the state hospitals board for scotland a g e n d a papers/2017... · 2017-10-26 · the state...

THE STATE HOSPITALS BOARD FOR SCOTLAND

Meeting of The State Hospitals Board for Scotland to be held on Thursday 26 October 2017 at 9.30am in the Boardroom, The State Hospital, Carstairs

A G E N D A

1 Apologies for absence and Chair’s introductory remarks - Chair 2 Conflicts of Interest - Chair 3 To approve the Minutes of the previous meetings held on 24 August 2017 For Approval Enclosed - Chair 4 Action Points and Matters Arising from previous minute Enclosed - Chair 5 Board Development Day Update Enclosed - Chief Executive

CLINICAL GOVERNANCE 6 Strengthening the Patient Voice at Board Meetings For Approval Enclosed - Report by Nursing and AHP Director

7 Educational Supervisor Annual Report For Noting Enclosed - Report by Medical Director 8 Forensic Network Annual Report For Noting Enclosed - Report by Medical Director

STAFF GOVERNANCE 9 Performance Management Nursing Resource Utilisation Data For Noting Enclosed - Report by Finance and Performance Director 10 Staff Governance Committee Meeting held on 17 August 2017 - Draft Minutes – Chair of Committee For Noting Enclosed /…..

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Continued /…..

CORPORATE GOVERNANCE 11 Board Diagnostic Tool For Approval Enclosed - Report by Chairman 12 Finance Report as at 30 September 2017 For Noting Enclosed - Report by Finance and Performance Management Director 13 LDP Performance Report as at 30 September 2017 For Noting Enclosed - Report by Finance and Performance Management Director 14 Information Governance Annual Report For Noting Enclosed - Report by Finance and Performance Management Director 15 Climate Change Report For Noting Enclosed - Report by Finance and Performance Management Director 16 Audit Committee Meeting held on 14 September 2017 For Noting Enclosed - Draft Minutes – Chair of Committee 17 State Hospital Draft Service Strategy 2017 - 2020 For Approval Enclosed - Report by Nursing and AHP Director 18 Final Draft State Hospital Service Strategy 2017-2020 For Approval Enclosed - Report by Nursing and AHP Director 18a Strategic Priorities – Delivery Plan For Noting Enclosed

− Report by Chief Executive

19 McCann v The State Hospital For Noting Enclosed - Report by Security Director 20 Chief Executive’s Report For Noting Enclosed - Report by Chief Executive 21 Annual Schedule of Board and Sub Board Meetings 2018 – draft For Approval Enclosed - Report by Chair 22 Any Other Business 23 Date and Time of next meeting Thursday 14 December 2017 at 9.45am in the Boardroom, The State Hospital, Carstairs 24 Exclusion of Public and Press

To consider whether to approve a motion to exclude the public and press during consideration of the items listed at Part II of the agenda in view of the confidential nature of the business to be transacted.

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THE STATE HOSPITALS BOARD FOR SCOTLAND Minutes of the meeting of The State Hospitals Board for Scotland held on Thursday 24 August 2017 at 9.45am in the Boardroom, The State Hospital, Carstairs. Present: Non Executive Director Bill Brackenridge Non Executive Director Elizabeth Carmichael Chair Terry Currie Employee Director Anne Gillan Non Executive Director Nicholas Johnston Non- Executive Director Maire Whitehead Chief Executive James Crichton Finance and Performance Management Director Robin McNaught Nursing and Allied Health Professions Director Mark Richards Medical Director Lindsay Thomson In attendance: Mental Health Manager for Social Work Service Kathy Blessing Security Director Doug Irwin Board Secretary Jean Wade Interim HR Director John White Observing: Boardroom Development Limited Margaret Williamson 1 APOLOGIES FOR ABSENCE AND INTRODUCTORY REMARKS Apologies were received from Caroline McCarron. Terry Currie welcomed everyone to the meeting and introduced Margaret Williamson, who was attending as an observer at successive meetings. Members noted an update from Terry Currie. The Cabinet Secretary’s meeting with the Board Chairs is scheduled to take place on Monday 28 August and a report will be provided at the next Board meeting which will be held on 26 October 2017. Members were asked to note that the third Masterclass on Quality Improvement which was scheduled to take place on 4 September 2017 has been cancelled. Terry Currie reported that the outline business case for the major capital project is progressing. He stated that the next level of approvals may be required sometime in September, which falls in between scheduled Board meetings. If this occurs, he gave note of his intention to call a special Board meeting to deal with this to ensure that the approval process can progress in a timely manner. Terry Currie also referred to the 2016 / 2017 Annual Review which is due to take place on Thursday 28 September 2017. Consideration has been given to revising the format of the public meeting in order to generate a good discussion on the key issues which must be addressed.

Action: Jim Crichton, Senior Team

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2 CONFLICTS OF INTEREST Other than those declared at earlier meetings, no other conflicts of interest were noted in respect of the business to be discussed. 3 MINUTES OF THE PREVIOUS MEETING The Minutes of the previous meeting held on 29 June 2017 were approved as an accurate record.

4 ACTION POINTS AND MATTERS ARISING FROM PREVIOUS MEETING All actions were completed or progressing satisfactorily. 5 APPROVED MEDICAL PRACTITIONER – REQUEST FOR SECTION 22 STATUS Members received a report from the Medical Director in respect of the Approved Medical Practitioner - Request for Section 22 Status. Lindsay Thomson informed members that following the successful recruitment of a Forensic Psychiatry Specialty Doctor is was necessary for the Board to consider the approval of their Approved Medical Practitioner Status. Lindsay Thomson confirmed that the Forensic Psychiatry Specialty Doctor has completed the pre-requisite Section 22 training in line with Mental Health (Care and Treatment) (Scotland) Act 2003. The Board approved Dr Amy Preston as Approved Medical Practitioner in line with the Mental Health (Care and Treatment) (Scotland) Act 2003 and she will be formally placed on the TSH Board’s list of Approved Medical Practitioners. 6 ANNUAL REPORT TO THE SCOTTISH GOVERNMENT ON THE IMPLEMENTATION OF

SPECIFIED PERSONS REGULATIONS Members received a report from Doug Irwin. The Safety and Security Regulations place a duty on The State Hospital to furnish the Scottish Government with an annual report on the implementation of the regulations. In the interests of openness and transparency, the annual report to the Scottish Government also includes information on the implementation of the regulations relating to correspondence and telephones. Doug Irwin informed members that there were no significant variations from the previous year’s report, however new technology and an associated policy are in the process of being introduced, this will allow staff to hear both sides of the call and allow recording of calls if deemed necessary. Members approved the Annual Report to the Scottish Government on the Implementation of Specified Persons Regulation. 7 CLINICAL GOVERNANCE COMMITTEE MEETING HELD ON 10 AUGUST 2017 Members received the draft Minutes of the Clinical Governance Committee meeting held on 10 August 2017 from Nicholas Johnston who summarised key points of the discussion that had taken place. Members noted the Minutes of the Clinical Governance Committee meeting held on 10 August 2017. 8 STAFF GOVERNANCE COMMITTEE MEETING HELD ON 17 AUGUST 2017 Members noted the draft Minutes of the Staff Governance Committee meeting held on 17 August 2017 were not available. John White provided members with a brief update on the following topics:

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EASY report August 2017 The State Hospital have implemented EASY (Early Access to Support for You) service as from 1st April 2017. The Easy service is telephone based sickness absence management service designed to provide additional support to staff who are off sick. The service was implemented in two phases. Phase 1 on 1 April 2017 and Phase 2 on 1 June 2017. Managers should refer staff to Easy on the first day of sickness. Staff will be called by Easy Service on day 1, 3 (for MH issues) and day 10. Members noted that the compliance rate at June 2017 was 62.5%. SWISS The sickness absence figure from 1 June 2017 to 30 June 2017 is 7.81% with the long/short term split being 3.91% and 3.90% respectively. The total hours lost for this period is 7,483.00 which equates to 45.97 wte. SSTS Industrial injuries represented 0.45% of available hours (5288.59) from 1 July 2016 to 30 June 2017. This represents an increase over the previous yearly figure for June 2016 to May 2017 of 18.42% from 0.38% (823 hours) Members noted the information received and were re-assured by the important and consistent processes in place. 9 FINANCE REPORT The finance report presents the financial results to month 4 – 31 July. A small underspend of £22k has been reported. At this stage last year we had a £(47)k overspend. Within individual budgets, the main variance continues to be nursing costs and overtime within the General Manager directorate. Ward nursing’s adverse variance of £(347)k is close to the same period last year (£(372)k). While the levels of clinical activity and sickness are high, work is ongoing on breaking down the figures on a weekly basis to specify the number of overtime hours attributable to each specific cause (clinical, sickness, outings etc.). Discussion and reviews continue on individual budget savings plans with the focus remaining on reducing any element of unidentified savings that we have still to address this year and to reduce the proportion of non-recurring. The principal focus is now being directed towards the contribution of £440k which is required as part of the National Boards’ £15m savings target. The capital resource budget is anticipated to be fully utilised in 2017/18. Members noted the Finance report as at 31 July 2017. 10 LDP PERFORMANCE REPORT AS AT 31 JULY 2017 The LDP / KPI report is presented for the period to June 2017. Paragraph 3 highlights the areas where we are doing very well, and those where additional work and focus is required. Key areas of concern continue to be patient activity, patient BMI and sickness levels. The paper also highlights the fact that work is underway on the key area of business intelligence / data warehousing options and systems support that will contribute to this overall project and improving the reporting of relevant information.

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Members noted the LDP Performance Report as at 31 July 2017. 11 WINTER PLANNING Members received a report from Doug Irwin regarding The State Hospitals Board for Scotland Winter Plan 2017 – 2018. Members noted that the DL (2016) 18 requires the development of a winter plan by the Board for publication and submission to the Scottish Government NHSS Directorate for Health Performance. The main areas of concern highlighted within DL (2016) 18 and appendices are primarily the concern of territorial Boards and do not have any significant effect on The State Hospital. A business continuity plan is in place to mitigate the effect of reduced staffing during severe weather and other plans exist to maintain essential services, utilities and the supply chain and are regularly reviewed. Members approved the 2017-2018 Winter Plan for submission to the Scottish Government NHSS Directorate for Health Performance and publication on the State Hospital website. 12 FIRE RISK ASSESSMENTS AND CLADDING Members received a report from Doug Irwin on the Fire Risk Assessments and Cladding. Doug Irwin informed members that a review of all cladding on State Hospital buildings had taken place and is being incorporated into the Fire Risk Assessments. Following the Grenfell Tower fire all NHS Scotland facilities have been inspected for cladding at the request of the Scottish Government. Particular concern exists around any aluminium composite cladding 18 metres from ground level. The State Hospital has a small number of buildings, all recently constructed, allowing our assessment of risk to have been rapidly completed. Members noted that each of our newer buildings have cladding, as has Harris. The cladding to the newest buildings is aluminium, but is not aluminium composite cladding, the cladding form that was used on Grenfell Tower. Harris has a copper cladding. The cladding used in the Hospital and the method of its use pose a very low fire risk. Members noted the content of this paper. 13 COMMUNICATIONS ANNUAL REPORT Members received a report from Jim Crichton. The Communications Annual Report covers performance from 1 April 2016 to 31 March 2017. All communications activity supports the Board in the delivery of its core objectives and legal obligations. The establishment of a Communications Annual Report is therefore an important assurance process in considering the effectiveness of State Hospital internal and external communications. All priority commitments strategically and operationally were met or exceeded. This included key performance indicators, quality assurance objectives, quality improvement objectives and devolved communications tasks deriving from the Boards Scheme of Delegation. The primary challenge for the service remains one of a high volume of activity and limited staffing resource. The service remains committed to continuous improvement. The Board noted the Communications Annual Report 2016 – 2017.

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14 AUDIT COMMITTEE MEETING HELD ON 29 JUNE 2017 Members received the draft Minutes for the Audit Committee held on Thursday 29 June 2017 from Elizabeth Carmichael who summarised key points of the discussion that had taken place. The key items discussed included the receipt of the Annual Reports from other Governance Committees and the External Audit Annual Report. The Committee received the Statutory Annual Accounts and was able to recommend approval by the Board. The Committee also approved the Annual Audit Committee Assurance Statement to the Board. Members noted the Minutes of the Audit Committee meeting held on 29 June 2017. 15 CHIEF EXECUTIVES REPORT Members received a report from Jim Crichton which highlight issues in the Hospital which do not feature on the Board’s formal agenda. Jim Crichton provided members with a verbal update on the following points: General Practice Provision Due to sessional changes in the Practice, Forth Medical Practice will no longer be able to provide GP services to the State Hospital from 1 November 2017. Discussions are taking place with Medwyn Medical Practice regarding extending their current provision to cover the forthcoming gap. An update will be provided to the Board on the outcome of these discussions. Corporate Parenting Under Part 9 of the Children and Young People (Scotland) Act 2014, there is a duty upon Boards as corporate parents. As part of this, a corporate parent must prepare, keep under review and publish a Corporate Parenting Plan. The Plan must set out how the organisation intends to meet its corporate parenting responsibilities as defined in the Act. Executive responsibility sits with the Director of Nursing and AHPs. A plan is under development and will be presented at a future Board meeting as part of the engagement process and to ensure that all Board members are sighted on the Boards responsibilities under the Act. Supporting Healthy Choices The Supporting Healthy Choices Implementation Group have developed an implementation plan to support the process around cessation of patient ordering of food / fluid items via external procurement. A lead in period has been agreed with the Senior Team with external procurement of food items ceasing from 1 November 2017. The Lead in period will enable clinical teams to support those patients at risk of behavioural changes resulting from this change and ensure support mechanisms are in place during this transition. 16 ANNUAL SCHEDULE OF BOARD AND SUB BOARD MEETINGS – 2018 (DRAFT) Members received the draft Annual Schedule of Meetings for the Board and Sub Board Committees in 2018. Members discussed the Annual Schedule of Meetings for 2018, these will be finalised at the October Board meeting. 17 ANY OTHER BUSINESS There was no other Business. 18 DATE AND TIME OF NEXT MEETING The next meeting would take place on Thursday 26 October 2017 at 9.45am in the Boardroom, The State Hospital, Carstairs.

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19 EXCLUSION OF PUBLIC AND PRESS Members approved a motion to exclude the public and press during consideration of the items listed at Part II of the agenda in view of the confidential nature of the business to be transacted. ADOPTED BY THE BOARD CHAIR __________________________________________ (Signed Terry Currie) DATE 26 October 2017

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 26 October 2017 Agenda Reference: Item No: 05 Sponsoring Director: Chief Executive Author(s): Chief Executive Title of Report: State Hospital Board Development Session 24 August 2017 Purpose of Report: For Information 1 SITUATION The State Hospitals Board had a development session on 24 August 2017. The following paper outlines the issues discussed and action points arising for approval. 2 BACKGROUND The State Hospital Board held a development session to allow a discussion on two elements of resilience: “organisational resilience” in terms of the services ability to deliver on its strategic objectives and “leadership resilience” related to forthcoming non-executive and executive turnover in positions. 3 ASSESSMENT Organisational Resilience

The Board received a presentation from the Chair of the Audit Committee on both the progress which the Executive Team have made on improving the service, while recognising that there were significant challenges ahead which will only become more pressing if not addressed effectively. Recent reports by the Care Quality Commission of High Secure Hospitals in England have focussed on a number of workforce related challenges which have impacted on the quality of patient care. We must seek to avoid similar difficulties within our own service and effective workforce planning is key. While the quality of workforce information and related clinical activity is improving, it is not yet as a stage where we can fully understand the complex drivers that impact on nursing workforce requirements on a daily basis. It is clear that nursing absence levels combined with fluctuating clinical activity are the two most significant drivers. Further information is required to ensure that resources are being deployed as effectively as possible. Actions Agreed The Chief Executive will ensure that work on the workforce information systems is accelerated with a view to providing a system of data collection and reporting that is consistent and more clearly reports on utilisation of nursing resources. The Chief Executive will progress dialogue with Meridian regarding an assessment of current nursing workforce utilisation and update the Board at a future meeting.

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Leadership Resilience There will be staff turnover in a number of Executive and Non Executive positions in 2018 / 19. As outlined in the workforce plan and previous discussions with the Board, the Executive Team will manage these changes to ensure leadership resilience over that period and mitigate any risks in terms of knowledge loss or focus on strategic objectives. The Chairman provided an update on the position with Non Executive posts including his own which will be vacated on the 31 of March 2019. One additional Non Executive will complete their term in November 2018. The Chief Executive updated on Executive and Senior Management positions and outlined transitional arrangements being put in place for the Director of Security; Head of Estates and Clinical Operations Manager. Two further positions were discussed but not finalised at this stage. Actions Agreed The Chairman and Chief Executive will continue to update the Board on progress with the recruitment process and transitional management arrangements at future meetings. 4 RECOMMENDATION

The Board is asked to agree the action points outlined in the paper.

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MONITORING FORM

How does the proposal support current Policy / Strategy / LDP / Corporate Objectives

Service Strategy / Corporate Objectives / Corporate Governance

Workforce Implications None

Financial Implications None

Route To Board Which groups were involved in contributing to the paper and recommendations.

Executive Team NHS Board

Risk Assessment (Outline any significant risks and associated mitigation)

None

Assessment of Impact on Stakeholder Experience

Positive

Equality Impact Assessment No impact identified.

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THE STATE HOSPITAL Date of Meeting: 26 October 2017 Agenda Reference: Item No: 06 Sponsoring Director: Mark Richards Author(s): Mark Richards Title of Report: Strengthening the Patient Voice at Board Meetings Purpose of Report: For Approval 1 SITUATION This brief paper sets out a proposal to strengthen the patient voice at the Board through use of an ‘emotional touchpoints’ approach. This approach was previously presented to the Board in 2014, when it was used to illustrate a carer’s experience of a visit. This proposal is focused specifically on strengthening the patient voice at the Board, but the principles and approach set out are equally applicable to our carers and volunteers. 2 BACKGROUND Ensuring a person centred approach is at the heart of the business of NHS Scotland and is set out in our national quality ambitions of safe, effective and person centred care. Many health boards in Scotland, and across the UK, use a patient story at the beginning of their Board meetings, whether through the use of a video recording, or through having a service user attend in person to tell their personal story of their experience of NHS services. This supports our focus on continuous improvement through listening to, and acting upon feedback. The voices of our patients are an effective and powerful way of making sure that the improvement of our services is centred on the needs of the people using our services and also in capturing and sharing positive feedback. Because a patient story captures the patient’s experience from their point of view, it has the potential to help put Board members in the patients’ shoes, and thus enable a focus on what matters most to our patients. It will help Board members consider the ‘touchpoints’ (moments of engagement) between our patients and our service, and the emotions and memories that these moments create. The approach described can also be utilised to share learning from other sources of feedback such as leadership walk-rounds, complaints, or from one to one discussions with our harder to reach patients.

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3 ASSESSMENT There are practical restrictions as to how we achieve this within a high secure environment, and as such, the proposed approach will utilise readily available technology to ensure the patient voice is more fully heard. This will involve capturing a voice recording of a patient story, and mapping the ‘emotional touchpoints’ into a presentation. Patient consent will be obtained to use the recording, and the safe governance of the recording will be the responsibility of the Director of Nursing and AHPs. This will be supported by the Involvement and Equality Team. This will be delivered as the first substantive agenda item of the Board meeting, and has the potential to help develop and sustain a culture of the board regularly talking about patients care experiences. The use of ‘emotional touchpoints’ will support the Board to identify the key themes in any patient story, highlighting positive and negative points, and to discuss actions in response to what they have heard. It is proposed that the use of ‘emotional touchpoints’ is tested at the December meeting of the Board. This will be formally evaluated after the meeting, and if feedback is positive, then this could be delivered at each meeting of the Board. The outputs from this will form part of our annual report on learning from feedback and also help support the Board in evidencing how we meet the national Participation Standards. 4 RECOMMENDATION The State Hospitals Board are asked to agree to the testing of this approach at the December Board meeting, and participating in the subsequent evaluation.

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MONITORING FORM


Workforce Implications eg Considered in Section 3 of the report

Financial Implications eg No financial implications if approved

Route To SMT Which groups were involved in contributing to the paper and recommendations.

eg Clinical Forum / Patient Forum / Medical Advisory Committee / other



Equality Impact Assessment

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: October 2017 Agenda Reference: Item No: 07 Sponsoring Director: Professor Lindsay Thomson, Medical Director Authors: Dr Callum A MacCall, Dr Natasha Billcliff Title of Report: Annual Medical Education Report 1 SITUATION The General Medical Council Quality Improvement Framework for Undergraduate and Postgraduate Medical Education in the UK sets out expectations for the governance of medical education and training. General Medical Council standards specifically refer to Board governance and it is within this context that this report is being presented to the Board. This report covers the period 1 August 2016 to 31 July 2017. 2 BACKGROUND Dr Callum A MacCall is Educational Supervisor at The State Hospital. He is responsible for postgraduate medical training while Dr Natasha Billcliff leads on issues relating to medical undergraduates. The medical staff group within The State Hospital hold a 3 monthly training committee meeting which is chaired by Dr Callum A MacCall. This committee reviews training issues of relevance to the Hospital. The Educational Supervisor reports within The State Hospital to Professor Lindsay Thomson, Medical Director. He reports externally to the Training Programme Director for Forensic Higher Training in Scotland, Dr John Crichton, and to local Training Programme Directors for Core Training. 3 ASSESSMENT 3.1 UNDERGRADUATE TRAINING Teaching Program for Edinburgh Undergraduate Medical Students Day Visit The State Hospital continued to deliver training to medical students in their fourth year during the academic year 2016/17 in the form of a one day visit incorporating clinical teaching in the morning and formal lectures in the afternoon. The lectures cover the civil mental health act and the more

specialized area of forensic psychiatry. There are six visits per academic year each comprising of approximately 50 students. Feedback is sought from the students on the day for both parts of the teaching. The clinical teaching is mostly in the “excellent” domain, with a choice of “poor, average, good or excellent” (poor 0, average 6, good 51, excellent 91). The formal lectures feedback is exceptionally positive, rated more highly than any other lectures delivered in the series. Feedback for the three consultants delivering these lectures was as follows:

3 quite useful 44 very useful okay 1 good 45 8 quite useful 35 very useful okay 6 good 37

1 not useful 14 quite useful 8 very useful okay 10 good 13 (1 lecture only) The undergraduate medical curriculum has undergone significant changes during 2017 which will necessitate altering the content of the day visit. The students visiting from September 2017 will be in their 5th year and will have received a lecture in forensic psychiatry at the start of the program in Edinburgh. The focus of the lectures delivered at the State Hospital will therefore be more able to concentrate on clinical examples and issues. The lecture program is currently being rewritten with this in mind. Clinical Attachment The hospital facilitates two week clinical attachments for four groups of two 4th year students per year. These students provide feedback via EEMeC, the Edinburgh Electronic Medical Curriculum (to become LEARN next academic year), which produces a yearly aggregate report for comparison with other hospital attachments. The feedback is generally positive although a persistent theme is the difficulty students have with limited access to IT, e.g. not being able to bring their electronic devices into the hospital, and that the very specialised nature of our environment and patients does not lend itself to meeting teaching aims of general psychiatry. The students also comment that they would prefer more formal teaching sessions within the placement. This has been fed back to Consultant trainers at the Medical Advisory Committee so that these comments can be taken on board with respect to future attachments. IT restrictions however are a feature of hospital security which we are unable to modify specifically for student access. Ad Hoc Attachments Individual students from other medical schools in Scotland and from abroad contact the State Hospital directly on occasion for day visits or seeking elective placements for several months. We have the capacity to accommodate these requests. Feedback A report is provided to the Medical Advisory Committee (MAC) yearly which gives the opportunity to discuss possible improvements to the undergraduate teaching. Medical staff also have the option of requesting individual assessment of their teaching skills as part of the Clinical Educator Program. To date, two staff have taken this up with positive results. As undergraduate teaching lead Dr Billcliff attends the Edinburgh University Undergraduate Sub-Committee Meeting annually where feedback from each psychiatry placement is discussed. This year’s meeting was focused on the significant changes to the curriculum. 3.2 POST GRADUATE TRAINING Core Training (previously Senior House Officer grade) During the six month period August 2016 to January 2017 we received only two Core Trainees rather than the usual three. Normally we receive two Core Trainees from the West of Scotland Training Scheme and one from the East. On this occasion however, due to recruitment difficulties in the West of Scotland, we received only one Core Trainee from the West of Scotland Training Scheme. We were able to persuade one of the Core Trainees who had worked with us

immediately prior to this period to remain in post for three weeks on a Locum basis prior to his departure to employment in Australia. For the remainder of this six month period however our first tier medical cover for the hospital consisted of four doctors (two Specialty Doctors and two Core Trainees) rather than the usual five doctors. This necessitated those individuals carrying a greater daytime workload and had an additional impact on our on-call rotas. During the period February to July 2017 the West of Scotland Training Scheme was again able to send us two Core Trainees hence bringing our first tier medical cover back up to five doctors. The recruitment environment for Core Trainees in psychiatry remains challenging and significant vacancies continue to exist, particularly on the West of Scotland Training Scheme. With this in mind, it seems inevitable that sooner or later we are likely to find ourselves in a similar position whereby we receive at least one fewer doctor than expected, in all likelihood with probably only a few week’s notice. The reason for this is that placements on training schemes for the forthcoming six months are usually only decided and shared around three to four weeks ahead of the rotational placement moves in early August and early February each year. On-Call Rotas At points over the past year the viability of our first tier on-call rota has been fragile. By sheer good fortune during the period August 2016 to January 2017 we had received from the Lothian Training Scheme an ST4 doctor (namely a Higher Trainee in the first year of their Forensic Specialist Training) and by virtue of the fact that this doctor had only just moved to Scotland, having previously worked in the South of England, she elected to undertake her on-call duties on The State Hospital rota thus bringing the numbers of doctors on our first tier overnight on-call rota to five (however still leaving an additional gap in our daytime on-call rota as it was not appropriate for her to take part in same). Hence during this six months we had five first tier doctors doing overnight on-call as opposed to the expected six, with those five individuals sharing the vacant overnight on-call rota slot between themselves on a paid locum basis. Had it not been for this good fortune the viability of a sustainable overnight first on-call rota with only four doctors would have been questionable. Since we only receive ST4 Trainees from Lothian on an occasional basis and they do not always choose to undertake their on-call on The State Hospital rota, there is a fairly high likelihood that in the event we have a short notice vacancy in our usual Core Trainee compliment we could run into difficulties with our first tier overnight on-call rota. On a more positive note, since the Scottish Government directive of November 2014 requiring an end to the practice of rostering non-Consultant grade doctors to work for more than seven days in a row, the implementation of a rota involving a day off during the week in lieu of weekend working has gone relatively smoothly and does not appear to have had a significant disruptive effect on doctors training or service provision. Higher Specialty Trainees Over the past year we have had five Specialty Trainees attached to The State Hospital for periods of either three or six months. We receive them from training schemes around Scotland, most commonly the Lothian and West of Scotland schemes and occasionally also from the North of Scotland. Our Specialist Trainees work under the supervision of Consultant Trainers, of which we currently have six working at The State Hospital (one of whom is currently employed by the Scottish Government – see Appendix 1). Specialty Trainees spend part of their weekly timetable undertaking research and special interest activities and overall generally spend less time at The State Hospital than Core Trainees and Specialty Doctors. Their role is distinct, represents a progression from Core Training and maintaining an appropriate distinction in their role from those of other non-Consultant grade doctors is important as they progress towards readiness for Consultanthood. Senior Specialty Trainees in their final year of training can act up as a Consultant for a maximum period of three months. This has not occurred during the last year.

Training in Forensic Psychiatry in The State Hospital is part of the National Forensic Psychiatry Training Programme which is overseen by NHS Education for Scotland. Attached in Appendix 2 is the Scotland Deanery Training Programme Director Report for the period 1 August 2016 to 31 July 2017. Overall I think this again is a strong report for The State Hospital. In the Trainee survey, The State Hospital performed above the national mean and in the top quartile nationally for workload, study leave and reporting systems. It will also have contributed to the National Forensic Psychiatry Training Scheme being ranked third of thirteen in the United Kingdom. Trainee feedback via Training Committee Trainees report their overall workload and training experience to be positive. Our induction programme remains comprehensive and continues to be modified on a six monthly basis to meet Trainee needs. Over the past year we have developed a list of accessible placements outwith The State Hospital by virtue of the fact that the large majority of our Consultant staff are employed in other roles alongside their State Hospital work. All Trainees over the past year have completed the Forensic Network “New to Forensic” programme. They are also being encouraged to enrol on the “New to Essentials of Psychological Care” programme also available. Teaching Programme A series of six lectures is delivered by Consultant colleagues to Core Trainees during the first three months of their placement at The State Hospital. The current programme encompasses six lecture topics which broadly cover the fundamentals of Forensic Psychiatry and related practice. State Hospital Visits Occasional requests for “taster visits” by Foundation grade doctors / Core Trainees / non-forensic Specialty Trainees continue to be received. Generally speaking these doctors are curious to find out more about Forensic Psychiatry and in some cases they have an interest in pursuing Forensic Psychiatry as a career. Three such requests have been facilitated over the past year (with a further request pending) and it is hoped that we may see some of these Doctors entering the specialty in the future. Psychotherapy Training We have part-time input from a Consultant in Forensic Psychotherapy, Dr Adam Polnay. He provides Balint / Reflective Practice sessions for non-Consultant grade doctors. Such work forms part of the core psychotherapy training requirements and feedback for same has been positive. GMC Recognition and Approval of Trainers (RoT) The past year has been a demanding one in relation to the above. Implementation of the General Medical Council (GMC) led recognition of secondary care trainers required full implementation by 31 July 2016. It applies to those who have one or more of the following roles:

a) Named Educational Supervisor in postgraduate training b) Named Clinical Supervisor in postgraduate training c) Lead Co-Ordinators of undergraduate training at each local education provider d) Doctors responsible for overseeing student’s educational progress for each medical school

All of those in the above roles are expected, during the annual appraisal process, to make a self-declaration of readiness or otherwise in terms of recognition as a trainer. It is expected that the appraisee reflects on their trainer role(s), presents evidence of competence for their role(s) and declares that they have met the necessary requirements to be recognised as a trainer. A summary table of the current trainer status of State Hospital Consultants is provided in Appendix 1. Overall I think we are in a good position in respect of RoT. All our Consultants have either already self declared as trainers or intend to do so during their next appraisal cycle. This includes the three new Consultant staff who have commenced work at The State Hospital over the past year.

In respect of RoT, our major challenges have been less about the training competencies of our Consultant staff but rather more around the establishment of an improved interface with NHS Education for Scotland given our status as a standalone health board which falls outwith the responsibilities of the Directors of Medical Education in the larger territorial boards from whom we receive Trainees. An example is the greater prominence of the NHS Education for Scotland online system designed for maintaining information on NHS Scotland Medical and Dental Trainees, Trainers, Programmes, Educational Providers and Study Leave. This online training management system is named “TURAS”, derived from the Scottish Gaelic for ‘journey’ or ‘visit’. With the full implementation of RoT we have been on a journey ourselves, one where we have registered with TURAS and are gaining growing familiarity with the in-house management of the system for the benefit of our Trainees and Trainers. NES Forensic Psychiatry Programme Inspection Visit Professor Thomson and Dr Callum A MacCall took part in the NES Inspection visit of the Forensic Psychiatry Training Programme which took place at the NHS Education for Scotland building in Glasgow on 27 July 2017. The visit was chaired by Professor Ronald McVicar, had representation from the Royal College of Psychiatrists, and both Trainee and Trainer input from across Scotland. While formal written feedback is awaited the verbal feedback given on the day of the visit recorded that it had been an “entirely positive” visit with a cohesive and happy group of Trainees and a noted “community feel” around Forensic Psychiatry training in Scotland. Highlights included the wealth of experience and expertise amongst Trainers, the provision of a Trainee centred approach with supportive handling of any issues or problems which may have developed, good curriculum coverage and positive Trainee ownership around the Perth based National Training Events. No conditions or requirements were made following the visit and it is anticipated the next inspection visit will occur in approximately five years time. Representation at External Committees Relevant to Medical Education Dr Callum A MacCall represents The State Hospital and / or the National Forensic Psychiatry Training Programme at the following:

• West of Scotland Committee in Psychiatry – this Committee meets to consider training issues across the whole of West of Scotland for all Psychiatric specialties, including Forensic. Recruitment difficulties have been a recurrent theme at meetings over the past year.

• Annual Review of Competence Progression (ARCPs) – Dr MacCall participates in the ARCPs which take place each June at the NHS Education for Scotland building at West Port, Edinburgh. These reviews consider the competence progression of all Higher Forensic Trainees in Scotland.

• National Forensic Psychiatry Specialty Training Committee – this Committee meets in Edinburgh on a quarterly basis. It is chaired by Dr John Crichton, Training Programme Director and has representation from the Post Graduate Deans Office and Educational Supervisors from around Scotland. There is additionally a Higher Forensic Trainee representative. Over the past year there has been an improvement in levels of recruitment to the National Forensic Psychiatry Programme and, at the time of writing, there is currently only one vacancy across the Programme. I think it is fair to say that Forensic Psychiatry recently has fared better than other specialties in terms of recruitment, particularly General Adult Psychiatry and Learning Disability. There are however growing concerns about the level of unfilled training (and Consultant) posts in Psychiatry across Scotland.

• Forensic Specialty Advisory Committee – Dr MacCall represents Scotland at this Committee which meets in London on a four monthly basis. It considers matters of national importance in relation to the training of Forensic Psychiatrists. Over the past year the functioning of certain Royal College of Psychiatrists Committees have changed and the Forensic Specialty Advisory Committee has taken over the role of the previous Forensic Faculty Education and Curriculum Committee (FFECC) which Dr MacCall previously attended.

4 RECOMMENDATION The Board is invited to note the following:

i) The continuing high standard of undergraduate and postgraduate medical training provided within The State Hospital.

ii) The Hospital is in a good position with regard to Recognition of Trainers and the past year has been productive in the establishment of greater links with NHS Education for Scotland, in particular the registration with, and growing familiarity with, the NES online training management programme TURAS.

iii) Recruitment challenges continue to be significant both locally and nationally. The State

Hospital over the past year has been fortunate in replacing a Specialty Doctor who left our service and in being able to sustain our first tier medical on-call rota despite one third of our Core Trainee cohort being absent during the first six months of the past year.

iv) For at least the forthcoming six months, our available Core Trainee and Specialty

Doctor posts look secure, however there continues to be a need for proactive contingency planning for non-Consultant grade medical staffing shortages which may arise at relatively short notice.

Dr Callum A MacCall

Dr Callum A MacCall Consultant Forensic Psychiatrist Educational Supervisor Date of next annual report – August 2018 Date of next Board report – October 2018

NES Clinical Supervisor Course

NES Educational Supervisor Course

Named Medical Trainer Role (e.g. Undergraduate / Postgraduate Supervisor

Approved Higher Trainer

Have you self declared Recognition of Trainers (RoT) section of appraisal (or do you intend to do so at next appraisal)

Duncan Alcock Yes Prathima Apurva Yes Natasha Billcliff Undergraduate Supervisor Yes Yes Ian Dewar Yes Yes Yes Yes Fergus Douds Yes Yes

Sheila Howitt Not attended but CEP Level 2 completed

Not attended but CEP Level 2 completed

I intend to do so at next appraisal which will be my first as a consultant.

Khuram Khan Undergraduate Supervisor Yes Callum MacCall Postgraduate Supervisor Yes Yes

Jon Patrick Completed CEP Level 2 on 25/07/16 Yes

Adam Polnay

Completed Clinical Educator Programme Level 3

Yes

Gordon Skilling Yes Nicola Swinson Yes Yes Lindsay Thomson Fellow HEA Yes Yes

Scotland Deanery Training Programme Director Report This report should be completed by the TPD on behalf of their specialty training committee and in consultation with education leads at the different sites. The information will be used by the Quality Review Panels to assess programmes at a national level with site specific information available from trainee surveys, inspection visits and other sources. The local knowledge of TPD is essential to put this information in perspective, and to highlight successes and training issues within their programmes, including where there may be a need for visits from the Deanery quality teams to specific departments or hospitals. TPDs are not expected to conduct an investigation into issues at particular sites, but instead to provide local and programme knowledge to help guide the review panels. The information provided will help to inform the NES Deanery visiting process for the specialty, the reports of which will be shared with TPDs.

Note to TPD: Please complete all sections of the report in relation to the last training year. For assistance,

please contact Jane Walls at [email protected] or 01224 805 134 Please complete and return to [email protected] by 01/09/2017. 1. Key findings from trainee surveys 1.1 GMC National Training Survey: summary programme report

Programme Forensic Psychiatry - Programme

Region Scotland Deanery

Lead Dean / Director Prof. Ronald Mac Vicar

Associate Postgraduate Dean Dr Rhiannon Pugh

Training Programme Director Dr John Crichton

College / Faculty Responsible Royal College of Psychiatry

GMC Programme Identifier SES505

Reporting Period From 1 Aug 2016 To 31 Jul 2017

mailto:[email protected]


Board Site Programme level

Ove

rall

Satis

fact

ion

Clin

ical

Sup

ervi

sion

Clin

ical

Sup

ervi

sion

OO

H

Han

dove

r

Indu

ctio

n

Ade

quat

e Ex

perie

nce

Supp

ortiv

e en

viro

nmen

t

Wor

k Lo

ad

Educ

atio

nal S

uper

visi

on

Feed

back

Loca

l Tea

chin

g

Reg

iona

l Tea

chin

g

Stud

y Le

ave

Rep

ortin

g Sy

stem

s

Team

wor

k

Cur

ricul

um C

over

age

Educ

atio

nal G

over

nanc

e

N Greater Glasgow and Clyde Leverndale Hospital - G302H Forensic

psychiatry ST 1

Greater Glasgow and Clyde Leverndale Hospital - G302H Forensic

psychiatry ST - ▼ - - ▼ - - - - ▲ 3 aggregated

Tayside Murray Royal Hospital - T215H Forensic psychiatry ST 1

Tayside Murray Royal Hospital - T215H Forensic psychiatry ST - ▼ ▲ - - - - ▼ - - 3

aggregated Greater Glasgow and Clyde Rowanbank Clinic - G612H Forensic

psychiatry ST ▲ - ▲ - - - - - ▲ - ▲ 3

Lothian Royal Edinburgh Hospital - S217H

Forensic psychiatry ST 1

Lothian Royal Edinburgh Hospital - S217H

Forensic psychiatry ST - - ▲ - - - ▼ ▼ - - - - 8

aggregated

National Facility State Hospital - D101H Forensic psychiatry ST 1

National Facility State Hospital - D101H Forensic psychiatry ST - - ▼ ▼ - ▼ - - ▼ - - ▲ - 5

aggregated

Key Result is below the national mean and in the bottom quartile nationally

Result is above the national mean and in the top quartile nationally

Result is in the bottom quartile but not outside 95% confidence limits of the mean

Result is in the top quartile but not outside 95% confidence limits of the mean

Result is within inter quartile range

▲ Better result than last year

▼ Worse result than last year

▬ Same result as last year

n < 3

n = 0

1.2 GMC National Training Survey: breakdown of outliers TPD comment required (right column). RAG = red, amber, green

Programme Site Survey Indicator

RA

G R

atin

g 20

15

RA

G R

atin

g 20

16

RA

G R

atin

g 20

17

Agg

rega

ted

outc

ome

TPD Comment Required: All additional information will be helpful to inform the ARP e.g. Do outliers relate to a known issue or good practice? If not, can they be explained? What is the good practice, can it be shared? What actions are in place to resolve known issues? Comments should be site specific where possible rather than relating to the whole programme. Do you think a Deanery visit should be considered here?

Forensic psychiatry Leverndale Hospital - G302H

Access to Educational Resources

The low numbers make this difficult to interpret – I have interviewed all the trainees and not identified any major concerns in the pink areas – the relevant geographical Educational Supervisors will be bearing the feedback in mind

Forensic psychiatry Leverndale Hospital - G302H Adequate Experience white

Forensic psychiatry Leverndale Hospital - G302H Clinical Supervision pink


Clinical Supervision out of hours white


Educational Supervision white

Forensic psychiatry Leverndale Hospital - G302H Feedback white

Forensic psychiatry Leverndale Hospital - G302H Handover

Forensic psychiatry Leverndale Hospital - G302H Induction white

Forensic psychiatry Leverndale Hospital - G302H Local Teaching white

Forensic psychiatry Leverndale Hospital - G302H Overall Satisfaction white

Forensic psychiatry Leverndale Hospital - G302H Regional Teaching white

Forensic psychiatry Leverndale Hospital - G302H Study Leave green


Supportive environment white

Forensic psychiatry Leverndale Hospital - G302H Work Load white

Forensic psychiatry Leverndale Hospital - G302H Reporting systems

Forensic psychiatry Leverndale Hospital - G302H Teamwork

Forensic psychiatry Leverndale Hospital - G302H Curriculum Coverage


Educational Governance

Forensic psychiatry Murray Royal Hospital - T215H Adequate Experience white

Much of the teaching is organised nationally but the ES will bear this in mind – only one years data?

Forensic psychiatry Murray Royal Hospital - T215H Clinical Supervision pink

Forensic psychiatry Murray Royal Hospital - T215H

Clinical Supervision out of hours


Educational Supervision white

Forensic psychiatry Murray Royal Hospital - T215H Feedback white

Forensic psychiatry Murray Royal Hospital - T215H Handover

Forensic psychiatry Murray Royal Hospital - T215H Induction white

Forensic psychiatry Murray Royal Hospital - T215H Local Teaching red

Forensic psychiatry Murray Royal Hospital - T215H Overall Satisfaction white

Forensic psychiatry Murray Royal Hospital - T215H Regional Teaching white

Forensic psychiatry Murray Royal Hospital - T215H Study Leave white


Supportive environment white

Forensic psychiatry Murray Royal Hospital - T215H Work Load white

Forensic psychiatry Murray Royal Hospital - T215H Reporting systems white

Forensic psychiatry Murray Royal Hospital - T215H Teamwork

Forensic psychiatry Murray Royal Hospital - T215H Curriculum Coverage



Forensic psychiatry Rowanbank Clinic - G612H

Access to Educational Resources light

green

An improving picture

Forensic psychiatry Rowanbank Clinic - G612H Adequate Experience white white

Forensic psychiatry Rowanbank Clinic - G612H Clinical Supervision white white


Clinical Supervision out of hours white


Educational Supervision white white

Forensic psychiatry Rowanbank Clinic - G612H Feedback white white

Forensic psychiatry Rowanbank Clinic - G612H Handover

Forensic psychiatry Rowanbank Clinic - G612H Induction pink green

Forensic psychiatry Rowanbank Clinic - G612H Local Teaching red white

Forensic psychiatry Rowanbank Clinic - G612H Overall Satisfaction white light

green

Forensic psychiatry Rowanbank Clinic - G612H Regional Teaching white white

Forensic psychiatry Rowanbank Clinic - G612H Study Leave white green


Supportive environment white white

Forensic psychiatry Rowanbank Clinic - G612H Work Load white white

Forensic psychiatry Rowanbank Clinic - G612H Reporting systems light

green

Forensic psychiatry Rowanbank Clinic - G612H Teamwork green

Forensic psychiatry Rowanbank Clinic - G612H Curriculum Coverage white


Educational Governance green

Forensic psychiatry Royal Edinburgh Hospital - S217H

Access to Educational Resources white

These pinks are a bit of a mystery – all trainees individually sensitively sought their views – the ES is excellent and at interview there was concern about some lack of clinical opportunity

Forensic psychiatry Royal Edinburgh Hospital - S217H Adequate Experience white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Clinical Supervision pink white


Clinical Supervision out of hours pink white


Educational Supervision white pink

Forensic psychiatry Royal Edinburgh Hospital - S217H Feedback white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Handover light

green

Forensic psychiatry Royal Edinburgh Hospital - S217H Induction white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Local Teaching white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Overall Satisfaction white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Regional Teaching white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Study Leave white white


Supportive environment white white

Forensic psychiatry Royal Edinburgh Hospital - S217H Work Load red pink

Forensic psychiatry Royal Edinburgh Hospital - S217H Reporting systems white

Forensic psychiatry Royal Edinburgh Hospital - S217H Teamwork

Forensic psychiatry Royal Edinburgh Hospital - S217H Curriculum Coverage



Forensic psychiatry State Hospital - D101H Access to Educational Resources light

green

With internationally renowned facilities the SGH always impressively performs

Forensic psychiatry State Hospital - D101H Adequate Experience white white

Forensic psychiatry State Hospital - D101H Clinical Supervision white white

Forensic psychiatry State Hospital - D101H Clinical Supervision out of hours green white

Forensic psychiatry State Hospital - D101H Educational Supervision white white

Forensic psychiatry State Hospital - D101H Feedback white white

Forensic psychiatry State Hospital - D101H Handover

Forensic psychiatry State Hospital - D101H Induction green white

Forensic psychiatry State Hospital - D101H Local Teaching white white

Forensic psychiatry State Hospital - D101H Overall Satisfaction green white

Forensic psychiatry State Hospital - D101H Regional Teaching white white

Forensic psychiatry State Hospital - D101H Study Leave white green

Forensic psychiatry State Hospital - D101H Supportive environment green white

Forensic psychiatry State Hospital - D101H Work Load green green

Forensic psychiatry State Hospital - D101H Reporting systems green green

Forensic psychiatry State Hospital - D101H Teamwork

Forensic psychiatry State Hospital - D101H Curriculum Coverage

Forensic psychiatry State Hospital - D101H Educational Governance

1.2 Scottish Training Survey: summary report.

Board Specialty Site N

Clin

ical

Sup

ervi

sion

Educ

atio

nal E

nviro

nmen

t

Han

dove

r

Indu

ctio

n

Teac

hing

Team

Cul

ture

Wor

k Lo

ad

Benchmark Group

Ayrshire & Arran Forensic Psychiatry Ailsa Hospital 0 Higher - Psychiatry

Ayrshire & Arran Forensic Psychiatry Ailsa Hospital 3 Higher - Psychiatry (aggregated)

Forth Valley Forensic Psychiatry HMP Polmont 1 Higher - Psychiatry

Forth Valley Forensic Psychiatry HMP Polmont 1 Higher - Psychiatry (aggregated)

Greater Glasgow and Clyde

Forensic Psychiatry Leverndale Hospital 1 Higher - Psychiatry


Forensic Psychiatry Leverndale Hospital 4 Higher - Psychiatry (aggregated)

National Facility Forensic Psychiatry Mental Welfare Commission 0 Higher - Psychiatry

National Facility Forensic Psychiatry Mental Welfare Commission 0 Higher - Psychiatry (aggregated)

Tayside Forensic Psychiatry Murray Royal Hospital 2 Higher - Psychiatry

Tayside Forensic Psychiatry Murray Royal Hospital 3 Higher - Psychiatry (aggregated) Greater Glasgow and Clyde

Forensic Psychiatry Rowanbank Clinic 4 Higher - Psychiatry


Forensic Psychiatry Rowanbank Clinic 8 Higher - Psychiatry (aggregated)

Lothian Forensic Psychiatry Royal Edinburgh Hospital 4 Higher - Psychiatry

Lothian Forensic Psychiatry Royal Edinburgh Hospital 14 ▬ ▬ ▬ ▬ ▬ ▬ ▬ Higher - Psychiatry (aggregated) National Facility Forensic Psychiatry State Hospital 3 Higher - Psychiatry

National Facility Forensic Psychiatry State Hospital 7 ▬ ▬ ▬ ▬ ▬ ▬ ▬ Higher - Psychiatry (aggregated)

Key

Low Outlier - well below the national benchmark group average

High Outlier – performing well for this indicator

Potential Low Outlier - slightly below the national benchmark group average

Potential High Outlier - slightly above the national benchmark group average

Near Average

▲ Significantly better result than last year*

▼ Significantly worse result than last year*

▬ No significant change from last year*

No data available * A significant change in the mean score is indicated by these arrows rather than a change in outcome.

1.3 Scottish Training Survey: breakdown of outliers

TPD comment required: please comment on each indicator. Specialty

Site Benchmark Group

Indicator

Out

com

e 20

15

Out

com

e 20

16

Out

com

e 20

17

Sign

ifica

nt

chan

ge

2014

-17

Aggr

egat

ed

outc

ome

TPD Comment Required: e.g. Do outliers relate to a known issue or good practice? If not, can they be explained? What is the good practice, can it be shared? What actions are in place to resolve known issues?

Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Clinical Supervision grey grey grey white Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Educational Environment grey grey grey white

Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Handover grey grey grey white Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Induction grey grey grey white Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Teaching grey grey grey white Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Team Culture grey grey grey white Forensic Psychiatry Rowanbank Clinic Higher -

Psychiatry Workload grey grey grey white Forensic Psychiatry

Royal Edinburgh Hospital

Higher - Psychiatry Clinical Supervision white grey grey white

Forensic Psychiatry


Higher - Psychiatry

Educational Environment white grey grey white

Forensic Psychiatry


Higher - Psychiatry Handover white grey grey white

Forensic Psychiatry


Higher - Psychiatry Induction white grey grey white

Forensic Psychiatry


Higher - Psychiatry Teaching white grey grey white

Forensic Psychiatry


Higher - Psychiatry Team Culture white grey grey white

Forensic Psychiatry


Higher - Psychiatry Workload white grey grey white

Forensic Psychiatry State Hospital Higher -

Psychiatry Clinical Supervision grey grey grey white Forensic Psychiatry State Hospital Higher -

Psychiatry Educational Environment grey grey grey white

Forensic Psychiatry State Hospital Higher -

Psychiatry Handover grey grey grey white Forensic Psychiatry State Hospital Higher -

Psychiatry Induction grey grey grey white Forensic Psychiatry State Hospital Higher -

Psychiatry Teaching grey grey grey white Forensic Psychiatry State Hospital Higher -

Psychiatry Team Culture grey grey grey white Forensic Psychiatry State Hospital Higher -

Psychiatry Workload grey grey grey white

1.4 GMC National Training Survey: comparison of ‘Overall Satisfaction’ indicator for your programme against other UK Deaneries/LETBs.

Programme Type Scotland/region UK Mean Scotland

Mean Negative Positive UK Ranking n

Forensic psychiatry Scotland Deanery 81.5 89.9 8.4 3rd of 13 10

Forensic psychiatry South-East Region 81.5 89.9 8.4 Equal 3rd of 15 10

Note: The results for the Scotland Deanery are taken from the “Programme type by LETB/Deanery” report from the GMC NTS reporting tool. The regional results ae taken from the “Programme type by Deanery” report. The ranking and number they are ranked out of may therefore be different. TPD comment required: Rather impressive ranking also revealing very high scores on average making interpretation of flags problematic

2. Key findings from trainer survey 2.1 GMC National Training Survey: summary programme report

Board Site Specialty Ove

rall

Satis

fact

ion

Wor

k Lo

ad

Han

dove

r

Supp

ortiv

e en

viro

nmen

t C

urric

ulum

Cov

erag

e

Educ

atio

nal

Gov

erna

nce

Rot

a D

esig

n

Res

ourc

es fo

r tra

iner

s

Tim

e fo

r Tra

iner

s

Supp

ort f

or T

rain

ers

Trai

ner D

evel

opm

ent

Response Rate Ayrshire & Arran Ailsa Hospital - A201H Forensic psychiatry 50%

Tayside Murray Royal Hospital - T215H Forensic psychiatry 80 53.75 61.67 70 68.33 62.5 79.17 51.25 80 74 72.5 100%

Greater Glasgow and Clyde Rowanbank Clinic - G612H Forensic psychiatry 82.5 70.42 77.5 82 84.17 82.5 75 86.25 73.75 82 77.5 100%

Lothian Royal Edinburgh Hospital - S217H Forensic psychiatry 67%

National Facility State Hospital - D101H Forensic psychiatry 33%

Key

Result is below the national mean and in the bottom quartile nationally

Result is above the national mean and in the top quartile nationally

Result is in the bottom quartile but not outside 95% confidence limits of the mean

Result is in the top quartile but not outside 95% confidence limits of the mean

No flag / no result available for last year

No data available

2.2 GMC National Trainer Survey: breakdown of outliers This information is provided for information but if TPD/ STC wish to share intelligence with the deanery in regard to these results they are welcome to do so below. Board Site Specialty Indicator Outcome

2016 Outcome

2017 Comment

Tayside Murray Royal Hospital - T215H

Forensic psychiatry

Overall Satisfaction 80 Curiously much more impressive that the Scottish survey – some natural variation perhaps Tayside Murray Royal

Hospital - T215H Forensic psychiatry

Work Load 53.75


Forensic psychiatry

Handover 61.67


Forensic psychiatry

Supportive environment

88.33 70


Forensic psychiatry

Curriculum Coverage

68.33


Forensic psychiatry


62.5


Forensic psychiatry

Time for training 73.61 79.17


Forensic psychiatry

Rota Design 51.25


Forensic psychiatry

Resources for trainers

80


Forensic psychiatry

Support for trainers 69.44 74


Forensic Psychiatry

Organisational culture

66.67


Rowanbank Clinic - G612H

Forensic psychiatry

Overall Satisfaction 82.5 Outstanding again for Glasgow



Forensic psychiatry

Work Load 70.42



Forensic psychiatry

Handover 77.5



Forensic psychiatry

Supportive environment

82



Forensic psychiatry

Curriculum Coverage

84.17



Forensic psychiatry


82.5



Forensic psychiatry

Time for training 75



Forensic psychiatry

Rota Design 86.25



Forensic psychiatry

Resources for trainers

73.75



Forensic psychiatry

Support for trainers 82

Year in review: 2016-2017 3.1 What have been the strengths of the programme?

The collegiality of the community, mutually supporting each other with respect to learn and excel for the benefit of our patients. Successful CCTs at the ARCPs and consultant opportunities for them all in Scotland and all staying in Scotland Filling two posts in North but no room for complacency Great deanery visit with uplifting feedback - a fillip to all Emma joining the team as our Deanery support

3.2 What are potential areas for improvement within the programme? For example: ARCP progress issues Clinical experience – access to appropriate level and range of experience for trainees Teaching – access to or quality of site based or regional teaching, including simulation Portfolios – issues with use or access Induction – including regional / programme GMC recognition of trainers – recruitment and retention of named Clinical and Educational Supervisors Finding a solution to equity of opportunity especially in psychotherapy would be very helpful if agreed study leave funds could be carried forward

3.3 What threats does your programme face in the coming year? If there is an incentive payment for GP recruitment as in Wales this will hit psych recruitment Confusion about CT interviews moving to Manchester with totally inadequate consultation and no support from the training community The fallout from Brexit

Form completed by Role Signature Date

Dr John Crichton Training Programme Director 8/8/17

FORENSIC MENTAL HEALTH SERVICES MANAGED CARE NETWORK

ANNUAL REPORT 2016-2017

Forensic Network & SoFMH www.forensicnetwork.scot.nhs.uk @FN_SoFMH 1

Contents

Foreword from Director of Forensic Network Advisory Board 3 Executive Summary of Achievements 4 1. Background and Structure 6 1.1 Background and Structure of the Forensic Network 6 1.2 Background and Structure of the School of Forensic Mental Health 7 2. Governance and Operation Structures 2.1 Network Structures 8 2.1.1 Forensic Network Advisory Board 8 2.1.2 Inter Regional Group 8 2.2 School of Forensic Mental Health Structures 9 2.2.1 School Governance Committee 9 2.2.2 SoFMH Operational Team 9 3. Network Operations 10 3.1 Professional Groups 10 3.2 Clinical Fora 12 3.3 Short Life Working Groups 13 3.3.1 Electronic Monitoring with Mentally Disordered Offenders 13 3.3.2 Admissions Criteria to Scottish High and Medium Secure Units 13 3.3.3 The Forensic Matrix Implementation Group 13 3.3.4 Behavioural Status Index Implementation Group 14 3.3.5 Disclosure Guidance Report 15 3.3.6 Conflict Resolution 15 3.3.7 National Forensic Mental Health Services Estate Review 15 3.3.8 Personality Disorder Training Strategy 15 3.4 Continuous Quality Improvement Framework Reviews 16 3.4.1 Second Round of Continuous Quality Framework Reviews 16 3.4.2 Breakdown of the Review Process 16 3.5 Joint Working with Other Networks 17 3.5.1 National Coordinating Network for Healthcare and Forensic Medical Services for People in Police Care

17

3.5.2 National Prisoner Healthcare Network 17 3.5.3 NHS National Education for Scotland 17 4. Activities from the School of Forensic Mental Health 18 4.1 Academic Courses 18 4.1.1 MSc Health and Social Care (Forensic Mental Health) 18 4.1.2 Forensic Mental Health Module 18 4.1.3 Graduate Certificate in Personality Disorder 18 4.2 Professional Short Courses 19 4.2.1 Approved Medical Practitioners 19 4.3 New to Forensic Programmes Suite 19 4.3.1 New to Forensic Mental Health Teaching Programme 19 4.3.2 New to Forensic: Medicine 20

http://www.forensicnetwork.scot.nhs.uk/


4.3.3 New to Forensic: Essentials of Psychological Care 20 4.3.4 New to Forensic Mental Health Teaching Programme (NI) 20 4.3.5 New to Forensic Mental Health (Richmond Fellowship Scotland) 20 4.4 Forensic Network Research Special Interest Group 21 4.4.1 Forensic Network Census and Inpatient Database 21

4.4.2 Randomised Control Trail of Medication Effects on Attention Deficit Hyperactivity Disorder

22

4.4.3 Research Mapping 22 4.4.4 Joint Review Protocol 22 4.4.5 Forensic Network Research Conference 22 5. Sustainability and Communication 23 5.1 Finance 23 5.2 Communications Overview 23 6. Overview and Future Plans 24 6.1 Overview 24 6.2 Future Plans 24 7. References 26 8. Appendices 28 Appendix 1: School of Forensic Mental Health Short Courses List 28 Appendix 2: Forensic Network Research Project List 2015 29

Scottish and Irish Collegues in Northern Ireland at event, ‘The Way Forward for Northern Ireland’ (from left to

right: Ian McMaster, Harry Kennedy, Lindsay Thomson, Mary Donaghy, Helen Walker) This report focuses on activities and achievements within the last 12 months; however it does not detail all activities but rather provides an overview of some of the work streams. If you would like to find out more about the work of the Network or SoFMH, please contact Nicol Shadbolt, Forensic Network Manager, by email: [email protected] or telephone: 01555 842018.




Foreword from Director of Forensic Network Advisory Board

It is a great pleasure to introduce the second public report on the work of the Forensic Mental Health Services Managed Care Network and the School of Forensic Mental Health. This report sets out the activities of the Network and School from April 2016 to March 2017. Quality improvement is the focus of our work whether on specific service developments or educational initiatives. This year has seen the commencement of the second round of quality improvement reviews across the Forensic Network. This is a major example of networking in practice. The standards were developed in consultation across the Network, the review process agreed, and Network members form the peer review panels that visit each site, providing feedback that leads to the development of local quality improvement plans. The provision of data is essential for quality improvement initiatives. This year has seen the exciting development of the Forensic Network Database which will be rolled out across the Network in the coming year. Local reports will be generated to meet local needs whilst an overall national picture will be obtained. Across the Forensic Estate we have at times continued to struggle with finding accommodation for people at the most appropriate level of security. We welcomed the Scottish Government review of the estate and will continue to contribute through our data systems and communication channels to improving patient flow. The School continues to extend its educational and research portfolio, with its refreshed MSc in Forensic Mental Health in conjunction with the University of the West of Scotland, short course programme and national research protocol to assist research across the Network. In particular this year, SoFMH has developed for NES new Approved Medical Practitioner training materials and courses including a revamped AMP training course and four new update courses for existing AMPs on core mental health, capacity, forensic, and child and adolescent mental health. I would express my thanks to all of you across the Forensic Network for your hard work and input into our quality improvement, service development and educational initiatives; to Scottish Government for its continued support and provision of challenging tasks; and to the Forensic Network core team who carry out their roles with aplomb and a smile. In particular, I would like to thank Andreana Adamson, The Forensic Network Board Chair who retired during this year, for her considerable work in establishing the Forensic Network, and Dr Fergus Douds who has been the Forensic Network Lead on Learning Disability since its inception in 2003 and a passionate advocate for the development and delivery of clinical services to this group. We look forward to welcoming Dr Jana de Villiers into this role as Forensic Network Lead on Intellectual Disabilities. Professor Lindsay Thomson Director, Forensic Mental Health Service Managed Care Network and School of Forensic Mental Health



Executive Summary of Achievements

The Forensic Mental Health Services Managed Care Network (Forensic Network) and School of Forensic Mental Health (SoFMH) are delighted to provide a report on the progress and achievements made from April 2016 to March 2017. This has been a year of development; with the commencement of the second round of Continuous Quality Improvement Framework (CQIF) reviews across forensic mental health services, the appointment of a new Clinical Lead for Intellectual Disabilities, Dr Jana de Villiers, and the inclusion of the Forensic Network in The State Hospital’s ministerial review for the first time. The Forensic Network continues to flourish and provide advice and support within and beyond Scotland. This year staff travelled to Northern Ireland to present on the development of the Network, strengthen links and support ideas for the development of similar work streams in Northern Ireland. Many members of the Network team are regularly invited to speak at conferences, regionally, nationally and internationally on our work, such as the annual conference of the International Association of Forensic Mental Health.

The work of the Forensic Network would not be possible without the commitment and contributions of a diverse range of professionals across the estate. We would like to thank all those involved with the Forensic Network and the SoFMH for their continued engagement over this past year, it is their input that makes all of these achievements possible. Key achievements in 2016-2017:

Clinical Developments Practitioners from NHS Forth Valley supported by the Forensic Network Consultant

Nurse in Psychological Therapies, were recognised at a national level and awarded 'Category Winner' in the 'Increasing Access to Psychological Therapies' category of the National Mental Health Nursing Forum's Excellence in Mental Health Nursing Practice Awards, for their low intensity psychological therapies work in Forth Valley prisons. The project emphasised the collaborative achievements of nursing and psychology in the endeavour. The team were further shortlisted for Royal College of Nursing national awards in the category of mental health.

A new short life working group to explore the utilisation of electronic monitoring with mentally disordered offenders was established at the request of Scottish Government.

Continued work around estate planning and a pan-dimensional Scotland approach to service provision, including support of the Scottish Government’s National Forensic Mental Health Services Estate Review and the development of increased data collection on patient flow.

Completion of two POMH-UK benchmarking audits by the Forensic Pharmacy Group

Development of new protocols by the Psychological Therapies Matrix Implementation Group: Patient Information Programme.

Development and design of a 5-day nurse induction training programme to support the opening of the new low secure unit in NHS Ayrshire & Arran.

Continuous Improvement Twelve Clinical Fora were facilitated on developing and cutting edge topic areas, such as

Novel Psychoactive Substances and Terrorism and Threat levels in the UK, this is an increase from 7 events in the previous year. 98% of delegates who completed evaluation forms across the year rated clinical fora events overall as either good or excellent.



The Continuous Quality Improvement Framework (CQIF) reviews began with low and community services. The reviews support improved delivery of care, development of processes and shared learning across the estate.

Completion of the fourth Forensic Network Census and development of the Inpatient Service Database. Data demonstrated a slight decrease (approximately 4.5%) in the overall size of the inpatient estate, with 88 new or readmissions to the estate across the year, 55% of which came from prisons or the court.

The Forensic Network and the SoFMH developed and launched a new website and twitter account, helping to increase connections and information sharing across the estate and with partner agencies. After 6 months the twitter account has grown to just under 200 followers and now accounts for approximately 2.5% of all traffic to our website.

The second Forensic Lead Nurse Annual Conference and the second annual conference of the Forensic Network Social Work Subgroup were both successfully facilitated.

A new Professional Chairs group was created, bringing together all professional groups chairs in a multi-disciplinary setting to work on cross discipline collaborations and quality improvement initiatives.

Education and Research Twenty-seven short professional courses were facilitated across the year on a range of

topics, including: risk assessment and risk management; legal aspects; clinical assessments; and psychological interventions. 100% of delegates who completed evaluation forms across these events rated the training overall as either good or excellent (82% rated training as excellent).

The MSc Forensic Mental Health, developed in conjunction with the SoFMH and taught by clinicians from across the estate, passed validation at the University of the West of Scotland following a move from Glasgow Caledonian University. The course will welcome applications for a September 2017 intake.

Work began on an estate wide training needs analysis which is hoped to be completed in Summer 2017, this will provide strategic direction for the development of the SoFMH.

The first continued professional development day for low intensity programme graduates was successfully launched in collaboration with NHS National Education Scotland (NES).

A new course was developed and delivered on Complex and Developmental Trauma.

Development and completion of a revised and updated Approved Medical Practitioner course Parts 1 and 2, and four new update courses on core, capacity, forensic, and child and adolescent practice.

Research commenced into the evaluation of Forensic Psychological Matrix protocols in conjunction with the University of Edinburgh.

The fifth annual National Forensic Network Research Conference was facilitated.

Development of research Joint Review Protocol to promote and support cross network research studies.

In the coming year the Forensic Network and the SoFMH look forward to continued advancements and achievements in service delivery following the second cycle of CQIF reviews and we will continue to work with colleagues across the estate to coordinate a national strategy to improve patient care and develop services. We are grateful to Scottish Government for their continued and ongoing support of our work.



1. Background and Structure 1.1 Background of the Forensic Network The Forensic Network was established in September 2003, following a review of The State Hospitals Board for Scotland ‘The Right Place-The Right Time‘(Scottish Executive Health Department, 2002). The Network was established to address fragmentation across the Forensic Mental Health Estate, to overview the processes for determining the most effective care for mentally disordered offenders, consider wider issues surrounding patient pathways, and align strategic planning across Scotland (Gordon, 2003; Scottish Parliament, 2003).

Aims Scottish Ministers requested the development of a Network to bring a pan-Scotland approach to the planning of services and patient pathways, including the commissioning of research to establish an evidence base for future service development.

Structure and Governance These aims are achieved through the coordination of a national oversight group known as the Network Advisory Board, the development of regional Multi-agency structures with links to NHS Regional Planning Groups which drive forward progress at regional levels, and the commissioning of short life working groups who are allocated responsibility on a range of topic specific or geographical specific projects, providing direction where national guidance is required. The Forensic Network take guidance and direction from our Clinical Leads; Dr Jana de Villiers Clinical Lead for Intellectual Disabilities; Dr Fergus Doud outgoing Clinical Lead for Learning Disabilities; Dr Martin Culshaw Clinical Lead for Women; and Dr Raj Darjee Clinical Lead for MAPPA and the NHS Lothian Sex Offender Liaison Service (SOLS).

Since the inception of the Network, there has been a strong multi-agency approach which has facilitated information sharing and enabled the development of strong working relationships with our partners in the third sector and with regional associates across the estate. These relationships support continual improvement to the planning of services and the patient journey across the forensic mental health estate. The Forensic Network has worked with regional and government colleagues to develop national policy on the configuration of services and the assessment and management of restricted patients.

The predominate focus of the Forensic Network’s attention since its development has been on key issues, such as: the configuration of the forensic estate; defining levels of security; admission and referral criteria; services for LD; services for women; management of personality disorder; resolving clinical conflicts; development of mental health services for prisoners; and quality improvement across the forensic estate.

Forensic Network Board

Inter Regional Group

Professional Groups

Clinical Fora

Working Groups

Continuous Quality

Improvement Framework

School Governance Committee

SoFMHOperational

Team

Academic Courses

Professional Short Courses

New to Forensic Suite

Research Special Interest

Group Research Projects



The Network hosts and supports several professional groups which provide guidance on best practice. In collaboration with national leads it organises Clinical Fora which provide opportunities for continued professional development and keeping abreast of new research and developments in relevant fields. In conjunction with Healthcare Improvement Scotland, the Forensic Network developed a Continued Quality Improvement Framework based on standards of care and treatment and initiated a review process to support benchmarking and auditing across these standards. In addition, the Network has hosted several national conferences, and has developed strong international links with representation on the board of the International Association of Forensic Mental Health Services (IAFMHS).

The School of Forensic Mental Health (SoFMH) 1.2 Background of the School of Forensic Mental Health The School of Forensic Mental Health (SoFMH) was established in 2007 under the auspices of the Forensic Mental Health Services Managed Care Network (Forensic Network). The SoFMH is a virtual school, offering teaching, training and research assistance to all professional groups and associated agencies involved in the assessment and care of individuals with a mental disorder who come in to contact with forensic services. The SoFMH has access to many experienced professionals and can support services in the development of teaching materials, courses or research. The model involves expert clinicians active in the forensic field developing and delivering short courses; the creation of formal qualifications through higher and further educational establishments; and the development and delivery of the New to Forensic Programme Suite. High standards of teaching are maintained and governed rigorously.

Aims The SoFMH aims to:

improve the quality of response, care, treatment and outcomes for people with a mental disorder who come into contact with, or whose behaviour puts them at risk of contact with the criminal justice system, in ways that are non-discriminatory, promote equality and respect diversity;

effect a shift in the overall institutional culture of services to one which emphasises care and treatment in a variety of settings, and the promotion of positive mental health delivered on a multi-disciplinary and multi-agency basis;

improve public safety through enhanced risk assessment and risk management;

offer multi-level and progressive provision of learning across the College and University interface; and

enhance clinical practice through the development and promotion of findings from large scale research projects.

Structure and Governance The SoFMH is governed by a committee which meets biannually and an operational team who meet bimonthly and reports to the Governance Committee. To date, the School has had commissions from the Scottish Government, NHS National Education Scotland, Police Investigation and Review Commission, Risk Management Authority, Scottish Social Services Council, and forensic services across Scotland. The School has become an invaluable resource, providing bespoke forensic training and cost effective solutions to teaching across Scotland. It is the primary educator in the forensic field in Scotland and supports the promotion of research and development of an evidence base for practice, hosting an annual research conference showcasing achievements from across the forensic mental health estate.



2. Governance and Operation Structures 2.1 Network Structures 2.1.1 Forensic Network Advisory Board The Forensic Mental Health Services Managed Care Network Advisory Board (Forensic Network Advisory Board) supports the Forensic Network to provide national strategic direction and bring a pan-Scotland approach to the planning of services and patient pathways, including the development of information systems and data collection for the management of patients. The Forensic Network Advisory Board develops and maintains links with Regional and Local colleagues across the NHS and with Partner agencies, such as the Scottish Prison Service, Police, Social Work, Community Justice Authorities and Housing, as well as user and carer organisations. It provides an invaluable forum for discussing cross managed care network concerns and ensuring continued maintenance of the high standards of delivery and work conducted across all areas of the Forensic Network. The Board has a Governance role in overseeing the Clinical Conflict Resolution Process and in developing and supporting self-assessment and peer review as part of the Continuous Improvement Quality Standards Framework for secure services. Over the past year the work of the group has focused on the implementation of new legislation in the Mental Health (Scotland) Act (Scottish Parliament, 2015), in particular the introduction of the Victim Notification Scheme (Forensic Mental Health Services Managed Care Network, 2016a), the National Prisoner Healthcare Network Mental Health Implementation Report, and the Scottish Government Forensic Estate review.

2.1.2 Inter Regional Group The Health Inter Regional Group has a crucial role within the Network in terms of operational working and patient flow. The group consists of regional and clinical leads, meets four times a year and reports annually to the Forensic Network Advisory Board. The group was established to support the Forensic Network Advisory Board to develop national operational working throughout the forensic estate, to coordinate and implement the decisions of the Forensic Network Advisory Board. It bridges the gap between strategy and policy arising from the work of the Forensic Network Advisory Board, and operational and clinical activity within forensic units.

There has been sustained focus on the forensic estate over the past year, with discussions around referrals and transfers central to the work of the group. The Forensic Network continues to collate and analyse data on the forensic estate, producing a weekly bed state report, a report on excessive security appeals, and completing a biannual needs assessment which helps to outline future requirements and patient movement across the estate. Work around the shape of the estate and capacity is ongoing and the Inter Regional Group are supporting the National Forensic Mental Health service estate review at present.



The Inter Regional Group is instrumental in the implementation and monitoring of the Exceptional Circumstances Clause of The State Hospital Referral Policy and Procedure. The Group has an established formal work plan with a schedule of themed meetings. Examples of agenda items include: Forensic Estate; Female Forensic Estate; Psychological Matrix; Multi Agency Public Protection Arrangements and Sexual Offenders Liaison Service (MAPPA and SOL update); Clinical Forum report; Prescribing Observatory for Mental Health; Learning Disabilities Update; Continuous Quality Improvement Framework Reviews; Forensic Census and Database; Partner Agency and Network Links; and Psychological Approaches to Personality Disorder.

This year specific topic categories have included: patient education; volunteer services update; management of physical health concerns across the patient population; ViSOR input for health; conditional discharge tribunals; expansion of the needs assessment to medium secure; strengthening connections with and between low and community services; the national update to the Approved Medical Practitioner programme; the continuation of a national license for the use of risk assessment instrument for all Forensic Services and the Scottish Prison Service (Historical Clinical Risk Management-20 Version 3); and smoking, including the use of e-cigarettes across the estate.

2.2 School of Forensic Mental Health (SoFMH) Structures

2.2.1 School Governance Committee The School Governance Committee meets twice yearly and supports the Forensic Network to meet its aims in regards to oversight of education, training and research across forensic mental health services in Scotland. In addition the School Governance Committee provides strategic advice and direction to support the continuing development and sustainability of the SoFMH, as well as ensure ongoing quality assurance of training courses delivered.

Over the past year, focus has been on the continued development of academic courses with particular focus on the transfer and update of the MSc in Forensic Mental Health to the University of the West of Scotland. There has been continued progress with our Module in Forensic Mental Health run at New College Lanarkshire which is now in its sixth year; and the Graduate Certificate in Personality Disorder ran at University of the West of Scotland. The Committee plays a key role in overseeing training needs across the estate and the professional chairs group has been working to complete a comprehensive national training needs analysis.

There has been a strong focus of the group this year on marketing and research, in particular the advancements of a new Forensic Network Inpatient Database, headed by the Research and Development Lead for the Forensic Network, Jamie Pitcairn. The work to develop the Forensic Network Inpatient database has been completed with the National Information Systems group (NISG) at National Services Scotland and will comprise details on patient whereabouts from the national census conducted in November each year across forensic mental health services since 2013. 2.2.2 SoFMH Operational Team The SoFMH operational team has a fundamental role in monitoring and approving the day to day running of the School. The Team is made up of key representatives from across the Network and partner agencies, such as National Education Scotland (NES). This group operationalises the decisions made by the School Governance Committee, overviews training calendars and considers proposals for new courses and training developments.



3. Network Operations 3.1 Professional Groups The Forensic Network supports a number of professional groups across the estate, which provides collegues with an opportunity to consider discipline specific issues. The Chairs of these groups attend the Forensic Network Advisory Board to ensure that groups remain linked in to ongoing work streams and ensure that professionals have the opportunity to contribute at a strategic level. These meetings provide opportunities to share good practice and identify any areas of shared work to avoid duplication. This year there has been the further introduction of a Professional Chairs group which brings together the Chairs for each of the professional groups to look at ongoing quality improvement across the estate. At present the Professional Chairs group is working on an estate wide training needs analysis which will help to shape the future development and direction of the SoFMH. The Network also maintains close links with the Royal College of Psychiatrists Forensic Faculty in Scotland. Professional groups currently supported:

- Forensic Allied Health Professional (AHP) Leads - Forensic Carer Coordinators - Forensic Carer Forum - Forensic Lead Nurse Forum - Forensic Network Social Work Sub Group - Forensic Pharmacy Group - Scottish Forensic Clinical Psychology Group (SFCPG) - Scottish Care Programme Approach

Key achievements from this year:

The Forensic AHP Leads have engaged with the Active and Independent Living Improvement Programme (AILIP) and reported on the potential impact on forensic AHP practice.

Research, audit and service evaluation have been embedded within the content of all meetings to further national strategies in these areas.

The Forensic AHP Leads are planning to consult on the final draft of the Disclosure Guidance and plans for a launch of the document are underway.

The Forensic Pharmacy Group organised a national training event in Motivational Interviewing for pharmacists with support from psychology.

The Forensic Pharmacy Group undertook two benchmarking audits with Prescribing Observatory in Mental Health (POMH-UK). The first on Lithium monitoring and the second on Rapid Tranquilisation.

The second Lead Nurses Conference was held in September 2016 and was highly successful with keynotes from both academics and practitioners.

From the Forensic Lead Nurse Forum, two clinicians, supported by Consultant Nurses from the Forensic Network achieved awards at the Mental Health Nursing Forum 2016. One from the Scottish Prison Service for the introduction of Low Intensity Interventions and one from The State Hospital for the introduction of Research and Evidence Based Practice Initiatives.

The Scottish Forensic Clinical Psychology Group (SFCPG) has been involved in the curriculum review for the forensic teaching on the University of Edinburgh Doctorate in Clinical Psychology course.



SFCPG have begun discussions with Scottish Government about the role of the psychologist within the Memorandum of Practice for Restricted Patients.

On the back of a previously completed Carers assessment Matrix, the Forensic Carer Coordinators group have begun looking at the development of a national carers pack for those supporting people accessing forensic services.

The Forensic Carers Coordinator Group is supporting the reinvigoration of the Forensic Carers Forum and with Support in Mind Scotland has organised and planned a national carers conference.

The Forensic Network Social Work Sub Group is in the process of developing local practitioner fora across the country in order to extend the reach of the subgroup and effectively draw upon the experience and skills of social work practitioners across the estate.

The Forensic Network Social Work Sub Group hosted their second national conference on social work in practice in forensic mental health settings.

Professional Group Work Streams for the coming year:

The Forensic AHPs are conducting a consultation survey in Spring 2017 to inform future planning of the forum and consider strategic direction. The working group will consider the structure of meetings to encourage wider engagement from all allied health professions, inclusive of research and audit themed meetings e.g. physical health, work, implementation of key strategy documents

Forensic AHPs will launch an updated Disclosure Guidance document

The Forensic Pharmacy Group has POMH-UK benchmarking projects planned for this year looking at use of high dose and combination antipsychotics.

The Forensic Lead Nurse Forum has work planned around the 20-30 Nursing Vision, Low Intensity Psychological Interventions and Nursing Observations in line with Scottish Patient Safety Programme (SPSP) developments in observation due out this year.

The SCFPG plans to host a team formulation continued professional development event.

The Forensic Carer Coordinators plan to consider and support the redevelopment of a national forensic carer forum following a large national conference in Summer 2017

The Forensic Network Social Work Sub Group are currently engaging with the Mental Health Officer (MHO) course providers with a view to developing enhanced, post-qualifying training in respect of mentally disordered offenders.



3.2 Clinical Fora The Clinical Fora continue to be well supported and valued by colleagues across Scotland, with twelve forums held over the past year, an increase from 7 in the preceding year. The Clinical Fora have four main aims: networking, education, policy development and operational development. Some forums are larger than others, but all average around 60 delegates from across a range of organisations and backgrounds. It was reported in our annual report last year that there was a possible drop (25%) in delegates attending clinical fora events, however on further analysis it was found that there was an unusually low number of clinical fora held across that year resulting in a drop in overall attendance figures rather than a drop in the number of attendees at each event. The average number of attendees at each event remained similar (approximately 60) and these numbers have been maintained across this year with an increase in the number of clinical fora offered. Over the last year topics have consisted of: - Addictions - Learning Disabilities - MAPPA - Personality Disorder and Problem Behaviours - Risk - Sex Offender Practitioners – jointly chaired by NOTA Scotland Branch - Victims and Trauma - Women Some highlights from Forums this year:

The Addictions Clinical Forum held an event focused on the recent rise of cases involving the use of Novel Psychoactive Substances. The day included presentations from Police, the Ambulance service, Pharmacy and Psychiatry, encompassing the truly multi-disciplinary and multi-agency approach to forums. The event was well attended from colleagues across prison, health and social care, third sector, and judicial backgrounds.

The Clinical Forum for Women regularly attracts a high volume of delegates and this year’s theme saw presentations on Managing Maternal Filicide in Medium secure services, Pregnancy Denial, Concealment and Infanticide, and Pregnancy, Motherhood and Secure care. As well as provided delegates with an opportunity to discuss ongoing developments and delivery in female low secure services.

The Learning Disabilities Forum held a successful and lively multi-disciplinary debate as part of their event discussing whether Learning Disability should be removed from the Mental Health Act as a category of Mental Disorder.

The Clinical Forum Sex Offender Practitioners held forums on Children and Young People with Harmful Sexual Behaviours and Developing Effective Interview Skills. The forums were well attended and for the coming year they have plans to host an event on the risk management of Trans Offenders from a Holistic Perspective; Diversity vs Deviance; Sexuality; and Common hormone treatments and effects on behaviours.

The Clinical Forum Risk held a well-attended event looking at terrorism and threat faced in the UK, with presentations from Detective Chief Superintendents and from lecturers at the Handa Centre for the Study of Terrorism and Political Violence (CSTPV), University of St Andrews. The event received extremely positive feedback and provided opportunities for considering risk assessment and threat in services.



Themes for clinical fora are sought from delegates attending events and these are reflected in the development of future programmes and events, ensuring that topics are relevant, current and desirable. Furthermore there is a robust feedback system in place to ensure that events continue to be of high quality and meet the demands and requirements of attendees. Of delegates who completed evaluation forms last year, 98% rated the event overall as either good or very good. This coming year sees the launch of a new Clinical Forum in Psychological Therapies to support the ongoing work of the Psychological Matrix Implementation Group and Low Intensity training delivered across the state in collaboration with NHS National Education for Scotland (NES).

3.3 Short Life Working Groups 3.3.1 Electronic Monitoring with Mentally Disordered Offenders The Forensic Network were requested by Scottish Government to set up a working to group to explore views and the possibilities for use of electronic monitoring with mentally disordered offenders. The group is cross disciplinary and agency, with representation from police, criminal justice, social work, MAPPA and prisons. The work of the group is ongoing and a report is expected to be submitted to the Scottish Government by November 2017. 3.3.2 Admission Criteria to Scottish High and Medium Secure Units This working group was commissioned by the Forensic Advisory Board to update the Network document, ‘Admission Criteria to Scottish High and Medium Secure Units’ (Forensic Mental Health Managed Care Network, 2010). The working group has met several times and work is ongoing to update referral criteria following developments of excessive security appeals extending to medium security and exceptional bed use in high security.

3.3.3 The Forensic Matrix Implementation Group The Forensic Matrix Working Group has continued to develop the range of psychological treatment protocols available. At present there are three completed Low Intensity (LI) protocols and two High Intensity (HI) protocols, with a steady uptake and rollout across the



estate. A national reporting pro forma has been developed to capture details of the groups. Protocols consist of:

‘Patient Information Programme’ (LI): an introductory information programme for patients, providing key information about forensic services. It includes; information on legal matters, about the roles of the various members of the clinical team and what to expect during their stay.

‘On the Road to Recovery’ (LI): comprises three distinct modules covering psycho education, basic coping skills and coping skills enhancement; dealing with motivation, engagement, substance misuse and other difficulties related to myriad unhealthy lifestyle choices. Modules consist of: ‘Awareness and Recovery’, ‘Looking after Yourself’ and ‘Making Healthy Changes’. Module three is due to be piloted in 2017.

‘Knowing Me’ (LI): focuses on the development of self-awareness and self-formulation skills.

‘Planning for the Future’ (HI): focuses on the consolidation of knowledge and skills gained during participation in cumulative psychological interventions, as well as covering relapse prevention skills. This consists of two modules: ‘My Journey so Far’ and ‘The Journey Ahead; Values and Needs Plan’.

‘Connections’ (HI): focuses on the development of relationship and social skills. The protocol comprises of two planned modules and is in the process of being updated.

The Forensic Matrix Implementation group also support two working subgroups:

Principles of Structured Clinical Care: The group has developed draft guidelines on the principles of structured clinical care which are currently being reviewed and consulted on within the group.

Reflective Practice Competencies: The group is in the process of developing a competency framework for Reflective Practitioners for use within the Forensic Network and clarifying definitions of the differences between supervision, reflective practice, consultation, line management and psychological therapy.

In addition, two highly successful eLearning modules have been developed:

‘See, Think, Act’: focuses on development of knowledge and skills related to relational security (1345 completers to date)

‘Working with Offenders with Personality Disorder’: provides information about personality disorder and practical advice on the management of people with this condition (approximately 500 completers to date).

In the coming year, the group plan to focus on completing a ‘Problem-solving’ HI protocol supported by NES, and overview and update the HI protocol ‘Tune-In’. Revisions and updates are also planned for the first two modules of the ‘On the Road to Recovery’ programme. An evaluation project in collaboration with Edinburgh University has begun to assess all the protocols currently being developed by the group and their utilisation across the estate. 3.3.4 Behavioural Status Index (BEST-Index) Implementation Group The BEST-index, a nursing assessment tool, continues to be implemented across the Forensic Network and progress is monitored through the national oversight group. Training took place with staff in the new Low Secure service at NHS Ayrshire and Arran this year and a pilot of the tool in the community is planned for the future. The national oversight group is due to meet in Autumn 2017.



3.3.5 Disclosure Guidance Report Work is ongoing in the Forensic AHP’s group to update the disclosure guidance report previously provided by Jean McQueen, Consultant AHP, ‘Guidance for Allied Health Professional supporting individuals with Criminal Convictions and Mental Health Conditions into Work, Volunteering or Education’ (McQueen, 2014). It is expected that the AHP group will host a launch event for the document in Autumn 2017. 3.3.6 Conflict Resolution The work of this group remains ongoing and crucial to the role of the Forensic Network. The group convenes as required when clinical disputes arise either within service or between Health Boards that cannot be resolved internally. The existence of the group encourages informal resolution of any conflict. 3.3.7 National Forensic Mental Health Services Estate Review The Scottish Government established a review of the clinical models of existing forensic mental health services to make recommendations for a sustainable, fit for the future, service in Scotland. The Forensic Network has supported this review, which was led by Andreana Adamson, and the results will be reported by the Scottish Government. The review aims to address issues and developments in:

The provision of high secure services for women

Prison transfers

Medium secure provision for men

Medium secure provision for learning disabilities

Appeals against excessive security in medium secure services

The report has been circulated to members of the reference group and consultation sought. It is expected to be released by Scottish Government later this year. 3.3.8 Personality Disorder Training Strategy This group was developed following the completion of a paper on ‘Psychological Approaches to Personality Disorder in Forensic Mental Health Settings’ (Russell, 2016) to consider a joined up training strategy for Personality Disorder (PD) across the estate. The group are currently working on a training digest to support this. As an example this contains:

Online training: See Think Act: Relational Security module, Working with PD Offenders

Short courses: Introduction to PD, International Personality Disorder Examination, PD in Formulation, Mentalisation Based Therapy, Cognitive Analytic Therapy

Academic courses: Graduate Certificate in PD, MSc Forensic Mental Health (Problem Behaviours module)



3.4 Continuous Quality Improvement Framework Reviews 3.4.1 Second Round of CQIF Reviews The Continuous Quality Improvement Framework Reviews (CQIF) have commenced their second cycle with an overarching theme of ‘person centred care’. The CQIF reviews, which were developed in conjunction with NHS Healthcare Improvement Scotland (HIS), provide an opportunity for consistent benchmarking and auditing across the forensic mental health estate. The aim is to use a multi-disciplinary approach to share good practice and support learning across the Forensic Network, through a culture of openness and enquiry facilitated to identify any potential gaps in practice and support the service’s work to improve delivery of care.

The review process calls for the definition of appropriate quality standards (developed originally from the Secure Care Standards developed by the Forensic Network for Medium Secure Services which formed part of HDL 48; Scottish Executive Health Department, 2006), measurement of performance against these quality standards (via self-assessment and peer review) and the development of an agreed action plan by the service to improve quality of care. The review cycle is then followed with a national conference to share good practice, spread learning and provide an opportunity for further professional development.

Review themes for this second round of reviews are:

Assessment, Care Planning and Treatment

Physical Health

Clinical Risk (including assessment, detention, compulsion and Patient Safety)

Management and Prevention of Violence

Physical Environment

Teams, Skills and Staffing The first low secure review day of this second round of reviews took place in January 2017 with other low secure and community service reviews scheduled from now until Autumn. Following completion of the low secure and community reviews, reviews for the LD units, Medium Secure units and finally High secure service will follow. It is expected that the review period will be completed by Summer 2018. Following this cycle of reviews work will commence with HIS to align our review process with the national framework for reviews currently being rolled out. 3.4.2 Breakdown of Review Process

Define Appropriate

Quality Standards

Service completes

Self-Assessment

Evaluation Review by

Peers

Report and Action Plan

Conference Sharing Good

Practice



3.5 Joint Working with Other Networks and Organisations

3.5.1 National Coordinating Network for Healthcare & Forensic Medical Services for People in Police Care The Forensic Network continues to work with colleagues in the Police Custody Network as members of the Education and Training Sub Group Healthcare & Forensic Clinical Services for People in Police Care.

3.5.2 National Prisoner Healthcare Network (NPHN) The Forensic Network have developed strong partnership working relations with the National Prisoner Healthcare Network (NPHN), leading on the NPHN Mental Health Sub Group (National Prisoner Healthcare Network Mental Health Sub Group Report, 2014) and subsequently the Implementation Group for this project (National Prisoner Healthcare Network Mental Health Sub Group Implementation Report, 2016). This year the Forensic Network have been supporting NPHN in the advancement of this work through the development of a Mental Health Audit Plan to drive forward implementation.

There have been several training initiatives between the Managed Care Networks, with mental health nurses from across NHS Forth Valley prisons successfully completing the five day Low Intensity Psychological Therapies and delivering cohorts across all three NHS Forth Valley prisons; HMP Glenochil, HMYOI Polmont, and HMP & YOI Cornton Vale. Practitioners from NHS Forth Valley, who were supported by the Forensic Network Consultant Nurse in Psychological Therapies were recognised at a national level and awarded 'Category Winner' in the 'Increasing Access to Psychological Therapies' category at the National Mental Health Nursing Forum's Excellence in Mental Health Nursing Practice Awards, for their low intensity psychological therapies work in Forth Valley prisons. The project emphasised the collaborative achievements of nursing and psychology. The team were further shortlisted for Royal College of Nursing national awards in the category of mental health.

The Consultant Nurse in Psychological Therapies also contributed a report to the recent Parliamentary Inquiry on Healthcare in prisons, which has been circulated to several other stakeholders including Scottish Government (Mental Health Unit), Royal College of Nursing and NHS NES.

3.5.3 NHS National Education for Scotland Several joint training initiatives have been facilitated between NHS National Education for Scotland (NES) and the School of Forensic Mental Health (SoFMH), which contribute to the continued professional development of colleagues across forensic services in Scotland. Examples of joint training and educational activities undertaken over the past year are:

Development of the Approved Medical Practitioner Course, including review and redesign of materials and development of four new update practitioner courses on core psychiatry, capacity, forensic, and child and adolescent psychiatry.

‘Low Intensity Psychological Therapies Practitioner Training’, which has now been delivered to over 270 practitioners, across 10 Health Boards. There are plans to deliver another two training dates centrally this year based on aggregated need and plans to deliver a specific course for NHS Highland.

A one-day Continuous Professional Development training event for graduates of the Low Intensity programme was provided in March 2017. The event focused on the development of motivational interviewing skills and provided participants with an introduction to the new ‘Making Healthy Changes’ LI module in ‘On the Road to Recovery’.



4. Activities from the School of Forensic Mental Health

The School of Forensic Mental Health (SoFMH) offers teaching and training to all professional groups and agencies involved in the assessment and care of those in forensic mental health services. It provides a focus for supporting, developing and delivering multi-disciplinary and multi-sector educational and research initiatives. The SoFMH has developed and delivered a range of educational resources and now provides an extensive range of 33 skills based short courses, including: risk assessment and risk management; legal aspects; clinical assessments and psychological interventions. Feedback has been gathered from participants following every event and a robust quality review process is in place to ensure that courses delivered are of the highest standards and meet the needs and requirements of delegates.

4.1 Academic Courses 4.1.1 MSc Forensic Mental Health The SoFMH is currently in the process of transferring the existing MSc Health and Social Care (Forensic Mental Health) from Glasgow Caledonian University to the University of the West of Scotland (UWS), under the new title of MSc Forensic Mental Health. The highly successful programme has passed through a stringent validation process and is in process of being updated. The revised programme will be ready for the September 2017 intake and formal applications will be invited from Summer 2017. In Summer 2016, the course had three successful MSc graduates.

4.1.2 Forensic Mental Health Module The SoFMH continues to deliver this introductory course in collaboration with New College Lanarkshire (Motherwell Campus) and it maintains as an articulation route to the MSc Forensic Mental Health, for those looking to reengage with education. The module is in its sixth year and this year’s course commenced in January 2017 with 12 students from across a range of health boards and third sector organisations. The course covers a range of topics including; ‘Characteristics of Mentally Disordered Offenders’, ‘Policies and Procedures for Risk Management’ and ‘Social and Occupational Activity’. 4.1.3 Graduate Certificate in Personality Disorder The SoFMH delivers this course in collaboration with the University of the West of Scotland. The course is now in its fourth year and continues to be highly popular with colleagues from across the Network. The SoFMH is currently accepting expressions of interest for the September 2017. Last year the course received over 100 expressions of interest and accepted twenty five students on to the course.



4.2 Short Courses The SoFMH has responded to the requests of practitioners around training needs and has developed courses and training events to satisfy these requirements, creating an appetite for new knowledge and opportunities for continued professional development. Prior to the introduction of the School there were no bespoke programmes for forensic practitioners, however there is now a wealth of options at all educational levels. During the last financial year from 2016-2017, 27 short courses were held with over 360 delegates. These included courses on Risk Assessment; Research Methods; Managing Personality Disorder; Personal Safety; Professional Witness skills; Staff Support after Violent Incidents and Psychological Interventions. Of delegates that completed evaluation forms on the training they received throughout the year, 100% rated the training overall as good or excellent, with 82% rating it as excellent. A breakdown of the training provided in 2016-2017 is detailed in Appendix 1. For the coming year there are over 30 short courses planned at present, with new courses in mental health and the law, working with sexual deviancy, ex-military mental health, the sexual sadism scale, working with perpetrators of stalking, and a sponsored training event in Stalking Risk Profile risk assessment tool.

4.2.1 Approved Medical Practitioners (AMP) The SoFMH was commissioned by NHS National Education for Scotland (NES) on behalf of the Scottish Government, to develop the advanced practice courses for Approved Medical Practitioners (AMP). Section 22 of the Mental Health (Care and Treatment) (Scotland) Act 2003 requires every medical practitioner who intends to use the powers of the Act to undergo training and to be appointed as an Approved Medical Practitioner (AMP) by the relevant Health Board. The SoFMH has developed new teaching materials for Parts 1 (online) and 2 (interactive course) of the training, developed training materials for update practice courses on core mental health, capacity, forensic psychiatry, and child and adolescent mental health, and is supporting the delivery of a ‘train the trainers’ model for rollout of the course. An AMP Steering Group, led by NES and supported by SoFMH is working to set up a training faculty for the delivery and co-ordination of AMP training, through a national cohort of trainers.

4.3 New to Forensic Programme Suite The New to Forensic Programme suite continues to grow and develop, with a variety of programmes all at different stages of development or implementation. The programme model attracts attention from home and abroad, and discussions are ongoing with colleagues in England, Canada and Australia about the development of similar versions. 4.3.1 New to Forensic Programme The original New to Forensic programme continues to grow and has become part of the induction training suite at many Health Boards. To date over 1300 practitioners have been trained across the NHS, independent sector, social work, voluntary sector, criminal justice services, Mental Health Tribunal for Scotland and Scottish Government. A further 60 are currently registered and due to complete within the next year. The programme has undergone a major revision due to changes in mental health legislation (Scottish Parliament, 2015) which come into force in June 2017 and an updated version will be available from Summer 2017.



4.3.2 New to Forensic: Medicine This programme was designed by SoFMH in 2014 (NHS National Education for Scotland, 2014a) for medical and nursing staff working in police custody. It has been delivered in Lanarkshire, Glasgow, Forth Valley, Lothian and the Highlands. The numbers remain small because the amount of people working in and across this service is thought to be around 80-100 practitioners, although this is an area of growth. At present there has been no formal feedback received from those who have engaged in the programme. Regional meetings will be organised throughout the summer and autumn period 2017 to discuss progress and gauge how the programme is being received. At present there are 50 participants registered on the programme and 32 completed in the last year. It is anticipated that the interest in this course will continue to grow across the coming year. 4.3.3 New to Forensic: Essentials of Psychological Care This programme was designed in 2014 (NHS National Education for Scotland, 2014b) and is still in implementation stages, but is proving to be popular with colleagues across the Network. To date, 85 participants are registered for the Programme and 20 have completed this year. The programme has now built a firm infrastructure of mentors across the estate and is beginning to develop. 4.3.4 New to Forensic Mental Health Teaching Programme (Northern Ireland) The SoFMH supported colleagues in Northern Ireland to establish a version of the original programme fit for purpose locally. Feedback on a formal programme review undertaken between 2015-2016 was presented at a special event in February 2017 in Belfast (Forensic Mental Health Services Managed Care Network, 2016b). Collegues are keen to begin implementation in the Prison service as well as continuing to deliver in NHS services. Themes indicated that staff highly valued the programme and that there was a positive influence on practice, highlighting greater confidence, an improved awareness of how to work with mentally disordered offenders and improvements in collaborative working by practitioners who completed. 4.3.5 New to Forensic Mental Health Teaching Programme (The Richmond Fellowship Scotland) The School has been commissioned by The Richmond Fellowship Scotland to work in collaboration to develop a programme fit for purpose within the community sector. Plans are in place to have the programme finalised by the end of the summer 2017 and provide ‘Training for Trainers’ in Autumn 2017.



4.4 Forensic Network Research Special Interest Group The School supports research across the forensic mental health estate through a variety of initiatives and these are coordinated through the Forensic Network Research Special Interest Group (FNRSIG), chaired by Dr Daniel Bennett. The FNRSIG meet on a quarterly basis to support and promote research across the network and a Forensic Evidence Bulletin detailing research relating to forensic mental health is published and distributed quarterly. The group have contributed towards a wide range of activities including the Forensic Network Census and Database development, an annual research mapping exercise, and the evaluation of psychological therapies across the forensic mental health estate. Some of these achievements are expanded below, however a detailed project list of research can be found in Appendix 2.

Jamie Pitcairn, Research & Development Manager

4.4.1 Forensic Network Census and Inpatient Database The fourth point prevalence data collection for the Forensic Network Inpatient Census was conducted on a patient whereabouts basis on the annual census date of the 26th of November 2016. Data were gratefully received from all but four inpatient sites and there is a strong investment in this as a tool for estate analysis going forward. From the data it can be established that there are approximately 502 inpatients across the estate, demonstrating a slight decrease from the 2015 results of 526 (4.5%). The data outlined 88 new or readmissions to the estate, with the highest percentage of these coming from prison (30%) and 25% coming from the courts. A small percentage of these new patients were admitted to forensic intellectual disabilities service (approximately 0.06%). Requests to access the Census data have been received from a number of sources and the data provided have helped to inform the development of trauma services, review of the forensic LD population, planning for the national evaluation of the Forensic Psychological matrix, and provide information on patient flow to the National Prison Healthcare Network. The work to develop the Forensic Network Inpatient database with the National Information Systems group (NISG) at NSS is nearing completion. The electronic platform for the database has been completed and initial training with the Network team has taken place with a view to rolling out wider training to all Forensic Mental Health service inpatient sites. Prior to providing training and making the live database available final approval amendments are to be completed through the Public Benefit and Privacy Panel (PBPP), and the information gathered within the 2016 patient whereabouts census will be used to ensure the most accurate and up to date patient list, will be in place on the database at the point of going live. The Census team then aim to conduct a catch up data collection process to ensure that all patients on the database have a complete initial data set in place, and that will allow the system to go live with data collected at the pre agreed timescales as prompted by the database and outlined in the accompanying Forensic Network Inpatient Database protocol and user instructions. The database dataset has also been expanded beyond that originally used within the Census to include Forensic Psychological matrix assessment data with the aim of supporting the national evaluation of the forensic psychological matrix.



4.4.2 Randomised Control Trial of Medication Effects on Attention Deficit Hyperactivity Disorder The first randomised control trial involving medications in prison in the UK has commenced in Scotland and is exploring the short term effects of OROS-methylphenidate on ADHD symptoms and behavioural outcomes in young male prisoners with attention deficit hyperactivity disorder (ADHD). The research implements recommendations from the National Institute for Health and Care Excellence (NICE; 2008) that there should be an assessment of efficacy of community recommended ADHD treatments in forensic populations. Clinical trials of ADHD treatments have yet to be conducted and the research will provide the foundation needed to establish long-term effectiveness studies and the data to establish effective healthcare pathways.

4.4.3 Research Mapping The research mapping exercise was conducted again in 2016. The information received informed the development of the Forensic Network project list which has been made available through the network website. The 2016 exercise identified 39 research and evaluation studies ongoing within forensic services. The 2016 project list is attached in Appendix 2 for information. The mapping exercise began again in spring 2017.

4.4.4 Joint Review Protocol One of the key aims of the FNRSIG has been to promote and support cross network research studies. The development of the Joint Study Review Protocol (Forensic Managed Care Network, 2016) is seen as an important stage in providing a single point of study review, using a common protocol that allows individual sites to have confidence in the consistent manner in which study proposal reviews are conducted, whichever of the regional research groups has conducted the review. The protocol has been further developed with input from the Inter Regional Group to ensure that researchers seeking access to a range of network sites have identified a specific study contact at each site and have received recent and appropriate personal safety training. It should be noted that the joint review process is a precursor to full Research Ethics and Research & Development review, and does not replace these approval processes.

4.4.5 Forensic Network Research Conference The FNRSIG held their fifth national Forensic Network Research Conference in November 2016 at the Scottish Prison Service College in Polmont. The day was chaired by Dr Daniel Bennett, current chair of the FNRSIG, and featured key note speeches from eminent speakers, Professor Seena Fazel, University of Oxford, who spoke on ‘Risk Assessment: Scaling up and simplifying’ and Dr Mike Doyle, University of Manchester, who spoke on ‘Investigating the validity of risk assessments in medium secure services (VoRAMSS) in England and Wales’. The conference received excellent feedback from delegates and the 2017 FNRSIG Research Conference (21st November) has secured key note speeches from Dr Caroline Logan, Consultant Forensic Clinical Psychologist in the NHS and an Honorary Research Fellow at the University of Manchester and Dr Andrew Forrester, Clinical Director, Offender Health Research Network, Manchester University.



5. Sustainability and Communication 5.1 Finance The Network and the SoFMH welcome continued funding from Scottish Government and continue to live within budget. The work of the Forensic Network and the SoFMH is further supported by The State Hospital in the supply of location and associated expenses; finance operations, library services and IT services. The Network have reduced costs significantly in recent years and maintained a development programme through the work of the SoFMH. We will continue to do this and to offer significant value for money in terms of our outcomes.

The Network and SoFMH’s work is supported by funds raised through the work of the SoFMH, which is always re-invested to develop training materials and courses for use across forensic services in Scotland. The work plan for 2017-18 includes a reprint of the New to Forensic Programme to reflect legislative changes, an evaluation of the Essentials for Psychological Care programme, the introduction of the Forensic Inpatient Database across Scotland, the development of further training courses directed from the estate wide training analysis, and the completion of the second round of Continuous Quality Improvement Framework Reviews supporting services in auditing, benchmarking and service development.

5.2 Communications The Forensic Network has continued to update and address communication processes over the past year. The Network and SoFMH send out a monthly training email detailing all upcoming training opportunities, which delegates can subscribe to on the website.

The website has undergone a major revamp to provide up-to-date and relevant information in a user friendly format. In particular, there is a current publications section which provides key reports and useful documents. The Forensic Evidence Bulletin, which is compiled by The State Hospital Librarian and released across the Network quarterly, outlines journal articles published in the previous quarter on a range of topics linked with forensic mental health.

In September 2016 the Forensic Network and the SoFMH launched their first social media platform, a twitter account. This provides a forum for connecting with partner agencies both nationally and internationally, an area for discussion and a means of communicating key information. By the end of the financial year the account had grown to just under 200 subscribers and referrals from social media to the website had significantly increased, now accounting for 2.5% of the overall traffic.

In addition, the Network and SoFMH compile a quarterly newsletter which outlines work streams across the Network and any developments across the estate, including ongoing research that might be of interest and updates from the Clinical Leads. The Network and the SoFMH provide biannual updates on all of their work streams and professional groups to the Forensic Network Board and School Governance Committee. The minutes from all professional groups and overviews of Clinical Fora and training events, including end of event evaluations, are available from the Network Office.

Over the coming year the Forensic Network and the SoFMH will continue to update its communications strategies and at present are working on an update and re-launch of our course prospectus.



6. Overview and Future Planning 6.1 Overview Over the past year the Forensic Network and the SoFMH have worked with stakeholders and colleagues from across the estate and partner agencies to continue to improve the quality and delivery of care across Scotland and to support communication, information sharing, and joint working across disciplines and agencies. This year has seen relationships and partnerships strengthened across all levels of mental health services and through all NHS regions, as well as with our Northern Ireland colleagues. The Forensic Network have continued to support a plethora of professional groups across all disciplines and to facilitate a large number of Clinical Fora on a range of interesting and thought provoking topics to further the continued professional development of our workforces. In addition, a number of working groups have been supported to provide national guidance and advice on key issues. These working groups continue to support a national approach to services and provide problem resolution at a pan-Scotland level, improving patient experience and service delivery across the estate. The SoFMH have continued to increase and develop the range of courses available to staff across the estate, offering multi-level provision of education from introductory programmes and short professional courses, to an MSc in Forensic Mental Health provided in partnership with higher education providers. The SoFMH have further begun a national training needs analysis to ensure continued support on key and relevant topics going forward.

6.2 Future Plans The Forensic Network and the SoFMH continue to work in partnership, across traditional organisational and geographical boundaries, to provide a framework to deliver and support national strategic service planning. In 2017-2018 the Forensic Network will continue to work to achieve its aims of determining the most effective care for people with a mental disorder who come into contact with the forensic service, provide guidance on best practice, address wider issues around patient pathways and support the delivery of local service development and implementation. Achievements and advancements could not be made without the strong support and commitment of our colleagues across the forensic mental health estate, who provide their expertise on professional and national working groups, and advise on training requirements, develop new courses and plan training events. Our extensive thanks and gratitude goes out to all our collegues for their hard work and commitment over the past year to deliver on these national aims and projects. Over the coming year the current areas of identified work are:

Clinical Development

Continued facilitation and administration of the short life working group exploring the use of electronic monitoring with mentally disordered offenders on behalf of Scottish Government.

Sustained support for the Forensic Matrix Working Group in the development of new High Intensity Protocols in Problem Solving, as well as continued support for the implementation and development of the Matrix programme suite.



Facilitating the revision of the admission criteria to Scottish High and Medium Secure Units which is underway.

Supporting the implementation of recommendations and findings from the Scottish Government National Forensic Mental Health Service Estate Review.

Continuous Improvement

To continue with the second cycle of the Continuous Quality Improvement Framework Reviews, with the aim of completing this round in Summer 2018. Following this to support a revision of the methodology in collaboration with NHS Healthcare Improvement Scotland (HIS) to realign the process with the new national framework.

To launch the new inpatient census database which will support the collation of estate wide data and contribute to national research projects underpinning the evidence base needed for development and improvement in practice. To continue offering a diverse range of clinical fora and support the development and facilitation of a new Clinical Forum on Psychological Therapies.

To further deliver on the original aims for the Forensic Network when it was established by Scottish Government, there is still work to be undertaken around auditing, benchmarking and Key Performance Indicators.

Education and Research To complete the estate wide training needs analysis and continue advancing and

developing training courses in line with needs of practitioners and services nationally. To facilitate the smooth transfer of the MSc Forensic Mental Health course to the

University of the West of Scotland and encourage its continued success. To continue to offer a diverse range of high quality courses and develop new training

courses and materials based on the needs of practitioners. New courses are proposed for: Mental Health and the Law; Working with Sexually Deviant Offenders; Ex-Military Mental Health; Assessment and Management of Sexual Sadism; Working with Perpetrators of Stalking; Working with Personality Disorder in the Community; and the continued development and rollout of the Approved Medical Practitioner training.

To support the delivery of training in Scotland on the Stalking Risk profile, a risk assessment tool training event being delivered by Australian collegues and developers in September 2017.

To support the Forensic Network Social Work Sub Group in the ongoing development of post-qualifying training in respect of mentally disordered offenders.

To revamp our course prospectus in light of the training needs analysis, outlining the training opportunities across the estate.

For further information about any projects taking place in conjunction with the Forensic Network, or to discuss training needs and suggestions for future topics of courses from the SoFMH, please contact Nicol Shadbolt, Forensic Network Manager, [email protected] or contact the Forensic Network Office 01555 842018, SoFMH 01555 842212. Many thanks to the Forensic Network and School of Forensic Mental Health administration teams who work to improve communication and connections across the forensic mental health estate and support all aspects of work.




7. References

Forensic Mental Health Service Managed Care Network. (2010). Admission Criteria to Scottish High and Medium Secure Units. Carstairs: Forensic Mental Health Service Managed Care Network. Accessible from: http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2012/10/Admission-Criteria-to-Scottish-High-Medium-Secure-Units.doc

Forensic Mental Health Service Managed Care Network (2016a). The Forensic Network Victim

Right’s Group Report. Carstairs: Forensic Mental Health Service Managed Care Network.

Forensic Mental Health Service Managed Care Network (2016b). A critical evaluation of the

“New to Forensic – Northern Ireland” (N2F-NI) programme in forensic healthcare and criminal justice services in Northern Ireland. Carstairs: Forensic Mental Health Service Managed Care Network.

Forensic Network Research Special Interest Group (2016). Joint Study Review Protocol. Carstairs:

Forensic Mental Health Service Managed Care Network. Gordon, I. (2003). Review of the State Hospital board for Scotland – The Response to the

Consultation Paper. Edinburgh: Scottish Executive Health Department. Accessible from: www.forensicnetwork.scot.nhs.uk

McQueen, J. (2014). Guidance for Allied Health Professionals supporting Individuals with Criminal

Convictions and Mental Health conditions into Work, Volunteering or Education. Carstairs: Forensic Mental Health Service Managed Care Network. Accessible from: http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2015/03/Disclosure-Guidance.doc

National Prisoner Healthcare Network Mental Health Sub Group (2014). Final Report. Edinburgh:

Healthcare Improvement Scotland and National Prisoner Healthcare Network. Accessible from: http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2016/02/NPHN-MH-Implementation-Report-2016.pdf

NHS National Education for Scotland (2014a). New to Forensic Essentials to Psychological Care

Teaching Programme. Edinburgh: NHS National Education for Scotland. NHS National Education for Scotland (2014b). New to Forensic Medicine Teaching Programme.

Edinburgh: NHS National Education for Scotland. National Institute for Health and Care Excellence (NICE) (2008). Attention Deficit Hyperactivity

Disorder: The NICE guideline on diagnosis and management of ADHD in children, young people and adults. London: NICE.

Russell, K. (2016). Psychological Approaches to Personality Disorder in Forensic Mental Health

Settings. Carstairs: Forensic Mental health Service Managed Care Network. Accessible from: http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2016/02/Position-Paper-Psychological-Approaches-to-Personality-Disorder-in-Forensic-Mental-Health-Settings.pdf


http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2012/10/Admission-Criteria-to-Scottish-High-Medium-Secure-Units.doc



http://www.forensicnetwork.scot.nhs.uk/documents/ian_gordon.pdf

http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2015/03/Disclosure-Guidance.doc

http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2015/03/Disclosure-Guidance.doc

http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2016/02/NPHN-MH-Implementation-Report-2016.pdf

http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2016/02/NPHN-MH-Implementation-Report-2016.pdf

http://www.forensicnetwork.scot.nhs.uk/wp-content/uploads/2016/02/Position-Paper-Psychological-Approaches-to-Personality-Disorder-in-Forensic-Mental-Health-Settings.pdf




Scottish Executive Health Department (2002). The Right Place, The Right Time: Improving the patient journey for those who need secure mental healthcare. Edinburgh: Scottish Executive Health Department.

Scottish Executive Health Department (2006). Directorate for Service Policy and Planning, NHS

HDL (2006) 48. Edinburgh: Forensic Mental Health Services, Scottish Executive Health Department.

Scottish Government (2007). NHS CEL (2007) 13: Guidance for forensic services. Edinburgh:

Scottish Government. Scottish Parliament. (2003). Meeting of the Parliament, Thursday 20th March. Edinburgh: Scottish

Parliamentary Corporate Body, Stationary Office. Scottish Parliament (2015). Mental Health (Scotland) Act 2015. Norwich: The Stationary Office.

Accessible from:

http://www.legislation.gov.uk/asp/2015/9/pdfs/asp_20150009_en.pdf .


http://www.legislation.gov.uk/asp/2015/9/pdfs/asp_20150009_en.pdf


8. Appendices

Appendix 1: School of Forensic Mental Health Short Courses List (from April 2016 to March 2017)

Event Title Date Personal Safety Scenario Training for Community Staff 14-Apr-17

N2F Training with Support in Mind Scotland 22-Apr-17

N2F Training with The Richmond Fellowship 29-Apr-17

An Introduction to Quantitative Analysis 19-May-16

Staff Support after Violent Incidents 02-Jun-16

RSVP 2-Day Workshop 09-Jun-16

Developing a Research Proposal 16-Jun-16

Personal Safety Scenario Training for Community Staff 16-Jun-16

Managing PD in Custody 21-Jun-16

Personal Safety Scenario Training for Community Staff 23-Jun-16

Professional Witness Course 24-Jun-16

PANSS 16-Sep-16

Writing for Publication 16-Sep-16

Managing PD in Custody 22-Sep-16

Personal Safety Scenario Training for Community Staff 06-Oct-16

Writing for Publications 12-Nov-16

IPDE 2-Day Workshop 30-Nov-16

Physical Health of Psychiatric Patients 18-Nov-16

HCR-20 Version 3, 2-Day Workshop (SLC) 28-Nov-16

SAPROF 09-Dec-17

HCR-20 Version 3, 2-Day Workshop 15-Dec-16

LI Training (NHS GG&C; 5 days) 31-Jan-17

PANSS 17-Feb-17

HCR-20 Version 3, 2-Day Workshop 07-Mar-17

LI CPD Day: MI and Making Healthy Changes 20-Mar-17

Complex and Developmental Trauma 21-Mar-17

Introduction to Formulation 16-Mar-17



Appendix 2: Forensic Network Research Project List 2016

Project Title Project Lead Lead Service /FN Organisation

Clinical Area

Population Needs Assessment in East Dunbartonshire Council Gordon Currie John Marshall/Jessica Killea

CAMHS

A case study of Mentalisation based staff training and case consultation on a forensic mental health ward

Patrick Doyle NHS Fife Psychology

" New to Forensic: Essentials of Psychological Care” training programme: An evaluation of Staff outcomes

Dr. Allan Thomson NHS Fife Psychology

An investigation into the relationship between resting heart rate, systolic blood pressure and antisocial/violent behaviour in a Scottish inpatient forensic population

Max Alford Fife, TSH Clinical Psychology

Service evaluation of Recovery Focus in community forensic mental health team

Rhona Blues NHS Fife Community Forensic Service

Autism and Serious Offending: Evaluation of a Pilot Advice and Consultancy Service

Dr Mike Doyle and Dr Jana de Villiers NHS Fife Psychology and Psychiatry

Forth Valley Prisons Health Needs Assessment: Substance Misuse and Mental Health Needs

Dr Claire Ogilvie NHS Forth Valley Clinical Psychology

A case series on the feasibility and acceptability of psychological assessment and case formulation of impaired treatment decisional capacity in psychosis

Philip Murphy (with Dr Robyn McRitchie and Dr Paul Hutton)

NHS Grampian Clinical Psychology

An audit on the nature of referrals to the Blair Unit, a low-secure forensic mental health service in NHS Grampian

Philip Murphy (with Dr Karen Allan and Dr Robyn McRitchie)


A systematic review and meta-analysis of the evidence relating to the attribution-self-representation model of persecutory delusions. Protocol available on PROSPERO:

Philip Murphy (with Prof Richard Bentall, Prof Daniel Freeman and Dr Paul Hutton)


The relationship between milieu training and ward environment within a Forensic Mental Health Setting

Emma Drysdale and Heather Tolland NHS GGC Psychology



An evaluation of the clinical utility of the new Glasgow Risk Screen Brian Gillatt, Emma Drysdale, Heather Tolland

NHS GGC General mental health

Exploring Staff Experiences & Perspectives of Low Intensity Working Emma Drysdale and Heather Tolland NHS GGC Psychology

An evaluation of the Recovery Groups at Rowanbank Emma Drysdale and Heather Tolland NHS GGC Psychology

An evaluation of reflective practice in Rowanbank and Leverndale Emma Drysdale and Heather Tolland NHS GGC Psychology

An Evaluation of Planning for the Future at Leverndale, Rowanbank and The State Hospital

Emma Drysdale, Natasha Purcell NHS GGC and TSH Psychology

Systematic Review: Effective interventions and management strategies for challenging behaviour in women in secure services

Mark Gillespie NHS GGC Psychology/Psychiatry/Nursing

Reducing levels of violence and aggression in a low-secure forensic setting

Suzanne Urquhart NHS Lanarkshire Nursing

Eye Movement Desensitisation and Reprocessing and people with learning disabilities : A feasibility study

Professor Thanos Karatzias and Professor Michel Brown

NHS Lothian Learning Disabilities

Motivation in female perpetration of intimate partner violence Lauren Forrest Willow, NHS Lothian

Clinical Psychology

Evaluation of The Healthy Living Group - weight management intervention.

Kate Lynch TSH Psychology

Exploring barriers to the uptake of bowel screening for patients at The State Hospital

Kate Lynch TSH Psychology

Service evaluation of the 'On the Road to Recovery' programme at the State Hospital

Natasha Purcell & Lindsey McIntosh TSH Psychology

Cognitive Behavioural Therapy (CBT) for psychosis and personality disorder in a high secure forensic setting: An evaluation of the impact of an integrated treatment programme using a mixed method design

Patricia Cawthorne TSH Arran Hub

The Recovery Model for Patients within a high secure setting: a 20 year follow up

Prof Lindsay Thomson, Cheryl Rees TSH Medical



The Forensic Matrix: an evaluation of psychological therapies across the Forensic Network

Prof Lindsay Thomson, Lindsey McIntosh, Dr Suzanne O'Rourke, Morag Slesser

TSH Psychology

Randomised control trial of the short term effects of OROS methylphenidate on ADHD symptoms and behavioural outcomes in young male prisoners with attention deficit / hyperactivity disorder

Prof Lindsay Thomson, Dr Sheila Howitt, Prof Philip Asherson

TSH Medical

Appeals against detention in conditions of excessive security Prof Lindsay Thomson, Dr Daniel Bennett, Dr Brian Gillatt, Dr Nick Hughes, Dr Sheila Howitt

University of Edinburgh (Dept of Psychiatry)

Medical

Early identification of unacceptable complainant conduct Prof Lindsay Thomson, Dr Gordon Skilling

SoFMH Non Clinical (SPSO)

Understanding needs, securing public safety: The Forensic Network Census

Prof Lindsay Thomson, Jamie Pitcairn Multidisciplinary

Effects of Implementation of a smoke free environment Prof Lindsay Thomson, Dr Briju Prasad Medical

Improving our understanding of the in vivo modelling of mental illness - PhD student 2013-16

Zsanette Bahor, Dr Emily Sena, Prof Malcolm MacLeod, Prof Lindsay Thomson

Medical

Working in a demanding environment: employee wellbeing in secure forensic settings

Amelia Cooper TSH Clinical Psychology

Study of physical health of patients detained within The State Hospital and Forensic Managed Care Network

Frances Waddell TSH Forensic

Exploring forensic mental health nurse's experience on the use of debrief following a violent and aggressive incident within a high secure service.

L. McCafferty TSH Nursing

Facial Affect Recognition in Psychosis Natalie Bordon TSH Psychology

An examination of the validity of the HCR-3 in predicting inpatient violence

Kerry-Jo Smith TSH Psychology

An exploration into how forensic mental health nurses predict and cope with violence and aggression in a high-security setting.

Katherine Nunn TSH Psychology



Date of Meeting: 26 October 2017 Agenda Reference: Item No: 09 Sponsoring Director: Chief Executive Author (s): Angela Robertson, Paul Dobbin, Barry Hill. Title of Report: Performance Management – Nursing Resource Utilisation

Data Requirements Preliminary Report Purpose of Report: To update the Board on initial diagnostics and investigation of

solutions. 1 SITUATION

The Chief Executive held a meeting on 14 September attended by The Directors of Finance & Performance, Human Resources, Nursing & Allied Health Professionals and the Clinical Operations Manager. The objective of the meeting was:

• To review the strands of work currently planned or in progress in relation to gathering and reporting on performance information (primarily relating to workforce and nurse resourcing)

• To establish if these can be synthesized into a single programme of work • To agree associated resource requirements and timescales

At that meeting the Senior Project Manager and Information Analysts were tasked with conducting a requirements analysis to determine the key questions that the stakeholders need to answer, and identifying the specific data and sources that will provide the answers. Essentially, the Hospital must put in place resilient information systems that are not person dependent and describe in full how nursing resources are used. The next phase will involve investigating Business Intelligence solutions that will provide better access to a single source of data and analytics, improve user experience and reduce time spent on administration, freeing-up staff to focus on value-adding activities. This is a preliminary report. The Team has been asked to produce a Project Initiation Document by the end of October 2017. 2 BACKGROUND Members of the Senior Management Team have been conducting various analyses in order to better understand areas of concern such as overtime well in excess of budget and high levels of sickness absence. However, the data currently available does not provide sufficient granularity to explain or attribute the factors influencing these trends. 3 ASSESSMENT The Team have held a series of interviews with key stakeholders. In addition to the group in attendance at the initial meeting, they have met with:

• The Medical Director • Two Ward Receptionists previously involved in nursing resource management • The Lead Nurses • Two Senior Charge Nurses • A Nursing Team Leader • Clinical Effectiveness Team Leader

These meetings have yielded valuable information; some initial descriptions of data requirements that will need to be specified in much more detail, and some anecdotal information that merits further investigation. The emerging themes can be categorised as follows: Budgeting and accounting for overtime Several interviewees expressed a requirement to have a detailed analysis of how overtime levels can be explained fully when compared to previous months/periods, against base establishment staff levels, and in light of the anticipated impact of the closure of two wards. The weekly analysis report currently produced by the Clinical Operations Manager attempts to explain the variance from forecast levels with a breakdown in attributable hours, but it is reported that this does not adequately capture all the factors impacting on overtime. The factors currently recognised as contributing to excess overtime include high sickness absence levels, high clinical activity and variances from nursing establishment levels.

a) Sickness absence levels Very high sickness absence levels within nursing clearly contribute to overtime pressures. The Human Resources Director is leading a series of initiatives that aim to reduce this level including HR advisors directly supporting staff managing absence and the introduction of the EASY initiative. Information is available about the levels and reasons for sickness absence but it can be challenging to produce information that is more detailed. Nursing and Human Resources staff describe real difficulties in accessing the data necessary to do their job. Work is underway to link SSTS to eESS, which will provide much better data for managers trying to control sickness absence and will enable us to better monitor compliance with the EASY system. The services of a Workforce Analyst have also been secured through a service level agreement with NHS Lanarkshire and this will support more advanced interrogation of our workforce data than has previously been possible. b) Clinical Activity The Clinical Operations Manager collates this information weekly from the 24 hour report. This report was originally developed as a briefing tool for the Executive Team but its scope has been expanded to fit other purposes, possibly diluting its utility. It is highlighted that the detail recorded in the 24 hour report cannot be relied upon. It involves a significant amount of work to draw all the numbers together and is prone to errors. The Information Analysts are working on a development to automatically produce ‘24 hour reportable’ data from RiO. The clinical activity extracted from the 24-hour report is currently reported as the number of additional hours worked. This data does not provide sufficient insight and more data is needed in order to also understand the number of staff involved throughout the observation period per patient.

It is critical that nurse leaders provide accurate reporting of clinical levels. The Information Analysts can provide a reporting framework to assist with this and have identified four possible

solutions for detailing labour used on clinical activity ranging from spreadsheets to adaptations to RiO. These will be refined in consultation with the stakeholders. Alongside the data it has been suggested that a secondary review system for PMVA should be introduced and incorporated into the new policy. In that event, some further enhancements can be applied to any of the solutions. For example, routines could be created so that automated emails are delivered to relevant users when review dates are missed, or when observation levels have not changed after a specific period. c) Nursing establishment Regular rounds of recruitment have now been programmed to ensure that the current agreed level of establishment is maintained. Any future discussions about the right level of nursing establishment may be informed by the Excellence in Care programme and the Care Assurance Information System (CAIR) dashboard, which includes nursing planning tools. E-Health are supporting Carolin Walker, Professional Nurse Advisor in the implementation of this project. This dashboard is being developed nationally by NSS using the Tableau Business Intelligence solution.

Planned versus actual staffing A potential 4th factor has emerged from the interviews and it may be that increased costs are being incurred because higher band staff are being brought in to cover lower band staff who are absent. This may be due to availability of suitable staff or inefficiencies in the rostering system, which will be described in the next section. Further investigation is needed to evaluate the evidence for this. The employment of the Workforce Analyst will facilitate the analysis of planned versus actual staffing of rosters, both in terms of the number and grades of staff deployed. Rostering Interviewees report that SSTS does not present data in a way that is useful in practice. Ward rosters are recorded on SSTS once they have been planned out using spreadsheets. SSTS is not being used to accurately record the hours worked or the reasons for overtime, and alternative records are being kept on other systems. Interviewees involved in rostering reported difficulties at every stage in the process. An initial review of the SSTS manual and its capabilities suggests that the system’s potential is untapped and it could address many of the areas identified in the recent RSM audit. Further investigation is needed into the barriers preventing SSTS being used more comprehensively, and any enhancements that could be requested to make it work better for the State Hospital before any conclusions can be drawn. There is a need to train staff and capture data more effectively at source. Training is available from SSTS colleagues in NHS Greater Glasgow and Clyde. Managing availability and covering deficits in nursing shifts is particularly challenging. The current system is cumbersome, frustrating and resource intensive and there is universal support for it to be improved. NHS Lanarkshire and other Boards use a software solution called Allocate. This system provides information to staff on shifts available to be covered and staff can book themselves on-line. The team have been gathering more detail on the specific requirements for the State Hospital and have been invited to meet with NHS Lanarkshire colleagues to discuss Allocate and SSTS in more detail. Business Intelligence Although more work is necessary to specify the exact data requirements, it is evident that it will be sourced from a variety of systems. A Business Intelligence Application will be needed to support data analysis and visualisation via interactive dashboards, and the dissemination of this information across the Hospital. The team had an exploratory meeting with Jill Smith, Head of Business Intelligence at NSS, and are working on more detailed requirements. The NSS Business Intelligence Team can provide

support to Health Boards wishing to implement a Tableau visual analytics platform and are involved in the development of the National Single BI Platform for the NHSScotland Finance Community. Next steps The Team will produce a Project Initiation Document, which will define the project more fully, form the basis for its management and the assessment of overall success by detailing the scope, timeline and deliverables. From this preliminary diagnostic report, elements are likely to include:

• Detailed specification for clinical activity data capture and reporting and consultation with stakeholder on the preferred solution

• Analysis of workforce data to investigate working patterns • Analysis of SSTS capability and current and potential usage • Investigation of electronic solutions to manage nursing availability • Improvements to sickness absence reporting and management systems • Identification of a Business Intelligence Solution

3 RECOMMENDATION The Board is asked to note the contents of this preliminary report.

MONITORING FORM

How does the proposal support current Policy / Strategy / LDP / Corporate Objectives?

The draft Service Strategy prioritises reducing the use of additional hours, promoting attendance and reducing sickness absence, and optimising efficiency in clinical practice and clinical service delivery.

Workforce Implications Preliminary report – resources will be examined as part of the PID.

Financial Implications Preliminary report – resources will be examined as part of the PID.

Route to the Board (Committee) Which groups were involved in contributing to the paper and recommendations?

The stakeholders who have contributed to date have been identified in the paper.


Preliminary report – risks will be examined as part of the PID.


Improved, timely decision support information should support service management.

Equality Impact Assessment Preliminary report – tbc.

THE STATE HOSPITALS BOARD FOR SCOTLAND Minutes of the meeting of the Staff Governance Committee held on Thursday 17 August 2017 at 9.45am in the Boardroom, The State Hospital, Carstairs. Present: Non Executive Director Bill Brackenridge (Chair) Board Chair Terry Currie Employee Director Anne Gillan Non Executive Director Nicholas Johnston Non Executive Director Maire Whitehead In attendance: Clinical Operations Manager Robert Alexander Organisational Development Manager Jean Byrne (part) Chief Executive Jim Crichton Unison Representative Tom Hair POA Representative Bobby Hunter Board Secretary Jean Wade Interim HR Director John White 1 APOLOGIES FOR ABSENCE AND INTRODUCTORY REMARKS Apologies were received from Allan Connor. Bill Brackenridge welcomed everyone to the meeting and advised that item number 5 on the Agenda, Attendance Management Report, would be moved to the end of the meeting to allow a fuller discussion to take place. 2 CONFLICTS OF INTEREST There were no conflicts of interest noted in respect of the business to be discussed. 3 MINUTES OF THE PREVIOUS MEETING HELD ON 1 JUNE 2017 The Minutes of the previous meeting had been received and noted by the Board at their meeting on 29 June 2017. The Committee approved the Minutes of the previous meeting on I June 2017 as an accurate record. 4 ACTION POINTS AND MATTERS ARISING FROM THE PREVIOUS MEETING Members noted that the Action Points from the last meeting were progressing or complete. 5 ATTENDANCE MANAGEMENT This item has been moved to the end of the Agenda. 6 PDPR QUALITATIVE REVIEW – ACTION PLAN UPDATE Members received a report from John White which provided a progress update in relation to implementation of the Personal Development Planning and Review (PDPR) Qualitative Review Action Plan that was presented to the Staff Governance Committee in December 2016. Members noted the summary details of progress made to date in implementation of the PDPR Qualitative Review Action Plan. Work is currently being undertaken at a national level to refresh the Knowledge and Skills Framework and associated PDPR process.

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As a consequence of the ongoing national work, timescales for several actions within the local action plan have been extended to ensure that changes and improvements being introduced within the State Hospital incorporate and comply with the revised national framework and any associated standards and new requirements. The Staff Governance Committee noted the content of this paper. 7 EVERYONE MATTERS: 2020 WORKFORCE VISION Members received a report from John White. Jean Byrne informed members that the Staff Governance Action Plan which set out a series of actions in support of Everyone Matters Workforce Vision 2016 / 17. The focus for 2017 / 18 now requires a refresh of the action plan for the coming year. Jean Byrne provided an update and highlighted a couple of key risks:

• Resource is currently a challenge and it is important that all employees contributing to the actions within the plan are supported to do so.

• The effective rollout of iMatter presents the organisation with some leadership challenges. To stem any creeping cynicism, it is imperative that managers are seen to support the ethos behind iMatter; ensuring staff fully understand the implications of staff engagement for patient care and staff experience, and the importance of action plans being meaningful.

The implications for the workforce of implementing the action plan will be positive in terms of creating and supporting a workforce that is fit for the future. The Staff Governance Committee endorsed the Staff Governance Action Plan for 2017 / 18. 8 DIGNITY AT WORK SURVEY Members received a paper from John White in relation to the Dignity at Work Survey. Jean Byrne informed members that on 6 November, the Dignity at Work Survey will be sent out to all employees across NHSScotland. This is a complementary questionnaire designed to cover a number of areas not included in iMatter but which were originally part of the national Staff Survey. A report will be ready in February 2018. The Staff Survey has now ceased to exist and has been replaced by iMatter, the continuous improvement tool designed to measure staff experience and engagement. The questions are based on the five strands of the Staff Governance Standard. They do not, however, cover all areas that were originally part of the Staff Survey i.e. bullying and harassment, experience of physical violence, unfair discrimination, ability to speak up, ability to get the job done with current staffing and demands as well as the demographic areas around the 6 ‘protected characteristic’ questions as asked in the census and reflected on the eESS system. Boards have been asked to nominate a lead person to undertake promotion locally, update the IT system if necessary and ensure the process runs smoothly. The OD Manager will be the lead at The State Hospital. Jean Byrne advised that the Dignity at Work Survey will pose a number of challenges to the organisation:

• There is a risk that it is conflated with the iMatter questionnaire. They are 2 separate things, designed to measure different experiences. It will be important for managers to understand and explain to their teams this difference.

• The workforce may experience some questionnaire fatigue and be less willing to complete a second national questionnaire.

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• The data stored on the Webropol system may need to be updated as workforce changes occur, particularly among the nursing teams. Managers will need to decide whether to use the iMatter team setups or not. If team data is changed, there is an additional workload created and teams will not be able to compare results against their iMatter reports.

To mitigate these risks, it is recommended that managers ensure they are fully informed of and prepare their teams for the completion of the Dignity at Work Survey. The Staff Governance Committee noted the contents of this report. 9 iMATTER Members received a paper from John White. Jean Byrne advised that it is the third year that The State Hospital has participated in the process. It is also the first year where all staff have participated at the same time. The report highlights the key findings from the 2017 organisational reports and makes comparisons with the previous two years’ reports. The State Hospital received a very positive report in 2017. The overall response rate is 78% (down from 80% in 2016). The employment engagement index (EEI) is 76% (up from 74% in 2016). There was a 78% response rate in 2017. This comprised 599 electronic questionnaires (completion rate of 81%) and 57 paper questionnaires (completion rate of 54%). 14% of paper questionnaires were spoiled due to being either partially completed or having errors in the way they were completed. It would be worth encouraging and supporting all employees to use the electronic questionnaire as there is less likelihood of a spoilt questionnaire.

Jean Byrne stated that although we are above average for NHS Scotland in our response rates and our EEI scores, our response rates have started to decline by a rate of 2% per annum over the past three years. The fall in the response rate might be due to any of a number of factors:

• Lack of buy-in to the process and growing disenchantment with the process; • Reflection of/comment on the changes taking place in the organisation e.g. staff/team

changes; ward closures. Several changes were happening at the time of the questionnaire and it appears likely that the changes had not been adequately embedded;

• Staff illness/absence when the report was being completed; • Anxiety about completing the questionnaire, confidentiality; • Reports being spoiled through inaccurate completion.

The EEI score has remained fairly steady, this year’s EEI is slightly higher than any of the previous two years. The slight rise in the EEI score is encouraging, with a 1% increase each year. There may be a link between the decreased response rate and the increased EEI score if disengaged staff did not participate in the questionnaire. Members noted that there is an increase in the number of teams overall at The State Hospital. The number of teams not receiving a report has also risen significantly (from 3% in 2015 to 16% in 2017). In fact, it has doubled in the past year, with ‘no reports’ being found at both senior and more junior levels. This is concerning. The percentage of green reports has decreased by almost 10% over three years. The percentage of yellow reports has seen a smaller decrease, but still stands at 10.4% of the total reports. In addition, this is the first year there has been an amber report. However, we continue to get a higher than average number of green reports compared with NHS Scotland. The numbers of teams developing action plans has risen slightly between 2015 and 2016 in contrast with the number of progress plans which has declined dramatically during the same period. The

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data for 2017 is not yet available. The Board yearly components over the past three years have not changed significantly. As before, the highest scoring areas lie in the second section of the iMatter report ‘My Team/My Direct Line Manager’, with the lowest scores lying in the third section ‘My Organisation’. The Staff Governance Committee noted the content of the report and approved the recommendations contained therein. 10 HEALTH, SAFETY AND WELFARE COMMITTEE – APPROVED MINUTES OF MEETINGS HELD ON 25 APRIL 2017 Members received and noted for their information, the approved Minutes of the Meetings of the Health, Safety and Welfare Committee which took place on 25 April 2017. 11 PARTNERSHIP FORUM – APPROVED MINUTES OF MEETINGS HELD ON 16 MAY 2017 AND 20 JUNE 2017 Members received and noted for their information, the approved Minutes of the Meetings of the Partnership Forum which had taken place on 16 May 2017 and 20 June 2017. Members were pleased to note the full discussion that had taken place at each meeting in respect of PDP completions. 5 ATTENDANCE MANAGEMENT Members received a paper from John White in relation to Attendance Management. National reporting and comparative Board tables are based upon the SWISS data and it is this figure, which is referred to by Scottish Government. The local data from SSTS enables the breakdown of the absence figures to a departmental level. SWISS The sickness absence figure from 1 June 2017 to 30 June 2017 is 7.81% with the long/short term split being 3.91% and 3.90% respectively. The total hours lost for this period is 7,483.00 which equates to 45.97 wte. The monthly absence figure has decreased slightly by 1.15% from May 2017 figure of 7.93%. The May 2017 long/short term split was 4.95% and 2.98% respectively. The current average rolling 12 month sickness figure is 8.83% for the period 1 July 2016 to 30 June 2017. The long/short term split is 6.53% and 2.31% respectively. The total hours lost for this period is 101,248.33 which equates to 51.92 wte staff. (calculated on the total yearly data) SSTS Industrial injuries represented 0.45% of available hours (5288.59) from 1 July 2016 to 30 June 2017. This represents an increase over the previous yearly figure for June 2016 to May 2017 of 18.42% from 0.38% (823 hours) EASY Members were advised that the EASY (Early Access to Support for You) service is a telephone based sickness absence management service to designed to provide additional support to staff who are off sick. The service was implemented in two phases. Phase 1 on 1 April 2017 and Phase 2 on 1 June 2017. Managers should refer staff to Easy on the first day of sickness. Staff will be called by Easy Service on day 1, 3(for MH issues) and day 10.

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The Committee discussed the implications of the high levels of sickness absence concluding that the high levels of sickness absence:

• Put a burden on other members of staff • Result in expensive overtime • Impact adversely on patient care

Staff side members indicated that management should be doing more to improve attendance that all three impacts might be reduced, but notably the impact on other staff. The Chairman proposed that a Task Force, consisting of the Director, managers who well understood that attendance management was a line accountability (and not an HR one) and any others he would like to contribute, be established the Interim HR Director to:

• Identify for the committee, those policies and procedures relating to attendance management that were unfit for purpose

• Identify for the committee those policies and procedures relating to attendance management that, currently, were not being fully implemented

• Identify new initiatives that needed to be taken to bring attendance close to target in short order.

He also proposed that the Task Force report to the next meeting of the Committee – at the end of November. He further proposed that the workings of Task Force be reported to Committee members monthly in the interim. The Committee agreed to the Chairman’s proposals and noted the content of this report. 12 ANY OTHER BUSINESS No other business to discuss. 13 DATE AND TIME OF NEXT MEETING The next meeting would take place on Thursday 30 November 2017 at 9.45am in the boardroom, The State Hospital, Carstairs.

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THE STATE HOSPITAL The State Hospitals Board for Scotland

Date of Meeting: 26 October 2017 Agenda Reference: Item No: 11 Sponsoring Director: John White, Interim Human Resources Director Author(s): Jean Byrne, Organisational Development Manager Title of Report: NHSScotland Board Diagnostic Tool 1 SITUATION The Board Diagnostic Tool is a developmental tool for the use of health boards in Scotland. It provides a rich source of feedback that enables boards to assess their strengths and their areas for development. Currently, out of 22 health boards, 18 have completed the self-assessment with some Boards ready to do it for the second time. The State Hospitals Board for Scotland has so far not participated. This report presents the key information around the process, the benefits and how the results are reported. 2 BACKGROUND Self-evaluation is recognised as a useful method of engaging individuals in their own self-development and in lifelong learning generally. It allows individuals to compare their self-perception with the perception of others and to identify any discrepancies. In the sports world, for example, performance profiling is now a popular approach to developing high-performing athletes. Athletes rate themselves against the ideal and, with the help of their coach, they identify areas for development. The Board Diagnostic Tool is a self-evaluation tool, commissioned by the Quality Portfolio Group (QPG), a sub-group of the NHS Board Chairs’ Group in 2015. The QPG oversees board development to ensure boards have access to a range of quality resources and support. The tool is a self-assessment tool composed of five domains; all are important contributing factors to board effectiveness:

• Engaging with stakeholders • Strategic intent • Holding to account • Board dynamics • Leadership of the board.

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The diagnostic tool asks a number of questions in each domain and also provides an opportunity for participants to add comments. The results are owned by the board and are used to measure performance. Boards also have access to a range of development support i.e. an induction framework, resource booklets, regional events and facilitated networks to support non-executives in specialist roles. 3 ASSESSMENT The benefits of participating By participating in the Board Diagnostic Tool, Board members have the opportunity to:

• Review their performance against the five domains of board effectiveness • Obtain objective feedback on their performance • Develop a shared understanding of what a high performing board looks and feels like and

how their board compares with this vision • Have a productive discussion around their performance, strengths and areas for

development • Agree priorities for improvement and how they will be implemented • Compare their performance from one year to the next • Improve team dynamics and relationships.

The process The aim is for each health board to complete the self-assessment every 18 – 24 months. The steps involved are:

• Chair meets with HR/OD Lead to agree who will facilitate the process and when • Chair and facilitator discuss the key areas of work and agree how this will be conducted • Board introductory session to discuss process, dates, and completion of the tool • Tool is completed (30-60 minutes) • Some one-to-one interviews (1-hour) with selection of board members to explore what works

well and what the challenges are • Chair and facilitator meet to review feedback • Board development session to consider the report and next steps (at least ½ day) • Board development plan with commitment to review regularly • Agreement about when to repeat the process.

How results are reported Results are reported at Board level and by respondent type. Respondents can be grouped together for the purpose of anonymity if desired. The results are based around each of the five domains noted in Section 2. A full breakdown of responses is also provided in the appendices. Questions are scored from 1-6, with 4-6 representing the positive scores. Summary measures used within the report are:

• Median scores for each question • Percent positive result (based only on positive scores).

The report provides information in the following areas:

• Domain ranking – board members’ individual ranking of the domains relative to development needed

• Domains with highest and lowest median scores • Table of responses to each statement within domains • Median scores by respondent type • Further comments by board members within each domain • Responses received for each statement, in each domain by respondent type.

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A full copy of the raw data is also provided, allowing the Board to carry out further analysis if required. Confidentiality Some respondents may be easily identified. Therefore, as stated in Section 3, respondents can be grouped together to preserve anonymity, if desired. The board report is not for onward distribution and is for the sole use of the board. 4 RECOMMENDATIONS The Board is invited to:

• Endorse the contents of this report • Agree the timescale for the diagnostic to commence.

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MONITORING FORM


Provides time for reflection and self-evaluation of strengths and areas for development, thereby supporting Corporate Objectives.

Workforce Implications

Considered at Section 3 of the report.

Financial Implications

Time implications as in Section 3.

Route to Staff Governance Which groups were involved in contributing to the paper and recommendations.

Paper prepared by OD Manager.


No identified risks.


Positive.


EIA Screened – no identified implications.

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THE STATE HOSPITAL BOARD FOR SCOTLAND Date of Meeting: 26 October 2017 Agenda Reference: Item No. 12 Sponsoring Director: Director of Finance and Performance Management Author(s): Head of Management Accounts Title of Report: Financial Position as at 30 September 2017 Purpose of Report: Update on current financial position 1 SITUATION

1.1 The Senior Team and the Board consider the Revenue and Capital plans, and financial monitoring. This report provides information on the financial performance to 30 September 2017 (half-year).

1.2 1.3

The three-year financial plan for 2017/18 – 2019/20 is an integral part of the Board Local Delivery Plan (LDP). The LDP is the strategic plan, which sets out the agreed vision for service delivery and development for the Board, and sets out a balanced budget for 2017/18 based on achieving £1.402m efficiency savings, as referred to in the table in section 4. Recognition of recurring posts, saved through recent workforce reviews, amounting to £0.315m have already been realised in the base budgets, so in effect that brings the total savings target to £1.717m. A further £0.440m is now expected, see note 1.3 below, and a new table has now been added to track this in section 4.3. National Boards are individually and collectively – through a number of non-clinical work streams – aiming to support a £15m efficiency savings gap. While the workstreams are underway in 2017/18, the timing of some benefits is such that additional contributions from each of the national boards are required. The effect of the second ward closure was expected to allow some contribution, albeit non-recurrently, to the share identified by TSH as £0.440m. The £0.440m was reduced non-recurring from our allocation in June 2017, phased to period 12 initially but as savings are realised against this we will bring forward the phasing, and this will be monitored separately from the £1.402m savings noted in section 4.2. Utilities reviews are taking place that will generate reductions in spend, some of which may contribute as recurrent savings. This month we have received income arrears of £0.127m for the backdated VAT benefit on electricity invoices, and a further amount is anticipated for the current year. We also intend to document suggested changes and improvements in the development of future workforce plans and projections.

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2 BACKGROUND

2.1 Revenue Resource Limit Outturn The Board is reporting an over spend position of £0.174m to 30 September 2017. There was an adverse movement in the month – mainly in connection with excessively high nursing overtime and excess hours, offset with the electricity income £0.127m noted in 1.3. The current overall position is summarised in the table below –

2.2 2.3 3

Outturn The forecast outturn trajectory to date (as set in the LDP) is an over spend of £0.130m, against the actual over spend of £0.174m so the position is worse than planned by £0.044m. Nursing overtime was exceptionally high again – which is considered to be due principally to patients on high observation levels and high levels of sickness. Revenue Resources The annual budget £34.624m matches the Revenue allocations received, plus anticipated from Scottish Government. ASSESSMENT YEAR TO DATE POSITION – BOARD FUNCTIONS

3.1 Medical Services

Annual Budget £2.2m. Year to date under spend of £0.151m. This is mainly in connection with reductions to EPAs, and increased external sessions recharged since base budget was set, these ongoing changes are to reflect savings to be made due to the ward closure. Also there are small underspends in internal recharges from other Boards.

3.2 Nursing and AHPs – see table overleaf. Annual Budget £17.9m. Year to date over spend of £0.487m.

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The £'s includes NI'ers @ 11%

2017/18 Ward Nursing Hours

2016/17 Ward Nursing Hours

Period Overtime

Hours Excess Hours

Period

Overtime Hours

Excess Hours

APR 3,732 734

APR 5,110 850 MAY 3,010 707

MAY 3,476 684

JUN 4,046 464

JUN 3,549 654 JUL 5,144 568

JUL 3,950 770

AUG 6,822 848

AUG 4,288 839 SEPT 6,885 496

SEPT 4,620 960

TOTAL 29,639 3,817

TOTAL 24,993 4,756

2017/18 Ward Nursing £s

2016/17 Ward Nursing £'s

Period Overtime £ Excess £

Period Overtime

£ Excess £ APR 93,077 11,283

APR 130,693 12,458

MAY 75,198 10,553

MAY 86,752 10,475 JUN 100,626 7,136

JUN 85,285 10,137

JUL 130,226 8,526

JUL 97,849 11,299 AUG 174,100 12,473

AUG 106,060 12,323

SEPT 177,335 7,781

SEP 118,216 14,246

TOTAL 750,562 57,752

TOTAL 624,855 70,937 The nursing over spend continues principally because of very high levels of clinical activity and staff sickness (that which exceeds what is built in to the establishment/budget). In addition to these statistics, on a weekly basis the Directors group look at activity data collated for nursing establishment, patient outings/escorting, training, and facility time. A review is underway to identify, record and highlight more accurately the specific factors causing the overtime hours.

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Some of the pressure is also to do with programmed monthly savings not yet realised, £0.168m year to date. There is also some benefit realised from the temporary ward closure. Vacancies within this directorate are offsetting some of this pressure. Nursing resources over spend is due to savings not yet realised.

3.3 3.4

Security and Facilities – see table below. Annual Budget £5.6m. Year to date under spend of £0.106m.

Facilities – under spends are in Housekeeping and Utilities. Security – the very small over spend is due to under achieved savings. Corporate Functions (Support Departments) – see table below. The total budget for Corporate Functions is £9.0m – reporting an under spend of £0.057m.

Capital Charges – actual spend should come back in line with budget as year progresses. Central commitments – initially phased to March, however some has now been released for the year to date, and the variance is due to phased savings offset with the electricity income. Miscellaneous Income – RHI income is included, less any transferred to match the corresponding RHI spend in Estates. Chief Executive – the research spend is less than planned to date, and there are vacancies in Psychology, plus the benefit of the HR Director secondment only being filled by 0.5 wte. Forensic Network & School of Forensic Mental Health sits within this Directorate, with the Scottish Government earmarking this funding. Some income has been deferred to 2017/18, being monthly pending spend accrued to reflect the projected breakeven, and there are also fluctuations due to timings of course income and expenditure. Finance – The legal fees spend to date is greater than budget, and savings are currently slightly under achieved. Human Resources – Underspend is mainly in course fees & vacancies.

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4 4.1 4.2

4.3

EFFICIENCY SAVINGS TARGET

To balance the financial plan in 2017/18 the Board was required to release £1.717m of cash from budgets through efficiency savings. As noted in 1.2 above, £0.315m is recognised in the recurring base budgets, with £1.402m savings still to be realised. The Territorial Boards £0.440m contribution is now tabled mid-year. The following table tracks the LDP savings, currently under achieved by £0.085m.

The following table tracks the new savings, post LDP.

Other windfall savings, for backdated water arrears and CNORIS income, will also go towards this £0.440m target, as well as ward closure savings. All of these were unknown at the time of the initial LDP setting.

5 CAPITAL RESOURCE LIMIT

Capital allocations from Scottish Government amount to £0.417m (including £0.148m vired from revenue for a water tanker and two eHealth projects).

The plan is forecast to breakeven, although there are some pressures noted that may need to be carried forward to next financial year.

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6 RECOMMENDATION

6.1 6.2

Revenue Actions from monthly budget meetings are noted in a ‘Financial Plan Action List’ by the Head of Management Accounts to record any deviations from plan – either expected pressures or benefits – to make the Board aware of the effects on the financial outturn. We have projected a year-end breakeven in the LDP (which was before the £0.440m contribution) but are still expecting to break-even with utilities income arrears and other efficiencies. Capital The projected year-end breakeven in the LDP remains the same after the virement to CRL from RRL, for two IT projects and a water tank.

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

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MONITORING FORM


Monitoring of financial position

Workforce Implications No workforce implications – for information only

Financial Implications No financial implications – for information only

Route to Board Which groups were involved in contributing to the paper and recommendations?

Head of Management Accounts


No significant risks identified


None identified

Equality Impact Assessment No identified implications

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 26 October 2017 Agenda Reference: Item No: 13 Sponsoring Director: Finance and Performance Management Director Author: Angela Robertson Title of Report: LDP Performance Report Q2 2017/2018 Purpose of Report: To provide KPI data and information on performance

management activities. 1 SITUATION This report presents a high-level summary of organisational performance for the period from July 2017 until September 2017 and is based on the Local Delivery Plan (LDP) and its associated targets and measures. An exception report is attached as Appendix 1. 2 BACKGROUND Members receive quarterly updates on Key Performance Indicator (KPI) performance as well as an Annual Overview of performance and Year-on-Year comparison each June.

3 ASSESSMENT We have maintained good levels of performance in many areas but performance in the following areas merit comment: • No 2: Patients will be engaged in Psychological Therapy

The percentage of patients engaged in psychological therapies has increased from 91.8% in June to 94.5% in September, well in excess of the 85% target.

• No 3: Patients will be engaged in off-hub activity centres The average attendance for Q2 was 80% compared to 81.8% in Q1 and performance remains below the target of 90%. This may be explained by the high number of new admissions and increased clinical activity over the period.

• No 5: Patients will undertake 90 minutes of exercise each week The new process that integrates physical activity recording within the RiO Electronic Patient Administration System rolled out to the final hub on the 2nd October. The three previous hubs are collecting the data routinely, and the pilot team are working with nursing staff on the last hub to ensure that consistent data is being input to the system. Once the process is embedded hospital-wide, this data will provide evidence at a population level of the percentage of patients meeting the current target, as well as reports that provide a personalised analysis for individual patients.

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• No 8: Staff have an approved Personal Review & Development (PRD)

There has been an improvement in performance from 80.4% in June to 87.2% at the end of September. Several factors may be contributing. The new leadership structure in nursing (i.e. having a Senior Charge Nurse in each ward) means that there is a named individual with accountability for meeting the PRD standard. Additionally, an increase in emphasis on compliance by the Chief Executive means that individual members of the Senior Team now have PRD compliance levels included as part of their individual performance objectives.

• No 15: Attendance by clinical staff at case reviews. Data from the previous quarter is provided for comparison. The drop in key worker attendance has coincided with exceptional levels of sickness absence and high clinical activity, which has had an adverse impact of the availability of key workers. There has however been nursing attendance at every review. Peak annual leave time and one member of staff commencing maternity leave during the last reporting period has contributed to the reduction in attendance of Occupational Therapists. The new Lead Allied Health Professional is exploring how attendance can be maximised. A new dietician has recently been recruited and attendance should therefore increase.

As anticipated in the June Report to the Board, Pharmacy attendance has fallen from 49% in Q1 to 37% in Q2 against a target of 60% due to a vacancy. The team has withdrawn from attendance at intermediate case reviews and prioritised pharmacy case review reports, which continue to be delivered at a high level. The new Pharmacist is now in post. The attendance of Clinical Psychologists and Psychological Therapy Service staff has greatly improved and the service has made concerted efforts to address the lower attendance figures reported in Q1. Security have increased attendance from 43% to 75%, well in excess of their target 60%.

5 BUSINESS INTELLIGENCE AND DATA WAREHOUSE

The Senior Project Manager and Information Analysts are now scoping out the Business Intelligence Project. The Chief Executive has tasked the team with conducting a requirements analysis to determine the performance information needed for workforce and nursing resource utilisation as a priority.

6 RECOMMENDATION The Board is asked to note the contents of this report.

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MONITORING FORM


Monitoring of Key Performance Indicator Performance in the TSH Local Delivery Plan (2016-2019).

Workforce Implications No workforce implications-for information only.

Financial Implications No financial implications-for information only.


Leads for KPIs contribute to report.


Gaps in KPIs previously identified are being actively addressed. Roll-out and reporting contingent on success of Business Intelligence project.


Improved, timely decision support information should support service management.

Equality Impact Assessment Not applicable.

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Appendix 1

Item Principles Performance Indicator Target RAG Actual Comment LEAD 1. 8 Patients have their care and

treatment plans reviewed at 6 monthly intervals

100% A 97% Figures for Sept 2017. There were 2 out of date due to a change in section date. LT

2. 8 Patients will be engaged in psychological treatment

85% G 94.5% Figures for Aug 2017, Sept not yet available. 91.8% in Jun 2017. 104 engaged in therapy. Of the 6 patients not engaged in treatment, 5 have recently completed other treatments and 1 is refusing to engage.

MS

3. 8 Patients will be engaged in off-hub activity centres

90% A 80% Average figure for Jul-Sept 2017, was 81.6% in Q1. Excludes shop / health centre information (brief visits).

MR

4. 8 Patients will be offered an annual physical health review

90% G 100% Figures for Jul-Sept 2017. All eligible patients were invited, 15 attended Annual Health Reviews, 10 admission physicals completed, 3 refused, 5 rescheduled.

LT

5. 8 Patients will undertake 90 minutes of exercise each week

60% - - A new method of collecting physical health information is being piloted. MR

6. 8 Patients will have a healthy BMI 25% R 14.4% Figure from Jun 2017, Dec 16 figure was 13.3%. Next audit due Dec 2017. LT 7. 5 Sickness absence (National

standard is 4%) 5% R 8.94% Rolling figure for Aug 2017, Sept not yet available. 8.83% in Jun 2017. JW

8. 5 Staff have an approved PRD 100% A 87.2% Rolling figure for Sept 2017. 80.4% in Jun 2017.

JW

9. 1, 3 Patients transferred/discharged using CPA

100% G 100% Figures for Jul-Sept 2017. 7 patients discharged/transferred, all relevant MAPPA notifications completed.

KB

10 1, 3 Patients requiring primary care services will have access within 48 hours

100% G 100% Figures for Jul-Sept 2017. 578 interventions in Q1 (576 requests in Q1). LT

11 1, 3 Patients will commence psychological therapies <18 weeks from referral date

100% G 100% Figures for Aug 2017, Sept not yet available. 17 patients have waited longer than eighteen weeks for engagement –all are involved in other therapies and therefore were/will be delayed in entering specific treatments due to time overlaps (thus individual availability issue, not therapy availability issue). 41 patients are awaiting additional treatments.

MS

12 1, 3 Patients will engage in meaningful activity on a daily basis

100% - - New indicators and business processes in development. MR

13 2, 6, 7, 9 Patients have their clinical risk assessment reviewed annually.

100% A 98% Figures for Sep 2017. 2 were out of date due to a change in section date. LT

14 2, 6, 7, 9 Hubs have a monthly community meeting.

- - - New indicators and business processes in development as reported to the June Board. MR

15 Refer to next table. All Clinical Leads

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Item Code Principles Performance Indicator Profession (Lead) Target RAG Overall attendance Jul-Sept 2017

Overall attendance Apr-Jun 2017

17 T 2, 6, 7, 9 Attendance by all clinical staff at case

reviews RMO (LT) 98% A 96% 98%

Medical (LT) 100% A 96% 100%

Key Worker/Assoc Worker (MR)

80% R 64% 76%

Nursing (MR) 100% G 100% 96%

OT(MR) 80% R 55% 63%

Pharmacy (LT) 60% R 37% 49%

Clinical Psychologist (MS) 80% G 82% 65%

Psychology (MS) 100% A 98% 90%

Security(DI) 60% G 75% 43%

Social Work(KB) 80% G 80% 90%

Skye Activity Centre (MR) (only attend annual reviews)

tbc - 0% 0%

Dietetics (MR) (only attend annual reviews)

tbc - 0% 13%

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 26 October 2017 Agenda Reference: Item no: 14 Sponsoring Director: Finance and Performance Management Director Author: Finance and Performance Management Director Title of Report: Information Governance Group annual report Purpose of Report: For noting 1 SITUATION This annual report outlines the work carried out by the Information Governance Group (IGG) and Caldicott Guardian in order to convey it in a summary form to the Board. 2 BACKGROUND The attached report summarises the work carried out by the IGG and Caldicott Guardian over the past year, including descriptions of new initiatives that have been developed and implemented in addition to the ongoing monitoring of progress against the Information Governance toolkit and Information Governance risk assessment. 3 ASSESSMENT

KEY ISSUES SUMMARY OF IMPACT

Information Governance Standards

Significant progress has been made by the group since implementation of self assessment of the standards. There has been a slight improvement in the year in overall attainment levels across the toolkit.

Information Governance Risk Assessments

Ongoing regular monitoring of risk assessments with action taken accordingly.

Information Governance Training

Increased levels of training completion. “Information Governance: Essentials” introduced as a new annual and mandatory training module (replacing “Overview”).

SUIs / CIRs

Implementation of recommendations from SUIs in progress.

Information Governance Datix Reports

Continuing review of Datix Incidents as they occur with action taken as appropriate.

Electronic Patient Records Ongoing review of EPR development.

Information Governance Walkrounds

Continuing to have a positive impact on overall Information Governance practice.

FairWarning System now fully operational and decreasing level of alerts noted.

Records Management Records Management Plan approved by Record Keepers Office and related work ongoing.

FOI / Subject Access Requests

No issues highlighted from regular reports of FOIs and access requests received.

Vision Project Now fully implemented with the support and input of the Group.

General Data Protection Regulation

Review of practices underway to identify actions and timings required re the implementation of the new regulations.

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Future Developments The main areas to be addressed by the group in 2017/18 are

WORK / SERVICE DEVELOPMENT TIMESCALE

Maintain and progress Information Governance module attainment levels Ongoing

Develop / consider use of national Information Governance training Ongoing

Continue Information Governance walkarounds Ongoing

Implementation of Records Management Plan and associated actions in line with the Public Record (Scotland) Act

Ongoing

Support for the development of CELCAT or equivalent timetabling system Ongoing

Support for RiO7 business case December 2017

Implementation of GDPR / DPA(2017) April 2018

4 RECOMMENDATION

The Board is asked to note the contents of this report.

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MONITORING FORM


Information Governance is a key area for monitoring and reporting to support the Hospital’s strategic objectives

Workforce Implications Certain specific responsibilities require confirmation as noted in the report and these are being addressed.

Financial Implications Specific projects have eHealth cost implications are considered within that department’s budget.


Information Governance Group report presented directly to the Board on instruction from the Chair, having formerly reported to Clinical Governance.


Risk of information governance breakdown – addressed on each specific area by the IGG.


Protection of confidentialities and of the Hospital’s reputation.


No potential inequalities have been identified.

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INFORMATION GOVERNANCE ANNUAL REPORT

APRIL 2016 – MARCH 2017

(Including Health Records and Data Protection Group Report)

Lead Author Finance & Performance Management Director / SIRO Contributing Authors Health Records Manager

Deputy Data Protection Officer Approval Group The State Hospitals Board for Scotland Effective Date September 2017 Review Date August 2018 Responsible Officer Finance & Performance Management Director / SIRO

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Table of Contents Description

Page Number

Introduction and Highlights of the Year

3

Group membership

3

Role of the group

4

Aims and objectives

4

Meeting frequency

4

Strategy and work plan

4

Management arrangements

4

Key work undertaken during the year :

1. Information Governance Standards 2. Information Governance Risk Assessments 3. Information Governance Training 4. SUIs / CIRs 5. Information Governance Datix Reports 6. Electronic Patient Records 7. Information Governance Walkrounds 8. FairWarning 9. Records Management 10. FOI / Subject Access Requests 11. Vision project 12. GDPR (General Data Protection Regulation)

4 5 6 6 7 7 7 8 8 8 8 8

Identified issues and potential solutions

9

Future areas of work and potential service developments

9

Next review date

9

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1 INTRODUCTION AND HIGHLIGHTS OF THE YEAR The Information Governance Group, chaired by the Senior Risk Information Owner (SIRO) is responsible for progression of attainment levels in relation to Information Governance Standards. The Caldicott Guardian principles have now been integrated within the initiatives and standards required by NHS QIS for Information Governance and attainment levels are recorded via the Information Governance Toolkit. Since October 2011 there is no longer a requirement to send the attainment levels to QIS or ISD. Despite this we continue to internally monitor our attainment levels biannually on a voluntary basis. From 2013 it was requested by the Chairman that this report (formerly the Caldicott Guardian Report) is submitted on an annual basis to the Board, replacing the previous requirement to report to the Clinical Governance Committee. Over the last year the Committee has continued to work to improve Information Governance standards across the Hospital. We have encouraged staff to adopt good Information Governance standards through a number of measures undertaken by the group, and to complete mandatory online Information Governance learning modules. Following a review of the Information Governance learning modules, a revised educational programme was introduced which included, in line with good practice, an annual refresher for all staff. We have continued to adhere to recommendations included in the Scottish Government’s “NHSScotland Information Assurance Strategy CEL 26 (2011)” document and as a result a regular schedule of Information Governance Walkarounds within the Hospital takes place, including non-patient areas. In addition the group has focussed on other key areas of priority such as the electronic patient record (EPR) system, the outcomes of the FairWarning system, and the full adoption of Vision (a GP electronic patient record) – together with ad hoc issues such as redaction practices and email scams. The Data Protection, Confidentiality and Clear Desk policies were updated during the period. Significant focus going forward into 2017/18 will be on GDPR (General Date Protection Regulation) and Records Management. 2 INFORMATION GOVERNANCE GROUP

2.1 Information Governance Group membership Robin McNaught Chair – Finance & Performance Management Director & SIRO Dr Duncan Alcock Deputy Chair – Associate Medical Director & Caldicott Guardian Thomas Best Head of IM&T Dr William Black Medical Representative Alison Buchanan Clinical Secretary Co-ordinator Moira Donoghue Finance Representative Louise Gray Health Records Assistant Ken Lawton Information Technology Security Officer Jackie McQueen Nursing Representative Karen Mowbray Health Records Manager Dr Natasha Purcell Clinical Psychologist Shona Smillie Security Representative vacant – awaiting nomination Human Resources Janet Warren Skye Centre Representative Nicola Watt Risk Management Team Leader Sandra Wishart Social Work Representative Morag Wright Pharmacy Lead vacant – awaiting nomination AHP Representative

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2.2 Role of the group The group has a wide reaching remit, being responsible for all matters in respect of Information Governance within the Hospital as the title suggests. The membership of the group is purposely broad. This allows the group to be representative of staff groups and departments from across the hospital. 2.3 Aims and objectives

• Ensure compliance and development of Information Governance overall as monitored by

the IG toolkit. • Address issues arising in the hospital in relation to Data Protection. • Address issues arising in the hospital in relation to Health Records including structure,

filing, storage, and archiving. • Address Caldicott issues including monitoring DATIX reports and ensuring relevant

training for staff. • Provide a forum for the various staff groups within the hospital to raise any eHealth

Information Governance issues and to receive feedback from eHealth on such matters. • To monitor requests made in relation to Freedom of Information and Subject Access

Requests. 2.4 Meeting frequency The group has continued to meet on a bi-monthly basis to discuss any issues as outlined above. Following agreement from the wider group, a small subgroup – the IG Risk Assessment Group – also meets 6 monthly in order to concentrate on the assessment of the current attainment levels and supporting evidence required for the Information Governance toolkit self assessment, which is undertaken regularly. In addition this small sub group also meets 6 monthly to review the Information Governance risk register (see para. 3.2). 2.5 Strategy and work plan As noted in previous reports, the Caldicott principles have now been integrated within the initiatives and standards developed by NHS QIS for Information Governance. The Information Governance Toolkit is completed twice yearly in order to monitor the performance of the hospital in relation to Information Governance. The schedule of work for the group is compiled in such a way as to allow the group to review progress with the Information Governance Standards. This monitoring allows the group to develop an action plan of work to be undertaken by the group members. In addition meetings are used to address the issues that may arise such as filing, relevant training, confidentiality issues etc. The group will continue to meet on a regular bi-monthly basis. 2.6 Management arrangements The Information Governance Group now reports annually to the State Hospitals Board for Scotland through the IGG Report. The IGG also reports to the Senior Management Team as relevant. 3 KEY PIECES OF WORK UNDERTAKEN BY THE GROUP DURING THE YEAR 3.1 Information Governance Standards In response to feedback from the Information Governance Team at ISD, following the implementation of Information Governance standards and Electronic Toolkit in 2007, the attainment levels for each of the standards were revised and new attainment levels introduced with effect from 2008.

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The revised attainment levels within the Information Governance Framework have been agreed in partnership with NHS QIS to ensure that the Framework remains fully compliant with NHS QIS Improvement Framework. In line with Clinical Governance and Risk Management (CGRM) standards a four point scale has been introduced that enables organisations better to demonstrate their compliance with the Information Governance Standards (IG). However there are differences between the stages of activities required to meet each level of attainment set within the CGRM standards and IG standards, the detail of which is listed below: Level CGRM Activities IG Activities

1 Development Developing and Implementation 2 Implementation Developed and Fully Implemented 3 Monitoring Monitoring and Evaluation of Effectiveness 4 Reviewing Change Implemented in light of Continuous

Review Cycle The introduction and assessment of these attainment levels is a significant part of the workload of the Information Governance Group with a focus on achieving progress against the high standard of activities set within each level. As of 2013, six additional toolkit targets were added in relation to Administrative Records, bringing the overall number to 52. Progress has been made by the group since the implementation of the self assessment of the standards. There has been a slight improvement over the period in our overall attainment across the toolkit. This improvement reflects the strengthening of Information Governance roles within the organisation which were identified through last year’s toolkit reviews. The following is a summary of the attainment levels in recent years:- Attainment

Level 2012/13

(Includes Admin Records)

2013/14 (Includes Admin

Records)


Records)


Records)


Records) 1 0 1 6 5 2 2 1 3 1 3 3 3 2 2 0 0 1 4 49 46 45 44 46

Generally we continue to maintain our previous attainment of Information Standards as shown by our monitoring through the Information Governance Toolkit. Of the targets where attainment level 4 has not been reached, the Group is hopeful that further progress can be made whilst at the same time maintaining the levels achieved on the other targets. A number of the attainment levels sitting at level 1 relate to the identification within the organisation of individual/s responsible for the Information Governance coordination, Freedom of Information requests and Data Protection. For each of these it is anticipated that when individuals are identified that the attainment level will move to level 4, and these roles are being addressed in 2017/18. Additionally 2 others at attainment level 1 relate to information sharing and security, on which reviews are ongoing. Those at level 2 are regarding Records Management and IT enhancements, and these are also being addressed – in part by the development of the Records Management Plan which has now been submitted and accepted. 3.2 Information Governance Risk Assessments Information Governance risks assessments are undertaken by a sub group of the IGG – the IG Risk Assessment Group – comprising the Caldicott Guardian, Health Records Manager and Information Technology Security Officer. (This group first met in November 2011 to update risk assessments following the move to the new hospital site.) Following on from this the subgroup has met 6 monthly to review current Information Governance risk assessments and update accordingly. The Group is next scheduled to meet in November 2017.

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There are currently 24 Information Governance risk assessments on the risk register covering a variety of risks (e.g. disclosure of loss of identifiable information through transportation of records, unauthorised access to health records areas). On each occasion that the Information Governance risk assessment has been updated steps have been taken to minimise the risks highlighted (e.g. procedures to ensure identifiable information is sent recorded delivery; procedures re mobile devices; risks associated with staff leaving the organisation). During the groups review relating to pending changes in data protection legislation, two areas were highlighted for action.

• Some older risks corresponding to electronic systems may be better mitigated using controls described in the information security standard (ISO 27001/2)

• Most risk assessments required an up to date privacy impact assessment to comply with the General Data Protection Regulation.

In the coming year, risks associated with IT systems will be considered for transfer to eHealth’s risk register and privacy impact assessments will be conducted for all Information Governance risks. The group expects a rise in identified risks during the transition period between the 1998 Data Protection Act and the General Data Protection Regulation/ Data Protection Act 2017. 3.3 Information Governance Training The four online learning modules, “Overview of Information Governance”, “Confidentiality”, “Data Protection” and “Records Management” were updated following a review. A new module “Information Governance: Essentials” was introduced in February 2017 as an annual requirement for staff. The “Overview” module was retired with the remaining modules updated to reflect the changes. All modules remain mandatory for all staff. Monitoring of completion rates by staff is undertaken by the Training & Professional Development Manager, with oversight by the IGG. A continuing high completion of the modules can be seen in the table below. The completion rates for the IG: Essentials module is expected to rise as it replaces the Overview module. Information Governance module completion

Module June 2013

June 2014

June 2015

June 2016

June 2017

IG: Essentials n/a n/a n/a n/a 32% Overview 80% 91% 93% 97% 65% Confidentiality 77% 88% 92% 95% 97% Data Protection 73% 87% 91% 95% 97% Records Management 60% 80% 87% 93% 95% The Group will continue review the contents of the modules to ensure that they continue to meet the needs of staff with the introduction of the General Data Protection Regulation and the Data Protection Act 2017. 3.4 SUIs/CIRs There were 3 SUIs during the reporting period that related to Information Governance – one being brought forward from late in the prior year. The Information Governance aspects of these related to the potential breach of patient confidentiality through external purchasing via procurement; publishing of an article in the media quoting an “insider”; and the inadvertent storage on a shared drive of a document containing confidential staff information.

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Following reviews it was felt that processes could be improved to prevent any future Information Governance risk in these areas. The recommendations from two of these SUIs have been completed, with those from the third pending. Completion of the remaining recommendations – which refer to the protection of specific reports, and specific mandatory refresher training – will be reported through SMT in the usual fashion. The group continues to address recommendations from previous Information Governance incidents. The only other outstanding recommendation related to the sharing of information between social work and TSH staff. An information sharing protocol was drafted in accordance with national guidance and passed to senior social work colleagues for review, and is now being progressed. 3.5 Information Governance Datix Reports While there were a number of patient related Information Governance incidents overall in the period, many of these incidents were relatively minor and related to use of NHS mail or sending information through the post. To address these issues the IGG have increased awareness of these problems and reiterated guidance relating to these issues through the staff bulletin. We continue to encourage staff as to the importance of displaying high standards in relation to Information Governance. To this end a number of guidance notes have been circulated through the Staff Bulletin. In addition the regular Information Governance Walkarounds provide an opportunity for informal contact with staff to give guidance on Information Governance matters. To support the roles of SIRO and Caldicott Guardian, those individuals attend SIRO training and the national Scottish Caldicott Guardian meetings. These meetings include elements of both professional development and practice updates. In addition there is regular participation in discussions on the national Caldicott Guardian electronic forum, plus membership of the national Caldicott Guardian Executive. 3.6 Electronic Patient Records Members of the IGG were actively involved in the ongoing development of the EPR (RiO) – and the project-specific EPR Group continues to meet regularly. This has included involvement in development of the business case for RiO7, giving advice on Information Governance matters and regular audits of the electronic Health Records. Following introduction of the EPR a revised Health Records Audit was constructed. On the whole the audit has shown that staff are applying high standards when making Health Record entries, and there is regular reporting on the results of these audits. Through completion of a number of audit cycles we have identified some particular areas requiring improvement, and continue to review these with particular regard to the levels of unvalidated entries which – while reducing – require to be addressed on an ongoing basis. A new process was introduced in 2016/17 which is intended to improve compliance. 3.7 Information Governance Walkrounds Having been introduced in 2015 as a recommendation following the publication of the NHS Scotland Information Assurance Strategy CEL 26 (2011) the Information Governance Walkrounds have built on the success of the previous years. The unannounced monthly walkrounds have expanded from only reviewing areas with clinical records to encompass all areas of the organisation were personal information is used. The staff members involved in conducting these walkrounds continue to be impressed by the high standards of Information Governance that have been apparent in visited areas, in particular noting that staff are already adopting previously issued guidance in relation to Clear Working Spaces. Only a small number of minor issues have been encountered during the walkarounds, with all issues being appropriately resolved after communication with the relevant staff members and managers.

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3.8 FairWarning The group regularly receives reports on the levels of FairWarning alerts raised and a sub group is tasked with maintaining appropriate alerts and thresholds to provide a proportionate audit of access to personal information. FairWarning alerting rate rose by 5% from 864 to 914 alerts, this change was anticipated and reflected changes to access rights in RiO and the patient population from last year. With no incidences of inappropriate access being recorded throughout the year, the group have been satisfactory assured that there are no areas of concern regarding inappropriate access. 3.9 Records Management The group is active in its involvement in the development of the Hospital’s Records Management Plan. This included attendance at national training, and the Plan has been submitted in 2017/18, has been approved by the Record Keepers Office, and its detailed work is now being taken forward. 3.10 FOI / Subject Access Requests The group is kept informed of all FOI requests and of the timescales achieved in responding to these, and also of the receipt and completion of subject access requests. There were no issues to be highlighted from either of these processes during the period. The Information Governance Group has reconvened the FOI Committee to improve the robustness of our FOI procedures and processes. The Committee also reviews FOI responses for inclusion in a new disclosure log which is due towards the end of this year. Training for committee members is planned for Q4 17 and this will compliment a certified practitioner in FOI also due to be in place in Q4. 3.11 Vision Project Members of the group assisted in the hospital more fully adopting the GP electronic patient record known as Vision. The project to bring about Vision being used to its full potential was led by Angela Robertson. This project progressed well to full implementation and should lead to substantial Information Governance improvements for the organisation. In addition there will be considerable benefits to the overall physical health of our patient group that will come from greater integration between our primary health care services and local secondary care services. 3.12 The General Data Protection Regulation / Data Protection Act 2017 In May 2018, the Data Protection Act 1998 will be replaced by the EU’s General Data Protection Regulation (GDPR). This new framework comes into place as the UK enters the process of uncoupling from the EU, with the proposed Data Protection Act 2017 being used to convert the regulation into British law. The group has reviewed the Hospital’s current practices and in conjunction the Information Commissioner’s Office (ICO) guidance, national Information Governance Leads advise and Scottish Government advise, is in the process of aligning ourselves to meet the new regulation by insuring that;

• Awareness of the change in law is being communicated to all staff, particularly to decision makers.

• We have documented the information we hold. • Our privacy notices are updated • We have reviewed our procedures to check data subject rights can be devilered • Our subject access provision can adapt to the shorter timescales. • We have recorded the legal basis for processing of personal data. • Where we rely on consent, we have robust and fair processes to obtain and record it. • A privacy by design framework, supported by privacy impact assessments is rollout to

the organisation. Page 8 of 9

• A qualified Data Protection Officer is in role prior to May 2018.

4 IDENTIFIED ISSUES AND POTENTIAL SOLUTIONS We have continued to try to improve attendance at the IGG meetings as full attendance at this group can sometimes be difficult to achieve. We strive to encourage attendance by making the remit of the group relevant to staff member’s roles and with this in mind we incorporated user feedback on the EPR (RiO) and wider user feedback on eHealth matters into the agenda for the group. The attendance by deputies in the event of diary pressures will be actively considered going forward. There continue to be challenges in maintaining the high standards of Information Governance found in the hospital. We are actively as a group engaged in addressing these challenges. 5 FUTURE AREAS OF WORK AND POTENTIAL SERVICE DEVELOPMENTS

Work/ Service Development Timescale

Maintain and progress Information Governance module attainment levels Ongoing

Develop/consider use of national Information Governance training Ongoing

Continue Information Governance walkrounds Ongoing

Implementation of Records Management Plan and associated actions in line with the Public Record (Scotland) Act

Ongoing

Support for the development of CELCAT or equivalent timetabling system Ongoing

Support for RiO7 business case December 2017

Implementation of GDPR/ DPA(2017) April 2018

6 NEXT REVIEW DATE

August 2018

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Date of Meeting: 26 October 2017 Agenda Reference: Item no: 15 Sponsoring Director: Finance and Performance Management Director Author: Finance and Performance Management Director / Angela Robertson / Sustainability Group Title of Report: Climate Change Reporting 1 SITUATION The State Hospital is responsible for submitting regular climate change reporting information in line with national statutory requirements. 2 BACKGROUND As part of the Scottish Government mandatory reporting requirements – specifically the Public Bodies Climate Change Duties Reporting Platform – every public body is now required to submit a completed assessment of its performance in relation to climate change compliance via an online monitoring tool. This tool has now been completed by the State Hospital’s Sustainability Group – with supporting input from NSS and additionally from Estates, Procurement and the Resilience Group – and is attached as an appendix to this paper. All sections relevant to the State Hospital have been completed, and any sections left blank are either optional or not applicable. 3 ASSESSMENT The completed tool is due for submission in November 2017, and requires the Board’s approval for this to be done. The Sustainability Group are satisfied that it is complete with regard to every aspect relevant to the Hospital. 4 RECOMMENDATION

The Committee is asked to note the contents of this report and to approve its submission.

MONITORING FORM


The completed tool is a requirement of the Hospital’s compliance with national sustainability requirements, which are a specific LDP item.

Workforce Implications None current – future requirements are under review.

Financial Implications As noted within the report – potential energy cost implications.


Sustainability Group.


Non-submission would create the risk of non-compliance with national reporting requirements.


Staff awareness of sustainability requirements is addressed by the Sustainability Group and will increase with the introduction of “green champions”.

Equality Impact Assessment n/a

THE STATE HOSPITALS BOARD FOR SCOTLAND Minutes of the meeting of the Audit Committee held on Thursday 14 September 2017 at 9.45am in the Boardroom, The State Hospital, Carstairs. PRESENT: Non Executive Director Bill Brackenridge (via teleconference) Non Executive Director Elizabeth Carmichael (Chair) IN ATTENDANCE: Internal Chief Executive Jim Crichton Board Chair Terry Currie Procurement Manager Tom Hair (part) Security Director Doug Irwin (part) Finance and Performance Management Director Robin McNaught Board Secretary Jean Wade Interim HR Director John White (part) External Senior Manager, RSMUK Asam Hussain Director, Scott-Moncrieff Karen Jones 1 APOLOGIES FOR ABSENCE AND INTRODUCTORY REMARKS Apologies for absence were noted from Anne Gillan, Maire Whitehead and Marc Mazzucco. 2 CONFLICTS OF INTEREST There were no changes to the conflicts of interest noted at the last meeting. All conflicts declared would be held on record for the year. Any changes would be reported and recorded as they arise. 3 MINUTES OF THE PREVIOUS MEETING The Minutes of the previous meeting held on 29 June 2017 were approved. 4 SUMMARY OF PREVIOUS MINUTE ACTION POINTS AND MATTERS ARISING Members noted the progress being made on the previous Minute action points. Action point 9: Summary of Special Loses and Special Payment Robin McNaught advised that there is a financial limit for recourse to the Board in respect of Special Losses and Special Payments, which is detailed within the Scheme of Delegation and it had been confirmed to the Chair that this had been followed in all instances in 2016/17 5 INTERNAL AUDIT FOLLOW UP REPORT Members received a report from Robin McNaught which provided an update on progress. The report confirms that good progress has continued with scheduled completion of audit recommendations. The small number of recommendations that are outstanding are mostly dependent on the same actions and these are ongoing and on course, e.g. the Clinical Quality Strategy is now in draft. A high number of audit reports have been undertaken in the previous year and good progress has been made particularly with many points completed in the last three months. The Hospital continues to drive individual realistic deadlines on all points. Members welcomed the good progress made and noted the update on audit follow up work.

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6 FRAUD UPDATE Members received a report from Robin McNaught which provided a quarterly update on the Hospital’s Fraud Policy and Response Plan to include a summary of alerts received from Counter Fraud Services (CFS) and also an update on the Fraud Log. Members noted that there had been two CFS alerts published since the last report. These are summarised in the report and have been circulated as appropriate with all necessary action taken. In terms of the Incident (Fraud) Log there were no allegations received since the last report. However following completion of this report three fraud allegations were reported, these are all a similar allegation relating to three different individuals. These are being progressed and will be reported back at a future meeting once concluded. Members noted the alerts circulated by CFS in the last quarter and also noted the update on the fraud allegations. 7 FRAUD ACTION PLAN Members received a report from Robin McNaught, in respect of the Fraud Action Plan. The report provided an update on the progress with counter fraud matters at dictated by the Government. A Fraud Awareness Session with the Senior Management Team was held on Wednesday 16 August 2017 which was well received. No matters of concern have been raised following the Boards participation in the NFI exercise on creditor and payroll reviews. Members noted the progress on engagement activities; noted the update on Communication, and reviewed the Fraud Action Plan. 8 EFFICIENCY AND BEST VALUE Members received a report from Robin McNaught, on Efficiency and Best Value. The report provided an annual update on the Best Value Programme for which the Hospital has completed a number of toolkits, concluding last year but with a number of the matters arising relating to actions which will continue to be ongoing to ensure the Hospital addresses best value on a recurring basis. There are no areas where the Hospital is not yet addressing the points raised in the toolkits and the Committee can be assured that the level of awareness is being maintained. It was suggested that a tabular format on what is complete and what is ongoing might be helpful. Members noted the update on the approach to Best Value within the Hospital. 9 STANDING DOCUMENTATION – SFI UPDATE Members received a report from Robin McNaught, on Standing Documentation. The report advised that the Hospital’s Scheme of Delegation – Financial Limits had been reviewed and approved in full at the March 2017 Audit Committee and June 2017 Board meetings. The report highlighted the work underway towards the Perimeter Upgrade and the scope for minor contract variations to arise in the normal course of business, for example, with the contract for the Lead Advisors who have recently been appointed. While other areas of capital expenditure have a limit appropriate for department heads to approve, this is not the case for contract variations where the lowest level required is by the Security Director (up to £25,000) and it is considered that it would be appropriate for the designated Project Manager to be able to issue approval at a lower limit and a level of £5,000 is considered appropriate.

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Members gave their approval to the request to amend the State Hospital’s Scheme of Delegation – Financial Limits section 14.8 d) to include approvals of variations to contract up to £5,000 by the designated Project Manager. 10 RISK MANAGEMENT ANNUAL REPORT Members received a report from Robin McNaught, on the Risk Management Annual Report for 2016/17. From the summary provided, members noted the key work undertaken by Risk Management in 2016/17 including ongoing work around risk registers; resilience planning; high graded incidents and health and safety training in relation to Control Books. The report also detailed the work underway in relation to the Patient Safety Programme with information on complaints received in the year. A separate report on Policy Reviews is on the Audit Committee agenda The report highlighted areas of good practice, issues currently being addressed and areas to be focused on for future work and service development. Members approved the Risk Management Annual Report. 11 CORPORATE RISK REGISTER Members received a report from Robin McNaught, on the Corporate Risk Register. The report provided an update on the Corporate Risk Register, noting those recently reviewed and confirms that all risk assessments are currently complete and up to date. The report details local risks under consideration from the Senior Management Team for possible inclusion in the Corporate Risk Register. As part of the internal audit plan the Corporate Risk Register will be reviewed in full in 2017/18. 12 POLICY UPDATE Members received a report from Robin McNaught which provided an update on the status of Hospital Policies. It was noted that the Hospital had 130 current policies on the intranet; there were two new policies, both are in the process of being written. Of the 130 current policies, 26 (20%) were currently out of date, however 14 of these are under review by the appropriate author or group. There are currently no policies under consultation however there are 13 which have recently completed their mandatory three week consultation period and awaiting to be sent to the Senior Management Team for approval. Progress has continued to be made in this area though there are a number of reviews remaining and each policy holder is monitored regularly to ensure that these are being addressed. The staffing within Human Resources is now at establishment level and it is expected that this will make a positive impact on the outstanding review level. Members noted that the Chief Executive is now including outstanding policies as part of his regular reviews with Directors and that where updates are overdue as a result of waiting on national guidance it has been agreed that these will be progressed now with a further review undertaken when the national guidance is issued. Members noted the review of overdue policies, with continued close monitoring through 2017/18.

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13 SECURITY AUDIT Doug Irwin joined the meeting to provide an update of the Security Audits and advised that an audit of practice is undertaken by the Forensic Network every 18 months, this alternates between being specifically targeted at State Hospital Security and a general State Hospital Audit that includes Security. An audit of the perimeter and physical security measures is undertaken annually by an independent specialist security advisor. Members noted that the physical security audit for 2017/18 took place in April 2017 and a summary of the issues raised and recommendations made were noted within the report with the full report circulated as an appendix. The Forensic Network Audit took place in June 2016 and was reported to the 15 September 2016 Audit Committee, a further audit is due in early 2018. The report also provided information on an additional review of the audit tools and methodology that was undertaken by the Ashworth Hospital and was requested by The State Hospital’s Security Director with the remit of looking for any areas that were suitable for audit that were not being covered by the existing audit framework. A summary of the recommendations is was included within the report with the full report circulated as an appendix. Members noted the content of the Physical Security Audit and the Audit Review and the assurances provided and approved the actions proposed to address any issues raised. Thanks would be passed on to the team from Ashworth Hospital. They thanked Doug Irwin for his good work and he left the meeting at this point. 14 ATTENDANCE MANAGEMENT UPDATE John White joined the meeting to provide an update of Attendance Management. Members reviewed the report and the accompanying data and noted that the SWISS sickness absence figure from 1 June to 30 June 2017 was 7.81%% with the long/short term split being 3.91% and 3.90% respectively. The total hours lost for this period was 7,483.00, which equates to 45.97 wte staff. The current rolling 12 month sickness figure was 8.83% for the period 1 July 2016 to 30 June 2017. The total hours lost for this period was 101,248.33 which equates to 51.92 wte staff. The report also included an update from EASY which had been implemented across the Hospital in a phased basis with phase 1 going live in April 2017 and phase 2 on 1 June 2017. The uptake on use of the Easy system was improving and reached 78% in July. Further improvements are being pursued. Bill Brackenridge, chair of the Staff Governance Committee advised that reducing staff absences remained a top priority for the Hospital and that staff side were supportive of the current approach at the last meeting of the Committee. Performance is closely monitored by SMT and the Board, the Staff Governance Committee has commissioned a 12 week improvement plan in August 2017 and the Task Force is now meeting. There was a discussion about gathering information on the length of absences and it was noted that more information would be provided in the interim report from Easy at the 6 month point. It was agreed that the Audit Committee would continue to monitor action at each meeting because of the critical importance attached to improving performance. Members noted the actions being pursued and content of the Attendance Management Update. John White left the meeting at this point.

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INTERNAL AUDIT 15 FOLLOW UP REPORT Members received a positive report in respect of the Internal Audit Plan 2016/17 from Asam Hussain who summarised the progress and changes made. Members discussed the status of progress and the revised plan and noted the assurance provided that improvements in implementing recommendations within the timeframe agreed had been maintained.

Members noted the follow up report undertaken by RSMUK. 16 PROGRESS REPORT 2017/18 Members received a report in respect of the progress against the Internal Audit Plan for 2017/18 from Asam Hussain who summarised the results of the work to date. It was agreed that consideration would be given to bringing forward the work on Risk Management Review. Members noted the progress report provided by RSMUK. 17 EFFECTIVE ROSTERING AND OVERTIME MANAGEMENT REPORT Members received a report in respect of the review of Effective Rostering and Overtime Management and noted its conclusion of partial assurance. The report concluded that a substantial amount of work was needed to operate an efficient roistering system and made recommendations on the use of protocols on the processes to be followed by staff, the need for more control over shift swaps and the provision of a clear audit trail. Asam Hussain summarised the audit work undertaken and recognised the significant complexities in operating a system to match staffing to the clinical activity of patients as well as complying with statutory guidance. This impacted upon the staffing levels which must be managed with consideration given to the quality of patient care, the health and wellbeing of staff and financial considerations. The audit recognised that the Hospital draws from its own pool of nursing staff to cover additional hours with no Agency staff being used. The high level of sickness currently being experienced within the Hospital reduced the number of available staff that can be called upon to undertake additional duties. This audit report built on the previous audit by KPMG, (Staff Scheduling issued March 2017) and Assam Hussain confirmed that its recommendations had been implemented. The State Hospital has moved from a spreadsheet based roster to utilising the computerised staff rostering function within the Scottish Standard Time System (SSTS), which is the national HR and Payroll software. The new report analysed the problem at a more detailed level. Issues were identified in the controls in place for the monitoring and managing both time in lieu and shift swaps to ensure that all time owed is repaid and overtime is not claimed and paid when negative balances in each are held. Mark Richards confirmed that the report provided a sound platform by identifying priorities and timeframes for further work. All of the recommendations and timeframes were accepted by management. Jim Crichton found the wider context of the report very helpful, in particular the need to rationalise the information and reporting systems and to make better use of the technology. The members welcomed the review and noted the serious issues raised, especially around management decisions, approval and control. They viewed the report as a critical first step in providing a plan for action but stressed the urgency in implementing the recommendations and then measuring its impact. A timeframe needed to be set for this. Whilst recognising that many of the problems were inherited and that time was needed for a significant amount of work, the Audit Committee wanted to see quick progress on an action plan and a measurable impact on the number of overtime hours worked and the shift swaps. These were essential in ensuring the Hospital has a rostering system which is efficient, effective, fair and affordable.

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Members noted the report on the audit of Effective Rostering and Overtime Management, the significance of the actions arising, and the importance of these being addressed as a matter of urgency. It was agreed that Jim Crichton would prepare a paper on the wider issues and timings.

Action: Mark Richards 18 GENERAL DATA PROTECTION REGULATION (GDPR) UPDATE Members received a report on General Data Protection Regulation (GDPR) Update from Asam Hussain. The report detailed that the GDPR will come into force in the UK on 25 May 2018 with the new legal framework the biggest change to data privacy legislation in over 20 years. It is likely that this new legislation will cause significant disruption to how organisations store, manage and process personal data, with significant penalties for those who do not comply. The report summarised how GDPR will affect the Hospital and provided an update on the current progress being made at the Hospital to address the changes required. The Audit Committee received assurance that GDPR is being addressed on behalf of the Hospital by Ken Lawton, Deputy Data Protection Officer, via the Information Governance Group, and that appropriate actions and timescales are being considered and implemented Members noted the content of the General Data Protection Regulation Update, asked for regular updates on progress and that this be added to the Corporate Risk Register. It was agreed that RSMUK would provide independent input if required.

Action: Robin McNaught 19 BOARD ASSURANCE FRAMEWORK UPDATE Members received a report on the Board Assurance Framework Update from Asam Hussain. The report provided information on the use of a Board Assurance Framework (BAF). A BAF approach to risk management allows the Board to focus its attention on areas that potentially have a lower level of assurance, moving from a risk appetite to an assurance appetite approach to strategic thinking. The Audit Committee noted the update on the use of a Board Assurance Framework and agreed to seek an update from management on whether the functionality of Datix Risk Management can be maximised to introduce the good practice surrounding the assurance framework at the State Hospitals Board. The Audit Committee also noted that in agreement with the Finance & Performance Management Director and the Chair of the Audit Committee a Risk Management Workshop will be held in January 2018 led by RSMUK where both members of the Board and other senior managers will be invited to attend. The Audit Committee agreed to review the Internal Audit Plan with a view to bringing forward the Risk Management Review to 2017/18. If it is not possible to reschedule the planned review then RSM can consider bringing forward the 2018/19 planned Risk Management review and deliver it in quarter 4 of 2017/18. OTHER ISSUES 20 PROCUREMENT ANNUAL REPORT Tom Hair joined the meeting to discuss the Procurement Annual Report. From the summary of the report, Members noted the main areas of activity in the previous year and the areas of known future activity. Members noted the Procurement Annual Report 2016/17 in advance of its publication on the Hospital’s website, and thanked Tom Hair and his department for their work through the year. Tom Hair left the meeting at this point.

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21 DRAFT AUDIT COMMITTEE WORKPLAN 2018 Members received and noted the Audit Committee Draft Plan of Work to September 2018. The Workplan would be updated as required following the business discussed at the meeting.

Action: Robin McNaught 22 ANY OTHER BUSINESS Audit Committee Effectiveness Robin McNaught reminded members that at the April 2016 meeting the Audit Committee agreed that members would complete a self assessment checklist, in line with the Scottish Government Handbook Guidelines. The results of this evaluation were then circulated later in 2016. Members were asked if they considered this process worthwhile to be repeated in 2017/18. It was agreed that this procedure should be followed again, and that the self-assessment checklist should be circulated.

Action : Robin McNaught 23 DATE AND TIME OF NEXT MEETING The next meeting would take place on Thursday 18 January 2018 at 9.45am in the boardroom, The State Hospital, Carstairs.

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Date of Meeting: 26 Oct 2017 Agenda Reference: Item No: 17 Sponsoring Director: Chief Executive Author(s): Chief Executive Head of Communications Title of Report: State Hospital Draft Service Strategy 2017 - 2020 Purpose of Report: For Approval

1 SITUATION Consultation on the Draft Service Strategy has now concluded and the document has been amended in light of this feedback. The strategy is attached for final consideration and approval. 2 BACKGROUND The Board operates within the context of a range of national health care strategies including:

• The Quality Strategy • Realistic Medicine • The Mental Health Strategy • 2020 Vision • Health & Social Care Delivery Plan

At present however, the Board does not have a service level strategy that clarifies its core mission, vision, values, and strategic aims and objectives. A recent audit of Board Effectiveness recommended that in the context of significant financial challenge, it would be beneficial to strengthen our strategic planning with an overall service strategy. At the Board Development Session on 19 January 2017, the Board considered its mission / vision and strategic priorities utilising a SWOT analysis. Strategic objectives to address current drivers for change over the short to medium term were identified. A first iteration of the draft strategy was shared with the Board on the 9 February and further amendments made on that basis. The Board supported the proposal to begin a stakeholder engagement process and to receive a final version of the strategy in light of that feedback at a future meeting. As part of that engagement process, a leadership event was held on the 22 March 17 to engage as many of the operational management and clinical leads in the hospital as possible. There were 45 attendees in total. The aim was to consider the draft service strategy for The State Hospital and the key organisational priorities for 2017-18. There was the opportunity to share the national and local context to service delivery, while ensuring that the views and opinions of local managers were given equal priority in shaping the strategy going forward. The event was held in partnership with staff side representatives. The outcome of this was shared in detail with the Board in May.

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A further iteration of the Draft Strategy was developed in light of this feedback and formed the basis of an all-staff consultation over August and September. Section 3 outlines the points captured through the additional feedback. 3 ASSESSMENT Five questions were asked regarding the strategy as part of the consultation process. These along with the responses are summarised below. Question 1 What do you see as our key strengths in terms of service delivery? I think the contribution of those involved in direct care and the evaluation of it is well framed in this document but I’d to see some celebration of the departments diligently delivering excellent services that enable the high quality care – estates, finance, procurement, e-Health, comms, HR etc. I think it was acknowledged in the Annual Review that the Hospital operated lean departments – all credit to these departments for doing more with less. Dedicated staff who are motivated to do the best for our patients Huge amounts of e-communications keeping people informed Availability of training and development to meet our statutory and mandatory requirements Strong levels of security ensuring the hospital is safe for patients and staff Wealth of professional/clinical experience. Single site, rapid access to specialist intervention. Effective multi-disciplinary team working. Informed and accessible support service networks. Multi-faceted roles enabling wide overviews which better informs cohesive service delivery. Question 2 Please list any weaknesses that are not captured in the Service Strategy and state how these could be mitigated. I think the main challenges are well articulated and wouldn’t want to dilute these by listing every known problem. I think the draft strategy covers the key challenges. However, it sometimes feels that we respond to recommendations and requests more slowly than we should at a senior level. Sometimes people have to be chased up several times before something gets done. Requests are made to carry out a piece of work, and when it is complete the follow-up does not happen. I wonder if this level of performance could be managed better. Is this challenge around managing apathy, or organisational performance? No mention of volunteers, as one of our key stakeholder groups – see note in comments section.

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Be specific about incorporating a review of the Clinical Model within this 3 year period - has remained unchanged since its inception, despite a much changed landscape. Within the ‘effective’ quality ambitions, it would be helpful to highlight the importance of ensuring that we have the right skills in the right place at the right time in terms of delivering ‘high quality’ care and treatment – this is currently defined by our model of continuity of care which, may mean that we are not placing our skill base where it is most needed e.g. staff who have specialist skills in working with critically unwell patients on admission. Would benefit from more specific mention of carer involvement, which would link with the need for us to develop a local ‘carer strategy’ as per the Carers’ Act (2017) I would like to see more mention of an assets based approach, to which I think the strategy alludes, however could be more specific. Question 3 Please identify opportunities for service development / delivery. We could benefit greatly from our staff getting out and about more - shadowing, mentoring, leadership exchanges – at all levels. Wider discussions around the Clinical Model in terms of service delivery, specifically consideration of the impact of providing care and treatment in a mixed ward model. I appreciate that this has been considered however, discussions have been limited to specific groups and I would like to see an engagement exercise undertaken to establish the views of the wider staff group. Better use of staff skills in relation to the opportunity to ‘sell our skills’ – consultancy work out with TSH out with the RMO group. We have two empty wards, can we consider developing niche services to supplement our income e.g. a mental health dementia ward, a sensory impairment ward with specialist services for the deaf, blind with a mental health diagnosis. Many of these people in the community have no family / contact and live alone and arguably therefore, may have a much better quality of life as part of TSH community. Opportunities for patients to be actively engaged in ‘caring for our community’ – a return to rehabilitation roles e.g. gardening, window cleaning, laundry, cleaning. This would support an increase in physical exercise and offer meaningful roles, in addition to contributing to the maintenance of their ‘home’.

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Question 4 Please list any threats affecting service development /delivery and state how these could be mitigated. Current financial situation nationally is resulting in reduced wages for some staff. I imagine this is affecting morale and mental health. There is also a possibility that interest rates are going to rise. I am aware that we already provide assistance to staff. Another area where we could ensure we are effective is to ensure Healthy Working Lives is well resourced (people who can contribute to the work agenda). With impending retirals, this could be affected. We are not keeping up with technological advances. There is a mixture of skills levels across the organisation. We need to look at how we could use social media to enhance our communications within and outside the organisation. Clearly our sickness absence is a significant threat to delivery of this service strategy. Industrial injuries could perhaps be reduced by a rethink of the service configuration e.g. patients who require more intensive support being cared for within one area with a higher concentration of staff who are highly skilled in working at this end of the mental health spectrum. Applying the ‘one size fits all’ rule to 3 staff in all areas - we have a group of patients who are settled, many of whom are waiting for transfer in terms of a bed becoming available and could be safely supported by 2 staff in an area. This could perhaps be better managed by having a transfer ward / hub, where risks are reduced. This would enable us to increase staffing elsewhere. Reluctance to change, often driven by the largest staff group who, in my opinion, are reluctant to understand the need to engage in new / different ways of working to ensure TSH can continue to flourish in very challenging economical times. Please use this space for any other comments I really like this strategy – it’s short, to the point and clearly states our reason for being, our values and challenges. It gives all staff a clear line of sight from their job to the strategic objectives of the Board. It is key that managers support the follow up from iMatter and the recommendations from recent meetings of the board etc. If we don’t take this opportunity, it will impact negatively in the future. For those of us with experience of working within the private sector, it is easier to understand that, although delivering health services, we are tasked with running a business, which requires a dynamic approach to balancing the books, whilst still delivering high quality services. I’m wondering if we have the balance right in respect of this emphasis in relation to our aspirations

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Following the consultation, a number of elements were revised and updated:

• A statement of the strategic priorities as added in Section 6 • The role of volunteers was given greater visibility throughout the document • The time frame for the strategy was revised from 5 to 3 years to give a sharper focus on

achieving the key priorities • A list of outcomes was added to “Section 7 Measuring Success” being clear what we will

have achieved by 2020. • An outcome was added to reflect the work with National Boards • Appendix 1 was removed pending further work to review the outcome targets in the LDP for

2018/19. The draft strategy clarifies The State Hospital’s core mission, vision, values, and strategic aims and objectives. It offers a set of broad strategic objectives which will focus the priorities of the Executive Team in the short to medium term, enabling great cohesion of strategic planning and understanding of organisational priorities within the service. 4 RECOMMENDATIONS

• The Board are asked to approve the draft strategy for implementation.

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MONITORING FORM


Supports LDP development / Service Strategy Development / Corporate Objectives

Workforce Implications To be specified in future related papers

Financial Implications To be specified in future related papers


Executive Team NHS Board Operational Leaders in all areas of the service.


None


Positive

Equality Impact Assessment No impact identified at present. Will be fully reviewed prior to approval.

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Item No: 18

FINAL DRAFT – October 2017 STATE HOSPITAL SERVICE STRATEGY 2017/20 The Service Strategy for the State Hospital sets out the purpose of our service, our shared values and a vision of the type of service we want to deliver. In looking at a three year horizon and drawing on the experience and insights of our staff, patients, carers and volunteers, we recognise that there are a number of significant challenges ahead. We share many of these with the wider NHS and the population health needs of Scotland. We also recognise those areas which are specific to our patient group and are often a feature of health and social inequalities. The Service Strategy builds on our current strengths and prioritises future actions towards those areas of service which can contribute most to the health and wellbeing of our patients and staff. It will serve as a blue print for our service objectives and be underpinned by our Local Delivery Plan (LDP) performance framework which links to both local and national performance measures.

1. OUR SERVICE The State Hospitals Board for Scotland provides care for patients who require to be detained in hospital under conditions of special security because of their dangerous, violent or criminal propensities. Patients without convictions will have displayed seriously aggressive behaviours, usually including violence. All patients are legally detained under The Mental Health (Care and Treatment) (Scotland) Act 2003 (as amended by the 2015 Act), The Criminal Procedure (Scotland) Act 1995, or The Crime and Punishment (Scotland) Act 1997.

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Item No: 18 2. OUR MISSION To provide high quality forensic mental health assessment, care, treatment and rehabilitation for male patients who require to be cared for within a high secure environment. 3. OUR VALUES Our values underpin everything we do both as individuals and as an organisation. We aim to ensure that every member of staff, whatever their role in the service, understands the importance of these values and how these are reflected in our behaviours. The State Hospital has adopted the core values of NHSScotland which are: • Care and compassion. • Dignity and respect. • Openness, honesty and responsibility. • Quality and teamwork. 4. OUR VISION “To excel in the provision of high secure forensic mental health services, to develop and support the work of the Forensic Network, and to strive at being an exemplar employer.” The Board is committed to fostering a forward-looking and “can do” organisational culture. We will ensure that a focus on continuous improvement underpins all of our activities and that our working environment is rich in educational and staff development opportunities. Quality care will be underpinned by person centred values and placing a high value on research and audit. We aim to attract and develop a highly skilled and resilient workforce; where the role of the multi-disciplinary team is central to delivery of high quality care and the experience and feedback of our patients / visitors, staff and volunteers actively shapes our service. 5. DRIVERS FOR CHANGE In order to achieve our vision for the future of the service, we need to maintain those areas in which we excel and identify and address priority areas for improvement. Over the early part of 2017, the views of stakeholders were sought in identifying what is currently affecting, and what is likely to impact on future services. This exercise involved identifying our strengths, weaknesses, opportunities and threats to enable us to target our resources to where they are most needed. The key themes are captured below: Areas of Success • Our service has a strong international reputation for the quality of clinical services, the focus on

research and clinical audit and our achievements in improving patient safety.

• We have an integrated approach to security within the service which ensures that our staff, patients, volunteers and the public remains safe.

• We have a strong human rights based care ethos which is underpinned by least restrictive mental health legislation.

• Our care is enhanced by a dedicated independent advocacy service, patient involvement and feedback support.

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Item No: 18

• Our staff are our greatest advocates and routinely deliver the compassion and commitment to high quality care that our reputation is founded on.

• We have excellent volunteer involvement which brings significant added value to our service and outcomes for patients.

• We achieve all of this in a resource constrained environment where continuous efficiencies in the use of our resources is essential to maintaining financial balance.

Current Challenges Health Inequalities • Physical health inequalities for our patient group is significant; reducing obesity and increasing

physical activity are key outcomes in addressing this issue. Workforce • Exceptionally high levels of sickness absence are lowering staff morale, are having a detrimental

effect on staff training / development and are creating financial pressures, which are diverting resources away from direct patient care.

• A large proportion of staff are approaching retirement age which presents risks to the

sustainability of our workforce and service if not proactively addressed. Efficient Use of Our Resources • We need to deploy our workforce more effectively if we are to continue to meet patients’ needs

and drive out unnecessary waste.

• We must ensure that we are working collaboratively and efficiently with other National and Territorial Boards to optimise opportunities for improved quality and reduced costs.

6. OUR STRATEGIC OBJECTIVES FOR 2017/20 While we will strive to maintain our areas of success, the strategy for 2017-18 will focus on the 3 areas of challenge outlined above:

• Health Inequalities • Staff attendance and resilience • Efficient use of our resources

In order to ensure that we address these challenges and fulfil our vision for the service, it is essential that everyone working at The State Hospital has a clear understanding of our mission, our values and our organisational priorities. All managers will therefore be responsible for ensuring that their teams are informed and engaged with these priorities as they are relevant to their individual roles. 7. MEASURING SUCCESS / CONTINUOUS IMPROVEMENT Monitoring systems are in place to review progress with these objectives through our governance framework. Performance targets have been aligned with the three quality ambitions in the national NHSScotland Healthcare Quality Strategy; person centred, safe and effective.

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Item No: 18 Outcomes will be measured against agreed targets, and achieved through an incremental continuous improvement approach by way of the existing governance structure, e.g. Local Delivery Plan (LDP) / Board and Committee Structures / Executive Appraisal. A strategy session will take place annually to review and re-confirm or amend the long-term direction of the Hospital. This engagement will be aligned with Local Delivery Plan (LDP) development to ensure that operational objectives are in line with strategic direction. By 2020 we will have:

• Reduced the proportion of our patients with a BMI in the overweight and obese range • Increased access to physical activity ensuring a minimum of 90 minutes of exercise each

week. • Reduced our staff absence levels to or below 5% • Maintained our workforce resilience ensuring the skill base has been effectively transitioned

to new staff entering the service. • Improved the effectiveness of our staff rostering arrangements ensuring that we have the

right skills in the right place at the right time. • Delivered long term efficiencies through greater collaboration with National and Territorial

Boards. . 8. FORMAT The State Hospital’s Board recognises the need to ensure all stakeholders are supported to understand information about the services we provide. Based on what is proportionate and reasonable, we can provide information / documents in alternative formats and are happy to discuss with you the most practical and cost effective format suitable for your needs. Some of the services we are able to access include interpretation, translation, large print, Braille, tape recorded material, sign language, use of plain English / images. If you require information in another format, please contact the Involvement and Equality Lead on 01555 842

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THE STATE HOSPITALS BOARD FOR SCOTLAND Date of Meeting: 26 October 2017 Agenda Reference: Item No: 18a Sponsoring Director: Chief Executive Author(s): Chief Executive Title of Report: Strategic Priorities – Delivery Plan Purpose of Report: For Information 1 SITUATION The State Hospitals Board has supported the development of a 3 year Service Strategy. The strategy outlines 3 high level strategic priorities for the Board to address over that timeframe. This paper provides an overview of progress against each of the 3 priorities outlining existing and new elements of work underway. 2 BACKGROUND The Board’s Service Strategy for 2017-20 has been informed by the views of staff, volunteers, service users and carers. It has established 3 strategic priorities which are critical to the success of the organisation and ensuring high quality care:

• Health Inequalities • Staff attendance and resilience • Efficient use of our resources

This paper sets out an overview of existing and planned activities in delivering against these priorities by April 2020. 3 ASSESSMENT a) Health Inequalities Patients in The State Hospital suffer from weight gain and associated physical/mental health problems. The obesogenic environment has been created by a number of factors including high calorie intake, side effects of psychotropic medication and problems in relation to the provision of physical activities as well patient’s motivation to utilise the available resources in a meaningful fashion. Following the approval of the supporting healthy choices recommendations in September 2016 by The State Hospital’s board, the Supporting Healthy Choices Implementation Group (SHCIG) was formed. The group first met in September 2016 and continues to meet on the first Wednesday of every month. The group has been progressing the implementation of the Healthy Choices Action Plan which covers a wide range of actions designed to improve patients BMI and reduce harmful aspects of our care environment which promote obesity.

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Diagramme 1 Strategic Priorities & Work Streams b) Active Day The Patient Active Day Project has been running in Lewis Hub since w/c 19th June 2017. In this model, one ward in Lewis Hub has been closing, with the patient group spending their day within the Skye Centre. 2 x staff from Lewis Hub are supporting the patient group and working within the sports department, which the remaining staff from the closed hub are staying behind and in the Hub are redeployed to support care delivery in the other 2 wards. On 10th October 2017, all patients from Lewis 2 attended the Skye Centre and took part in activity. The operational feasibility of this model has now been thoroughly tested. It has been demonstrated that this model is viable and sustainable, and that it is flexible enough to respond to clinical pressures such as patients being unable to leave the ward due to acute care needs. The direct impact of this has been that the sports department is able to fully open (sports hall and gym) and that more patients have been able to access activity on the day that the model is being delivered. There has been an increase of over 60% in the number of placements provided in sports on the days that the project has been running with average attendance increasing from 24 to 39. This has benefited the patients who are involved from Lewis Hub, and also other patients in the Hospital who have been able to ‘drop in’ on sports sessions. There has been a benefit to patients who have been ‘harder to reach’ who are now involved in sports, crafts and patient learning centre activities. The model has also mitigated against departmental closure within the Skye Centre during a time when there have been significant workforce gaps. Staff and patient experience of the project has been formally evaluated. Feedback to date has been almost entirely positive. The next stage in this work is to discuss and agree how to scale up this approach. Our aim is to deliver a clinical model that, based on assessed need, supports more of our patients, to be more meaningfully active, more of the time. This is the subject of Clinical Governance Group

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development session which is being held on 25th October. c) Attendance At Work Improving attendance at work remains a key priority and additional actions beyond the existing initiatives was commissioned through Staff Governance in August. An operational task group has been established and produced an improvement action plan to detail the various work streams scheduled to contribute to the overall improvement in attendance. The non executive supervisory group has met once with the next meeting scheduled for 26th October. The appointment of a Workforce analyst has been made via an SLA with NHS Lanarkshire. A meeting took place on 6 October to discuss the connection between eESS and SSTS. The work planned with the SSTS 2017 refresh will provide an opportunity to review system accuracy and use. An additional point identified was the need to ensure that only sickness absence was categorised as such and any redirection to alternative leave was appropriate. It is planned to incorporate a number of actions from the effective rostering audit by RSM into the Attendance Management Improvement Plan. It is anticipated that some of the improvement work will be covered by the recommendations from the Audit. A separate audit on Attendance will be conducted by RSM in October and the output from this will also be considered and adopted as appropriate. The additional HR advisor has now commenced employment and the replacement Advisor is also in post. The three HR advisors will be allocated specific workforce groups to provide named HR Advisory Support. The intention is that the advisors will act as a business partner to service managers linking to the wider HR directorate. The Chief Executive has confirmed that specific attendance management targets have been incorporated into the Executive Team’s performance management arrangements for the year 2017/18. A meeting has been scheduled (9 October) with Mark Kennedy, General Manager from SALUS. The contract is scheduled for renewal, and needs to be designed with specific Key Performance Indicators in place to ensure the service provided is meeting the needs of the Hospital. EASY will also be discussed during this meeting. Alternatives to Sickness Absence will be introduced in partnership with SALUS to introduce an earlier incremental return to work. The principles of this process have been agreed with partnership and the model is evidenced to work within NHS Lanarkshire. Communications – John White and Anne Gillan will issue a joint communication to all staff, Caroline McCarron will assist with this. In addition a number of meetings are scheduled for John White to meet with staff. There was discussion around the current compliance levels, and it was noted that Iona 1 is 100% with their PDP reviews and 100% compliance with EASY. This is acknowledged this is a best practice example and will be promoted as such. The Partnership Forum established a short life working group to examine guidance on Working longer and specifically how this may provide an opportunity to introduce part-time substantive employment as a viable alternative to overtime working. A pilot will run in the Lewis Hub, this will

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be 10 x 7.5hour contracts, The posts are now moving to advert with recruitment planned to follow existing policy and procedures. The skill mix will be as per current agreement and where appropriate gender balanced for the needs of the hospital. An initial improvement target of 1% has been set for November 2017, followed by a sustained improvement with a trajectory set for the achievement of the 5% standard required. d) Effective Rostering In line with the Board’s 2017/18 internal audit plan, RSM undertook a review of effective reporting and overtime. This was reported to the audit Committee in August 2017 with only partial assurance offered and that action was needed to strengthen the control framework and to manage the identified risks. A number of medium and high priority action were identified and actions, timescales and lead officers were agreed. With reference to the high priority actions that were due for completion before the end of October 2017, the following changes have been made:

• The Recording of Time in Lieu Protocol was in draft form at the time of the audit. This has now been agreed in partnership as a final version.

• Staff time in lieu records have been reviewed across all wards, with Senior Charge Nurses focused on ensuring this is managed within the limits set out in the aforementioned protocol. This is also reviewed during the 1:1 review meetings that are described below.

• All Senior Charge Nurses and Nurse Team Leaders are explicitly aware that staff will not be offered or paid overtime when they owe the Hospital time.

• A common record for the recording of Time in Lieu has been introduced across all of our wards.

• An SSTS processing calendar has been developed by the Lead Nurses which sets out the roster production cycle from initial drafting of rosters through to the issuing of approved rosters.

• Compliance with overtime working limits is now monitored daily. Where staff exceed this limit, an exception report is generated by Senior Clinical Cover and circulated to our Lead Nurses, Clinical Operations Manager and Director of Nursing and AHPs.

• The Overtime Limit Protocol was in draft form at the time of the audit. This has now been agreed in partnership as a final version.

Over and above these actions, the processing of overtime has changed from being the responsibility of the night Senior Charge Nurse, to the ward Senior Charge Nurse. These are now processed daily, with the Senior Charge Nurse being responsible for processing these for their own staff, and for entering the reasons for overtime being worked into SSTS. This also supports the monitoring of excessive additional hours being worked by staff. With regard to overall governance and assurance, the Director of Nursing and AHPs now chairs a weekly resource meeting with all Senior Charge Nurses, Lead Nurses and the Clinical Operations Manager. The purpose of the meeting is to collectively review a wide range of issues as they relate to the management of nursing resources including our projected staffing requirements, staff availability, additional hours being worked by staff, and adherence to our attendance management policy. This is informed by a weekly ‘ward round’ in which prior to this meeting, every ward is visited by the Clinical Operations Manager and Lead Nurses, with a specific focus on safe and effective staffing. This is joined once a month by the Director of Nursing and AHPs. A weekly 1:1 review with individual Senior Charge Nurses has also been introduced. This is ‘deep dive’ at ward level, where the Senior Charge Nurse meets with the Director of Nursing and AHPs, their Lead Nurse, and the Clinical Operations Manager. This covers a broad range of workforce issues including review of in post staffing versus funded establishment, sickness absence management including potential patterns, EASY monitoring, additional hours being worked by staff, and intelligence regarding projected retirements.

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In addition to the work undertaken by RSM, the Chief Executive has been in discussion with Meridian regarding an external diagnostic of our current rostering and deployment of staffing resources. This will be considered separately by the Board and a decision taken whether to progress this initiative. e) Performance Dashboard Development Effective deployment of nursing resources needs to be underpinned by a performance management system that allows management to record and report on their use. A number of challenges currently exist which means limits the effectiveness of workforce reporting and utilisation of additional hrs. A separate report has been provided to the Board at its October meeting to outline the work currently being taken forward. This is at an early stage but it is anticipated that the system will be developed and in place by the end of March 2018. 4 RECOMMENDATION

a) The Board is asked to note the update on the work streams associated with delivery

of the Strategic Priorities.

b) To consider what whether an overarching update is a useful approach to capturing progress or whether separate reports going forward would be preferred.

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MONITORING FORM


Service Strategy / Corporate Objectives / Corporate Governance

Workforce Implications As outlined in individual projects

Financial Implications As outlined in individual projects


Executive Team


As outlined in individual projects


Positive

Equality Impact Assessment No impact identified.

Page 6 of 6


Private Session Date of Meeting: October 2017 Agenda Reference: Item No: 19 Sponsoring Director: Security Director Author(s): Security Director Title of Report: Response to the Supreme Court Judgement in McCann Vs The State Hospitals Board for Scotland Purpose of Report: For Noting 1 SITUATION The paper provides a summary for the public session of the Board on the Boards actions and decisions related to the final judgement in McCann Vs The State Hospitals Board. 2 BACKGROUND The Supreme Court Judgment regarding the smoking ban at The State Hospital was issued on 10

April 2017. A number of private meetings of the Board have taken place since in order to clarify the Boards response to the judgment, the wording of the submission requested by the Court and the actions required by the hospital. More detail on each of these areas is provided below. 3 ASSESSMENT At the private session of the Board on 25 April 2017 the Board considered its duties and powers under the 1978 NHS (Scotland) Act, the 2003 Mental Health (Care and Treatment)(Scotland) Act and the 2005 Mental Health (Safety and Security) Regulations. Lindsay Thomson summarised a report which provided updated medical advice on smoking cessation for the Board’s consideration. Members noted that the Supreme Court’s ruling on 11 April 2017 found that a ban on smoking at The State Hospital was lawful and justifiable but that the ban on possession of tobacco and entitlement to search was unlawful. Members noted that the report included a further literature search since Lindsay Thomson’s original report of 2011; evidence from the Recovery Study on State Hospital patients showing early mortality due to respiratory and cardiovascular causes; and results of the evaluation of smoking cessation within The State Hospital which suggest that smoking cessation has been safely implemented in this setting. Members discussed a range of issues of the report and Lindsay Thomson confirmed that the evidence that a smoke free environment was of benefit to the Hospital’s patients was strong. The medical advice was that the Board should continue to support a smoke free environment with The State Hospital.

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The Board reaffirmed its decision to prohibit smoking on the basis of this medical advice. Doug Irwin raised his concerns regarding the impact of a restriction on the ability to search for and prohibit tobacco products. Members noted the following the points: • That cigarette lighters have not and should not be permitted due to the risk of fire • That the previously experienced management and security risks are known by the Board • That possession of tobacco products when a smoking ban on their use is in place will create a contraband market • That a contraband market will lead to coercion, bullying, aggression and violence • That possession of tobacco products will lead to covert attempts at ignition or the smuggling of ignition devices with the risk of fire this brings • That the risks of coercion, bullying, aggression and violence will apply to anyone that enters the Hospital • That the above issues mean that any tobacco products being on the site when there is a ban on their use will create a significant risk to the safety of individuals and the security and good order of the Hospital The Board agreed that, having given consideration to the 2003 Act, particularly sections 1 and 286, and having further considered the 2005 regulations, that it was reasonable and proportionate to ban all tobacco products from The State Hospital. In this consideration, discussion also took place as to whether any less restrictive way of implementing the ban on use was possible. The Security Director highlighted to the Board that the existence of tobacco products on site would create a constant temptation and pressure to some which would create the risks highlighted above, therefore the absolute need to ensure that the presence of tobacco products on site is prevented leads to a necessity to include tobacco products within the items that staff, visitors and patients are searched for. The Board formed the view that the ban on tobacco products was the least restrictive way of ensuring that the ban on use was effectively implemented and that the ban on tobacco products should be made under 286 of the 2003 Act. In addition to those decisions The Board also agreed that:

1 The notification to patients given on admission, currently including reference to regular searches, needed to be revised to include due reference to the 2003 Act, sections 1 and 286, the 2005 Regulations and the type and frequency of searches.

2 This revision should also include the duty to inform relevant parties and the right to request

a review of the way in which the legislation is individually implemented. The provision of this notification will be noted in the clinical record.

3 The notification to patients should explicitly mention the ban on smoking and tobacco, the

grounds for it and the availability of smoking cessation support.

4 The revised notification regarding specified person status and the smoking ban should be given to all current patients. This will be noted in the patient’s clinical record.

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5 Targeted searches based on information and intelligence will continue to be recorded in the medical record on each occurrence and all relevant persons notified.

6 Notices and leaflets detailing prohibited items should continue to refer to tobacco products

and should be revised to ensure due reference is made to the 2003 act and the 2005 regulations.

The Board agreed that an interim policy and the changes described in the bullet points above would be implemented within two weeks, and that the final policy would be developed with appropriate discussion and consultation with an implementation planned prior to the Board Meeting on 24 August 2017. All of the actions agreed have been completed. An evaluation of the final judgement confirmed that further action was not required at this time. 4 RECOMMENDATION The Board is invited to note the content of the report and the actions taken

Page 3 of 4

MONITORING FORM


Physical Health of Patients, Safe and Secure Environment

Workforce Implications None

Financial Implications None


N/A


Possibility of further litigation


Improves knowledge of legal basis for specified person status, search and prohibitions or restrictions


Needs further work to ensure all patients are able to understand specified person status, search and prohibitions or restrictions

Page 4 of 4


Date of Meeting: 26 October 2017 Agenda Reference: Item No: 20 Sponsoring Director: Chief Executive Author(s): Chief Executive Title of Report: Chief Executive’s Report Purpose of Report: For Information 1 BACKGROUND

The items noted below highlight issues in the Hospital, which do not feature on the Board’s formal agenda. 2 GENERAL ISSUES OF NOTE The Chief Executive will provide the Board with a verbal update on the following issues: Annual Review The Board hosted its Annual Review for 2016 / 17 on 28 September. This was a non-Ministerial Annual Review and Scottish Government was represented by Penelope Curtis, The Head of Mental Health and Protection of Rights Division and Jenny Simons Senior Policy Advisor. The Board had requested support for higher levels of staff engagement at the review and a change to the normal arrangements certainly facilitated this. A total of 37 questions were recorded and responded to either at the session or as a follow up communication to staff. Particular thanks go to the Heads of Departments who helped facilitate the session. As well as the very informative presentations, attendees were also provided with a 1 page summary of the key performance outcomes for the year in question. Service Strategy and Clinical Quality Strategy Consultation Two key strategies were consulted on over September. The overarching Service Strategy for the organisation and the new Clinical Quality Strategy which will replace the Clinical Effectiveness Strategy. We aim to have these approved and in place by the end of November. National Boards Delivery Plan A number of meetings were held to progress the development of the National Boards Delivery Plan and this is now in final draft pending consideration and feedback. Forthcoming Events The Service has been approached by the Chinese Central Government requesting a visit for a delegation of 25 people from the Ministry of Public Security. Arrangements are being made for the visit to take place on 12 December 2017. A similar visit was held in 2015 and was very successful. The 5th Health and Justice Summit is being held in Glasgow on the 27 and 28 of November. A number of our staff are involved in presenting at the summit and the theme this year is “Aging Well In Secure Environments”.

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3 PATIENT SAFETY UPDATE A brief summary of SPSP activity across the Hospital in the last two months includes: Locally, steady progress is being made across all five of the agreed national workstreams. Work is also ongoing around Improving Observation in Practice.

Work is being co-ordinated via a multi-disciplinary steering group which is meeting regularly. Data suggests that the programme having a positive impact on practice. These are evidenced as follows:

• Psychotropic PRN medication documentation (‘8 rights’) spot check completed in September with median completion of 7.92 against the ‘8 rights’, with 2 hubs administering less than 10 PRN medications during the week of the spot check. Iona 2 saw a reduction from 41 PRNs at the weekly spot check in July to 10 PRNs in September spot check.

• Initial Risk Assessment completion in less than 4 hours has clear improvement, with the

last 60 admissions having all items of the 12 required information sets completed. All bar 3 being completed within the 4 hour timescale.

• Post Physical Intervention debrief rolled out site wide, feedback sought from staff during

December 2016. Analysis has been discussed at the Patient Safety Group with discussions now being taken forward to progress actions required. This is also being considered as part of a wider group discussion around supporting staff after serious incidents.

• Medicines reconciliation completion on admission since January 2015, 90 sets completed.

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• The SPSP group is also overseeing the roll out of DASA, a structured professional

judgement tool which will support decision making regarding how we support our patients on a day to day basis through, for example, enhanced clinical observation. As part of this work, we will introduce essenCES as a measurement of staff and patient safety and therapeutic milieu. This will start in October 2017.

• Linked to this workstream will be a project on observation practice, which will be a joint improvement project between one of our medical staff who is in the Scottish Improvement Fellowship programme and Nursing Practice Development. This is in the planning stage at the moment, with an improvement aim being defined. It is anticipated that this work will start in October 2017.

Our programme of leadership walk-rounds recommenced on 2017. 3 walk-rounds have been completed to date. The sharing of information from the walk-rounds has been changed to ensure that the Board are better sighted on the feedback offered during this process. A thematic analysis will be completed and reported once this programme of walk-rounds has been completed at the end of 2017. 4 HEALTHCARE ASSOCIATED INFECTION (HAI) This is a summary of the Infection Control activity from 1 July – 30 September 2017 (unless otherwise stated). Key Points

• The submission of the hand hygiene audits continues to be a key priority which is monitored and reported both to this committee and Senior Ward staff routinely. The number of submitted audits remains consistent. Individual wards which are non compliant are being contacted by the APIC routinely 20th – 30th of the month to allow a late submission.

• DATIX incidents continue to be monitored by the APIC and Clinical Teams, with no trends or areas identified for concern.

• The antimicrobial prescribing is minimal in comparison to other NHS Boards; however the prescribing that occurs within The State Hospital is being monitored by the antimicrobial pharmacist and the Infection Control Committee quarterly with no trends or areas identified for concern.

Audit Activity Hand Hygiene During this review period, there was a notable increase in the number of audits submitted towards the latter end of the quarter. Reminders to submit and follow up of non compliance will continue to be carried out by the Advanced Practitioner for Infection Control. July: 11 out of a possible 12 were submitted August: 10 out of a possible 12 were submitted September: 10 out of a possible 12 were submitted The overall hand hygiene compliance within the hubs varies between 80-100%, Skye Centre 50-90% and health centre consistently attaining 100%.

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Following approval by the Senior Management Team both the product and the location of the hand gel within the Skye Centre was changed. This change occurred in September and progress will be monitored by the Infection Control Committee. The existing product remains in situ to provide options for staff. Healthcare Waste From January 2017 a number of the econtrol book inspection tools were merged with the Infection Control Audits, in order to streamline work and avoid duplication. The audit submissions are reviewed by the Risk Team and a quality check of the audits by the Advanced Practitioner for Infection Control. The audits submitted demonstrate a 100% compliance with all aspects of the management of healthcare.

Workplace Inspections From January 2017 a number of the econtrol book inspection tools were merged with the Infection Control Audits, in order to streamline work and avoid duplication. The audit submissions are reviewed by the Risk Team and a quality check of the audits by the Advanced Practitioner for Infection Control. Ward This quarter 9 of the audits were submitted; however all of which were completed on the correct form. The Risk Management Team will continue to monitor non submissions. The scores range from 97-100% compliance with estates issues continuing to be cited as areas of concern. Skye Activity Of the areas that submitted the audits all of the scores are above 95%. The majority of the defaults in these areas relate to previously reported estates issues. All of the forms used were on the correct forms. The Risk Management Team have liaised with the areas regarding non submission of the audit.

0

50

100

% C

ompl

ianc

e

Area

Healthcare Waste Checklist (inc Clinical Waste, Sharps Containers and Safe

Management of Linen) 1st July - 30th September 2017

Page 4 of 7

DATIX INCIDENTS FOR INFECTION CONTROL 1 July – 30 September 2017 There were a total of 8 incidents for the period under the Category of Infection Control.

• 6 incidents relating to patient with Vomiting & Diarrhoea. • 2 exposure to bodily fluids

There were 10 incidents where Infection control was cited as a secondary category:

• 1 Spitting • 8 Self harm (exposure to blood) • 1 exposure to faeces

All DATIX incidents are reviewed by the Infection Control Committee quarterly. Scotland’s Infection Prevention and Control Education Pathway (SIPCEP) (previously Cleanliness Champions) The SIPCEP implementation pathway was approved by the Infection Control Committee in August and by the SMT in September 2017. This has been added to the mandatory modules and will be monitored by the Learning Development. An update will be provided in the next report. Healthcare Environment Inspection (HEI) The Standards of Dress and Clinical / Non-clinical Uniform Policy has been out for consultation and an EQIA has been completed. It however requires to be presented to the Senior Management Team for approval. This is the only outstanding action from the HEI report. Blood Borne Virus Screening Following approval of the Sexual Health and Blood Borne Virus Screening policy in June 2017 by the SMT the practice of BBV screening on admission and at annual reviews has been embedded into practice. This appears to be successful. To date 97 patients have consented to BBV screening. 5 PATIENT ADMISSION / DISCHARGES TO 12 OCTOBER 2017 A detailed report on admissions and discharges is provided to the Clinical Governance Committee on a 6 monthly basis. The following table outlines the high level position from 13 June to 13 October 2017

97 99 100 96

0

50

100

Atrium Sports & Fitness

Gardens Craft & Design

Health Centre

% C

ompl

ianc

e

Activity Centre

Workplace Inspection Compliance

1st July - 30th September 2017

0%

20%

40%

60%

80%

100%

% C

ompl

ianc

e

Ward

Workplace Inspection Compliance

1st July - 30th September 17

Page 5 of 7

6 CIR REVIEWS OUTWITH THREE MONTH COMPLETION DATE There was one Review outwith the three month completion date as follows: CIR 17/02 Assaults, Lewis – Risk Management reviewer was on long term absence and the report was left with the other reviewers to complete. Due 18 August 2017. 7 RECOMMENDATION The Board is invited to note the content of the Chief Executive’s report.

MMI LD Total Bed Complement 128 12 140 Staffed Beds (i.e. those actually available)

108 12 120

Bed Occupancy 12/10/17

104 8 112

Admissions 4 1 5 Discharges / Transfers

3 1 4

Average Bed Occupancy June 2017

-

-

112 93.3% of available

beds 80% of all beds

Page 6 of 7

The State Hospital

ANNUAL SCHEDULE OF MEETINGS - 2018 BOARD AND SUB-BOARD

MEETING Chair/

Members

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEPT

OCT

NOV

DEC

Board

Terry Currie* All Members

Thur 15.2.18 9.45am

Boardroom

Thur 26.4.18 9.45am

Boardroom

Thur 28.6.18 1.00pm

Boardroom

Thur 23.8.18 9.45am

Boardroom

Thur 25.10.18 9.45am

Boardroom

Thur 13.12.18 9.45am

Boardroom

Audit Committee

E Carmichael* B Brackenridge A Gillan M Whitehead

Thur

18.1.18 9.45am

Boardroom

Thur 5.4.18 9.45am

Boardroom

Thur

28.6.18 9.45am

Boardroom

Thur

20.9.18 9.45am

Boardroom

Clinical Governance Committee

N Johnston* E Carmichael M Whitehead

Thurs 22.2.18 9.45am

Boardroom

Thurs

10.5.18 9.45am

Boardroom

Thurs 9.8.18 9.45am

Boardroom

Thurs 8.11.18 9.45am

Boardroom

Staff Governance Committee

B Brackenridge* A Gillan N Johnston M Whitehead

Thur

1.3.18 9.45am

Boardroom

Thur 31.5.18 9.45am

Boardroom

Thur 16.8.18 9.45am

Boardroom

Thur 29.11.18 9.45am

Boardroom

Remuneration Committee **

T Currie* B Brackenridge E Carmichael A Gillan N Johnston M Whitehead

Thur

15.2.18 1.00pm

Boardroom

Thur

28.6.18 3.00pm

Boardroom

Thur

23.8.18 1.00pm

Boardroom

* Chair of Committee ** Remuneration Committee also meets as and when required

2018 PUBLIC HOLIDAYS: New Year : Monday 1 January & Tuesday 2 January : Easter : Friday 30 March & Monday 2 April Christmas : Tuesday 25 December & Wednesday 26 December : Autumn Holiday : Friday 21 September & Monday 24 September

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