trust board meeting in public (part 1) to be held in the ... · board . draft minutes of the...

TRUST BOARD MEETING IN PUBLIC (PART 1) To be held in the White Room, Trust Headquarters

Armstrong Way, Southall UB2 4SA on Wednesday 9th May 2018 - from 0900 to 1130 hrs

AGENDA

Approx. Timing

Agenda No.

Title Lead Enclosed or Verbal

Item 0930 1 Opening & Welcome Chairman Verbal 2 Apologies for Absence Chairman Verbal 3 Declaration of Interests

If any member of the Board has an interest in any item on the agenda, they must declare it at the meeting, and if necessary withdraw from the meeting.

Chairman Verbal

MINUTES & ACTION SCHEDULE 0935 4 Draft minutes of 11th April 2018 meeting Chairman Enclosed 5 Board Action Schedule & Matters Arising Chairman Enclosed

ITEMS FOR DECISION 0940 6

7

Revised Terms of Reference for the Trust Management Team Broadmoor Hospital Redevelopment Programme Board – Terms of Reference

Chief Executive Chief Executive

Enclosed Enclosed

ITEMS FOR DISCUSSION AND TO NOTE 8 Chairman’s Report Chairman Enclosed 9

9.1 9.2 9.3

Chief Executive’s Report Deloitte – Well Led Review Action Plan S2 Undertakings

Chief Executive Enclosed

10 Integrated Performance Report Chief Executive Enclosed 11

11.1 11.2

Director of Finance’s Report: Finance Report – March 2018 Budget setting update 2018/9

Director of Finance

Enclosed

12 12.1 12.2 12.3 12.4 12.5 12.6

Executive Directors’ Reports Medical Director’s Report Director of Nursing’s Report Director of Local Services’ Report Director of High Secure & Forensic Services’ Report Director of Workforce & OD Director of Communications & Engagements’ Report

Executive Directors

Enclosed

13

13.1

Nurse & Health Care Assistant Staffing Levels – Exception report Biannual Nurse staffing 6 Month Review

Director of Nursing & Patient Experience

Enclosed

14 Level 1 Risk Register and Board Assurance

Framework update Chief Executive Enclosed

REPORTING COMMITTEES 1120 15

15.1 Finance & Performance Committee Draft minutes of meeting held on 28/03/18

Committee Chair

Enclosed

16 16.1 16.2

Quality Committee Draft minutes of the meeting held on 21/03/18 Draft minutes of the meeting held on 18/04/18

Committee Chair

Enclosed

17 17.1 17.2

Workforce & Development Committee Draft minutes of the meeting held on 21/02/18 Verbal update of the meeting held on 02/05/2018

Committee Chair

Enclosed

18 18.1 18.2

Trust Management Team Agreed minutes of the meeting held on 28/03/18 Approved minutes of the meeting held on 25/04/18

Committee Chair

Enclosed

19

19.1 19.2

Broadmoor Hospital Redevelopment Programme Board Draft minutes of the meeting held on 04/04/17 Verbal update of the meeting held on 08/05/17

Committee Chair

Enclosed Verbal

20.1 20.2

Transformation Board Chair’s report 09/05/2018

Committee Chair

Enclosed

ANY OTHER BUSINESS

1130 21 Any Other Business previously notified to the Chairman

Chairman Verbal

INVITATION FOR QUESTIONS FROM THE PUBLIC 22 Questions from Members of the Public Chairman Verbal

RESOLUTION The Board is invited to adopt the following: “The trust hereby resolves that the remainder of the meeting shall be held in private because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted.” 23 Date of the Additional Trust Board Meeting

Wednesday 23rd May 2018 Time: 11.30 – 12.30 Venue: Trust Headquarters Date of Next Trust Board Meeting in Public: Wednesday 13th June 2018 Time: 0930 hrs Venue: Broadmoor Hospital

DRAFT MINUTES OF THE TRUST BOARD MEETING (PART 1) Held on Wednesday 11th April 2018

In Trust Headquarters, Armstrong Way, Southall Present: Mr Tom Hayhoe Chairman

Ms Carolyn Regan Chief Executive Professor Paul Aylin Non-Executive Director Moriam Bartlett Non-Executive Director Ms Stephanie Bridger Director of Nursing and Patient Experience Mrs Wendy Brewer Director of Workforce and OD Hassaan Majid Non-Executive Director Miss Leeanne McGee Director of High Secure & Forensic Services Mr Neville Manuel Non-Executive Director Ms Elizabeth Rantzen Non-Executive Director Ms Sarah Rushton Director of Local Services Mr Paul Stefanoski Director of Finance & Business / Deputy CEO Dr Jose Romero-Urcelay Medical Director Ms Sally Glen Non-Executive Director Ms Janice Barber Non-Executive Director

Attending: Mr Peter Jenkinson Trust Secretary

Dr Johan Redelinghuys Deputy Medical Director Ms Iscelyn Richards Deputy Trust Secretary (Minutes) Ms Sally Sykes Director of Communications and Engagement Mr Jai Jayaraman NExT Director participant (observing)

Mr Stanley Riseborough Improvement Director Items were discussed in the sequence they are recorded in the minutes Ref: Discussion: Action: 63/18 Item 1

OPENING & WELCOME Mr Hayhoe welcomed everyone to the meeting, including Ms Janice Barber, newly appointed Non-Executive Director. Mr Hayhoe also welcomed Mr Stanley Riseborough, Improvement Director, to his first Trust Board meeting. Mr Riseborough was undertaking a three month role funded by NHS Improvement as part of the improvement programme. Ms Iscelyn Richards the Deputy Trust Secretary was also welcomed to the Board. Mr Hayhoe noted Ms Richards would be taking the minutes for the Board meeting. A formal introduction was also extended to Mr Jai Jayaraman, observing the meeting as a member of the NExT Director scheme. The meeting was preceded by Mr Bradley Platt (Highly Specialist Clinical Psychologist) reading out a testimonial from a service user it was agreed that the Board would formally respond.

Director of Local Services

Ref: Discussion: Action: 64/18 Item 2

APOLOGIES FOR ABSENCE No apologies received.

65/18 Item 3

DECLARATIONS OF INTEREST No interests declared.

66/18 Item 4

MINUTES OF THE LAST MEETING The minutes of the meeting held on Wednesday 14th March 2018 were agreed to be a correct record, subject to agreed amendments: 49/18 item 9.2: Deletion of the following sentence ‘– the Trust had met the year’s CIP target for the first time ever in 2017/18’ from the minutes. 50/18 item 10.3: Minutes to be updated to specify that achievement was being reached within Local Services for the first time, instead of in the Trust for the first time. The minutes will now read ‘The reduction, was noted within Local Services, in delayed transfers of care for the first time below the national average of 7.5%’ 48/18 item 9.1: Deletion of the word major from the minutes. The minutes will now read ‘team led to an inability to initiate and deliver on some projects. Lessons had been learnt for 2018/19 to avoid a similar position, including greater awareness and planning to include the required lead time for capital schemes’ 48/18 item 9.1: Minutes amended to change ‘was applied to NHS Improvement’ to ‘had applied to NHS Improvement’. The minute now reads as follows ‘The Board noted that the Trust had applied to NHS Improvement to have the £2m underspend added to the Trust’s capital resource limit for 2018/19, in order to enable the Trust to invest in quality and safety improvements, and noted that the revised capital plan had been included in the draft budget for 2018/19’ 52/18 item 12: Ms Richards to liaise with Ms McGee to rephrase the following ‘The Board noted that the less positive aspects of NTC, previously outlined in the report, would be the impact that moving into the new hospital for the rehabilitation patients would have.’ Board concerned that the minute is negatively skewed and overemphasises the weight of the associated risk.

67/18 Item 5

BOARD ACTION SCHEDULE & MATTERS ARISING The Board considered the action schedule and noted the completed actions which would now be archived. The Board noted that the changes to the current format of the Integrated Performance Report will be remitted to Finance and

Director of

Ref: Discussion: Action:

Performance Committee. Therefore, IPR will return to Board in June 2018. Action amended to reflect change in date from April 2018 to June 2018. Matters Arising No matters arising

Finance

68/18 Item 6

CHAIRMAN’S REPORT Mr Hayhoe presented his report which provided an update on his activities over the period since the last meeting. He highlighted his participation on a variety of interview panels both internal and external to the Trust, owing to a reciprocal arrangement with CLCH. The CLCH Chair was present on the interview panel which appointed Ms Barber, and was also present at the Non-Executive Director panel which sat 10th April 2018. Further to the second interview panel on the 10th April 2018, a recommendation had been made to NHS Improvement on an appointment. Mr Hayhoe informed the Board a number of good Consultant appointments have been made, particularly taking into consideration the recruitment difficulties caused by a shortage of Psychiatric medical trainees nationally. Mr Hayhoe was pleased to report to Board the appointment of 3 Consultants. It was noted that the Trust’s ability to attract high calibre candidates, despite the shortage, was a reflection of how the Trust is viewed by senior trainees. The Board noted that Ms Rantzen and Mr Hayhoe have been reappointed to the Board for an additional year. The short-term appointment would allow synchronisation with the NHS Improvement appointments cycle. The Board discussed arrangements for the Board member visits by Non-executive Directors. Concerns were raised regarding the manner in which these visits were coordinated. Mr Aylin reported to the Board that a visit to the Art Therapy in March was conducted outside of session. It is imperative that the visits were coordinated to ensure stakeholder engagement as well as allowing for conducive and insightful visits. The Secretariat function will further address this action. The Board noted the Chairman’s report.

Trust Secretary

69/18 Item 7

CHIEF EXECUTIVE’S REPORT The report had been reviewed to ensure no commercial information had been included and any commercial information was to be considered in Part II of the meeting.


Ms Regan introduced her report highlighting her involvement in the North West London delivery area relating to the Mental Health Programme ‘like-minded’. Ms Regan has been asked to Co- Chair the associated Transformation Board. Ms Regan has agreed to Co-Chair this meeting subject to support from CNWL with conditions conducive to transparency as well as delegated authority. Ms Regan awaiting a response to the letter. The Board received an update on the NWL CCG accountable officers. Claire Parker will be leaving NWL at the end of April 2018. Rob Larkin who was due to leave NWL in April, will remain at NWL CCG to provide cover for his post as well as Ms Parker. Currently there is no substantive accountable officer in place, until an appointment is made. Ms Regan reported to the Board progress in regards to the monthly Performance Oversight meetings. Good progress has been made due to the regular communication that members of the Trust Board have had with NHS Improvement colleagues. Feedback form these meetings is positive within finance and plans for agency spend 2018/19. The Board noted that the Trust had met the Information Governance toolkit compliance with thanks to Mr Jenkinson and the Workforce team. A GDPR steering group has been established and will be Chaired by Dr Romero-Urcelay. Additionally, an interim Information Governance Manager has been appointed to focus specifically on GDPR. Previous considerations regarding the free consultancy offered by ICO have been superseded by the recent appointment. This is due to a deferment of availability from the ICO to November 2018. Mr Hassan informed the Board that IG toolkit would be raised at Audit Committee for assessment and feedback from a compliance perspective. The Board was informed that the Trust won the CAMHS Forensic service bid. A further update was given to the Board on the change of Trust name. The changes are subject to an establishment order which is a legal instrument which must be administered by Governmental Legal department; this is anticipated to take place by July 2018. The Board noted the Chief Executive’s report.

Ref: Discussion: Action: 70/18 Item 8

INTEGRATED PERFORMANCE REPORT (IPR) The Board received and considered the IPR for month 11, and noted that it had been considered by the Finance and Performance Committee in March. The Board noted that the IPR for 2018/19 has been updated to reflect the reordering of KPI’s. Mr Stefanoski reassured the Board of the good performance with month 11. Mr Hayhoe commended the Board on the successful KPI position. The Board also agreed that the IPR should include New Models of Care for Adult Services. A report would be brought to the next Board meeting, and incorporated in to the June IPR. Mr Manuel commented that the positive year end outcome should encourage a refresh of the areas that are reviewed within the IPR. A priority for Board focus was Leadership. Leavers from the Trust should not impact on the Trust’s ability to achieve a positive trajectory. Mr Hayhoe agreed that this was a single point of failure and should be revisited at the Board away day, focusing on succession plans and insurance against unplanned departures.

Director of Finance Trust secretary

71/18 Item 9.1 72/18 Item 9.2

DIRECTOR OF FINANCE’S REPORT Finance Report The Board received and considered the month 11 financial performance report to the Board, noting that this had been discussed in detail by the Finance and Performance Committee. The Board noted the Trust was still on track for the £8m surplus, as per the plan. Mr Stefanoski has adopted a conservative approach to ensuring all costs are accountable within the correct financial period. The Board was informed that there were no expected changes to the forecasted position for month 12. Auditors would be attending at the end of the month; Mr Stefanoski is not anticipating any material difference to be raised. The auditors did not raise any notable points of significance at the interim audit. Mr Stafanoski acknowledged the need to include references to the new Broadmoor site within the notes. Mr Manuel confirmed that the Finance & Performance Committee had supported the approach and received assurance regarding the year-end position. The Committee had agreed to include regular assurance over the achievement of the capital plan in its work plan for 2018/19. The Board noted the Finance Report. Finance Plan 2018/19 The Board was informed that the Financial Plan for 2018/19 needs to be submitted to NHS England by 25th April 2018. The plan has been


scrutinised at Finance and Performance Committee, the Board discussed levers within the plan, and the key issues. The Local Services were awaiting confirmation and signatures from the two key Commissioners, NHS England the local CCGs. The NHS England contract had been signed. Correspondence has been exchanged with the Local CCGs,. Mr Stefanoski provided assurance to the Board that the local CCG contract would be signed to meet the deadline. The Board discussed the CIP targets from 2018/19 reflecting on the outstanding issues and risks. The CIP target is in various stages of development across the Trust. The Board noted that CIP development is ongoing, and will be completed prior to the attendance of the auditors. The Board noted that the Trust is in line to meet the agency target of £12.7m. Emphasis was given to the need for continued monitoring of agency to mitigate against a high risk. Ms Rantzen commended the Board for reducing agency spend. However, expressed some concern that there is still a agency spend deficit of £1m, clarity was sought on how this gap might be closed. Ms Brewer confirmed to Board that discretionary spend is being reduced, gaps in establishment is being reduced, with a focus on recruitment. In addition, the new agenda for change pay rates, should they be confirmed, will encourage an opportunity which needs to be captured. Mr Risebourgh commented that the Board should also focus on retention.

Director of Finance

73/18 Item 10.1 74/18 Item 10.2

EXECUTIVE DIRECTORS’ REPORTS Medical Director’s Report The Board received and noted the Medical Director’s report, noting the Medical Director’s activities in the month. The Board noted in particular the ongoing issues with medical trainee staffing and the impact on medical rotas, to be discussed further in part 2. Dr Romero-Urcelay was considering joining the Chelwest medical bank. which would provide the Trust with non-psychiatric medical cover to ensure that the risk to physical health care was mitigated against, thus avoiding patient safety concerns. Dr Romero-Urcelay to confirm non psychiatric medical trainees could detain patients under section 5.2 Director of Nursing & Patient Experience’s Report The Board received and noted the Director of Nursing’s report, noting the CQC quality improvement plan. Summary plans are retrospective and had been reviewed at Quality Committee in March. Board discussed the review of ligature anchor points and lines of sight by the Head of Health and Safety. Board also discussed the receipt of official notice from CQC regarding the full and comprehensive inspection of Broadmoor Hospital commencing on 4 June 2018; The Board noted that the Pead inspector will be coming to Board in May. Ms Regan advised the Board the high secure hospital authorisation process that taking place

Dr Romero-Urcelay

Ref: Discussion: Action: 75/18 Item 10.3 76/18 Item 10.4 77/18 Item 10.5

in Broadmoor had been brought forward, so that the inspection was conducted in the same year as Rampton and Ashworth. Director of Local Services’ Report The Board received and noted the Director of Local Services’ report, highlighting the changes in access to urgent care. The Board engaged in discussion regarding the CNWL recommendation of 12 month postnatal and perinatal service against the 6 month service funded for the Trust by our local CCGs. A review would be made of the service period, Ms Regan informed the board that a letter will be drafted and published in a public domain outlining where the Trust is against the Five Year Forward View. Mental Health was a national priority, and this extends to perinatal services. Board expressed concerns regarding the 6 month service. The Trust has been awarded no additional IAPT funding. The Board noted the Trust was an outlier in terms of underfunding of recovery and community teams. Director of High Secure & West London Forensic Services’ Report The Board received and noted the Director of High Secure & West London Forensic Services’ report, noting developments in high secure services and forensic services. The Board were informed that the service had been successful in the bid for Forensic CAMHS. The Board learnt that New Models of Care would go live for forensics services across North London on the 1 April 2018. The Board received notice that Dr Julia Renton was appointed as the new Clinical Director for Planned and Primary Care this month. The Board acknowledged Dr Chris Bench will be leaving the Trust. Following 20 years of service, he will retire in March 2018. Director of Workforce & OD’s report including workforce performance report The Board received and considered the Director of Workforce & OD’s report, including the workforce performance report, noting the recent letter from NHS Improvement commending the Trust on improvements to agency spend. The Board discussed the retention initiative involving transparency and communications to promote knowledge of promotion amongst colleagues. The gender pay gap had been discussed at Workforce and OD committee. The Board also discussed the Agenda for Change plans, and the current ongoing conversations with Trade

Director of LS/ Director of Finance


Unions for Trust staff at the top of their band. The Board noted the workforce report.

78/18 Item 10.6 79/18 Item 11

Director of Communications and Engagement’s report The Board received and noted the Director of Communications and Engagement’s report, noting the successful nursing conference. Ms Sykes informed the Board of the nominations for NHS at 70 and Quality awards. The Board received an update on the refresh of the Trust intranet, noting that this month 400 pages received updates and the directorate continue to support the Direct of Nursing and Patient Experience in preparation for the CQC inspection in June. HEALTH BASED PLACES OF SAFETY (HBPOS) The Board received and noted the update from Director of Nursing and Patient Experience. Highlights from report, there have not been any increases in section 1 presentations since the legislative changes, due in part to the use of the qualified Nurse within the Single Point of Access at nights. The Board were informed correspondence has been sent to Healthy London Partnership in response to the non-acceptance of recommendations for the work on health based places of safety and that further modelling was required for street triage and early diversion schemes would be considered along with service user views being incorporated. This letter was sent in conjunction with CNWL and local commissioners.

80/18 Item 12

NURSE AND HEALTH CARE ASSISTANT STAFFING LEVELS – EXCEPTION REPORT The Board received and noted the quarterly exception report on safe staffing levels, noting a slight decrease in the number of red rated shifts.

81/18 Item 13

LEVEL 1 RISK REGISTER AND BOARD ASSURANCE FRAMEWORK UPDATE The Board received and noted the latest Level 1 risk register and Board Assurance Framework (BAF), noting the significant changes to risk ratings due to the recent quarterly review. The risk review was scrutinised at the March Trust Management Team meeting. The Board noted the addition of a new risk regarding GDPR.

Ref: Discussion: Action: 82/18 Item 14 83/18 Item 15

QUALITY COMMITTEE The Board received and noted the chairman’s report from the meeting held on 21st March 2018, and the approved minutes from the meeting on 28th February 2018 FINANCE AND PERFORMANCE COMMITTEE The Board received and noted the chairman’s report from the meeting held on 28th March 2018, and the approved minutes from the meeting on 28th February 2018

84/18 Item 16

TRUST MANAGEMENT TEAM The Board received and noted the draft minutes from the meeting held on 28th March 2018, and the approved minutes from the meeting on 28 February 2017

85/18 Item 17

BROADMOOR HOSPITAL REDEVELOPMENT PROGRAMME BOARD The Board received and noted the approved minutes of meetings held on 7th March 2018 and received a verbal report from the meeting held on 4th April 2018. Revised terms of reference would be considered at the May Board meeting.

86/18 Item 18 87/18 Item 19 88/18 Item 20

ANY OTHER BUSINESS Mr Hayhoe suggested to the Board that the agenda for part 1 references the items for the development session. This would ensure adequate capture of current strategic discussions. Mr Hayhoe thanked Mr Jenkinson for his service as Trust Secretary at West London Mental Health Trust, and wished him the very best on behalf of the Board. QUESTIONS FROM MEMBERS OF THE PUBLIC There were no members of public in attendance. DATE OF NEXT MEETING IN PUBLIC Wednesday 9th May 2018 Trust Headquarters Armstrong Way Southall

Chief Executive

Signed: _____________________________________ Date: _______________________

TRUST BOARD MEETINGACTION SCHEDULE

WEST LONDON MENTAL HEALTH NHS TRUST

Work in progress, not yet due WIPCompleted on time GreenCompleted late AmberIncomplete and overdue Red

MEETING DATE

MINUTE NUMBER

AGENDA ITEM

AGREED ACTION ACTION LEAD BY WHEN(end of)

REVISED DATE

UPDATE ON PROGRESS STATUS

11-Apr-18 68/18

Update April 18: board member visits to include contact with staff and service users.

Trust Secretary Jun-18

11-Apr-18 70/18

Board Away Day to focus on succession plans and insurance against unplanned departures.

Chief Executive/Trust Secretary

Oct-18 on Away Day agenda.

11-Apr-18 73/18

To confirm - detaining patient under sec 5.2 by psychiatric medical trainess

Medical Director May-18

14-Mar-18 46/18 Item 7 Chief Executive's report: Update April 2018: EDs to take housing options for staff as part of R&R initiative. Resource identified to fund a post to take this project forward.

Chief Executive Jun-18

14-Mar-18 53/18 Item 13

Estates strategy update : to have Board Strategy session on Estates and development

Director of Finance

Jun-18

14-Mar-18 47/18 Item 8 Integrated Performance Report : The Board noted the previous discussions on proposed changes to the indicators within the IPR for the new financial year, and agreed that this should include indicators to track progress in areas where the Trust aimed to achieve top quartile or decile performance, such as physical health assessments in community services.

Director of Finance

Jun-18

14-Mar-18 47/18 Item 8 Integrated Performance Report: The Board discussed whether the IPR reflected the short-term, medium-term and long-term aims of the Trust, and agreed that this would be discussed further as part of the Board’s away-day in Oct 2018.

Director of Finance

Jun-18 Oct-18

KEY

INCOMPLETE & OVERDUE

COMPLETED - on timeCOMPLETED - late

WORK IN PROGRESS

TRUST BOARD MEETINGACTION SCHEDULE

WEST LONDON MENTAL HEALTH NHS TRUST

MEETING DATE

MINUTE NUMBER

AGENDA ITEM

AGREED ACTION ACTION LEAD BY WHEN(end of)

REVISED DATE

UPDATE ON PROGRESS STATUS

14-Feb-18 26/18 Item 7 Chief Executive's report: The provision of access to Tableau to non-executive directors to be considered as well as to commisioners.

Director of Finance

WIP

14-Feb-18 29/18 Item 10Medical Director's report: To present the quality improvement methodology using a case study, following the appointment of the Head of Quality.

Medical Director TBC

10-Jan-18 07/18 Item 7Local Services Transformation Programme: The Board agreed that future reports would include tracking of progress against programme milestones

Director of Local Services

May-18 WIP

14-Feb-18 29/18 Item 10Medical Director's report: To discuss with Prof Glen the approach to supporting implementation of the mental health act using a similar model as used for safeguarding.

Medical Director May-18

10-May-17 159/17 Item 12.1 Medical Director's Report: Dr Romero-Urcelay to align publications with service lines in the list of publications for future years

Medical Director May-18 Jul-18 Update May 2018: in discussion with R&D Director Dr Scholtz

WIP

11-Oct-17 308/17 Item 7Speak up Guardian annual report: the executive to work with Professor Glen to agree the appointment of additional champions to support her role.

Director of Workforce & OD

Nov-17 May-18 Update March 2018: Recruitment of associate Speak-Up champions delayed but advertisements now published. Further update in May 2018.

WIP

TERMS OF REFERENCE

TRUST MANAGEMENT TEAM 1. CONSTITUTION 1.1 The Board of Directors hereby resolve to establish the Trust Management Team

(TMT) as an executive committee of the Board of Directors. 2. DUTIES 2.1 The TMT is chaired by the Chief Executive and is directly accountable to the Trust

Board for the operational management of the Trust. 2.2 It will oversee the effective operational management of the Trust, including the

achievement of statutory duties, standards, targets and other obligations, and the delivery of safe, effective, high quality patient care. It will inform and advise the Trust Board in setting and delivering the organisation’s strategic direction and priorities. TMT will promote effective two-way communication between the levels of senior management in the organisation. TMT is also the formal route to support the Chief Executive in effectively discharging her responsibilities as Accounting Officer for the Trust.

2.3 The TMT will review performance of the organisation and agree actions where

required. The TMT may delegate responsibility for specific aspects of performance and management to its subcommittees or specially established (and time limited) working groups.

2.4 TMT has delegated powers from the Board to: 2.4.1 Strategy & objectives

i. Shape, develop and implement proposals on the Trust’s vision and values,

purpose and strategic direction.

ii. Review and advice on the Trust’s annual objectives and annual plan, including the revenue and capital budgets to support delivery of the annual plan.

iii. Review strategies, strategic development proposals and proposals for major

service change ahead of submission for formal Chief Executive or Trust Board approval, as appropriate

iv. Undertake business development, innovation and investment opportunities

and associated planning. Develop and monitor strategic planning for the Trust in line with objectives and agreed priorities, including regular review of business development opportunities.

v. Ensure that each service line and corporate service has an annual business

plan, with identified quality, risk/mitigations and financial components clearly articulated and aligned to the Trust’s annual plan.

vi. Review the Trust’s level 1 risk register regularly (at least every other month),

to ensure it corresponds with the Trust’s annual plan and objectives. Confirm that the Board Assurance Framework (BAF) will robustly manage and reduce the risks identified. Maintain oversight of the Board Assurance Framework; this will include agreeing all additions and amendments to and deletions from the BAF.

vii. Review business cases in excess of £100,000 up to £999,999.99, challenging the strength of the proposals against the Trust’s strategic aims and robustness of the financial case and associated risks prior to referral for approval in line with the Trust Standing Orders.

2.4.2 Clinical quality & safety

i. Ensure that systems are in place to demonstrate compliance with CQC essential standards for quality and safety.

ii. Monitor the CQC action plan following inspection and re-inspection activity.

iii. Ensure that key Trust policies affecting clinical quality and safety are discussed and ratified and are NHSLA compliant to support high quality and safe care.

iv. Identify at each meeting, any immediate quality or safety concerns and agree

on the action to be taken to review and address these.

2.4.3 Performance management

i. To conduct a monthly service line performance review. This will include but not be limited to finance (e.g. budget management and achievement of CIPs1) and HR issues (staffing levels, recruitment and retention, sickness management, agency spend, mandatory training compliance, PDR completion). To agree actions and responsibilities to address shortcomings.

ii. Review the trust’s overall performance to inform monthly performance

reporting to the trust board, including review of the integrated performance report and other performance reports (including finance and workforce) which are presented to the Board.

iii. Monitor and review workforce issues including, but not limited to, training and

education needs and funding, the PDR process, coordination of workforce planning, recruitment and retention, staff-side election process, single equity scheme plan, review of equality access and diversity trends.

2.5 Other duties 2.5.1 In addition to these core duties, the TMT will:

1 Detailed scrutiny of performance against CIPs is delegated to the Financial Oversight Leadership Group, a sub-committee of TMT

i. Agree re-structures within the organisation that affect more than 202 members of staff (below this number, plans can be agreed at the relevant SMT).

ii. Oversee the resolution of any IT related operational issues through exception reporting from Strategic Technology Investment Group (STIG). Specific items may be brought directly to TMT with the agreement of the Chair.

iii. Review and endorse the draft IG Toolkit year-end return, and oversee effective arrangements for information governance.

iv. Consider matters relating to emergency planning, as advised by the Emergency Planning Forum.

v. Identify and consider innovation, best practice and leading edge developments from other trusts and organisations for consideration and adoption.

vi. Deliver work and projects assigned to the group by the Trust Board and the Chief Executive, ensuring decisions are implemented.

vii. Monitor information received and act accordingly to ensure the Trust complies with statutory and regulatory requirements regarding all Trust operational matters, including health and safety and emergency planning.

viii. To provide a corporate view on Trustwide issues of current concern ensuring coordination between different departments within the Trust.

ix. Ensure that staff are kept updated on Trustwide issues. x. Task sub-committees and working groups to undertake specific work packages

/ projects. xi. Oversee the work of the Medical Education Committee in the development,

monitoring and promotion of the highest standards of medical education in support of the delivery and continuous improvement in training and clinical care within the Trust.

xii. work collaboratively with other committees to ensure interdependencies are recognised and gaps do not arise throughout the process, overlap of tasks is reduced and the business of the Trust is not affected.

2.6 Reporting committees 2.6.1 Receive reports from the following sub-groups:

• Local Services Senior Management Team • Forensic Services Senior Management Team • High Secure Services Senior Management Team • Nursing Leadership meeting • E-rostering project group • Capital Estates & Facilities Senior Management Group • Clinical Design Group • Strategic Technology Investment Group • Trust-wide Recover Programme Board • Strategic Trust-wide Psychological Therapists Group • Strategic Trust-wide Allied Health Professionals (AHPs) Group • Medical Education Committee

2 The grade of the staff should be taken into account, and the restructure should also be agreed by the relevant SMT. If there is an impact on any service outside the area being restructured, the restructure should be approved by TMT.

2.6.2 Receive reviews and updates on key issues and developments with Trust-wide impact on a rotational basis from the following areas:

• Pharmacy • Social work • AHPs • Psychological therapies

3. MEMBERSHIP 3.1 The Trust Management Team will be appointed by the Trust Board and its core

membership shall consist of the following (or their deputies):-

Chief Executive (Chair) Director of High Secure & Forensic Services Director of Local & Specialist Services Director of Nursing and Patient Experience Medical Director Director of Finance & Business Director of Workforce and Organisational Development Clinical Director Local Services – CAMHS Clinical Director Local Services – A&UC Clinical Director Local Services – P&PMH Clinical Director Local Services – CIDS Clinical Director Local Services – L&LTC Clinical Director High Secure Services Clinical Director Forensic Services

3.2 The following (or their deputies) will be regular attendees,

Chief Pharmacist Director of Safeguarding Director of Communications and Engagement Director of Business Technology Director of Business & Strategy Deputy Nursing Director (Corporate) Deputy Director of Finance Deputy Director of Business & Strategy Strategic Lead for OT & Allied Health Professionals Strategic & Professional Lead for Psychological Therapies Social Work Lead Trust Secretary

3.3 The chair of the TMT is the Chief Executive and the Chief Executive will identify a

vice chair. The vice chair will automatically assume the authority of the Chair should the latter be absent.

4. QUORUM 4.1 A quorum will be six members, at least one of whom will be either the chair or vice

chair of the Committee or, in the event that both the chair and vice chair are required to be absent, an Executive Director formally designated by the Chief Executive to chair the meeting.

5. ATTENDANCE AT MEETINGS 5.1 All members of the committee will be required to attend a minimum of 9 meetings in

each year and will nominate a deputy to attend in their absence. Deputies will act as a full member of the group with respect to decision making.

5.2 Other members of staff (i.e. not listed in 3.1 or 3.2 above) will be invited to attend

when the TMT is discussing particular areas of the operation that are the responsibility of that individual.

6. FREQUENCY 6.1 Meetings shall normally be monthly and there should be no less than ten meetings

in a year. Additional meetings may be arranged from time to time, if required, to support the effective functioning of the Trust.

7. REPORTING ARRANGEMENTS 7.1 The minutes of the TMT shall be formally recorded and submitted to the Trust

Board at the next available opportunity. Draft minutes, approved by the Chair but not yet confirmed by the TMT, may be submitted. The Chair will report to the oBard on the most recent meeting, whether or not minutes are available, highlighting to the Board any particular areas that the TMT wishes to draw to its attention.

8. AUTHORITY 8.1 The Trust Management Team is authorised by the Trust Board to oversee the

operational delivery of high quality, safe recovery focussed in line with the values of the Trust and its strategic aims. The Trust Management Team operates within the Trust’s approved Scheme of Delegation, ensuring that appropriate issues are referred to the Board, as set out in the scheme.

9. ACCOUNTABILITY & MONITORING EFFECTIVENESS

9.1 The TMT will review its own performance and Terms of Reference annually to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the Board for approval.

10. OTHER MATTERS 10.1 TMT shall be supported administratively by the Trust Board Secretary whose duties

in this regard will include (a) agreement of the agenda with the Chair; (b) collation and dispatch of papers (c) taking the minutes and keeping a record of matters arising, actions and issues to be carried forward, and (d) advising TMT on any other pertinent matters.

10.2 The power and authority of TMT may, when an urgent decision is required between

meetings, be exercised by the Chair in conjunction with a minimum of 2 Executive Directors. The exercise of such powers shall be reported to the next formal TMT meeting.

10.3 If the Chair agrees, a decision can be made out of committee (i.e. virtually) between

meetings – all TMT members will be emailed details of the proposed decision with an opportunity to respond within 2 working days.

11. REVIEW 11.1 The Terms of Reference of this Committee will be reviewed annually. Approved by TMT: 26th April 2017 (revised November 2017) Review date: 26th April 2018

Report summary Trust board meeting: Part 1 (in public)May 2018

Report title: Broadmoor hospital redevelopment – programme board terms of reference

Executive lead: Carolyn Regan, CEO and Project SRO

Report authors: Tony Cloke, Business & Performance Manager

Report discussed previously at: BHR Programme Board, 4th April & 2nd May 2018

Purpose and action requiredFor approval

For discussion / decision

To note

Relates to? Strategy & Planning Quality & Safety Performance & Activity Legal & Governance

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

If yes, insert relevant risk reference:

5917 (Broadmoor

redevelopment) Do you recommend a new entry to the Board Assurance Framework is made?

No

Relationship to trust strategic objectives? Outstanding We coordinate and collaborate – to deliver holistic care

We innovate – to turn research into practice

Improving quality

We invest – in people, estates, technology We listen and learn – from patients, carers, staff, the public

Compassionate care

We work together – and implement the principles of recovery We are recommended – by patients, carers, friends and families

Summary

• Trust Board last approved the terms of reference of the BHR Programme Board in

February 2017 • Independent review of governance by Arcadis LLP in late 2017 • The approach of completion of Section 1 and the Gate 4 Review means this is an

opportune time to review the terms of reference • Various amendments are recommended in relation to ‘roles & responsibilities’ and

‘assurance’ (see report)

Supporting documents and/or further reading None.

Trust board meeting (Part 1): 9th May 2018 Broadmoor hospital redevelopment – programme

board terms of reference

1 Purpose 1.1. To review the terms of reference of the Broadmoor Hospital Redevelopment (BHR)

Programme Board. 2 Recommendation 2.1 The board is asked to review and approve the terms of reference of the BHR

Programme Board. 3 Introduction 3.1 Trust Board last approved the terms of reference of this programme board in

February 2017, following a review by the Programme Board in January 2017 when some minor amendments to membership were made.

3.2 Arcadis LLP was engaged by the Trust in 2017 to review the BHR project and, in

particular, the following two areas:

(a) the trust’s handling of the current discussions with Kier about Compensation Events (CEs) and ‘extension of time’; and,

(b) the governance structure of the project (at the request of the Audit Committee). 3.3 At its meeting on 4th April the BHR Programme Board reviewed its terms of

reference and agreed to recommend various amendments to the Trust Board; some of these were identified at the meeting (which was not quorate at that point) and the programme board is expected to approve these at its meeting on 2nd May 2018.

3.4 This report is written on that basis, but any further amendments identified by

the programme board will be reported to Trust Board at the meeting. 4 Key issues Roles & responsibilities 4.1 Recommendation 1 of the report on the governance structure stated that the trust

should “clarify programme roles and responsibilities and ensure that roles on the programme are clearly understood and formally appointed”.

4.2 The current terms of reference for the programme board have been reviewed

against the roles & responsibilities of the ‘Project Board’ as set out in appendix C to the HM Government Cabinet Office publication, ‘Managing Successful Projects with PRINCE2’.

4.3 There are 10 bullet points listed for the stage ‘During the project’. It has been possible to match bullet points 1, 2, 3, 4, 5, 7 and 8 to elements in the existing terms of reference, but the bullet points below are not currently explicitly reflected:

• Bullet point 6: ‘Respond to requests for advice from the Project Manager’

This is currently implicit if not explicit – the PM regularly seeks advice from the Programme Board through the ‘design & construction’ update and other reports – but new text at 2.3 (xxvi) makes this explicit.

• Bullet point 9: ‘Make decisions on escalated issues’ This is implicit if not explicit – the terms of reference of the Steering Group include the following: “Issues which must be referred to the BHR Programme Board” – but new text at 2.3 (xxvii) makes this explicit.

• Bullet point 10: ‘Approve completed products’

This is implicit if not explicit – programme board approves all ‘products’ either by approving recommendations for the Steering Group or by direct consideration – but new text at 2.3 (xxviii) makes this explicit.

4.4 The review suggests that all the recommended roles & responsibilities of a ‘project

board’ are covered in the current approved terms of reference, but the proposed ‘tweaks’ set out above make the ‘implicit’ statements more visible and ‘explicit’.

4.5 The current terms of reference have also been reviewed against the roles &

responsibilities of a ‘programme board’ as set out in the Office of Government Commerce (now part of The Cabinet Office) publication, ‘Managing Successful Programmes’.

• Bullet point 3: ‘Resolving strategic and directional issues between projects …’

The new text at 2.3 (vii) covers this.

• Bullet point 4: ‘Assuring the integrity of benefit profiles and realization plan’ The new text at 2.3 (x) covers this.

• Bullet point 6: ‘Providing assurance for operational stability and effectiveness …’

The new text at 2.3 (xvii) covers this. 4.6 In addition, MSP defines the final stage in the transformational flow as ‘Closing a

programme’ and the new text at 2.3 (xxix) covers this. Membership 4.7 The Deputy Director of High Secure Services has been added to the membership,

in order to report directly on transition activities and progress on ‘readiness for service’.

4.8 In line with 4.12 below, the role of ‘External Adviser (programme management) has

been added to the membership. 4.9 The Trust’s Medical Director has been added to the list of those who may be invited

to attend, in his role as ‘Design Champion’ (originally covered by the previous Medical Director).

Assurance 4.10 Recommendation 6 of the report stated that the trust should “enhance assurance

provided by governing bodies of the programme through improved process and addition of external expertise”.

4.11 The Trust has agreed to bolster the programme board through the provision of an

experienced and independent individual, who will act as a ‘critical friend’ to the Board, and additionally provide strategic support to the Trust’s Project Director.

4.12 CHP has put forward its London and South Programme Manager, Simon Waters, to

fulfil the above role; he is one of CHP’s most experienced programme managers, with an extensive work history covering both main contracting and client side operations. The programme board agreed at the February meeting to recommend to trust board the formal appointment of Simon Waters as a member of the BHR Programme Board.

5 Conclusion 5.1 Given the changes outlined above, the amended terms of reference mean the

programme board is ‘fit for purpose’ for the coming months. 6 Recommendation 6.1 The board is asked to review and approve the terms of reference of the BHR

Programme Board. 7 Appendices 7.1 Appendix: Current terms of reference, with proposed amendments shown in ‘track

changes’ – those identified before the programme board meeting in red; those identified at the meeting in blue.

Tony Cloke BHR Business & Performance Manager

May 2018

TERMS OF REFERENCE

BROADMOOR HOSPITAL REDEVELOPMENT PROGRAMME BOARD

1. CONSTITUTION

1.1 The Broadmoor Redevelopment Programme Board has been established as a committee of the Trust Board to oversee the delivery of the Broadmoor Hospital Redevelopment Programme on behalf of the Trust Board.

2. DUTIES

2.1 The Committee is accountable for providing assurance to the Trust Board via the metrics and work progress of the following sub-committees:

• Steering Group• Local External Stakeholder Group• Working Groups which report to the Steering Group (directly or indirectly)• Any other sub-committees that may from time to time be created

2.2 The Programme Board is a decision making body dealing with the strategic and high level operational aspects of the redevelopment of the Broadmoor Hospital site.

2.3 The Committee will:

(i) Deliver a ready-for-service modern, high secure hospital for those mentally disordered patients who:

- Are liable to be detained under the Mental Health Act 1983 (c.20), or equivalent legislation, and

- In the opinion of the Secretary of State, require treatment under conditions of special security on account of their ‘dangerous, violent or criminal propensities’ (S4 The National health Service Act 2006)

(ii) Deliver a solution that meets national policy objectives and provides a safe and secure environment for patients and staff.

(iii) Deliver an effective, evidence based model of service that promotes risk reduction, recovery and rehabilitation.

(iv) Ensure that the redevelopment project progresses satisfactorily and in line with the overall timescale and costs agreed with key stakeholders.

(v) Ensure that the programme remains viable through:

- Identification and active management of risks facing the programme. - Monitoring of progress and key milestones for individual workstreams. - Identification and prioritisation of appropriate resources to support the

programme. - Continued level of engagement and support of key stakeholders. - Regular assessment of the best value and financial viability. - DH Gateway Reviews. - Quality and Equality Impact Assessments.

(vi) Provide advice and guidance to the Trust Board on the strategic direction of the programme.

(vii) Resolve strategic and directional issues between projects, which need the

input of senior stakeholders to ensure the progress of the programme. (viii) Raise concerns with the Chief Executive/Executive Directors if issues

cannot be resolved within the programme structure.

(ix) Ensure that risks associated with the programme are rigorously reviewed and areas of concern are raised with the Chief Executive/Executive Directors if necessary.

(x) Assure the integrity of benefit profiles and the benefits management plan.

(xi) Ensure that learning and evidence based outcomes are shared (including

benefits management and post-project evaluation).

(xii) Ensure stakeholders are actively represented in the programme.

(xiii) Keep a watching brief on associated property and land sales at the Broadmoor Hospital estate to ensure the approved programme remains viable.

(xiv) Ensure the delivery of work and projects assigned to the group by the Board

of Directors and the Chief Executive ensuring decisions of the Board of Directors are implemented.

(xv) Provide a programme plan for the Board of Directors that aligns with the

Trust strategic objectives and incorporates specific measurable deliverables that ensure reporting by exception is embedded in the reporting framework. The achievement of agreed objectives will be reported quarterly to the Board of Directors.

(xvi) Monitor the operational performance of the programme, allocating

individuals or sub-groups with specific projects/work packages to remedy any variances that exceed targets and tolerances set by the Trust.

(xvii) Provide assurance for operational stability and effectiveness through the

programme delivery cycle.

(xviii) Monitor and review workforce issues including, but not limited to, training and education needs and funding, coordination of workforce planning, recruitment and retention, planning for transition to the new hospital, review of equality access and diversity trends.

(xix) Review all financial proposals associated the Redevelopment Programme

and provide clear recommendations to the Trust Board.

(xx) Approve appropriate programme and project change management requests

which have been referred to the committee as a result of exceeding the tolerances of the Steering Group.

(xxi) Ensure that approved developments and action plans are allocated

appropriately and delivered within agreed time and quality parameters.

(xxii) Work collaboratively with other committees to ensure interdependencies are recognised and gaps do not arise throughout the process, overlap of tasks is reduced and the business of the Trust is not affected.

(xxiii) Provide the required information/reports to the Trust Board in order to

assure the committee management of the Trust business is assured.

(xxiv) Provide overarching leadership and strategy for the programme, taking into account the prevailing health economy and identifying business opportunities and areas for future development.

(xxv) Make recommendations to the appropriate authorising person/s or body in

relation to expenditure (as set out in Standing Order 17.8).

(xxvi) Respond to requests for advice from the Project Manager.

(xxvii) Make decisions on issues escalated from the Steering Group.

(xxviii) Approve completed products.

(xxix) Close the programme (following formal confirmation of the following: business case has been satisfied, all projects have been completed satisfactorily, business performance is stable, and remaining handover or transition activities have been assigned to

relevant business operations. 2.4 The committee is responsible for the oversight of the work of Programme Board

sub-committees, the Board Assurance Framework in relation to the development of the new hospital, and the associated actions and audit programme.

3. MEMBERSHIP 3.1 The Programme Board will be appointed by the Board of Directors and its

membership shall consist of the following:-

Chief Executive (Chair – as SRO) Executive Director of Finance & Business (Vice Chair) Executive Director of High Secure Services Deputy Director of High Secure Services * Redevelopment Programme Director Clinical Director Non-Executive Director (or nominated alternate) Director of Communications & Engagement Director of Security

E&F Lead (Service & Business Change) Commissioner Representative External adviser (Programme management)

* The Redevelopment Programme Director is the designated ‘project manager’ for the contract with Kier and so may not vote when the programme board is considering Compensation Events notified under that contract.

3.2 The Chief Executive (as ‘Senior Responsible Owner’) is appointed as Chair of

the Programme Board and the Executive Director of Finance & Business as its Vice Chair. The Vice Chair will automatically assume the authority of the Chair should the latter be absent, unless the Programme Board decides otherwise.

3.3 Others may be invited to attend (when appropriate), such as the following:

Executive Director Nursing & Patient Experience Executive Director of Organisation Development & Workforce Medical Director as ‘Design Champion’ Redevelopment Operational Commissioning Manager

(to be invited to attend all meetings) 4. QUORUM 4.1 A quorum will be five members including a Non-Executive Director,

Redevelopment Programme Director (or nominated representative), Executive Director of High Secure Services (or representative) and either the Chair or Vice Chair of the committee. The Trust Board may nominate another Non-Executive Director to attend in the absence of the Non-Executive Director to ensure that all meetings are quorate.

5. ATTENDANCE AT MEETINGS 5.1 All members of the committee will be required to attend a minimum of 70% of

meetings in each year and will confirm the name of an appropriate deputy (who should be a senior member of the team and able to act for the member) to attend in their absence. Deputies will act as full members of the group with respect to decision making.

5.2 Other members of staff will be invited to attend when the Programme Board is

discussing particular areas of the operation that are the responsibility of that individual.

5.3 A secretary to the Programme Board will attend to take minutes of the meeting

and provide appropriate support to the Chair and the members. 6. FREQUENCY 6.1 Meetings shall normally be monthly and there should be no fewer than six

meetings in a year. Additional meetings may be arranged from time to time, if required, to support the effective functioning of the programme.

7. ACCOUNTABILITY AND REPORTING ARRANGEMENTS 7.1 The minutes of the Programme Board shall be formally recorded by the secretary

and submitted to the next meeting of the Board of Directors. The Chair of the Programme Board shall draw to the attention of the Board of Directors any issues that require disclosure.

8. AUTHORITY 8.1 The Programme Board is authorised by the Board of Directors to oversee the

operational delivery of high quality, safe recovery focussed in line with the values of the Trust and its strategic aims. The Programme Board operates within the Trust’s approved Scheme of Delegation, ensuring that appropriate issues are referred to the Board, as set out in the scheme.

8.2 Duties and Powers delegated by the Trust Board to the Broadmoor Hospital

Redevelopment Programme Board:

(i) Approve a scheme of delegation of powers from the Programme Board to the sub-committees.

(ii) Approval of sub-committee Terms of Reference and appointment of Chair. (iii) Oversight of the implementation of the agreed programmes of work for the sub-

committees. (iv) Adoption/ratification of sub-committee recommendations where the sub-committee

does not have delegated powers. (v) Continuous appraisal of the work undertaken by the sub-committees to ensure

keeping on track as set out within the design programme. (vi) Providing advice to specific sub-committees. 8.3 Issues which must be referred to the Trust Board:

(i) Proposed changes to Programme Board Terms of Reference. (ii) Actions which will result in a delay to the project. (iii) Actions which will increase the overall cost of the project (particularly if beyond the

DH approval limit) or impact adversely on the income of the Trust. (iv) Issues or actions which have legal implications for the Trust. (v) Disputes which members of the Programme Board are unable to resolve

themselves. 8.4 The Programme Board will undertake an annual review of its performance in

order to evaluate the achievement of its duties. 9. MONITORING EFFECTIVENESS 9.1 The Board of Directors will monitor the work of the Programme Board and ensure

that all targets are achieved to schedule. 10. OTHER MATTERS 10.1 The Programme Board shall be supported administratively by a secretary, whose

duties in this respect will include: - Agreement of agenda with the Chair and attendees and collation of papers

- Taking the minutes & keeping a record of matters arising and issues to be

carried forward - Advising the Committee on pertinent areas

11. REVIEW 11.1 The Terms of Reference of this Committee will be reviewed from time to time as

the Trust Board or Programme Board decides and not less than annually. Approved: Trust Board (INSERT DATE) Review date: December 2018 (BHR Programme Board)

Report summary Trust board meeting: Part 1 (in public) May 2018 Report title:

Chairman’s Report

Executive lead:

n/a

Report authors:

Tom Hayhoe, Chairman

Report discussed previously at:

n/a

Purpose and action required

For approval


To note

Relates to? Strategy & Planning Quality & Safety Performance & Activity Legal & Governance Relationship to board assurance framework? Are any existing risks in the Board Assurance Framework affected?

No

If yes, insert relevant risk reference: N/A

Do you recommend a new entry to the Board Assurance Framework (i.e. Trust-wide level 1 risk) is made?

No



Improving quality


Compassionate care


Summary The report contains updates on recent activity undertaken by the Chairman and non- executive directors.

Supporting documents and/or further reading

Trust board meeting (Part 1): 9th May 2018 Chairman’s Report

1 Activities undertaken 1.1 Since preparing my report for the 11th meeting of the Board, I have:

- Attended meetings of the Finance & Performance Committee, Audit

Committee and the Broadmoor Hospital Redevelopment Programme Board

- Chaired a meeting of the Mental Health Act Managers - Chaired the interview panel for the appointment of a non-executive

director - Visited the Hammersmith & Fulham CIDS service - Visited Woburn and Harrogate wards at Broadmoor - Met with the NHSI Delivery and Improvement Director for North West

London - Met with the most recently appointed NED as part of her induction - Met with the Turnaround Director to discuss his forthcoming report on his

time with the trust - Met with two candidates for appointment to vacancies in the Access and

Urgent Care service - Undertaken Medical Appraiser training - Sung with the St Bernards choir - In the company of the chief executive, met with one of our local MPs - Attended events hosted by Deloitte, addressed by the Medical Director of

North West Ambulance Trust, and by Odgers, addressed by a representative of the Karolynska Institute

1.2 Since my last report to the Board, the non-executive directors have undertaken

various activities in addition to attending board committees: Paul Aylin attended a joint research meeting between the Trust and Imperial College; and Sally Glen chaired the last meeting of a working group that has been consulting on improving the fairness and ensuring the legality of nursing shifts, attended a conference on schools, health and community support young people's mental health, and took part in a workshop facilitated by the Suicide Prevention Clinical Lead at Mersey Care entitled Zero Suicide Approach. The non-executive directors will report verbally at the Board on any other activities undertaken in the past month and, alongside the chair, will be happy to answer any questions.

2 Board membership 2.1 I am very pleased to welcome Professor Nick Barber to the board as a non-

executive director. Tom Hayhoe

Chairman 30th April 2018

Report summary Trust board meeting: Part 1 (in public)

May 2018 Report title: Chief Executive’s report to the board

Executive lead: Chief Executive

Report authors: Chief Executive

Report discussed previously at: N/A


For approval


To note


No

If yes, insert relevant risk reference: N/A


No



Improving quality


Compassionate care


Summary Supporting documents and/or further reading Item 3.1 Appendix A

WLMHT WLG - Deloitte Final Report 2 Item 3.1 Appendix B

West London Mental Health NHS Trust draf Appendix C

WLMH Undertakings success measures pro

Trust board meeting (Part ): May 2018 Chief Executive’s Report

1 Purpose 1.1 The report aims to highlight recent key activities and to draw the Board’s attention

to a number of recent developments. 2 Recommendations 2.1 The board is asked to note the content of the report. 3 Trust Issues 3.1 The Well-led Review report from Deloitte has been received and a draft action

plan produced. 3.2 Stanley Riseborough, interim Improvement Director, will be completing his three-

month assignment on the 22nd of May. His report is currently being finalised and will be considered by the Board at a development session.

3.3 As part of our regular performance oversight meetings with NHS Improvement, we

presented an updated progress against the undertakings which is attached at appendix C.

3.4 Preparing to implement the General Data Protection Regulations (GDPR) Across the UK, businesses, charities and public bodies are getting ready to

implement the new legislation on data protection -the General Data Protection Regulations (GDPR) on May 25th 2018. https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/

This overhauls the UK's current data protection regime under the Data Protection

Act 1998 (the "DPA"). The Government has also published the Data Protection Bill, which will replace the DPA and is intended to ensure that UK and EU data protection regimes are aligned following Brexit. It also strengthens individuals’ rights to their data and improves safeguards.

As a responsible NHS healthcare provider, many of our existing processes are fit

for the new purpose, but will require technical updates to reflect the wording of the new legislation.

We have additional responsibilities as a service that processes sensitive personal

data from medical records through to criminal convictions and safeguarding vulnerable people. We also have new obligations because we share and process data and we have key data protection interactions with patients, like consent to treatment.

https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/

https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/

We also run clinical trials, which have strict data processing requirements and there are new special categories of data in the legislation covering identifiable personal data like genetic material.

At West London NHS Trust, we have been building on our successful Information

Governance (IG) Toolkit completion. We have a new Information Governance Manager, Ray Jordan and we have reconvened our Information Governance (IG) Steering Group, chaired by Medical Director and the Trust’s Caldicott Guardian, Dr Jose Romero - Urcelay.

There are a number of deliverables in progress, which have been prioritised by the

new IG Steering Group, supported by our internal auditors. We have procured a web based software system to do an initial data discovery exercise using a specially designed programme to look for potential ‘personally identifiable data’. This work stream is being pursued in parallel to, for example, an awareness programme and communication to the Trust’s senior management teams.

3.5 High Secure Services Authorisation The Trust has been advised by NHS England that the timeframe for authorisation

of the three high secure hospitals is to be aligned. This will bring forward West London Mental Health NHS Trust to March 2019 to be in line with Mersey Care NHS Foundation Trust and Nottinghamshire Healthcare Foundation NHS Trust. Timeframe for the assessment process is as follows:

• March 2018 – Specialised Commissioning Oversight Group signed off final

criteria and launched process • April 2018 to July 2018 – Regional assessment processes • August 2018 – National confirm and challenge meeting • September 2018 – Draft recommendations made available to NOG • September 2018 to November 2018 – further work, if required • November 2018 – Final national sign off process led by SRO • December 2018 – NOG to be advised of final recommendations by NHS

England • December 2018 – NHS England make final recommendations to the DHSC • March 2019 – Providers authorised, subject to satisfactory passage of the

above 4 Strategy 4.1 Hounslow CCG have drafted an outline paper regarding their intentions to drive

service transformation with closer integration of primary care and community services, although the timescale is unclear at this stage. This will cover primary care mental health plus the whole range of community services and involve all current providers. Further details to follow.

5. Recent Activities & Meetings include: 5.1 A listening event at Trust HQ. Topics raised included staff getting involved in a

clean up of the canal next to Trust HQ; the Armstrong Way working group; and the varying opening times of the staff canteen, being reviewed.

I presented the Team of the Month award to the Hammersmith and Fulham team including nursing and estates & facilities teams who managed the burst water pipe in the Hammersmith and Fulham inpatient unit and the temporary evacuation of patients.

A Leadership Forum for senior managers, where the agenda included

consideration of the staff survey and next steps; feedback from the Well-Led Review; and the rollout of West London Business Intelligence.

Visits to a number of wards at Broadmoor Hospital and the Hounslow Recovery

Team East. I attended the High Secure Services’ Patient Forum and the West London

Forensic Men’s Medium Secure Service Staff Forum. With the Trust Chairman, met with Ruth Cadbury MP for Brentford and Isleworth to

discuss Ealing Hospital, CAMHS beds, Cherry Tree House and Brentford Lodge, and a follow up on waiting times which was discussed at our last meeting. We have invited Ruth to officially open Brentford Lodge, which will house the recovery college, some Hounslow IAPT services and the Hounslow health and wellbeing network.

With Stephanie Bridger, Director of Nursing & Patient Experience, I visited One

Housing to see Cliff Road, an integrated health and housing model delivered in partnership by Camden & Islington NHS Foundation Trust and One Housing Group. The partnership aims to improve the quality of housing and support for patients through implementation of a jointly developed ‘Care Support Plus’ model. John Hoar, Head of Health Partnerships, suggested he attend a future Executive Director or Clinical Director meeting to do a presentation and answer any questions. The HR team had also arranged a visit to SoHostel regarding nursing accommodation.

With Jose Romero-Urcelay Medical Director, met with Piers McCleery Director of

Strategy, and Dr Grocott-Mason Medical Director of Royal Brompton & Harefield NHS Foundation Trust to discuss planned service changes and potential mental health collaboration.

6. Recommendation(s) 6.1 The Board is asked to note the content of the report.

Carolyn Regan Chief Executive

May 2018

West London Mental Health Services NHS TrustDevelopmental review of leadership and governance using the well-led framework

Final Report | 2 May 2018 | Strictly private and confidential | For approved external use only

This Final Report is strictly private and confidential and has been prepared for the Board of Directors of West London Mental Health Services NHS Trust. This Final Report is prepared for the Board of Directors as a body

alone, and our responsibility is to the full Board of West London Mental Health Services NHS Trust, not individual Directors. It should not be communicated to any third party without our prior written permission. For

your convenience, this document may have been made available to you in electronic as well a hard copy format. Multiple copies and versions of this document may, therefore, exist in different media. Only the Final

signed copy should be regarded as definitive.

https://brandspace.deloitte.com/file/gallery/id/1341

https://brandspace.deloitte.com/file/gallery/id/1341

Deloitte LLP2 Hardman StreetManchesterM60 2ATUnited Kingdom

Tel: +44 20 7007 2054 www.deloitte.co.uk

Board of DirectorsWest London Mental Health Services NHS Trust Headquarters1 Armstrong Way,SouthallLondon,UB2 4SD

2 May 2018

Dear Board of Directors

West London Mental Health Services NHS Trust – Developmental review of leadership and governance using the well-led framework

In accordance with our contract , reference 201790 COR LPP Framework Access Code: 11/859/16/LPPL1-5/2151 dated 5 January 2018, (‘the Contract’) for the developmental review of leadership and governance using the well-led framework, we enclose our final report dated 2 May 2018.

The Final Report is confidential to the Trust and is subject to the restrictions on use specified in the Contract. No party, except the addressee, is entitled to rely on the Final Report for any purpose whatsoever and we accept no responsibility or liability to any party in respect of the contents of this Final Report. This report is prepared for the Board of Directors as a body alone, and our responsibility is to the full Board and not individual Directors.

The Final Report must not, save as expressly provided for in the Contract be recited or referred to in any document, or copied or made available (in whole or in part) to any other person. The Board is responsible for determining whether the scope of our work is sufficient for its purposes and we make no representation regarding the sufficiency of these procedures for the Trust’s purposes. If we were to perform additional procedures, other matters might come to our attention that would be reported to the Trust.

We have assumed that the information provided to us and management's representations are complete, accurate and reliable; we have not independently audited, verified or confirmed their accuracy, completeness or reliability. In particular, no detailed testing regarding the accuracy of the financial information has been performed.

The matters raised in this Final Report are only those that came to our attention during the course of our work and are not necessarily a comprehensive statement of all the strengths or weaknesses that may exist or all improvements that might be made. Any recommendations for improvements should be assessed by the Trust for their full impact before they are implemented.

Yours faithfully

Deloitte LLP

Deloitte confidential: Public sector - for approved external useWest London Mental Health Services NHS Trust: FINAL REPORT

3

Contents

Deloitte confidential: Public sector - for approved external use

Scope of work and approach 4

Executive summary 6

Key findings 10

Appendices 27

Glossary of terms used 28

Summary of recommendations 29

Survey analysis – Board and Staff 32

Basis of review 35

The key contacts in relation to this report are:

Dr Jay Bevington, Partner

Tel: 07968 778 [email protected]

Lucy Bubb, Associate DirectorTel: 07770 [email protected]

Wil Bevan, ManagerTel: 07584 [email protected]

West London Mental Health Services NHS Trust: FINAL REPORT

mailto:[email protected]



4

Scope of work and approach


5

Scope of work and approach

This report sets out the findings from our independent developmental review of leadership and governance at West London Mental Health Services NHS Trust, using the NHS Improvement Well-Led framework (2017).

As set out in our contract dated 5 January 2018, our approach to delivering our work with you has consisted of:

1. A desktop review of the self assessment and key supporting information. This has included a review of: Board and relevant Committee papers; divisional performance information; and relevant strategy documents;

2. Facilitation of an on-line Board Member survey and Staff survey (231 responses);

3. 1.5 hour non-attributable interviews with each member of the Board;

4. 1 hour non-attributable interviews with a sample of senior staff;

5. Undertaking three focus groups with a range of staff;

6. Observing a series of key meetings throughout February and March, including: the Board of Directors, the Quality Committee, Finance and Performance Committee, Workforce and Development Committee, Audit Committee, the Trust Management Team meeting and the three Clinical Service Unit Senior Management Team meetings;

7. Conducting a series of service visits into clinical and non-clinical areas across the Trusts’ sites;

8. Undertaking telephone interviews with a series of external stakeholders;

9. Following the conclusion of these activities we have held an initial feedback meeting with the Chair and Chief Executive Officer (CEO) to share the emerging findings prior to issuing our draft report; and

10. We held a workshop with the Board in April to socialise our emerging findings and recommendations prior to issuing our draft report.

Surveys

Throughout the body of this report we have presented graphical findings from our Board and staff surveys, with the full analysis at Appendix 3. The key for these graphs is as follows:

SA Strongly agree

A Agree

Sl A Slightly agree

Sl D Slightly disagree

D Disagree

SD Strongly disagree

CS Cannot say


How to read this Final Report

In preparation for this Review, the Trust undertook a detailed self-assessment exercise, and this Final Report should be read in conjunction with the output of this.

This Final Report summarises the exceptions arising from the self-assessment (both positive and developmental) and makes a number of recommendations for further improvement.

The key findings against all eight key lines of enquiry (KLOE) can be found from page 10 onwards. Throughout the Final Report we have provided examples of good practice insights from our experience with other NHS organisations and, where possible, have benchmarked survey data against other NHS organisations to provide context.

Glossary

Throughout the body of this Final Report, we include reference to a number of terms and abbreviations. A full glossary of terms can be found at Appendix 1 on page 28.

Basis of our work

Our findings in this Final Report are based on the views expressed by Board members, internal and external stakeholders, and our own observations. We have assumed that the information provided to us and management's representations are complete, accurate and reliable; we have not independently audited, verified or confirmed their accuracy, completeness or reliability.

Our work, which is summarised in this Final Report, has been limited to matters which we have identified that would appear to us to be significant within the context of the scope. In particular, this review will not identify all of the gaps that exist in relationship to the Trust’s approach to governance; rather the review will seek to consider performance against the NHS Improvement Well-Led Framework to identify the most material gaps, key exceptions or areas where insufficient evidence may give rise to the identification of material gaps in the future.

6

Executive summary


7

Executive summary

Context and Overview

West London Mental Health Services NHS Trust (hereafter “the Trust”) is a provider of community and inpatient mental health and community health services in London. In addition it is a national provider for forensic and specialist mental healthcare. It serves a local population of 0.7 million people across West London, and employs over 3,500 staff.

The Trust was rated overall by the CQC in February 2017 as Requires Improvement with the ‘Caring’ domain being rated as Good. As at March 2018, the Trust is rated in segment ‘3’ by NHS Improvement using the Single Oversight Framework methodology.

This Final Report sets out the findings from our independent developmental review of leadership and governance at the Trust, using the NHS Improvement Well-led Framework (2017) and should be read in conjunction with the Trust’s self assessment against the framework. This Final Report highlights specific areas of good practice and areas for further development.

We would like to thank Board members, staff and external stakeholders for their valued engagement in this project.

Throughout our work, we have been able to identify some areas of particular strength. These include:

• Stability of Trust leadership – Both internal and external stakeholder commented positively about change over the last 2 years at Board-level recognising improvements under the current CEO leadership;

• Trust values - The Trust’s vision and values are clear, well publicised and embedded within recruitment and retention processes;

• Board visibility – Board members are visible throughout the organisation, leading the engagement with staff and patients, services users and carers;

• Openness and transparency – Stakeholders recognised the improvement in openness and transparency by Board members and wider into the organisation;

• Committee structure – The Trust’s Board Committee structure is in line with good practice; and

• Focus on innovation and improvement – Over the last 2 years, the Board has encouraged a focus on innovation and improvement, supported by a quality improvement methodology and celebrated, for example, the monthly and annual Quality Awards.

Throughout our work, we have been able to identify some specific areas for development. These include:

• Board and Executive Director development and portfolios – As the Board and Executive Director team has stabilised, the timing is appropriate to develop comprehensive Board and Executive Director development programmes, focusing on both ‘hard’ and ‘soft’ skills, including topics such as ‘assurance vs reassurance’, ‘what good challenge looks like’ and ‘team dynamics and business preferences’. Furthermore, our benchmarking highlighted some anomalies between Executive Director portfolios compared to common practice, which the Board should consider as part of its assurance of being fit for future purpose.

• Performance management and accountability – Based on our experience, the Trust is an outlier as it does not have robust performance management arrangements for Service or corporate teams, nor is supporting performance information easily accessible or aligned to the Trust strategic objectives. There is a lack of clarity about accountabilities between Service and corporate teams, which is impacting on the effectiveness of the governance structures, and the arrangements for escalation and corporate oversight of risk and horizon-scanning of emerging risks require further strengthening. The Board are aware of these issues and have started to make changes.

A summary of our findings against each of the eight KLOEs is outlined below.

1. Leadership capacity and capability

• After a number of changes at Board level, the Board has reached a point of stability under the leadership of the current CEO and, although the Board has good visibility within the organisation, this could be further enhanced.

• The level of challenge and debate at Board meetings could be improved with greater corporate oversight (see sections 4, 5 and 6). Benchmarking the Executive Director portfolios against common practice has highlighted some anomalies, which the Board should assure itself do not present any issues for the future.

• Given the recognised stability, the timing is now appropriate to develop a comprehensive Board and Executive Director team development programme, together with clear succession plans for the Board and Clinical Service Unit /Service leadership team roles.

Deloitte Public Sector - Confidential - For approved external use West London Mental Health Services NHS Trust: FINAL REPORT

8

Executive summary (continued)

2. Clarity of vision, strategy and plans to deliver

• The Trust’s vision and values are clear, well publicised and referred to in practice, which compares favourable with other NHS organisations that we have worked with previously. The corporate strategy has recently been refreshed, however, we found that staff were not clear on the strategic objectives and priorities of the Trust. Furthermore, there is no cohesive monitoring of strategy delivery as the Integrated Performance Report is yet to be aligned to the strategic objectives.

• There is a need to more clearly align supporting strategies to the corporate strategy and to ensure that there are well defined arrangements for monitoring their delivery at Board and Committee level.

3. Culture of high quality, sustainable care

• High quality care is a priority for the Trust and this is recognised and shared by staff at all levels across the organisation. The Trust is generally seen as a good place to work and the culture is described as friendly and supportive. The Board has ensured a focus on equality and diversity, which is recognised in our staff survey results.

• Reporting of patient safety concerns has improved over time, although further improvement is required to provide feedback and ‘close the loop’ for those staff that raise concerns. Furthermore, processes for dealing with poor performance and behaviour, in line with the Trust values, need to be improved.

4. Clarity of roles and responsibilities to support good governance

• The Board Committee structure is in line with good practice; some enhancements could be made to the terms of reference of some Committees, including revising the membership so that the Trust Chair is not a regular member. Furthermore Committee assurance reporting (content, format and agenda position) could be improved to focus Board discussion on the risks to the strategic objectives. The purpose and effectiveness of the Trust Management Team should be reviewed to ensure it is fit for purpose.

• There is a lack of clarity about accountabilities between corporate teams and CSU and service level teams, with some arrangements demonstrating the Trust as an outlier. These need to be addressed as part of the recommended Performance Management and Accountability framework (see section 5).

5. Management of risks, issues and performance

• Whilst there is a Board Assurance Framework and Level 1 risk register in place, supported by an electronic risk management system, the arrangements for escalation and corporate oversight of risk and horizon-scanning of emerging risks require further strengthening.

• Based on our experience, the Trust is an outlier as it does not have robust performance management arrangements for Service or corporate teams. In line with good practice, the introduction of a performance management and accountability framework through which these teams will be held to account for delivery will create a performance culture within the organisation that is supportive, challenging and transparent.

6. Information

• Although progress has been made, there is a need to further develop the Integrated Performance Report to better align to good practice. Work is in progress to develop Service dashboards, which must align to the Trust’s strategic priorities and enable staff, when considering their performance at service level, to see how their performance contributes to that of the Trust.

• We found a lack of clear assurance reporting to the Board and Committees on the reliability of the data presented in performance reporting, partly explained by local teams creating their own reporting systems rather than using a single reporting system. As a result Board members during interview found it difficult to explain how they were assured about data quality.

7. Stakeholder engagement

• We received positive responses from external stakeholders and staff on the communication and engagement from the Trust, this included a positive view as to the impact of the current CEO and Executive Team on the engagement agenda. Whilst there are many mechanisms in place for patient, service user and carer engagement, there is a need to more clearly share this information more widely, particularly with non-clinical staff. Similarly there is room to improve the feedback loop with staff when seeking their views.

• Engagement with external stakeholders remains a high priority for the Trust and the Board is clear that they need to proactively manage relationships.


9

Executive summary (continued)

8. Learning, continuous improvement and innovation

• The Trust has a number of initiatives in place to support and recognise quality improvement and innovation and these are well received by staff. The monthly and annual Quality Awards and the interactive apps for induction represent good examples of these approaches. Based on our experience, the Trust benchmarks positively against other Mental Health Trusts by encouraging learning and development. A Quality Improvement methodology has been introduced with training and guidance available, which has been well received by staff.

• The Trust should consider opportunities for learning and good practice approaches to be shared further across the organisation, specifically across the Clinical Service Units.

Key recommendations and next steps

Throughout this Final Report, we have raised a number of recommendations, for consideration and approval by the Board, with a full summary included inAppendix 2 at page 29. Notable recommendations to address areas for development include:

R1: Assess whether the anomalies between Executive Director portfolios (compared to common practice) will present an issue to the future effectiveness of the Board.

R4: Design and implement a Board and an Executive Team development programme, focusing on dynamics, roles and responsibilities, shared priorities and reflecting the outcome of Board effectiveness reviews.

R14: Clarify the accountability between the corporate teams and the Clinical Service Units and Service leadership teams to ensure that governance arrangements are robust. This should form part of the Performance Management and Accountability Framework (see R18).

R15: Strengthen the Board horizon scanning processes, in order to ensure that emerging external risks are appropriately captured and considered.

R16: Introduce an Executive led risk management forum to consider and moderate corporate and operational Level 2 risks identified, creating an opportunity to corporately oversee risk across the Trust. This forum should undertake a complete thematic analysis, determine which services have or have not identified or reviewed their risks, and identify those single low scoring risks that may be across several services and therefore require escalation.

R18: Implement an Executive Director-led performance review cycle with Service leadership teams and corporate teams, supported by a clear Performance Management and Accountability Framework, based upon a model of ‘earned autonomy’.

R19: Develop Board performance reporting, with Board members actively discussing and influencing its content to ensure that it is an Integrated Performance Report, incorporating KPIs across finance, quality, workforce and performance. The report should be aligned to the Trust’s strategic priorities and should be supported by a pyramid of detailed reporting to Committees.

R20: Introduce a Data Quality Group with oversight of the quality of information being used internally and externally and membership from operational and corporate teams.

R24: Improve the communication of actions taken to address staff feedback, such as ‘You Said, We Did’ boards.

R26: Commission an independent review to assess progress of the recommendations within this report within the next nine months.

We suggest that the Chair and CEO, in consultation with the Board, consider the findings outlined within this Final Report and collectively agree a response to the matters raised. In particular, the Board should: define clear timescales for delivery; clearly align recommendations to Executive leads; and align groups of recommendations to the appropriate Committee to enable oversight of progress.


10

Key findings


11

Key findings Supporting information and evidence

Board stability and cohesion

• During interviews many talked positively about the stability of the Board after a number of difficult years, and the strength of the Executive Team appointments. The CEO, who has been in post for two years, has introduced new members to the team so that there is now a mix of new and established Executive Directors (EDs). Staff and external stakeholders commented that the Executive Team feels stable, open and able to guide the organisation through the next few years. Board members (BMs) responded positively to our survey about operating as a unitary Board (see graph opposite) and commented during interviews that there is trust between BMs and a willingness to solve problems together, which was lacking in past years.

• We observed the Board working together in an open and transparent style, with Non-Executive Directors (NEDs) providing some challenge, albeit impacted by the number of NEDs attending Board Committees (see section 4) and the lack of Trust-wide thematic reporting (see section 6). Rather than behaving consistently with their Corporate Director role, we also observed EDs limiting their contribution to their own portfolio area. This was compounded by the focus of the agenda on individual Director reports (see section 6) and the lack of ED-led performance management of the organisation (see section 5).

See related recommendations later in this section together with sections 4, 5 and 6.

Executive Director portfolios

• As part of our work we benchmarked the ED portfolios and identified some anomalies compared to common practice in other NHS organisations, and the Board should assure themselves that this will not present an issue in the future. These include:

• Medical Director portfolio - Safeguarding (commonly within the Director of Nursing and Patient Experience portfolio);

• Director of Nursing and Patient Experience - Clinical Audit (Medical Director); Health and Safety (sitting with Estates and Facilities); Business Continuity/Emergency Planning (Director of Operations).

• Furthermore, it is uncommon to have two Directors of Operations. We were informed that this was a recommendation of the Francis Report to ensure consistent and appropriate high level focus on high secure services. We understand the Board also wants a clear focus on the new Broadmoor Hospital development, however, some BMs and stakeholders commented that a single Director of Operations, supported by a robust Service leadership structure, may give more cohesion across services even though there are no shared patient pathways between Local Services and High Secure Services and we concur with this.

R1: Assess whether the anomalies between Executive Director portfolios (compared to common practice) will present an issue to the future effectiveness of the Board.

Board Visibility

• During our on-site work, many staff commented that BMs were very visible across the Trust, comparing favourably to other NHS organisations. We understand that each NED is expected to undertake one patient facing activity per month and there is a service visit feedback form that is used to close the loop to each service and for pertinent points to be included in the Chair’s Board report.

STAFF QUOTES:

“The senior members are visible on the shop floor”

“I'd say the NEDs are visible (and I like to think) approachable”

1. Leadership capacity and capability


Summary:

• After a number of difficult years, the Board has reached a point of stability under the leadership of the current CEO and, although the Board has good visibility within the organisation, this could be further enhanced. The level of challenge and debate at Board meetings could be improved with greater corporate oversight (see sections 4, 5 and 6). Benchmarking the Executive Director portfolios against common practice has highlighted some anomalies, which the Board should assure itself do not present any issues for the future.

• Given the recognised stability, the timing is now appropriate to develop a comprehensive Board and Executive Director team development programme, together with clear succession plans for the Board and Clinical Service Unit /Service leadership team roles.

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• In the past there has been a programme of visits throughout the year, co-ordinated by the Trust Secretary, and NEDs felt that this should be re-introduced and for EDs to join.

• The responses to our staff survey (see graph opposite) highlighted that staff were not as aware of BMs visiting non-clinical areas. BMs confirmed that service visits have traditionally focused on clinical areas.

• Although the Trust intranet, The Exchange, is used for publicising visits, Board visibility could be improved by enhancing the communication to staff that these visits take place with resulting changes.

R2: Re-invigorate the programme of NED service visits and develop to include EDs wherever possible. The programme should include clinical and non-clinical areas and be publicised.

Succession planning

• Although there is now a greater focus on leadership development at the Trust, many of those interviewed commented that succession planning throughout the organisation has been an area of weakness.

• Our BM survey responses have highlighted there is not a consistent view that the Board has considered future skills requirements and have succession plans in place (see graph opposite). There is currently a NED vacancy and from our interviews we understand that a skills gap analysis has not been undertaken and we could not glean a collective view on what skills and experiences the Board needs to deliver its strategy. Given the Trust’s focus on delivering integrated care and partnership working, we would expect to see some experience of this amongst the NED group.

• As the Trust continues its journey to encourage staff responsibility and accountability, Clinical Service Unit (CSU) and Service leadership teams need to consider the skills, experiences and capabilities required as the Trust determines its role in the integrated delivery of mental health and community services in the future. Determining clear succession plans should be a key part of this work.

R3: Develop succession plans for all Board, Clinical Service Unit and Service leadership roles, focusing on the skills and capacity required to ensure delivery of the Trust’s strategic objectives and also to promote greater diversity at Board level.

Board and Executive Team Development

• Whilst the cycle of Board meetings includes development sessions, focusing mainly on bringing BMs up-to-speed on key topics, many BMs commented that there was a need to regularly focus on ‘softer’ skills to improve team working, both amongst the Board and the Executive Team. This was felt to be important as many of the EDs are in their first Executive Director role and there are first time NHS NEDs. It was also felt that this should include opportunities to get to know each other, particularly as there are some new BMs (see graph opposite). This can be particularly helpful to build relationships between EDs and NEDs so that EDs can make more use of NED skills and experiences.

• We understand that the CEO has introduced Executive Team away days and some informal dinners. We also understand there are regular informal NED dinners to which the CEO joins on a quarterly basis, and there are twice yearly Board away days including dinner.

• In our experience, high performing Boards and Executive Director teams have a clear development programme that focuses both on ‘hard’ and ‘soft’ skills, including topics such as ‘assurance vs reassurance’, ‘what good challenge looks like’ and ‘team dynamics and business preferences’.

R4: Design and implement a Board and an Executive Team development programme, focusing on dynamics, roles and responsibilities, shared priorities and reflecting the outcome of Board effectiveness reviews.

1. Leadership capacity and capability (continued)


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Values

• The Trust’s vision and values are clear, well publicised and referred to in practice, which is supported by our staff survey results (see graph opposite). During our service visits, focus groups and interviews, staff spoke positively about the Trust values and demonstrated that these are embedded within the recruitment and retention processes. This compares favourably with other NHS organisations that we have worked with recently.

Corporate strategy

• Towards the end of 2017, the Trust refreshed their corporate strategy and also consulted widely about changing the name of the organisation to ensure it was in line with the Trust strategy to be an integrated organisation providing community and mental health care to the local population. The Board has agreed to change the name to West London NHS Trust, dropping ‘Mental Health’ from its name, and is currently following due legal process.

• During our focus groups, staff commented that they were aware of the name change, although felt there had been limited communication about timelines for the name change. We understand that this is, in part, due to the time taken to legally change the Trust’s name, however, staff could be given regular updates so that they are aware of the work going on.

• During our service visits, we found that very few staff were clear on the strategic objectives or priorities for the organisation, this included some of the more senior staff. The response to our staff survey (see graph opposite) also highlighted that staff did not feel that they had been engaged in the development and setting of the Trust strategy. In our experience, the development of a ‘strategy on a page’ is a useful tool for engaging staff with the corporate strategy, making it easily accessible to staff who can be clear on the strategic objectives. The Trust developed and disseminated a ‘strategy on a page’ in July 2017. Some Trusts have taken this a step further by encouraging Services to replicate the ‘strategy on a page’ to make it their own and demonstrate a clear link between the service objectives and the achievement of the overall strategy.

• The Board makes use of board development sessions in order to cover strategic discussions and decisions in more detail. Some BMs felt that greater emphasis could be put on the longer term strategicdirection, looking 5 – 10 years ahead rather than 2 – 3 years (see section 5).

• The Integrated Performance Report (IPR), which is received by the Board, is yet to be aligned to the strategic objectives. To this extent, although BMs felt that they monitored delivery against the strategy, there is no cohesive monitoring against progress (see further commentary in sections 5 and 6).

• Many external stakeholders commented that the Trust is also engaged within the STP planning and is a key partner in local partnership boards.

R5: Re-circulate the ‘strategy on a page’ for engaging and communicating the Trust’s strategic objectives and encourage leadership teams to replicate this at Service level.

2. Clarity of vision, strategy and plans to deliver


Summary:

• The Trust’s vision and values are clear, well publicised and referred to in practice, which compares favourable with other NHS organisations that we have worked with previously. The corporate strategy has recently been refreshed, however, we found that staff were not clear on the strategic objectives and priorities of the Trust. Furthermore, there is no cohesive monitoring of strategy delivery as the Integrated Performance Report is yet to be aligned to the strategic objectives.

• There is a need to more clearly align supporting strategies to the corporate strategy and to ensure that there are well defined arrangements for monitoring their delivery at Board and Committee level.

Good practice insights / potential solutions

Many Trusts find the development of a ‘strategy on a page’ to be a useful tool for engaging staff with the corporate strategy. This is then replicated to service level, to ensure that staff can visualise their role in their service plan for the future and its link to achieving the overall organisational strategy.

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Enabling strategies

• The Trust has a variety of enabling strategies such as the Estates strategy and the IM&T strategy that are current and align to the organisational strategy. There are, however, several enabling strategies that require further development particularly with respect to aligning to each other and the recently updated corporate strategy, implementation plans and embedding within the organisation including the Patient and Service User engagement strategy and the Communication strategy.

• The Workforce strategy has been developed and, to give greater oversight to the strategy implementation, the Trust have introduced a Workforce and Development Committee. The response to our BM survey (see graph opposite) suggested that there was not complete agreement that the Board has considered the necessary size and shape of the future workforce, and there were differences between ED and NED views on this statement. On discussion with BMs, many felt that the EDs were more aware of the work being done in this area. It is important that the whole Board understand and have ownership of issues such as the future size and shape of the workforce, especially given the shorter term issues of bank and agency staff usage experienced by the Trust.

R6: Review the supporting strategies in place or in development to ensure that they clearly identify how they will support and enable the successful delivery of key aims of the corporate strategy. It will also be important to ensure that the arrangements for monitoring and reporting of these supporting strategies is clearly defined.

2. Clarity of vision, strategy and plans to deliver (continued)


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Culture

• During our on-site work, staff spoke about the culture in the Trust promotes high quality care and they are encouraged to focus on care quality and safety. BMs commented that the Trust is on a journey of culture change, led by the CEO, encouraging staff to feel responsible and accountable (see section 5). The Board aims to have a patient or staff story at each Board meeting to ensure a focus on quality and safety.

• Furthermore, we received a range of feedback expressing a significant degree of support for the organisation, with the Trust being viewed as a good place to work. When speaking to staff working at Broadmoor Hospital, they described it as ‘their family’. Many staff told us that they feel valued and respected. However, this was not consistent throughout our work.

• As outlined in section 2, we received feedback that staff recognise the Trust’s values are well known and used. However, we also received some underlying messages regarding how well staff are held to account where behaviours are not in line with these values, particularly at middle and senior levels. This feedback is also shown in the results of our staff survey (see graph opposite). The Trust has developed a training programme ‘Leading by Example’ to equip managers with skills and support to deal with poor performance and behaviours.

R7: Assess the impact of the available training programmes designed to equip managers to deal with poor performance and behaviours at all levels of the organisation.

Raising concerns

• Where concerns related to patient safety, staff were very clear that this would be reported and taken seriously. This is also reflected in our staff survey results (see graph opposite). We understand that this has been an area of focus within the Trust as historically there has been low rates of incident reporting. This has improved over time, with a significant proportion of low or no harm incidents.

• During service visits and focus groups, some staff stated that there are times when there was no feedback or evidence of changes in practice as a result of incidents being reported.

R8: Strengthen the mechanisms for providing feedback and closing the loop where concerns are raised.

Development opportunities

• During our service visits, focus groups and interviews, staff consistently spoke about the development opportunities that were available to all levels of staff in the organisation. Some staff spoke of their concerns about limited career progression in some areas where there was a very stable senior workforce, for example, allied health professionals. These staff were not clear about succession planning within their teams.

See section 1 for recommendations relating to succession planning.

STAFF QUOTES:

“This feels like a listening, responding and open organisation in which to work”

“I do not believe that (across the board) staff are held accountable for their performance and behaviour. I think it depends on the area and the individual(s)”

“From a managers view - extreme difficulties with addressing staff's poor performance and behaviours”

3. Culture of high quality, sustainable care


Summary:

• High quality care is a priority for the Trust and this is recognised and shared by staff at all levels across the organisation. The Trust is generally seen as a good place to work and the culture is described as friendly and supportive. The Board has ensured a focus on equality and diversity, which is recognised in our staff survey results.

• Reporting of patient safety concerns has improved over time, although further improvement is required to provide feedback and ‘close the loop’ for those staff that raise concerns. Furthermore, processes for dealing with poor performance and behaviour, in line with the Trust values, need to be improved.

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Appraisals

• During our service visits, focus groups and interviews, staff reported that appraisals took place with a focus on the Trust values (see section 2). Although the recent NHS staff survey results show that the Trust is above the national average for the quality of appraisals, staff told us that the quality of appraisals was a concern. This was also noted in the Trust’s self-assessment and re-iterated by the results of our staff survey (see graph opposite), which highlights that appraisals are not always value adding, particularly for non-clinical staff.

As the Trust is already aware that this is an area for further focus, we have not suggested additional recommendations.

Equality and Diversity

• The Trust has focused attention on actively promoting equality and diversity. Recent innovations include: establishing a Black and Ethnic Minority Leadership forum, chaired by the CEO; creating Equality and Diversity Champions, who sit on senior staff panels; developing Unconscious Bias training sessions for all staff; and improvements in the Workforce Race Equality Standards. We understand that a Diversity strategy is being developed, which will bring together all of the equality and diversity work-streams, with implementation being monitored by the Workforce and Development Committee.

• The responses to our staff survey (see graph opposite, which includes benchmarking against other NHS organisations) also demonstrates the positive views of staff that equality and diversity are actively promoted at the Trust.

Staff Health and Wellbeing

• Some staff had knowledge of initiatives to promote staff health and wellbeing, for example, smoking cessation and a celebration of World Mental Health day, which focussed on mental health in the workplace. The Exchange, the Trust’s intranet site, was noted as a source of information for staff to access wellbeing services such as Occupational Health and Counselling.

• However, many staff commented on a lack of time and capacity to participate in wellbeing initiatives due to the staffing pressures, particularly those in clinical roles, and the responses to our staff survey (see graph opposite) were not wholly positive.

R9: Promote a range of health and well-being activities and ensure that, as much possible, staff have the capacity to access these initiatives, particularly those in clinical roles.

3. Culture of high quality, sustainable care (continued)


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4. Clarity of roles and responsibilities to support good governance


Summary:

• The Board Committee structure is in line with good practice; some enhancements could be made to the terms of reference of some Committees, including revising the membership so that the Trust Chair is not a regular member. Furthermore Committee assurance reporting (content, format and agenda position) could be improved to focus Board discussion on the risks to the strategic objectives. The purpose and effectiveness of the Trust Management Team should be reviewed to ensure it is fit for purpose.

• There is a lack of clarity about accountabilities between corporate teams and CSU and service level teams, with some arrangements demonstrating the Trust as an outlier. These need to be addressed as part of the recommended Performance Management and Accountability framework (see section 5).


Committee Structures and Assurance Reporting

• Our review of the Trust’s Board and Committee structures find them to be in line with what we would expect to see, with committee structures representing many elements of good practice. We also found Board Committees to have clear roles with effective delegation of responsibility for seeking deeper, more granular assurance on behalf of the Board.

• We found the Board Committees to be generally well chaired and to discharge their roles effectively. We also noted that there are arrangements for regular cross-attendance by Committee Chairs, for example the Finance and Performance Committee Chair attends the Quality Committee c3 times per year. Although BMs responded positively to our survey that Board Committees provide the Board with assurance and do not stray into managing the business (see graph opposite), we found that there is scope to improve the consistency of their escalation and reporting into the Board, and how effectively this is then used to drive debate.

• Each Committee provides a report to the Board, together with the minutes of the last meeting. Our observation of these reports is that they are a summary of the discussions rather than focusing on providing positive or negative assurance against the risks to the strategic objectives or escalating concerns. Furthermore, the reports are placed at the end of the board agenda.

• In our experience, Committee assurance reports are better placed alongside the respective Executive-led report, for example, the Integrated Performance Report is presented and the Finance and Performance Committee assurance report is then discussed. We note that the Board is already in the process of improving the Committee assurance reports and concur with this need (see section 5). Many Trusts find it helpful to have a short discussion at the end of each Committee to agree matters for assurance and escalation to the Board, which forms the basis of the assurance report.

R10: Review the Board agenda to ensure that Committee assurance reports, focused on providing assurance against the risks to the strategic objectives, are presented and discussed alongside the relevant Executive-led report.

Board Committee Terms of Reference (ToR)

• We have reviewed the Committee ToR against good practice ToR and found them to generally be in alignment. There are some enhancements that could be made including:

o Finance and Performance Committee – provide detailed scrutiny against CIPs, revenue and capital forward plans;

o Quality Committee - overseeing the trust’s policies and procedures with respect to the use of clinical data; promote a culture of open and honest reporting; to assure that there are processes in place that safeguard children and adults; and to ensure that processes are in place to ensure the escalation of risks from local and clinical unit risk registers to the Board Assurance Framework (BAF).

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4. Clarity of roles and responsibilities to support good governance (continued)


Key findings

• We have also benchmarked Committee membership. We note that the Trust Chair is a member of several Board Committees and the Trust is an outlier in this respect. The Trust Chair is a member of: Quality Committee; Finance and Performance Committee; Workforce & Development Committee; and the Charitable Funds Committee.

• In line with good practice, both within the NHS and other sectors, given that the Chair is ultimately the custodian of good governance within the organisation, we would not expect the Chair to be a member of any of the Board Committees or to regularly attend Board Committee meetings. It is considered good practice for the Chair to attend all Board Committees on a rolling basis as part of their governance oversight role. Our observation of the various Board Committees that took place during our on-site work was that the Chair was an active member of each Committee which may have affected the discussions. There is also a chance that this could impact the level of discussion at Board as several BMs, including the Chair, have been party to detailed discussions already.

R11: Review the Board Committee terms of reference in light of good practice enhancements that have been identified.

R12: Amend the membership of the Board Committee terms of reference to reflect attendance of the Trust Chair on a rolling basis only as part of their governance oversight role.

Trust Management Team (TMT)

• The Trust Management Team is chaired by the Chief Executive and is directly accountable to the Trust Board for the operational management of the Trust,including the achievement of statutory duties, standards, targets and other obligations, and the delivery of safe, effective, high quality patient care. It will inform and advise the Trust Board in setting and delivering the organisation’s strategic direction and priorities. TMT will promote effective two-way communication between the levels of senior management in the organisation.

• During our interviews, it became clear that those who attend TMT are not clear on its purpose and therefore whether it was effectively discharging its responsibilities. Several interviewees commented that it could be improved by having greater discussion about operational and strategic matters, actively sharing lessons and good practice rather than sharing information, which many felt was its purpose.

• As noted in section 5, the Board is reviewing its performance management arrangements and, in the process, will be reviewing the frequency of TMT meetings. This also provides an opportunity to review the purpose and ways of working of TMT.

R13: Review the purpose and effectiveness of the Trust Management Team and improve the ways of working to ensure that it is able to appropriately discharge its responsibilities and has a positive impact on the operational management of the Trust.

Clinical Service Unit Governance Arrangements

• The Board governance structures are replicated within each CSU with similar agendas and information being considered.

• During our interviews, numerous individuals commented on the lack of clarity about lines of accountability between the corporate teams and the CSU or Service teams. Several examples were cited:

o Clinical governance – a history of relationship issues between the corporate team and the CSU team, couple with varying levels of support within each CSU and Service. The current backlog of Serious Incident investigations within Local Services has, in part, being created by these issue;

o Business Intelligence – limited engagement between the corporate team and the CSU teams leading to a lack of clarity about responsibilities and workload. Furthermore, the Head of Knowledge Management who is responsible for the corporate team has no involvement in the appraisals for the devolved CSU analysts;

o Finance – the Finance Managers are line managed by the CSU with a professional line of accountability to the Director of Finance and Business. We were informed that the Director of Finance and Business is not formally involved in their appraisals. In our experience, we would expect to see a Finance Business Partner model with Finance staff line managed by the Director or Deputy Director of Finance and Business but aligned to a specific CSU. To this extent the Trust is an outlier within its model used by the Trust.

R14: Clarify the accountability between the corporate teams and the Clinical Service Unit and Service leadership teams to ensure that governance arrangements are robust. This should form part of the Performance Management and Accountability Framework (see R18).

19


Risk Management Arrangements

The Board Assurance Framework (BAF)

• The Board has a BAF, which is the Trust’s level one risk register comprising the risks to achievement of its strategic objectives. The BAF is received at each Board meeting and the strategic risks have also been allocated for oversight to the relevant Board Committees. Each Board Committee has a programme of risk ‘step-through’ by which specific strategic risks are reviewed in detail. This supports the positive responses to our Board survey (see graph opposite).

• A recent Internal Audit review of the BAF, the review concluded that whilst the BAF was fit for purpose and in general compared favourably to other Mental Health NHS Trusts, there was room to improve the assurances on the effectiveness of the controls and the gaps in assurance. The Trust is currently working to improve this, with a proposal submitted to the March 2018 Audit Committee that we observed. We concur with the proposals that were agreed (see also section 4 for Committee assurance reporting).

Given the work already being undertaken we have not suggested additional recommendations.

Horizon scanning

• During our interviews, some commented that whilst the Board and Board Committees regularly reviews the BAF and therefore have an awareness of the risks to the strategic objectives, these risks tend to be focused on those coming from within the organisation rather than from Board horizon-scanning discussions. In addition, some commented that the Board tends to focus on the short-term rather than the longer term, for example, focusing on the year ahead rather than looking 3-5 years into the future.

• Our review of the current BAF found no strategic risks related to emerging external risks, for example, relating to the Ealing Out of Hospital tender and the impact on the Trust’s strategy to be an integrated organisation, or the Sustainability and Transformation Plan impacting on North West London.

• Our experience of good practice from other organisations (see good practice insights opposite) is where Boards actively undertake work each year to consider and identify those risks to the successful delivery of their strategic priorities, both internal and external risks, and immediate short-term risks and longer term emerging risks.

R15: Strengthen the Board horizon scanning processes, in order to ensure that emerging external risks are appropriately captured and considered.

5. Management of risks, issues and performance



Boards that use their Board Assurance Framework more effectively actively undertake work each year to consider and identify those risks to the successful delivery of their strategic priorities. Where this works well it is driven by the Board and the BAF captures key sources of, or gaps in, assurance that these strategic risks are being effectively managed.

An effective way to ensure that the BAF is a live document is for the Executive level risk forum to take responsibility for any arising corporate risks which are, or have become, strategic in nature and to escalate these onto the BAF via Board.

Summary:

• Whilst there is a Board Assurance Framework and Level 1 risk register in place, supported by an electronic risk management system, the arrangements for escalation and corporate oversight of risk and horizon-scanning of emerging risks require further strengthening.

• Based on our experience, the Trust is an outlier as it does not have robust performance management arrangements for Service or corporate teams. In line with good practice, the introduction of a performance management and accountability framework through which these teams will be held to account for delivery will create a performance culture within the organisation that is supportive, challenging and transparent.

20


Risk Reporting and Risk Management

• During our service visits, focus groups and interviews, staff spoke confidently about being able to identify and escalate risks, and were very much aware of the Trust risk management system (IR1) accessed through the Trust’s intranet, The Exchange. This was reiterated by the positive responses to our staff survey (see graph opposite, including average benchmarking) together with responses about being aware of key risks that could have a negative impact on their area of the Trust.

• In addition, CSU staff spoke about discussing risk registers in monthly team and governance meetings, and we observed this during the CSU Senior Management Team (SMT) meetings. Staff also commented that the format of the IR1 system does not easily enable themed analysis for example across the risk register, incident reporting, complaints and claims.

• As part of our desktop review, we obtained an extract of the current Level 2 and 3 risk register and undertook some analysis. From this we found that 44% of risks had not been reviewed within 30 days, and 35% had not been reviewed for over 90 days. The mean elapsed time for risks not reviewed over 90 days was 198 days. This suggests that although teams are discussing their risk registers in meetings, this does not translate into actions being noted on the IR1 system or old risks being removed.

• Based on our experience, we consider good practice to include an Executive-led risk scrutiny forum, where all divisions (corporate and operational) come together to consider and moderate their risks, which results in ownership and engagement in risk management. This type of forum creates an opportunity to corporately oversee risk across the Trust, undertake a complete thematic analysis, determine which services have or have not identified or reviewed their risks, and identify those single low scoring risks that may be across several services and therefore require escalation.

• We observed that Internal Audit has engagement across the organisation to design and implement their annual audit plan, which focuses c70% of audit days on non-financial audits, as a source of assurance for the Board. In other Trusts, members of the Internal Audit team will regularly attend the Executive-led risk scrutiny forum.

R16: Introduce an Executive led risk management forum to consider and moderate corporate and operational Level 2 risks identified, creating an opportunity to corporately oversee risk across the Trust. This forum should undertake a complete thematic analysis, determine which services have or have not identified or reviewed their risks, and identify those single low scoring risks that may be across several services and therefore require escalation.

Quality Impact Assessments

• From our interviews with BMs, we understand that there is a process for reviewing the quality impact assessments for cost improvement programmes. This includes a quarterly review of 4 – 5 programmes pre, during and post implementation. This review is led by a NED with the Medical Director and Director of Nursing and Patient Experience in attendance.

• However, the responses to our staff survey highlight that staff are not as clear on either the process for assessing the potential impact on quality or that their views have been sought (see graph opposite). It is important that staff have the opportunity to engage with the quality impact assessment process and understand how this assessment is undertaken.

R17: Review and communicate the quality impact assessment processes to ensure staff can engage and influence the assessments.

5. Management of risks, issues and performance (continued)



An aspect of good practice in NHS risk management is to establish an executive-led risk management forum. The role of this group is to oversee assurance and reporting of the highest rated corporate risks within the organisation and ensure that systems and controls are in place to effectively manage these risks within the organisation. This group is also presents an important opportunity through which the corporate risk register can interface with the BAF, by identifying arising risks which have strategic implications and escalating them to Board / Committee as appropriate.

21


Performance Management

• When reviewing organisational performance (finance, quality, workforce, operational), there are a number of meetings where this takes place. These include: the three CSU SMT meetings (Local Services, High Secure Services, and West London Forensic Services), which are chaired by the respective CSU Executive Director; the Finance Oversight and Leadership Group (FOLG), which was established over the Summer to focus mainly on the Trust cost improvement programmes; and the Trust Management Team (TMT) meeting, which comprises the EDs and Clinical Directors with several Deputy Directors and Strategic Leads as attendees.

• Performance assurance oversight takes place at the Finance and Performance Committee, chaired by one of the NEDs, and also at the Board.

• During our on-site work, many interviewees commented that performance management was not a strength of the organisation and this was a perception echoed by some external stakeholders. Some staff referenced use of the Support and Intervention Plans, a process instigated where there are specific concerns within a service and led by a named ED; staff who had experienced this process commented that it was generally supportive and was welcomed. We understand that this process has been developed over recent years as part of the Trust’s cultural change journey to encourage staff to feel responsible and accountable.

• The response to our survey (see graph opposite, benchmarked against other NHS organisations) showed that BMs do not wholeheartedly agree that when corrective action is taken, changes made are embedded; recent examples include the identification and delivery of CIPs, bank and agency spend, and outstanding Serious Incident investigations.

• There is significant scope to improve accountability arrangements for Service and corporate teams at the Trust. This is in part due to the lack of a clear structure or process for holding to account for delivery. We did not observe this to happen effectively at TMT, and could find no other structure where this key function is being discharged, and particularly being led by the Executive Director team. The Trust is an outlier in this regard. Discussions with some of the Service leadership teams suggested that teams would welcome the opportunity to meet with the Executive Director team on a regular basis to share challenges and solutions.

• In March 2018, proposed changes were discussed at TMT to introduce at least bi-annual meetings between the EDs and each Service leadership team, to consider a holistic view of performance. In doing so, the frequency of FOLG and TMT would change to quarterly meetings.

• Whilst we concur that introducing Service performance review meetings with EDs is a positive step, this should be encompassed within a performance management and accountability framework that sets out the overarching principles (based on the Trust values) and approach to delivering a high performing organisation. In line with good practice, such a framework will help create a performance culture within the organisation that is supportive, challenging, transparent and proportionate based upon a model of earned autonomy. It should also be applicable to corporate teams as well as Service leadership teams.

R18: Implement an Executive Director-led performance review cycle with Service leadershipteams and corporate teams, supported by a clear Performance Management and Accountability Framework, based upon a model of ‘earned autonomy’.

Stakeholder Feedback

“Performance of the Services sits on the shoulders of CSU Executive Directorswithout full Executive ownership”

“Lack of operational grip let’s them down every time”

“There needs to be stronger performance management arrangements”

5. Management of risks, issues and performance (continued)



Performance Review

Effective performance and accountability structures can help not only to hold divisions to account, but also to bring divisions and the executive closer together, through common understanding of challenges and solutions.

Performance review meetings should be focussed on delivery of divisional plans, supported by clear dashboards aligned to priorities.

It is important to establish an appropriate tone for performance review meetings. Their core purpose should be to identify any risks to successful delivery and provide support to enable this where issues are identified.

22


Performance Reporting

• The Board and the Finance and Performance Committee receives an Integrated Performance Report (IPR) at each meeting, which largely displays information graphically with very limited supporting narrative. Whilst the IPR has been through some changes, for example, removing RAG rating and including use of run charts, further improvements could include:

‒ Alignment to the Trust’s strategic objectives;

- Consistent use of trajectories and forecasting;

- Inclusion of internal and external benchmarking information where available;

‒ Reference to NHS Improvement Single Oversight Framework metrics;

‒ Inclusion of thresholds for all reported metrics, with identification of the source of KPI (e.g. local, SOF, CQUIN); and

‒ Supporting narrative to clearly articulate the planned remedial actions and anticipated impact for all underperforming or deteriorating performance.

• This latter point was referenced several times during our interviews with BMs commenting that ‘we have lots of data but we don’t actually say what we’re doing about it’.

• The Board also receives a report from each Executive Director, including each of the CSU Directors. The Trust is an outlier in this respect as it is common practice for the IPR to be supplemented by thematic analysis such as patient experience and patient safety. This reiterates the lack of corporate oversight as noted in sections 1 and 5.

• In our experience, we would expect to see a pyramid of reporting with summary reports presented to Board and more detailed reporting being discussed at Committees. We understand that this happens for some Committees at the Trust, for example, the Finance and Performance Committee, however, many BMs commented that there is a sense of duplication between reporting to Board and Committees.

• BMs told us that they had not taken time as a Board to consider what metrics they would like to see in Board performance reporting, aligned to the delivery of the Trust’s strategic objective, although this hasbeen raised at recent Board meetings. There was also a view that the Trust’s commissioners were more interested in the Trusts’s KPIs than they were.

• In line with good practice, the Board need to build a performance reporting suite which is aligned in core content determined at Board level as being key to the delivery of the Trust’s strategic priorities and tailored to Service and CSU context.

• During our service visits we found some awareness of local performance amongst staff, in line with our staff survey responses (see graph opposite) however this was driven by managers rather than available performance reporting.

6. Information


Summary:

• Although progress has been made, there is a need to further develop the Integrated Performance Report to better align to good practice. Work is in progress to develop Service dashboards, which must align to the Trust’s strategic priorities and enable staff, when considering their performance at service level, to see how their performance contributes to that of the Trust.

• We found a lack of clear assurance reporting to the Board and Committees on the reliability of the data presented in performance reporting, partly explained by local teams creating their own reporting systems rather than using a single reporting system. As a result Board members during interview found it difficult to explain how they were assured about data quality.


Performance information at Board level has most impact when Board’s are active rather than passive in determining its content and presentation. We have observed some Boards to create time in their development programme to annually review the Integrated Performance Report to ensure that it continues to capture the key metrics which represent delivery of the organisation’s strategic priorities and that target thresholds continue to be both realistic and stretching. An effective means of further strengthening the embedding of the Trust’s strategic priorities is to align performance reporting to these from ward to Board. Ensuring that performance reporting is consistently presented at all levels, with common core content enables staff and leaders to more clearly see how the performance of their team, service or CSU is contributing to the overall performance of the Trust.

23


• At the time of our on-site work, the Trust was starting the processes of rolling out Tableau, a data visualisation software, across Services to enable staff to access performance reporting on a real time basis. This will also enable the production of Service dashboards, which are currently not available, although initially this will be for clinical data only.

• Discussions with service level leadership teams showed that teams were clear on the 4-5 KPIs that they monitored to test the ‘health’ of their services, their concern being that the information was not easily accessible from one place. These KPIs tended to be operational and quality metrics rather than a balanced set of KPIs including finance, workforce, quality and operations.

R19: Develop Board performance reporting, with Board members actively discussing and influencing its content to ensure that it is an Integrated Performance Report, incorporating KPIs across finance, quality, workforce and performance. The report should be aligned to the Trust’s strategic priorities and should be supported by a pyramid of detailed reporting to Committees.

Data Quality

• We saw limited information presented to the Board and Board Committees to provide assurance in relation to the data quality of the information being presented and reported externally. BMs were less clear as to how they were assured of the reliability of data during interview compared with other areasand this is borne out by the responses to our Board survey (see graph opposite and benchmarked against other NHS organisations).

• Furthermore, the majority of interviewees commented on the ‘need for a single version of the truth’ because there are known issues with teams setting up local data collection systems in reaction to the problems accessing performance information from the Trust systems. This has led to differences between Trust-level data and local team data and instances where local data has been shared externally without quality checking.

• The introduction of Tableau is seen as an answer by providing the ‘single version of the truth’ for all staff to use and access, although the Board are aware that there will still be an issue with getting data input correctly in the first instance. From our interviews we understand that there is a target date of the end of 2018/19 Q1 for all clinical data to be available on Tableau, however, discussions with Service leadership teams were at a very early stage during our onsite work.

• The Trust does not have a corporate team responsible for data quality, in terms of validation and training, however, we understand that the Local Services CSU has a small data quality team. The corporate knowledge management team has no oversight of this local team. Furthermore, we understand that the Trust does not have a Data Quality Group which is common practice in other Trusts, to bring together operational and corporate teams to have oversight of the quality of information being used internally and externally.

R20: Introduce a Data Quality Group with oversight of the quality of information being used internally and externally and membership from operational and corporate teams.

R21: Develop and implement a rolling programme of data quality testing and audit focussed on key internally and externally reported indicators. Consideration should be given to kite marking Board KPIs based upon the outcome of this activity.

6. Information (continued)



A number of Trust’s have adopted a kite marking system, incorporate within the Board performance report, to demonstrate the data quality of each indicator against the 6 elements of good data quality. Good practice would see this based upon an internally resourced, rolling programme of data quality testing and audit.

24


Patient, Service User and Carers

• The Board start their meetings with a patient or service user story. We did not observe the service user story at the Board meeting we observed as it took place later in the day at a development session held in the secure part of Broadmoor Hospital. BMs commented that they find these stories helpful.

• During our service visits and focus groups, staff were able to give examples of patient, service user and carer engagement, for example, all inpatient areas had a patient forum or council. Similarly, staff were able to give examples of changes that had been made as a result of feedback, such as the co-production of service user information. Furthermore, we observed several ‘You Said, We Did’ boards during our service visits. These comments and examples were not reflective of the responses to our staff survey (see graph opposite), which were less positive. The responses also highlighted the knowledge differences between clinical and non-clinical members of staff.

• The Trust has a bi-monthly Service User and Carer Engagement committee, co-chaired with a service user and the Director of Nursing and Patient Experience co-chairs, which was felt to be positive. The Trust has recently introduced the Triangle of Care, developed by the Carer’s Trust, for engaging with patients, service users and carers.

R22: Identify suitable methodologies for replicating and sharing areas of good practice in patient, service user and carer engagement activities across the Trust. This should include improving communication about engagement to non-clinical staff.

Staff

• Staff we spoke to were positive about the Trust as a place to work and generally felt the Trust to be a good employer. The 2017 staff survey results show that all areas have either improved or maintained their level of performance.

• Staff commented that they enjoyed reading the CEO blog and welcomed the guest bloggers such as the Director of Finance and Business recently. Staff also commented that NEDs could be invited to write a guest blog to help with visibility.

• The results of our staff survey showed that staff recognised that the Trust regularly seeks feedback from staff; however, actions taken as a result of that feedback and being able to give examples of changes made showed much less positive responses. This demonstrates a need to improve the communication of actions taken to address staff feedback. Based on our experience, utilising similar methods to communicating with patients and service users works well, for example, ‘You Said, We Did’ boards in areas with high staff footfall as well as the Trust intranet.

R23: Improve the communication of actions taken to address staff feedback, such as ‘You Said, We Did’ boards.

7. Stakeholder engagement


Summary:

• We received positive responses from external stakeholders and staff on the communication and engagement from the Trust, this included a positive view as to the impact of the current CEO and Executive Team on the engagement agenda. Whilst there are many mechanisms in place for patient, service user and carer engagement, there is a need to more clearly share this information more widely, particularly with non-clinical staff. Similarly there is room to improve the feedback loop with staff when seeking their views.

• Engagement with external stakeholders remains a high priority for the Trust and the Board is clear that they need to proactively manage relationships

25


External stakeholders

• External stakeholders were consistent in their views that the Trust’s reputation is improving under the current CEO and ED team, finding them to be more engaging, open and transparent. Comments were made such as:

“There’s a will to engage and integrate and improve”

“The CEO is a proactive leader, taking the team from strength to strength. She is taking staff with her”

“They have spent time building relationships”

“There are positive relationships re the integrated care agenda”

“They are good at partnership working and contribute well to partnerships”

“The Board is getting better at involving stakeholders earlier”

“They had good clinical engagement with the Red to Green initiative”

• However, a number of external stakeholders expressed some concerns about a lack of knowledge about the Trust’s strategy and the Trust’s ability to consistently deliver operational performance:

“I don’t really know anything about their strategy”

“We know about their planned name change but not their strategy”

“They haven’t sought our views on how they could position themselves locally”

“We feel like our relationship is remote; we’ve tried to engage with them but not sure they see that its important”

“The Trust has good intentions but they’re not so good at implementation”

“We can see changes but is it embedded?”

• When discussing this feedback with BMs, there was a view that the Board need to better at managing expectations with all stakeholders, both internal and external. This was particularly the case when needing to explain about barriers and obstacles to making service changes. Furthermore, there was a view that the Board needs to be better at telling their story to external stakeholders and a sense that the Board had ‘missed a trick’ to manage their regulators.

• The results from our Board survey showed that the Board were very positive that they had a strong external focus, proactively influencing and responding to key partners in the local health economy (see graph opposite).

R24: Review the external stakeholders communications approach to ensure that external stakeholders are proactively managed at the right level and a consistent story is told.

7. Stakeholder engagement (continued)


26


Focus on continuous learning and improvement, and support to innovate

• The culture for continuous learning and development across the organisation is mostly viewed as positive and geared towards innovation. The responses to our staff survey (see graph opposite) is largely positive that the Trust encourages learning and development. We have also used benchmarked against other NHS organisations (see graph opposite), which shows that responses were slightly more positive than average responses.

• The monthly and annual staff awards, the ‘Quality Awards’, include categories for innovation and quality improvement and are well regarded by staff across the organisation. Several examples of innovation were mentioned during our service visits, focus groups and interviews including the use of apprenticeships and interactive apps for induction (particularly for HR topics), and the Nursing Conference, using external speakers.

• Staff also commented positively about the number of training and development courses available, such as ‘Leading by Example’, and that reflective practice is fully embedded within wards. Furthermore, bitesize learning opportunities have been developed by HR to enable staff to receive ‘just in time’ learning.

• The Trust have a Quality Improvement (QI) methodology which is applied under the guidance of the Medical Director and the Director of Local Services. QI training courses are widely available and we found good awareness of the training and the QI methodology across staff groups.

• The current approach to addressing and tracking CQC recommendations has built confidence amongst BMs. Under the leadership of the new Director of Nursing and Patient Experience, the work to address the 2017 CQC recommendations has had greater pace, rigour and effectiveness than the previously developed action plan, now taking a more strategic approach to addressing the concerns raised.

• A number of regular newsletters are used to share learning from incidents, for example the Medical Director and Director of Nursing and Patient Experience monthly newsletters and the Safety Bulletin, as well as CSU SMTs being used as a forum for sharing. During the last year, the Board commissioned an external review of the human factors involved in Serious Incidents and staff and BMs alike commented that this had been helpful, particularly when considering the actions required from investigations going forward. We also received feedback from our service visits and focus groups that staff would value more opportunities to share good practice and learning across the CSUs and Services.

• Both internal and external stakeholders referenced the backlog of Serious Incident investigations that the Trust has been dealing with for some time, and the impact this is having on the Trust’s ability to identify lessons learnt and disseminate learning across the organisation.

R25: Identify opportunities to share good practice and learning across the Clinical Service Units.

8. Learning, continuous improvement and innovation


Summary:

• The Trust has a number of initiatives in place to support and recognise quality improvement and innovation and these are well received by staff. The monthly and annual Quality Awards and the interactive apps for induction represent good examples of these approaches. Based on our experience, the Trust benchmarks positively against other Mental Health Trusts by encouraging learning and development. A Quality Improvement methodology has been introduced with training and guidance available, which has been well received by staff.

• The Trust should consider opportunities for learning and good practice approaches to be shared further across the organisation, specifically across Clinical Service Units.


Examples of ways to focus on continued learning and improvement, and supporting innovations include: #yesyoucan innovate monthly reward scheme; nominations for regional and national awards; herograms; and presentations to the Quality Committee from services that are implementing a change.

27

Appendices


28

Glossary of terms

Appendix 1


AC Audit Committee

BAF Board Assurance Framework

BME Black and Minority Ethnic

BMs Board members

CEO Chief Executive Officer

CSU Clinical Service Unit

EDs Executive Directors

IPR Integrated Performance Report

KLOE Key lines of enquiry

KPI Key performance indicators

NEDs Non-Executive Directors

QI Quality Improvement

SMT Senior Management Team

STP Sustainability and Transformation Plan

ToR Terms of Reference

TMT Trust Management Team


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Summary of recommendations

Appendix 2

Set out below is a summary of the recommendations contained within this report, including a reference to the section to which they relate. Recommendations for improvements should be assessed by the organisation for their full impact before they are implemented.


KLOE # Recommendation

1

1Assess whether the anomalies between Executive Director portfolios (compared to common practice) will present an issue to the future effectiveness of the Board.

2Re-invigorate the programme of NED service visits and develop to include EDs wherever possible. The programme should include clinical and non-clinical areas and be publicised.

3Develop succession plans for all Board, Clinical Service Unit and Service leadership roles, focusing on the skills and capacity required to ensure delivery of the Trust’s strategic objectives and also to promote greater diversity at Board level.

4Design and implement a Board and an Executive Team development programme, focusing on dynamics, roles and responsibilities, shared priorities and reflecting the outcome of Board effectiveness reviews.

2

5Re-circulate the ‘strategy on a page’ for engaging and communicating the Trust’s strategic objectives and encourage leadership teams to replicate this at Service level.

6Review the supporting strategies in place or in development to ensure that they clearly identify how they will support and enable the successful delivery of key aims of the corporate strategy. It will also be important to ensure that the arrangements for monitoring and reporting of these supporting strategies is clearly defined.

3

7Assess the impact of the available training programmes designed to equip managers to deal with poor performance and behaviours at all levels of the organisation.

8 Strengthen the mechanisms for providing feedback and closing the loop where concerns are raised.

9Promote a range of health and well-being activities and ensure that, as much possible, staff have the capacity to access these initiatives, particularly those in clinical roles.


30

Summary of recommendations (continued)

Appendix 2

Set out below is a summary of the recommendations contained within this report, including a reference to the section to which they relate. Recommendations for improvements should be assessed by the organisation for their full impact before they are implemented.



4

10Review the Board agenda to ensure that Committee assurance reports, focused on providing assurance against the risks to the strategic objectives, are presented and discussed alongside the relevant Executive-led report.

11 Review the Board Committee terms of reference in light of good practice enhancements that have been identified.

12Amend the membership of the Board Committee terms of reference to reflect attendance of the Trust Chair on a rolling basis only as part of their governance oversight role.

13Review the purpose and effectiveness of the Trust Management Team and improve the ways of working to ensure that it is able to appropriately discharge its responsibilities and has a positive impact on the operational management of the Trust.

14Clarify the accountability between the corporate teams and the Clinical Service Unit and Service leadership teams to ensure that governance arrangements are robust. This should form part of the Performance Management and Accountability Framework (see R18).

5

15 Strengthen the Board horizon scanning processes, in order to ensure that emerging external risks are appropriately captured and considered.

16

Introduce an Executive led risk management forum to consider and moderate corporate and operational Level 2 risks identified, creating an opportunity to corporately oversee risk across the Trust. This forum should undertake a complete thematic analysis, determine which services have or have not identified or reviewed their risks, and identify those single low scoring risks that may be across several services and therefore require escalation.

17 Review and communicate the quality impact assessment processes to ensure staff can engage and influence the assessments.

18Implement an Executive Director-led performance review cycle with Service leadership teams and corporate teams, supported by a clear Performance Management and Accountability Framework, based upon a model of ‘earned autonomy’.


31

Summary of recommendations (continued)

Appendix 2



6

19Develop Board performance reporting, with Board members actively discussing and influencing its content to ensure that it is an Integrated Performance Report, incorporating KPIs across finance, quality, workforce and performance. The report should be aligned to the Trust’s strategic priorities and should be supported by a pyramid of detailed reporting to Committees.

20Introduce a Data Quality Group with oversight of the quality of information being used internally and externally and membership from operational and corporate teams.

21Develop and implement a rolling programme of data quality testing and audit focussed on key internally and externally reported indicators. Consideration should be given to kite marking Board KPIs based upon the outcome of this activity.

7

22Identify suitable methodologies for replicating and sharing areas of good practice in patient, service user and carer engagement activities across the Trust. This should include improving communication about engagement to non-clinical staff.

23 Improve the communication of actions taken to address staff feedback, such as ‘You Said, We Did’ boards.

24Review the external stakeholders communications approach to ensure that external stakeholders are proactively managed at the right level and a consistent story is told.

8 25 Identify opportunities to share good practice and learning across the Clinical Service Units.

Whole Report

26 Commission an independent review to assess progress of the recommendations within this report within the next nine months.


32

Board survey analysis

Appendix 3


Question SA A SA SD D SD CS

1 I can articulate the strategic priorities that have been agreed by the Board to deliver the vision. 5 11 0 0 0 0 0

2 I can explain how the strategic priorities will be progressed this year. 4 11 1 0 0 0 0

3 Our strategy is based upon clear consultation with key internal and external stakeholders. 5 9 2 0 0 0 0

4 As a Board, we have considered the necessary size and shape of our future workforce. 2 9 3 2 0 0 0

5 There are clear mechanisms in place to disseminate strategic objectives throughout the Trust. 5 5 6 0 0 0 0

6I am assured that risks are appropriately identified and controlled and can provide evidence of that assurance if required.

2 13 1 0 0 0 0

7 I can clearly articulate the top 5 risks within the organisation’s internal and external environment. 5 8 3 0 0 0 0

8There are clear mechanisms in place to monitor the impact of Cost Improvement Programmes before, during and after their implementation.

5 8 3 0 0 0 0

9I am clear on the role of the Board and its committees in relation to risk management, including the Board Assurance Framework.

9 7 0 0 0 0 0

10 The Board gets the balance right between supporting and challenging one another. 7 8 1 0 0 0 0

11 We operate as a unitary Board. There are no factions. 10 6 0 0 0 0 0

12 The Board has the right blend of experience, knowledge and skills to oversee the implementation of the Board’s vision. 8 6 2 0 0 0 0

13 As a Board we have considered our future skills requirements and succession plans are in place. 2 6 3 4 0 0 1

14All Board members act as Corporate Directors, demonstrating the ability to think strategically and contribute to areas outside their specialist field.

4 11 1 0 0 0 0

15 The backgrounds and skills of the Board are sufficiently diverse. 4 7 5 0 0 0 0

16 Board members spend sufficient informal time together as a group to get to know one another better. 4 5 4 2 1 0 0

17 The Chair and Chief Executive Officer work effectively together. 6 10 0 0 0 0 0

18 As a Board member I feel able to say what I am thinking and can openly express any doubts or uncertainties. 11 4 1 0 0 0 0

19Non-Executive Directors are involved sufficiently early in issues in order for them to make a meaningful contribution to the organisation.

4 8 4 0 0 0 0

20I am confident that the Board will oversee the successful implementation of the actions arising from this review / survey.

9 7 0 0 0 0 0


33

Board survey analysis (continued)

Appendix 3



21 Staff have appropriate opportunities to present to the Board. 4 8 4 0 0 0 0

22 I have objectives that clearly focus on my role as a Board Member. 5 6 4 1 0 0 0

23 I can demonstrate that the Board has sought to learn from other organisations. 5 6 4 1 0 0 0

24 The Board’s committees provide the Board with assurance and do not stray into managing the business. 2 13 1 0 0 0 0

25 There is minimal duplication between the work of the various Board-level committees. 0 9 5 2 0 0 0

26 Sub-groups provide appropriate support to enable effective delegation to occur. 2 7 6 1 0 0 0

27 The process by which committees highlight key issues and escalate decisions to be made to the Board is effective. 3 10 3 0 0 0 0

28 When corrective action is taken, changes made are embedded. It is rare for our Trust to have issues which reoccur. 0 3 9 2 1 0 1

29 When performance slips it is clear how the Board will monitor the progress of the corrective actions taken. 1 9 6 0 0 0 0

30 After a decision has been made by the Board it is clear who is responsible for implementing it and by when. 4 10 2 0 0 0 0

31 Staff receive appropriate and timely responses to issues raised to the Board. 2 5 7 0 0 0 2

32The Board has a strong external focus, proactively influencing and responding to key partners in the local health economy.

4 11 1 0 0 0 0

33 The performance information I receive as a Board member enables me to effectively hold management to account. 3 12 1 0 0 0 0

34 It is very rare for the Board to be made aware of an issue by an external party that it was not already aware of. 3 11 1 1 0 0 0

35 We seek to triangulate the information we receive at Board with other sources. 3 11 1 1 0 0 0

36 We spend appropriate time as a Board analysing performance to make our NHS Improvement self-declaration. 3 12 1 0 0 0 0

37 I am assured of the quality of data used in Board reporting. 0 6 10 0 0 0 0


34

Staff survey analysis

Appendix 3



1 I am aware of members of the Board visiting non-clinical areas. 36 45 30 15 47 40 18

2 I am aware of members of the Board visiting service or patient areas. 59 67 24 16 26 28 11

3 I know who the Executive members of the Board are. 68 54 40 19 26 23 1

4 I know who the Non-Executive members of the Board are. 39 48 40 31 42 29 2

5 Leaders at every level are visible and approachable. 22 48 44 31 39 39 8

6 I am aware of the Trust’s vision. 60 79 50 16 17 8 1

7 The Trust has a clear set of values. 67 101 35 9 10 7 2

8 The strategic priorities for the Trust have been clearly communicated to me. 30 67 54 32 24 24 0

9 I understand how my personal objectives contribute to the Trust’s strategic objectives. 33 71 45 20 31 27 4

10 I have been engaged in the development and setting of the Trust strategy. 14 28 31 23 54 70 11

11 The standards of behaviour that are expected from staff are clear. 51 102 30 12 21 15 0

12 Staff at all levels are held to account for poor performance and behaviours. 21 48 42 28 38 47 7

13 I know how to raise concerns when I think quality has been compromised. 57 114 34 6 9 7 4

14 I am able to access training to enable me to deliver my role effectively. 70 104 29 15 3 10 0

15 My annual appraisal is value adding. 31 56 44 23 32 29 16

16

The Trust ensures there are a variety of methods and activities available for staff which help to promote their wellbeing. 31 56 71 23 33 13 4

17 Equality and diversity are actively promoted at the Trust. 55 80 44 17 18 13 4

18 I am clear on my role and accountabilities. 78 108 25 12 6 2 0

19 I know how to effectively identify and escalate a risk. 82 110 27 7 2 2 1

20 I am aware of the key risks that could have a negative impact in my area of the Trust. 75 111 23 11 3 5 3


35

Staff survey analysis (continued)

Appendix 3



21 There is a clear process which allows cost improvement initiatives to be assessed for their potential impact on quality. 18 31 37 37 32 39 37

22 I have been asked for my views on the impact on quality of a cost saving initiative in my work area. 21 29 20 34 42 70 15

23 My ward/department holds regular team meetings. 115 67 20 7 6 14 2

24 I attend or receive information about these meetings. 111 66 19 8 6 18 3

25 I am provided with meaningful information which helps improve performance in my part of the Trust. 39 68 51 25 21 24 3

26 I understand how my specialty performs in relation to other similar services in this Trust. 40 59 45 24 20 24 19

27I understand how the performance of my own area of the Trust contributes to the performance of the whole organisation.

48 74 48 22 15 18 6

28 Information technology systems are used effectively to monitor and improve the quality of care. 23 49 49 29 32 36 13

29 The Trust regularly seeks feedback from staff. 35 58 55 32 25 22 4

30 Actions are taken as a result of staff feedback. 21 35 46 37 36 41 15

31I am encouraged to contribute new ideas to improve our services and have been engaged in key service developments/changes.

41 51 46 31 23 31 8

32 I could give examples of changes that have been made as a result of staff feedback. 24 33 40 37 40 32 25

33 I could give examples of changes that have been made as a result of patient and service user feedback. 26 38 42 37 32 25 31

34 I am encouraged to contribute new ideas to improve our services. 42 58 45 36 18 26 6

35 This is a Trust that encourages learning and development. 58 74 47 18 15 15 4

36 Learning from internal and external reviews is shared effectively and used to make improvements. 26 61 54 36 21 24 9


36

Basis of this Review

Appendix 4

The enclosed Final Report has been prepared principally from information supplied by and obtained from discussions with the Board, staff, and stakeholders and a review

of documentation pursuant to the scope of the work agreed in the engagement letter dated 5 January 2018. You are responsible for determining whether the scope of

our work specified is sufficient for your purposes and we make no representation regarding the sufficiency of these procedures for your purposes. If we were to perform

additional procedures, other matters might come to our attention that would be reported to you. This Final Report should not be taken to supplant any other enquiries

and procedures that may be necessary to satisfy the requirements of the recipients of this Final Report. You will appreciate that our work was not designed to identify all

matters that may be relevant to you and this Final Report is not necessarily a comprehensive statement of all weaknesses which may exist in the governance of the

organisation or of all improvements which may be made,

Our work, which is summarised in this Final Report, has been limited to matters which we have identified that would appear to us to be significant within the context of

the scope. In particular, this Review will not identify all of the gaps that exist in relationship to the Trusts approach to governance; rather the review will seek to consider

performance in the areas outlined in the scope and to identify the most material gaps or areas where insufficient evidence may give rise to the identification of material

gaps in the future.

We have not undertaken a detailed review of the skills, competencies and expertise of individual Board and Committee Members. Further, we have not undertaken: a

detailed review of the effectiveness or appropriateness of the governance structure or framework; management information; the level of company secretarial resources;

the IT systems; or the appropriateness of any strategy or risk document.

This work does not constitute an internal audit in accordance with relevant UK Chartered Institute of Internal Auditors – UK and Ireland Standards and Guidance. As

agreed with you in our engagement letter, unless otherwise stated in our Final Report, we have not sought to verify the information contained herein nor to perform the

procedures necessary to enable us to express an audit opinion on any of the financial or non-financial information contained in this Final Report. Indeed, as you will

appreciate, much of the additional, non-financial information contained in this Final Report cannot be subjected to audit or otherwise independently verified.

This Final Report has been prepared in accordance with the terms of our contract with West London Mental Health Services NHS Trust dated 5 January 2018 (“the

Contract”), and is subject to the restrictions on use specified in the Contract. No party other than West London Mental Health Services NHS Trust is entitled to rely on

this Final Report for any purpose whatsoever and we accept no responsibility or liability to any party other than West London Mental Health Services NHS Trust in respect

of the contents of this Final Report. Should you wish to make this Final Report available or communicate it to any other party you will require our prior written

permission, which will not be unreasonably withheld. All copyright and other proprietary rights in the Final Report remain the property of Deloitte LLP and any rights not

expressly granted in these terms or in the Contract are reserved. This Final Report and its contents do not constitute financial or other professional advice. Specific

advice should be sought about your specific circumstances. To the fullest extent possible, both Deloitte LLP and West London Mental Health Services NHS Trust disclaim

any liability arising out of the use (or non-use) of the Final Report and its contents, including any action or decision taken as a result of such use (or non-use).

This Final Report is dated 2 May 2018 and may only be relied upon in respect of the matters to which it refers. In relying upon this Final Report, you agree that we have

no responsibility to and we will not perform any work subsequent to the date of the Final Report nor to consider, monitor, communicate or report the impact upon

governance arrangements of any events, circumstances or inaccuracies which may in future occur or may come to light subsequent to the date of the Final Report

(“Subsequent Events”).


This document is confidential and is not to be copied or made available to any other party. Deloitte LLP does not accept any liability for use of or reliance on the contents of this document by any person save the intended recipient(s) to the extent agreed in a Deloitte LLP engagement contract.

Deloitte LLP is a limited liability partnership registered in England and Wales with registered number OC303675 and its registered office at 2 New Street Square, London EC4A 3BZ, United Kingdom.

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© 2018 Deloitte LLP. All rights reserved.

Deloitte confidential: Public sector - for approved external use - Draft Report

1

West London Mental Health NHS Trust Deloitte Development Review of Leadership and Governance Using the Well-led Framework Recommendations and Action Plan No. Recommendation Trust’s response Responsible and

end date Progress

1 Assess whether the anomalies between Executive Director portfolios (compared to common practice) will present an issue to the future effectiveness of the Board

Current portfolios (separate ED for High Secure Services) are as a result of recommendations from the Francis Report and the need for balanced portfolios. The current structure supports the Trust to achieve its business. No immediate plans to change although review regularly takes place at PDRS and when vacancies arise.

CE Ongoing

2 Re-invigorate the programme of NED service visits and develop to include EDs wherever possible. The programme should include clinical and non-clinical areas and be publicised.

Re-establishment of NED visits to be finalised by July 2018. EDs visit via Listening Events. Non-clinical areas are included in Listening Events. Review to take place on commencement of Interim Director of Communications and Engagement.

Director of Comms and Engagement July 2018

3 Develop succession plans for all Board, Clinical Service Unit and Service Leadership roles, focusing on the skills and capacity required to ensure delivery of the Trust’s strategic objectives and also to promote greater diversity at Board level.

Recruiting and Retaining talent programme in place includes specific roles for talent management succession. All executive roles to be considered via PDR process. All clinical directors and clinical service unit managers to be considered via PDR process with CSUs. A standard template to be made available. BME leadership development programme in place.

Director of Workforce Directors of CSUs September 2018

4 Design and implement a Board and Executive team development programme, focusing on dynamics,

Board development programme already in place. Executive awayday programme and

Chairman CE

2

roles and responsibilities, shared priorities and reflecting the outcomes of the Board effectiveness reviews.

informal dinners already in place. All Executives undertake personal development. Board effectiveness feedback generally positive about how the Board conducts itself. Review of development programme content to take place.

August 2018

5 Develop a ‘strategy on a page’ for engaging and communicating the Trust’s strategic objectives and encourage leadership teams to replicate this at Service level.

The Trust has a ‘strategy on a page’ which was created last July, disseminated in the Trust and as part of the consultation, and a copy provided to the Deloitte team. Consideration of further communication of strategy on a page to take place. Clinical strategy being prepared.

Director of Comms and Director of Strategy and Business July 2018 September 2018

6 Review the support strategies in place or in development to ensure that they clearly identify how they will support and enable the delivery of key aims of the corporate strategy. It will also be important to ensure that the arrangements for monitoring and reporting of these supporting strategies are clearly defined.

Work already in place to take this forward. Director of Strategy and Business June 2018

7 Improve processes for dealing with poor performance and behaviours at all levels within the organisation, including delivering a programme of training to equip managers at all levels with the skills and support to undertake this.

Lead by Example programme in place. 2 Hours 2 Learn and coaching programmes in place. Review of process for managing conduct in place.

Director of Workforce July 2018

8 Strengthen the mechanisms for providing feedback and closing the loop where concerns are raised.

It is understood this recommendation relates to staff feedback. Listening Events are in place and the outcomes are on the Exchange. Speak Up Guardian in place. More regular feedback from Listening Events to be provided. Speak Up Guardian

Director of Comms July 2018 Director of Workforce

3

staff champions to be recruited. August 2018 9 Promote a range of health and well-being activities

and ensure that, as much as possible, members of staff have the capacity to access these initiatives, particularly those in clinical roles.

The Trust is undertaking a self-diagnosis of the wellbeing support provided via the DH wellbeing self-diagnostic tool.

Director of Workforce July 2018

10 Review the Board agenda to ensure that Committee assurance reports, focusing on providing assurance against the risks to the achievement of the strategic objectives, are presented and discussed alongside the relevant Executive-led report.

Minor amendment to agenda order to be implemented.

Acting Trust Secretary July 2018

11 Review the Committee terms of reference in light of good practice enhancements that have been identified.

Committee terms of reference are reviewed annually. Deloitte recommendations to be included.

Acting Trust Secretary with Committee chairs October 2018

12 Amend the membership of the Board (sub?) Committee terms of reference to reflect attendance of the Trust Chair on a rolling basis only as part of their governance oversight role.

This action is understood to refer to the Board sub committees. Terms of reference to be reviewed.

Acting Trust Secretary Committee chairs October 2018

13 Review the purpose and effectiveness of the Trust Management Team (meeting?) and improve the ways of working to ensure that it is able to appropriately discharge its responsibilities and has a positive impact on the operational management of the Trust.

Decision made to reduce number of meetings to quarterly. To introduce performance management meetings for each service line on a quarterly basis.

Chief Executive May 2018

14 Clarify the accountability between the corporate teams and the Clinical Service Unit and Service Leadership teams to ensure that governance arrangements are robust. This should form part of the Performance Management and Accountability

Agreed to introduce a performance management framework with effect from May 2018. Clarification of relationships between Clinical Governance teams and between

Chief Executive May 2018 Director of Finance and

4

Framework. Finance and Business Intelligence Teams and the CSUs to be undertaken.

Business Director of Nursing July 2018

15 Strengthen the Board horizon scanning processes, in order to ensure that emerging external risks are appropriately captured and considered.

. Horizon scanning sessions to be included in regular Executive away day sessions.

Chief Executive Quarterly as of August 18

16 Introduce an Executive led risk assessment management forum to consider and moderate corporate and operational level 2 risks identified, creating an opportunity to corporately oversee risk across the Trust. This forum should undertake a complete thematic analysis, determine which services have or have not identified or reviewed their risks, and identify those single low scoring risks that may be across several services and therefore require escalation.

First level review to be undertaken by Director of Local Services and by Director of Forensic and High Secure Services. Further review to be undertaken of whole Trust by Executive Directors on regular away day sessions. To be included in monthly performance management sessions.

Chief Executive Quarterly

17 Review and communicate the quality impact assessment processes to ensure that staff can engage and influence the assessments.

Review of how to take this recommendation forward to be undertaken.

Director of Finance and Business, Director of Nursing, Medical Director July 2018

18 Implement an Executive Director-led performance review cycle with Service leadership teams and corporate teams, supported by a clear Performance Management and Accountability framework, based upon a model of ‘earned autonomy’.

Agreed to introduce a performance management framework with effect from May 2018. Further work will be required to develop an Accountability Framework and examples of any successfully in place in other trusts would be welcome.

Chief Executive May 2018 September 2018

5

Recruitment Board including CSU representation to be implemented.

Director of Workforce May 2018

19 Develop Board performance reporting, with Board members actively discussing and influencing its content to ensure that it is an Integrated Performance Report, incorporating KPIs across finance, quality, workforce and performance. The report should be aligned to the Trust’s strategic priorities and should be supported by a pyramid of detailed reporting to committees.

The Board performance report includes KPIs for workforce and performance and some quality measures. Further work is taking place to update all of the KPIs in the context of the Trust having achieved much of its performance KPIs. It has already been agreed that the report needs to include quality measures. The sub-Committees review different and more detailed reports than are presented to the main Board.

Director of Finance and Business June 2018

20 Introduce a Data Quality Group with oversight of the quality of information being used internally and externally and membership from operational and corporate teams.

There is a Statutory Submissions Review Group in place which monitors data quality impacting performance and statutory submissions. Areas that require intervention are co-ordinated with data quality leads and Service managers.

21 Develop and implement a rolling programme of data quality testing and audit focused on key internally and externally reported indicators. Consideration should be given to kite marking Board KPIs based upon the outcome of this activity.

Internally and externally reported indicators developed within WLBI (West London Business Intelligence) are going through a process of data validation and testing before publication. The development of data quality dashboards within WLBI will respond to any data quality issues identified. Presently the focus is on all existing KPIs reported to commissioners and external stakeholders, where possible internal measures are aligned to externally reported indicators. Consideration will be given to Kitemarking KPIs following the outcome of above.

6

22 Identify suitable methodologies for replicating and sharing areas of good practice in patient, service user and carer engagement activities across the Trust. This should include improving communication about engagement to non-clinical staff.

Communications regarding patient, service user and carer engagement already in place in multiple forums. Director of Communications and Engagement to consider further ways to communicate including quality improvements. A QUISR microsite is in development awaiting further content from the QI team, to be led by the new head of quality.

Director of Communications and Engagement August 2018

23 Improve the communications of actions taken to address staff feedback, such as ‘You said, we did’

Significant volume of feedback available via the Exchange including a staff survey video. Non-electronic forms of communication to be developed.

Director of Communications and Engagement Director of Workforce August 2018

24 Review the external stakeholders’ communications approach to ensure that external stakeholders are proactively managed at the right level and a consistent story is told.

Stakeholder management to be included in regular Executive Director away day discussions.

Chief Executive Quarterly

25 Identify opportunities to share good practice and learning across the Clinical Service Units.

Quality Committee including accessible vignettes that can be used as part of discussion based learning and in clinical improvement groups.

26 Commission an independent review to assess the progress of the recommendations within this report within the next nine months.

Report and recommendations will be considered during CQC visit anticipated for final quarter 2018

CR/May 2018/v.2

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West London Mental Health Trust

Undertakings and related Success Measures required return the Trust’s status to segment 2.

Undertaking Success Measure Status as of 17/4/18

The Trust will undertake an externally commissioned Well-Led review to inform the strengthening of governance arrangements.

To undertake the review and the Board to agree an action plan resulting from the findings with NSH Improvement oversight. To agree an action plan, owners and timelines plus evidence of action.

Well-Led review complete. Action plan to be agreed by Trust Board 9/5/18. TO BE COMPLETE BY MAY 2018

The Trust will develop a revised balanced financial plan leading up to March 2019 which includes:

• an understanding of the underlying financial position;

• detailed analysis of the causes of the underlying position;

• a link to workforce optimisation; and, • stretching and deliverable agency

plans and trajectories.

To develop a revised financial plan which meets the requirements of the undertakings and has income assumptions signed off by Commissioners. Principles for a financial plan are set out below for discussion. The plan should then be assured through the Trusts auditors and submitted to NHSI for final review and sign off.

Draft plan submitted to NHSI that meets the requirements of the undertaking. Plan agreed by Trust Board and “final” plan to be submitted in line with NHSI’s timetable. ACTION COMPLETE

The Trust will develop a robust plan to deal with the requirements of the CQC inspection and delivers the improvements highlighted by Health Education England.

To make sufficient progress against its quality improvement plans that Health Education England confirms to the Trust that their concerns regarding the experience of trainees have been addressed.

Completion of the action plan is progressing at good pace. ALL ACTIONS WILL BE COMPLETED IN MAY 18.

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To ensure that the CCG is able to confirm that the quality improvement plan to address the concerns of the CQC is sufficiently robust, being effectively driven and monitored and that there are systems and processes in place to address any slippage.

Copy of Copy of West London Mental H

Copy of FINAL West London Mental Health

The Trust has a Quality Improvement Plan in place to address the must and should do’s identified in November 2016 and subsequent service specific re-inspections. Monthly updates are provided to the Trust CQC Working Group / CQC. Regular service specific updates are provided to the CCG through the Clinical Quality Group; any slippages will be addressed in these forums. A full and comprehensive re-inspection of Broadmoor will take place week commencing 4th June. The rest of the Trust is likely to be re-inspected before the end of September 2018. ACTIONS IMPLEMENTED .

The Trust will continue to work with NHS Improvement to secure assurance of delivery of the 6 quality themes as agreed as part of the Quality Risk Profiling Tool meetings.

To ensure that the CCG is able to confirm that the quality improvement plan to address the concerns of the CCG is sufficiently robust, being effectively driven and monitored and that there are systems and processes in place to address any slippage.

A report was presented to the CCG Clinical Quality Group (26th March 2018) summarising the work across the Trust to address the 6 quality themes in the QRPT. This report is attached with the papers for the April POM meeting.

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There is evidence that the actions taken are having the desired impact.

Evidence is now being pulled together to support this work. ACTION TO BE COMPLETED IN MAY 18

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The Trust will ensure CCG engagement and support in the business changes required such that the Trust remains a sustainable entity and is able to transform its services in line with the agreed transformation and the commissioning intentions.

To demonstrate a financially viable clinical model, supported by Commissioners and achievable within the current staffing environment. To be agreed by the Trust Board and Commissioners and submitted to NHSI. Review and implementation over two years. NHS Improvement and NHS England review progress with the Trust and Commissioners.

The contract agreed with the CCG for 2018/19 supports a financially viable clinical model as evidenced by the 2018/19 financial plan as submitted to NHSI. ACTION COMPLETE

The Trust will appoint an Improvement Director to lead the development and delivery of a sustainable clinical model which will assure compliance with the 2018/19 Financial Control Total.

To ensure the position is recruited to under the guidance of NHSI, ensuring compliance with rules.

ACTION COMPLETE

The Trust will agree a clear timetable and milestones for delivering the Financial Plan with NHS Improvement and submit such progress reports as NHS Improvement shall request.

To agree a timetable and reporting programme with NHSI,

ACTION COMPLETE

The Trust will ensure adequate senior management (PMO resource) to support the Improvement Director and the Directors of Finance and Nursing to deliver the undertakings above.

To ensure there is sufficient management capacity in place. The Trust will keep NHSI informed on capacity issues on an ongoing basis. The Trust proposes the structure and develops a timetable for implementation and

Roles and responsibilities have been reviewed and clarified such that there is adequate and appropriate supporting resource. The Trust is committed to availing itself of any further resource and/or expertise as

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recruitment in relation to the CQC and Quality Risk Profiling Tool and the Local Services Transformation Programme. Progress against the plan reported via Provider Oversight Meetings

advised by NHSI. The DoN has been in discussions with the Director Quality of Improvement regarding the project management resource to support this. Progress against plan is a standing agenda item for the monthly Provider Oversight Meetings. ACTION COMPLETE

The Trust will take all reasonable steps to ensure adequate capacity and capability is in place to deliver the Financial Plan.

To ensure there is sufficient management capacity in place. This includes finance, operations and clinical support on CIP development and delivery. The Trust will keep NHSI informed on capacity issues on an ongoing basis. To be included in the scope of the well led review. Demonstrate progress in delivering the financial plan.

The Trust has demonstrated to NHSI that it has sufficient management capacity to deliver the financial plan. Delivery has been evidenced for 17/18 and the publication of a credible plan for 18/19. This undertaking was included in the scope of the well led review. ACTION COMPLETE

The Trust will keep the Financial Plan under review, and agree necessary amendments with NHS Improvement.

To ensure sufficient governance of the financial plan such that any potential amendments are highlighted early to the Trust Board and sub-committees as appropriate and shared with NHSI. Progress, risks and mitigations are report to

Achievement of the success measures can be evidenced through agenda and minutes of Board meetings and meetings of the Finance & Performance Committee. ACTION COMPLETE

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every Trust Board and scrutinised through the sub-committee structure of the Board.

The Trust will implement sufficient programme management and governance arrangements to enable delivery of these undertakings. Such programme management and governance arrangements must enable the Board to:

• obtain clear oversight over the process in delivering these undertakings;

• obtain an understanding of the risks to the successful achievement of the undertakings and ensure appropriate mitigation; and

• hold individuals to account for the delivery of the undertakings.

As above ACTION COMPLETE – AS ABOVE

The Trust will attend meetings or, if NHS Improvement stipulates, conference calls, at such times and places, and with such attendees, as may be required by NHS Improvement.

Monthly oversight meetings with Trust Executive team and NHS Improvement

Compliance can be evidenced. ACTION COMPLETE

The Trust will provide such reports in relation to the matters covered by these undertakings as NHS Improvement may require.

The Trust has responded accordingly. ACTION COMPLETE

Report summary Board meeting March 2018 Report title:

Integrated Performance Report

Executive lead:

Paul Stefanoski - Director of Finance & Business

Report authors:

Babs Dhillon – Head of Knowledge Management


N/A

Purpose and action required This report summarises the Trust performance compliance against statutory targets and internally set priorities at Month12 (March 2018) and identifies areas of underperformance that are being investigated and monitored.

For approval

To note

Summary Within the Areas of concern: Performance improvement has been noted for the following metrics:

• KPI 001: Admissions via CRHT Gatekeeping at 98.2% • KPI002: DToC rate of 3.9%, slightly higher than last month. • KPI008 : New Complaints received in period – 30 incidents commissioned in March

compared to 34 in February • KPI009: Number of complaints not responded to within agreed timeframe – 0 in

March • KPI 021: % Risk assessments within 72 hours of admission – achieved 97.5%. • KPI015 : Level 1 Incidents commissioned –There were 5 reviews • KPI019: CPA 7 day follow up – achieved 96.9%.

Concerns : • KPI022A: % of Inpatients Physical health check within 24hrs admission – breached

at 94.7%. This is the second month this KPI performs below 95%. Workforce and Finance performance are reviewed within respective reports.

As part of the annual review of the IPR and areas that need closer monitoring, it is proposed that the following indicators are added to IPR. New KPIs to be added :

• KPI079 : EIP waiting times, and where applicable other access waiting times • Q-RISK (Physical health) • Seclusion Hours • Restraint : prone and supine • Rapid Tranquilisation • Supervision compliance • Waiting Times • Addition of key charts from the London MH dashboards

The following KPIs can be removed and will continue to be reflected in the main scorecard

• KPI001: % Admissions CRHT Gatekeeping - we have been performing well and this is stable in terms of performance compliance

• KPI008 and KPI009 – complaint indicators • KPI015: Level 1 Incidents commissioned

Within the Areas of concern: Performance improvement has been noted for the following metrics:

• KPI 001: Admissions via CRHT Gatekeeping at 98.2% • KPI002 : DToC rate of 3.9%, slightly higher than last month. • KPI008: New Complaints received in period – 29 incidents commissioned in March

compared to 34 in February • KPI 021: % Risk assessments within 72 hours of admission – achieved 97.5%. • KPI015: Level 1 Incidents commissioned –There were 5 reviews • KPI 019: CPA 7 day follow up – achieved 96.9%.

Concerns : • KPI022A: % of Inpatients Physical health check within 24hrs admission – breached

at 94.7%. This is the second month this KPI performs below 95% Workforce and Finance performance are reviewed within respective reports. Relationship to trust strategic objectives? Outstanding We coordinate and collaborate – to deliver holistic care


Improving quality


Compassionate care


Relationship to board assurance framework (risks)? Are any existing risks in the board assurance framework affected?

Yes

If yes, insert relevant risk reference: Various Do you recommend a new entry to the board assurance framework (i.e. trust-wide level 1 risk) is made?

Acronyms / terms used in the report SPC Statistical Control Chart DToC Delayed Treatment of Care KPI Key Performance Indicator F&P Finance and Performance Committee Supporting documents and/or further reading https://improvement.nhs.uk/uploads/documents/Single_Oversight_Framework_published_30_September_2016.pdf

https://improvement.nhs.uk/uploads/documents/Single_Oversight_Framework_published_30_September_2016.pdf

https://improvement.nhs.uk/uploads/documents/Single_Oversight_Framework_published_30_September_2016.pdf

Integrated Performance Report (IPR)

March 2018

Summary of overall performance is set out below

Indicator Description Key Highlights Target Previous Month

Current Month

KPI001: Inpatient admissions Gatekept March performance at 98.2% >=95% 100.0% 98.2%

KPI002: Delayed Transfers of Care In March the Trust level DToC was at 3.9%, slightly up from last month but well below the 6.7% average for this year . <=7.5% 3.5% 3.9%

KPI008: New Complaints received in period

30 complaints were received during March 2018, which shows an reduction of 4 compared with the previous month 34 30

KPI009: Number of complaints not responded to within agreed timeframe (Open)

There were no complaints overdue without an agreed extension date in March0 3 0

KPI014: Level 2 Incidents commissioned There were two Level 2 reviews commissioned, both in Primary and Planned Care. P&PC account for 37% of the total Level 2 incidents commissioned during 2017/18 2 2

KPI015: Level 1 Incidents commissioned There were 6 Level 1 incidents commissioned in March 2018. Level1 incidents have shown a sustained downward shift on last 12 months' observations. 8 5

KPI019: CPA 7 day follow upPerformance in March was at 96.6% against the 95% target. There were 3 breaches (out of 98 discharges) this month, 2 in WLFS (MSU FALCON and MSU GARNET) and 1 in Local Services (HOU KINGFISHER MALE).

>=95% 97.80% 96.90%

KPI021: Inpatient risk assessments within 72 hours

There were 2 breaches out of 133 admissions this month (98.5%). >=95% 97.5% 98.5%

KPI022A: % of Inpatients Physical health check within 24hrs admission

March 2018 data shows that physical health assessments (PHA) within 24 hours of admission was at 94.7%. >=95% 94.2% 94.7%

1.0 Areas of Concern Data Month 12 (Mar 2018)

Comments: As a result of the reporting and recording improvements, we have achieved a compliance of 99.4% for Q3. Performance in March was 98.2%. A sustained shift in performance continues with above 95% compliance since April 2017. A new dashboard to give services on demand access to this KPI has been developed and rolled out.

Overview CRHT Gatekeeping is a key target within the NHS Improvement Single Oversight Framework with a target of 95%. Gatekeeping has remained above the target of 95% since April following review of processes earlier in 2017.

Data Source: RiO as at 10 April 2018

1.1 - KPI001: Admissions CRHT Gatekeeping Data Month 12 (Mar 2018)

OverviewThe national target for Delayed Transfer of Care (DToC) was set by the Single Oversight Framework as 7.5%. In its 2017/18 mandate to NHS England, the Department of Health set a delayed discharge target of no more than 3.5 per cent of all beds by September 2017. The Trust in collaboration, with Local Authorities and CCGs, has taken a more rigorous approach to reporting and management of delayed patients. This has resulted in significant reduction in our DToC levels since August 2017.

Notes:- Data reported here is month end snapshot position before Local Authority sign off and may be different from final submitted data to NHS England- Broadmoor patients on trial leave or those on the MOJ waiters are not required to be reported on DToC under the ‘safe’ for discharge definition, and are reported here for local performance monitoring only.

1.2 - KPI002: Delayed Transfers of Care Data Month 12 (Mar 2018)

Comments: In March the Trust level DToC was at 3.9% , slightly up from last month but well below the 6.7% average for this year . Significant improvement has been observed across three main Local Authorities (Ealing, H&F and Hounslow) and Forensic over last 4 months as a result of joint DToC sign off with Local Authority colleagues.

Trust wide, 'Social Care' attribute accounted for 40% of Equivalent DTOC beds (10.5 out of 26) . Decreased compared to last month, this proportion has also reduced considerably in Local Services since local authorities and commissioners have started to sign off the delays. The biggest reason for delayed beds this month was 'Awaiting public funding' (29% of the total DTOC monthly reasons) followed by 'Awaiting further non-acute NHS Care' (21% of the total DTOC monthly reasons). Out of 12 patients delayed across WLFS, 3 each in Male Medium Secure and Male Low Secure, 2 each in Women's Medium Secure and Low Secure Pre-Discharge, and 1 each in WEMMS and Women’s Low Secure. Half of the WLFS are due to 'Awaiting public funding'.

Hounslow, Ealing and H&F LAs queried/ disputed the historical reason for delayed patients. These adjustments have now been agreed and a revised submission will go to Unify when the revision window is opened in May 2018.

Data Source: Manual data submitted by services as at 10 April 2018

Comments• A total of 30 complaints were received during March 2018, which shows an reduction of 4 compared with the previous month • The trust is 100% compliant acknowledging the complaint within three working days • High Secure Services receive the highest number of complaints, 32% (n=123) of the trust total 381 from 1st April 2017 to 31st March 2018.• During 2017/18, main theme was 'all aspects of clinical treatment' which account for 33% (n=125) of the complaints, followed by 'attitude of staff' which received 29% (n=111)

• Key themes are further analysed and reported on in:o The weekly patient experience data summary produced for the Director of Nursing and Patient Experience o The monthly Being Open report which is presented at the Clinical Governance Committee Meetingo The quarterly patient experience report presented at the Service User and Carer Sub- committee

Data Source: Central Governance : Complaints System (Exchange) as at 17 April 2018

Overview Complaints can be received verbally, by telephone, letter or email. An acknowledgement is sent to the complainant within three working days of receipt providing an overview of the main issues and the timescale for the investigation. Themes from complaints are analysed to identify key areas for action.

Key themes are further analysed and reported on in :o The weekly patient experience data summary produced for the Director of Nursing and Patient Experience o The monthly Being Open report which is presented at the Quality Matters Committeeo The quarterly patient experience report presented at the Service User and Carer Sub- committeeo A recommendation from the annual patient experience report is for service lines to provide feedback on improvements/action being taken to address areas of concern raised which will be included in this commentary

1.3 - KPI008: New Complaints received in period Data Month 12 (Mar 2018)

Comments

Data Source: Central Governance : Complaints System (Exchange) as at 17 April 2018

Overview The investigation response will be required by a specified date which is agreed with the complainant at the start of the process. However this will not exceed 30 days from receipt of complaint, unless a longer timescale is required due to exceptional circumstances which should not exceed 35 days.If an extension is agreed and signed off by the Director of Nursing and Patient Experience and Executive Director the extension should be for a maximum of 10 days, and there should be a maximum number of extensions granted per complaint, which must not exceed three.

A weekly summary of patient experience data including overdue complaints is provided to the Director of Nursing and Patient Experience for discussion at the Executive Directors meeting, the monthly Being Open report presented at the Quality Matters Committee, and the quarterly patient experience report presented at the Service User and Carer Sub- committee. A recommendation from the annual patient experience report goes to each service lines to provide feedback on improvements/action being taken to address areas of concern.

The data was drawn from the live system on 17th April 2018 and showed that there are no complaints overdue without an agreed extension date.

2017/18 full year analysis by Service Line shows that A&UC had the highest number of complaints still open (not responded to - calculated at each month end) 39% of the total followed by P&PC where the proportion is 25%.

Number of complaints closed outside agreed timeframe in March 2018 were at 11 just below the 2017/18 average of 12. Year on year comparison shows that performance improved in 2017/18 by about 20%. There were 120 cases closed outside timeframe in 2017/18 compared to 149 in 2016/17.

1.4 - KPI009- Number of complaints not responded to within agreed timeframe (open) Data Month 12 (Mar 2018)

CommentsDuring March 2018 there were 2 'Level 2' reviews commissioned, both in Primary and Planned Care. P&PC account for 37% of the total Level 2 incidents commissioned during 2017/18, followed by A&UC (22%) and L&LTC (18.5%). Patient death was the largest type of Level 2 incident (81.5% of total) followed up by 'Self Injury to patient' (11.1% ) during 2017/18.

Work is underway to improve processes and systems to capture and report data more accurately and consistently.

Data Source: Central Governance : Incidents System (Exchange) as at 12 April 2018

OverviewThe nature, severity and complexity of serious incidents vary on a case-by-case basis and therefore the level of response is dependent on and proportionate to the circumstances of each specific incident. Level 2 incidents commissioned require comprehensive internal investigation and include all the elements of a credible investigation. Level 2 reviews are conducted where there are complex issues with generally moderate to severe level of harm. These are managed by a multidisciplinary team, and involve experts and/or specialist investigators.

1.5 - KPI014: Level 2 Incidents commissioned Data Month 12 (Mar 2018)

CommentsThere were 6 Level 1 incidents commissioned in March 2018. Level 1 incidents have shown a sustained downward shift on last 12 months' observations and 2017/18 full year average is 6 compared to an average of 10 in 2016/17. 'Patient death', 'Self-injury to Patient' and 'Bed Occupancy Levels' are the largest type of level 1 incidents commissioned and account for 22%, 16% and 13% of the 2017/18 incidents respectively. In 2017/18, Level 1 incidents in Access and Urgent Care service remain highest (55% of the total) followed by Primary and Planned Care (23% of the total). WLFS and HSS recorded lowest number on Level 1 incidents in 2017/18 (2 each).

Note: That date of incident may not be same as commissioned date and some incidents that happened in previous months may appear this month based on commissioned date.

Data Source: Central Governance : Incidents System (Exchange) as at 12 April 2018

Overview Level 1 Incidents Commissioned require concise internal investigation and include the essentials of a credible investigation. Level 1 reviews are conducted for less complex incidents, where the level of harm is generally none/low/moderate. These are managed by individuals or a small group at a local level external to the team.

1.6 - KPI015: Level 1 Incidents commissioned Data Month 12 (Mar 2018)

Overview The national target for CPA 7 day follow up is 95%. This key target had been underperforming since June 2016 with the exception of few months.The accuracy of recording and reporting has improved following a comprehensive review of processes. Better timely weekly reports and the efforts of the Data Quality manager have proved effective.

Performance in March is at 96.6% against the 95% target. There were 3 breaches (out of 98 discharges) this month, 2 in WLFS (MSU FALCON and MSU GARNET) and 1 in Local Services (HOU KINGFISHER MALE). Quarter 4 performance is predicted at 96.5% (awaiting published data) and is highest in last 2 years.

Until August 2017, this KPI was monitored for CPA discharges only (excluded patients who were not on CPA at the time of discharge). From August 2017, as a stretch target, all discharges are being monitored against the 7 day follow up compliance but as the NHS England guidance only requires for CPA discharges, non CPA discharges are not reported. Out of 3 breaches this month, one was followed up on the 14th day after discharge, one discharge couldn't be followed up despite several attempts to contact, and no contact information found for 1 breach.


Comments:

1.7 - KPI019: CPA 7 day follow up Data Month 12 (Mar 2018)

CommentsThere were 2 breaches out of 133 admissions this month (98.5%). The breakdown by service as follows : A&UC (99.2%, 1 breach in HOU KESTREL), CID (100%), P&PC (100%),WLFS (88.9%, 1 breach in WEMSS PARKLAND)

Both admissions that missed the 72 Hour Risk Assessment target did have a risk assessment outside the 72 hour period.

High Secure data is not included in this analysis but will be added in future.

Overview Trust has a 95% target for completing an initial risk assessment within 72 hours of admission to an inpatient ward. Trust has been compliant except in 3 instances since April 2015. This indicator does not provide a measure of the quality or completeness of the risk assessment carried out.


1.8 - KPI021: % Risk Assessment within 72 hrs admission Data Month 12 (Mar 2018)

Comments:

Overview 95% of inpatients should have a physical health assessment within 24 hours of admission (previously 72 hours). The new target went live mid April 2017. Further monitoring of the new target will continue with focus on individual services and wards and training as the new target is embedded. There is also work planned around the evaluation of the new physical health portal regarding usage and feedback.

This indicator does not provide a measure of the quality or completeness of the physical health assessment carried out.


March 2018 data shows that physical health assessments (PHA) within 48 and 72 hours of admission are both at 95.5%, with 94.7% of patients having a PHA within 24 hours. PHA can be completed before admission and this is taken into account when calculating compliance.

There were 133 admissions in March across the Trust, 126 of them had a PHA within 24 hours of admission. There were 7 breaches, 5 in A&UC and 2 in P&PC.

Of the 8 breaches (24 Hr PHA Measure) this month, one went on to receive a Physical Health Assessment in 29 hours while 7 admissions have no assessment recorded at the time of reporting this data. Performance by Service is as follows; A&UC 95.8% (120 admissions), CID 100% (2 admissions), P&PC 0% (2 admissions), and WLFS 100% (9 admissions).

Data excludes Broadmoor records as they are recorded on EMIS.

1.9 - KPI022A: % of Physical health assessment within 24hrs of admission Data Month 12 (Mar 2018)

KPI # Access and Waiting Time Standards Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4

17/18Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

vs. Last Month

Trend Comments

KPI079% of People experiencing a first episode of psychosis treated with a NICE approved care package within two weeks of referral - overall Trust level

SR 50% E 50.8% 53.2% 48.7% 59.3% 36.0% 60.0% 50.0% 40.0% 60.0% 77.8% This figure represents the number of referrals that met the target as a percentage of completed SFEPs in month. Only EIS and CAMHS teams can contribute to the completion figure as this necessitates assessment by and allocation of an EI care coordinator. As SFEPs over 35yrs are dealt with by Recovery Teams who cannot offer EI assessment and care co allocation this group will always breach the target.

KPI079ANumber of People waiting more than two weeks to enter the Suspected First Episode Psychosis Pathway - EIS

SR 2/8 3/6 8/14 10/15 16/21 7/13 2/8 3/6At the end of the month there were 6 patients waiting to enter treatment in EIS teams : 2 in Ealing, 3 in Hounslow and 1 in H&F. 3 out of 6 incomplete referrals had a wait of over two weeks : 2 in Ealing and 1 in H&F.

KPI079BNumber of People waiting more than two weeks to enter the Psychosis Pathway - CAMHS

SR 0 0 0 0/1 0 0 0 0

KPI079CNumber of People waiting more than two weeks to enter the Psychosis Pathway - Recovery

SR 8/8 8/8 12/13 13/14 13/14 11/12 8/8 8/8

All SFEPs over 35s are dealt with by Recovery Teams and as they cannot offer an EI service the pathway will always remain incomplete and breach the target. The trust is not currently commissioned to provide EI services for over 35s but continue to identify this group in order to comply with the AWT and also to highlight the funding gap. 8 patients were waiting to enter treatment at the end of the month. All 8 patients have waited more than 12 weeks to enter treatment.

KPI080IAPT - % of referrals that finish a course of treatment in the reporting period who received their first treatment appointment within 18 weeks of referral

SR 95% E 99.7% 99.9% 99.7% 99.7% 99.4% 99.9% 99.7% 100.0% 99.5% 99.6%

KPI081IAPT - % of referrals that finish a course of treatment in the reporting period who received their first treatment appointment within 6 weeks of referral

SR 75% E 90.5% 93.5% 93.7% 92.6% 95.6% 94.9% 90.5% 90.1% 93.8% 93.9%

KPI082Avg Waiting times Referral to Assessment (Routine) - Local Services (Weeks)

SR 4 wks E 5.5 4.9 4 4.3 3.7 4.1 4.1 4.6 4.3 3.9

KPI050Elective Inpatient: Broadmoor Referral to admission >12 wks (No. of patients)

LM 12 wks I 3 2 0 7 0 0 0 3 1 3

KPI084Number of referrals accepted to the service (Ealing Home Ward)

SR I 1068 1098 1286 1341 396 441 449 463 431 447

KPI085Number of claimed avoided admissions (Ealing Home Ward)

SR I 851 820 645 627 207 205 233 217 202 208

KPI #Quality - Clinical Effectiveness indicators

Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4

17/18Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 vs. Last

Month Trend Comments

KPI001 % Admissions CRHT Gatekeeping SR 95% E 97.3% 99.6% 99.5% 99.4% 98.5% 100.0% 100.0% 100.0% 100.0% 98.2% There were 2 breaches in March. Qtr4 performance at 99.4%.

KPI002 % Delayed Transfer of Care (Sitrep) - All reasons SR&LM <7.5% E 9.2% 8.6% 4.9% 3.8% 6.2% 5.0% 4.3% 3.9% 3.5% 3.9%

KPI005 Data completeness: identifies MHSDS SR >=97% E 99.2% 99.2% 99.2%99.0%

99.2% 99.3% 99.0% 99.0%99.0% 99.0%

KPI006 Data completeness MHSDS: Outcomes for Pts on CPA SR >=50% E 51.3% 50.8% 49.6%49.0%

50.4% 49.3% 49.0%49.0% 49.0% 49.0% HoNOS 12 month reviews' and 'In Settled Accommodation' performance has declined by about

2% since start of the year.

KPI011 % Overall Trust Community DNA rate (All HCPs) SR <15% I 14.5% 15.0% 14.9% 12.6% 14.8% 15.0% 15.0% 14.4% 11.9% 11.4% Highest in A&UC (14.1%) followed by P&PC (12.3%)

KPI013% Inpatient Readmission Rate for Acute Local CSU (All ages and wards) (30 Days)

SR <8.1% E 3.8% 6.1% 6.8% 8.0% 2.5% 7.4% 10.4% 5.2% 6.4% 12.5%

KPI # Quality - Patient Experience Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4


vs. Last Month Trend Comments

KPI008 Number of new Complaints received in period (Trust) SB I 107 103 82 88 37 26 19 25 34 30 KPI009

Number of complaints not responded to within agreed timeframe (Open)

ALL 0 I 7 2 4 3 1 6 4 3 3 0 KPI010

Number of complaints responded to outside agreed timeframe (closed)

ALL 0 I 46 32 17 25 3 6 8 7 7 11 KPI012 % Overall Trust Cancellation rate (All HCPs) SR <5% I 3.0% 2.4% 2.6% 4.0% 2.8% 2.6% 2.4% 2.9% 3.5% 5.5% Highest cancellations in CID (10%) followed by P&PC (8%)

Quarterly Performance Trend

2.0 Trust Summary Scorecard 2017-18 Data Month 12 (Mar 2018)

KPI # Quality - Patient Safety indicators Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4



KPI014 Number of Level 2 Incidents commissioned SB I 4 13 4 6 2 1 1 2 2 2 KPI015 Number of Level 1 Incidents commissioned SB I 20 13 15 17 3 8 4 4 8 5 KPI016 Number of Level 2 incidents reports overdue ALL 0 I 15 8 9 9 8 8 9 8 8 9 KPI017 Number of Level 1 incidents reports overdue ALL 0 I 39 5 5 8 1 4 5 3 9 8 KPI018 Number of Community Suicides JR&SB 0 I 3 5 2 4 0 0 2 2 1 1 KPI019 CPA 7 day follow up SR >95% E 95.8% 95.2% 95.8% 96.5% 96.4% 97.1% 93.8% 94.7% 97.8% 96.9% There were 3 breaches (out of 98 discharges), 2 in WLFS and 1 in A&UC

KPI020 Service user CPA review 12 months JR >95% E 95.5% 94.7% 93.4% 94.0% 92.9% 93.7% 93.6% 94.0% 94.0% 94.0% KPI021

% of Inpatient Risk Assessment within 72 hrs admission

BM >95% I 96.5% 98.1% 96.7% 97.8% 96.3% 96.9% 97.0% 97.3% 97.5% 98.5% Two breaches in March, one on A&UC and one in WLFS.

KPI022A% of Inpatients Physical health assessment within 24hrs of admission

JR&SB >95% I 70.1% 80.7% 94.0% 94.8% 92.5% 93.1% 97.8% 95.6% 94.2% 94.7% KPI023

Number of Safeguarding Adult Referrals made to Local authorities

JR E 141 135 141 160 64 50 27 48 65 47

KPI # Workforce Indicators Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4



KPI024 % staff who have Objectives Set for the financial year WB 90% E 38% 87% 88% 61% 88% 88% 87% 88% 89% 7% The PDR data has been reset as a result of the new PDR year

KPI025 % Vacancy rate WB <=10% E 17.0% 16.3% 15.8% 16.0% 15.5% 15.7% 16.1% 16.3% 16.0% 15.8% KPI026 % Sickness rate WB <=4.1% E 3.7% 4.1% 4.1% 4.6% 4.0% 3.9% 4.5% 5.2% 4.3% 4.2% KPI027 % Spend Agency WB <=5% E 9.3% 8.7% 8.0% 8.0% 8.8% 8.4% 6.8% 8.4% 7.9% 7.7% KPI028 Compliance Overall Mandatory Training WB >85% E 86% 89% 88.9% 90% 88.9% 89% 89% 90% 89% 90% KPI029 Dignity at Work reported (new cases) WB 0 E 0 1 1 1 0 1 0 0 0 0 KPI030 Turnover rate (rolling 12 months) WB 12% E 14.9% 14.7% 14.9% 14.8% 14.8% 14.9% 15.1% 15.1% 15.1% 14.2% A significant programme of work, based on feedback from new starters, is in place to ensure that

new members of staff are able to settle well into their roles.

KPI031 Average Number of Weeks to fill a vacancy WB 15 wks E 11.1 11.8 11.1 15.7 7.4 11.0 15.0 17.0 15.0 15.0

KPI # Finance Indicators Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4



KPI032 Financial Efficiency - I&E Surplus Margin (%) PS 1.5% -1.4% -0.8% 0.2% 3.2% -0.4% 0.1% 0.2% 2.2% 2.5% 3.2% KPI033 Cash position versus plan PS +/- 10% 51% 32% 58% 60% 72% 75% 58% 75% 40% 60% KPI034 Capital spend v plan ratings PS +/- 10% -35% -43% -46% -37% -44% -45% -46% -47% -44% -37%

KPI # External Assessment indicators Exec Lead

Plan E&IQtr1

17/18Qtr2

17/18Qtr3

17/18Qtr4



KPI037 NHSI - Financial Risk Rating PS >3 E 3 3 2 2 2 2 2 2 2 2 KPI083 CQC - Warning notices (Enforcement Actions) SB 0 E 1 0 0 0 0 0 0 0 0 0 KPI041

Compliance with Information Governance Toolkit (IGT)

SB 74% E 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% We attained 75% against the 74% target as per 2017/18 IGT assessment.

Key : Compliant Risk of not meeting target Non- Compliant Predicted

Report summary Finance & Performance March 2018 Report title: M11 Trust Financial Position

Executive lead: Paul Stefanoski

Report authors: Paul Stefanoski


n/a

Purpose and action required This paper summarises the M11 Trust position .Further detail in relation to the individual CSU position will be presented by the relevant Executive Directors at this meeting.

For approval

To note Summary The position for M11 is an improvement on the planned year to date position and shows an underspend of £1,276k in month. The year to date position is a £6,000k underspend as compared to a planned position of £4,751k. The improved position is the result of a revaluation of the trust estate which has led to a significant reduction in the cost of capital charges as compared to plan. The Committee will recall the establishment of a “stretch” target accounting for the additional actions agreed at month 3. It is now expected that this target will be over achieved at year-end



Improving quality


Compassionate care



Yes

If yes, insert relevant risk reference: 8023 Do you recommend a new entry to the board assurance framework (i.e. trust-wide level 1 risk) is made?

No

Acronyms / terms used in the report Q&I Quality and Innovation QCIPs Quality Cost Improvement Programme CIS Community Integrated Service CSU Clinical Service Units NHSI National Health Service Improvement I&E Income and Expenditure

Finance & Performance meeting: March 2018 M11 Trust Finance Position

1 Purpose

1.1 The purpose of this paper is to summarise the M11 position for the Trust and

the forecast for the financial year. Further detail is provided in the individual CSU/Directorate papers.

2 Recommendation

2.1 The committee is asked to note the M11 position. 3 Overview for the year to 28th February 2018

3.1 Table 1 below outlines the M11 position and compares this to M9 and M10.

Detailed explanations for this have been set out in the individual CSUs/directorate papers. It shows the overall position improving month on month.

3.2 The full value of the CIPs has been removed from the CSUs and directorates.

Use of reserves was in advance of plan for the first half of the year and was identified as being unsustainable. Therefore, there was a commitment to implementing the actions implicit in achieving the stretch targets and the full delivery of CIPs. As a result, there have been great improvements in all areas such as control of out of area placements, additional funding for WEMS beds and control of agency spend.

3.3 For the CSUs/Directorates the cumulative position to the end of M11 the

position is £8.2m overspent.

Table 1: M9 to M11 position and year end forecast

M9

position M10

position M11

position YTD

position M12

forecast ‘£000 ‘£000 ‘£000 ‘£000 ‘£000

Specialist and Local services -112 -299 -66 1,752 1,700

West London Forensic Service 445 405 413 4,678 5,158

High Secure services 239 -492 213 1,026 1,000 Estates and Facilities 59 12 59 1,418 1,300

Corporate -87 85 1 -644 -440 Subtotal CSU/directorate

position 544 -289 620 8,229 8,718

Profit on land sales -3,717 -3,717 -3,717 Funding to cover overspend -333 -333 -333 -3,667 -4,000

Planned Surplus -51 -51 -51 -564 -615 STF -1,295 -1,413

Centrally held budgets e.g. innovation fund and

underspend on planned capital charge

-396 1 -1,512 -4,986 -6,980

Trust net underspend -236 -4,389 -1,276 -6,000 -8,007 3.4 The delivery of the stretch target had the dual aim of recovering from poor

financial performance in Q1 and leaving the current financial year in a balanced position. Notwithstanding the contract shortfall in Local Services, it was important that the CSU established at minimum a break-even run rate by Q4.The position at M11 shows this to be achievable.

3.5 In the short term, the aim for WLFS is to reduce the monthly run-rate overspend to below £400k per month. The recent opening of two further beds, and the additional income associated with this, should assist in this goal.

M5 3.6 The delays in the opening of the new Broadmoor Hospital, puts at risk the

achievement of further significant cost improvements. However, this is a known risk and is being planned for as part of the 2018/19 budget setting process. Circa £1m will be put aside from the previously unspent Q&I reserve to help cover this shortfall.

3.7 The further implementation of the Estates Strategy and continued efficiencies in Corporate Services will need to result in a combined break-even run rate so as not to cause a further drain on resources.

4 Agency Usage

4.1 Agency usage in M11 was £1.1m, which is an improvement on the January

position which showed £1.2m spend. Cumulative spend to date is £13.6m as compared to a plan of £11.7m. The planned annual position is £12.7m.

4.2 The majority of the agency expenditure was within Specialist and Local Services (85% - which is the same as previous months). The tables below outline the agency usage by service line and disciplines. The percentage of Admin and Clerical agency remains steady at 3% (having reduced from 16% at the end of 16/17).

4.3 The NHSI agency risk rating is currently 3, however if agency expenditure

exceeds £15.6m in the financial year the Trust will slip into a 4 rating which will in turn trigger an overall finance risk rating of 3. The overall finance risk rating is currently 2.

4.4 There are specific funding arrangements for certain posts and these costs are shown separately in the tables below:

Table 3a: CSU/Directorates agency usage CSUs/Directorates Year-to-date

Spend £’000

Recharge elements

£’000

Net YTD spend £’000

Proportion

Corporate 384 384 3% Capital, Estates & Facilities 556 556 4% High Secure Service 444 444 3% Specialist and Local Services 12,344 -833 11,511 85% WL Forensic Services 676 676 5% Trust agency year to date expenditure

14,403

-833 13,570

Table 3b: CSU/Directorates agency usage

CSUs/Directorates Year-to-date Spend £’000

Recharge elements

£’000


%

Admin & clerical 786 -392 394 3% Nursing qualified 5,361 -111 5,250 39% Health care assistant 1,321 1,321 10% AHPs 1,201 1,201 9% Medical 3,717 3,717 27% Other 2,018 -330 1,688 12% Total 14,403 -833 13,570

Table 3c: Specialist and Local services agency usage by disciplines Specialist and Local services

Year-to-date

Spend £’000

Recharge elements

£’000


%

Admin & clerical 471 -392 79 1% Nursing qualified 5,013 -111 4,902 43% Health care assistant 1,178 1,178 10% AHPs 1,099 1,099 10% Medical 3,202 3,202 28% Other 1,381 -330 1,051 9% Total 12,344 -833 11,511

Table 3d: Specialist and Local services agency usage by Service lines

Specialist and Local services

Year-to-date Spend £’000

Recharge elements

£’000


%

LS Planned and Primary care 2,469 2,469 21% LS Management 516 -392 124 1% LS Liaison and LTC 1,920 1,920 17% LS Developmental Services 1,635 -441 1,194 10% LS Cognitive Impairment & Dementia 1,295 1,295 11% LS Access and Urgent Care 4,509 4,509 39% Total 12,344 -833 11,511

5 Quality Cost Improvement Plans (2017/18) 5.1 The Trust has a target to deliver £9.4m QCIPs for the financial year. There is

confidence that this will be achieved in advance of the year-end. 5.2 The Finance Oversight and Leadership Group is tasked with ensuring

identification and delivery of CIPs, both for current and future years. This Committee receives the minutes of the meeting as further assurance.

5.3 Plans are in place for the majority of QCIPs for 2018/19.

6 Conclusions

6.1 For the first 11 months of the financial year the Trust has reported an underspend of £6.0m. This is an improvement on the planned position as a result of a significant reduction in the cost of capital charges as compared to plan.

7 Recommendation

7.1 The committee is asked to note and discuss the information provided in this report.

Paul Stefanoski

Director of Finance and Business March 2018

Report summary Trust Board May 2018 Report title: Trust Budget 2018/19

Executive lead: Paul Stefanoski


F&P meeting (March 2018)

Purpose and action required This paper provides a more detailed analysis of the proposed budgets for 2018/19 and outlines the initial plan submitted to NHSI. At the time of writing contract figures have still to be agreed so the figures provided are based on assumed income figures. The Committee is asked to recommend the proposed budget to the Trust Board.

For approval

To note

Summary The Trust had anticipated budgeting for a surplus of £4.456m as per the agreed NHSI control total, which included £1.986m Sustainability Transformational funding (STF). This is based on CSUs/Corporate receiving income of £258m. As yet, agreement needs to be reached around the exact level of funding which will be received from commissioners. This figure also assumes £1m growth for Local services. The QCIPs target for 2018/19 is £8.6m, which includes unmet QCIPs relating to previous year, the majority of which has been identified to date. The proposed plan shows the Trust achieving and maintaining a financial risk rating of “1” throughout the year.



Improving quality


Compassionate care



Yes

If yes, insert relevant risk reference: 8027 Do you recommend a new entry to the board assurance framework (i.e. trust-wide level 1 risk) is made?

No

Acronyms / terms used in the report NHSE NHS England CCGs Clinical Commissioning Groups NHSI NHS Improvement STF Sustainability Transformational funding QCIPs Quality Cost Improvement Programmes SLA Service Level Agreement I&E Income and Expenditure

Finance & Performance Committee: March 2018 2018/19 Budget

1 Purpose

1.1 The purpose of this report is to provide the committee with an update on the

forecasted 2018/19 financial position and propose the opening 2018/19 income & expenditure budgets. At the time of writing, final contract values have still to be agreed with the Trust’s key commissioners. Therefore the income values included in this paper are estimates based the expected outcome of negotiations.

2 Recommendations

2.1 The committee is asked to note the information provided in this report and consider

the recommendation that the Trust Board formally agree the Trust’s income, expenditure and capital budgets for 2018/19, and the subsequent financial plan submission to NHS Improvement.

3 Financial overview 2018/19 3.1 The Trust is on track to deliver and exceed the required control total surplus for

2017/18. This has resulted in a revised surplus target for 2018/19 and also increased STP funding. Therefore the proposed plan shows the Trust delivering a £4.4m surplus (including £2m STP funding). This remains a challenging target as it assumes full QCIP delivery (which includes a reduction in agency expenditure) and relies on CSUs/corporate areas managing within their set control budgets.

3.2 The graph below provides details of the financial bridge from the 2017/18 outturn to

the planned surplus for 2018/19.

3.3 Table 1 shows the income and expenditure budget for 2018/19. This is based on

the assumed signed values of the contract with both NHSE and CCGs. Details of the draft plan submitted to NHSI in March is shown in appendix 1. The matching figures are highlighted for ease of reference.

Table 1: 2018-19 Income and Expenditure budgets

8,000

4,486 +1,000

+5,463 +1,986

+8,673

-3,821

-3,321

-1,414

-3,486 -4,471 -4,123

(10,000)

(8,000)

(6,000)

(4,000)

(2,000)

0

2,000

4,000

6,000

8,000

10,000£0

00's

2017/18 FOT position to 2018/19 planned position

2017/18 2017/18 2017/18 2018/19 2018/19 2018/19 2018/19 2018/19 % of Trust Non Additional Reduction to Efficiency Growth Income

Forecast Budget Recurrent Income budget Income identified forecast£'000 £'000 £'000 £'000 £000 £'000 £'000 £'000

West London Forensic CSU -45,887 -46,001 -1,646 1,700 -1,127 -459 -47,533 18%High Secure Services CSU -76,595 -78,411 4,129 -1,393 2,582 0 -766 -73,859 29%Specialist & Local Services CSU -121,002 -116,812 1,500 -4,595 -2,250 -1,839 -123,996 48%Other income -14,046 -9,556 3,740 -3,859 0 -1,026 0 -10,701 4%STF -1,414 -1,414 -572 -1,986Total income -258,944 -252,194 9,369 -12,065 4,282 -4,403 -3,064 -258,075 100%

2017/18 2017/18 2017/18 2018/19 2018/19 2018/19 2018/19 2018/19 % of Trust Non additional reductions to Savings inflation Expenditure

Forecast Budget Recurrent expenditure budget expenditure budget Identified costs budget£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

West London Forensic CSU 36,446 31,560 873 -488 354 32,299 13%High Secure Services CSU 40,533 38,460 -1,469 1,393 -440 431 38,375 15%Specialist & Local Services CSU 100,210 93,798 -1,534 3,535 -727 -1,367 939 94,644 37%Sub total 177,189 163,818 -3,003 5,801 -727 -2,295 1,724 165,318 64%

Estates and Facilities 18,525 17,382 -137 684 -303 285 17,911 7%Estates and Facilities 18,525 17,382 -137 684 0 -303 285 17,911 7%

Corporate services 25,130 24,537 -224 150 0 -500 201 24,164 9%Corporate services 25,130 24,537 -224 150 0 -500 201 24,164 9%

Capital charges/depreciation 25,130 31,494 -454 920 0 -726 201 31,435 12%Centrally-held budgets 4,963 9,636 2,230 3,342 -417 0 14,791 6%

Total expenditure 250,937 246,867 -1,588 10,897 -727 -4,241 2,411 253,619 98%

(Surplus)/Deficit -8,007 -5,327 7,781 -1,168 3,555 -8,644 -653 -4,456 2%

INCOME & EXPENDITURE FORECAST 2018-192018/19 Income

2018/19 Expenditure

3.4 The total revenue is made up from anticipated Service Level Agreement block

(NHSE and CCGs) and cost per case income, income from Service Increment for Teaching (SIFT), Postgraduate Medical Education (PGME) and non-patient related income such as rent and recharges.

3.5 The Trust is anticipating an income base of £258m, which includes £1m growth

funding from CCGs. This is a risk to the plan as it has been subject to significant debate in contract negotiations. Therefore, any variation to this will need to be managed through identifying additional QCIPs or potential service redesign.

3.6 The generic national uplift includes a 2.0% efficiency target deducted at source.

This is assumed to be delivered by all Trusts. 3.7 The overall budget includes £14m of centrally held budgets. These will be allocated

to the CSUs and corporate directorates during the year to fund certain income/cost pressures/initiatives as they materialise (see Table 2)

Table 2: Centrally held budgets

Centrally-held budgets: £’000 WLFS overspend 3,500 Specialist & local services 0 E&F overspend 500 Pay reserves (including apprentice levy) 4,000 Non-pay inflation 1,500 Contingency/risk 2,821 Surplus 2,470 Total 14,791

3.8 The Agenda for Change pay uplift has not yet been announced. However, the plan

assumes a 1% increase plus incremental drift. The pay award increase will be covered by the pay reserve which also includes reserves for consultant incremental drift, medical awards, the apprenticeship levy and pension changes.

3.9 The centrally held budgets also include £4m to cover predicted overspends in West

London Forensic service and Estates & Facilities, which will need to be further managed downwards during the financial year. There is also a £2.8m (1%) contingency/risk reserve – which has been increased from 2017/18 to mitigate against any potential QCIP slippage or specific additional cost pressures relating to the Broadmoor move. In addition to this all the relevant Q&I funds have been transferred to the CSUs/corporate budgets, and as such there will be no further Q&I budget available centrally.

3.10 Table 1 clearly highlights that in order for the Trust to achieve its planned position of

£2,470k surplus (net of STF funding of £1,986k), the full value of planned QCIPs (£8.6m) needs to be delivered in full. The QCIPs target of £8.6m presents approx. 3.3% of Trust income (or 3.9% of controllable spend) - which will be challenging to deliver. Additionally, it assumes that the CSUs will manage within the set control total.

4 2018/19 Capital plan 4.1 The Trust has submitted a capital plan for 2018/19 of £33.9m to the Department of

Health. This figure relates to the extended plan of £27.4m plus a further £6.5m in relation to forecast underspend on the Broadmoor redevelopment in 2017/18. The plan includes £17.3m for the balance of the Broadmoor redevelopment (Phase 1 completion) and £8m in relation to Medway Lodge, see table 3 summary below. Further details to be submitted to NHSI are shown in appendix 2.

Table 3: 2018/19 Capital Programme

4.2 The capital programme for 2018/19 will be funded through £14m depreciation with

the remainder by a Trust cash contribution in lieu of the sale of the old Broadmoor site in 2020/21. The impact of this contribution on the balance sheet and cashflow is detailed in section 6.

5 Quality Cost Improvement Plans 2018-19

5.1 The Trust needs to apply a £8.6m cost reduction programme in 2018-19, which

includes the 2% national efficiency savings target on the overall Trust budget plus any previously unmet QCIP targets. Due to a number of exclusions such as capital charges and contracts exempt from QCIPs a 2.8% cost reduction has been applied to the individual CSUs/corporate to enable delivery of the total required QCIPs for 2018-19.

5.2 Table 3 outlines the QCIPs target by each CSU/Corporate areas. The NHSI plan

assumes that the identified QCIPs will be delivered in full. Further details of the individual QCIPs schemes can be found in Appendix 3

PlanDescription 31/03/2019

£'000Broadmoor Redevelopment 17,346Medway Lodge Maintenance 8,000Backlog / Regulatory / Environment 4,125Business Technology 1,500Local Services Re-Provision of Accommodation 500Paddock Refurbishment 500Broadmoor Retained Estate Projects 500THW Environmental Improvements 400Other / Contingency 1,026Total Capital Expenditure 33,897

Table 4: Financial efficiency plans by service

Directorate 2018-19

CIPs QCIPs relating

to previous years

Total QCIPs identified

Specialist and Local Services 2,597 1,697 4,294 3,626 West London Forensic Services 825 684 1,509 1,523 High Secure Services 969 1,000 1,969 868 Estates & Facilities 308 107 415 675 Corporate 457 457 1,981 Total 5,156 3,486 8,644 8,673

5.3 The Trust has identified £8.7m savings for 2018/19, which is slightly above the required amount. However a number of these schemes are at an early “work in progress” stage and do not have worked up Project Initiation Document (PIDs). In addition, other QCIPs are reliant on the Broadmoor move, which is unlikely to happen during 2018/19 and as such may not deliver the full amount - these schemes have been rated RED. Any slippage in the CIPs relating to the Broadmoor move which the CSU is unable to achieve will be covered using the risk reserve. This has been increased to support this potential requirement.

5.4 Of the £8.7m QCIPs identified, 20% relate to non-recurrent schemes and as such

will need to be identified recurrently in 2019/20. This is an improved position compared to previous years, but it does pose an additional pressure for 2019/20. The chart below shows a breakdown of the QCIPs, by pay, non-pay and income.

5.5 In relation to the financial deliverability of the 45 currently identified schemes, 22 (£4,727k) have been rated GREEN, 21 have been rated AMBER (£3,261k) and 2 schemes have been rated RED (£700k) as highlighted in the chart below. It is essential that schemes that have been rated and GREEN and AMBER are able to deliver as plan, as these account for the 92% of the total. Any deviation from this will pose a material risk to the Trusts ability to deliver the required surplus.

26%

48%

6%

20%

Non- pay

Pay (skill mix)

Pay (WTE reduction)

Income

5.6 Each QCIP scheme is required to be assessed and signed off by the Medical

Director and/or Director of Nursing and approved by the Trust Management Team (TMT). The Trust continues to hold a month Finance Oversight Leadership Group which is chaired by the Chief executive and attended by all Executive and clinical directors who have overall responsibility for delivery of QCIPs and are held accountable for progress on each of their schemes. On-going assurance of their delivery will be monitored through the Finance and Performance Committee. This will ensure that corrective action is taken as soon as any variance arises. The findings of this committee will are shared with the Board.

5.7 Expenditure on agency staff is one of the key targets from NHSI, which will also

contribute to the planned savings and the Trusts ability to deliver the required surplus. Appendix 3 provides details of what was submitted within the draft plan to NHSI. The target spend for 2018/19 is £12m, to which there is a delivery risk detailed in section 5.10 below. In order to achieve this position, the plan assumes the following changes:

2017/18 FOT 2018/19 plan % changes Substantive post 147,051 155,280 5% Bank 16,499 16,644 1% Agency 15,893 12,689 -20% Total 179,443 184,613 3%

• Doesn’t include capital transfer and apprentice levy

5.8 Agency expenditure significantly reduced in 2017/18 compared to the previous

year (c£6.5m). This was the result of work within HR to increase the size of the Trust internal bank including ensuring that all that all administrative and clerical temporary posts are sourced through the bank, increasing the capacity of the nursing bank, encouraging all AHPs to transfer to bank through matching rates and recruiting to vacant posts.

5.9 This work will continue throughout 2018/19 to enable a further reduction of £3m.

In addition to the above, the HR department has begun a programme of “deep dive performance meetings” within Specialist and Local Services, to understand and challenge agency expenditure, which contributed to 85% of total agency spend in 2017/18.

5.10 However, whilst there is confidence that discretionary spend on agency usage,

and the vacancies that contribute to agency expenditure can be reduced, the

High risk Meduium risk Low risk£'000s 685 3,261 4,727QCIPs scheme 2 21 22

01,0002,0003,0004,0005,000

impact of an insufficient allocation of doctors in training in the February rotation will impact on the Trusts ability to control medical agency spend. The Trust is working with other London mental health trusts to achieve a coordinated approach to medical agency usage and price cap breaches.

5.11 In order to secure future supply of qualified nurses the Trust is one of the only

organisations to have developed a nursing apprenticeship programme with Bucks New University and is also undertaking a programme of overseas recruitment. In addition to this, the Trust has implemented a number of recruitment and retention initiatives that will continue in 2018/19, which includes relocation allowance for Band 5 and Band 6 staff, encouraging nursing trainees to work within our Trust, developing career pathways for all nurses, increased engagement with dissatisfied nurses and introduction of practitioner roles/higher apprenticeships in health assistant practitioner.

5.12 Details of the plan submitted to NHSI are shown in appendix 4

6 Impact on Balance Sheet/Cashflow of Broadmoor

2018/19 6.1 The capital programme for 2018/19 is £33.9m including £17.3m in relation to the

Broadmoor redevelopment. To fund this programme the trust will rely on internal cash funding resources of approximately £23.5m. Internal funding will be recouped when the old Broadmoor site is sold which is planned for the 2020/21 financial year.

6.2 Table 5 below shows the plan cashflow position at the end of each quarter in

2018/19. As can be seen it is forecast that the Trust will start the year with £57.1m cash and cash equivalents and end the year at £35.1m.

Table 5: 2018/19 plan cashflow extract:

6.3 Table 6 below shows the forecast impact on the balance sheet by quarter

including Q4 2018/19 when the Broadmoor redevelopment is planned to be completed and the previous site is impaired to represent estimated sale value.

STATEMENT OF CASH FLOWSForecast Out-turn Plan Plan Plan Plan Plan

31/03/2018 Q1 Q2 Q3 Q4 31/03/2019

£'000 £'000 £'000 £'000 £'000 £'000Cash flows from operating activitiesOperating surplus/(deficit) 23,415 1,778 1,807 1,875 1,943 22,136Non-cash income and expense:

Depreciation and amortisation 12,691 1,167 1,167 1,167 1,141 13,978(Increase)/decrease in trade and other receivables 1,840 (609) (1,000) (205) (2,773) (1,366)Increase/(decrease) in trade and other payables 1,026 0 305 0 0 (199)Increase/(decrease) in provisions (67) (50) (50) (50) (50) (600)

Net cash generated from / (used in) operations 38,905 2,286 2,229 2,787 261 33,949Cash flows from investing activities

Interest received 140 12 12 12 10 142Purchase of property, plant and equipment (27,534) (2,500) (2,500) (3,000) (3,397) (33,397)Proceeds from sales of property, plant and equipment 9,361 0 0 0 0 0

Net cash generated from/(used in) investing activities (18,033) (2,488) (2,488) (2,988) (3,387) (33,255)Cash flows from financing activities

Loans from Department of Health and Social Care - repaid (3,576) (298) (298) (298) (298) (3,576)Interest paid (2,588) 0 (976) 0 (946) (2,484)PDC dividend (paid)/refunded (15,477) 0 (8,967) 0 (7,667) (16,634)

Net cash generated from/(used in) financing activities (21,641) (298) (10,241) (298) (8,911) (22,694)Increase/(decrease) in cash and cash equivalents (769) (500) (10,500) (499) (12,037) (22,000)

Cash and cash equivalents at start of period 57,829 62,060 60,560 49,060 47,097 57,060Cash and cash equivalents at end of period 57,060 61,560 50,060 48,561 35,060 35,060

Table 6: 2018/19 plan balance sheet extract:

6.4 The reduction in the value of fixed assets will reduce the overall value of the

balance sheet and in turn PDC liability charges. Conversely, depreciation will also reduce impacting on available capital depreciation funding.

6.5 The Trusts plan risk rating across all five metrics is planned to be a 1 throughout the

2018/19 financial year apart from capital service cover rating which is 3 (which relates to the loan taken out for forensic and Broadmoor redevelopments), see Table 7 below.

6.6 The impact of the Broadmoor redevelopment in terms of planned expenditure and

impairments does reduce the Trusts ratio’s in terms of capital service cover and liquidity rating but not to the extent where the rating is impacted. The liquidity days is forecast to reduce from 81 days to 51 days during 2018/19 based on forecast expenditure. The cash held by the Trust would have to reduce by a further £13.7m before liquidity falls below 30 days.

STATEMENT OF FINANCIAL POSITION 05FOTPY 05PLANM03 05PLANM06 05PLANM09 05PLANM12 05PLANCY

Forecast Out-turn Plan Plan Plan Plan Plan

Year Ending Q1 Q2 Q3 Q12 Year Ending

£'000 £'000 £'000 £'000 £'000 £'000Non-current assets

Intangible assets 73 67 61 55 49 49Property, plant and equipment: other 577,500 580,854 584,208 587,562 460,919 460,919Total non-current assets 577,573 580,921 584,269 587,617 460,968 460,968

Current assetsInventories 566 566 566 566 566 566Trade and other receivables 9,095 9,095 9,095 9,095 9,095 9,095Trade and other receivables 1,800 3,000 3,704 3,000 3,000 3,000Cash and cash equivalents 57,060 61,560 50,060 48,560 35,060 35,000Total current assets 68,521 74,221 63,425 61,221 47,721 47,721

Current liabilitiesTrade and other payables: capital (3,000) (4,000) (4,000) (4,000) (2,000) (2,000)Trade and other payables: non-capital (8,244) (17,585) (11,430) (13,867) (7,011) (7,011)Borrowings (3,576) (3,576) (3,576) (3,576) (3,576) (3,576)Provisions (1,100) (1,025) (950) (875) (800) (800)Other liabilities: deferred income (3,200) (3,125) (3,050) (2,975) (2,900) (2,900)Total current liabilities (19,120) (29,311) (23,006) (25,293) (16,287) (16,287)Total assets less current liabilities 626,974 625,831 624,688 623,545 492,402 492,402

Non-current liabilitiesBorrowings (81,817) (80,923) (80,029) (79,135) (78,241) (78,241)Provisions (3,206) (3,131) (3,056) (2,981) (2,906) (2,906)Total non-current liabilities (85,023) (84,054) (83,085) (82,116) (81,147) (81,147)Total net assets employed 541,951 541,777 541,603 541,429 411,255 411,255

Financed byPublic dividend capital 392,444 392,444 392,444 392,444 392,444 392,444Revaluation reserve 189,846 189,846 189,846 189,846 99,846 99,846Income and expenditure reserve (40,339) (40,513) (40,687) (40,861) (81,035) (81,035)Total taxpayers' and others' equity 541,951 541,777 541,603 541,429 411,255 411,255

Table 7: 2018/19 plan risk ratings:

7 Forward projection 7.1 The chart below shows a high-level bridge from the proposed 2018/19 outturn to the

2019/20 expected plan. The plan assumes that the Trusts control total and STP funding remains as per 2018/19 and that the new Broadmoor Hospital will open in April 2019.

7.2 It can been seen from the plan that there is expected to be approximately £4m of

additional cost pressures arising from the move to the new hospital - £2m from a reduction in transitional funding as per the ten year financial plan and c.£2m additional costs made up as follows:

• £455k additional maintenance costs over and above the existing maintenance

budgets (based on available benchmarking information); • £470k additional IT costs including, for example, enhanced system support

costs (e.g. Wifi), patient entertainment systems and the new ASCOM system; • £100k additional estate and facilities team costs;

Plan Risk RatingsForecast Outturn Plan Plan Plan Plan

31/03/2018 Q1 Q2 Q3 Q4

Rating Rating Rating Rating RatingCapital Service Cover rating 3 3 3 3 3Liquidity rating 1 1 1 1 1I&E Margin rating 1 1 1 1 1Variance From Control total rating 1 1 1 1 1

Agency rating 3 1 1 1 1

4,486 4,486 +1,986 +2,000

+7,500 -2,000 -1,986

-1,000 -5,500 -1,000

(8,000)(6,000)(4,000)(2,000)

02,0004,0006,0008,000

10,000

£000

's

2018/19 FOT position to 2019/20 planned position

• £1m redundancy costs resulting from the downsizing of the redevelopment team.

7.3 The impact of the expected national efficiency target of 2% is calculated as £4.5m

as per 2018/19 plus a further £1m to reflect any non-recurrent CIP achievement being carried forward.

7.4 It is further assumed that WLFS will exit 2018/19 with a run rate consistent with a

deficit of no greater than £2m (a £1.5m improvement on the current deficit) and that Estates & Facilities will exit at a break-even run-rate (a £500k improvement).

7.5 Based on the assumptions above, the expected QCIP target for 2019/20 is likely to

be in the region of £7.5m and provides some headroom against further cost pressures that may come to light.

8 Conclusions 8.1 The Trust is anticipating income from SLAs to the value of £258m, discussions are

still underway with commissioners to finalise these figures. 8.2 The Trust has planned to hold a 1% contingency, and is planning to achieve its

control total of £4,456k, which includes £1,986k STF funds. 8.3 The 2017/18 QCIPs target is £8.6m of which there are schemes in plan to cover this

total, work is still ongoing to ensure the PIDS are in place for these schemes. The planned position depends on these QCIPs being achieved in full.

8.4 In addition to the above the Trust needs to further reduce agency expenditure,

which will be challenging in some areas, particularly Medical. 8.5 It is important to emphasise therefore that as new cost pressures arise, expenditure

can only be committed once the source of funding (i.e. the real reduction in expenditure) is also identified. It is not sufficient to simply identify why the over-spending arose – mitigating actions must also be taken.

8.6 The CSUs, particularly Specialist and Local services have indicated that they will be

managing their underlying cost pressures and unmet QCIP relating to previous years in 2017/18. As such, this paper assumes that the Specialist and Local Services CSU will deliver a breakeven position in 2018/19 and deliver their QCIPs in full as no contingency has been provided to support any potential overspend.

8.7 The centrally held budget includes a minimum level of reserves to cover known

commitments, such as pay (including the pension change), non-pay inflation, and increase in interest payable. There is no further funding available to offset further cost pressures other than other identified in this paper.

8.8 Moving into 2019/20 the current planning assumption is the CIP requirement will be

circa £7m (3.1%).

9 Recommendation 9.1 In order to ensure that the Trust is able to deliver as planned, this paper

recommends that the following initiatives implemented in 2017/18 will continue:

a) Scrutiny of all recruitment to vacancies prior to advertising b) All access to temporary staff to be made through the temporary staffing team. c) Review of training costs and increasing “e-learning only” options for mandatory

courses. d) Out-of-hours requests for temporary staff to be approved by the on-call director. e) A ban on the use of Admin & Clerical agency staff. f) Non-pay authorisation levels to be increased. g) A financial control team within Specialist and Local Services to be set up to provide

oversight, challenge and control over service lines to help the CSU achieve the required financial position.

h) Enhanced oversight of e-rostering performance through TMT, and the development of KPIs to be included in the Trust’s IPR.

i) A review of the claiming of expenses (e.g. travel, accommodation, hospitality) to establish whether existing rules are being adhered to (and/or whether they need to be enhanced).

j) In the event that cost reduction plans raise issues regarding service quality, the Medical Director and Finance Director will agree any mitigations and/or further assurance and report to TMT.

9.2 The committee is asked to note the information provided in this report and

recommend approval of the budget to the Trust Board.

Paul Stefanoski

Executive Director of Finance & Business Strategy March 2018

Appendix 1

1 STATEMENT OF COMPREHENSIVE INCOME 04FOTPY 04PLANM01 04PLANM02 04PLANM03 04PLANM04 04PLANM05 04PLANM06 04PLANM07 04PLANM08 04PLANM09 04PLANM10 04PLANM11 04PLANM12 04PLANCY Maincode

Forecast Out-turn Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

31/03/2018 30/04/2018 31/05/2018 30/06/2018 31/07/2018 31/08/2018 30/09/2018 31/10/2018 30/11/2018 31/12/2018 31/01/2019 28/02/2019 31/03/2019 31/03/2019

Expected Year Ending Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Year Ending

Sign £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Subcode

Operating income from patient care activities + 243,484 20,448 20,449 20,450 20,449 20,447 20,450 20,447 20,448 20,450 20,449 20,451 20,450 245,388 SCI0100 FlowOther operating income + 11,603 978 978 979 1,011 1,012 1,013 1,079 1,079 1,079 1,113 1,114 1,108 12,543 SCI0110 FlowEmployee expenses - (177,363) (15,054) (15,060) (15,058) (15,058) (15,057) (15,061) (15,056) (15,060) (15,058) (15,060) (15,052) (15,049) (180,683) SCI0120 FlowOperating expenses excluding employee expenses - (54,309) (4,593) (4,594) (4,593) (4,595) (4,594) (4,595) (4,595) (4,596) (4,596) (4,597) (4,598) (4,566) (55,112) SCI0130 Flow

OPERATING SURPLUS / (DEFICIT) +/- 23,415 1,779 1,773 1,778 1,807 1,808 1,807 1,875 1,871 1,875 1,905 1,915 1,943 22,136 SCI0140 FlowFINANCE COSTS

Finance income + 140 12 12 12 12 12 12 12 12 12 12 12 10 142 SCI0150 FlowFinance expense +/- (2,792) (209) (209) (210) (209) (209) (210) (209) (209) (210) (209) (209) (210) (2,512) SCI0160 FlowPDC dividends payable/refundable i +/- (16,473) (1,277) (1,277) (1,278) (1,278) (1,278) (1,278) (1,278) (1,278) (1,278) (1,278) (1,278) (1,278) (15,334) SCI0170 Flow

NET FINANCE COSTS +/- (19,125) (1,474) (1,474) (1,476) (1,475) (1,475) (1,476) (1,475) (1,475) (1,476) (1,475) (1,475) (1,478) (17,704) SCI0180 FlowOther gains/(losses) including disposal of assets +/- 3,717 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0190 FlowShare of profit/ (loss) of associates/ joint ventures +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0200 FlowGains/(losses) from transfers by absorption i +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0210 FlowMovements in fair value of investments, investment property and financial liabilities +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0220 FlowCorporation tax expense - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0230 Flow

SURPLUS/(DEFICIT) FOR THE PERIOD/YEAR +/- 8,007 305 299 302 332 333 331 400 396 399 430 440 465 4,432 SCI0240 FlowPrior period adjustment i +/- 0 SCI0250 Flow

SURPLUS/(DEFICIT) FOR THE PERIOD/YEAR PER ACCOUNTS +/- 8,007 305 299 302 332 333 331 400 396 399 430 440 465 4,432 SCI0260 Flow

2 Adjusted financial performance 04FOTPY 04PLANM01 04PLANM02 04PLANM03 04PLANM04 04PLANM05 04PLANM06 04PLANM07 04PLANM08 04PLANM09 04PLANM10 04PLANM11 04PLANM12 04PLANCY Maincode


31/03/2018 30/04/2018 31/05/2018 30/06/2018 31/07/2018 31/08/2018 30/09/2018 31/10/2018 30/11/2018 31/12/2018 31/01/2019 28/02/2019 31/03/2019 31/03/2019


Sign £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Subcode

Surplus/(deficit) for the period/year including STF +/- 8,007 305 299 302 332 333 331 400 396 399 430 440 465 4,432 SCI0270 FlowAdd back all I&E impairments/(reversals) i +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0280 FlowAdjust (gains)/losses on transfers by absorption +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0290 Flow

Surplus/(deficit) before impairments and transfers +/- 8,007 305 299 302 332 333 331 400 396 399 430 440 465 4,432 SCI0300 FlowRetain impact of DEL I&E (impairments)/reversals i +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0310 FlowRemove capital donations/grants I&E impact i +/- 23 2 2 2 2 2 2 2 2 2 2 2 2 24 SCI0320 FlowRemove prior period adjustments to correct errors and other performance adjustments i +/- 0 0 SCI0330 FlowRemove impact of 1617 STF post accounts reallocation +/- 0 0 SCI0331 Flow

Adjusted financial performance surplus/(deficit) including STF i +/- 8,030 307 301 304 334 335 333 402 398 401 432 442 467 4,456 SCI0340 FlowControl totals including STF i +/- 5,239 307 301 304 334 335 333 402 398 401 432 442 467 4,456 SCI0350 FlowPerformance against control total including STF +/- 2,791 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0360 Flow

Adjusted financial performance excluding STFAdjusted financial performance surplus/(deficit) including STF +/- 8,030 307 301 304 334 335 333 402 398 401 432 442 467 4,456 SCI0362 FlowLess sustainability & transformation fund (STF) - (1,414) (99) (99) (100) (132) (132) (133) (199) (198) (198) (232) (232) (232) (1,986) SCI0364 Flow

Adjusted financial performance surplus/(deficit) excluding STF +/- 6,616 208 202 204 202 203 200 203 200 203 200 210 235 2,470 SCI0366 FlowControl total excluding STF +/- 3,826 208 202 205 202 203 201 203 199 202 200 210 235 2,469 SCI0368 FlowPerformance against control total excluding STF +/- 2,790 0 0 (1) 0 0 (1) (0) 1 1 (0) (0) (0) 1 SCI0369 Flow

3Earnings Before Interest, Taxation, Depreciation and Amortisation (EBITDA) 04FOTPY 04PLANM01 04PLANM02 04PLANM03 04PLANM04 04PLANM05 04PLANM06 04PLANM07 04PLANM08 04PLANM09 04PLANM10 04PLANM11 04PLANM12 04PLANCY Maincode


31/03/2018 30/04/2018 31/05/2018 30/06/2018 31/07/2018 31/08/2018 30/09/2018 31/10/2018 30/11/2018 31/12/2018 31/01/2019 28/02/2019 31/03/2019 31/03/2019


Sign £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Subcode

Operating surplus / (deficit) +/- 23,415 1,779 1,773 1,778 1,807 1,808 1,807 1,875 1,871 1,875 1,905 1,915 1,943 22,136 SCI0370 FlowAdd back depreciation and amortisation + 12,691 1,167 1,167 1,167 1,167 1,167 1,167 1,167 1,167 1,167 1,167 1,167 1,141 13,978 SCI0380 FlowAdd back all I&E impairments/(reversals) +/- 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0390 FlowLess donations of physical assets (non-cash) - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0392 FlowLess cash donations / grants for the purchase of capital assets - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 SCI0394 Flow

EBITDA +/- 36,106 2,946 2,940 2,945 2,974 2,975 2,974 3,042 3,038 3,042 3,072 3,082 3,084 36,114 SCI0400 FlowIncome relating to EBITDA + 255,087 21,426 21,427 21,429 21,460 21,459 21,463 21,526 21,527 21,529 21,562 21,565 21,558 257,931 SCI0402 FlowEBITDA percentage % 14.2% 13.7% 13.7% 13.7% 13.9% 13.9% 13.9% 14.1% 14.1% 14.1% 14.2% 14.3% 14.3% 14.0% SCI0404 Flow

Appendix 2

i i i i i i i i i i i i i i i i i i i i i i

1 Capital Schemes 15CAP01A 15CAP01B 15CAP01C 15CAP01D 15CAP01E 15CAP01F 15CAP01G 15CAP01H 15CAP01P 15PLANM01 15PLANM02 15PLANM03 15PLANM04 15PLANM05 15PLANM06 15PLANM07 15PLANM08 15PLANM09 15PLANM10 15PLANM11 15PLANM12 15PLANCY 15PLANFY 15PLANFY2 15PLANFY3 15PLANFY4 15PLAN5YR 15CAP01I 15CAP01J 15CAP01K 15CAP01L 15CAP01M 15CAP01N 15CAP01O Maincode

Capital Scheme Grant/Donat

ion Scheme Category DHSC Programme

Asset

SchemeIFRS

Expenditurey

CommittedPlanned funding

method

reference number Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

Scheme Start Date

Scheme End Date

Ongoing Scheme

costs of scheme

Scheme Need

and

Funding

Expenditure

and

Desc Desc Desc Desc Desc Desc Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

31/03/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 30/04/2018 31/05/2018 30/06/2018 31/07/2018 31/08/2018 30/09/2018 31/10/2018 30/11/2018 31/12/2018 31/01/2019 28/02/2019 31/03/2019 31/03/2019 31/03/2020 31/03/2021 31/03/2022 31/03/2023 31/03/2023 31/03/2023 31/03/2023 31/03/2023 01/04/2023 31/03/2023 31/03/2023 31/03/2023

Expected 5 Year Plan 5 Year Plan 5 Year Plan 5 Year Plan 5 Year Plan 5 Year Plan 5 Year Plan 5 Year Plan 5 Year Plan Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Year Ending Year Ending Year Ending Year Ending Year Ending 5 Year Plan 5 Year Plan 5 Year Plan 5 Year PlanPost 5 Year

Plan 5 Year Plan 5 Year Plan 5 Year Plan

Sign FREE TEXT DROP-DOWN DROP-DOWN DROP-DOWN DROP-DOWNDROP-DOWNDROP-DOWN DROP-DOWN FREE TEXT £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 DD/MM/YY DD/MM/YY DROP-DOWN £'000 DROP-DOWNLOCKED TEXTLOCKED TEXT Subcode

Capital Schemes i

Capital Scheme 1 + Broadmoor Redevelopment New Build - Land, buildings and dwellings Non central programme Non-IFRS Y Internally Funded 1,445 1,445 1,445 1,445 1,445 1,445 1,446 1,446 1,446 1,446 1,446 1,446 4,125 689 1,780 1,690 0 24,500 01/12/2013 01/11/2018 0 Essential - Business

Non central

Non-IFRSInter

CAP0100

Capital Scheme 2 + Backlog / Regulatory / Environment Backlog Maintenance - Land, buildings and dwellings Non central programme Non-IFRS N Internally Funded 343 343 343 344 344 344 344 344 344 344 344 344 8,000 4,125 4,125 4,125 4,125 1,900 01/04/2019 31/03/2023 Ongoing 0 Essential - Business

Non central

Non-IFRSInter

CAP0104

Capital Scheme 3 + Medway Lodge Maintenance Backlog Maintenance - Land, buildings and dwellings Non central programme Non-IFRS Y Internally Funded 666 666 666 666 667 667 667 667 667 667 667 667 1,500 400 0 0 0 6,500 01/04/2017 01/06/2019 0 Essential - Business

Non central

Non-IFRSInter

CAP0108

Capital Scheme 4 + Business Technology IT Non central programme Non-IFRS N Internally Funded 125 125 125 125 125 125 125 125 125 125 125 125 500 1,500 1,500 1,500 1,500 1,700 01/04/2018 31/03/2023 Ongoing 0 Essential - Business

Non central

Non-IFRSInter

CAP0112

Capital Scheme 5 + Local Services Re-Provision of Accommodation Other Non central programme Non-IFRS N Internally Funded 41 41 41 41 42 42 42 42 42 42 42 42 200 1,000 500 0 0 5,300 01/04/2018 31/03/2021 0 Essential - Business

Non central

Non-IFRSInter

CAP0116

Capital Scheme 6 + Landsale 3 Enabling Works Other Non central programme Non-IFRS N Internally Funded 16 16 16 16 17 17 17 17 17 17 17 17 400 500 1,700 2,700 0 50 01/04/2018 31/03/2022 0 Essential - Business

Non central

Non-IFRSInter

CAP0120

Capital Scheme 7 + THW Environmental Improvements Routine Maintenance (non-backlog) - Land, buildings and dwellings Non central programme Non-IFRS N Internally Funded 33 33 33 33 33 33 33 33 34 34 34 34 50 0 0 0 0 2,550 01/04/2018 31/03/2019 0 Essential - Business

Non central

Non-IFRSInter

CAP0124

Capital Scheme 8 + THQ Re-Location Other Non central programme Non-IFRS N Internally Funded 4 4 4 4 4 4 4 4 4 4 5 5 500 50 1,000 1,000 0 3,500 01/04/2018 31/03/2022 0 Essential - Business

Non central

Non-IFRSInter

CAP0128

Capital Scheme 9 + Paddock Refurbishment Routine Maintenance (non-backlog) - Land, buildings and dwellings Non central programme Non-IFRS N Internally Funded 41 41 41 41 42 42 42 42 42 42 42 42 500 1,000 1,000 1,000 0 1,576 01/04/2018 31/03/2022 0 Essential - Business

Non central

Non-IFRSInter

CAP0132

Capital Scheme 10 + Broadmoor Retained Estate Projects Other Non central programme Non-IFRS N Internally Funded 41 41 41 41 42 42 42 42 42 42 42 42 776 400 200 200 0 2,920 01/04/2018 31/03/2022 0 Essential - Business

Non central

Non-IFRSInter

CAP0136

Capital Scheme 11 + Other Other Non central programme Non-IFRS N Internally Funded 64 64 64 64 65 65 65 65 65 65 65 65 0 730 730 730 730 0 01/04/2018 31/03/2023 Ongoing 0 Essential - Business

CAP0140

Gross Capital Expenditure (Including IFRS) 2,819 2,819 2,819 2,820 2,826 2,826 2,827 2,827 2,828 2,828 2,829 2,829 33,897 10,394 12,535 12,945 6,355 76,126 0 CAP0308

Capital Receipts - Disposals at Net Book Value iExchange

DateCompletion

Date recast NBV £'

disposal

proceeeds

(gain) or loss on

Disposals 1 - Broadmoor Hospital 0 (22,612) 0 01/09/2020 01/10/2020 (22,612) (22,612) 0 CAP0312

Total Capital Receipts - Disposals - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (22,612) 0 0 (22,612) (22,612) (22,612) 0 CAP0392

Other Adjustments: Grants/Donations i

Other Adjustments: Grants/Donations 1 - 0 0 CAP0396

Total Other Adjustments: Grants/Donations - 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 CAP0412

Charge against CRL including IFRS impact (NHS TRUSTS ONLY) +/- 2,819 2,819 2,819 2,820 2,826 2,826 2,827 2,827 2,828 2,828 2,829 2,829 33,897 10,394 (10,077) 12,945 6,355 53,514 CAP0416

Project

Desc

Trust scheme 1 E&F workforce savings

Trust scheme 2 Vacancy for Director of C, E & F

Trust scheme 3 Part year sub lease for the Cassel

Trust scheme 4 0.5 WTE of Head of Capital and Estates post

Trust scheme 5 Car park reconfiguration

Trust scheme 6 Cricket Field Grove rates

Trust scheme 7 Night Time confinement - Broadmoor

Trust scheme 8 New Broadmoor Hospital - new clinical model

Trust scheme 9 Skill Mix Review- Male Medium Secure

Trust scheme 10 Reconfiguration of Women’s Services

Trust scheme 11 Standardisation of Forensic Community

Trust scheme 12 Skill Mix Review- Male Low Secure

Trust scheme 13 New models of Care Forensic

Trust scheme 14 Sale of 2 WEMSS beds

Trust scheme 15 Physical health care restructure

Trust scheme 16 Overseas patients

Trust scheme 17 New models of Care CAMHs

Trust scheme 18 Pathology

Trust scheme 19 Inpatients modelling

Trust scheme 20 s12 rota

Trust scheme 21 Vacant central posts (below)

(A) Identified at plan and commencing in 2018/19:

Trust scheme 22 LPS border

Trust scheme 23 Increase AUC NCA target

Trust scheme 24 E&F Catering efficiencies

Trust scheme 25 Full year effect of part year savings from 2017/18

Trust scheme 26 CE budget realgnment

Trust scheme 27 Comms budget

Trust scheme 28 Business and Strategy budget realignment

Trust scheme 29 HR

Trust scheme 30 Finance

Trust scheme 31 IM&T

Trust scheme 32 Nursing

Trust scheme 33 rates changes

Trust scheme 34 Review of medical retirement costs

Trust scheme 35 PHC budget realignment

Trust scheme 36 Social work budget realignment

Trust scheme 37 Re-banding of B5 to B3

Trust scheme 38 Polygraph testing and increase anti Stigma incom

Trust scheme 39 Underspend from vacant post

Trust scheme 40 Review of admin budget

Trust scheme 41 S12 admin

Trust scheme 42 Comm management post

Trust scheme 43 Ealing IAPT Budget Realignment

Trust scheme 44 NR non pay CIPs under development

Trust scheme 45 Meridian savings - Security

Pay (Skills Mix) RecurrentPay (WTE Reductions) Non-recurrentNon-payIncome (Patient Care Activities)Income (Other operating income)

Type of Expenditure / IncomeRecurrent or Non

Recurrent

Desc Desc

DROP-DOWN DROP-DOWN

UnidentifiedUnidentified as a % of

total

Pay (Skills Mix) Recurrent

Pay (WTE Reductions) Non-recurrent

Income (Other operating income) Recurrent


Income (Other operating income) Recurrent

Non-pay Recurrent








Income (Patient Care Activities) Recurrent




Non-pay Recurrent



Pay (WTE Reductions) Recurrent

Where no opportunity has been identified. This can include savings held centrally or allocated to departments or service lines



Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent

Non-pay Recurrent








Non-pay Recurrent

Non-pay Non-recurrent


8,644,000 0 0%

Appendix 3

High risk High risk as a %

of totalMedium risk

Medium risk as a % of total

Low Risk

200,000

105,000

100,000

45,000

60,000

15,000

185,000

300,000

133,500

150,000

72,000

75,750

462,223

500,000

130,000

500,000

500,000

100,000

1,500,000

100,000

231,000

Either actual or anticipated concerns arising from Quality Impact

Assessments (QIA) / and / or high risk of non- delivery

Minimal actual or anticipated concerns arising from QIA or medium risk of non-delivery

No anticipated concerns. No con

deliv

400,000

200,000

66,540

22,399

11,000

10,000

8,000

80,000

73,000

75,000

44,000

83,000

38,000

24,500

20,000

7,500

8,000

100,000

35,000

49,000

40,000

5,831

1,623,000

185,104

985,000 11% 3,260,948 38% 4,427,399

Low risk as a % of total

d or actual QIA ncerns regarding

very

AGENCY STAFF SPEND BY STAFF GROUP i 12FOTPY 12PLANM01 12PLANM02 12PLANM03 12PLANM04 12PLANM05 12PLANM06 12PLANM07 12PLANM08 12PLANM09 12PLANM10 12PLANM11 12PLANM12 12PLANCY 12PLANFY Maincode Out-turn Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

i

Out-turn Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan

31/03/2018 30/04/2018 31/05/2018 30/06/2018 31/07/2018 31/08/2018 30/09/2018 31/10/2018 30/11/2018 31/12/2018 31/01/2019 28/02/2019 31/03/2019 31/03/2019 31/03/2020

Expected Year Ending Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 Year Ending Year Ending

Sign £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Subcode

Non-Medical - Clinical Staff AgencyRegistered Nurses + 5,575 450 450 443 413 410 410 410 410 370 410 370 370 4,916 STC1500

Allied Health Professionals + 1,210 60 60 60 60 60 60 60 60 60 60 60 60 720 STC1520

Other Scientific, Therapeutic and Technical Staff + 1,529 75 75 75 75 75 75 75 75 75 75 50 50 850 STC1530

Health Care Scientists + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STC1540 Technical staff + 2,739 135 135 135 135 135 135 135 135 135 135 110 110 1,570 0 STC1510

Qualified Ambulance + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STC1550

Support to nursing staff + 1,405 100 100 75 75 75 75 75 75 75 75 69 69 938 STC1570

Support to Allied Health Professionals + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STC1580

Support to other clinical staff + 413 20 20 20 20 20 20 20 20 20 20 20 20 240 STC1585

Support to clinical staff 1,818 120 120 95 95 95 95 95 95 95 95 89 89 1,178 0 STC1560

Total Non-Medical - Clinical Staff Agency + 10,132 705 705 673 643 640 640 640 640 600 640 569 569 7,664 0 STC1590

Medical and Dental Staff AgencyConsultants + 2,011 180 180 180 180 140 140 140 140 140 135 135 135 1,825 STC1600

Career/Staff Grades + 1,000 80 80 80 80 80 80 80 80 80 80 80 80 960 STC1610

Trainee Grades + 1,150 50 50 50 50 50 50 50 50 50 50 50 50 600 STC1620

Total Medical and Dental Staff Agency + 4,161 310 310 310 310 270 270 270 270 270 265 265 265 3,385 0 STC1630

Non Medical - Non-Clinical Staff AgencyNHS infrastructure costs + 1,000 90 90 90 90 90 90 90 90 80 80 80 80 1,040 STC1638Any others + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 STC1639

Total non medical - non-clinical staff agency + 1,000 90 90 90 90 90 90 90 90 80 80 80 80 1,040 0 STC1640

Total pay bill - agency staff excluding capitalised staff + 15,293 1,105 1,105 1,073 1,043 1,000 1,000 1,000 1,000 950 985 914 914 12,089 0 STC1645Capitalised staff costs i + 600 50 50 50 50 50 50 50 50 50 50 50 50 600 STC1647

Total pay bill - agency staff including capitalised staff + 15,893 1,155 1,155 1,123 1,093 1,050 1,050 1,050 1,050 1,000 1,035 964 964 12,689 0 STC1650

Report summary Trust board meeting: Part 1 (in public) Part 1

May 2018 Report title:

Medical Director

Executive lead:

Dr Jose Romero-Urcelay

Report authors:

Medical Director


N/A


For approval


To note




No


We innovate – to turn research into practice Improving quality


Compassionate care


Summary This report is to provide the Trust Board with an update on:- • Medical Management • Medical Education • Medicines Management • Research and Development


Trust board meeting (Part 1): 9th May 2018

Medical Director’s Report

1. Purpose 1.1. To inform the board regarding particular developments related to the Medical Director’s

portfolio of responsibilities. 2. Recommendations

2.1. The board is asked to note the report.

3. Areas of responsibility 3.1. Medical Management

The management of the on-call rotas continues to present a significant challenge. A “task and finish group “formed by medical staff from all grades is due to meet to consider options to minimise the impact that the current trainees’ vacancies have on the on-call rotas. The GDPR steering group met on the 24st of April 2018. An action plan has been developed to prepare the Trust to the changes in legislation regarding Data Protection

Electronic Patient Record Development

• With respect to re-procurement of the Electronic Patient Record (EPR), the timescale to make a decision has been put back as the outcome of the community contract bid will not be known until the autumn. The formal review of RiO and Systm1 has been completed and will be presented to TMT in the coming months by Celia Blake and Jonathan Scott.

• Current priorities are progressing as below:

• Clinical Summary Portal: It has now been agreed this will be made available to

practitioners on 4th June. The new risk recording process will go live on September 4th.

• Seclusion and Observations monitoring: The new recording system is in place and no major issues have been raised. Data quality has improved substantially and we anticipate the process will be fully effective before the CQC inspection.

• Physical health portal: Work is being undertaken to review the current version and

develop it to facilitate implementation of the National Physical Healthcare CQUIN.

• External projects: There has been recent involvement with a NW London system called Whole System Integrated Care (WSIC). This system has the potential to integrate physical health care between ourselves and GPs and we anticipate this will be piloted in the coming few months. A universal consent process is now nearing completing which will enable much more widespread use of currently available integration systems

3.2. Medical Education

GMC National Training Survey (GMC NTS)

This survey closed on 2nd May 2018. Response information provided by HEE suggests a completion rate towards 100% for eligible trainees and an estimated 40% of eligible trainers which reflects an improvement on last year. At this point we have not received any alerts regarding patient safety or bullying or undermining.

HEE Visit Action Plan

Following our initial response, we have submitted our first update on the action plan from the HEE Visit on 7th November 2017. In a comprehensive, evidenced, response we have reported on:

o Improved site security measures at St Bernard’s o Trainee safety measures (alarms, bleep systems, personal radios) and the roll out of

enhanced personal security sessions during trainee induction o Physical Healthcare training and trainee inclusion in policy development o Physical Healthcare audit reports across the organisation o The embedding of ‘Junior/Senior’ meetings across the organisation o Measures to develop new trainings posts and strengthen choice and post allocation

2018.04.30-Action

Plan April 2018-DME.d

Doctors in Training (DIT) – Streamlining Programme

The programme has been extended to August 2018 and we will report on progress in our next report.

Recruitment

18 of 20 CT1 vacancies in NW London were filled from the recent round of National Recruitment and appointees have been allocated to training posts from August 2018.

We are awaiting ST recruitment information from HEE and note continuing interest from our ST6’s in recent consultant recruitments.

Response to GMC - v - Bawa-Garba case

Over fifty consultants and trainees attended the event on Wednesday 2nd May 2018 to discuss the issues raised by this high profile case. Ms Kim Tolley, GMC Regional Liaison Adviser, gave a keynote address and gave positive feedback on the manner in which this was received.

3.3. Medicines Management

Pharmacy Service Provision Requests to expand the Pharmacy Service Provision to additional services within WLMHT such as SPA, and Psych liaison cannot not be met by the existing staffing complement. Additionally staffing Levels have been identified as a high risk to business continuity for Pharmacy service provision. Challenges emanating from the initial commission for the Pharmacy service have been further compounded by a high vacancy rate, loss of staff and expertise through retirement and due to a lack of developmental roles and the challenge presented by cost improvement plans. An external review of our Pharmacy services will take place during June 2018

Electronic Prescribing and Medicines Admin (EPMA)

We are waiting confirmation from London Digital for a funding bid for a EPMA project to expand beyond the current limited pilot.

3.4. Research and Development The R&D strategy was presented for consultation to TMT in April. The strategy will be presented to the board in May. Alongside the dementia research portfolio, recruitment to non-dementia research studies across Trust has been on the increase and our clinical studies officers have exceeded their target of recruiting 100 service users and carers to NIHR LCRN portfolio studies in the past 4 months.

4. Recommendation

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

Dr Jose Romero-Urcelay Medical Director

May 2018

Report summary Trust board meeting: Part 1 (in public) May 2018 Report title: Director of Nursing and Patient Experience’s Report

Executive lead: Stephanie Bridger, Director of Nursing and Patient

Experience

Report authors:

Stephanie Bridger, Director of Nursing and Patient Experience


N/A


For approval


To note

Relates to? Strategy & Planning Quality & Safety Performance & Activity Legal & Governance Relationship to Board Assurance Framework? Are any existing risks in the Board Assurance Framework affected?


BAF 7838


Relationship to Trust strategic objectives? Outstanding We coordinate and collaborate – to deliver holistic care


Improving quality


Compassionate care


Summary A standing report is given on the matters of note relating to the responsibilities of the Director of Nursing and Patient Experience. This report notes matters arising since the April 2018 Board meeting. Supporting documents and/or further reading N/A

Trust Board meeting (Part 1): 9th May 2018 Director of Nursing & Patient Experience’s Report

1 Purpose 1.1 This report gives the Board an update on matters relating to the responsibilities of the

Director of Nursing and Patient Experience. 2 Recommendation 2.1 The Board is asked to note the contents of this paper. 3 Activities 3.1 During this reporting period I have undertaken a number of clinical visits. These were

to Horizon and Hope Ward, Melrose Ward (PLACE Assessment), all the wards at Broadmoor and Mott House. I have also attended a national conference: Women in Mental Health Secure Care on 24th April 2018.

3.1 Oliver Shanley, Chief Nurse for London, NHSI/NHSE visited the Trust on Friday 27th

April. He visited Broadmoor Hospital and The Orchard. He was very positive about his visit and spoke to both staff and patients.

3.2 A meeting took place with the CQC on Wednesday the 2nd May followed by an

informal visit to Thames Lodge. 4 Care Quality Commission Quality Improvement Plan 4.1 Progress relating to the CQC Quality Improvement Plan continues to be discussed on

a monthly basis at the CQC Working Group and Quality Committee. Preparations are underway for the Trust wide re-inspection. Communications on the exchange have commenced.

4.2 The Trust wide information requests for the full re-inspections were received on 19th

April 2018. The information requests need to be submitted back to the CQC by the 11th May 2018.

4.3 The Lead inspector met with the team at Broadmoor on 27th April to explain the programme for the full inspection in June.

4.5 They were informed that there will be 30-32 members in the inspection team. A service presentation will take place in the afternoon on Monday 4th June. The main inspection will commence on the Tuesday, Wednesday and Thursday. It was confirmed there would be no more than 3 inspectors on a ward at any one time. Each ward will have a day’s inspection.

The ‘new’ areas of focus will be: • Mail and telephone monitoring • Dress code (infection control) • Physical Health Care i.e. sepsis.

4.6 During the inspection week they will look at IR1s and complaints whilst they are on site.

4.7 The larger number of inspectors means they will be available for the focus groups and

‘drop in’ sessions for staff. 4.8 The lead inspectors from Ashworth and Rampton will be on the Broadmoor inspection

to ensure consistency and the report will go to a panel focused on high secure hospitals.

4.9 The CQC will provide us with comment cards and boxes for patients and staff, before

the inspection and aim to have them collected in time for the BME focus group which is scheduled for the week before the inspection starts.

4.10 On the Friday 8th June Victoria Hart (Lead Inspector) and Emily Watson will attend the

hospital, only to check everything through and pick up on any small issues. They will then provide feedback at 2pm on the Friday.

5 CQC Sexual Safety on Mental Health Wards 5.1 The CQC have been working with NHS Improvement to examine how specialist

mental health NHS trusts in England are reporting patient safety incidents of a sexual nature. As part of this, they analysed nearly 60,000 reports submitted to NRLS by trusts over a three month period. More than 900 of these reports related to sexual incidents on mental health wards. A number of these appeared to describe incidents of sexual assault or harassment; with variation in how staff had categorised these incidents.

5.2 A workshop was convened on Friday 20th April 2018 with Trusts relating to this issue. The Associate Director of Clinical Governance attended this co-production event, along with approximately 100 others from Trusts across the country.

5.3 The event was focused on agreeing what recommendations providers would like to see made, concerning the reporting of, and prevention of sexual safety incidents. The workshop took the form of short scene setting presentations, followed by group discussions; concluding with presentations of group recommendations.

Some key points noted from the day were:

• Using ‘None’ or ‘Low’ as levels of harm after a sexual safety incident is rarely if ever appropriate.

• There was low involvement of safeguarding in sexual safety incidents, across the country – and there should be a very ‘low’ bar set for involvement.

• The standard of reporting (initial and any subsequent RCA investigations) was poor – lacking quality assurance.

• The involvement of other agencies (police, local authorities, third sector) is inappropriately low

• Consideration of physical/sexual health (perpetrator and victim) post an incident was lacking

• There is an overwhelming need to up-skill and engage staff, to allow the right conversations to happen, both amongst staff, and with service users.

• Work needs to happen to support staff to understand sexual safety, and its prevention, as well as including how to manage an incident if/when it happens

• Engagement and leadership and culture on wards/units was stressed as imperative.

• The need to have quality engagement with service users was critical in prevention.

• There was a long debate about single sex v mixed sex wards. Jury remains out.

5.4 The final outcome of the day was that the CQC will produce a national framework/best practice guidelines, whilst engaging NHSI/NHSE in the need to indicate appropriate direction to providers.

5.5 Notwithstanding the ‘framework’, there are a number of points that we can learn from immediately, and integrate into our current work, to improve incident reporting, RCA investigations, and other relevant aspect of the Quality Risk Profile Tool / CQC Action Plan.

5.7 These issues will be dealt with through the Trust Governance processes and safeguarding.

6 Quality Risk Profile Tool (QRPT) 6.1 The Trust provided stakeholders with a first submission of the Quality Risk Profile Tool

(QRPT) evidence, with narrative, at the March 2018 Ealing CCG Clinical Quality Group. The group were asked to review the content and format and provide feedback as required. Following further work involving the Trust and stakeholders, a template has now been agreed that will allow the Trust to demonstrate what progress has been made, and what is planned to mitigate the areas of concern previously identified in the QRPT process. A second update with evidence, has also been provided to Ealing CCG (as lead commissioner for Local services), and NHS Improvement for their review and consideration on 1st May 2018. The QRPT submissions are intended to follow a longitudinal progress across the six QRPT themes identified, linking the work that is being done across the Trust.

6.2 The next update will be submitted for stakeholder review and discussion at the May 2018 Ealing CCG CQG.

7 WLMHT Nursing Engagement Event and NWL Capital Nurse Foundation Programme

7.1 Following our nursing engagement events held on the 1st March 2018 and 3rd April

2018, 38 students are on course to join the Trust once they qualify in September 2018. In this cohort of students, the most requested services were men’s medium secure; Hope and Horizon wards.

7.2 Student feedback was that the recent redecoration projects on both Hope and Horizon

had contributed to increased morale on these wards and the positive shift in recruitment numbers is a welcome development for the respective teams.

7.3 Of the 38 students, 7 are due to join the Capital Nurse Foundation Programme. For

the first time, the Trust will be piloting a cross-CSU rotation where the nurses will complete one rotation in each of the Trust’s CSUs.

7.4 The Capital Nurse Foundation Programme has seen two of the nurse’s progress to

Band 6 roles within the Trust’s community services, including one nurse who trained

via the seconded student route. This development is in line with the strategy to ‘grow our own’ community nurses, nurturing our own locally trained talent.

8 Nursing Degree Apprenticeship 8.1 Our 14 Nursing Degree Apprentices have completed their first week at university and

provided us with really positive feedback on their experiences so far. The Nursing and Workforce Directorates are working closely with the apprentices and their managers, establishing systems for feedback and support in order to provide the best possible learning environments for the apprentices.

9 Carers Week (11-17 June 2018)

9.1 Carers Week is an annual awareness campaign to bring caring right out into the open – recognising and celebrating the contribution carers make to families and communities throughout the UK.

9.2 WLMHT will be supporting the campaign; raising awareness, recognising and celebrating the contribution made by carers as well as affirming our ongoing commitment to implementing the Triangle of Care.

9.3 Carers Week 2018 is made possible by Carers UK joining forces with Age UK, Carers Trust, Independent Age, Macmillan Cancer Support, Motor Neurone Disease Association, MS Society and Which? Elderly Care and kindly supported by Nutricia Advanced Medical Nutrition. The eight charities driving Carers Week are calling on individuals, services and organisations across the country to help carers stay Healthy and Connected – accessing the practical, financial and emotional support they need to maintain their own wellbeing.

10 Service User and Carer Involvement

10.1 A meeting took place on 26th April 2018 with the Director of Nursing and Patient Experience, Deputy Director of Nursing (Corporate) and Jane McGrath West London Collaborative. Further work was completed to put more detail against the underlying principles set out in the service user and carer strategy. A draft of this will be provided to the Service User and Carer Experience sub-committee and a draft implementation plan.

10.2 An initial review of the trusts recovery strategy was presented to the Service User and Carer sub-committee on the 13th March 2018. Workshop with a wider group of service users is planned for mid-June 2018.

11 Allied Health Professions update

11.1 Venus Kan (Occupational Therapist/Vocational Services Manager, Broadmoor) has been nominated for a NHS@70 Parliamentary award by her local MP. Venus said ‘At Broadmoor we are passionate about using occupational therapy to help our patients in their recovery journey. It gives me enormous job satisfaction to see, for example, patients enjoying their work in our gardens and workshops. I am delighted to be nominated for these NHS@70 awards and to attend on behalf of Allied Health Professionals in the NHS and to represent Broadmoor’.

11.2 Recruitment continues to be a significant challenge for AHPs across the Trust. This has recently been compounded by the introduction of the cap for the number of restricted visa’s that will be awarded each month. This has led to a situation where an occupational therapist in one of Recovery Teams (who has worked for the Trust for 2 years) has had her visa renewal application rejected twice, and on the basis of the

new criteria it is unlikely that her application will ever be approved. Wendy Brewer (Director of Organisation Development & Workforce) and I have been in direct contact with NHS Employers and we are in discussion about how best to raise the profile of the impact the visa cap is having on the AHP workforce. We would welcome further suggestions from the Board as to how we might influence this agenda.

Stephanie Bridger

Director of Nursing and Patient Experience 1st May 2018



Executive Director Report – Local Services

Executive lead:

Sarah Rushton, Executive Director of Local Services

Report authors:

Sarah Rushton


n/a


For approval


To note


no






Compassionate care


Summary The report updates the Board on events and issues related to Local Services.


Trust board meeting (Part 1): 9th May 2018 Executive Director Report - Local Services

1 Purpose

1.1 The purpose of this report is to inform the Board of key issues not covered in other specific reports.

2 Recommendations 2.1 The Board is asked to note the report 3 CAMHS crisis care service update, (Alliance) 3.1 I briefed the Board in December 2018 on the new crisis care model and an update

on progress is provided below along with a reminder of the key new components of the service.

3.2 In 2017, WLMHT worked in partnership with CNWL to agree and introduce a new crisis care pathway for young people under the age of 18. The aim is to provide a consistent approach and response to young people across NW London, from the 3 Boroughs in particular, regardless of where they present in crisis.

3.3 A number of related, but independently commissioned, CAMHs components and services have been consolidated to increase capacity and capability to allow for a comprehensive 24/7 CAMHS crisis response team across the 3 boroughs. The service will provide intensive home treatment during daytime and twilight hours with liaison services across 24/7.

3.4 The aims of the service are:

• Provide an evidenced based model of CAMHs crisis support. • Provide a Consultant led/Nurse governed service that is able to respond rapidly and

flexibly to young people in crisis • Work in partnership with existing Tier 2 and 3 CAMHs clinicians as a “bolt on”

service to support a young person in crisis, facilitated by a rapid access and transfer free referral

• Provide a 24 hour, 7 day a week 0-18 crisis response service across Hounslow, Ealing and Hammersmith & Fulham

• Offer phone support for children, young people and their parents/ carers • Offer A&E liaison including timely assessments, consultation and training • Paediatric ward liaison and support for assessments, intervention, consultation and

training • Provide out of hours support in acute settings

• Provide crisis assessment and response for primary care, community CAMHs and home

• Deliver intensive home/ community treatment and outreach alongside community CAMHS clinicians to support medication and therapy interventions.

• Act as a gate keeper to admission and explore alternatives to Tier 4 admission or stay in acute hospital ward, they will be party to all requests for admission, be involved in MHA assessments, be central to decision making process for admission.

• Facilitate early discharges from acute and tier 4 inpatient units and support review of children and young people on paediatric, adult and tier 4 wards.

• Assist the service user and carers to learn from the crisis and support protective factors, coping strategies and crisis management plan to maximise resilience and recovery

• Provide consultation and training to professionals to build capability and capacity to respond to children and young people in crisis.

3.3 The Service had been operating in a shadow up until April 1st. Following the Easter

period the service has gone live and been open to and accepting referrals from local CAMHS and Adult Liaison services.

3.4 The developments since the previous Board report include:

• The team has been recruiting to meet the full staffing complement – currently 80% fully staffed.

• The team has been reviewing all previous out of hours data, A&E, CAMHS admissions across Charing Cross, Ealing and West Middlesex, alongside the presentations at out of area hospitals. This is to ensure we can target staff to be able available at the right time, right place and with the right skills to support young people in crisis.

• There have been workshops for developing a joint model of operation of the service with CCG Commissioners, Like Minded and wider partners to refine the model and to ensure a synchronized NW London approach between the two Trusts.

• There has been close work with CNWL to develop swift referral pathways with CNWL Crisis Team

• Developing pathways with Adult Liaison Service – still to be finalised pending decision on model of delivery agreed with CCG commissioners.

• Service information is being slowly cascaded out to local teams to enable a soft start and avoid a surge in referrals.

• The team has been trained in brief DBT (dialectical behavioural therapy) for adolescents and adopting the approach of the good practice model from NELFT.

• A strategy to reduce agency use in the out of hours provision is underway through developing greater use of bank staff in twilight and weekend shifts. Once the model of service is fully agreed, we can finally implement a staffed 24/7 provision

• Following service user and parent’s workshops, the team has agreed to use the name Alliance to represent its style of working and approach to supporting young people.

3.5 The team was initially based at Heart of Hounslow CAMHs but has subsequently transferred to a temporary location at Brentford Lodge but there are plans to work alongside Adult Liaison Services and be co-located at West Middlesex Hospital. However, if that proves unfeasible then we will explore if can re-develop space at St Bernard’s .

4 Local Services proposed management restructure 4.1 Local Services CSU has opened a staff consultation on the senior structure of the

service. The consultation proposes moving from having two associate directors to a single deputy director role and deleting the current Head of Finance & Performance role and replacing this with a broader role of Head of Finance, Performance & Business Planning.

4.2 The purpose of the consultation is to review the senior management structure in

Local Services in light of the embedding of the clinical director structure. The directly affected posts are; the two associate directors in Local Services and the Head of Finance & Performance.

4.3 The proposed changes would also affect the line management reporting for a number of posts which report to the associate directors. No change is proposed to the clinical director structure.

4.4 At the point at which the service lines were implemented, the associate director

capacity was required to deliver support to the newly appointed clinical directors. As the Local Services Senior Management Team matured, the associate director roles were reviewed and redefined with one AD role focusing on operational support to the service lines and the other on business planning, contracting and governance. With the maturity of these roles, the same level of support is no longer required.

4.5 Local Services expects each service line to deliver on its cost improvement savings each year, it is also incumbent on the senior management team to consider if CIPs can be delivered as part of that contribution. The annual saving for the new structure is £119,000.

4.3 Should no suitable alternative role be available, the proposal would incur a

redundancy cost for one of the current associate directors of £160,000. The CIP would therefore be fully realisable within 16 months.

5 Hammersmith & Fulham mental health unit reconfiguration

5.1 Local Services senior management team has approved a reconfiguration of H&F

MHU which will move the older adult ward, currently Meridian ward to the ground floor and to be redesigned to improve the functionality of the layout for older people. This will allow us to have a number of bedrooms that would be accessible for disability and the use of hoists.

5.2 The reconfiguration will also enable us to provide sufficient seclusion facilities to

address the CQC concerns from the last inspection on gender separation and safe transfers. In the new configuration both male wards will be on the same floor and will have access to a de-escalation room and a seclusion room. The same facilities will be available on the second floor for women.

5.3 Current configuration of wards Ward Name Floor Ward type Bed Numbers Gender Askew Ground PICU 12 Male Avonmore Ground Male acute

generic 20(22) Male

Lillie 1st Female acute generic

16 Female

Ravenscourt 1st Male acute generic

20(22) Male

Meridian 2nd Older people; acute fucntional(Mixed)

16 Segregated/mixed

5.4 Proposed configuration of wards

Ward Name Floor Ward type Bed Numbers Gender Askew Ground PICU 12 Male

Avonmore Ground Older people (Mixed)

20(22) Segregated/mixed

Lillie 1st Male acute generic

16 Male

Ravenscourt 1st Male acute generic

20(22) Male

Meridian 2nd Female acute generic

16 Female

5.4 The work is currently in the scoping stage and a timetable has yet to be developed

but it is envisaged this will take place within this financial year. 6 Options for the provision of an older peoples recovery

service

6.1 The Trust currently delivers an ‘all age’ adult mental health service which includes those over the age of 65. This service model was developed in 2012 in response to the Age Discrimination Act 2010 and evidence that nationally older people were not receiving the same level of care as those of working age. It was intended to deliver non-discriminatory mental health and care services on the basis of need not age, as well as holistic person-centred older persons health and care services which addressed mental and well as physical health needs. However, since this time guidance from the CQC and Royal College of psychiatrists as well as advice given to CCGs regarding the commissioning of older people’s mental health services has indicated a preference for dedicated older adult’s mental health services.

6.2 The Local Services SMT has therefore taken a decision to review the current

provision for older people and to explore options for a dedicated older people’s recovery service.

6.3 The SMT has received a paper which reviews the current context and possible

options for developing a new older adult’s service which takes into account changing demographics and the need to consider physical as well as mental health needs of this population.

6.4 The preferred option is to develop a separate Older Adults Recovery and

Assessment service (OPRA) to function alongside the CIDS team under the leadership of the CIDS Clinical Director and Service Manager in order to retain the advantages of being led by staff experienced in working with older people without disrupting the existing dementia services which operate to very different work flows. This would develop an Older People’s Service Line.

6.5 The next steps are to carry out more detailed work on how the current structure

within the all age adult recovery teams could be safely disaggregated and to conduct discussion on the model with our commissioners.

7 Other service delivery information 7.1 The Primary & Planned Care service line (PPC) held a productive ‘Moving on’

workshop which established consensus as to the optimal clinical settings across a wide range of clinical presentations. The workshop highlighted the need for ongoing work to support ‘shifting setting of care’ and the need to continue this work within primary care mental health services.

7.2 Dr Zarate takes up her position as consultant in the Hounslow Cognitive Impairment

and Dementia Team on 28th May. 7.3 Meetings to improve the care pathways for patients with dementia are due for

completion this month. This should reduce the time spent by staff completing assessments and improve the waiting times for a diagnosis.

7.4 Concerns due to continued flooding at Sycamore Lodge. This has been an

intermittent issue over the last year. This month we have had to locate staff to other units whilst the issue is being resolved.

Sarah Rushton Executive Director Local and Specialist Services

May 2018

Report summary Trust board meeting: Part 1 May 2018 Report title:

Monthly update from High Secure and West London Forensic Services

Executive lead:

Leeanne McGee, Executive Director of High Secure & Forensic Services

Report author:

Leeanne McGee


n/a


For approval


To note Relates to? Strategy & Planning Quality & Safety Performance & Activity Legal & Governance

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

No



N/a




Compassionate care


Summary Feedback on activities and visits to Broadmoor Hospital and West London Forensic Services. Supporting documents and/or further reading

Trust board meeting (Part 1): 9th May 2018 Monthly Update from High Secure

and West London Forensic Services

1 Purpose 1.1. To update the Board on matters of fact within the High Secure Services CSU and West

London Forensic Services CSU. 2 Recommendations 2.1. The Board is asked to note the contents of this report. 3 Introduction 3.1. The details in this report are to make the Board aware of clinical and salient issues

affecting the services and recommendations, where applicable, of action required or taken.

4 Issues Relating to High Secure and Forensic Services 4.1. General Issues - High Secure Services 4.1.1. The consultation on the revised High Security Psychiatric Services (Arrangements for

Safety and Security) Directions 2013 will open in May and run for 12 weeks through July. Focus groups for patients, staff and carers will be held at Broadmoor in July.

4.1.2. Professor Oliver Shanley (Regional Chief Nurse) NHS England visited a number of

wards and workshops at Broadmoor hospital on the 27th April. 4.1.3. The Moderator of the General Assembly of the Church of Scotland visited Broadmoor

on 11 April and had a tour of the hospital site with the Trust’s Head of Chaplaincy & Spiritual Care.

4.1.4. Delore Jones (PA to Leeanne McGee) will represent the hospital at HM the Queen’s

garden party on 15th May. 4.1.5. Preparation work is ongoing for the CQC inspection of the hospital week beginning 4th

June 2018. 4.2. General issues – Forensic Services

4.2.1. Following the North London Partnership new Model of Care going on live on the 1st

April further engagement events locally have been set up. In addition a meeting with the local CCG’s is being organised.

4.2.2. A number of staff and a service user from The Orchard attended the Women in Secure

Care Conference in London on 24th April. Of particular note was the exceptional presentation made by two service users by experience at the conference. The work presented will inform our local CQUIN for The Orchard in 2018/19.

4.2.3. Professor Oliver Shanley (Regional Chief Nurse) NHS England visited a number of

areas within The Orchard on 27th April. 4.2.4. An Away Day was held on 18th April for West London Forensic Service Senior

Management Team. Included on the agenda were discussions on the service strategy for the next 3-5 years. This will involve consultation with all staff.

5. Conclusion 5.1. The Board is asked to note the contents of this report. 6. Recommendation(s) 6.1. The Board is asked to note the contents of report and agree the proposed actions.

Leeanne McGee Executive Director

High Secure & Forensic Services May 2018


(April) 2018


For approval


To note



7808 4186 4127 5563


No



Improving quality


Report title:

Director of Workforce and OD monthly report

Executive lead:

Director of Workforce and OD

Report authors:

Wendy Brewer


N/A

Compassionate care


Summary This workforce report provides:

• An update on progress measured through the Workforce Performance Report • A review of progress on the introduction of the Trust’s talent management programme • A summary of feedback from new starters and those who are leaving the Trust • An update on the implementation of apprenticeship schemes


Trust board meeting (Part 1): (11th April) 2018

Director of Workforce Update

1 Purpose 1.1 To update the trust board on workforce issues and on progress with the

implementation of the workforce strategy.

2 Recommendations 2.1 The board is asked to note the contents of the paper. 3 Workforce performance report 3.1 There was a general positive movement in all key workforce indicators in March. In

particular it is pleasing to note the sustained reduction in voluntary turnover in staff with less than 1 year’s service. A significant programme of work is now in place to support the retention of this group of staff. The key performance indicators were reviewed at the Workforce Committee in May and these revised indicators will be included in future Board reports. The intention is to ensure that targets are stretching but also achievable and reflect the Trust’s priorities. In order to drive a reduction in the vacancy rate a Recruitment Board has been established.

3.2 Agency expenditure 3.3 The NHSI Agency team visited the Trust on 17th April and provided briefing

sessions to the Executive team, to senior managers and to members of the Workforce team. The feedback provided on the Trust’s performance was detailed and helpful. The team advised the Trust that percentage usage is as important as achieving the overall agency expenditure ceiling target. The Trust has committed to achieving the target of £12.7m for 2018/19 and has submitted a detailed workforce plan that supports this commitment.

4. Recruiting and retaining talent scheme 4.1 The R&R Talent Scheme has now attracted 33 applications to date. 4.2 There is an issue with managers at present not having rated the applications but

this is being addressed through reminders. 4.3 The deadline for applications to the talent pool closes on 18th May 2018 and the

Talent Steering group will meet to review applications on 22nd May 2018. 4.4 Roger Kline, who is the academic who led the development of the national WRES

scheme following the publication of his report, ‘The Snowy White Peaks’ is currently undertaking a review of talent management schemes across the NHS at the request of the DH. He met with Wendy Brewer, Ali Webster and Maggie Morgan Valentine to gain information about our scheme and processes and gave the following

comment, “I met the team leading West London Mental Health Trusts work on talent management. I was really, really impressed. It is a systematic, evidenced and thoughtful approach which I am sure some other trusts can learn from. I came away knocked out”. Roger Kline

5. On-boarder feedback and exit data 5.1 Our On-Boarder feedback for January 2018 to March 2018 based on views of 71

new starters shows a number of improvements including an improvement in new starter engagement of 21%.

5.2 Our recruitment experience is at 96%

Our Induction experience is at 98% Our Local Induction experience 96%

5.3 Based on the first set of on-boarder feedback, an employee handbook was

designed for new starters providing additional information. 5.4 Other interventions include the Promotion, Praise and Promise scheme which will

be launched in May and aims to promote the Trust as a place where careers can thrive by recognizing promotions, providing praise from the CEO via a card congratulating the staff member on their promotions and outlined support available through development opportunities to support them in their new roles.

5.5 Our Exit interview data continues to raise concerns around Bullying and unfairness

with some of our recruitment processes. 5.6 The Promotion, Praise and Promise scheme will also help to promote a culture of

fairness and transparency, once managers are aware that their actions in relation to promotions are being communicated more widely.

5.7 The data shows 29% of leavers within the first 2 years of employment and has

prompted the introduction of ‘Anniversary/Stay’ interviews by managers who will be prompted coming up to the 1 and 2 year anniversaries of their new starters in order for them to have discussions around retention.

5.8 The rehire figure of 62% suggests that staff will consider returning and to promote

this an Alumni group is being established. 5.9 There was a more detailed review of feedback from new starters and members of

staff leaving the Trust at the Workforce Committee meeting in May. 6. Apprenticeships 6.1 The 14 Nursing Degree Apprentices have completed their first week at Bucks New

University and have provided excellent feedback on their experiences.

6.2 Ali Webster, Assistant Director of Workforce presented the work that the Trust has done on Nursing Degree Apprentices at Kings Business School at the Support Worker event in April 2018 which was well received.

6.3 The 9 Chartered Management Degree apprentices have now completed their first

semester as they commenced in January 2018. Again, very positive experiences expressed from members of the group.

7. Recommendations 7.1 The Board is requested to note this update.

Wendy Brewer

Director of Workforce May 2018

7 Nursing Degree Apprentices The 14 Nursing Degree Apprentices have completed their first week at Bucks New University and have provided excellent feedback on their experiences. Ali Webster, Assistant Director of Workforce presented the work that the Trust has done on Nursing Degree Apprentices at Kings Business School at the Support Worker event in April 2018 which was well received.

Nursing Degree Apprentices First Wee 8 Chartered Manager Degree Apprentices The 9 CMDA apprentices have now completed their first semester as they commenced in January 2018. Again, very positive experiences expressed from members of the group –see feedback below.

Chartered Manager Degree Apprentices.d



Monthly communications and engagement report

Executive lead:

Sally Sykes, Director of Communications and Engagement

Report authors:

Sally Sykes, Director of Communications and Engagement Elizabeth George, Head of Communications


N/A


For approval


To note


N/A



N/A




Compassionate care


Summary This paper summarises the recent communications and engagement activity carried out by the Communications and Engagement Team.

Supporting documents and/or further reading In the last month, the communications team has produced a range of materials to support the Trust’s activities, including:

• Film: o We have started filming staff who volunteered to take part in a short film to celebrate

the NHS 70th anniversary.

• Design and copywriting work has included: o Hounslow Mental Health Employment Network Services Directory – design work

under way. o The first of seven key intervention leaflets has been completed – Family Support

and Recovery. We are finalising the additional six leaflets. o We are writing and designing the annual report and annual review. This year, we

are taking a different approach: we will be printing a short version (the annual review) and making a full document including governance details and annual accounts online (the annual report)

o Broadmoor Carers Guide completed • Press

o The Trust’s CEO, Carolyn Regan, was featured in the May edition of consumer trade magazine, Happiful - Happiful article

o We also promoted Carolyn’s article in the Imperial College Health Partners’ newsletter

o We highlighted work done with We-coproduce to develop standards of inpatient care as part of service transformation

https://subscribe.happiful.com/read/d629a19dbc8dd9ddd2725ae2e07e23e4

Trust board meeting (Part 1): Wednesday 9 May 2018 Communications and engagement activity

29 March – 30 April 2018

1 Purpose 1.1 To update the Board on the work of the Communications and Engagement Team.

This report covers the period since the previous board meeting in April. 2 Executive summary 2.1 The board is asked to note the contents of this report, to provide feedback and indicate any

other areas they may wish to see included. 3 Key issues 3.1 External media 3.1.1 The communications team has engaged with external media on the following issues.

• Issued press releases including:

o Launch of coproduced standards of care – the standards and the press release itself were developed with We coproduce (formerly the West London Collaborative)

• The Trust’s CEO contributed to a blog post published by Imperial College Health Partners’

(ICHP).

• Happiful magazine – consumer trade magazine focusing on mental health. Available in all major supermarkets e.g. Sainsbury’s and Waitrose. Q&A feature with Carolyn talking about her LGBT+ work in the Trust, art therapy and a look ahead to the new Broadmoor Hospital. • The communications team prepared communications and confidential board briefings for a

number of incidents and issues including:

o Patient matters o Publication of reports into our work o Freedom of Information requests from media sources o Service continuity issues and potential issues.

3.2 Social media 3.2.1 The Communications Team uses Twitter as its primary social media platform. Between 29

March and 30 April 2018, the Trust’s Twitter following has grown by 64 to a total of 3,761. In addition it has earned:

• 43,600 impressions (this is the number of people who have seen our social media

content) • 102 retweets (onward sharing of our content) • 144 likes (a further measure of engagement)

http://www.wlmht.nhs.uk/news-events/coproduced-new-vision-for-standards-of-care-on-inpatient-wards/

https://imperialcollegehealthpartners.com/carolynregan/

https://subscribe.happiful.com/read/d629a19dbc8dd9ddd2725ae2e07e23e4

• 101 clicks on links through to additional content.

3.2.2 During this period our tweets included:

• Promoting our new refurbished gym at St Bernard’s. • Pushing the Quality Awards nomination deadline – and exceeding last year’s number of

entries at now over 450. • Celebrating our staff’s nominations in the NHS 70 Parliamentary Awards . • Signposting to Carolyn’s interview in Happiful magazine • We’ve taken part in #NationalWalkingMonth and #NationalPetDay.

3.2.3 A tweet anticipating the May edition of Happiful featuring Carolyn Regan gained the highest

impressions (1,942) in this period. 3.3 Website 3.3.1 The Trust’s website is constantly being updated with new content, news stories and links to

significant content or microsites. Below are some overall statistics for visitors to the Trust’s site and other microsites the Communications Team runs.

• During this period, we have had 25,996 sessions, 16,702 of which were new visitors to

the website. • More than half of visitors came to the site via a search tool, such as Google. • The careers site had 2,121 sessions in the same period – most of which resulted in a

job search. • The use of mobile devices continues to increase, with almost half of all visitors

accessing the site using a mobile phone or tablet. 3.3.2 We have launched a plan to redesign the website and we have put out a call via Executive

Directors for content to be reviewed and updated. Departments have been sending in their updates and changes. Phase 2 of the plan ‘development’ is underway, with expected completion June 14th.

3.3.3 The communications team is also continuing to develop the perinatal mental health service

microsite. The perinatal team is currently consulting service users about what they want to see.

3.4 Exchange and internal communications: 3.4.1 In April, Chief Executive Carolyn Regan’s blog highlighted key issues for the Trust including

the recent High Sheriffs’ awards at Broadmoor, the staff survey results, our Information Governance compliance rate and the need to carry out Performance Development Reviews. The blog post received 2,106 hits with 15 comments from staff.

3.4.2 The Communications team promoted a range of events and stories to staff, notably:

o NHS incident – breast screening error o Preparing staff for our CQC inspection with checklists o PDRs/Appraisal information o Information on GDPR o Mental Health Awareness Week o Promoting Sally Glen as Freedom to Speak up Guardian o Physical healthcare policy launch event o Guidance on the Trust renaming

o Announcing our flu vaccination uptake (overall, 38.7%) 3.4.3 An analysis of the most read news stories on the Exchange shows the most popular in

March were (most popular first):

Spring issue of @WestLondon Employee of the Month – Appia Oyinka Planned tube strikes Appraisals/PDR Red parking permit renewal Last day to nominate for Quality Awards

3.5 Patient and carer engagement 3.5.1 The communications and engagement team has supported communication with patients

and carers by drafting materials to support the Triangle of Care. 3.5.2 We produced a comprehensive new Broadmoor carers’ guide. 3.6. Staff engagement 3.6.1 During this time, the communications team organised a listening event with Carolyn Regan

and Jose Romero-Urcelay at Trust Headquarters. A summary of the event was published on the Exchange.

3.6.2 April’s Employee of the Month award went to Kay Sondhi. 3.6.3 We continued to promote nominations for the Quality Awards 2018 (20 September 2018). 3.6.4 We heard that two of our nominations for the NHS70 Parliamentary Awards have been put

forward by MPs Andy Slaughter and Maria Miller. The two staff members are Venus Kan and Saeed Khalilirad. We are promoting on the Exchange and social media, and will issue a press release.

3.7 Service line communications - High secure and forensic services 3.7.1 The Communications Team has undertaken a number of service line specific activities:

• The Transitional Events Programme has been further developed with patients to

provide momentum and enthusiasm for the move to the new hospital including a range of events, including one to mark NHS 70.

• Members of the redevelopment team will be attending the May hospital wide Occupational Therapy meeting to discuss details of the transitional art competition and ways of getting patients involved.

3.8 Service line communications – Local and specialist services 3.8.1 The Communications Team produced the first issue of Transformation News outlining

developments in the local services transformation programme and distributed this to local services staff and external stakeholders, including GPs.

3.8.2 We are working with the psychiatry liaison colleagues to commission a short recruitment

film.

3.8.3 We are producing a range of new leaflets for service users including Cognitive Behavioural Therapy and Decluttering.

3.9 Stakeholder engagement 3.9.1 Stakeholder engagement has been limited during this period due to the election purdah.

The communications team supported a meeting the Trust Chief Executive and Chair held with Ruth Cadbury MP for Brentford and Isleworth.

3.9.2 Mental health leaders and experts by experience, Tony and Angle Russell of Positive

Practice in Mental Health http://positivepracticemh.com/ visited new Broadmoor, toured the hospital and spoke positively about their visit on social media afterwards.

3.10 Communications and engagement staffing 3.10.1 We have appointed an interim Communications Officer, Dee Noel, and will be advertising

for a permanent post holder. The first round of advertising for a permanent Web and Design Manager did not secure enough suitable applicants so we will be re-advertising in a wider range of outlets. The Head of Communications has been given a six month contract. An interim Director of Communications and Engagement – Henrietta Joy will start with the Trust on 22 May 2018.

Ends/

http://positivepracticemh.com/

13. Nurse staffing (REPORTING May 18) (Mar 18 figs) V2 Page 1 of 8

Report summary Trust board meeting: Part 1 (in public) May 2018 Report title: Nurse and Health Care Assistant Staffing Levels –

Exception Report to the May 2018 Trust Board meeting, which includes March 2018 data

Executive lead: Stephanie Bridger Director of Nursing & Patient Experience

Report authors:

Stephanie Bridger Director of Nursing & Patient Experience Gillian Kelly Deputy Director of Nursing (Corporate)


n/a


For approval


To note


No

If yes, insert relevant risk reference: Do you recommend a new entry to the Board Assurance Framework (i.e. Trust-wide level 1 risk) is made?

No



Improving quality


Compassionate care


Summary The May 2018 safer staffing report to the Board sets out the March 2018 data. On the basis of three shifts per day (early, late and night) for 31 days on 51 in-patient areas, there were a total of 4,743 shifts. Of those, 64 (3%) were RAG rated as red, this is an increase from February 2018 when 15 (0.4%) of shifts were RAG rated as red. The increase in red rated shifts being reported is noteworthy. This change may reflect an emerging theme whereby there is an increase in red rated shifts during March. This change, although not as great as March 2017, could be attributable to the management of annual leave and will continue to be monitored. It is of note that incident forms have not been completed for all red RAG rated shifts and therefore incident data does not correspond with the number of reported red rated shifts, which is an ongoing concern. The Board can be assured there is local monitoring and oversight of staffing. The Board can also be assured that the Nursing Directorate, in collaboration with operational and profession leads, has undertaken a review of our safe staffing monitoring arrangements in light of the National Quality Board’s (NQB’s) Safe, sustainable and productive staffing - An improvement resource for mental health – First Edition (January 2018). An action plan to enhance and standardise our monitoring and reporting arrangements has been developed. The biannual safe staffing report to the Board is provided under separate cover. Supporting documents and/or further reading Full details of all red rated shifts are reported within section 4 (below) and Trustwide Nurse and Health Care Assistant staffing fill rates are provided in Appendix 1.

Trust board meeting (Part 1): May 2018 Registered Nurse and Health Care Assistant Staffing

Levels – Exception Report: March 2018 1 Purpose 1.1. The purpose of this exception report is to advise the Board of shifts within the

Trust’s in-patient areas, where Nurse and Health Care Assistant staffing levels fell below planned requirements and due to being regarded as having an impact on care or being potentially unsafe, were escalated to senior nurses or site managers who employed contingency plans.

2 Recommendation(s) 2.1 The Board is asked to note the contents of this paper. 3 Introduction

3.1 This report is provided in accordance with the expectations set out in the National

Quality Board Guidance (2013, 2016 and 2018) that Trust Boards take full responsibility for nursing and care staffing capacity and capability.

3.2 In March 2018, the Nursing Directorate, in collaboration with operational and profession leads, undertook a review of our safe staffing monitoring arrangements in light of the National Quality Board’s (NQB’s) ‘Safe, sustainable and productive staffing - An improvement resource for mental health’ – (NQB, 2018). An action plan to enhance and standardise our monitoring and reporting arrangements has been developed. The biannual safe staffing report to the Board is provided under separate cover.

3.3 All 51 in-patient areas within the Trust have reported the details of their staffing levels on a shift by shift basis for the month of March 2018.

3.4 Managers are required to report their planned numbers of registered nurses and

health care assistants on duty, against the numbers actually present on shift. Each shift was then RAG rated as follows:

Green Staffing meets planned requirement Amber Staffing does not meet planned requirement but is safe Red Staffing does not meet planned requirement and this has been

escalated to a senior nurse or site manager 3.5 This exception report provides details of all shifts that were RAG rated red during

March 2018. On the basis of three shifts per day (early, late and night) for 31 days on 51 in-patient areas, there were a total of 4,743 shifts. Of those, 64 (3%) were RAG rated as red, this is an increase from February 2018 when 15 (0.4%) of shifts were RAG rated as red.

3.6 Full details of red rated shifts are reported in section 4, along with reasons given for

not meeting the planned staffing. Where details of mitigation and impact on quality

have been provided, these have been noted. Trustwide Nurse and Health Care Assistant staffing fill rates by hour and site are provided in Appendix 1.

3.7 Safe staffing reports are published on the Trust website monthly; promoting transparency and providing assurance in relation to the Trust monitoring of safe staffing. Our fill rates are reported via monthly UNIFY submission; a requirement of all NHS providers. From 01st April 2018 our UNIFY submission will also include Care Hours Per Patient Day (CHPPD) data, following testing and adaption for mental health inpatient wards.

4 Analysis 4.1 Of 4,743 shifts. Of those, 64 (3%) were RAG rated as red, this is an increase from

February 2018 when 15 (0.4%) of shifts were RAG rated as red. The increase in red rated shifts being reported is noteworthy. This change, although not as great as March 2017, may reflect an emerging theme whereby there is an increase in red rated shifts during March. This change could be attributable to the management of annual leave and will continue to be monitored.

4.2 Chart 1 below shows percentage red RAG rated shifts for the past year.

4.3 Chart 1: Trust - percentage red RAG rated shifts month by month

4.4 Chart 2: Red RAG rated shifts from March 17 to March 18 by CSU

1.03% 0.60% 0.70% 0.63%

1.24%

0.40% 0.40% 0.30% 0.30% 0.50% 0.60%

0.40%

3.00%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

0 0

23

3

17

3 2 1

7

13

5 7

18

4 1

3 6

4 0

7

13

2 0 1 1

3

45

27

9

20

38

16

9

0 4

11

22

7

43

0

5

10

15

20

25

30

35

40

45

50

Mar-17 May-17 Jul-17 Sep-17 Nov-17 Jan-18 Mar-18

LS

FS

HSS

4.5 Chart 2 above shows the number of red rated shifts reported per month by CSU. It

is difficult to draw a conclusion from this data as reporting is also influenced by the reporting culture as much as the incidence of short staffed shifts.

4.6 Full details of all red rated shifts are provided in Chart 3 below along with reasons given for not meeting the planned staffing.

4.7 Chart 3: Red RAG rated shifts for March 18 breakdown by ward

RMN HCA RMN HCALea Mens Medium Secure 18 1 AM 3 2 1 2 Unable to cover shiftGarnet Womens Medium Secure 10 1 AM 2 2 1 1 Unable to cover shiftBarron Mens Low Secure 16 1 AM 2 4 0 3 Unable to cover shift. RMN provided by another ward. Cranfield Ward Mens High Dependency 12 7 AM 4 5 2 3 Unable to cover shift

AM 4 5 2 4 Unable to cover shiftAM 4 5 2 4 Unable to cover shiftPM 4 5 2 4 Unable to cover shiftPM 4 5 3 4 Unable to cover shiftPM 4 5 3 2 Unable to cover shiftPM 4 5 3 4 Unable to cover shiftAM 3 4 4 1 Unable to cover shiftAM 3 4 2 3 Unable to cover shiftAM 3 4 2 3 Unable to cover shiftPM 3 4 3 2 Unable to cover shiftPM 3 4 2 3 Unable to cover shiftPM 3 4 3 2 Unable to cover shiftAM 3 5 4 2 Unable to cover shiftPM 3 5 4 2 Unable to cover shiftPM 3 5 2 4 Unable to cover shiftPM 3 5 2 4 Unable to cover shiftPM 3 5 3 3 Unable to cover shiftPM 3 4 3 2 Unable to cover shiftPM 3 4 2 3 Unable to cover shiftPM 3 4 2 3 Unable to cover shiftPM 3 4 2 3 Unable to cover shiftAM 2 3 1 2 Unable to cover shiftPM 2 3 1 2 Unable to cover shift

Sandown Mens Admission 12 1 AM 3 4 2 3 Unable to cover shiftAM 3 5 2 5 Unable to cover shiftAM 3 6 3 3 Unable to cover shiftAM 3 7 2 5 Unable to cover shiftAM 3 7 3 5 Unable to cover shiftPM 3 7 2 5 Unable to cover shiftPM 3 5 2 4 Unable to cover shiftPM 3 5 3 3 Unable to cover shiftPM 3 5 3 3 Unable to cover shiftPM 3 5 2 3 Unable to cover shiftPM 3 6 2 3 Unable to cover shiftPM 3 7 2 4 Unable to cover shiftPM 3 7 2 5 Unable to cover shiftPM 3 7 2 4 Unable to cover shiftPM 3 5 2 4 Unable to cover shift

Harrogate Mens Rehab 20 1 AM 2 3 2 1 Unable to cover shiftAM 2 3 1 2 Unable to cover shiftPM 2 3 1 2 Unable to cover shiftPM 2 3 2 1 Unable to cover shift

NIGHT 2 5 1 4 Unable to cover shiftPM 2 7 2 5 Unable to cover shiftAM 3 5 3 5 Unable to cover shiftPM 3 3 4 2 Unable to cover shiftAM 3 2 1 3 Unable to cover shiftAM 3 2 2 1 Unable to cover shiftAM 3 2 1 2 Unable to cover shiftAM 2 3 1 3 Unable to cover shiftPM 2 2 1 3 Unable to cover shiftPM 2 2 1 4 Unable to cover shift

NIGHT 2 1 1 3 Unable to cover shiftKestral Mens 20 1 AM 2 2 1 2 Unable to cover shift

AM 3 5 1 5 Unable to cover shiftPM 3 4 2 4 Unable to cover shiftAM 3 3 2 2 Unable to cover shiftAM 3 3 1 3 Unable to cover shiftPM 3 3 2 2 Unable to cover shiftPM 3 3 1 3 Unable to cover shift

64

Newmarket Ward Mens Admission 12 6

Womens 20 2

Kingfisher Mens 20 7

Sandhurst Mens Rehab 12 2

The Limes CIDs 20 2

Step Up Rehab 20 4

Chepstow Mens Medium Dependancy 12 14

Avonmore

Sheffield Mens Rehab 20 3

LSS

Askew Mens PICU 12 2

Magnolia

Mens High dependancy 12 4

HSS

Epsom Mens High dependancy 12 5

Ascot

Actual

WLFS

RED RATED SHIFTS

Mar 2018Ward Type

No

of B

eds

Shift

Exce

ptio

ns

Day /

AM/P

M/N

i

Planned

4.8 The overall sickness rate of registered and unregistered nursing staff in March 2018

was 4.6%. 4.9 Newly available figures from the Corporate Scorecard include the nursing vacancy

rates for March 2018. The vacancy rate of registered and unregistered nursing staff was 20.1%. Vacancy levels remain variable across all wards even with the recent initiatives in respects to recruitment and retention.

4.10 Detailed workforce information is available and triangulated via the workforce

committee and includes nursing establishment WTE, nursing staff in post WTE and nursing voluntary turnover figures.

4.11 A total of 21 incident forms were raised during March 2018 for staffing level

concerns; 9 were received from high secure services, 5 from local and specialist services and 7 from forensic services. It is of note that incident forms have not been completed for all red RAG rated shifts and therefore incident data does not correspond with the number of reported red rated shifts, which is an ongoing concern.

4.12 Chart 5: Staffing Incident Forms completed for March 2018

4.13 It should be noted that high secure services have to deploy staff for a significant number of escorts. A breakdown of these escorts is provided in Chart 6 below.

4.14 Chart 6 High secure staff on escort March 2018

Mitigation and impact of short staffing 5.1 Mitigation plans remain in place as previously detailed to the board of directors. 5.2 The impact of short staffing at Broadmoor Hospital continues to be closely

monitored following feedback from the CQC on the risk to quality.

2 4

2 1 1 1

2 1

6

1 01234567

Cran

field

War

d

Epso

m W

ard

New

mar

ket W

ard

Sand

hurs

t War

d

Aske

w P

ICU

(Loc

al S

ervi

ces -

Inpa

tient

)Av

onm

ore

War

d(fo

rmer

ly A

rea

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ard)

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on /

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r War

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inch

)

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on 1

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Win

drus

h W

ard

HSS LS WLFS

Staffing Levels

13 Patients, 30 episodes Total number of shifts staff were out on LOA duties 140 Total number of shifts patients were out on LOA duties 39 Average staff per escort 3.6

6 Conclusion 6.1 The data available supports the view of staff, managers and the executive team,

that recruiting high quality registered nurses, whilst also remodelling establishments to ensure sustainable staffing, is top priority. The Director of Nursing will provide more analysis on trends overtime and confidence intervals.

7 Recommendations 7.1 Staff to be kept fully informed of newly recruited staff and when they are coming into

post and where. This is now happening in Monday Matters. 7.2 The executive team to continue to monitor very closely the impact of the recruitment

strategies in place and to continue to progress the plans to improve retention. 7.3 The executive team will continue to support an improved use of e-Rostering in order

that the available resource can be used more efficiently and effectively.

Stephanie Bridger Director of Nursing and patient Experience

13. Nurse staffing (REPORTING May 18) (Mar 18 figs) V2 Page 8 of 8

Appendix 1: Trust Wide Fill-Rates by hour and site for March 2018

Day Night

Site Name

Total monthly planned staff

hours

Total monthly

actual staff hours

Total monthly planned

staff hours

Total monthly

actual staff hours


staff hours

Total monthly

actual staff hours


staff hours

Total monthly

actual staff hours

BROADMOOR HOSPITAL 20385 20348 25058 21225 8110 7560 9400 9300 99.8% 84.7% 93.2% 98.9%

THREE BRIDGES REGIONAL SECURE UNIT 16028 15728 15908 19013 8302 7904 6311 7983 98.1% 119.5% 95.2% 126.5%

Thames Lodge 6210 6188 6045 6968 2945 2926 2945 3164 99.6% 115.3% 99.4% 107.4%

ST BERNARD'S WING 3953 3870 4410 5205 1860 1950 3410 3760 97.9% 118.0% 104.8% 110.3%

THE LIMES 930 885 3255 3225 620 600 1550 1530 95.2% 99.1% 96.8% 98.7%

HAMMERSMITH & FULHAM MENTAL HEALTH UNIT 6398 6308 7913 7673 3040 3060 3990 4060 98.6% 97.0% 100.7% 101.8%

LAKESIDE UNIT 4260 3773 3818 4140 2480 2450 2180 2320 88.6% 108.4% 98.8% 106.4%

CLAYPONDS REHABILIATION HOSPITAL 1523 1493 1395 1380 589 570 295 323 98.0% 98.9% 96.8% 109.7%

CASSEL HOSPITAL 1035 975 323 308 295 295 295 295 94.2% 95.3% 100.0% 100.0%

Trust 60720 59565 68123 69135 28241 27315 30375 32734 98.1% 101.5% 96.7% 107.8%

Average fill rate -

registered nurses/midwives (%)

Average fill rate - care staff (%)

Day Night

Registered midwives/nurses Care StaffRegistered

midwives/ nursesCare Staff Average fill

rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

13.1 Biannnual Nurse staffing 6 Month Review April 18 Page 1 of 7

Report summary Trust board meeting: Part 1 (in public) May 2018 Report title: Biannual Review of Safe Staffing

Executive lead: Stephanie Bridger

Director of Nursing & Patient Experience

Report authors: Stephanie Bridger Director of Nursing & Patient Experience And Gillian Kelly Deputy Director of Nursing (Corporate)

Report discussed previously at: n/a


For approval


To note


No

If yes, insert relevant risk reference: Do you recommend a new entry to the Board Assurance Framework (i.e. Trust-wide level 1 risk) is made?

No



Improving quality


Compassionate care


Summary Nursing, midwifery and care staff, working as part of wider multidisciplinary teams, play a critical role in securing high quality care and excellent outcomes for patients. There are established and evidenced links between patient outcomes and whether organisations have the right people, with the right skills, in the right place at the right time. The Deputy Directors of Nursing and Heads of Nursing have conducted safer staffing reviews within their respective services. These reviews are summarised within this paper and the full reviews available on request. The Board can be assured that there is clear process of monitoring and escalating staffing issues across all services. Supporting documents and/or further reading The safe staffing reviews for Broadmoor, West London Forensic Services, and Local and Specialist Services are available on request.

Biannual Review of Safe Staffing 1.0 Introduction

1.1 Nursing, midwifery and care staff, working as part of wider multidisciplinary teams,

play a critical role in securing high quality care and excellent outcomes for patients. There are established and evidenced links between patient outcomes and whether organisations have the right people, with the right skills, in the right place at the right time. Compassion in Practice (2012) emphasised the importance of getting this right, and the publication of the report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry (2013) and more recent reviews by Professor Sir Bruce Keogh into 14 trusts with elevated mortality rates (2013), Don Berwick’s review into patient safety (2013) and the Cavendish review into the role of healthcare assistants and support workers (2013) also highlighted the risks to patients of not taking this issue seriously (Cummings, J. 2014).

2.0 Background

2.1 The evidence base in relation to workforce planning and safe and effective staffing

within mental health settings and older people/rehabilitation services continues to be less well established than that for acute care settings.

2.1 Currently there are no nationally defined minimum safe staffing levels for

community or intermediate care. Further, there is no single ratio or formula that can calculate nursing requirements in inpatient mental health care and there is currently limited methodological evidence to support this calculation. Following completion of a scoping consultation during 2015 NICE decided not to progress the development of safer staffing guidelines for Mental Health services.

2.3 NHS Improvement have developed a Safe, Sustainable and productive staffing

improvement resource for community (District Nursing) and mental health services (1st Edition, January 2018). These resources align with the National Quality Board’s (NQB) improvement resource, Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time - safe, sustainable and productive staffing, published in July 2016.

2.4 The Deputy Directors of Nursing and Heads of Nursing have conducted safer

staffing reviews within their respective services. The details have been summarised below, the full papers are available if required.

3 High Secure Services 3.1 A safe staffing review was report was completed in March 2018, including shift

allocation, preferred gender and skill mix required.

3.2 Current vacancies for registered nurses at the end of February was 48 WTE (21% of RN posts), vacancies for Health Care Facilitators was 17 WTE (8% of posts). Total vacancies for ward staff at 14.8 %.

3.3 The hospital has on-site site management to oversee dynamic deployment of staff

24/7, and has an escalation process for staffing issues. There is on call management support to site management, on site medical cover and on call Responsible Clinician cover 24/7.

3.4 Incident reports on staffing, are considered at weekly heads of service meeting. 3.5 Site management log has “real time” staff deployment information, and also key

information of hospital acuity. The hospital also has a daily communications meeting that considers current and planned staffing.

3.6 On-going work in relation to staff recruitment and retention is underway, and is reported to hospital Senior Management Team and Trust.

3.7 Staffing issues and impact is discussed at the hospital Senior Management Team

(SMT) and with patients and the patient’s representatives at the patients’ forum.

3.8 The hospital continues to work on staff development initiatives including work on Nursing Degree Apprenticeships and Nursing Associates.

3.9 The hospital has on-site site management to oversee dynamic deployment of staff

24/7, and has an escalation process for staffing issues. Incident Reports on staffing issues are raised at weekly heads of service meeting.

3.10 Further to a review of budgeted headroom to effective staffing based on parity and

internal and external benchmarking with the other high secure hospitals, Broadmoor Hospital is requesting an increase in headroom from 18% to 22%, this will result in a request for investment in staffing. A paper outlining proposals has been discussed at the hospital SMT and has been provided to Executive Directors.

4 West London Forensic Services (WLFS) 4.1 A safe staffing review report was completed in April 2018, routine discussions at

WLFS SMT, Heads of Service meetings and Nursing leadership meetings have been held to determine safe levels of staffing within WLFS wards. This work has been undertaken within the context of the transfer of medium secure wards to a new purpose built environment (Thames Lodge, Medium Secure Unit), an increase in staffing budget headroom and the regional challenge of recruiting band 5 nurses.

4.2 The qualified nursing staff vacancy rate in WLFS in April 2018 is 16.5%. On-going

work in relation to staff recruitment and retention is underway, and is reported to hospital SMT and Trust.

4.3 All Healthcare assistant posts are currently covered. 4.4 A review of skill mix in Men’s Medium Secure Services was undertaken during

2017. The review was presented to the WLFS SMT for consideration. The SMT agreed a reduction in band 5s from 3 to 2 per shift. This option is modelled on 2 band 5s per shift and replaces the 3rd qualified with a band 4 HCA, i.e. 2 x RMNs, 2 x band 3 HCAs 1 x band 4 HCA with 1 x 9-5 band 3 HCA. The new model has been subject to the necessary quality governance processes and was implemented on 1st April 2018.

4.5 In the last 6 months there has been continuing, comprehensive dialogue between

service lines, human resources and finance about the effective rostering of staff. Significant progress in effective rostering has been made with all WLFS wards completing rosters 6 weeks ahead of time; there is also an improved use of existing staff resource to cover shortfall and an overall reduction in agency staff spend. There is more work to do to ensure that the ratio of temporary staffing does not exceed current vacancy rates.

4.6 The service continues to utilise the safer staffing escalation process set out in the

trust E-Rostering policy (E9). Identified staffing shortfall is reviewed each morning with ward managers, senior nurses and service Director representatives (during the weekend by unit co-ordinators).

4.7 The service continues to review and monitor their staff fill rate on a monthly basis to

ensure that they have achieved all planned shift numbers and skill mix or appropriately escalated to address shortfall.

5 Local and Specialist Services 5.1 A safe staffing review was report was completed in March 2018, the review covers

the mental health unit in each of the three boroughs including The Limes which is a stand-alone Dementia ward. There are a total of 15 wards catering for a wide range of patients – Dementia, PICU, long term rehabilitation and treatment resistant schizophrenia as well as a number of assessment and recovery wards.

5.2 The aggregated vacancy rates for nursing within LSS, across all six service lines, in

March ‘18 is 24.4%. The vacancy rates for nursing staff within inpatients services is particularly high; specifically within Lakeside, Wolsey Wing and The Limes and Jubilee.

5.3 We continue to utilise the safer staffing escalation process set out in the WLMHT E-

Rostering policy (E9). Identified staffing shortfall is reviewed each morning with ward managers, senior nurses and service Director representatives (at weekend by unit co-ordinators).

5.4 We continue to review and monitor our Staff fill rate on a monthly basis to ensure

that we have achieved all planned shift number and skill mix or appropriately escalated to address shortfall.

5.5 Access and Urgent Care (AUC) - Inpatient ward staffing

5.5.1 Since the last staffing review no changes have been made to the nursing staffing

levels on the inpatient wards. However, in Hammersmith and Fulham (H&F) the two 22 bed male assessment and recovery wards have now established a bed base of 20 beds each rather than 22. This has enabled the wards to be staffed on planned numbers rather than increasing staffing (at a cost pressure) to safely manage the additional patients.

5.5.2 In addition from August 2017 the inpatient service in AUC has sustained a bed occupancy of around 85% following a number of interventions to systematically improve flow through the service. Prior to that there was what can only be described as a bed crisis from February 2017 to July 2017 during which time

patients were admitted to ‘non-beds’ such as S136 (Health Based Place of Safety) beds, seclusion room beds, sofas and the private sector.

5.5.3 This bed capacity has also extended to the Local Services PICU in H&F meaning that very disturbed patients can be safely managed in a more appropriate setting where staffing is automatically higher rather than employing additional bank or agency staff on an acute ward.

5.5.4 Following approval by AUC SMT on the 9th October 2017, the service is in the process of re-profiling the specialist assessment and recovery wards as ‘generic’ wards. This means that these nine wards will become acute mental health wards that provide assessment and treatment of an acute phase of treatable mental illness that cannot be managed in the community.

5.5.5 The core nursing establishment of the 9 wards affected by this change will be 2/2/2 registered nurse and 2/2/2 unregistered nurse (early/late/night). Moving to generic wards means a realignment of the staffing establishment required per ward. These shifts will also be supported by a Band 4 Assistant Practitioner (eventually Nursing Associates) on a 9am-5pm, Monday to Friday basis. This role is part of a national initiative, which the Trust is working towards and in AUC for the inpatient service, the roles will be developed to support the inpatient pathway and particularly discharge planning. These are new roles and will require a recruitment drive.

5.5.6 In order to bridge the gap created by the vacant roles, the wards will rotate existing Band 5s (via bank shifts) to cover the Band 4 role as a temporary measure. This will create an additional cost pressure of £10k per ward, per month. The Head of Finance has agreed to this for an interim period up to a maximum of 6 months to cover the role whilst recruiting substantive Band 4 staff.

5.5.7 Recruitment remains the top priority with both the Wolsey Wing and Lakeside MHU having high vacancy levels. Some recruitment has occurred but this remains a significant challenge.

5.5.8 All 3 of the inpatient units retain a Health Based Place of Safety in which to accommodate men or women detained under S136. It is recognised that although a person can be detained at any time of day or night the majority of detentions occur out of hours and/or at weekends. Therefore additional staffing is provided for every night shift and at weekends of 1 supernumerary Health Care Assistant for each Unit (at a cost pressure). Across London there is a pan London group working on how to best provide a S136 service to the whole of London.

5.6 Cognitive Impairment and Dementia Services (CIDS) 5.6.1 Staffing at the Limes and Jubilee has been reviewed taking into account clinical

demands and skill mix. Further work to consult on the shift patterns is underway. 5.7 Meridian Ward 5.7.1 Following a number of discussions and workshops in relation to the purpose and

possible overlap of Meridian and Jubilee wards, a paper was provided setting out a summary of the provision currently available and proposing what is predicted to be necessary. The proposal paper was agreed at the Local Services SMT in January 2018 and a detailed implementation plan will be provided to the SMT.

5.8 Rehabilitation Wards – Planned and Primary Care 5.8.1 Since the last review the staffing regime has not changed. However due to the

clinical demand of the ward situation, both Glyn ward and Mott House have added an additional HCA to their shift patterns. In Glyn ward this is to the early shift and in Mott House it is to the late and night shift. This has been done as a cost pressure and is a temporary measure due to the complex health needs of patients at this given time. It is not expected to be a permanent situation.

5.9 Magnolia Ward - Liaison and Long-term Conditions 5.9.1 Magnolia Ward is a 20 bedded unit based in Clayponds Hospital. It is

commissioned to provide “step up care” as an alternative to an admission in an acute hospital. The ward is a predominantly a nurse led unit with a full physical examination, initial treatment plan and provisional diagnosis being completed on admission by Advanced Assessors.

5.9.2 The ward currently has 3 non-medical prescribers. A ward round with the Home

ward Geriatrician is held x3 per week, out of hour’s medical cover is provided by LCW GPs, including GP attendance for 4 hours per day at weekends.

5.9.3 Over the last year there has been an improvement with the recruitment of both

qualified and HCA staff. There is currently a discussion with finance as to whether there is scope to create a further B6 post using current vacancies.

6 Six month staffing review conclusion 6.1 The detailed reviews for Broadmoor, West London Forensic Services, and Local

and Specialist Services are available on request. The Board can be assured that there is clear process of monitoring and escalating staffing issues across all services.

Stephanie Bridger Director of Nursing and Patient Experience

May 2018

Report summary Trust board meeting: Part 1 (in public) May 2018 Report title:

Level 1 Risk Register & Board Assurance Framework

Executive lead:

Carolyn Regan, Chief Executive

Report authors:

Iscelyn Richards, Trust Secretary


Workforce and Development Committee, 2 May 2018 Finance & Performance Committee, 25th April 2018 Trust Management Team, 25th April 2018


For approval


To note


Yes

If yes, insert relevant risk reference: See paper

Do you recommend a new entry to the Board Assurance Framework (i.e. Trust-wide Level 1 risk) is made?

See paper



Improving quality


Compassionate care


Summary

The Board last reviewed the BAF and Level 1 risk register at its meeting on 11th April 2018. Following discussion at meetings of the Quality Committee, Finance & Performance Committee and TMT, the Board is asked to consider the latest Level 1 Risk Register (attached at Appendix 1). The Board is invited to consider the latest BAF and Level 1 risk register and consider the assurance it receives relating to the management of the most significant risks to the Trust’s achievement of strategic objectives.


The full entries for the BAF and Level 1 Risk Register are available on request from the Board Secretariat, and are presented to Board committees at their respective meetings.

Trust board meeting (Part 1): 8th May 2018 Level 1 Risk Register & board assurance framework

1 Introduction 1.1 The effective application of board assurance arrangements to produce and maintain

the board assurance framework (BAF) helps management and the Board to gain assurance using a formal process that promotes good organisational governance and accountability.

2 Level 1 Risk Register 2.1 There has been one addition to the level 1 risk register since the Trust Board meeting

on 11 April 2018, and two reclassifications of forecasted risk rating.

Trust Management Team – 25th April 2.2 BAF8496 added to risk register and reflects the risk of regulatory intervention and

financial penalties if the Trust is not compliant with the GDPR regulations by 25 May 2018.

Workforce and Development committee – 2 May 2018 2.3 At its meeting on 2 May the Workforce and Development committee considered the

latest version of the level 1 risk register, and agreed the reduction in the forecasted risk rating for the following BAFs:

o BAF8429 - Engagement score from national staff survey: “If the Trust fails to engage with members of staff, this could lead to poor levels of motivation and poor quality of care.”

o BAF8431 - Metrics used for delivery of transformation programmes - e.g. reduction in length of stay: “Risk If the Trust cannot support the people change management aspects of organisation transformation, the required patient care and quality improvements will not occur”

3 Recommendations 3.1 The Board is invited to consider the latest BAF and Level 1 risk register and consider

the assurance it receives relating to the management of the most significant risks to the Trust’s achievement of strategic objectives. The full entries for the BAF and level 1 Risk Register are considered by the respective Board sub-committee.

Iscelyn Richards Trust Secretary

May 2018

WLMHT Board Assurance Framework

BAF REF : BAF4190

Risk The proposed works to Medway Lodge will take longer than

expected and commissioners have supported an extension of the derogation to the Tony Hillis Wing until March 2019. This delay will have a financial impact on the trust in terms of resources and may impact on patient safety and experience for patients in THW

2017 2017 2017 2018 Level of assurance Forecast Tolerated Q2 Q3 Q4 Q1 since last update Rating Rating

5 x 5 5 x 5 5 x 5 5 x 5 3 x 5 3 x 5

Source Assessment against standards; Assessment of St Bernard's estate Governance Group St Bernards Redevelopment Programme Board Risk Owner : Leeanne McGee

Last Updated : 23/04/2018

Key Controls to Mitigate Risk Internal assurance on controls External / independent assurance on

controls Gaps in controls Gaps in assurance Action Plan to Remove Gap

Dedicated Three Bridges Programme Board established, comprising appropriate internal and external stakeholder membership. Steering Group supports the programme board, working through detail of significant risks and issues - either itself or through the sub-groups for various strands of work.

Monitoring by Board via receipt of the Programme Board Chair's report (Opinion: positive) Membership of Steering Group reviewed (February 2016) to ensure appropriate level of clinical engagement in project for works to Medway Lodge (former RSU building).

(i) NHS London (and, from April 2013, the NHS Trust Development Authority), DoH Capital Dept and Treasury Dept, who are updated ad hoc on a regular basis, monitoring and review of redevelopment plans and organisational arrangements (opinion: +ve) (ii) English Heritage (and local authority Planning Dept) involvement and oversight (iii) Specialised Commissioner involvement and feedback (+ve)

nothing identified at present

To confirm dates for programme board meetings. Action Owner : John Atkins Date of Action : 31/01/2017

Adherence to DH and HM Treasury investment business case processes for redevelopment.

Trust Board approved draft full business case (FBC), October 2012 for submission to NHS London.

DH Gateway Review 3 (October 2012) was very positive, giving a 'Green' rating with no recommendations. (Opinion: positive.) DH Gateway Review 4 (September 2015) was very positive, giving a 'Green' rating with only one recommendation. (Opinion: positive.) Strategic Outline Case (approved by NHS London in 2010), Outline Business Case (approved by DH/HM Treasury in December 2013) and Full Business Case (approved by

DH Gateway Review 5 (operations review and benefits realisation) required in 2018 - date to be confirmed.


December 2017 - Date of submission of DH Gateway Review 5 to be confirmed. Action Owner : Hannah Parsons Date of Action : 31/05/2018

DH/HM Treasury in December 2013).

Robust financial management and monitoring of project expenditure.

Monthly meeting with capital accountant. (Opinion: positive.) Regular expenditure reports to CAPMG, Programme Board and Trust Board. (Opinion: positive; reasons for under/over spend are explained and recorded.) Business case approved and funding agreed by Trust Board.

Monthly report from cost consultant (QS) and independent assessment of contractor invoices before payment. (Opinion: positive.) DH Capital Department, which provides the loan, monitors and endorses development plans and is updated on a regular basis. (Opinion: positive)

No gaps identified


Adherence to property and land sales programme. Action Owner : Viv Mowatt Date of Action : 31/12/2016 Agree marketing strategy for main property and land sales at Broadmoor. Action Owner : Viv Mowatt Date of Action : 15/03/2017

Active commissioner engagement in the redevelopment project.

Discussion of redevelopment progress at regular contract monitoring meetings with commissioners. (Opinion: positive; commissioners support new clinical model.)

Commissioner representative on Programme Board. (Opinion: positive; commissioners fully support the project.) Updated letter of commissioner support at Gateway Review 4 (readiness for service). (Opinion: positive; commissioners fully support the project.)

No commitment from NHS England to fund the 15 'unfunded' beds.


Property & Land Sales Steering Group established to oversee disposal of property and land sales to fund the project.

(see BAF risk 5972)

(see BAF risk 5972)

Detailed programmes for design & construction, transition planning and operational commissioning.

Monthly reporting on each of the programmes to the Steering Group and the Programme Board. (Opinion: positive)

DH Gateway Review 4 (September 2015) was very positive, giving a GREEN rating with only one recommendation. (Opinion: positive)

No gaps identified.


Building the new medium secure unit to recognised standards (e.g. medium secure standards, building regulations, BREEAM, HTMs, BS standards).

Redevelopment team; programme managers for service & business change and design & construction.

Cost consultant (QS) and programme assurance. (Opinion: positive; monthly and ad hoc reports.) Local authority building control and planning officers. (Opinion: positive; confirmation of discharge of planning conditions and compliance with building regulations.)



Planning permission granted, May 2012. No formal objection to planning application by statutory consultees (e.g. English Heritage, Victorian Society). (Opinion: positive)

Building plans complement the delivery of high standards of clinical care.

Trust Board endorsement of building plans and (through QAC) new clinical model of care. (Opinion: positive) Involvement throughout the project of clinical & non-clinical staff and service users (e.g. bedroom design, art strategy, ward names).




BAF REF : BAF5889

Risk If local services CSU is unable to deliver the transformation plan

then this would have a significant impact on the financial sustainability of the trust and on service quality for the local community


5 x 5 3 x 5 5 x 5 5 x 5 2 x 5 2 x 5

Source Strategic risk identified in current version of the Integrated Business Plan (Oct 12)

Governance Group Finance and Performance Committee Risk Owner : Sarah Rushton


Key Controls to Mitigate Risk Internal assurance on controls External / independent assurance

on controls Gaps in controls Gaps in assurance Action Plan to Remove Gap

The Transformation programme has sustained commissioner engagement, demonstrated through a joint programme and a joint transformation director role.

Reports to Trust Board via the Transformation Programme Board.

Transformation board and governance structure across the trust & CCGs, with membership including commissioners. Transformation Programme Board reports progress to NWL Mental Health & Wellbeing Transformation Board. The London-wide Transformation Board has a programme with common themes / initiatives and monitors delivery against the programme's objectives at a London-wide level.

Financial payment mechanism for 2018/19 contracts to be agreed.

Jointly commissioned internal audit review of transformation programme to be agreed with commissioners.

DoF / DoF meetings and contract meetings to discuss gaps in contracts and to agree financial payment mechanism. Action Owner : Paul Stefanoski Date of Action : 31/03/2018

Joint ownership of the service development & improvement plan (SDIP)

Monitoring at local services' SMT and minutes from those meetings are presented to TMT.

Monitoring at FIG, monthly contract group and escalation route to PCE

none identified at present

There is a joint programme in place with associated governance structures, including delivery project structure for each workstream with timescales. The programme has a risk register for the programme and a comms plan, both reviewed and discussed at each exec group meeting.

Board receipt of Chair's report from the Transformation Board work programme Transformation team and governance structure across the trust & CCGs which includes the Programme Executive Steering Group, ED/MD, CCG

Transformation team and governance structure across the trust & CCGs which includes Programme Exec Steering Group, ED/MD, CCG. Delivery against programme is monitored by NWL Mental Health &


Wellbeing Transformation Board and associated governance structures.

External political will to deliver plan Transformation board and governance structure across the trust & CCGs, with membership including commissioners.

Overview & Scrutiny Committees CCG governing bodies

Political will within local boroughs Hammersmith & Fulham and Ealing regarding bed closures and public consultation is a risk identified in the programme risk register.

Agree mechanism for public consultation process with commissioners Action Owner : Sarah Rushton Date of Action : 31/05/2018

BAF REF : BAF5917

Risk If we do not move patients into the redeveloped Broadmoor

hospital in 2018 there will be an adverse impact on patient progress and an impact on the Trust’s overall financial position and the NWL control total.


5 x 5 5 x 5 5 x 5 5 x 5 4 x 5 4 x 5

Source CQC Report regarding quality of patient environment Governance Group Broadmoor Redevelopment Programme Board Risk Owner : Leeanne McGee




Dedicated Broadmoor Hospital Redevelopment Programme Board, comprising appropriate internal and external stakeholder membership. Steering Group supports the programme board, working through detail of significant risks and issues - either itself or through the sub-groups for various strands of work.

Monitoring by Board via monthly progress reports from CEO as SRO/Chair of Programme Board. (Opinion: positive)

Broadmoor Redevelopment stakeholder group meetings with commissioners and other stakeholders (Opinion: positive). Also. a quarterly Local External Stakeholder Group which picks up local authorities other than Bracknell Forest Council (planning authority) and other local groups (e.g. Crowthorne Village Action Group, Crowthorne Traders, local schools, GP practices, Women's Institute etc.) Independent review of programme governance completed by Arcadis November 2017. Recommendations presented to Trust Board and Programme Board December 2017.



Building plans complement the delivery of high standards of clinical care.

Trust Board endorsement of building plans and (through QAC) revised clinical model of care. (Opinion: positive) Involvement throughout the project of clinical & non-clinical staff and patients (e.g. bedroom design, art strategy, ward names).




Robust financial management and monitoring of project expenditure.

Monthly meeting with capital accountant. (Opinion: positive)

Monthly report from cost consultant (QS) and independent assessment of contractor invoices before

Timing of associated capital receipts not optimum or as expected.


Outline business case - submission to, and approval by, NHS Improvement Action Owner : Vanessa Lee

Regular expenditure reports to CAPMG, BHR Programme Board and Trust Board. (Opinion: positive; reasons for under/over spend are explained and recorded.) BHR Programme Board, Audit Committee and Trust Board have approved invoice approval and payment process. (Opinion: positive; SO/SFIs amended to include non-standard approval limits.) Audit Committee received report in March 2015 on operation of invoice approval process. (Opinion: positive)

payment. (Opinion: positive) Counter-fraud specialist review of Redevelopment assessed it as Medium risk; existing areas of good practice noted and highlighted to Audit Committee 4.11.15. (Opinion: positive) DH Capital Department, which provides the PDC and loan, monitors and endorses development plans and is updated on a regular basis. (Opinion: positive)

Quantum of associated capital receipts not optimum or as expected.

Date of Action : 29/06/2018 Agree marketing strategy for main property and land sales at Broadmoor. Action Owner : Vanessa Lee Date of Action : 29/06/2018 Marketing the BHR main property & land disposal sites. Action Owner : Vanessa Lee Date of Action : 28/09/2018 Assessment of bids and recommendation to Trust Board. Action Owner : Vanessa Lee Date of Action : 31/01/2019 Full business case - submission to, and approval by, NHS Improvement Action Owner : Vanessa Lee Date of Action : 31/12/2018

Detailed programmes for design & construction, transition planning and operational commissioning.

Regular reporting to the Steering Group (monthly) and the Programme Board (quarterly) on the design & construction programme. (Opinion: positive)


Need to develop detailed transition planning & operational commissioning programmes.


Active commissioner engagement in the redevelopment project.

Discussion of redevelopment progress at regular contract monitoring meetings with commissioners. (Opinion: positive; commissioners support the revised clinical model.)

Commissioner representative on the programme board. (Opinion: positive; commissioners fully support the project.)



Building the new hospital to recognised standards (e.g. high secure design guide, high security psychiatric services directions, NOMS, building regulations, BREEAM, HTMs, BS standards).

Redevelopment team; programme managers for service & business change and design & construction.

Cost consultant (QS) and programme assurance. (Opinion: positive; monthly and ad hoc reports). Local authority building control and planning officers. (Opinion: positive; confirmation of discharge of planning conditions and compliance with building regulations.)



Planning permission granted, March 2012. (Opinion: positive) No formal objection to planning application by statutory consultees (e.g. English Heritage, Victorian Society). (Opinion: positive) Development being built in accordance with High Secure Building Design Guide. (Opinion: positive)

Adherence to DH and HM Treasury investment business case processes for redevelopment.

Trust Board approved draft full business case (FBC), September 2012 for submission to NHS London.

Strategic Outline Case (approved by DH in 2005), Outline Business Case (approved by DH/HM Treasury in July 2012) and Full Business Case (approved by DH/HM Treasury in December 2013). DH Gateway Review 3 (March 2013) was positive, giving a 'GREEN' rating with 3 recommendations.

Successful Gateway Review 4 (readiness for service).


Put in place suitable arrangements to secure successful passage through Gateway Review 4. Action Owner : David Phillips Date of Action : 28/09/2018

Property & Land Sales Steering Group established to oversee disposal of property and land sales to fund the project.

(see BAF risk 5972)

BAF REF : BAF4182

Risk If a major fire occurs, there is a risk that death or injury will occur

and that there will be a major loss of service capacity and assets 2017 2017 2017 2018 Level of assurance Forecast Tolerated Q2 Q3 Q4 Q1 since last update Rating Rating

4 x 4 4 x 4 4 x 5 4 x 5 3 x 5 3 x 5

Source Assessment of Fire Code; Fire Incidents Governance Group Trust Management Team Risk Owner : Paul Stefanoski




Alarm systems - active & reactive Tested weekly

Contractor provides certificate of compliance with S5839


Gap in knowledge and training in procedure when responding to tampering of smoke alarms

Ensure in-patient staff have received training on alarm panels Action Owner : Suzanne McMillan Date of Action : 28/02/2017

Mandatory fire training requirements (in patient services)

Mandatory training centrally provided. Compliance monitored by SMTs, TMT, F&P and Trust Board

London Fire Brigade inspections Department of Health FireCode compliance

Not all staff are trained : there is an issue with DNA-ing after booking

Limiting access to ignition sources application of smokefree operational protocol application of search protocol staff training and equipment provided to effectively implement search protocol

external contractor undertakes dog searches London Fire Brigade inspections

Open & therapeutic environment, including for visitors and informal patients with free access Open & therapeutic environment, including for visitors and informal patients with free access Unable to search everyone

Creativity of individuals to obtain or use unusual ignition sources.

Seek to improve intelligence and control measure through learning lessons (internal & external). Action Owner : Suzanne McMillan Date of Action : 31/03/2017

Localised fire training & drills Table top incident planning exercises

London Fire Brigade inspections

2 fire officer posts have been vacant for 7 months

Unable to deliver site specific training for local services owing to

Recruit to vacant fire officer posts Action Owner : Jonathan Campbell

Annually reviewed and tested fire evacuation procedures and response arrangements Fire evacuation exercises

NHS England EPRR compliance of at least one table top exercise per year

Clinical pressures & nursing staff vacancies

geographical spread of its sites

Date of Action : 30/10/2016

Effective and up to date clinical risk assessments

Annual clinical risk training Clinical risk policy CPA policy Engagement & Observations policy Search policy

CQC inspections London Fire Brigade inspections

Nursing vacancies In local services, open environment means risks associated with obtaining ignitions sources is increased

Not all staff are up to date with their clinical risk training Not all patients have a current, in depth risk assessment (especially those previously unknown to services)

Ensure an ongoing audit cycle of clinical risk assessment compliance, including a timely and effective feedback loop to the CSUs / Service Lines to alert clinical directors to areas of deficit and required action. Action Owner : Clare Harris Date of Action : 30/09/2016

Sample all cladding on Trust buildings identified to NHSI

Cladding samples being taken by Estates & Facilities Departments London and Broadmoor and Broadmoor Redevelopment to be submitted to BRE - Building Research Establishment for testing.

BRE to test samples from Trust identified buildings Appointment of Authorised Engineer - Fire for the Trust - to undertake a review of Fire Safety structure, governance and processes across the Trust to advise on improvements to management of fire and to provide assurance to the Trust Board.

Lack of clarity from DH. NHS Trusts taking action to address cladding issues locally. WLMHT doing likewise.

lack of Dh clarity on the situation resulting in Trust taking local action to provide assurance/ mitigation to Trust Board

managing in conjunction with D Phillips the cladding review for the trust Action Owner : Barbara Wood Date of Action : 29/09/2017

Fire management plan developed, following findings and recommendations from externally commissioned fire safety review and internal audit review.

Internal audit review of fire safety (November 2017) identified gaps in fire safety arrangements. Recommendations agreed by TMT.

External fire safety review of fire safety (October 2017) identified gaps in fire safety arrangements. Recommendations agreed by TMT and report / actions presented to Board (October 2017).

Implementation of fire safety action plan to address recommendations from fire safety review.

To establish a Fire Safety Group, reporting to the Trust Fire, Health and Safety Committee, to oversee implementation of the agreed action plan.

To establish a Fire Safety Group, reporting to the Trust Fire, Health and Safety Committee, to oversee implementation of the agreed action plan. Action Owner : Paul Stefanoski Date of Action : 30/11/2017

BAF REF : BAF7838

Risk If all services do not implement the required CQC quality

improvement actions the Trust's overall rating of "requires improvement" and the rating of "inadequate" for Adult Acute Wards and PICU and High Secure Services under the "Responsive" domain; this would impact on the quality of care and ultimately failure to improve may result in a threat to trust registration with the CQC and legal action.


4 x 5 4 x 5 4 x 5 4 x 5 2 x 5 2 x 5

Source CQC report published on CIH inspection Governance Group Quality Committee Risk Owner : Stephanie Bridger




Service Lines have developed Quality Improvement Plans which are monitored by: - Action owners providing monthly update position and evidence. - Overseen by the service line and CSU governance. - Reported and assurance tested by the CQC Workgroup and Quality Committee.

Serviceline and trustwide monthly reports are produced for service line Directors, CSU Directors, SMTs, CQC Workgroup and Quality Committee. Despite capital/estates issues services have their QI Plans put in place, procedures to mitigate risks identified by CQC. A high level dashboard with run charts has been developed with 5 key indicators - RP, Seclusion, Ptt, Supervision/AP, ward/team data, risk assessments. Reviewed by CQC steering group and Quality Committee.

Internal audit commissioned to complete an audit of randomly selected actions. March 2016. The internal audit was postponed due to proximity of November 2016 re-inspection. CQC, NSHI, CCG and NHS England all attend and receive the full papers of the Quality Committee. High Secure Services were re-inspected (26th/27th July) following the instigation of two warning notices. this inspection noted improvements made to these two areas. The warning notices have now been lifted however there remain two requirements notices; actions already in place will address these. Vacancy rates being reported to CQC monthly and regular reports to NOG from CQC, collated from Trust reporting. Re-inspection of adult acute wards & PICU in January 2018. Improvements noted and +ve assurance re bed management, but five regulatory improvement notices remain.

Not all action owners produce monthly updates, however, governance processes are in place to address this through the governance structures. A small number of actions requiring either significant capital investment or delivery over the long-term cannot be delivered before the CQC inspection. Not all actions can be delivered within timescales due to inter-dependencies and the need for additional capital expenditure. 10.01.18 There remain gaps in control about capital expenditure & performance of general maintenance for minor works.

Format of the CQC improvement report to Quality Committee being redeveloped to provide trust-wide assurance re compliance with standards.

September 2017 - The CQC QI plan continues to make progress although there has been some slippage in some actions. A different narrative is being asked of Service Lines regarding how they mitigate and manage current risks. These will be tested through audit and peer reviews. Action Owner : Stephanie Bridger Date of Action : 31/03/2018 January 2018 - A review of the CQC must do's has been undertaken by the Head of Regulatory Compliance. Evidence is being tested to support delivery of these actions and further work is required. Run charts on key performance areas were presented to the Quality Committee. Further work is required on these with associated narrative. Action Owner : Stephanie Bridger Date of Action : 30/03/2018 January 2018 - Evidence to support the delivery of the current CQC action plan continues to be uploaded on the action zone. this is being tested by the Head of Regulatory Compliance and Director of Nursing. Action Owner : Stephanie Bridger Date of Action : 30/03/2018

CQC to attend / observe Board meeting in May 2018.

An 'Action Zone' exchange application has been developed to capture all CQC regulation breaches. The action zone identifies the breaches, actions, action owners, timescales etc.

The action zone provides a live database of all breaches and how each action is progressing. Each action is automatically RAG against timescales set. Servicelines are now familiar with the reporting system and have opted to continue to work with the Action Zone.

Internal audit commissioned to complete an audit of randomly selected actions. March 2016. CQC, NHSI, CCG and NHS England all attend and receive the full papers of the Quality Committee.

Not all action owners produce monthly updates, however, governance processes are in place to address this through the governance structures.

Currently there are two recording databases, excel spreadsheet and action zone on the exchange. This has the potential for human error to occur.

September 2017 - The CQC QI Plan continues to make progress although there has been some slippage in some actions. A different narrative is being asked of Service Lines regarding how they mitigate and manage current risks. These will be tested through audit and peer reviews. Action Owner : Stephanie Bridger Date of Action : 31/10/2017

Before actions are signed off as fully completed, full Executive review will occur. If the action relates to "regulatory sign off" then this will include the Executive Director responsible plus those delegated by the Quality Committee to assure themselves that all steps taken have resulted in the required change to patient experience, safety and effectiveness.

Walkarounds, audits and accreditation tool developed. For each action, it is clear what the outcome measures and evidence is.

Internal Audit commissioned to complete an audit if randomly selected action. March 2016, CQC, NHSI, CCG and NHS England all attend and receive the full papers for the CQC Programme Board. Mental Health Action Inspection Reports CQC Compliance Inspection November 2016

The trust has not yet been in the position for an internal regulatory sign off process to be tested. This will occur in the forthcoming months and this action can then be tested and quality assured.

Regular reviews of progress of CQC Quality Improvement Plan Action Owner : Stephanie Bridger Date of Action : 31/12/2017 January 2018 - Process relating to sign off remains unchanged. Action Owner : Stephanie Bridger Date of Action : 30/03/2018

BAF REF : BAF8024

Risk If the trust does not adequately manage its estate portfolio this will

compromise the safety and quality of service delivery. 2017 2017 2017 2018 Level of assurance Forecast Tolerated Q2 Q3 Q4 Q1 since last update Rating Rating

4 x 5 4 x 5 3 x 5

Source Governance Group Quality Committee Risk Owner : Paul Stefanoski




Regularly updated, risk-adjusted prioritised backlog maintenance programme. Annual Service Contracts, e.g. Legionella, Asbestos, PAT, Fire prevention.

Capital Steering Group monitoring via receipt of Trust condition appraisal updates Annual backlog maintenance plan agreed at CAPMG and incorporated into the Trust Capital Plan

ERIC returns CQC inspections include assessment of the physical environment.

Formal monitoring of maintenance contracts to ensure they are performing to specification.


Independent periodic review of service contracts Action Owner : Michael Harbour Date of Action : 31/03/2018

Patient Led Assessments of the Care Environment (PLACE)

PLACE reports will go to the Capital Steering Group for assessment and recommendations to CAPMG.

PLACE report benchmarking PLACE assessment findings and recommendations submitted to Quality Committee - October 2017.

Pre-assessment of the environment prior to PLACE process Increased service representation in PLACE assessments.


Establish pre-PLACE assessment process and link to CQC audits. Action Owner : Jennifer Holmyard Date of Action : 01/12/2017

(Annual) work programme of the Capital Estates & Facilities service, included in Trust capital programme

Board and Finance & Performance Committee Team monitoring of Capital work programme via receipt of planned reports Examples of capital works to improve the physical environment - Medway Lodge, Thames House.

Annual PLACE assessment, with service user input. Results presented to Quality Committee Oct 2017.

CSU representation at CAPMG to be reviewed and improved.


To review CSU representation at CAPMG with SMTs. Action Owner : Paul Stefanoski Date of Action : 30/04/2018

Maintenance resources adequately available and skilled to provide required maintenance for new facilities being developed at

Training and familiarisation planning to ensure maintenance teams at both sites are ready to take on all aspects of maintenance support for the new

Independent review of the estates & facilities function, completed 2016.

Operational responsiveness of estates to maintenance requests.

Requirement identified to restructure the Broadmoor E&F department.

Agree and implement restructure plan. Action Owner : Barbara Wood Date of Action : 31/01/2018

Broadmoor Hospital and the Three Bridges Medium Secure Unit at St Bernard's

facilities at the time of handover from the contractor. Detailed plans and activities for this purpose monitored via monthly Steering Group and Programme Board meetings for both schemes. Operational planning overseen by Broadmoor Redevelopment Steering Group which in turn reports to the Programme Board. Process review completed with service leads and facilities team, to review and agree processes for requesting maintenance jobs, and financial controls removed for low level requests.

ERIC returns benchmarked against other providers within peer group.

Internal Audit review of backlog maintenance and minor works due in April 2018, reporting to Audit Committee July 2018.

Auditing (at least monthly) by ward managers and E&F against the infection prevention control and cleaning standards

Infection control and PEG quarterly report on cleanliness. Annual infection control report to Quality Committee and Board (October 2017).


Potential lack of capacity within infection control function


Estate Strategy approved by Trust Board Feb 2017

Actions contained within Strategy monitored by Trust Board. Six monthly updates presented to F&P Committee and Board. Estates strategy update reported to Board in March 2018.

PLACE assessments

Estates strategy to be reviewed and revised, in line with the master planning. Board strategy session to be arranged for this (Board away-day June 2018?).

Estates strategy to be reviewed and revised, in line with the master planning. Board strategy session to be arranged for this (Board away-day June 2018?). Action Owner : Paul Stefanoski Date of Action : 30/06/2018

BAF REF : BAF8184

Risk If HSS is unable to deliver the transformation plan within the

defined timescale then this would have a significant impact on the financial sustainability of the trust and on service quality and NWL control total


5 x 5 5 x 5 5 x 4 5 x 4 2 x 5 2 x 5

Source Agreed at F&P 28 September 2016 Governance Group Finance and Performance Committee Risk Owner : Leeanne McGee




Monthly monitoring of expenditure and income; Analysis of core services; Oversight of Broadmoor redevelopment through Steering and Programme Boards

BMR Steering Group / Programme Board QCIP programme Contractual meetings with NHSE

Quarterly Contract meeting

None

None

Monthly monitoring of environments in existing hospital which are deteriorating and replacement is not always an option

Monthly Estates report to SMT

Follow up actions of external audit reports

none

External scrutiny through Broadmoor Programme Board through additional membership

Scrutiny provided through external appointee providing rigour and challenge to programme

BAF REF : BAF8279

Risk If WLFS is unable to deliver the reconfiguration of services through

New Models of Care, this would have a significant impact on the financial sustainability of the trust and on the clinical viability of the service


4 x 5 4 x 5 4 x 5 4 x 5 2 x 5 2 x 5

Source Finance & Performance Committee Governance Group Finance and Performance Committee Risk Owner : Leeanne McGee




Clinical ownership Clinical Leads reviewing Care Pathways Monthly Medway Lodge Steering Group Escalation procedures in place

Contract meetings with NHSE as per signed contract Away day for all clinicians 15/12/17

none

none

Sustained commissioner engagement

Benchmarking data Contract meeting monthly and quarterly

None identified

None identified

Medway Lodge programme delivered in budget and on time

Monthly Steering Group

NHSE involvement through Contract meetings Removal of WEMSS from NMOC

none Awaiting confirmation from NHSE regarding exclusion of WEMSS from NMOC

Project management structure overseeing all work streams

Medway Lodge Steering Group

Quarterly reporting to TMT and Trust Board Consortium Mobilisation Board

None

The final plan relating to patient numbers and associated income to be determined

Confirmation of patient numbers reported quarterly Action Owner : Hannah Parsons Date of Action : 29/06/2018

Mobilisation Board Monthly meetings of consortium reporting to relevant trust boards

Key financial and patient data awaiting final sign off

To confirm financial and patient data Action Owner : Hannah Parsons Date of Action : 31/03/2018

BAF REF : BAF8496

Risk There is a risk of regulatory intervention and financial penalties if

the Trust is not compliant with the GDPR regulations by 25 May 2018.


4 x 5 2 x 5 2 x 5

Source Internal audit review of readiness. IG Toolkit submission 31 March 2018. Board discussions.

Governance Group Trust Management Team Risk Owner : Carolyn Regan




Interim IG management resource appointed to cover for absence of substantive IG manager.

Submission of IG toolkit by deadline of 31 March 2018. Level 2 compliance achieved, including 95% compliance in mandatory training.

Project plan for preparation for GDPR to be signed off by EDs 10 April 2018. Substantive IG Manager in post from 30 April 2018. Information Governance steering group to be established to oversee implementation of GDPR preparation plan and ongoing compliance with GDPR and IG Toolkit.

Internal audit advisory audit of readiness for GDPR ongoing (March 2018). Findings and recommendations to be reported to EDs and Audit Committee. Independent audit of Data Protection by ICO planned for November 2018.

BAF REF : BAF8010

Risk If clinicians do not conduct high quality clinical risk assessments

which result in appropriate clinical risk management this may increase the risk of serious harm to patients, carers, staff and the public


4 x 4 3 x 4 2 x 4

Source CQC report, Level 1 and 2 reviews, CPA scorecard data, Clinical audit findings

Governance Group Quality Committee Risk Owner : Stephanie Bridger




Compliance with various policies and duties, in particular, 1. Clinical risk policy 2. Care programme approach policy 3. Incident reporting and management policy 4. Complaints policy 5. Therapeutic engagement and supportive observations policy. 6. Clinical supervision policy

All policies updated recently (1. Clinical Risk Policy - Oct 16) (2. Care programme approach policy - July 2016) (3. Incident reporting and management policy - Apr 16) (4. Complaints Policy - Feb 17) (5. TESO policy - Feb 16) High secure services has inhouse clinical risk training which is appropriate and valued. Nursing staff are inducted to the standards of practice in the revised Therapeutic engagement and enhanced observations policy. Clinical supervision and management supervision will provide assurance about compliance with listed policies. West London forensic services primary nurse standards audit. Record quality audit. The revised Enhanced engagement and observations policy - now the Therapeutic engagement and supportive observations policy was ratified and implemented in February 2016. A suite of tools, which include a video, powerpoint presentation, leaflets for staff and patients, and a mandatory annual eAssessment for

CQC MHA inspection reports. CQC compliance inspection November 2016

Serious incident reviews often note the lack of good risk assessments. Delay in commencing revised training and funding non-recurrent. Supervision not consistently happening and there are concerns about the quality of supervision.

Specialist and local services senior nurses indicate a lack of assurance that supervision is taking place consistently.

Clinical Supervision policy has now been reviewed and will be added as an appendix to the Trust wide Supervision Policy. Action Owner : Stephanie Bridger Date of Action : 31/10/2017 Supervision will be reported on through a high level CQC dashboard - Performance against Appraisal/PDP's is reported through the HR dashboard. Action Owner : Stephanie Bridger Date of Action : 31/10/2017 January 2018 - The Director of Nursing is getting monthly reports on the performance relating to supervision from the Deputy Director of Nursing and Heads of Nursing. Performance is also being illustrated in newly developed run charts. Action Owner : Stephanie Bridger Date of Action : 30/03/2018 January 2018 - A report commissioned using 'human factors' methodology was commissioned to look at themes/learning from SI from 2016/17. This was presented to the Quality Committee in October 2017. Learning Lessons work planning being developed. Clinical Vignettes learning cascaded to Senior Leaders. Action Owner : Stephanie Bridger Date of Action : 30/03/2018

staff involved in observations was launched in early June. Internal audit of supervision Clinical Supervision Policy being reviewed by Corporate Deputy Director of Nursing Training procured of a professional Clinical Risk Trainer for Local and Specialist and West London Forensic Services. Monthly TESO Practice Assurance Audit results produced for CSU's and reports to TW and CSU Nursing Leadership meetings for review and actions. Clinical supervision is a Quality Priority (QP3) for all services from 2017 - 2019

Effective review, analysis and learning from incidents and, where necessary, consequent changes in practice.

Trust wide learning lessons events each year & local events held twice yearly. Make it Safe briefings circulated and published on Exchange. Presentation of learnings of Level 2 to Board of Directors. Service lines track the implementation of learnings. The Board were presented with learning from two SIs at its meeting in October 2017 Quality Matters meeting in October 2017 focussed on SIs and complaints.

A Trust-wide learning event is scheduled for November 2017.

Implementation of a Suicide prevention strategy.

Key policies consulted on, approved and ratified. Suicide Prevention Workgroup formed New Strategy being developed by

none identified at present CQC MHA inspection reporting

Elements of the 2014 - 2018 Suicide prevention strategy relate to public health and community. All actions not within Trust control.

the Suicide Strategy was agreed on 4th September 2017. Action for CSU to formulate local delivery plans. Action Owner : Stephanie Bridger Date of Action : 31/10/2017

Suicide Prevention Workgroup

CQC compliance inspection November 2016

Prioritised potential ligature anchor point reduction programme, arising from most recent Ligature Audit (2016). Feeding into the annual capital programme.

Revised policy in place with a clear guide of now to use. In accordance with the Trust Ligature Risk Reduction Policy and Procedure all wards completed their annual ligature anchor point audits between March and May 2017. No significant uncontrolled risks requiring immediate escalation were identified in this year's audits. Annual ligature anchor point assessment. Workplace inspections. Ligature risk awareness is also included in the Trust defibrillator / basic life support course that all new staff receive on induction through annual refresher training. Ward specific ligature risk floor plan and management arrangements summary produced for all wards. Distributed to all staff and included in all new secondary induction to ward. 2016 Annual Ligature Anchor Point Assessment completed for all wards. Results reviewed and reports presented to CSU SMT's and H&S Committees with prioritised recommendations to address high risk ligature anchor points. Funding ring-fenced in 2017 - 2018 capital programme to action prioritised high risk ligature anchor points.

CQC MHA inspections CQC compliance inspection November 2016

Inability to remove all ligature anchor points from inpatient services.

The CSU SMT will receive an annual review of the ward LAP audits by October 2017 and produce a remedial works plan for consideration in the 2018/19 capital programme.

Following the audits in 2016, £600k ligature risk remedial works is included in the current year 2017/18 capital programme. Action Owner : Colan Ash Date of Action : 29/12/2017 2017 LAP Audit Reviews underway - Dec 2017 Action Owner : Colan Ash Date of Action : 29/12/2017 The ligature risk floor plan and management plans summary have been communicated to all staff and are included in the secondary induction of new staff to the ward (including bank and agency staff). Action Owner : Colan Ash Date of Action : 09/10/2017

BAF REF : BAF8252

Risk The Trust may lose sensitive data and/or experience serious

disruption of services as a result of a successful cyber-attack on its computer systems.


4 x 4 3 x 3 3 x 3

Source Strategic Technology Investment Group Governance Group Trust Management Team Risk Owner : Paul Stefanoski




Enrolment as an early adopter of the NHS Digital CareCert scheme

STIG reviews and reports to TMT

Internal Audit

Nothing identified at present


Urgent replacement of unsupported network devices

STIG reviews and reports into TMT

Internal Audit & Independent Penetration Testing

Network equipment list not up to date. Vulnerable devices not identified.

Review of network attached "Estates systems" to identify immediate security risks. Establishment of strategic approach to future procurement & support of network based Estates systems.

STIG reviews and reports into TMT

Internal Audit

List of E&F network attached equipment and support arrangements not available.

Procurement strategy for new purchases of network attached equipment not defined. Funding to address replacement of unsupported / vulnerable equipment not identified/approved.

Audit of Estates network attached systems, their current patch level, and support arrangements to identify high risk systems in conjunction with Amolak Soor, Head of Infrastructure Services Manager. Action Owner : Michael Harbour Date of Action : 18/12/2017 Define new procurement standards and source strategic partners for procurement and support. Action Owner : Trevor Nelms Date of Action : 27/04/2018 Migrate to supported products or isolate high risk systems from the network. Action Owner : Amolak Soor Date of Action : 31/07/2018

Establishment of cyber-security support contract to access specialist


Internal Audit

Cyber security support service specification not drafted.

Define and procure support service Action Owner : Amolak Soor

resources.


Review local dept business continuity plans to ensure inclusion of pre-longed system outages/loss of data has been considered.

STIG reviews and reports to TMT Emergency Planning Group monitors compliance with review

Internal Audit

Emergency Planning Group (EPG) to review business continuity plans.

Emergency Planning Group to co-ordinate review of continuity plans. Action Owner : James Harris Date of Action : 31/07/2017

Review and test technical disaster recovery plan and put in place protocols to ensure change control.

STIG reviews and reports to TMT Trust response to cyber attack (July 2017) confirmed processes for managing incidents.

Internal Audit

Current Bus Tech DR plan untested.

Carry out a review of the current IT DR plan and change controls around it and carry out a table top test Action Owner : Amolak Soor Date of Action : 18/12/2017

Verify 3rd party hosted service providers security and recovery plans are robust.


Current suppliers security and recovery plans/arrangement are unknown

Contracts with suppliers do not routinely include assurance regarding precautions avoid to prevent/respond to cyber-attack.

Contact providers of hosted systems and verify security arrangements and continuity plans. Head of Procurement & Head of Infrastructure Services: Review standard T&Cs for IT service contracts and adopt industry best practice. Action Owner : Syed Hasnain Date of Action : 31/10/2017

BAF REF : BAF8428

Risk If external education funding is reduced, the supply of

undergraduate staff to the Trust, including unqualified nursing and doctors in training, may be significantly reduced and the opportunities for skill development for the current workforce may also reduce.


4 x 4 4 x 4 3 x 4

Source Persistently high vacancy rates Governance Group Workforce and development committee Risk Owner : Wendy Brewer




The development of the unregistered workforce for nursing and AHP roles. Development of apprenticeships and pathways into nursing. Networking and ensuring that the trust is well placed to bid for available funding. Ensuring that education provided meets QA requirements and is seen as very high quality. Exploration of opportunities for overseas recruitment. Development of relationships with HEI.

Board development session in September 2017 on educational funding. Workforce and Education Committee monitors a detailed workforce strategy action plan designed to mitigate the risk. Learning and development strategy includes a plan for the development of the unregistered workforce.

The trust is currently in special measures with the GMC.

HEE funding and policy is externally driven.

The trust needs to ensure that the strategy for the unregistered workforce is understood by the organization.

Board development session in September 2017 on educational funding. Workforce and Education Committee monitors a detailed workforce strategy action plan designed to mitigate the risk. Learning and development strategy includes a plan for the development of the unregistered workforce.

The trust is currently in special measures with the GMC.

HEE funding and policy is externally driven.

The trust needs to ensure that the strategy for the unregistered workforce is understood by the organization.

Participating in NHS Employers Doctors in Training streamlining programme.

Reviewing medical rotas. GMC Junior doctors survey results - expected March 2018.

Workforce Committee, Quality Committee and Board to receive assurance re the actions being taken to manage medical rotas and any risks re impact on quality.

BAF REF : BAF8430

Risk If the Trust cannot attract and retain key staff - nursing, AHPs,

medical staff & some other groups of registered staff - this could lead to high use of agency staff and the inability to deliver services to patients


4 x 4 3 x 3 3 x 3

Source Persistently high vacancy rates Governance Group Workforce and development committee Risk Owner : Wendy Brewer




Delivery of a recruitment and retention plan funded by £120k resources from HENWL. Development of apprenticeships and pathways into nursing. Independent economic review of High Secure Lead Additional resources allocated to clinical recruitment team. Exploration of opportunities for overseas recruitment. Review of experience of new starters including induction and buddying schemes.

Workforce performance report submitted to board monthly includes vacancy and turnover information and KPIs. Workforce and Education Committee monitors a detailed workforce strategy action plan designed to mitigate the risk. Results of electronic exit survey reported to Workforce Committee in February 2018.

Staff survey 2016 indicated higher levels of staff engagement. Trust participation in the NHSI retention programme. +ve feedback received on the Trust's retention plan.

Turnover and vacancy factor are driven in part by national policy regarding educational funding, BREXIT and wage control.

Workforce committee reviewed a report of the exit interview data, which has provided the focus for the allocation of resources of an additional £120k from HEE to support retention. Focus will be on developing an alumni for staff who leave but would be willing to return and for extending the time that staff who leave at around 2 years' service remain with the trust, even if only by a few months. Further funding will also go to support a further cohort of the Lead by Example programme and coaching for managers, which has been very well received.

BAF REF : BAF8023

Risk If the trust does not maintain its financial sustainability it will not be

compliant with its terms of authorisation and will risk its continued existence as an independent NHS organisation.


3 x 5 3 x 5 3 x 5

Source . Governance Group Finance and Performance Committee Risk Owner : Paul Stefanoski




Five year financial plan, regularly updated, to provide a forward view of the financial risks faced by the Trust. This includes a medium-term (2 year) financial plan, approved by F&P Committee and Board.

Scrutiny by the FOLG / TMT, reporting to Finance & Performance Committee and Board. Monthly financial performance and forecast reports to Board

Monthly monitoring meetings with NHSI As part of the Trust's undertakings agreed with NHSI (January 2018), NHSI has reviewed the Trust's medium-term financial plan. Trust's financial risk rating has moved from 3 to 2 on NHS New Models Hospital portal (+ve assurance) - February 2018. Annual audit letter from external auditors confirm the trust as a going concern.

Financial position of other organisations in the NW London STP may require the Trust to identify and deliver additional efficiencies.

To present the medium term financial plan to TMT, F&P and Board for approval Action Owner : Paul Stefanoski Date of Action : 30/04/2018 Reporting of NWL STP financial position to Trust Board as part of the monthly reporting process, to identify and mitigate any risks in external environment. Chief Executive involvement in NWL Providers meetings and regular meetings with commissioners. Action Owner : Paul Stefanoski Date of Action : 31/03/2018

Annual budget agreed and in place before the start of the financial year

Scrutiny by Finance & Performance Committe in advance of approval by the full Trust Board Monthly sign off of budgets by budget holders Monthly budget meetings with HR and finance. Deep dive of service line budgets by FOLG. Internal audit reports during 2017/18

ISA 260 produced by external auditors Monthly FIMS returns by Trust and performance reviews by NHS Improvement.

Board understanding of the assumptions and sensitivities in budget setting for 2018/19.

Ensuring that budgetary responsibility is fully understood in a clinically led management structure

"Deep dives" ongoing at service line level by FOLG Action Owner : Paul Stefanoski Date of Action : 31/03/2018

covering budget setting and financial management processes. Interim budget for 2018/19 approved by Board in March 2018, subject to conclusion of contract negotiations.

CIP plans developed and implemented

QCIP panel chaired by a non executive director Internal audit review of the processes and systems in place for CIPs Financial Oversight & Leadership Group monthly review of CIP delivery and reporting to TMT & Board.

Periodic review of CIPs by NHSI.

Horizon scanning - update and record tender opportunities

All tendering opportunities recorded on the tracker and reported to Trust Management Team on a monthly basis to ensure the co-ordination of an appropriate response. Sign-off for commercial bids through the Finance & Performance Committee.


Capacity to respond effectively to multiple tendering opportunities


Prioritisation of resources and responses to commercial opportunities by EDs & TMT, based on strategic and financial benefit Action Owner : Christopher Hilton Date of Action : 31/03/2018

BAF REF : BAF8026

Risk If the trust does not improve its compliance with serious incident

reporting timescales, there is a risk of failing to implement the lessons learned in a timely manner and of eroding the trust's reputation with external stakeholders


4 x 3 2 x 3 2 x 3

Source IPR Governance Group Quality Committee Risk Owner : Sarah Rushton




Agreed & published action plan has been implemented to clear backlog of serious incident root cause analysis investigations by the end of October 2016

Weekly updates provided to E.Ds meetings Monthly updates provided to the trust board

Monthly updates to CCGs and NHS England

No gaps identified


List of RCA trained investigators to minimise the time required to appoint an investigator and panel

Clinical directors are involved in the appointment of investigators Clinical directors have ensured that the requirement to participate in RCAs is included in consultants' job plans.


Timely appointment of investigators not always achieved Face to face RCA training is oversubscribed & e-learning not easily accessible. This leads to difficulties in increasing the number of trained investigators


Action plan to increase access to training in RCA and developing robust recommendations from investigations to be sought from Learning & Development team, Action Owner : Ali Webster Date of Action : 31/05/2018

Conducting an initial review of incidents for immediate learning & quickly implementing interim actions minimises the risk of reoccurance whilst a full RCA is completed.

Assessment of 48hrs reports, by clinical directors and head of governance, to ensure that they provide evidence of immediate learning & actions taken


48hrs reports not always completed within the required timeframe Quality of first draft 48hrs reports is inconsistent

Additional root causes may be indentified in the review and the implementation of actions may be delayed to address these.

Follow-up of outstanding 48hrs reports by governance team, with escalation to clinical director if no progress (ongoing & with immediate effect) Action Owner : Kashmir Sidhu Date of Action : 27/04/2018

Quality assurance of reports and feedback to investigators and

All reports are quality assured by (i) head of governance, (ii) director of

Agreed process in place for ongoing review of queries raised by CCGs,

Ensuring quality, whilst the training & development of


Incident review facilitators provide support and guidance to the panels throughout the

clinical directors improves the quality of draft reports and minimises the risk of delays in submission due to numerous iterations before final approval

local services and clinical director, (iii) medical director & director of nursing & patient experience

including process for review of requests for de-escalation of incidents.

investigators continues, sometimes requires several iterations of the report

process (ongoing) Action Owner : Gail Webster Date of Action : 31/03/2017

There is an accurate current status log of all SIs so that potential delays are identified and acted on.

SI matrix in place with initial logging administered by central governance team and follow-up on progress by head of governance

CCG maintains log of all SIs and local services cross reference with this, monthly

Changes in personnel & vacancies in the governance team has meant reduced resources to log all new SIs on the matrix straight away Follow-up of completion of reports or action plans by IRFs is not always regular and/or robust

Evidence of regular follow-up of requests for progress updates and action plans is not available

Action zone to be brought up to date Action Owner : Janet Bell Date of Action : 01/09/2016 Review the progress and evidence of follow-up with IRFs weekly and escalate non responders to associate director for further action (ongoing) Action Owner : Gail Webster Date of Action : 31/03/2017

BAF REF : BAF5972

Risk If the trust does not receive the anticipated land sales receipts total

that supports its capital redevelopment programmes, either at the appropriate time or at the expected value, it may be unable to deliver future capital projects and associated service transformations.


3 x 4 3 x 4 3 x 3 3 x 3 1 x 3 1 x 3

Source Strategic risk identified in the Integrated Business Plan (version Oct 12)

Governance Group Finance and Performance Committee Risk Owner : Paul Stefanoski




Proper governance arrangements to identify and oversee proposed disposals of property and/or land.

Terms of Property and Land Sales Steering Group reviewed by Trust Board; newly created Property & Land Management Group reports direct to Trust Board on acquisition, disposal or change of use of land and/or buildings. Professionally qualified programme manager employed to manage and monitor process for disposals. Property and land sales risk register (not Level 1) OBC presented to BHR Programme Board (in June) and then approved by Trust Board (in July) for submission to NHS Improvement. Capital programme position monitored by F&P and Board. November 2017 - on track vs plan, with funding of priorities such as Medway Lodge redevelopment. Successful sale of Cricket Field Grove land, reported to Board February 2018.

Where appropriate, outline/full business case for disposal/s submitted to NHS Improvement to review and approve. Trust has appointed property and land sales advisor (BNP Paribas Real Estate) to advise on the valuing, marketing and disposal of trust sites. Periodic valuations of trust property and land by District Valuer Services from Valuation Office Agency. Auditor advises on treatment of capital receipts from property and land sales. The content of the economic and financial cases in the Broadmoor property & land sales OBC has been contributed to, and reviewed by, external consultants.

None identified at present

P&LS risk register not up-to-date.

Property & Land Management Group to review and approve updated risk register. Action Owner : Tony Cloke Date of Action : 30/04/2018

Detailed programme for property and land sales.

Property & Land Management Group will review progress against land sales programme and report exceptions to Trust Board.

Successful sale of Cricket Field Grove land, reported to Board February 2018.

Need a detailed programme for main property and land sales at Broadmoor.


Create a detailed programme for main property and land sales at Broadmoor. Action Owner : Vanessa Lee Date of Action : 30/04/2018

The outline process and timetable covering the detailed programme for the main Broadmoor disposals was agreed by the Trust Board at its meeting in January 2017.

Detailed discussions with planning officials at Bracknell Forest Council in respect of the Cricket Field Grove site.

Submit OBC to NHS Improvement Action Owner : Vanessa Lee Date of Action : 29/06/2018 Submit FBC to NHS Improvement Action Owner : Vanessa Lee Date of Action : 31/12/2018 Complete marketing, receipt and assessment of bids. Action Owner : Vanessa Lee Date of Action : 31/12/2018

Compliance with legal and best practice requirements for managing property and land.

Trust Estate Strategy 2017-2022 Legal advice is sought on all disposals. The trust has retained Bevan Brittan LLP as its legal advisers for the Broadmoor property & land sales (including Cricket Field Grove).

Audit/s of disposals. Health Building Note (HBN) 00-08 Part B, October 2014 (Estatecode)



Robust arrangements for managing and monitoring expenditure.

Regular budget reports for Property & Land Management Group - and for BHR Programme Board on Broadmoor main property & land sales.

Regular budget reports for P&L Management Group.

BAF REF : BAF8027

Risk If the Trust fails to meet the digital maturity challenge, this risks its

ability to win or maintain service contracts, the efficiency of Trust systems and the Trust's ability to deliver its strategy.


3 x 3 3 x 3 3 x 3

Source . Governance Group Finance and Performance Committee Risk Owner : Paul Stefanoski




Strategic Technology Investment Group established to ensure engagement of key internal stakeholders in the prioritisation of IT investment.

STIG reports to TMT Digital maturity self-assessment completed. STIG oversees investment is aligned to strategy objectives & recommends investment priorities.

External benchmarking within NHS as output of digital maturity assessment. External digital maturity return submitted to STIG - December 2017.



Business Technology Strategy in place and regularly reviewed

2015-2020 Strategy in place and signed off by Trust Board Annual review of strategy conducted by STIG, endorsed by TMT. Local strategy aligned to LDR

WLMHT Strategy included in NWL Local Digital Roadmap (LDR). LDR/STP submissions reviewed by NHS England.



Completion of digital maturity assessment

Baseline Digital Maturity Assessment (DMA) return completed WLMHT contribution to NWL Local Digital Roadmap completed. Annual DMA returns will be reviewed by STIG and endorsed by TMT. The STIG ToR have been amended and agreed by the group to reflect this addition to the groups responsibilities

Benchmarking with other Trusts The NHS England annual DMA is a requirement upon all Trusts Commissioners review results for all NWL organisations.


Engagment with NW London development of an STP IT

Trust represented at NWL Digital Programme Board level and across

Digital CQUINs aligned to NWL STP/LDR objectives.

Formal links required between STIG (ie LDR delivery) and

Insufficient funding available to full meet digital maturity

Follow up bid to NW London STP - ongoing. Action Owner : Trevor Nelms

investment strategy the new NWL Digital governance structure. STIG advised of developments and opportunities to access investment

internal STP programme delivery.

requirements


Cyber security measures in place and monitored (cross-reference to risk BAF8252)

Internal audit review of cyber security included on the IA plan for 2018/19.

BAF REF : BAF8028

Risk If the Trust does not improve the RiO system to ensure user

friendliness & satisfaction, there is a risk to the quality of care provided to service users and to staff efficiency


3 x 3 2 x 2 2 x 2

Source . Governance Group Quality Committee Risk Owner : Jose Romero-urcelay




RiO Clinical Design Group is updating and improving the RiO functionality and user friendliness. These improvements are taking place following a prioritisation process. Physical health and seclusion portals completed, clinical risk portal in pilot, and clinical record summary almost finalised. A new training programme for RiO users has also been by the clinical design group.

Outcomes and Recommendations of Serious Incident Reviews End user feedback to CDG positive. Progress being made on the physical health and seclusion portals. Outstanding action on the clinical summary and clinical risk portals Deep dive of risk at Quality Committee (November 2017) Reporting to CDG, TMT and Quality Committee.

North West London Digital Roadmap CQC review of record keeping in last inspection was critical of mixed method of record keeping.

Plan of progress with RiO system required

Monthly feedback from Chief Information Officer regarding progress with the RiO system required Action Owner : Jose Romero-urcelay Date of Action : 31/12/2017

Mutidisciplinary membership of Clinical Design Group with significant clinician membership

Regular progress reports by the Clinical Design Group to Quality Committee, TMT and the Board


Clinical Design Group has not submitted the annual plan to the Quality Committee

Current use of RiO prevents formal audits taking place

BAF REF : BAF4198

Risk If the trust does not have robust emergency planning and

business contingency protocols in place, there will be an unnecessary risk to service users and staff during a crisis


2 x 4 2 x 4 2 x 4 2 x 4 2 x 4 2 x 4

Source 2009 Internal Audit assessment Governance Group Finance and Performance Committee Risk Owner : Stephanie Bridger




Adherence to the Trust's emergency planning and business continuity arrangements, including the Trust Major incident and Emergency Response Plans (e.g. Flu pandemic plan, heatwave plan, fuel crisis plan, severe cold weather plan)

Trust's Emergency Planning Forum review of EPRR plans and oversight of compliance including implementation of the Trust's annual EPRR work plan. During July 2017 Emergency and Business continuity plans were audited as part of the Fire Safety audit.

Annual EPRR assurance review carried out by NHS England. The action plan arising from the 2017 process when the Trust had improved from 2016, forms the work plan for the 2018 assurance process and will be completed by the end of Autumn.

Actions identified as part of NHS England EPRR Assurance process. Current gap in decant facilities for secure patients.

Actions identified as part of NHS England EPRR Assurance Process.

The EPRR assurance review with NHS England concluded that the Trust had improved its overall rating to SUBSTANTIALLY COMPLIANT with EPRR core standards. There is now an action plan to address areas of weakness and will be monitored internally via the Emergency Planning Forum and also via review meeting throughout the year with NHS England. Action Owner : James Harris Date of Action : 29/06/2018

Table-top exercises, testing the robustness of the EP and BC plans.

All of the CSUs have tested their EPRR plans during 2016/17 either through live exercise, Table Tops or actual incidents. A live exercise in June 2017 facilitated by Local Services provided assurance that plans were in place and could be mobilised. Board development session and EDs session, November 2017, re role of Gold Command in major incident management.

None identified at present Job descriptions for SB and Hassaan Majid to include their respective responsibilities re emergency planning. To include in Hassaan Majid's objectives for 2018/19.

Date for Gold Command desktop exercise to be confirmed (March 2018)

Adherence to the duties set out for Category 1 responders under the Civil Contingencies Action 2004, which NHS England state we must comply with.

Annual EPRR assurance review, including a deep dive on EPRR corporate governance and a detailed assessment of Broadmoor as a strategic asset.

The EPRR assurance action plan has now been completed and we await our review meeting with NHS England EPRR team on 30.10.17

EPRR policy currently being reviewed

BAF REF : BAF4217

Risk If trust services do not implement learning from service user and

carer feedback and incidents we may fail to improve services and this will result in sub optimal care


2 x 4 2 x 4 2 x 4 2 x 4 1 x 4 1 x 4

Source Patient surveys; complaints; Grade 1 and 2 Serious Incident Reviews

Governance Group Quality Committee Risk Owner : Stephanie Bridger




Compliance with Trust complaints policy

Trustwide Service User and Carer Experience Sub-committee and Quality Committee receive Quarterly and Annual Patient Experience Report which includes information on complaints. Quality Metrics - Serviceline Workbooks - Board IPR Scorecard Weekly report to Director of Nursing - circulated to all Executive Directors. EDs review complaints performance regularly through the EDs' meeting.

Bi annual CQC surveys RSM Tenon audited against KPI indicators April 2017. Results due end of July 2017

Complaints not closed within timescales

Weekly patient experience data summary provided to Director of Nursing and Patient Experience highlighting compliance. This is circulated to all Executive Directors and performance is regularly reviewed through the Executive Directors Meeting and actions taken as required. Action Owner : Stephanie Bridger Date of Action : 31/05/2018

Board member visits around the Trust

Receipt of feedback following board member visit Robust tracking of feedback Will be considered in process mapping exercise Quality Committee receive reports on proposed areas to visit and keeps an oversight. Embedded in Quality Improvement Programme following mention in CQC Inspection and Re-inspection

Visits by NHSI, CCG and NHSE

BMV schedule being updated and process revised for 2018/19, including roll out of new reporting template.

Revised Visit schedule and monitoring process to be circulated. Action Owner : Peter Jenkinson Date of Action : 27/04/2018 Report Commissioned is due at the beginning of October 2017. Action Owner : Stephanie Bridger Date of Action : 31/10/2017

Implementation of the Trust 'Working in Partnership: service user and carer involvement strategy'

SUCE Committee now has joint Service User/Carer Chairs Patient Experience report received quarterly

The Director of Nursing and Patient Experience has commissioned a review of service user and carer involvement. Report due August 2016.

The review of Service User and Carer involvement highlighted - need to review strategy Recent review of Service User and Carer involvement highlighted - need to review strategy

The draft strategy is yet to be finalised.

First meeting to co-produce the recommendations from the 2016 reviews of service user and carer involvement held in January 2017. Two further meetings to be held and feedback to be given regularly to Quality Committee and Trust Management Team meetings until recommendations completed. The SUCE meeting agreed that the co-produced recommendations would be completed by World Mental Health Day 2017 - October. The Trustwide Service User and Carer Experience Sub-committee’s members co-produced recommendations drawing from the service user and carer involvement reviews. These have been amalgamated into the Draft Trustwide Service User and Carer Coproduction and Partnership Strategy. Finalise strategy by 31st May 2018 then seek ratification via SUCE. Action Owner : Gillian Kelly Date of Action : 31/05/2018 January 2018 - Draft strategy presented to the Service User and Carer Experience sub-committee on 09/01/2018. The draft strategy was discussed at the January 2018 Trustwide Service User and Carer Experience forum. Work is underway to finalise the strategy in April 2018. Action Owner : Stephanie Bridger Date of Action : 31/05/2018

Effective capture of patient feedback, including information sourced from Care Opinion, and responding appropriately to that feedback to improve Trust services

The SUCE Committee and the CQC receive a quarterly report on patient experience Care Opinion is being implemented across all services Improvement plan in relation to the Quality Health Inpatient Survey to be managed by Clinical Director for AUC. Improvement plan in relation to the Quality Health Community Survey to be managed by Clinical Director for PPC.

CQC annual survey results for community and inpatient services. Annual CQC (Community) Patient Survey reports to Trustwide Service User and Carer Experience Sub-committee Annual CQC (Community) Patient Survey reports to Trustwide Service User and Carer Experience Sub-committee

Care Opinion take-up was initially low although this is improving. Care Opinion not working for high secure. Currently exploring other ways of receiving feedback.

Low response rate to surveys and Patient Opinion patient feedback tool.

Patient Experience Co-ordinator, Sara Kerry is providing support to enhance and develop existing feedback channels to compliment Care Opinion and provides regular updates in the Quarterly Patient Experience Report. Action Owner : Gordon Turner Date of Action : 31/07/2018

Implementation of the Trust Recovery Strategy

Recovery Strategy reviewed by TMT and SUCE in September 2015 Recovery Strategy monitored by Trustwide Recovery Programme Board.

West London Collaborative (WLC) work as co-production partners with the Trust, ensuring that the Trust remain sighted on recovery and that recovery remains a key agenda within any service developments.

The Trust Recovery Strategy in itself will not ensure that services learn from the feedback offered by our service users and carers. It is a philosophical framework that needs to sit

The Trust Recovery Strategy in itself will not ensure that services learn from the feedback offered by our service users and carers. It is a philosophical framework that needs to sit alongside operational

The WLC has now agreed its work plan with the Director of Nursing and Patient Experience. An initial review of the strategy has been undertaken. There is a further workshop planned for May’18 to ensure we capture feedback on achievements and

Strategy updated and ratified by Trust Management Team October 2015.

alongside operational policy and process, in order to become a lived reality.

policy and process, in order to become a lived reality. A review of the Trust Recovery Strategy and its implementation is required. The Trustwide Recovery Programme Board has been suspended whilst there is a review of the Trust recovery Strategy. The governance around the work of this board is currently being overseen by the Trust wide Service User and Carer Experience Meeting. The co-production partners of the Trust (WLC) continue to have limited resource to support this work. Review taking place and to be presented at the Service User and Carers Experience sub committee in March 2018.

areas for further work before formulating a plan going forward. Action Owner : Stephanie Bridger Date of Action : 31/07/2018

The development of a Being Open and Compliance report which is shared widely across service lines and all quality goverance groups.

Regular scrutiny by board's quality sub-committee. Report now made available on Trust website. The report was received by the April 2017 Quality Committee.

Report was received by the Ealing Clinical Commissioning Group, Clinical Quality Group meeting in April 2017. Although the impact of the report is not known or measured.

Development of a serious incident theme report.

A report has been commissioned and is due at the beginning of October 2017. The report will detail themes of serious incidents in order that services can learn more from them. Action completed The review report was provided in October 2017 and has been discussed within the Trust Clinical Governance meeting as well as shared with key stakeholders. WLMHT is sharing cross cutting themes with relevant services, investigation leads and review panels and work to address themes is being initiated.

BAF REF : BAF8025

Risk If we are unable to deliver a consistent quality of physical health

care assessments and interventions to all our patients then there could be adverse health outcomes for patients in our care


2 x 4 1 x 4 1 x 4

Source serious untoward incident review findings Governance Group Quality Committee Risk Owner : Jose Romero-urcelay




The physical healthcare steering group is now firmly embedded within our governance processes, to oversee the development and implementation of policy and strategy and to monitor compliance.

Steering Group reports to Quality Committee Trustwide formal review and investigation of all incidents in which physical healthcare appears to have been a significant contributory factor. Commenced a monthly audit process to review the quality of physical health assessments Physical health policy, consistent with NICE guidance, approved by Quality Committee February 2018 - trust-wide communications to follow.

CQC inspection - last inspection identified issues in community. CQUIN target

Issues identified in CQC inspection to be addressed. Physical Health strategy, including collation of all trust-wide PH activities, to be developed to support the approved policy.

Implementation of policy and embedding an ongoing audit process Action Owner : Jose Romero-urcelay Date of Action : 31/03/2018

The consultant nurse in physical healthcare is leading a comprehensive training programme for medical and nursing staff. MD / DoN are reviewing the resources provided to support physical health.

Reports on training levels to local services' governance meetings and monitored by PH Steering Group. More than 95% of our inpatient nursing staff trained. In addition, all nursing staff and trainee doctors receive relevant training regarding different aspects of physical healthcare by the consultant nurse for physical healthcare. Broadmoor Hospital and WLFS both have dedicated primary care teams.



BAF REF : BAF8407

Risk If there is insufficient acute inpatient bed capacity, then there is a

risk that patients requiring admission will be delayed in other parts of the system such as in A&E and in s136 suits


2 x 4 2 x 4 2 x 4

Source Trust Management Team, 28th June Governance Group Quality Committee Risk Owner : Sarah Rushton




Inpatient Transformation Continuous Improvement Plan which focuses on embedding cultural and behavioural changes needed to encourage new ways of working to achieve sustained capacity. The plan is closely linked with the Planned and Primary Care Transformation plan and there is a meeting with senior PCC colleagues once a month.

Fortnightly Inpatient Transformation meeting (which is extended once a month to include colleagues from P&PC to address interface issues). Access & Urgent Care SMT No out of area placements for six months, sustained over winter.

Urgent Care Steering Group attended by commissioners, Trust staff and service users meets on a 6-weekly basis and oversees progress on inpatient improvement plan. The West London Transformation Board is the group with the Urgent Care Steering Group reports into, and is co-chaired by Sarah Rushton and the Hounslow GP lead. It is widely attended by CCG MDs, Like Minded and patients and carers. The West London Programme Executive meets on a monthly basis to scrutinise progress against the continuous improvement plan to improve patient bed capacity. CQC inspection (January 2018) highlighted good practice in bed management.

No gaps identified

AUC Recovery Plan developed by Associate Director with CD and AUC Heads of Service which sets out detailed plan for improving immediate bed capacity. The key areas of focus in the plan include bed management, and patient flow

Fortnightly Inpatient Support meeting with Executive Directors to scrutinise progress against the plan, particularly focusing on helping immediate improvements to flow

WLMHT / CCG Transformation Programme Executive Group

Potential for a similarly detailed P&PC plan about how they will contribute to improvement of bed capacity.

at ward and system level.

Joint DToC action plan which the Trust leads working with commissioners (CCG and LA) to address the high level of DToC, especially in Ealing. Plan identifies actions to resolve some of the key pathway blockages.

Monthly report to Local Services SMT which includes updates and risks Fortnightly review of DTOCs by executive directors.

There is a weekly call on the Ealing DToC action plan with the Trust and commissioners. H&F and Hounslow DToC meetings take place.

No gaps identified

Inpatient Performance Framework launched and working to embed. It sets out key metrics and thresholds for managing the pathway. The metrics are planned to ensure optimum bed capacity so that if targets are met there is sufficient bed capacity. It will be supplemented by ward action plans.

Monthly ward performance data circulated to all AUC clinicians and discussed at AUC SMT. 6-weekly individual ward meetings with Clinical Directors to discuss progress against action plans. Quarterly inpatient performance monitoring meeting. Fortnightly Inpatient Support Meeting with EDs. Local Services SMT.

Progress against thresholds is reviewed and scrutinised by Urgent Care Steering Group, West London Transformation Board, and West London Transformation Programme Executive.

No gap identified

Scope and initiate plan to implement 'Red to Green Bed Days', which is a visual management system to assist in the identification of wasted time in a patient's journey. This is an NHS England promoted tool that has been implemented in other trusts and is recommended as best practice. The Inpatient Transformation Group is scoping a plan to consult with staff and implement on a pilot basis.

Inpatient Transformation Operational Delivery Group. Fortnightly Inpatient Support Meeting with EDs. AUC SMT. Local Services SMT.

Progress will be reviewed and scrutinised by Urgent Care Steering Group, West London Transformation Board, and West London Transformation Programme Executive. Like Minded will also be reviewing progress.

Plan is yet to be completed.

Sonya Clinch leading a team on overflow patients to facilitate discharge and repatriation of private patients. CD provides medical review where necessary.

Weekly meeting scrutinising progress on private patients. Fortnightly Inpatient Support Meeting with EDs. Weekly updates to Heads of Service.

Progress will be reviewed and scrutinised by Urgent Care Steering Group, West London Transformation Board, and West London Transformation Programme Executive. Like Minded will also be reviewing progress.

No gap identified.

(i) A detailed internal clinical engagement plan focusing on targeted engagement for a range of professionals has been developed

Inpatient Transformation Operational Delivery Group.

Progress will be reviewed and scrutinised by the Urgent Care Steering Group, West London Transformation Board, and West

No gap identified.

and signed off by the ED, Medical Director, Director of Nursing and Director of Workforce. The Head of Nursing is taking a lead role in working with the CD and Head of Inpatient Care in developing the plan. (ii) Borough based meetings across all the teams about working together to improve the follow and bed capacity, chaired by the Executive Director of Local Services, Medical Director and Director of Nursing starting in July 2017. This is in addition to the bi-monthly tri-borough key clinicians meetings chaired by the Clinical Director.

London Transformation Programme Executive. Like Minded will also be reviewing progress.

Daily Bed Huddle Call which is focused on promptly discharging current inpatients and reducing any currently pending admissions.

BAF REF : BAF8429

Risk If the Trust fails to engage with members of staff, this could lead to

poor levels of motivation and poor quality of care 2017 2017 2017 2018 Level of assurance Forecast Tolerated Q2 Q3 Q4 Q1 since last update Rating Rating

2 x 4 2 x 3 2 x 3

Source Engagement score from national staff survey Governance Group Workforce and development committee Risk Owner : Wendy Brewer




Listening event engagement programme led by the Chief Executive. Monthly staff and team awards. Annual quality awards. Communications strategy including CE’s blog on the Exchange system. Active and constructive relationships with trade unions. Review of experience of new starters including induction and buddying schemes. BME communication forum. Development programme for middle managers, ‘Lead by example’.

Workforce performance report submitted to board monthly includes quarterly staff Friends and Family Test results. Workforce and Education Committee monitors a detailed workforce strategy action plan designed to mitigate the risk. Staff survey 2017 indicated continual improvement in all areas, including higher levels of staff engagement. Analysis of exit survey results reported to Workforce Committee (November 2017) showing 70% staff saying that the trust is a good place to work and would consider returning at some stage. 73% of medical trainees completed their most recent survey. Positive feedback from inaugural long service awards ceremony (November 2017).

CQC inspection included 'well led' review, with no negative findings. HEE visit (November 2017) - no negative findings and positive feedback re trust engagement with junior doctors.

The FFT results are available only quarterly and cover a small sample of staff. The FFT results are available only quarterly and include a small sample of staff.

BAF REF : BAF8431

Risk If the Trust cannot support the people change management

aspects of organisation transformation, the required patient care and quality improvements will not occur


2 x 3 2 x 3 2 x 3

Source Metrics used for delivery of transformation programmes - e.g. reduction in length of stay

Governance Group Workforce and development committee Risk Owner : Wendy Brewer




The Trust's Workforce strategy and plan has been agreed and continues to be implemented, including initiatives such as: Inclusion of Lead Business Partner on Transformation Board. Delivery of patient centred workforce planning workshops. Lead by Example leadership programme Coaching programme for managers NW London Like Minded workforce transformation programme.

Workforce and Education Committee monitors a detailed workforce strategy action plan designed to mitigate the risk. Transformation board monitors workforce indicators Delivery on the Trust inpatient transformation plan demonstrates increased change management skills and development of a change management culture. Improved capacity and capability in HR to support.

Like Minded delivery board.

Inclusion of lead business partner on the board for planning for the Ealing bid.

DRAFT MINUTES OF THE FINANCE AND PERFORMANCE COMMITTEE Held on Wednesday 28 March 2018

In the White Room A Trust Headquarters, Armstrong Way, Southall UB2 4SA

Present: Mr Tom Hayhoe Non-Executive Chair Mr Neville Manuel Non-Executive Director (Committee Chair)

Ms Elizabeth Rantzen Non-Executive Director Dr Jose Romero-Urcelay Medical Director Mr Paul Stefanoski Director of Finance & Business Ms Stephanie Bridger Director of Nursing

Attending: Ms Wendy Brewer Director of Workforce and Organisational

Development Ms Pamela Farrow Head of Costing Mr Chris Hilton Director of Business & Strategy Mr Peter Jenkinson Trust Secretary Mr Peter Milliken Head of Finance & Business Performance (Local

Services) Mr Trevor Nelms Director of IM&T Ms Hannah Parsons Head of Business & Finance, WLFS Mr Jim Phillips Head of Finance Ms Iscelyn Richards Deputy Trust Secretary (Minutes) Items were discussed in the sequence they are recorded in the minutes Ref:

Discussion: Action:

1. WELCOME AND APOLOGIES 1.1 1.2

Mr Manuel welcomed everyone to the meeting. Apologies for absence were received from Ms Carolyn Regan, Chief Executive Mr Hassaan Majid, Non-Executive Director Ms Sarah Rushton, Director of Specialist & Local Services Ms Leeanne McGee, Director of High Secure and Forensic Services

2. 2.1

DRAFT MINUTES OF THE PREVIOUS MEETING Amendments to February Finance and Performance committee draft minutes to be discussed outside of the committee.

3.1 3.1.1 3.2 3.2.1

ACTION SCHEDULE AND MATTERS ARISING The committee discussed the action schedule, noting the completed actions which will now be archived. Matters Arising No items arising.

Ref:

Discussion: Action:

4. 4.1

ACTIONS FROM BOARD AND/OR OTHER COMITTEES No actions.

5. 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9

MONTHLY POSITION - TRUST To allow for sufficient time to discuss the 2018/19 financial plan, Mr Manuel instructed the committee to take items 6 to 9 as read and discuss by exception only. Mr Stefanoski informed the committee that at month 11 the Trust was still on target for an £8m surplus. CIP target is expected to be achieved in full by end of year notwithstanding the balance between current and recurrent. Mr Stefanoski reported a capital underspend position but confirmed that the Trust will be permitted to carry forward the under-spend from Broadmoor, which will be updated on the Trust’s capital resource limit for 2018/19. Mr Manuel queried agency expenditure noting that the current track is approximately £1.1m per month, assurance was sought that the Trust would not exceed £15.7m and that controls we in place to prevent over expenditure. Mr Stefanoski assured the committee that controls continue to be applied to prevent breaching the £15.7m ceiling. Further, the reported position from month 9 and month 10 on agency expenditure was not indicative of any anticipated breach. Ms Rantzen sought assurances in regards to the process for CAPMG. In particular, are processes in place to monitor underspends in addition to the prevention of overspend? Mr Stefanoski informed Ms Rantzen and the committee that in month 8 changes were made to the CAPMG processes to enable the more timely agreement capital expenditure, which should mitigate this issue to some extent. Mr Stefanoski has agreed to return to the committee with a briefing outlining the process and providing assurance to the committee Ms Rantzen expressed concern that the Trust was providing estate services to Ealing Hospital. It was felt that it would be more constructive that Estates services were directed exclusively to meeting the needs of the Trust, as opposed to providing services to Ealing Hospital. Mr Stefanoski clarified to the committee that the Capital and Estates team have established a capital plan for 2018/19. The plan created by Michael Harbour utilises a 3-dimensional approach which incorporates quality issues. Ms Bridger informed the committee that she has initiated a conversation with Michael Harbour about the Capital and Estates

Paul Stefanoski

Ref:

Discussion: Action:

5.10 5.11 5.12

2018/19 plan, highlighting the importance of a plan with clear and defined time frames. It was noted that the CQC will request details with regards to timeframes for delivery. A timeframe will allow the Trust to respond comprehensively by identifying where issues exist and the efforts the Trust was making to resolve these. Ms Rantzen raised the positive impact agreed time frames would have on promoting good internal morale. Mr Manuel agreed with the above points raised by Ms Bridger and Ms Rantzen. Mr Stefanoski agreed to bring a review of Q1 capital expenditure to Finance and Performance Committee in September 2018. The review would provide a detailed review of Q1 Trust performance, excluding Broadmoor. The objective of the review was for the Trust to become an enterprise that spends according to plan. Ms Rantzen requested that the Q1 review be made available in an accessible font and font size.

Paul Stefanoski

6. 6.1

Monthly position – Local Services No significant forecast changes to Local Services monthly position. Report taken as read, no further points.

7.1

Monthly Position - HSS & West London Forensic Services No significant forecast changes to High Secure Services and West London Forensic Services monthly position. Report taken as read, no further points.

8 8.1

Monthly Position – Estate & Facilities Mr Stefanoski advised the committee that the forecast for month 11 was in line with the 2017/18 stretch target. Discussion on rates still ongoing may not be resolved this year.

9 9.1 9.2 9.3

Monthly Position – Corporate Report taken as read. Mr Manuel was satisfied that the agency spend exit trajectory appeared to be reasonable, consistent with what has been planned for 2018/19. Mr Manuel emphasised the need for agency expenditure at £1m or less for the financial year 2018/19. Mr Manuel noted the reports from month 9, 10 and 11 have provided high assurances regarding forecast delivery and operating finances. The committee was in agreement that the organisation had proved

Ref:

Discussion: Action:

itself to be control of a range of finances.

10 10.1 10.2 10.3 10.4 10.5 10.6

Financial ‘deep dive’ – Medical Expenditure Dr Romero-Urcelay noted the importance of medical expenditure being subject to the same level of scrutiny as all other service areas. The budgets were regularly reviewed and the financial position was healthy. £200k had been allocated to the budget for quality improvements as of January 2018. Concern was expressed to the committee that the budget has not historically been sufficiently scrutinised, particularly in the following areas:

1) Responsibility allowances: inconsistencies between the distribution of responsibility allowances between Directors.

2) Provision of safeguarding team: The cost associated with the safeguarding team has been subsidised significantly by CAMHS e.g. increased Personal Assistants. Currently, the Clinical Director of CAMHS has expressed reservation in paying for the additional safeguarding Personal Assistants.

3) Underutilised budgetary income of £11,400 derived from Anglo-American medical association

Dr Romero-Urcelay has requested a more realistic budget for 2018/19 with the ability to offer a responsibility allowance to all Directors within the medical budget on a consistent basis. The development of a learning disability strategy, will also require a lead for this. The committee discussed the reabsorption of the £140k underspend, in conjunction with the re-costed safeguarding team and allocation of consistent responsibility allowances. It was noted that the identified costs could be consumed within the existing medical budget. Mr Manuel agreed with Dr Romero-Urcelay that the Medical budget should be subject to the same level of scrutiny as the other service lines. The Committee agreed that the budget should be reviewed by the Finance and Performance committee once a quarter. The committee agreed that medical expenditure would return to Finance and Performance committee in June 2018 with a review of the current budget and discussion on three areas that were identified as needing improvement in March 2018

Jose Romero-Urcelay

Ref:

Discussion: Action:

11 11.1

Capital – Year end update Covered at item 5.

12 12.1

Capital Dashboard 2017/18 Covered at item 5.

13 13.1 13.2 13.3

Costing process to support the submission of 17-18 reference costs In advance of submitting 2017/18 reference costs, Mr Stefanoski provided assurance to the committee that the correct processes would be followed. Assurance can be illustrated inter alia the work that is being conducted at patient level in regards to road mapping. Mr Hayhoe agreed with the committee that this approval process is of strategic importance to the Trust for benchmarking our position against previous years, and acute services. The reference cost index is currently at 96% and is due to be submitted over summer. Following on from this, the next submission will be in December 2018. The Committee gave approval for the 2017/18 reference costs to be submitted.

14 14.1 14.2 14.3 14.4

Budget SLA Review Mr Stefanoski reminded the Committee that the control total for the Trust was a £5.2m surplus for 2017/18. The Trust has recently been notified that the control total surplus for 2018/19 will be £4.5m. The STF funding available to meet this target has increased from £1.6m to £2m. The planning aim is to reach the proposed control target for 2018/19. The attention of the committee was directed towards the bridge diagram in the report that outlined the key drivers in achieving the 2018/19 target given the 2017/18 outturn. The inflationary uplift is 2.2%, which includes an assumed 1% pay increase for all staff. This does not include the estimated 5% pay increase over 3 years which was recently announced and is assumed will be funded additionally. The methodology for the funding of the 5% pay increase is yet to be disclosed. The CIP target of £9.4m in 17/18 has been reduced to £8.6m for 18/19 as a result of increased recurrent CIP achievement and the reduction in the control total target. The Trust has signed a contract with NHSE for forensic and High Secure Services, and the Trust was on the verge of signing with the

Ref:

Discussion: Action:

14.5 14.6 14.7 14.8 14.9 14.10 14.11 14.12 14.13 14.14

local CCGs. Mr Stefanoski informed the committee that the anticipated CCG gap is approximately £3m income to expenditure but it was hoped that this gap could be bridged. The CCGs were expected to meet the mental health investment standard. Mr Stefanoski informed the committee that there has been no material changes to plan reported last month. However, a greater level of assurance has been provided which could be incorporated into the plan for NHSI. Mr Hayhoe queried the impact on the budget of a move into the new Broadmoor prior to the end of the next financial year as per the 2018/19 budget assumption. Mr Stefanoski informed the committee that it would result in a net reduction in the quarterly capital charges due to the earlier revaluation as well as bringing forward CIP delivery. Mr Stefanoski informed the committee that the cost of Broadmoor has been assumed as per the business case. The sale of the old Broadmoor site has been put back to 2020/21 but the Trust will still have c£17m headroom before its liquidity rating is affected. Mr Manuel informed the committee that the Trust is starting the new financial year with a substantial cash balance. Chairmans report to include statement on stable liquidity and capital position of the Trust. Ms Parsons advised the committee the NHSE contract gave 3.5% growth across services including women’s services. Additionally, there has been additional capacity funded within The Orchard, women’s medium secure services at the higher bed price (approximately £300k difference). The committee discussed the NHSE contract and concluded that the risk of not achieving the overspend target set in the plan would be reduced due to the fact thatoverall service contracts have increased by £1.7m. Mr Manuel discussed with the committee that although the Trust was breaking even, the Trust was providing women’s services above the level of income received. In 2017/18 the Trust has endured cost pressures relating to QIPP, Women’s services, repatriation and length of stay. Mr Stefanoski highlighted to the committee the 2019/20 position, forensic overspend was forecasted down to £2m as the Trust relocated some wards to Medway Lodge. Mr Manuel and Mr Hayhoe emphasised the need to highlight existing and continuing issues with women’s services to NHSE during the financial year 2018/19.

Iscelyn Richards

Ref:

Discussion: Action:

14.15 14.16 14.17 14.18 14.19 14.20

Mr Stefanoski continued his report to the committee. There was an anticipated overspend within West London Forensic Services of £3.5m and £500k for Estates and Facilities. This would reduce to £2m and £0k respectively for 2019/20. CIP plan is currently in outline format, they will be entered into the strategic plan which will be submitted to NHSI. Mr Stefanoski anticipates that the Trust will met the agency spend target for 2018/19 by reducing agency usage and increasing substantive staff. Agency spending target for 2018/19 is £12m, to be monitored against a £1m per month spend. Cash flow balance to reduce from £57m to £35m during 2017/18 to pay for capital expenditure. Assets down in Q4 by approx. due to the revalue and transfer of Broadmoor sites. Mr Stefanoski advised the committee that three of the key focuses for 2018/19 are as follows:

1) To deliver recurrent CIPs 2) The close monitoring of Forensic and Estates & Facilities

outturn position 3) Closely monitor the transition of Broadmoor site

Mr Stefanoski provided assurance by drawing on the agency spend in Q1 17/18, highlighting the change in behaviours towards agency spend. Mr Stefanoski emphasised the importance of remaining vigilant. Mr Manuel agreed that the monitoring of agency needs to become an embedded process. The 2018/19 budget was approved and commended to the Board.

15 15.1 15.2 15.3

Integrated Performance Report Committee agreed to a review of the current Integrated Performance Report format. The IPR would be refreshed and a draft proposal presented to TMT in May. Ahead of presentation at TMT, Mr Hayhoe requested that the draft proposal return to Finance and Performance committee in May with a proposed list of KPI’s including a section on complaints. Further, it was agreed that the new IPR format would undergo detailed scrutiny in June, with a substantial proportion of the agenda dedicated to the IPR.

Paul Stefanoski Paul Stefanoski

16

BAF and Risk register

Ref:

Discussion: Action:

16.1 The committee queried the status of Information Governance in light of GDPR and IG toolkit training and toolkit. Miss Richards provided assurance that preparations were in progress for implementation in line with GDPR and ICO deadlines.

17 17.1

Terms of Reference and draft Work Plan 2018/19 The committee endorsed the Terms of Reference and draft work plan for 18/19.

18 18.1

Capital and Asset Planning Management Group meeting Noted. No amendments made to minutes.

19 19.1 19.2 19.3

FOLG Noted. The Committee noted that there were still minor amendments required to the minutes as presented, The Committee were informed that the Trust’s financial plan had been discussed and endorsed at the meeting held earlier in the day.

20 20.1

Consider If Any New Risks Were Identified Or Changes To Risks Proposed The committee considered the perceived impact of GDPR.

21 21.1

Actions Remitted to Other Committees No actions remitted.

22 22.1

Any Other Business No other business.

Date & Time of next meeting Wednesday 25 April 2018 1300 – 1500 White room A, Trust Headquarters, Armstrong Way

MINUTES OF THE QUALITY COMMITTEE MEETING

Held on Wednesday 21st March 2018

Present: Prof Paul Aylin Non-Executive Director (Chair) Ms Moriam Bartlett Non-Executive Director Dr Chris Bench Clinical Director, Planned & Primary Care Services Dr Robert Bates Clinical Director, High Secure Services Dr Claire Dillon Clinical Director, WLFS Dr Jose Romero-Urcelay Medical Director Ms Sarah Rushton Director of Local Services Dr Angharad Ruttley Clinical Director Liaison and Long-Term Conditions Paul Stefanoski Director of Finance and Business Dr Nicky Goater Interim Clinical Director, Access & Urgent Care Attending: Peter Jenkinson Trust Secretary Gillian Kelly Corporate Director of Nursing Stanley Riseborough Interim Director Jinelle Rodrigues Secretariat Assistant (minutes) Donna Sloss Practice Development Nurse Dr Samantha Scholtz R&D Director Ms Sally Sykes Director of Communications and Engagement Gordon Turner Associate Director of Clinical Governance Agenda items are recorded in minutes in the sequence they were considered Item

Discussion Action

1. 1.1

INTRODUCTION & WELCOME Prof Aylin welcomed everyone to the meeting and a round of introductions was made.

2. 2.1

APOLOGIES FOR ABSENCE Apologies for absence were received from the following: Wendy Brewer Director of Workforce & OD Stephanie Bridger Director of Nursing & Patient Experience Dr Nevil Cheesman Clinical Director, Cognitive Impairment and Dementia Services (CIDS) Tom Hayhoe, Chairman Ms Leeanne McGee Director of High Secure and Forensics Services Dr Vijay Parkash Clinical Director CAMHS & Developmental Services Ms Carolyn Regan Chief Executive

3. 3.1

MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on Wednesday 21st February 2018 were agreed to be a correct record subject to some minor amendments and corrections.

J Rodrigues

4. 4.1

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Committee reviewed the action schedule and noted the completed actions. The following updates were provided:

Item

Discussion Action

4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11

19/07/17: item 15.1 Clinical Governance Group Terms of Reference: Mr Turner advised that the terms of reference would be circulated by the end of March after approval from Trustwide Clinical Governance Group 20/09/17: item 26.2 SUCE: 18/10/17: item 9.5 SUCE Lay: Ms Kelly provided an update to the Committee and reported that the job description for the lay representative had been drafted and that an invitation to express an interest in the role would be published. It was noted that the current lay representative, Ms Mary Jane would also be invited to express her interest. Prof. Aylin stated that this matter had been outstanding for a longer period than anticipated and urged urgent action to conclude this process. 20/09/17: item 14.4 : Annual Trust Patient Experience Report 2016-17: The Committee noted the previous discussions regarding mechanisms for obtaining patient feedback and possible options for the future, including technical solutions. The Committee noted the need for a strategic framework for patient feedback to be developed over the next three months, to include mapping of existing mechanism for capturing patient feedback and options for developing new platforms. 21/02/18: item 9.4 Physical Healthcare Policy: it was noted that Linda Nazarko was considering the addition of prompts in dental care in community into the policy. Action closed. 21/02/18: item 10.6 BAF8026 – Serious Incidents: Action closed. 21/02/18: item 9.2 Use of mobile apps for Jr. Doctors: Dr Romero-Urcelay reported that there was one app for medical rostering, from Allocate, that was being considered, and that discussions were ongoing with HR regarding rollout. Dr Bates queried if there was a web page available for this app and Mr Stefanoski confirmed that a web-based application should also be available. 24/01/18: item 9.2 Q3 Quality Governance (compliance, quality improvement, being open & well led): Mr Turner stated that the Q4 report, with updated format, would be presented at the next meeting in May 2018. 21/02/17: item 16.3 AOB: It was agreed that the timetabling of an update into the committee work plan would be agreed with Leeanne McGee and Dr Vijay Parkash. Matters Arising There were no other matters arising.

Ms Kelly/Ms Bridger Ms Kelly/Ms Bridger G Turner

5. 5.1

ACTIONS REMITTED BY THE BOARD OR OTHER COMMITTEES No actions had been remitted by the Board or other committees since the Committee had last met.

Item

Discussion Action

7. 7.1 7.2 7.3 7.4 7.5 7.6

Cost Improvement Plan Report (Item brought forward due to presenter availability) The Committee received and considered a quarterly update on the Trust’s Cost Improvement Programme, including details of the annual Cost Improvement Plans (CIPs) identified for 2017/18 and the potential impact upon quality of care of implementation in order to meet the target of £9.4 million, and mitigations in place to address the amber and red quality impact risk ratings regarding quality assurance for 2017/18 CIPs. The Committee considered the process for assessing the impact on quality from CIPs and agreed that it has positive assurance regarding the QCIP process and the due diligence applied to the quality impact of CIPs. It was however agreed that it was important to communicate to staff the positive impact of some QCIP schemes, such as the transformational impact on inpatient bed capacity. Ms Rushton reported that a newsletter surrounding transformation would be published soon. The Committee considered the amber rated schemes. Mr Stefanoksi stated that there were potential risks around e-rostering and West London Forensics Services, and agency staff. Feedback around agency staff was going well and that there was no quality risk present however a lack of benefit was noted. The Committee also discussed the Trust’s approach to calculating staffing establishments and the consistency of the approach Trust-wide. Mr Riseborough questioned the different approaches being used across the service lines. Ms Rushton stated that there issues had been addressed around establishments and headroom in Local Services. Mr Riseborough advised that progress should be monitored in each service line. Ms Kelly confirmed that nursing and professional leads were assessing establishments against the National Quality Board guidance on safe staffing levels. The Committee noted the ongoing work being done to improve the rostering and noted the assurance provided to the Board on achieving minimum staffing levels through the quarterly reporting. The Committee discussed workforce planning and rostering and agreed that further action around rostering and establishments should be addressed at the Workforce and Development Committee meeting.

Ms Rushton/Elizabeth George

9. 9.1 9.2

Risk ‘Deep Dive’ - Estates BAF (Item brought forward due to presenter availability) The Committee reviewed the management controls in place to manage the risk “If the Trust does not adequately manage its estate portfolio this will compromise the safety and quality of service delivery”. The Committee discussed the relationship between this risk and the fire safety risk also on the BAF and Mr Stefanoski outlined the controls in place to manage this risk, including an update from the Fire Safety

Item

Discussion Action

9.3 9.4 9.5 9.6

Steering Group, established to oversee implementation of the remedial action plan. Mr Stefanoski stated that there were risks around technological estates surrounding IT, CCTV camera’s poor functionality, and a capital of £1.7m being available towards covering fire safety and ligature risks. The Committee also noted the relationship between this risk and the CQC compliance risk, noting that one of the regulatory improvement notices from the last inspection relates to estates maintenance and responsiveness. Mr Stefanoski assured the Committee that he along with Ms Bridger were overseeing that the work around estates and fire safety mirrored the CQC action plans including looking into budget codes. The Committee were concerned to receive assurance that the impact of changes recently made to processes and systems for requesting estates maintenance are adequate to address the CQC findings, and agreed that action needs to be taken to monitor progress in the actions being taken through feedback from local managers. The Committee noted the ongoing concern regarding the condition of some of the Trust’s estate and note the importance of exiting from certain buildings, as part of the implementation of the Trust’s estates strategy. Mr Stefanoski assured the Committee that a revised estates strategy would be approved and circulated by end of July 2018.

6. 6.1 6.2 6.3 6.4

CQC Inspection of Local Services Adult Acute & PICU Wards The Committee noted the outcome of the recent CQC inspection of adult acute and PICU wards in local services. The Committee noted the positive assurance provided from the inspection, including the improvements made since the last inspection in inpatient bed capacity and risk assessments. The Committee noted the five regulatory improvement notices, including seven actions requiring urgent attention. The Committee noted that three of the seven actions related to minor works and proper understanding of safeguarding. The Committee noted that the Trust’s comments on the draft report were submitted on 16 March and that the Trust’s response to the regulatory improvement actions would be submitted by 26 March. Dr Goater noted the regulatory improvement action required regarding governance structures and reporting structures for serious incidents. She reported that the governance arrangements within AUC were being reviewed to provide robust assurance processes. Prof. Aylin noted the issue of under reporting of incidents and suggested that the Committee should have regular updates on this data.

Mr Turner

8. 8.1

Health, Safety and Welfare update The Committee received and considered an update on health and safety developments since the last Trust Fire, Health and Safety

Item

Discussion Action

8.2 8.3 8.4 8.5

Committee on 19 January 2018 and the report circulated with papers for the previous month’s Quality Committee. Ms Kelly highlighted additional assurance provided in the report around the management of Medical Devices, the additional controls in place to minimise ligature risks and the management of risks around working of oxygen cylinders.

Ms Rushton advised that assurance should be provided that work around medical devices was being confirmed. She also raised concerns on old defibrillators being seen at some services which needed addressing. Dr Romero-Urcelay agreed to Ms Ruston’s suggestion and suggested maintenance contract to include an update on Health and Safety and to take the matter to Health and Safety Committee. Dr Bates advised that there should be a review of blind spots and to also take this action up to Health and Safety Committee for further discussions.

10. 10.1 10.2

Quality Account and Quality Priorities The Committee considered an update on progress against the quality priorities for 2017/18, including a summary of actions in areas rated as ‘limited assurance’. Dr Romero-Urcelay highlighted the summaries included in the report for each of the service lines. The Committee was assured that the service lines were progressing well and that mechanisms were in place for the few areas requiring additional support.

The Committee confirmed that the current priorities should remain the same for the second year of the plan, for 2018/19.

11. 11.1 11.2 11.3

BAF and Level 1 risks The Committee reviewed the quality-related risks on the BAF, noting that the individual risks were currently being reviewed with executive owners and any proposed changes would be considered by TMT and Board. Mr Jenkinson reported on discussions at the March Trust Board meeting and the agreed recommendations to strengthen committees’ assurance processes and the use of the BAF, including the evaluation of the level of assurances being received at Board committee level and at sub-committees via deep dives and sub-group reports / minutes. It was noted that a revised template for risk ‘deep dives’ would be implemented to support this. Dr Romero-Urcelay questioned about the risks in relation to medical workforce and expenditure on agency staff as these involved external factors. The Committee discussed the current issues in medical workforce recruitment, leading to increased agency expenditure. We noted that the scope of the BAF risk relating to workforce planning and recruitment also included medical workforce, but agreed that TMT should consider whether the current issues merit a specific risk.

Medical Director

Item

Discussion Action

11.4 11.5 11.6

Ms Rushton suggested taking this issue up to the Clinical Director’s meeting to have a better understanding on quality issues. Mr Jenkinson explained that this issue was currently covered by the Workforce and Development Committee however Dr Romero-Urcelay agreed to take this action to the Clinical Director’s meeting for further discussion. Prof. Aylin advised on having a historical perspective to the BAF featuring long term risks. Mr Jenkinson stated that the BAF featured dates of when the risk was first identified and against the forecast risk and how it being managed and when the risk lowers. The Committee noted the importance of linking the risks on the BAF with the Quality Risk Profile (QRP) for the Trust and noted that the Associate Director of Clinical Governance was mapping the QRP with sources of assurance.

12. 12.1

Trustwide Clinical Governance Group The Committee noted the agreed minutes of the meeting held on 5th February 2018

13. 13.1

SUCE Sub Committee The Committee noted the ratified minutes of the meeting held on 9th January 2018.

14. 14.1

Clinical Design Group The Committee noted the agreed minutes of the meeting held on 5th December 2017 and that the next meeting will be held on March 2018.

15. 15.1

Physical Health Steering Group The Committee noted the ratified minutes of the meeting held on 15th January 2018.

16. 16.1

Fire Safety Steering Group The Committee noted the draft minutes of the meeting held on 27th February 2018 and the approved minutes of meeting held on 29th January 2018.

17. 17.1 17.2 17.3 (as per agenda)

ANY OTHER BUSINESS Board member visits Prof Aylin commented that the quality of feedback provided following site visits by Non-Executive Directors had deteriorated and queries the process for management of board member visits. The Committee noted that a new reporting template had been circulated to non-executive directors but agreed that additional guidance should be published to highlight the need to complete the summary section rather than each individual prompt. It was also agreed that the schedule of visits and recommended locations for visits would be re-issued. The future of patient safety investigations The Committee noted the survey launched regarding the future of patient safety investigations, noting a potential move away from

P Jenkinson

Item

Discussion Action

17.4 17.5

investigations based on root cause analysis to ones based on human factor, due to the RCA methodology not lending itself to learning lessons. It was noted that the Trust would review its approach to investigations following publication of the findings and recommendations from this survey, but Prof Aylin noted that ideas and recommendations were being rolled out from Jane Carthy’s Thematic Review. Mr Turner confirmed that a new incident investigation reporting template and policy was to go live soon. On behalf of the Committee, Prof Paul thanked Non-Executive Director Moriam Bartlett, Trust Secretary Peter Jenkinson and Clinical Director Dr Chris Bench for their dedication and accomplishments towards the betterment of the Trust and wished them all the very best in their future endeavours.

18. 18.1 18.2 18.2

QUALITY COMMITTEE WORKPLAN 2017/18 The workplan was noted. The Terms of Reference were approved by all and the Committee was reminded of the new format that was due to commence from next month April 2018. There being no other business the meeting was declared closed at 10.45am.

DATE & TIME OF NEXT MEETING Wednesday 18th April 2018 0900 to 1100 hrs, White Rooms A&B

DRAFT MINUTES OF THE QUALITY COMMITTEE MEETING

Held on Wednesday 18th April 2018

Present: Prof Paul Aylin Non-Executive Director (Chair) Dr Robert Bates Clinical Director, HSS Ms Wendy Brewer Director of Workforce & Organisation Development

Ms Stephanie Bridger Director of Nursing and Patient Experience Ms Angela Dolan Deputy Director of HSS Mr Tom Hayhoe Trust Chairman Dr Fintan Larkin Clinical Director, Access & Urgent Care Dr Julia Renton Clinical Director, Planned and Primary Care

Dr Vijay Parkash Clinical Director, CAMHS Dr Jose Romero-Urcelay Medical Director Ms Sarah Rushton Director of Local Services Dr Angharad Ruttley Clinical Director, Liaison & Long-Term Conditions Mr Gordon Turner Associate Director of Clinical Governance

Attending: Celia Blake Clinical Change Manager Mr Stanley Riseborough Improvement Director Ms Sally Sykes Director of Communications and Engagement Ms Samantha Scholtz R&D Director Agenda items are recorded in minutes in the sequence they were considered Item

Discussion Action

1. 1.1

INTRODUCTION & WELCOME Prof Aylin welcomed everyone to the meeting and a round of introductions was made.

2. 2.1

APOLOGIES FOR ABSENCE Apologies for absence were received from the following: Ms Leeanne McGee, Executive Director of High Secure and WLFS Ms Carolyn Regan, Chief Executive Dr Claire Dillon, Clinical Director WLFS

3. 3.1

MINUTES OF THE PREVIOUS MEETING The minutes of the meeting held on Wednesday 21st March 2018 were agreed to be a correct record subject to some minor amendments and corrections.

Jinelle Rodrigues

Item

Discussion Action

4. 4.1 4.2 4.3 4.4 4.5

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Committee reviewed the action schedule and noted the completed actions. The following updates were provided: 19/07/17: 15.1: Clinical Governance Group Terms of Reference: Action Closed. 18/10/17: item 9.5 SUCE Lay: Expressions of Interest closing end of month. Action closed. 21/03/18: 6.2: Trust’s comments on the CQC draft report: Action Closed Matters Arising There were no matters arising.

5. 5.1

ACTIONS REMITTED BY THE BOARD OR OTHER COMMITTEES No actions had been remitted by the Board or other committees since the Committee had last met.

6. 6.1 6.2 6.3 6.4 6.5 6.6

SYSTMONE EVALUATION Ms Celia Blake (Clinical Change Manager) presented the presentation on the SystmOne Evaluation. She explained that the Board had made a decision in October 2017 to evaluate the working, advantages, and disadvantages of SystmOne. Ms Blake stated that their team was not only looking at the Forensics point of view but was also looking into IT actions as well however the main question revolved around what the Trust wanted as a whole. The Committee was informed that a ‘deep dive’ was conducted and a number of cultural challenges were noticed (see slide number 5). A number of site visits were also carried out and it was discovered that 40 sites across the Trust used RiO whereas 8 sites used SystmOne and another 4 sites were to go live by September one of which was identified as LCNWL. Ms Blake informed the Committee that an overview of multiple units’ model was created to accommodate a multi-user approach. High level findings were also presented before the Committee with rating Blue, Purple and Green. Blue indicating benefits presented by both RiO and SystmOne. Purple indicating benefits only from Systmone and Green indicating benefits from RiO alone. (See slide 8) Possible efficiencies, advantages and disadvantages and maintainability of SystmOne were also explained to the Committee (see slides 9-17) Ms Blake informed the Committee of the identified risks such as transferring our bespoke developments from Rio-Complex Forms (SQL), data quality issues, capacity test-multi—using-pilot which is set to go live in September and a poor after sales reputation of SystmOne.

Item

Discussion Action

6.7 6.8 6.9 6.10

Ms Blake concluded the presentation by advising the Committee that SystmOne, following its evaluation was deemed safe as a clinical system and for collection of quality information however it was not a quality system in terms of interoperations or willingness. Ms Rushton questioned on what it meant by ‘’Systmone being safe for clinical and quality information collection but not a quality system?’’ Ms Blake explained that although SystmOne states that they can have a multi-supplier approach they have only been in contact with EMIS, whereas Rio is actually uses a multi-supplier approach therefore making SystmOne not a quality system. Prof. Aylin questioned on if there will be interactions between SystmOne and RiO to have a quality system in place and Ms Blake stated they although SystmOne states that they are willing to have conversations they have never had one. Dr Bates commented that EMIS was going to have further conversations with SystmOne in the months to come on a multi-supplier approach. Prof. Aylin asked Ms Blake if there would be any learning lessons following SystmOne that would go live by September. Ms Blake stated that CNWL would go live and after ten months of going live they were aiming to draw finding and lessons would then be shared with the Trust. The Committee received the update and thanked Ms Blake for sharing the evaluation with the Committee.

7. 7.1 7.2 7.3

SERVICE LINE DEEP DIVE – HIGH SECURE SERVICES The Committee received the presentation on the service line ‘deep dive’ from Dr Bates. Dr Bates briefly explained the contents of the ‘deep dive’ to the Committee. Dr Bates explained that Broadmoor Hospital was celebrating 155 years this year and that it provided high secure care for men over the age of 18 with a personality disorder or mental illness, who present a “grave and immediate danger” to the public. He also explained the objectives of the hospital all of which are stated on slide number 3 of the presentation. The Committee was explained the catchment area the service covered, beds available, patients detained under MHA. Dr Bates informed the Committee that the majority of patients had convictions for serious offences and that 70% of the patients suffered with schizophrenia or a schizoaffective disorder. He also informed all that 50% primary or secondary diagnosis of personality disorder and had high levels of comorbidity while 65% were admitted from prison, 35% from lower levels of security and 70% of the patients were moved to medium security on discharge. The Committee noted that that the average LOS was approximately five and a half years and that this had remained the same for the past 45 years.

Item

Discussion Action

7.4 7.5 7.6 7.7 7.8 7.9 7.10 7.10

Dr Bates explained that the components of the care pathways in Broadmoor Hospital were described in five parts (see slide 5). He also explained that there was a 93% bed occupancy that was running low with no delayed discharges noted in the last two quarters. It was also noted that there were no delayed discharges in Quarter 3. (see slide number 6) Dr Bates updated the Committee on the CQC recommendations from last visit held in November 2016 and that one of the issues highlighted were around staffing. Graphs on registered and unregistered vacancies were shown along with starters and leavers which showed that the percentage of starters remained higher compared to leavers. It was also noted that the vacancies in other staffing groups were a concern especially around medical, social work and occupational therapists and that overall staff turnover remained elevated. Ms Bridger questioned if Broadmoor Hospital were following robust procedures in order to retain staff and Dr Bates stated that there were assurances mechanisms in place and that the Trust was the first to appoint a Band 5 R&R manager. The Committee also noted that new starter focus groups were in place. An update on the meaningful activities which offered with a view to streamlining, patient engagement showed improved management of cancellations and a significant improvement was noticed. It was also noted that a Total Mobile to provide a tablet based solution for recording activities was recently engaged. Dr Bates provided assurance on training provided for Responsible Clinicians which was delivered by Dr Simon Wood in May 2017. Capacity to consent was also reviewed at the Broadmoor Hospital Medical Advisory Committee and at two Consultants Away Days. Audits of capacity and consent were also undertaken in July 2017 and November 2017. There were noted to be improvements but still some issues and therefore a monthly audit, carried out jointly by nursing and medical staff was commenced in January 2018. Carer involvement update was provided to the Committee. It was noted that a carer information pack was created and the hospital has signed up to the Triangle of Care and initial self-assessments of all wards was also completed. Carer champions were appointed for each ward and quarterly meetings are ensured. Dr Bates pointed out the other risk identified by CQC was around ligature and blind spot assessments and that blind spots and assessment of ligatures were being audited. Dr Bates explained reducing restrictive practices and the Overview of organisational structure of reducing restrictive practices HSS along with Identification of roles of individuals, teams and organisation. He also explained that the LTS project included two phases and interventions and significant improvement in recording and monitoring was noted. Dr Bates explained the LTS project, bundle of interventions and overall stems

Item

Discussion Action

7.11 7.12 7.13 7.14 7.15 7.16 7.18 7.19

performance of LTS. (see slides 22 – 28). Dr Romero-Urcelay commented that in areas of LTS PMVA had advised on being linked with clinical nurse to Wards along with CNM’s checklist of training and support plans. Dr Bates stated that Jimmy Noak and he were working together on provided external assurances. Dr Bates explained the chart on slide number 30 over improved monitoring of restraint and Dr Romero-Urcelay questioned if there were any assurances on the cultural shift that was present and Dr Bates stated that there assurance mechanisms in place and a significant improvement on monitoring of restraint was noted. (see slides 30 – 35) Dr Bates explained on the Serious Incidents reported around physical violence of patients towards staff, number of assaults from patients towards staff, number of patients who have self-harmed and learning lessons all listed in presentation (see slides 35 – 41) An incident review example was shared with the Committee on how a member of staff was involved in drawing ten times more of the dose of Actrapid insulin required by patient. The lesson of what happened, the findings and the learning lesson of removing vials and introducing Novorapid Insulin pens. Prof. Aylin questioned if all vials of medications have been removed and to conduct an audit to ensure medications in vials is not being used to prevent further incidents from happening. Dr Romero-Urcelay stated that he would liaise with the chief pharmacist to ensure no vials are being used. Dr Bates talked about the complaints made and Q3 showed there was a decrease in the number of complaints made and that there were 28 complaints made compared to 38 in Q2. There was also a decrease in the number of individual patients who complained that is 22 patients in Q2 compared to 20 patients in Q3 of which 8 patients made more than 1 complaint during the quarter. Dr Bates explained the complaint investigation and action taking process to all. Mr Turner questioned if there were any compliments or positive feedback received apart from the complaints. Dr Bates stated that there were five compliments received in Q3 and two compliments received in the last two months. Dr Bates stated that there still an issue around gaining patient feedback and although the systems were in place to obtain this it was not proving to be a positive outcome and emphasized on a need to have a more robust system in place to obtain patient feedback. Dr Bates explained the number of medications incidents. (See slides 50 – 51). Dr Bates provided assurance that there were initiatives being taken such as patient forum, recovery committee, PLACE, training and DREEM survey towards betterment of Patient Experience.

Dr Romero-Urcelay

Item

Discussion Action

7.20 7.21

The Committee was updated on the Innovation Progress for 2018 (see slide 54). Dr Romero-Urcelay questioned if there was an ongoing development program in place for staff. Ms Dolan explained that every staff would be enrolled to the Training Familiarization Program which would be from a basic to enhanced level for all staff starting at the new hospital with exception of the Estates and Facilities personnel as they were waiting for a consultation regarding the same. Mr Riseborough commented on having assurance over all units/wards to have the mobile tablet devices as this would be easier and quicker than carrying a laptop for recording activities. The Committee thanked Dr Bates for hard work in producing the deep dive and presenting it all for their understanding.

8. 8.1 8.2

CQC QUALITY IMPROVEMENT PLAN UPDATE REPORT The Committee received and reviewed the CQC action plan and progress against the plan and considered the performance dashboards showing compliance in a number of quality standards across different clinical service lines. The Committee were assured that appropriate supervision was taking place and noted the action being taken to address the recording issue through the implementation of new systems. (Discussion carried forward to Item 9)

9. 9.1 9.2 9.3 9.4 9.5

BAF RISK DEEP DIVE –BAF7838 Ms Bridger provided the service line summary with details of the progress made in relation to the delivery of the Trust’s Quality Improvement Plan And that the plan was developed to address the CQC’s findings and recommendations following the re-inspection of the trust in November 2016.

Ms Bridger explained that the new format of reporting was developed in response to the Quality Committee and NHS Improvement’s recommendations for a more streamlined report. She outlined the areas of risk and assured support is being provided through service SMT meetings and the CQC Work Group. Ms Bridger explained that the 7838 risk rating of the delivery of CQC plan and key controls did not change and that a robust process was in place. There was also assurance around supervision and that a revised system around supervision was in place. It was noted that adult wards and PICU that staff were receiving supervision. Ms Bridger highlighted that the key area was recruitment and retention which was an ongoing challenge however AUC had their own regulatory plan in place along with a good narrative around it. Ms Bridger assured the Committee that she has started a process of redoing ligature risks and to have robust plans in place. She explained to the Committee that there was still a backlog surrounding this however a

Item

Discussion Action

significant improvement was noted. The Committee noted the ‘deep dive’ update and thanked Ms Bridger for her efforts.

10. 10.1 10.2 10.3

BAF RISK DEEP DIVE – BAF4217 ‘LEARNING FROM SERVICE USER AND CARER FEEDBACK AND INCIDENTS’ Mr Turner explained that there was a worry around the process of gathering, sharing and learning from the service user and carer feedback and incidents. He also emphasized on the report being reworded and rescored as the current forecast rating was rated at 8 which was low and therefore would also require rescoring. He explained that this report needed to be redone which would require a longer time frame to produce. Dr Romero-Urcelay stated that he was happy for Mr Turner to conduct and produce a ‘deep dive’ and review the report by rewording and rescoring. Ms Bridger stated that there two risk still present one surrounding learning issues and the other was a performance issue. Prof. Aylin questioned if it would be better to merge these two risks and produce one report. Ms Rushton seconded this; however Ms Bridger advised the Committee that they would relook at both the risks and bring proposals at the next meeting. The Committee noted the update.

11. 11.1 11.2

QUALITY STRATEGY REFRESH Ms Bridger stated that she was not aware of Quality Strategy and looking up the Exchange noticed that there was indeed a quality strategy that ran out in 2016 and as the Trust already had a Quality Priorities and Quality Account strategy, she along with Dr Romero-Urcelay and Dr Christopher Hilton were working on producing a complete Quality Strategy amnesty. Ms Sykes commented that this may not be a quality strategy but a Clinical Strategy. Ms Bridger stated that she was aware and the main focus would be to have a clear definition or wording of articulating the report for the understanding of all. The Committee thanked Ms Bridger for the update.

12. 12.1 12.2 12.3 12.4 12.5

ANY OTHER BUSINESS TRUSTWIDE CLINICAL GOVERNANCE GROUP TERMS OF REFERENCE The terms of reference were noted by the Committee. Prof Aylin questioned the Committee on their thoughts on the new format of the Quality Committee. Dr Romero-Urcelay stated that he found the Quality Seminar ‘Refreshing’ mostly because there was ample time to present, explain and discuss the ‘deep dives’. Mr Hayhoe stated that there was enough time provided as compared to

Item

Discussion Action

the Quality Committee meetings agenda that provided only 20 minutes to present an item - which would be difficult in terms of presenting, explaining and discussing heavy items such as the ‘deep dives’. The Committee agreed this and were happy with the new format of the Quality Committee. There being no further business the meeting was declared closed at 10.55hrs.

13. 13.1

QUALITY COMMITTEE WORKPLAN 2017/18 The workplan was noted.

DATE & TIME OF NEXT MEETING Wednesday 23rd May 2018 0900 to 1100 hrs, White Rooms A&B

DRAFT MINUTES OF THE WORKFORCE AND DEVELOPMENT COMMITTEE Held on Wednesday 21 February 2018

White Room A&B Trust Headquarters, Armstrong Way, Southall UB2 4SA

Present: Mr Tom Hayhoe Chairman Prof Sally Glen Non-Executive Director (Committee Chair)

Ms Moriam Bartlett Non-Executive Director Ms Wendy Brewer Director of Workforce and OD Ms Stephanie Bridger Director of Nursing & Patient Experience Ms Sarah Cuthbert Non-Executive Director Ms Dawn Harwood Service Director, Women’s and Adolescent

Services Mr Peter Jenkinson Trust Secretary Ms Katie Lynn Harfield Team Leader, High Secure Services Ms Helen Mangan Assistant Director Local Services (deputising for

Sarah Rushton) Attending: Carolyn Regan Chief Executive Mr Amin Cader Senior Clinical Manager (deputising for Leeanne

McGee) Mr Nathan Christie-Plummer Assistant Director of Workforce and OD Ms Iscelyn Richards Deputy Trust Secretary (minutes) Ms Sally Sykes Director of Engagement and Communication Ms Maninder Walia Lead Workforce Partner Ms Alison Webster Assistant Director of Learning and Development Ref:

Discussion: Action:

1. WELCOME AND APOLOGIES 1.1 1.2

Prof Glen welcomed everyone to the meeting. Apologies for absence were received from Ms Sarah Rushton, Director of Local and Specialist Services Mr Johan Redelinghuys, CAMHS Consultant Ms Leeanne McGee, Director of High Secure and Forensic Services Ms Alice Foyle, Service Director, High Secure Services Ms Gillian Kelly, Deputy Director of Nursing Mr Jai Jayaraman, NeXT Director

2. 2.1

DRAFT MINUTES OF THE PREVIOUS MEETING 2 AUGUST 2017 The minutes of 1 November 2017 were agreed to be a correct record of the meeting.

3.1 3.1

ACTION SCHEDULE The Committee discussed the action schedule, noting the completed actions which will now be archived.

Ref:

Discussion: Action:

3.2 3.2

MATTERS ARISING There were no matters arising.

4. 4.1

ACTIONS FROM BOARD AND/OR OTHER COMMITTEES No actions remitted.

5. 5.1 5.2 5.3 5.4 5.5 5.5 5.6

Workforce Strategy Action Plan January The Committee were advised of the key areas to be included in the strategic action plan to be submitted to NHSI. Key areas: retention, diversity, talent management, bullying. The Committee noted that a talent management strategy, and acknowledged contact with leavers will be established. Ms Brewer reported positively on the diversity seminar which took place in February, as well as an increased investment in BME leadership. It was noted that a key focus over the coming months would be disabilities The Committee were advised of the positive progress on the reporting of bullying by colleagues and line managers; as well as the updated and revised policy on Bullying in the Workplace. It was noted that a communication plan needs to be drafted on bullying in order to re-educate line managers and senior managers on the impact of their management style and how best to manage their roles effectively. The plan will also allow for clarity about workplace adjustments in regards to supporting employees with physical and mental health issues. Ms Glen noted that WLMHT should be seen to lead in Mental Health concerns. Ms Bartlett requested further information on whether the Trust had engaged an alumni group and whether the Trust has a method of keeping in touch with leavers and informing them of details such as changes in CQC rating. Ms Bartlett further emphasised the benefits of being able to sort the leavers in to work groups e.g. Clinicians / Allied Health Professionals for targeted recruitment. Mr Hayhoe further expanded on the above points noting that an alumni group may encourage ex-employees back to the Trust on the basis of training opportunities and promotions. The Committee discussed the Dignity at Work policy which needs to be revised. Concerns were raised over the duration of time taken for claims to be proposed. Changes need to be encouraged to reduce the amount of formal investigation by allowing for preliminary conversations to encourage transparency in decision making, fairness in shift allocation which will in turn reduce chronic embitterment.

Sally Sykes

6. WLMHT Agency Recommendations and Responses

Ref:

Discussion: Action:

6.1 6.2 6.3 6.4

. The Committee noted the good progress in reducing agency spend by £6m. Currently, agency spend is £1m per month. The deep dive into agency spend has been instrumental to identifying ways in which agency spend can be reduced. Ms Brewer advised the Committee of the constant need for Allied Health Professional and medical staff, but is encouraged by the ongoing progress. Ms glen commended the Committee, Local Services and Ms Brewer for the progress on agency spend. The Committee discussed medical education and long term locums. Consideration was given to potentially increasing the usage of Nurse Practitioners, but concerns raised over the nursing shortage. Culture shift needs to be encouraged to attract junior doctors from universities other that Imperial and Oxford. Ms Brewer has agreed to raise this for discussion at the next HR Director Pan London Forum. Mr Hayhoe noted that the Trust was not doing enough to highlight its ‘high yield’ learning environment. Ms Regan expanded further by encouraging the use of bespoke job advertisements which are role and site specific, with alumni quotes. Mr Hayhoe directed the committee towards to the consideration of focus groups to find solutions to influencing and marketing towards potential candidates, exploring what makes a good employer from the perspective of potential candidates.

Ms Brewer

7. 7.1 7.2 7.3

On Boarder Questionnaire Information and Response The Committee received a presentation from external consultants, Great with Talent, summarising the analysis of exit surveys completed by 47 staff leavers in the last quarter June to September 2017. The survey, an anonymous questionnaire, was issued to all leavers during this period. The figure of 47 completed questionnaires represented around 40% of leavers during this period and although the size of the dataset was small, the analysis gave the Committee a good insight into the reasons why staff were leaving the Trust. The analysis data was considered by demographics and by professional discipline. The Committee noted, in particular, the level of staff leaving within their first 24 months working in the Trust. Some of this was due to career progression and was probably reflected in the 53% of respondents who were ‘happy leavers’ and the 55% of respondents who would recommend the Trust as a place to work. The Committee agreed that this cohort of leavers were important ambassadors for the Trust and should be managed as alumni of the Trust, with the aim of attracting them back to the Trust at a later stage in their careers. The Committee also noted the importance of being a local employer in the reasons given for joining the Trust and agreed that a focus on

Ref:

Discussion: Action:

7.4

the reasons why staff choose the Trust to work would strengthen the Trust’s future recruitment campaigns. It was agreed that there was a need to celebrate the career development opportunities within the Trust, including the number of internal promotions. The Committee noted the results from the exit survey and agreed to receive similar analysis on a quarterly basis in order to monitor trends, with an update coming to the May 2018 meeting, and the Trust commissioned Great with Talent to run a similar exercise with staff who have stayed on at the Trust, to compare the differences between those staff who elect to leave versus those who stay.

A Webster W Brewer A Webster

8. 8.1 8.2 8.3 8.4

Gender Pay Gap Report Mrs Brewer presented the step through of risk ref 8428 (‘if external education funding is reduced, the supply of undergraduate staff to the Trust may be significantly reduced and the opportunities for skill development for the current workforce may reduce’), noting the dependency on external factors, such as national policy, and the controls in place to mitigate the risk. It noted that the Trust was working with Health Education North West London to develop the London response to the HEE strategy on the future of the mental health workforce. The Committee discussed the impact of reduced funding for training for AHPs and the need to identify other methods of training and development, such as AHP apprenticeships. It was also noted that Helen Lycett was currently looking at improving retention. The Committee agreed that an update on the development of AHP apprenticeships and retention initiatives would be presented to the Committee at its May meeting. The Committee agreed to maintain the risk ratings as per the current version of the BAF, but agreed that a target date should be given for reduction of the current risk to the target risk rating. Mr Jenkinson agreed to meet with Ms Brewer to discuss. The Committee noted the risk step through.

A Webster / H Lycett P Jenkinson/ W Brewer

9. 9.1 9.2

AHP Workforce Strategy The Committee reviewed the workforce related risks on the BAF and associated controls and agreed that the current risk ratings remained the same. The Committee noted that it would be useful for a narrative description of the impact of the risk to be included in the BAF. It was agreed that the Trust Secretary would consider this recommendation as part of his review of the format and content of the BAF. The Committee noted the update.

P Jenkinson

Ref:

Discussion: Action:

10. 10.1 10.2 10.3

Retention Action Plan for NHSI The Committee received an update on learning and development, including an update on the numbers of staff attending Trust induction as a result of a successful recruitment campaign. The Committee welcomed the improvement in attendance at mandatory training in some subjects but noted concern over the level of compliance with Information Governance training, currently at 86% against a target of 90%, and the level of staff not attending fire safety and information governance training when booked onto courses. The Committee noted that a new system had been implemented for tracking compliance with mandatory training requirements that would enable managers to be alerted if staff members are non-compliant. The new system would also advise staff members of available spaces on courses to improve access to training. The update was noted by the Committee.

11. 11.1 11.2 11.3

Talent Management The Committee noted and welcomed Trust Management Team’s decision to move ahead with establishing a nursing degree apprenticeship scheme, and discussed the draft curriculum for the scheme. The Committee noted that the curriculum would remain as per the current BSc Mental Health Nursing or Adult pathway but would be delivered in a different way, enabling it to be delivered as an apprenticeship and in doing so, enable the organisation to train the future nursing workforce whilst benefiting from having them working in the Trust for large amounts of time. The Committee noted that the tendering process for the course provider was currently ongoing, and that numbers for each cohort across the different areas of the Trust were to be confirmed. The Committee also noted the possibility of arranging joint arrangements with CNWL which would allow placements across both organisations, and noted LNC validation of the programme. The Committee agreed to monitor progress in the establishment of the scheme. The update was noted by the Committee.

12. 12.1 12.2

Workforce Performance Report – December 2017 The Committee noted the launch of long service awards for staff, noting that around 120 were expected to attend the inaugural ceremony on 17 November 2017 at The Stoop. The Committee noted that the criterion for being awarded a long service award was 25 years continual service within the Trust. The Committee noted the update.

13. Committee Effectiveness Review The Committee received an update on the staff survey, noting that the

Ref:

Discussion: Action:

survey had been circulated to staff, with a response rate to date of 27%.

14. 14.1

Board Assurance Framework The Committee considered a proposed template for the self-assessment of the Committee’s effectiveness and agreed that any comments on the format and questions used in the template should be forwarded to the Trust Secretary. The Committee agreed that it would review the results of the effectiveness review at its next meeting.

P Jenkinson

15. 15.1

Apprenticeship Steering Group Meeting The Committee received and noted the approved minutes from the Trust Partnership Forum meeting held on 13 July 2017. The Committee also noted that September’s meeting had been cancelled due to a high number of apologies.

16. 16.1

Any Other Business The Committee received and noted the draft minutes from the meeting held on 3 August 2017.

Date & Time of next meeting Wednesday 2 May 2018 0900 – 1100 White Room A, Armstrong Way

DRAFT MINUTES OF THE TRUST MANAGEMENT TEAM Held on Wednesday 28th March 2018 In White Room, Trust Headquarters, Armstrong Way, Southall UB2 4SA

Present: Dr Jose Romero-Urcelay (Chair) Dr Rob Bates Clinical Director, High Secure Services Dr Chris Bench Clinical Director, Planned and Primary Care Stephanie Bridger Director of Nursing and Patient Experience Dr Claire Dillon Clinical Director, West London Forensic Services Angela Dolan Deputy Director of High Secure Services Dr Nicky Goater Interim Clinical Director, Access and Urgent Care Dr Chris Hilton Director of Strategy Dr Angharad Ruttley Clinical Director, Liaision and Long Term Conditions Paul Stefanoski Director of Finance & Deputy Chief Executive Dr Sam Scholtz Director of Research Attending: David Cochrane Head of Forensic Social Work Nathan Christie-Plummer Associate Director of Workforce for Mrs Brewer Peter Jenkinson Trust Secretary Estelle Moore Strategic & Professional Lead for Psychological Therapies Stanley Riseborough Interim Improvement Director

Ref: Discussion: Action: 1. 1.1

WELCOME & APOLOGIES Dr Romero-Urcelay welcomed everyone to the meeting. Apologies were noted from: Wendy Brewer, Dr Fintan Larkin, Trevor Nelms, Dr Vijay Parkash, Carolyn Regan, Sarah Rushton

2. 2.1

MINUTES OF THE LAST MEETING The minutes of the meeting held on Wednesday 28th February 2018 were agreed to be a correct record, subject to removal of Dr Claire Dillon as an attendee.

3. 3.1

ACTION SCHEDULE & MATTERS ARISING Action Schedule The Group reviewed the actions arising from previous meetings and noted updates, including in particular: 28-Feb-18 10.1 IPR: Mr Stefanoski reported that the draft revised IPR, including the revised KPIs for 2018/19, would be presented to TMT in May 2018 (month 1 data). 28-Feb-18 10.1 Workforce report: Mr Christie-Plummer confirmed that the increase in sickness was due to increased performance

Ref: Discussion: Action: management and seasonal sickness and was in line with expected levels given the circumstances. 31-Jan-18 12 Staff consultation – Broadmoor Estates and Facilities: TMT noted that the consultation had been extended until the end of March, and therefore the final restructure would be concluded by end of April.

4. 4.1

MATTERS ARISING No other matters arising were discussed.

5. ACTIONS FROM BOARD AND/OR OTHER COMMITTEES

6. 6.1

PHARMACY TMT noted that this presentation would be deferred to the next meeting.

7. 7.1 7.2 7.3 7.4 7.5 7.6

RESEARCH AND DEVELOPMENT STRATEGY Dr Romero-Urcelay welcomed Dr Sam Scholtz to the meeting. Dr Scholtz gave a presentation on the development of the Trust’s research and development (R&D) strategy, including the vision and aims for R&D, current strengths and challenges, and progress made to date. TMT noted that the infrastructure to support research had improved, including the appointment of two clinical studies officers which had led to an additional 30 participants in research projects in two months. TMT noted the aim to create a Research Delivery Service, supporting the delivery of service-based research and driving new research, and to link research with quality improvement and recruitment and retention. Dr Scholtz presented the short-term, medium-term and long-term actions required to achieve the strategy. TMT discussed the draft strategy and approach to R&D. It was agreed that there should be a focus on information dissemination and cross-organisational learning, so that expertise and knowledge could be shared and translated into service practice. TMT also agreed that the focus should be on development as well as research. TMT also discussed service user participation in research programmes, noting that was being done in some areas and that lessons should be learned from those to support further service user participation Trust-wide. Dr Romero-Urcelay thanked Dr Scholtz for the progress made to date and her commitment to develop R&D in the Trust. It was agreed that the strategy would be developed to reflect the input from TMT and then presented to the Trust Board.

Director of Research

Ref: Discussion: Action: 8. 8.1

FINANCIAL PERFORMANCE Finance report month 11 TMT received and considered the financial position at month 11, noting the current year-to-date position and the year-end forecast. TMT noted the position for month 11 was an improvement on the planned position and an underspend of £6m year to date. Formal noting of outputs from FOLG meeting TMT noted the key outputs from the FOLG meeting, held immediately prior to this meeting:

• Financial plan / budget 2018/19: FOLG had considered the draft budget and financial plan for 2018/19, subject to final confirmation of contracts. FOLG agreed the budget and financial plan, noting that service line level budgets would follow, and agreed for the budget to be presented to the Finance & Performance Committee.

• CIP update: FOLG considered the summary of CIP performance as at month 11 and the forecast year end delivery. It was noted that the Trust was on track to achieve the year-end target.

9. PERFORMANCE REPORTS Month 11 Integrated Performance Report (IPR) TMT considered the monthly performance report for month 11, noting exceptions in performance. TMT noted improvement in performance in:

• KPI 001 : Admissions via CRHT Gatekeeping – at 100% for the last 4 months

• KPI002 : DToC rate of 3.8% in February, the lowest in over 2 years.

• KPI 021: % Risk assessments within 72 hours of admission – achieved 97.5%.

• KPI 019: CPA 7 day follow up – performance improved in Feb and achieved 97.8%.

TMT noted that the number of new complaints received in the period had increased by 9 compared with January, with 34 incidents commissioned. TMT also noted that the percentage of Inpatients Physical health checks completed within 24hrs admission had breached at 93.4%. TMT agreed that respective service line leads should access the patient level data available via Tableau to identify exceptions. Month 11 Workforce Performance Report TMT received and noted the workforce performance report for month 11, noting exceptions. TMT noted that the Trust was ‘running to stand still’ in nursing recruitment and agreed that a focus needed to be on retention of staff. Mr Riseborough advised that the focus should be on recruitment to fill vacancies that were currently being filled with agency staff, leading to the Trust being an outlier in agency expenditure.

Ref: Discussion: Action: TMT agreed to a proposal from the executive team to establish a recruitment programme board, to drive forward further improvement in recruitment including driving down the time to recruit and linking with other academic institutions.

Director of Improvement / Director of Workforce

10. 10.1 10.2

AGENCY TRAJECTORY AND ACTION PLAN TMT noted the current agency expenditure and considered the plan to ensure the continued reduction in expenditure, including a summary of progress to date and current areas of focus – nursing and midwifery and STT. TMT noted the actions and outcomes to be achieved in 2018/19, including launch of a talent management framework and an alumni group, the establishment of a promotion, promise and praise scheme, speeding up recruitment times and development of middle management. TMT noted the risks to achieving further reduction in agency expenditure, including the February allocation of doctors in training and the recruitment to ‘hard to fill’ posts.

11.

BUSINESS DEVELOPMENT UPDATE COMMERCIALLY CONFIDENTIAL

12. 12.1 12.2 12.3

LONE WORKING – UPDATE Dr Bench presented an update on lone working and compliance with the Trust’s lone working policy. It was noted that the contract for provision of lone working devices had been awarded to a new supplier, SoloProtect, and TMT noted the plan to relaunch the Trust approach to lone working with a rollout of devices to services with appropriate training. The target completion date was end of June 2018. TMT noted that HSS staff would continue to use the old devices due to contractual issues. TMT discussed the Trust’s lone working policy and the process for reviewing the policy as part of the relaunch. TMT noted the risk that there were some areas where devices did not work due to lack of signal / reception, and agreed that procedures were required regarding manage the risks in these circumstances. It was noted that each respective team would know these risk areas and the procedures in place for each location, but it was agreed that the exceptions to the policy should be codified and the local management arrangements to mitigate these risks. It was agreed that the Trust policy would be reviewed and updated as part of the relaunch of the devices.

Director of Nursing / Jim Tighe, LSMS

13. 13.1

PERFORMANCE MANAGEMENT FRAMEWORK TMT considered proposals for the implementation of service line performance reviews as part of the Trust’s performance management framework. It was noted that these proposals had been discussed with clinical directors at the away-day meeting on 9 March.

Ref: Discussion: Action: 13.2 13.3 13.4

TMT noted that the proposed approach would involve FOLG / TMT meetings becoming quarterly to accommodate the additional meetings and that the data set for the reviews should be based on the information already presented to the SMT meetings. The adequacy of this data set would then be reviewed through the performance review meetings. TMT considered the proposed approach but clinical directors were not supportive of the approach on the basis of the level of duplication of time and effort in presenting service line level quality reviews to both the Quality Committee and the performance management review meetings. TMT discussed the differences in purpose of the presentations to the Quality Committee and performance reviews, and the differences in audience. Clinical directors agreed that there remained significant duplication in content, purpose and audience. Clinical directors confirmed that they supported the principle of service line level performance reviews but would only support the implementation if this duplication is removed. It was therefore agreed that the proposed approach would be reconsidered by executive directors, in conjunction with the Chair of the Quality Committee and Trust Chairman. It was noted that there had been agreement with Quality Committee and Board to introduce the service line reviews of quality in Quality Committee seminars from April.

14. 14.1

BOARD ASSURANCE FRAMEWORK AND LEVEL 1 RISK REGISTER TMT received and noted the latest version of the BAF and the level 1 risk register, noting proposed changes to current risk ratings or assurance levels following a review of risks with executive risk owners.

15. 15.1

HIGH SECURE SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the agreed minutes from the meeting held on 25 January 2018.

16. 16.1

FORENSIC SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the agreed minutes from the meeting held on 3 January 2018.

17. 17.1

LOCAL SERVICES’ SENIOR MANAGEMENT TEAM TMT received and noted the agreed minutes from the meeting held on 17 November 2018.

18. 18.1

STRATEGIC TRUST-WIDE ALLIED HEALTH PROFESSIONS GROUP TMT received and noted the agreed minutes from the meeting held on 14 February 2018.

19. TRUST-WIDE NURSING LEADERSHIP GROUP

Ref: Discussion: Action: 19.1 TMT received and noted the draft minutes from the meeting held on 23

January 2018.

20. 20.1

PSYCHOLOGICAL THERAPISTS GROUP TMT received and noted the draft minutes from the meeting held on 9 January 2018.

21. 21.1

CAPITAL ESTATES & FACILITIES SENIOR MANAGEMENT TEAM TMT received and noted the draft minutes from the meeting held on 30 November 2017.

22. 22.1

STRATEGIC TECHNOLOGY INVESTMENT GROUP TMT received and noted the draft minutes from the meeting held on 17 January 2018.

23. 23.1

MEDICAL EDUCATION COMMITTEE TMT received and noted the agreed minutes from the meeting held on 4 December 2017.

24. 24.1

CLINICAL DESIGN GROUP TMT received and noted the agreed minutes from the meeting held on 5 December 2017.

25. 25.1 25.2

ANY OTHER BUSINESS TMT noted that the roll-out of the e-expenses system would be delayed by one month. Dr Romero-Urcelay informed TMT that the next Board development session, on 11 April, would include a session on learning lessons from the energy sector regarding developing a safety culture and he invited TMT members to join the Board for this session. It was agreed that the timing of the session would be confirmed.

Trust Secretary

Date & Time of Next Meeting Wednesday 25th April 2018 09.00hrs to 10.00hrs, White Room (A&B)

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DRAFT MINUTES OF THE TRUST MANAGEMENT TEAM MEETING

Held on Wednesday 25th April 2018 In White Rooms A&B, Trust Headquarters,

Armstrong Way, Southall UB2 4SA

Present: Carolyn Regan Chief Executive (Chair) Dr Jose Romero-Urcelay Medical Director Dr Rob Bates Clinical Director, High Secure Services Dr Julia Renton Clinical Director, Planned and Primary Care Dr Claire Dillon Clinical Director, West London Forensic Services Angela Dolan Deputy Director of High Secure Services Dr Chris Hilton Director of Strategy Paul Stefanoski Director of Finance & Deputy Chief Executive Dr Sam Scholtz Director of Research Wendy Brewer Director of Workforce Dr Fin Larkin Clinical Director, Access & Urgent Care Deborah Baidoo Chief Pharmacist Helen Lycett Strategic lead for OT & AHP Trevor Nelms Director of IM&T, Business Technology Sally Sykes Director of Engagement & Communications Dr Vijay Parkash CAMHS Clinical Director Dr Nevil Cheesman Consultant CIDS Gillian Kelly Deputy Director of Nursing Attending: David Cochrane Head of Forensic Social Work Estelle Moore Strategic & Professional Lead for Psychological Therapies Stanley Riseborough Interim Improvement Director Amandeep Sandhu Deputy Board Secretary (minutes) Iscleyn Richards Acting Trust Board Secretary Apologies: Leeanne McGee Director of High Secure & Forensic Services Stephanie Bridger Director of Nursing & Patient Experience Sarah Rushton Director of Local & Specialist Services

Ref: Discussion: Action: 1. Welcome & Apologies 1.1 Carolyn Regan welcomed Angela Dolan (for Leeanne McGee), Gillian

Kelly (for Stephanie Bridger) and Julia Renton to her first meeting as Clinical Director.

2. Minutes of the last Meeting 2.1 The minutes of the meeting held on Wednesday 28th March 2018 were

agreed to be a correct record, subject to recording Leeanne McGee’s apologies at the last meeting.

3. Action Schedule 3.1 The Group reviewed the actions arising from previous meetings and

noted updates, including in particular:

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Ref: Discussion: Action: 28 Mar 18 Item 9 Recruitment Programme Board has been set up to focus on how we can streamline the process and identify any obstacles that delay the process. The first meeting would take place the week of 27.04.18. Professional leads and appropriate managers have been invited. Action closed. 28 Mar 18 Item 12.3 Julia Renton re Lone devices – JR reported that all devices were ready for distribution and an implementation procedure was on schedule and ready to go live. Action closed. 28 Feb18 Item 8.2 ESR Self service - all staff now able to print payslips and P60. A FAQ sheet had been produced. Action closed. Wendy Brewer confirmed that payslips would have to be printed before staff left as they were not accessible once an employee had left. Sally Sykes suggested that a prompt for staff could be included in the exit interview so staff are reminded of this when they leave the trust. 28.02.18 Item 10.2 re Workforce - WB to update in May meeting on workforce KPI’s.

4. Matters Arising 4.1 The meeting was reminded to ensure senior level attendance at

Strategic Technology Information Group (STIG , chaired by Jose Romero-Urcelay) and Capital Asset Planning Management Group (CAPMG, chaired by Paul Stefanoski).

5. ACTIONS FROM BOARD AND/OR OTHER COMMITTEES None.

6. Allied Health Professionals 6.1 AHP Presentation delivered by Helen Lycett – slides attached for

information. The following topics were covered: High Quality Clinical Care - (Evidence Based Practice) enhanced support and supervision for staff (Governance) and Speech and Language Therapy (innovation in practice) Helen Lycett reminded everyone that the Trust Wide AHP event would be held on 01.11.18. Helen Lycett confirmed that she has already been working with the HR team on the potential of apprenticeships and a revised skill mix and support for pre-registration placements. Jose Romero-Urcelay expressed concerns about understanding of the Quality Improvement (QI) formal methodology. More advisors would

JR

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Ref: Discussion: Action: be required and greater sharing of projects and ideas. A position report on QI was required with enhanced Trustwide communications including a newsletter and greater links with research and development.

7. Finance 7.1 Paul Stefanoski reported that, pre audit, the Trust was presenting a

£8.1m surplus in the 17/18 accounts. The stretch targets agreed in Q1 had been achieved and the overall position had been further enhanced by savings on capital charges due to the delay in the Broadmoor redevelopment. NHSI had sent notification on 23/04/18 that a further £4.7m was going to be distributed to WLMHT as a result of achieving the financial targets in 17/18. Paul Stefanoski suggested that some enhanced communications should be sent to be clear how this was achieved and that staff do not feel that there was money available which was not distributed in 17/18.

7.2 For 18/19 the key was to plan and deliver CIP’s within the £8.6m target early. Paul Stefanoski stressed that the proposed savings should not impact on the quality of care that was delivered as the schemes would be subject to quality impact assessments. Whilst savings were required this was not heroic compared to other trusts. There were concerns over Agency spend and this still needed to be improved further in18/19. This would equate to £1m or slightly less each month which would assist the Trust to meet the target of £12.1m. Carolyn Regan stressed that we must also reduce the agency bill as a percentage of the total workforce/salary bill, where the Trust remained an outlier. As mentioned at the previous FOLG meeting, which was held immediately prior to this meeting, Carolyn Regan stated whilst we were reducing this expenditure we remained above the national average for agency expenditure. Paul Stefanoski stated we needed to carry on with our initiatives and to continue with the plan sent to NHSI for 18/19.

7.3 The North West London financial STP position overall remained outstanding.

7.4 Paul Stefanoski stressed that the Trust expected to receive the STF incentive and bonus funding as a result of delivering a higher surplus than planned in 17/18 (see 7.1 above).

Carolyn Regan summarised that the Trust had achieved our financial plans and additional money was given from NHSI. We would be submitting a revised set of accounts for the end of 17/18, which was

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Ref: Discussion: Action: subject to audit. For 18/19 there was £8m CIP and all service lines need to ensure this was delivered.

8. Performance Reports 8.1 The proposed performance management framework had been

discussed in Carolyn Regan’s asence at the last meeting. It was agreed to proceed with these, using service data from CSU’s and quality information from the deep dives to the Quality Committee.

Areas to be covered included: • Workforce including recruitment & retention initiatives and

agency/bank staff • Finance including CIP’s and capital • Reference to any Quality outstanding issues • Performance, KPI’s and risks • Strategic issues. In light of CQC visit in June to Broadmoor, the first performance management review would take place on 30.05.18 of High Secure Services followed by Local Services/community services e.g. Home ward, CIS.

In order to facilitate these, it was suggested that the frequency of TMT meetings move to quarterly meetings with a renewed focus on Trust business.

CR/IR

The timetable of meetings would be confirmed and meetings synchronised where possible to maximise contributions and outputs.

It was agreed where possible some meetings could be scheduled at Broadmoor for their November review

Carolyn Regan requested that the slides be circulated by each Clinical Director in advance of meeting with sufficient time for discussion.

Clinical Directors

8.2 IPR Paul Stefanoski introduced a follow-up discussion on performance

measures, noting new indicators to be added like: a) High Secure reducing restrictive practice and benchmarking data

supplied for NOG between the three hospitals. b) Indicators for London MH dashboard including EIS & dementia

diagnosis. c) Waiting times and focus on the areas where this was excessive. d) Key workforce KPI’s e.g. agency spend and recruitment times. e) Finance KPI’s against plan and progress with CIP’s. These would be kept under review and further suggestions were welcome.

TMT raised concerns that some of this information was already provided to external regulators and it was important for all TMT members to ensure we were not duplicating work already being carried out elsewhere.

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Ref: Discussion: Action: It was agreed to find a way to ensure that restrictive practice data was included as this was an issue for us which we needed to monitor.

Paul Stefanoski stressed that this was still up for discussion and happy to receive comments from all attendees. The focus should be on what information was valuable to trust for management purposes with the focus on the quality of care provided.

All

8.2 Wendy Brewer referred to slow progress on the workforce targets. A paper to the Workforce Committee in May would propose some minor changes to the KPI’s. The aim was to make them achievable including reducing vacancies and turnover. Agency spend was currently down to 7.7% this month and we were continuing to reduce the overall spend. The aim was to reduce agency spend from £14m currently to the 18/19 target of £12m and crucially halve the percentage of agency as a proportion of total pay from 8% to 4%.

8.3 Service lines were requested to complete PDR’s for 17/18 and agree 18/19 objectives by June.

All

8.4 Jose Romero-Urcelay raised concerns about the medical staffing vacancies. A suggestion was made to split these figures between trainees and other positions. Jose Romero-Urcelay stated this would help in identifying concerns and potential solutions.

WB

8.5 Stanley Riseborough raised a question about the time to hire of 15 weeks. WB responded that some project work was being done to improve this. The project was currently looking at how we measure the figures and differentiate stages of the process.

8.6 Paul Stefanoski raised concerns about the increase in sickness cases. WB stated that this was how we were measuring and recording this and that this may not reflect an accurate picture. Carolyn Regan enquired how the disciplinary numbers correlated with the Just Culture initiative and the recent seminar that took place about changing the culture of managing cases. Wendy Brewer informed TMT that a meeting with Capsticks took place last week and various service managers had attended to understand how the trust could adopt a different culture to managing formal cases. Plans were to review the current disciplinary policy and formal management of such cases.

9. Capital Procurement/Management protocol for Personal Computers

9.1 Trevor Nelms stated two main objectives with regard to PC‘s was to replace PC’s as they hit the 5th year and where appropriate limit the number of devices held by an individual to one. This would allow IT to have central oversight of all equipment and required replacements. Benefit of this would assure the quality of devices across the trust and

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Ref: Discussion: Action: site security would also improve. This programme would rebalance the hardware and software across the trust over time and reduce expenditure on unused Microsoft licences.

In addition, patient devices would also be included in capital plans, subject to an appropriate protocol.

TN

The purpose of raising this at TMT was to note the changes in Capital Policy and acceptance of the protocol.

Chris Hilton raised concerns as the business intended to grow. Trevor Nelms suggested that mobilisation funding should be included in all service bids.

Stanley Riseborough mentioned that this would help services ensure bespoke solutions.

Carolyn Regan recapped points were made are as follows: • The need for front facing IT • Faster access to new kit and software • Building in new business • Relevant data for monitoring TMT members agreed all points raised and the revised policy.

10. Agency Trajectory and Action Plan 10.1

Wendy Brewer stated that the majority of the points have already been discussed. The presentation enclosed, which had been presented by NHSI to the executive team and to some senior managers, was noted. The main focus of this was to review breaches of the agency cap which overall were good. It was noted that Mental Health trusts have a higher percentage of agency staff as a percentage of the total pay bill, but other MH trusts were 5-6%.

11.

Business Development Update COMMERCIALLY CONFIDENTIAL

12. Medicines Optimisation Strategy 12.1

Deborah Baidoo stated this has been presented at the meeting for approval. Keys areas to be covered included: • Patient experience • Evidence based medicine • Medicine safety – medicine safety officer appointed and • Communications TMT noted the use of “may” too many times, to be amended to “will do/must/we will”. The review form should read April 18.

Carolyn Regan requested that the amendments to be made and sent to the board with an action plan.

DB

TMT approved the stragegy. 13. Learning Development Year End 13.1 Carolyn Regan wanted to acknowledge and thank Ali Webster for all

the hard work gone into this report, highlighting work to date and L&D opportunities for staff to access. Wendy Brewer confirmed this information would also be included in the

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Ref: Discussion: Action: Board Report.

14. Board Assurance Framework and Level 1 Risk Register 14.1 Iscelyn Richards reported that no changes had been made 15. Reporting Group and Items for Information Only 15.1 The meeting noted and agreed that Clinical Governance minutes

should be presented to Quality Committee. SB

16. AOB 16.1 Jose Romero-Urcelay requested an improved response to POM audits. 16.2 TMT noted the icon on desk tops and urged roll out of WLLBY to all

wards and teams. It was agreed that customisation was essential.

16.3 GDPR: TMT were urged to look out for communications and actions to meet the 25.05.18 deadlines. A steering group would be chaired by the Medical Director. Quarterly updates would be presented to TMT and more regularly to the Executive Team.

16.4 Sally Sykes promoted the Quality Awards (open until 03.05.18 for nominations) and the need for national award submissions for the NHS’s 70th anniversary.

All

Date & Time of Next Meeting Wednesday 25th July 2018 10.00hrs to 12.00hrs, White Room (A&B)

Chair’s report West London Mental Health Transformation Board 09th May 2018 Key Issues to highlight (points from the meeting(s) being highlighted for attention and why) 1. NWL Mental Health & Wellbeing programme Prioritisation exercise NWL Mental Health & Wellbeing programme has led on a series of workshops with wider stakeholders to refresh a common work programme for Mental Health across North West London. Building on the original ‘Like Minded’ strategy and linking with MH FYFV, this work has identified key areas of work cross children’s and adult mental health services. The Transformation Board has requested that

- the work programme needs to fully map to the priorities set in the MH FYFV and where gaps exist further work needs to be done to address them

- the programme should continue to promote the fundamental principle of equity of care across NWL, so that residents of NWL have access to equitable services

- work should commence in terms of developing the optimum rehab model for patients with complex mental health needs across NWL

- the enabling priority list should be revised to include workforce as well as detailed data analysis and modelling support to develop overarching business case

2. Proposal for developing a NWL Health Based Place of Safety (HBPOS) case for change and options

New legislation and guidance affecting the use of S135/136 of the Mental Health Act has prompted a review of London’s of HBPOS arrangements under the auspices of the London Mayor’s office. Healthy London Partnerships (HLP) published a pre-consultation document in January 2018 which proposed a reconfiguration of HBPOS sites across London from 20 to 9 by 2020/21 (including from 3 to 1 in WLMHT and 8 to 3 across NWL).

- Consultation with local stakeholders has raised concern whether 3 sites across NWL is sufficient and that robust demand management models should be deployed rather than proposing an estate focused solution.

- While some modelling work based on London Ambulance Service and Metropolitan Police data has informed the original HLP work, a more thorough activity and flows analysis and audit of suitability of potential sites is required to identify the optimal options for NWL.

- Like Minded team sought mandate from the Board to commence a NWL level HBPOS site configuration case for change and options development. The timescale for developing a local business case is December 2018.

- Significant work needs to take place in terms of understanding patient flows, developing workforce model, and related contractual and financial implications.

- Any potential reconfiguration of HBPOS sites would be a significant service change and

require public consultation. 3. Liaison Psychiatry Services Commissioner commitment to recurrently fund an enhanced model of 24/7 Liaison Psychiatry Services at Charing Cross, Ealing and West Middlesex Hospital sites was formally agreed with the Trust in Q4 of 2017-18. This funding would enable us to provide 24/7 LPS cover on the sites outlined above and 24/7 CATT function. Work has begun on implementation and the 24/7 LPS model is expected to be started in July 2018. The teams continue to work in terms of addressing recruitment challenges. 4. Specialist Rehabilitation service transformation The Board noted that Specialist Rehabilitation service transformation will require a larger focus as work needs to progress at pace in detailing the optimum rehabilitation model and outlining impact in terms of wider service configuration. There were no issues for escalation.

Items of limited assurance: (detail any issues where there is limited assurance and what further action is being taken; state if any changes are needed to the risk register) n/a Decision / referral required: (in respect of key issues indicate what your recommendations are, what referral is required and/or what the receiving committee needs to do; indicate timescale) n/a

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