%

Devon Partnership NHS Trust 5 1 1 -1 7 -1 5.30% -0.26%

Central and North West London NHS Foundation Trust 8 4 0 -2 8 0 5.56% 0.00%

South Essex Partnership (SEPT) 4 N/A 2 N/A 8 N/A 5.56% N/A

Greater Manchester West Mental Health NHS Foundation Trust 7 3 1 -1 9 1 6.29% 0.73%

Cumbria Partnership NHS Foundation Trust 7 3 1 -1 9 1 6.72% 1.16%

Southern Health NHS Foundation Trust 1 -3 4 2 9 1 6.72% 1.16%

Camden and Islington NHS Foundation Trust 4 0 3 1 10 2 7.04% 1.48%

Mersey Care NHS Trust 6 2 2 0 10 2 7.04% 1.48%

Northamptonshire Healthcare NHS Foundation Trust 5 1 2 0 9 1 7.50% 1.94%

Leicestershire Partnership NHS Trust 6 2 2 0 10 2 7.63% 2.07%

5 Boroughs Partnership NHS Foundation Trust 7 3 2 0 11 3 7.64% 2.08%

Derbyshire Healthcare NHS Foundation Trust 3 -1 4 2 11 3 7.64% 2.08%

Cheshire and Wirral Partnership NHS Foundation Trust 4 0 3 1 10 2 8.06% 2.50%

West London Mental Health NHS Trust 6 2 3 1 12 4 8.45% 2.89%

Lancashire Care NHS Foundation Trust 10 6 2 0 14 6 9.72% 4.16%

Manchester Mental Health and Social Care Trust 9 5 2 0 13 5 9.85% 4.29%

Sussex Partnership NHS Foundation Trust 6 2 6 4 18 10 12.50% 6.94%

North Essex Partnership University NHS Foundation Trust 10 6 4 2 18 10 12.50% 6.94%

Coventry and Warwickshire Partnership NHS Trust 13 9 3 1 19 11 14.39% 8.83%

Norfolk and Suffolk NHS Foundation Trust 5 1 8 6 21 13 15.79% 10.23%

Isle of Wight NHS Trust 9 5 4 2 17 9 18.48% 12.92%

Appendix 3

CQC MH Intelligence Monitoring Report

For the Trust the following indicators have been listed as an Elevated Risk:

Indicator Data Period

Data Comparison against last report

Comments Action Taken

Proportion of discharged patients without a recorded crisis plan (CP_MH01)

July 2014 – June 2015

1.00 (100%)

New indicator The data is calculated by the total number of patients discharged without a crisis plan against the total number of patients discharged. The data indicates that 100% of patients discharged did not have a crisis plan. This data is correct. It should be noted that this is the indicator which the most trusts were rated as elevated risk.

Action is being taken to develop a specific crisis plan electronically. Crisis plans are currently included in care plans but systems not in place to routinely report that they meet criteria to HSCIC.

Fully and partially upheld investigations into complaints (PHSOMH01)

April 2014 – March 2015.

6.00 Previously listed as “3 to 5” and given as a “Risk”

The data is calculated by a count of the total number of fully or partially upheld complaints against the total number of patients. This data is correct: 1 partially upheld complaint may relate to a complaint made in 2009 for Bedfordshire and Luton Mental Health services, which is prior to the Trust acquiring the services. The investigation was commenced in 2011 and not concluded until 2014.

The Complaints Team monitor all complaints and action is being taken to improve the quality of responses. A report is provided to the Executive Operational Committee on a bi-weekly basis providing details of any complaints referred to the Ombudsman and any recommendations made as a result of their investigation.

The following indicators have been listed as a Risk:


Data Comparison with June 2015


Ratio of occupied beds to all nursing staff (MHESR02)

30th Sept 2015

9.44 Increase from 4.87

This indicator relates the number of occupied beds to the number of qualified nursing staff on Inpatient wards. The National average is 4.53. The data is correct.

The ratio of beds to nurses can only be resolved by recruiting to vacancies and there is currently a project reviewing this. However, it should be noted that safer staffing is in place and is monitored on a daily basis to ensure there are enough staff to safely operate inpatient areas.

Mental Health Act complaints received by CQC as a ratio to MHA activity (MHA_COMP01)

Nov 2014 –

Oct 2015

23.30 New Indicator

This data is calculated by the total number of MHA complaints against the total number of detentions and CTO’s. The CQC confirmed that complaints made to them regarding MHA which are only forwarded to the Trust if permission is received from the complainant and that they have sent 10 of the 24 complaints received to the Trust. Further internal investigation has identified that there is a potential gap in internal systems as these complaints are not passed to the Complaints Department.

A process has now been developed to ensure any incoming concerns / enquiries from the CQC are recorded via complaints team to ensure these can be monitored and analysed for any trends. Action is also being taking to review historic information received from the CQC to analyse trends and identify any hotspots.

Composite indicator to assess bed occupancy (COM_BEDS)


Data Comparison with June 2015


Occupancy ratio, looking at the average daily number of available and occupied beds open overnight (MHASAF65c)

Oct 2014 – Sept 2015

0.89 No change This data is calculated by a count of the number of occupied beds against the total number of beds available overnight. This data is correct.

The occupancy ratio is higher than the RCPSYch benchmark, but this is in line with all mental health units as there is a need to maximise the use of beds and deliver efficiencies.

Composite Indicator: Proportion of Mental Health Act (MHA) and hospital inpatient episodes closed by the provider (COM_CPEMH)

Proportion of provider closed hospital inpatient episodes (MHSDS_CPE02)

July 2014 – June 2015

0.75 New Indicator

This data is calculated from the number of Provider closed Hospital Inpatient Episodes where the provider has informed the HSCIC against the total number of closed Hospital Inpatient Episodes. This data is correct.

The indicator is measured on a system where it is looking for activity from month-to-month. If the system finds that no activity for a patient has been inputted, it automatically discharges from the system. Therefore, the data from the CQC could relate to two scenarios:

There was a one off issue in Beds & Luton when the patients were transferred to ELFT

The Inpatient discharges from the ward are not completed timely on the Trust Inpatient system, therefore patients are being retrospectively discharged but this is too late to be captured on the datasets sent to HSCIC

The Information Team is currently analysing the data set for April 2015 to check if the issue relating to Beds & Luton is the problem. If this is not the case, a full monthly analysis of the data sets will be undertaken to understand whether there is an issue with late discharging.

#8(d) Board of Directors Meeting Part 2 30 March 2016 Page 1 of 3

Agenda Item: 8(d)

SUMMARY REPORT

BOARD OF DIRECTORS PART 1 MEETING

30 March 2016

Report title: Views of Governors and Members Report Non-Executive Lead: Lorraine Cabel, Chair

Report Author(s): Cathy Lilley, Acting Trust Secretary & Business Administration Manager (Chair’s Office)

Report discussed previously at: n/a

Level of Assurance:

Level 1

2

3


This report is provided to the Board of Directors by the Chair of the Trust and outlines the approach the Trust takes in ensuring that the views of Governors and members are communicated to the Board as a whole.

Approval

Discussion

Information


The Board of Directors is asked to note the opportunities in the Trust for engaging and gathering views which are directly related to the role of the Council of Governors (Council).


One of the main principles of Monitor’s NHS Foundation Trust Code of Governance (revised July 2014) focuses on relations with stakeholders, and in particular there is dialogue with members, patients and the local community. This report provides assurance to the Board that the Trust is meeting Code provision E.1.3 which states that the “The Chair should ensure that the views of Governors and members are communicated to the Board as a whole. The Chair should discuss the affairs of the Trust with Governors. Non-Executive Directors should be offered the opportunity to attend meetings with Governors and should expect to attend them”. The Trust encourages quality engagement with stakeholders and regularly consults and involves Governors, members, patients and the local community through various routes. It also supports Governors in ensuring they represent the interests of the Trust’s members and the public, through seeking their views and keeping them informed. This report focuses on those opportunities for engagement and gathering views which are directly related to the role of the Council of Governors (Council). However, it should be recognised that the Trust has a wider framework of strategies and activities which addresses patient engagement and experience, equality and diversity, and communications.


The Trust’s membership strategy sets out a series of objectives for the Trust to continue to encourage a wide and diverse membership with a focus on quality engagement, which is delivered through an action plan and within the wider framework of Trust strategies as mentioned above. Listed below are some examples of how the Trust engages and gathers views of Governors and members; it should be recognised, however, that this list is not exhaustive:

Attendance and agenda item presentations by Executive Directors and NEDs at all Council meetings held quarterly

These standing agenda items include a report on Trust’s performance and finances, and quality. Other items during the year included updates on significant transactions including potential merger, tender outcomes, CQC comprehensive inspection visit, etc

Holding Council meetings in public

NEDs and Governors informal meetings held quarterly

CEO briefing sessions with Governors held quarterly

Lead Governor/Governor Coordinator meetings with Chair and Senior Independent Director held quarterly

Lead Governor and Senior Independent Director meetings

Attendance by Governors at Board of Director meetings

Governor Strategic Planning Working Group led by Executive Director Corporate Governance

Joint Director/Governor Task & Finish Groups

Public member meetings – topics covered include safe services: protecting patients and staff and provided members and the public to meet with the Chair, CEO, Directors, Senior Managers and Governors

Annual members meeting

Annual planning events

Our website www.sept.nhs.uk

In addition, the Trust fosters an ‘open door’ policy where issues, queries and feedback can be raised with the Chair, the CEO and any Board member as appropriate either on a face to face basis or via email. Feedback and views are captured and shared with the Board as described above and are also reported, for example, through:

Report from the Council in the Trust’s Annual Report

Statement from the Council in Trust’s Quality Report/Account

Annual members meeting

SEPT News (membership newspaper).






http://www.sept.nhs.uk/




No

If yes, insert relevant risk n/a


No



Data Quality Issues

Involvement of Service Users/ Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains


Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity

Equality Impact Assessment (EIA) Completed? Yes / No If yes, EIA Score


NED Non-Executive Director(s) CEO Chief Executive Officer


Main report

Executive Lead

Lorraine Cabel Chair of the Trust Chair of the Board of Directors Nominations Committee