A G E N D A Board/Trust Board... · 2014-08-27 · A G E N D A Item Number Item FOIA Exempt Presenting PART ONE TB 061/13 . Welcome and opening comments/celebrating success : Chair

LANCASHIRE CARE NHS FOUNDATION TRUST BOARD to be held at the Trust Headquarters

2nd May 2013, 9.30am

A G E N D A

Item Number Item FOIA

Exempt Presenting

PART ONE

TB 061/13 Welcome and opening comments/celebrating success

Chair

TB 062/13 Apologies and Declaration of Interests Chair

TB 063/13 Minutes of the Trust Board meeting held on 9th April 2013

Chair

TB 064/13 Matters Arising Chair

TB 065/13 Feedback on Director Activity Chair

TB 066/13 This Agenda Chair

TB 067/13 TB 068/13

TB 069/13

TB 070/13

Formal Business of the Board

• Chief Executive Briefing Pack

• Quality Governance Framework including proposition post Francis

• Chief Operating Decision Maker/Segmental Reporting

• Annual Plan Submission

Chief Executive Director of Nursing

Director of Finance

Director of Finance

TB 071/13 TB 072/13 TB 073/13 TB 074/13

Compliance Reports (information and assurance)

• Integrated Quality and Performance Report

• Finance Report

• Quarterly Workforce Report

• Sub-Committee Minutes

Director of Finance Director of Finance Director of Workforce & OD

Company Secretary

PART TWO

TB 075/13 Action Tracker Chair

TB 076/13 TB 077/13 TB 078/13

Formal Business of the Board

• Board Assurance Framework 2013/14

• CIP Addendum

• CAMHS Tier 4 Service Update

Company Secretary Director of Finance Chief Operating Officer

TB 079/13 Any Other Business

• Review of the meeting

TB 080/13 Date and Time of Next Meeting Strategy and Policy Development Committee – 9.30am, 4th June 2013, Boardroom, Sceptre Point

BOARD OF DIRECTORS Minutes of the meeting of the Board of Directors (Part One) held on Tuesday 9th April 2013 PRESENT: Steve Jones, Chair Peter Ballard, Non-Executive Director Derek Brown, Non-Executive Director (from item TB 053.13) Gwynne Furlong, Non-Executive Director Chris Heginbotham, Non-Executive Director Mark Hindle, Director of Service Delivery and Transformation Max Marshall, Medical Director Jim Taylor, Non-Executive Director Heather Tierney-Moore, Chief Executive Dave Tomlinson, Director of Finance Teresa Whittaker, Non-Executive Director IN ATTENDANCE: Diane Halsey, Company Secretary Steve Jameson, Property Services Director

Tom Lawman, Public Governor Jo Alker, Executive Board Support Officer (Minutes)

TB 038.13 WELCOME AND OPENING COMMENTS

The Chairman welcomed everyone to the meeting in particular Public Governor Tom Lawman. The Chair noted that this was the first meeting to be held in in public under the provisions of the Health and Social Care Act and noted that no members of the public or press were present. The Chair commented on the success of the staff awards event highlighting the quality of the work which represented the evident achievements of the staff involved.

TB 039.13 APOLOGIES AND DECLARATION OF INTERESTS

Apologies for absence were received from Hazel Richards and Leila Grieves. The Chief Executive updated the Board on the position of the Lancashire County Council (LCC) representative under the Section 75 agreement noting that the position at LCC was currently being filled on an interim basis with a view to appointing to the post permanently soon. It was suggested that it would make sense to wait until the permanent replacement was in position before inviting them to the Board meetings.

No declarations of interest were received from Board members. It was noted that a declaration of interest would be made in respect of the presenter of a paper under item TB056/13 of the Part Two meeting.

TB 040.13 MINUTES OF THE TRUST BOARD MEETINGS

The minutes of the Trust Board meetings held on 5th March and 13th March 2013 were confirmed as a true and accurate record.

TB 041.13 SUMMARY OF BOARD ACTIVITY

A Non-Executive Director provided some feedback from recent meetings with one of the Trusts stakeholders, Making Space. Some of the key issues and messages were outlined and he noted the actions that had been agreed to follow up on the initial discussion.

The Chair advised the Board that he had been on one of the new good practice visits which formed part of the Quality Strategy and provided feedback on his experience. This was a new initiative and once other members of the Board had also been on these visits it was agreed that there would be a high level review of the process by the Board. He had also been on a number of visits to various services across the Trust and once again remarked on the commitment of staff. A discussion followed around one of the visits to the prison service and the implications of demand on our services.

TB 042.13 CHIEF EXECUTIVE BRIEFING PACK

The Chief Executive circulated her report and provided some further updates. The following items were noted. TB 042.13.1 – CONTRACTS For technical reasons two of the contracts were not formally signed as reported but are agreed. She highlighted the investment received in relation to dementia services and the Board noted that it was likely that a whole system review will be commissioned moving forward. TB 042.13.2 – FRANCIS REPORT The Quality Strategy was a fundamental part of the Boards response to the Francis Report. Following on from the discussion on Francis at the last Board meeting, work was ongoing to progress a systematic approach to quality improvement and the Chief Executive provided a verbal overview of the progress being made. A Non-Executive Director confirmed her view that once this new system was in place, there would be a robust governance system that was equal to the best comparator organisations. The complaints process was being reviewed and in particular the differentiation between complaints and concerns. A comphrehensive

approach to patient and carer experience feedback including the Family and Friends test is being progressed. The Non-Executive Directors involvement in complaints was discussed and the principle of absolute transparency was agreed albeit that the specific mechanisms still needed to be worked out. Three NED agreed to be involved in developing this process further. The work being undertaken in relation to strengthening professional practice through PDPs and the improvements in the governance arrangements were also noted. The Chief Executive reported that she was commissioning an independent piece of work on raising concerns. A formal paper that captures all this activity along with the outcome of the audit of Quality Governance Framework following the Board discussion on Francis would come to the next meeting. The Governance Declarations to Monitor were reviewed by the Board and confirmation given of approval to publish to Monitor.

In response to a question on the areas that did not achieve high performing results in the staff survey the Chief Executive confirmed that these were in relation to staff reporting errors, health and safety training and hand washing materials always being available. These three areas all scored lower than the national average. Two other areas that scored low were staff feeling able to contribute to improvements at work and equality and diversity training however these were on par with the national average. A discussion on the interpretation of the survey results and some of the potential inconsistencies followed. It was noted that the survey was carried out last year and related to the CQC mandated sample. The Trust had commissioned a similar piece of work internally to validate the sample and to provide further intelligence across the Trust.

TB 043.13 PERSONAL HEALTH BUDGETS

The Director of Service Delivery and Transformation presented his paper and gave an outline of the nature of the services that personal health budgets impacted. The potential impact on the Trust in the future had been outlined in the paper but he advised that the Department of Health were currently concentrating on continuing care which was a relatively small issue for us. The risks were around income but there was also an opportunity for the Trust in terms of developing and improving services which could lead to increased service provision for the Trust. He raised some of the difficulties in getting good information around people with continuing healthcare needs and provided an explanation of the definition of continuing healthcare needs in this context. The complexities of choices available under this system were explored, in particular the discretion between what individuals choose to spend money on and the choice between providers of essential evidence based therapeutic services. The implication of this on packages of care, what we chose to provide and how we structure our offering including brokerage type services and branding were highlighted. The personal health

budgets/personalisation agenda will be a challenging theme across much of our business and this was being actively explored by service lines across the Trust. It was noted that this was also being picked up in discussions with Commissioners. There was agreement that the paper had been well structured and indicated that Trust thinking was advanced. Exploration was now needed around the mechanisms for delivery of some of the ideas presented and how this could be modelled through Long Term Conditions was also considered. The need to ensure that the whole organisation see this as part of the transformation culture and agenda and as an opportunity, not a threat was re-enforced. The strategic intent of putting the customer at the heart of service design and delivery was also highlighted. The future agenda in this area would be further scoped following the strategy discussion with the Board in June. The following recommendations made in the paper were approved: • Review and receive lessons learned; • Develop a costing system at a patient level, which can easily be

understood by service users and allow LCFT to be comparable against other competing providers;

• Review technology available and commissioned to support the introduction and administration of personal health budgets;

• Review how the Trust currently markets its services and ensure that all services are continuously looking for new opportunities to expand and develop their service where appropriate;

• Ensure that Service User feedback is regularly obtained and acted up to enhance their experience;

• Ensure the Trust provides good information to ensure that service users know about their available options and have the information they need to make informed decisions;

• Address cultural issues to ensure that the organisation begins to see personalisation and the introduction of personal health budgets as an opportunity as opposed to a threat;

• Review and develop relationships strategy particularly with commissioners particularly schools, social care and CCGs;

• Consider the longer term implications in line with the Department of Health’s intent to further expand the availability of personal health budgets and to encourage further introduction of personal health and social care budgets. It is recommended that personal health budgets are considered by the Board when creating the LCFT 5 year plan at the Board session in June 2013.

TB 044.13 PRODUCTION OF THE QUALITY ACCOUNT

The Chief Executive advised that the paper had been circulated to the Board to provide assurance that the Quality Account was in production and the timelines were highlighted. She advised that the production of the Account

was very prescribed in terms of process, content and presentation. The key difference in this years process is that all of the Board must now sign to declare that they understand and agree with the comments. The process was supported by external audit and the Audit Committee have, as in previous years, a particular focus on this work. The draft report presented provided the start of the process of review and eventual approval by the Board. The Chair of the Audit Committee added that the presentation by KPMG today on their technical update will provide more detail on the requirements.

TB 045.13 INTEGRATED QUALITY AND PERFORMANCE REPORT

The report was noted by the Board and the Chair commented on the extent to which benchmarking and upper quartile performance could be presented in the report. Some examples were given and the Chief Executive would look at how this could be improved in the development of this report.

TB 046.13 FINANCE REPORT

The Finance Report was noted by the Board. The Director of Finance provided some further detail about the process and impact of the technical revaluation of the Estate and the impact on the financial outcome. Cash was particularly strong and although this would reduce slightly at yearend it would remain above plan.

TB 047.13 SUB-COMMITTEE MINUTES

The unconfirmed minutes of Audit Committee held on 14th February 2013 were circulated to the Board for information. The Company Secretary noted that the minutes in the pack were described as ‘confirmed’ and this was an error. It was agreed that in future sub-committee minutes would not be circulated until they had been confirmed by the committee. The confirmed minutes of the Council of Governor meeting held on 19th February 2013 including the Part Two minutes were circulated to the Board for information.

TB 048.13 USE OF THE COMMON SEAL

The Board noted the use of the common seal since the last Board meeting.

Minutes of the meeting of the Board of Directors (Part Two) held on Tuesday 9th April 2013 TB 049.13 CHIEF EXECUTIVE REPORT

TB 049.13.1 – CONISTON WARD The Chief Executive gave an update on the position in relation to Coniston Ward. The ward is currently closed and the majority of staff have been redeployed to support other parts of the system. The outcome of the investigation into care on the wards has now concluded and the report is being considered by management. There were some gaps in the specific governance arrangements in the Network and these were being addressed. An action plan has been produced for the CQC and is being followed up. The internal action plan goes beyond the requirements of the CQC and additional resources have been deployed to do this. Some of the issues in this wider review are being picked up as part of the Quality Strategy such as the leadership. Whilst the ward is temporarily closed, the opportunity to improve the physical environment is being exploited. It was expected that the ward will reopen in September. In response to a question about the individual patients and their carers that were affected by the closure, the Director of Service Delivery and Transformation provided a detailed response about how each individual case had been managed and led by a senior clinician. The generality of issues around the suspensions were discussed without prejudicing the outcome of the disciplinary process. It was noted at an appropriate point a discussion on why the issues arose would be held at the Board and the Chief Executive would advise on the timing of this in the context of the ongoing disciplinary process. Further questions around the extent to which the quality SEEL will pick up the issues were raised. The Chief Executive confirmed that all other wards have been reviewed to ensure that the same issues are not present there. TB 049.13.2 – COMPLAINT A briefing note about a complaint received from an MP on behalf of a constituent had previously been circulated and the Chief Executive advised that a detailed investigation had been undertaken and the stated facts in the complaint had been proven to be inaccurate in part although there remained some learning from the issue. The Chief Executive explained that she had responded to the MP.

TB 050.13 DECLARATION OF INTEREST The Director of Finance highlighted the position in relation to the Property Strategy Director. He advised that the Property Strategy Director would be discussing the demand aspects of the strategy and not the operational principles. Steve Jameson is a Director of Ryhurst Limited and operates in the Trust under a Service Line Agreement. He will be declaring his interest in this item on the agenda but will not be present at the discussion on the operating principles.

Questions of clarity around the relationship between Ryhurst Limited, Red Rose Services Corporation and Lancashire Care NHS FT were explored in more detail and further information provided. The need to make sure that there was real transparency in all our documentation and renewed rigour in our conflict of interest process in support of our position was highlighted. The Chair of Audit Committee advised that she had recently received a briefing on the arrangements as a reminder prior to the finalisation of the Harbour funding arrangements and it was clear that this type of the briefing would be of benefit to the Board. This would be scheduled into the informal briefing plan. There was a recognised need to have a process of continuous review of any partner organisation that we have with organisations.

TB 051.13 ACTION TRACKER

The items on the action tracker were closed off and noted as necessary however the item around Non-Executive Director involvement in the complaints process would stay open.

TB 052.13 NOTES OF THE POLICY DISCUSSION SESSION

The notes of the Policy Discussion session held on 5th February 2013 were confirmed as a true and accurate record.

TB 053.13 OVERVIEW OF BUSINESS PLANS The Director of Finance had produced the Overview of Business Plans paper which had been circulated to the Board. The Chief Executive outlined the planning process and confirmed her need for robust strategies and business cases from Networks to institute the Plan. The Board and Monitor need to see these plans underpinned by strong financial and capital plans which will contain trigger points prior to formal approval of specific aspects of the plan. A summary of where the plans were up to and the process for assessing these against the Risk Assessment Framework (Compliance Framework) was outlined. Service Line plans were being developed further following the review of them in March and drafts would be available for review in June. The market parameters were outlined and discussed in relation to risk appetite and aspiration and there was clear distinction drawn between short and longer term requirements and objectives. The nature of opportunities in the market were noted but this needed to be in the context of clarity around the mechanisms and vehicles of delivery. Information around the reference costs and benchmarking against other regional providers was outlined and some of the difficulties and anomalies in the collation of this information were identified. The competition for mental health beds in the context of reference costs was identified, however the data

did not relate to quality or scope of service provision. Finally the strength in our position in relation to the Monitor Financial and Governance Ratings and the sustainability of organisations in the foundation trust sector was discussed. The key enablers and how we leverage from other opportunities, including non-core business, and interest in the Trust were identified and discussed. The Trust was good on generating ideas but this needed to be matched by good execution and options for effective resourcing in this area were being explored. The Financial position remained largely the same as previously reported in the paper of the Risk Assessment Framework in March 2013. In response to questions the Director of Finance confirmed that the proposed Financial Plan would enable the Trust to deliver its investment plan and remain within the Monitor risk profile requirements. The Chief Executive added that the budget being proposed was reasonable and allows some flexibility to facilitate the sort of pace and capacity to move forward quickly where needed and to deliver sustained progress. The Chair thanked the Director of Finance for the informative presentation and asked that the slides be circulated to the Board for information. At the June meeting it was felt that the information should be revisited at the beginning of that meeting as a reminder and that the key questions could be distilled out of this discussion to address at the conclusion of the meeting.

TB 054.13 FINANCIAL BUDGET AND CIPS

The Director of Finance provided a verbal update to the report and in particular the contract position. There were some reductions in contract income but there was also mitigating non-recurrent funding which would allow the Trust to manage the risk. The Chief Executive provided some further information around the funding of RAID and dementia services, the longer term impact and the negotiating position. The Board discussed the implications of the Commissioning decisions and the risks associated with it. The balance between collaboration and protecting the Trusts interests was discussed in relation to the contract settlement and how this could be brought to the CCGs attention. It was agreed that the Board should draft a letter to the CCG. The Chief Executive would propose the nature of this communication.

TB 055.13 HEALTH INFORMATICS PLAN

The Director of Finance presented the plan on behalf of Director of Health Informatics. The key themes from the business plans had been analysed and

the priorities identified. In particular how maturity of the eCR system would be achieved was presented and the key milestones noted. A reminder of some of the underpinning principles was provided and the plan incorporated all of these aspects. The need to ensure that success was built on clinical leadership and engagement, clear requirements, good project and change management and benefits realisation was noted. The Chair of Audit Committee and the Chief Executive provided some feedback from their discussions with the IM&T department. It was acknowledged that the organisational understanding and maturity of informatics systems was not consistent across the Trust. There was a need to lead partly from the centre whilst at the same time instil the disciplines of embedding benefits realisation in the management structure in order to move forward. Some of the mechanisms to make this happen and the potential risks were outlined. The Chief Executive reminded the Board of the work in progress on capability and capacity that could facilitate how this approach can be resourced and structured. Other initiatives around the fundamental design of the clinical records systems from a clinical perspective were explained by the Medical Director. It was essential to understand and design these drivers first before the system was made electronic. The Chair of Audit Committee confirmed that the current year had a focus on the development of these base systems. The Director of Finance added that a significant proportion of the resource in year would be concentrating on developing the skills needed to ensure engagement in design and benefits realisation. The cost of the Trusts ICT as a percentage compared with others in the public sector was reviewed. The Chair of Audit Committee advised that she had looked at the costs in detail. In conclusion it was agreed that the Trust is well placed with this plan to move forward. The Chair summarised the discussion and acknowledged that the plan seemed to be sound and following a question raised at the Cost and Resource Effectiveness Committee, the Director of Finance confirmed that an electronic procurement system was included in the plan. The Director of Finance would circulate some of the detail of the procurement system outside of the meeting.

TB 056.13 PROPERTY STRATEGY REVIEW The Director of Finance provided some context around the presentation and in particular drew the distinction between the Property Strategy principles and the actions that the Board would want to consider in follow up. The discussion around deployment of the plan through Red Rose would be deferred to a later discussion.

The Property Services Director joined the meeting. He declared his interest in the item as a Director of Ryhurst Limited. The Property Service Director advised that the current plan was a refresh of the previous property strategy and outlined the process that had been undertaken to reach the current strategy. He identified the extent of the estate and some of the key issues. The geographical spread of the enlarged organisation including community properties was presented and there was opportunity in rationalisation of this. He went on to identify the Trusts aspirations for the future and the specific initiatives subject to the usual business plan and justification approval. How this could be achieved through developing new inpatient units and refurbishing community resource centres was also outlined. He described the proposed process for locality rationalisation reviews to ensure the plan was achieved long term whilst ensuring fit for purpose premises to deliver services today. A tool to evaluate the surplus estate had been deployed and was demonstrated to the Board together with the initial findings. The Non-Executive Director aligned to working with the Executive in this area commented on some of the detailed discussion currently in progress in relation to specific properties. He commended the team on the depth and extent of the analysis that had been undertaken in a relatively short space of time which enabled the organisation to take informed decisions moving forward. Questions around the impact of services such as waste and infection control under the current arrangements in non-owned or managed premises were raised and the Trusts approach identified. The Board thanked the Property Service Director and his team for the work that has been done to get to this point. The Board acknowledged the context of the current strategy and the ongoing work around the in depth reviews against each property and enquired about potential timescales for completion of those reviews. The Property Service Director advised that the timescale was difficult to identify but after the pilot project there would be a clearer view. It was agreed that this would come back to the Board with a view of the likely timescales to achieve the estate rationalisation. The EMT governance arrangements to progress the plan longer term were raised and a proposition of how property issues were addressed in the structure would also be brought back to the Board in due course. The Property Service Director left the meeting.

TB 057.13 CAPITAL PROGRAMME OVERVIEW

The Director of Finance presented the paper and advised that the programme highlighted the external funding options and potential partners in relation to each scheme. This was a working document and did not represent firm decisions across the whole of the plan. There were some aspects which

required approvals to enable the planning process to progress and these were identified specifically in the paper. The Director of Finance provided further explanation of the approvals sought, in particular for the minor estate schemes and IT programme and assumptions on lining up funding would continue but other specific schemes were not approved to proceed unless and until a business case had been seen and approved under the agreed mechanisms. It was agreed that where schemes were approved in accordance with the authority at a level lower than the Board, then the approvals would be reported to the Board individually and on a running total basis. The Board endorsed the Capital Programme for 2013/16 and approved the following schemes:

• To proceed with - IT Minor and Major Schemes - £4.5m, £3.9m and

£2.9m, as per the Informatics Plan • To proceed with – Estates minor schemes for 13/14 £3.3m • Provisional approval now for confirmation in second half 13/14 –

Estates minor schemes for 14/15 £2.8m • Provisional approval now for confirmation in second half 14/15 –

Estates minor schemes for 15/16 £2.8m • To proceed with – Feasibility studies for schemes identified in

business plans 13/14 - £270k – and contingency £500k pa • Already approved – MH Inpatient schemes including The Harbour

£37.3m, £30.9m and £0 • Already approved – TCS properties £6.6m • All other schemes/propositions require appropriate approval

following preparation of business cases A reconciliation of the financials in the paper would be circulated outside of the meeting.

TB 058.13 CIP ADDENDUM

The CIP addendum was noted by the Board. The Chief Executive commented on the discussion at Cost and Resource Effectiveness Committee around accountability for delivery for CIPs and how that accountability was brought back to the Committee.

TB 059.13 ANY OTHER BUSINESS There was no other business to be discussed. TB 060.13 TIME AND DATE OF THE NEXT MEETING

9.30am, 2nd May 2013, Boardroom, Sceptre Point

LINK TO VALUES: Accountability LINK TO PRIORITIES: 1. To improve compliance, performance and

quality by strengthening our organisational delivery and assurance systems.

LINK TO NHS CONSTITUTION: Not Applicable LINK TO BOARD RISK REGISTER: Choose an item.

INTRODUCTION

This report is designed to provide an overall summary of the Trust position and highlight the areas for further discussion. The format is based upon the proposed Balanced Score Card currently under development. BOARD ACTION

The Board is invited to consider both the content and the format of this report and the implications of the items contained within it.

The Board will discuss in more detail those areas for which additional papers are provided and consider any recommendation made within them.

AGENDA NUMBER: TB 067/13

AGENDA ITEM: Chief Executive Report DATE OF MEETING: 2 May 2013

PREPARED BY: Heather Tierney-Moore, Chief Executive

FOIA STATUS: No exemption Not Applicable

Part exemption applies to page:

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CHIEF EXECUTIVE REPORT

MAY 2013

1.0 FINANCE Finance Position The Finance Department is currently preparing year end accounts. Late transactions and adjustments are likely to arise; figures are subject to significant change and must therefore be treated with extreme caution. An update will be provided at the Board meeting. The Trust is expected to significantly over perform against plan (£6.7m surplus before exceptionals v £4.1m plan). An overall risk rating of 3 has been achieved for the year as a whole. CIP Position The Trust has achieved savings of £13.4m for the year against a plan of £14.4m. Net under spends elsewhere mitigate this under performance by £3.6m. The outturn has changed little from that forecast in October (£13.0m). Annual Plan The Plan is being populated based on documents and resourcing strategies considered and endorsed in earlier months by the Board, and the views of the Council of Governors have been sought and built into plans. As previously reported, monitoring arrangements relating to The Harbour transaction requires careful consideration in preparing the financial elements of the submission to Monitor. These are unlikely to be completed until the second half of May and will be circulated to Board members outside of the meeting. It is anticipated that these will be in line with previous forecasts and allow us to deliver a Financial Risk rating of at least 3 and a Continuity of Services Rating of 4. Evidence supporting the Corporate Governance Statement is supplied within the relevant paper. Contracts • The Community Contract and The Mental Health Contract were signed on 23rd April 2013. • Q4 CQUIN was submitted on Friday 19 April for mental health, community and specialised

services contracts and reconciliation is scheduled to take place on Friday 26th April. We are confident that we have achieved the necessary performance to achieve the target.

• 2013/14 CQUIN indicators to be agreed by end April 2013 Tenders and Developments Specialist Services Substance Misuse North Lancs A bid for this service was unsuccessful and formal feedback is yet to be completed. We did match the winning bid in cost and timing but scored less than in performance and risk. Child & Families Education Endowment Foundation Bid The Sexual Health Team has submitted a bid (seeking funding of £219,412) to the Education Endowment Fund to deliver a 2-year project to work with young people in school to raise awareness of digital issues that affect communities across East Lancashire and improve the attainment of disadvantaged pupils in challenging schools. Child & Families Fulfilling Lives: A Better Start Fund A partnership bid with BwD Council for a new Big Lottery Fund £165m initiative for babies and young children - Fulfilling Lives: A Better Start Fund was unsuccessful. The feedback indicated a high level of strong expressions of interest and that priority was given to bids which demonstrated the greatest level of need, showed the greatest commitment to early years’ provision and had the strongest partnerships.

2. CUSTOMERS Quality SEEL Results All 295 Clinical teams have now completed the Quality SEEL self-assessment and have participated in the validation process which is a key quality assurance element. Teams are in the process of developing 'Team information boards which incorporates their 'Quality Map' with their SEEL findings as a minimum displayed. The information boards in place thus far are supporting regular conversations about patient safety, patient experience, effectiveness and leadership and the actions being taken to address any necessary improvements. The risk advisors are continuing to work with teams to ensure the proactive use of the Datix system and that actions to address risks are progressed. Final refinements are currently being made to the electronic solution which will enable performance reporting of the Quality SEEL for each team across the 16 Essential Standards of Quality and Safety and the associated outcomes via the Clinical Quality Committee in May 2013 will subsequently be available to the Board. Coniston Ward Update The assurance group continues to monitor progress against the improvement plan which remains on track. The Board will receive an update next month on a proposal to enhance the care environment at Ribbleton. Engaging for Excellence Programme Schematic A overall programme plan for the Engaging For Excellence big ticket elements is attached at Appendix 1. This illustrates the clinical service transformation programmes, and highlights relationships between the various programmes and their respective activities. Now that these programmes are in a more mature state it is possible to review the finer details of the interdependencies between programmes, and between the programmes and enabling strategies. The overall programme development is detailed below. Brief progress update on big tickets During April EMT reviewed big ticket programmes with their respective programme leads. Key highlights and decisions reached are outlined below.

• Long Term Conditions, Hospital Liaison and Dementia are being managed under a single project director. Resources have been allocated to develop in detail the underpinning IM&T plans and workforce implications.

• Inpatient Transition and the Mind the Gap projects are monitored together because of their

interdependency. The bed closure timeline continues to be reviewed in terms of service quality and will be influenced by the planning assumption review to be undertaken with CCGs.

• EMT review agreed the transfer of accountability and governance for Universal Services

and Mental Health and Wellbeing to the Senior Management Team of Children’s and Families Network.

• The Outline Business Case for E-Prescribing was approved to further develop the benefits

and programme implementation resources required in greater detail. The Full Business Case will be reviewed September 2013. It will be implemented using a phased approach to ensure that systems are embedded prior to transfer of inpatient units to the Harbour.

• The Agile and Space Utilisation programmes have been combined to ensure that both

transactional and transformational benefits are fully realised. Work is now on-going to

develop the detailed process and governance requirements to establish the combined programme.

Overall programme development

1. Single Programme • Recent development activity has focused upon governance, strategic alignment and

programme robustness. Work is in progress to develop a consistent and shared understanding of how these fit together, and to ensure that the programmes’ interdependencies are fully identified and reflected in plans.

• A session to deliver these outcomes is now being planned for May, to initially bring together Executive, Network and Clinical Directors to:

Understand the strategic context and drivers for the change journey Confirm that the content of the existing programme will deliver the

strategic blueprint Understand relationships between Trust initiatives and ensure that these

are planned for Bring together the various elements of governance and processes and

agree the process of review and reporting Understand the complete picture of benefits sought through the

programme Ensure we have what we need to deliver the plan

• Following our Board discussions with AQUA we will consider how to use the above in

helping to communicate and build a shared understanding of the overall Trust wide change and quality improvement system.

2. Capacity and capability development

• A high level estimate of the capacity required to deliver the programme has been prepared.

• This has been supplemented by a structured capability survey with SRO’s from Network and Corporate functions completed. The findings were shared with Network and programme leads and a number of priority areas were identified where gaps in knowledge and skill need to be addressed.

• A proposal for a standardised model of developing capability using Transformation Hubs is in production. This includes an approach for deploying internal and external resources to support development, as well as a plan in the short term to address immediate priorities.

In-Patient Transition Programme The mental health In-Patient Transition Programme update will now be reported to the July Trust Board. This will enable the findings and recommendations of the delayed Discharge Project to be included. The project is being undertaken by independent consultants and is jointly commissioned with CCGs and Lancashire County Council. The findings are not yet available and will be fully reported by the end of this month. In addition, the 8 Lancashire CCGs have agreed to collaborate with LCFT in a refresh of the planning assumptions for the In-Patient Transition Programme. As a result, they have implemented a contractual agreement to pause any further functional bed closures while the refresh completes in October 2013. A comprehensive update will be reported to the July Trust Board. In-Patient Reconfiguration The Harbour The ground breaking ceremony for The Harbour development took place on 23rd April 2013 including local media attendance. The programme is on track with a planned occupation for the end February 2015. There is a lot of activity planned over the next 22 months working with service managers and networks to prepare for the new services at the Harbour and the transition from the current service and locations.

North Lancashire – Lancaster The Lancaster Oaklands inpatient unit is planned for a start in May this year with an occupation in February 2014. The remaining inpatient services at Ridge Lea will be moving to Oaklands at this time. Central Lancashire The outcome of the Commissioners review of overall capacity and dementia provision may impact on location for the Central Lancashire site, should the requirement be for a larger site than currently anticipated. We continue to ensure that the work streams are progressed in such a manner and to timescales which are cogniscent of each other. East Lancashire The overall bed demand review as part of the option appraisal also impacts the service plans for East Lancashire. The agreed option for the Central Lancashire service will influence the plans and configuration of the East Lancashire service. The East Lancashire inpatient service is planned to be on the Royal Blackburn Hospital site, owned by ELHT. LCFT are continuing to support the master planning and pre-planning application for the overall development of the Royal Blackburn Hospital site as a joint enterprise. LCFT’s plans for the East Lancashire mental health inpatient service are limited by the time ELHT may take to progress their own plans. This activity will be progressed over the next few months and will inform how the timescales for ELHTs capital programme will impact on our capital programme plans which aim to complete by 2016/17. CAMHS Tier 4 Update Service planning has continued to try to design a cost effective service, catering for 12-18 year olds with a PICU facility. This would be an enhanced service offer which the specialist commissioners support but the costs currently exceed the level to which the commissioners will commit. Work is continuing to try to reconcile aspirations and costs to produce an affordable and quality solution. This activity and the associated Outline Business Case will not be concluded until the end of the summer. Engagement Stakeholder Engagement Strategy The Stakeholder Engagement Strategy and its associated Implementation Plan were approved by EMT on 26 March. The ultimate aim of the Stakeholder Engagement Strategy is to support the business objectives of the Trust. The focus of activity for 2013/14 will be to strengthen relationships with GPs, Clinical Commissioning Groups, other commissioners and MPs. Pennine Lancashire Clinical Summit East Lancashire CCG and Blackburn with Darwen CCG hosted a Clinical Summit on 21 March. The Trust was represented by members of the Executive and Senior Leadership Team led by Professor Max Marshall who delivered a presentation featuring areas where LCFT is performing well. From the summit, 8 pledges were created for all member organisations to hold as a shared vision. A clinically led Quality Improvement Group will be set up with multidisciplinary membership. This will be a key forum for the development of service strategy for the Pennine Lancashire footprint and consequential commissioning therefore will be a priority for Executive and Clinical involvement from the Trust Affiliate Members’ Wellbeing Conference The Trust hosted a wellbeing conference for affiliate members and other relevant organisations at UCLan on 10 April. Guest speakers from Greater Preston CCG, Chorley & South Ribble CCG, UCLan and Lancashire County Council complemented a variety of workshops and a presentation from the Trust Chief Executive. Over 80 delegates from 60 organisations attended providing an excellent opportunity to explore new ideas and make new connections.

MP’s Visit Norman Lamb, MP, Minister of State for Care & Support will be visiting the Trust on 16th May 2013 in order to recognise the success of the Improving Access to Psychological Therapies (IAPT) Psychosis demonstration site, which is part of the Early Intervention Service. He is due to visit The Mount and meet service delivery staff including Clinical Director, Dr Warren Larkin and members of the Executive team. The visit will include a session spent with EIS service users and carers to discuss their experiences of care. Local media will be in attendance. NHS Sustainability Award Lancashire Care NHS Foundation Trust signed up to a day of action in support of NHS Sustainability Day on the 28th March 2013 celebrating the ‘Grow Your Own Project’, official opening day. The initiative was a day of action for the NHS and healthcare facilities aimed at raising awareness of the health implications of climate change as well as encouraging changes in behaviour and action on the day itself. The Grow Your Own Project has been awarded best Community Engagement Initiative. This integrates food growing into patient care/treatment pathways. 3. INTERNAL BUSINESS PROCESSES Key Performance Issues

• Fully compliant against Monitor indicators for Q4, although there is still an increase in the level of delayed discharges

• Big fall in reported incidents of physical violence from Feb to Mar 13 (189 to 114) • Significant increase in Bank and Agency spend • There has been a significant reduction in complaints (40%) quarter on quarter

Annual Report & Accounts Process The Annual Report 2012/13 has been drafted over the last two months in line with the Monitor Annual Reporting Manual 2012/13. It has been circulated to Board members for comments and was submitted to the auditors and updated on the Monitor Portal on Monday 22nd April 2013. A draft copy will be presented at Audit Committee on 30th April. Formal sign off will take place at the Meeting on 29th May 2013 subject to notification of changes between versions. Board Assurance Framework The Assurance Framework has been revised and includes emerging risks that have been identified following the introduction of Monitor’s Licensing regime. The Board is required to agree that the risks/controls and assurances are both accurate and adequate. Quality Governance Framework / Francis A range of actions have been identified following recent discussions around recommendations from the Francis Report and the KPMG Quality Governance Review carried out in 2012. On 23rd April 2013 Monitor issued new guidance on Quality Governance entitled: How Does a Board Know That its Organisation is Working Effectively to Improve Patient Care. The Board paper (TB/068/13) makes a series of recommendations around strengthening existing processes and structures to enhance the Trust’s Quality Governance Framework. Use of the Common Seal The Board are asked to note the use of the common seal on three occasions in the interim between the last report and the Board meeting on 09 April 2013. The Common Seal has been used as follows:

28 March 2013 1 year lease for the land at Friday Street whilst scheme is in design and planning stages

28 March 2013 Land Registry forms for strip of land at Ormskirk Hospital 28 March 2013 Parent Company Guarantee between (1) Vinci PLC and (2) LCFT

4. LEARNING & GROWTH Agenda for Change National changes to Agenda for Change terms and conditions came into force from 1 April 2013. Some of the changes require minor adjustments to policies and procedures or will happen automatically through our system. There are a range of areas in the new guidance which allow for the application of local organisational change policies. Significantly, pay during sickness absence will be paid at basic salary level - not including any allowance or payments linked to working patterns or additional work commitments. This change will not apply to the lowest paid staff or to those whose absence is due to work-related injury or disease but is still anticipated to make significant financial savings across the NHS. There is scope, to consider non-Agenda for Change, pay arrangements for Band 8C and above. Additionally, progression through all incremental pay points in all pay bands can be conditional on individuals demonstrating that they meet locally agreed performance requirements. Further work will be done to assess the options available for further consideration. It could be possible to link to mandatory training and PDR compliance for example. In addition a review of the new ePDR system will be done to improve compliance. Additionally, for staff in bands 8C, 8D and 9, pay progression into the last two points in a band will become annually earned, and only retained where the appropriate local level of performance is reached in a given year. Organisational Capacity / Appointments Recruitment to the Executive Director of Innovation & Transformation is in process with interviews taking place on 14 May 2013. Network Director Recruitment will follow with interviews scheduled for the 28 May. The external recruitment partner is also searching for Business and Commercial talent in order to support the Trust’s needs. An update will be provided on all senior recruitments in due course.

Implementation

Engaging for Excellence Programme Schematic: Big Tickets May 2013

Apr-13 Apr-12 Apr-14 Apr-15 Apr-16

Scoping Planning Implementation Long Term Conditions Evaluation

Mind The Gap

Inpatient Transition

Children's’ Complex Needs

Hospital Liaison

Dementia

Agile/ Space Utilisation

E - Prescribing

GP Portal

One Stop Shop

EMT review

Implementation

Phased intro of neighbourhood teams (Feb 14) Embed new models/

pathway (Mar 14) Staff recruitment begun ( Mar 13)

Scoping Planning Implementation

Procurement spec and costs agreed (May 13)

PID agreed

Business case agreed

Risk strat’ tool in place (Oct 13)

Full Main Access Point introduced (Feb 14)

Nov 12

Integrated workforce and informatics planning

Scoping Planning Implementation Evaluation Jun 13

Planning workshops for integrated teams( Feb 13)

Ongoing transition of staff

Commissioner non recurrent funding agreed (Apr 13)

Public consultation completed ( Feb 13)

Scoping Planning Implementation May 13 Evaluation

May 13

Ongoing review and ward closure

Scoping Planning Implementation & ongoing review Nov 12

Programme initiation ( Jul 12)

Scoping Oct 12 Planning Implementation

Deployment of Productive Community Services (Mar 13 on)

Evaluation

CIP achieved (Mar 14) FBC for ECR agreed (Jun 13)

April 13 Aug 13

Scoping Planning

EMT review options and procurement spec’. (May 13)

April 13

May 13

Full business case agreed (Sep13)

Implemented on wards from (Jul 14)

Scoping Jun 13

Scoping paper reviewed (Jun 13)

15 GP practice pilot (Jun 12)

Pilot benefits appraisal - decision taken to (Oct 12)

Options paper considered( Feb 13)

Review options with cost/ benefits (Jun 13)

May 13

May 13

Jun 13

Jun 13

July 13

Aug 13

Aug 13

Aug 13

Sep 13

Sep 13

Sep 13

Octy 13

Clinical & operational blueprint agreed (Apr 13)

Refreshed implementation plan

Oct 12

Planning

Elec portal established (May 12)

Completion of TAP review (Oct 13)

Programme lead & multi agency governance in place ( Jul 12)

Programme lead & multi agency governance in place ( Mar 12)

Commissioner funding agreed for 2 yrs ( Apr 13)

Evaluation and contractual review (Sep 14 – Mar 15)

Dementia site option appraisal (May to Oct 13)

Business case for recurrent funding completed (Sep 13)

Contract review (Sep 14 – Mar 15)

Continued implementation

Harbour opens (May 15)

Planning assumption review with (Oct13)

Ward 19 closure (Sep13)

Altham Meadows closure (Dec 13)

Ride Lee closure (Mar14)

Pathfinders unit opens(Feb14)

Delayed discharge report and plan actioned (Nov 13)

Outline business case agreed (Apr 13)

Programmes integrated (Apr 13)

Work style analysis to scale benefits (Aug13)

Implementation

Scope of programme confirmed (Sep 13)

Resource seconded into programme (Apr 13)

Programmes connected by joint IM&T and workforce needs

LINK TO VALUES: Excellence, Teamwork, Accountability LINK TO PRIORITIES: 1. Strengthen organisational delivery and assurance

systems, through organisational re-design, to improve compliance and quality and achieve upper quartile performance.

LINK TO NHS CONSTITUTION: Quality of Care & Environment LINK TO BOARD RISK REGISTER:

6. Maintain quality of services and value for money

IMPACT ON THE RISK SCORE OR ASSURANCES IN PLACE:

The report provides new/ongoing assurance around an existing risk; no change to risk scoring

EXECUTIVE SUMMARY This paper reviews the recommendations of the Quality Governance Review (KPMG, 2012) and the key applicable recommendations of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) and maps these to the existing strategies and work programmes. This paper and attached appendix identifies areas of good practice where the Trust has actions in place that meet key recommendations and proposals aimed at enhancing the Trusts Quality Governance Framework. This paper also includes additional recommendations that have in part been generated by discussions at Board and with the Council of Governors and supports the recent guidance issued by Monitor; Quality governance: How does a board know that its organisation is working effectively to improve patient care? (April 2013) 1.0 BOARD ACTION

The Board is asked to: • Acknowledge the current systems and processes in place to address Monitor’s

Quality Governance Framework and recommendations from The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) contained within the body of the report and in more detail within Appendix A.


AGENDA ITEM: Quality Governance

DATE OF MEETING: 02/05/2013

PREPARED BY: Colin Dugdale, Deputy Director of Nursing Helen Lee, Head of Governance

FOIA STATUS: No exemption Choose an item.


REVIEW DATE: Click here to enter a date.

• Agree actions identified in section 6 of this report designed to enhance the Trust Quality Governance Framework and address the recommendations of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013).

2.0 INTRODUCTION

The purpose of this paper is to provide an overview of the key applicable recommendations of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) and map these to the recent Quality Governance Review (KPMG, 2012) and existing strategies and work programmes. This paper and attached appendix identifies areas of good practice where the Trust has actions in place that meet key recommendations and proposals aimed at enhancing the Trusts Quality Governance Framework. This paper also includes additional recommendations that have in part been generated by discussions at Board and with the Council of Governors and supports the recent guidance issued by Monitor; Quality Governance: How does a board know that its organisation is working effectively to improve patient care? (April 2013).

3.0 BACKGROUND

An external audit was undertaken by KPMG in December 2012 to provide an independent assessment of the evidence available to support the Trust’s assessment of its compliance with Monitor’s Quality Governance Framework. In addition KPMG undertook deep dives into key areas in anticipation of the publication of Francis Two. In February 2013 The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) was published and outlined 290 recommendations “to contribute to a safer, committed and compassionate and caring service”. Lancashire Care NHS Foundation Trust is committed to providing safe, high quality care and there are a number of strategies and work streams in place to support the findings of the KPMG report and The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). In addition the Trust is implementing key national drivers, including Compassion in Practice (The 6 Cs) and Harm Free Care, which will support the Francis recommendations and the delivery of high quality care.

4.0 RECCOMENDATIONS FROM THE QAULITY GOVERNANCE REVIEW (KPMG, 2012), AND THE MID STAFFORDSHIRE NHS FOUNDATION TRUST PUBLIC INQUIRY (2013) External auditors KPMG were asked to undertake an assessment of the evidence available to support the Trust’s own assessment of its compliance with the framework. The framework outlines 4 domains relating to quality governance: • Strategy • Capability and Culture • Process and Structure • Measurement

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Under these domains sit 10 questions for review. Following the review KPMG reported finding no red areas, no amber/red areas, five amber/green areas and five green areas. Amber/green scores relate to:

• Strategy - Is the Board sufficiently aware of risks to quality? • Capabilities and Culture - Does the Board promote a quality-focused

culture throughout the Trust? • Process and Structure - Does the Board actively engage patients, staff and

other key stakeholders on quality? • Measurement - Is appropriate quality information being analysed and

challenged and is quality information being used effectively? Monitor authorisation criteria is that a Trust must score 3.5 or less and have no overall domain with all the questions rated entirely amber/red. On the basis of this guidance the governance arrangements for the Trust meet Monitor’s requirements. 19 recommendations were made of which 11 are low priority and 8 are medium priority. The themes in The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) relate to:

• Putting the patient first and having common values • The importance of fundamental standards • Non tolerance of non-compliance • Openness, transparency and candour • Compassionate, caring and committed nurses and staff • Patient centred healthcare leadership • Accurate, useful and relevant information

Details of the KPMG recommendations can be found in appendix A with a proposed action plan that addresses the recommendations which are linked to the themes from The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013).

5.0 STRATEGIES AND PROCESSES IN PLACE 5.1 Quality Strategy

A number of the recommendations from The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) are being taken forward by the Trust’s Quality Strategy.

All clinical teams have completed a Quality SEEL which provides a picture of compliance against the 16 CQC Essential Standards of Quality and Safety (2010). The electronic solution enabling reporting of the Quality SEEL findings at team, Network and organisational level is expected during April 2013, and a report will be presented to the Clinical Quality Committee in May 2013.

Clinical teams are progressing their quality maps of safety, effectiveness, experience and leadership as part of their Team Information Boards (TIBs) and all teams will have a quality map in place which as a minimum displays their Quality SEEL data by the end of June 2013. The TIB will then be used by the team to facilitate conversations about the quality of care provided, any risks to the quality of care and corrective actions to be taken and evaluated, using team level risk registers. Thus empowering clinicians and clinical leaders to strive for high quality

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care, with team level data available to support and challenge these discussions. The development of the electronic solution to the Quality SEEL reporting and the team level quality map information will be pulled through to the balanced score card which will afford the Board of Directors a more comprehensive understanding of the quality of our services. With risks identified at the point of patient care informing Network and organisational risk registers. The Quality Strategy Programme Year 2 (2013-14) draft implementation plan outlines the plan to develop a shared understanding of quality progressing from a focus on compliance with the Essential Standards of Quality and Safety (CQC, 2010) to the implementation of development programmes supporting a culture of continuous quality improvement. Quality improvement enablers/methodologies will support reflective practice and the need to focus on personalised care. The means to capture the experience of service users will be strengthened, alongside the family and friends test. 5.2 Annual Quality Account

The Annual Quality Account reports on the quality indicators mandated by Monitor and the progress achieved in relation for the organisations priorities for improvement. The Clinical Audit Programme has been reviewed to reflect the quality improvement priorities and is now Network led. 5.3 Complaints Review

A complaints review is underway and due to be reported to the Clinical Quality Committee in May and incorporates the key recommendations from The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Plans are being developed to establish a complaint panel involving Non-Executive Directors and actions to ensure Non-Executives can view all complaints within the Trust. 5.4 Review and Implementation of Governance Structures

A revised Governance structure is being implemented to enable the effective use of Board time and of strengthening assurance systems for clinical quality, risk management and workforce development. The revised terms of reference are being dovetailed with Network Governance Committees. 5.5 Compassion in Practice

Work has begun to promote Compassion in Practice (The 6 Cs – Care, Compassion, Courage, Communication, Competence and Commitment) throughout the organisation. Nurses Day on the 10th May will focus on the 6 Cs, Quality and Innovation and “Pride in your Profession”. This event is being supported by the Chief Executive, Director of Nursing and Deputy President of the RCN. 5.6 Harm Free Care

The Harm Free Care initiative (focusing on pressure ulcers, catheter acquired urinary tract infections and falls) will be further embedded across all eligible teams with best practice shared. Individual teams and the clinically led sub-groups are using the data to challenge current practice and support developments to support patient safety and ensuring a positive experience. Directors, Non-Executive

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Directors and Governors are participating in monthly “Good Practice Visits” to clinical teams who are participating in Harm Free Care. 5.7 Energising for Excellence at Parkwood

Building on the findings form the Balmoral review a programme of work is in place to enhance services within Parkwood. More recently the Psychiatric Intensive Care Unit has been nominated for a national award.

6.0 PROPOSED ACTIONS The Board has previously received the KPMG audit report and considered the findings of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) at informal discussions. 6.1 Proposed Trust Board Actions

Trust Board is asked to agree to the following actions aimed at strengthening the Boards approach to quality: • Agree the range of actions to date summarised in this report and contained

within appendix A • To progress the Non-Executive Director involvement with complaints, the ability

to review all complaints and the establishment of a complaints panel • To develop a process of triangulation of data from visits and discussions with

staff and stakeholders • Non-Executives to attend revised Trust Governance Committees. In addition Board is asked to approve the range of Executive actions discussed at the Informal Board discussion on the Francis report, Board Quality Development Day and Council of Governors Committee: 6.2 Proposed Executive Action 2013/14

• Undertake a review of Nursing Leadership • Review of the process for raising concerns • Undertake a cultural survey • Implement the action plan for Quality Strategy Year 2 including the development

of a Patient Experience Strategy • Review of balanced score card and performance data • Implement ‘Putting a Face on Data’ • Action on 6Cs – Compassion in Practice • Strengthen supervision and appraisal across the Trust • Implement a structured process learning from student feedback • Roll out values based recruitment across the Trust • Review capacity and capability for quality improvement.

7.0 SUMMARY AND CONCLUSIONS

The key applicable recommendations of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) have been identified and mapped to existing actions and

5

strategies, national drivers and the recommendations following the recent Quality Governance Review (KPMG, 2012). This paper and attached appendix identifies areas of good practice, existing work streams and additional action required to address the recommendations of The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) and the Quality Governance Review (2012).

8.0 RECCOMENDATIONS

The Board is asked to: • Acknowledge the current systems and processes in place to address Monitor’s

Quality Governance Framework and recommendations from The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013) contained within the body of the report and in more detail within Appendix A

• Agree actions identified to enhance the Trust Quality Governance Framework articulated in Appendix A

• Agree additional Trust Board and Executive actions to support the recommendations from The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013)

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Appendix A

KPMG Quality Governance Framework Recommendation (Priority as defined by KPMG)

Link to Key Theme from Francis Report

Current Action Date Development Proposal

Lead Monitoring

1 Volume of information on risks to quality (low priority) There are a large number of processes in place that ensure the Board are aware of the potential risks to quality including the Board Assurance Framework, strategic risk registers, EAM risk register at service line and Network level, quality impact assessment of CIP’s and the process for new service improvements. The volume of interacting and overlapping systems may make it difficult for Board to identify sources of risk. A routine management summary of the current key risks to quality could focus discussion.

Accurate Useful and Relevant Information

A revised Governance structure is being implemented to enable the effective use of Board time and of strengthening assurance systems for clinical quality, risk management and workforce development. This supports a more robust and lean Board Assurance Framework enabling Trust Board to have greater transparency of risks and assurances. The QRP is produced by CQC and reported to Trust Board. A performance report against key quality indicators is submitted to Trust Board monthly.

April 2013

HTM Risk Management Committee

2 Structured follow up to Board actions (low priority) We would recommend that the Board seek to establish a more structured approach to the follow up and monitoring of progress against quality issues highlighted at Board level.


A revised Governance structure is being implemented to enable the effective use of Board time and of strengthening assurance systems for clinical quality, risk management and workforce development. This supports a more robust and lean Board Assurance Framework enabling Trust Board to have greater transparency of risks and assurances.

April 2013 May 2013

HJR HJR

Clinical Quality Committee Trust Board

1

Appendix A

A baseline assessment of compliance with CQC standards will be reported to Trust Board.

3 Board self- assessment (low priority) The Board self-assessment exercise is a valuable exercise and identifies areas for further development. This assessment should be undertaken on an annual basis even if there has been no change in Board membership.

Patient Centred Healthcare Leadership Common Values

Chair-led reflection based on 360 assessments carried out during the appraisal process. The Council of Governors also take part in individual director appraisals/assessments.

HTM Trust Board

4 Board Skills Matrix (low priority) A Board skills matrix should be developed and should aim to satisfy Monitor’s Foundation Trust Board requirements covering the seven domains; • Board capability and capacity; • Understanding the business; • Quality, resilience and safety; • Legally constituted; • Good business strategy; • Financially viable; and • Sound governance

Openness Transparency and Candour

The recruitment process for Directors uses skill matrices. The Council of Governors Nominations Committee has reviewed and contributed to the development of the recruitment process for Non-Exec Directors.

HTM Trust Board

5 Board Training and Quality Governance Framework Training (medium priority)

Patient Centred Healthcare Leadership

AQuA Quality Board Session held on 11th April 2013.

HTM Trust Board

2

Appendix A

The Board training programme should be reviewed to ensure that the Board members are provided with the knowledge they require to challenge the quality agenda. The Board should also receive specific training on the requirements of the Quality Governance Framework. This training should be provided as part of the Board development programme.

Thematic review session to be held on the Quality Governance Framework.

6 Quality of the Board Agenda (medium priority) More could still be done to focus Board meeting agendas on quality. The structure of agendas and the depth of debate allowed by the information provided could be improved to ensure quality received primary attention. The Board should evaluate how much priority it gives to quality within its meeting.

Patient Centred Healthcare Leadership Accurate Useful and Relevant Information

‘Putting a Face to the Data’. Review transformation goals and discuss as part of 5yr strategy. Development of the Balanced Score Card.

June 2013 July 2013

DH EMT

7 Patient Stories (medium priority) The Trust should implement the routine use of patient stories at Board level, as recommended by Monitor. The Trust should formalise the process for a patient story opening every Board meeting and

Patient- Centred Healthcare Leadership

Introduce patient stories to open Trust Board meetings.

June 2013 Opportunity for teams to “Celebrate and Share” their quality stories with the Clinical Quality Committee.

HJR Clinical Quality Committee

3

Appendix A

commit to open each Board with such a session. Once established, the Trust should then be able to demonstrate action taken as a result.

Develop the concept of patient shadowing.

September 2013

8 Closing the loop on patient feedback (medium priority) Where the Trust captures patient feedback which suggest a valid quality concern (through complaints, focus groups and other channels), action taken should be recorded and fed back to the patient as a matter of routine.

Patient –Centred Healthcare Leadership

A programme of “Good Practice visits” by Executives and Non-Executives is undertaken around the ‘harm free’ care agenda. Patient Experience Team Review of Complaints procedure and process.

On-going May 2013

HJR Clinical Quality Committee Clinical Quality Committee

9 Unscheduled Board Visits (low priority) The Board to Ward visits should have an increased level of unpredictability in the announcement, timing and focus of the visit in order to give a truer picture of performance.


HTM Trust Board

10 Monitoring staff engagement with quality (medium priority) The Board should establish ways of monitoring staff adoption and engagement with the Quality Strategy, and act where evaluation suggests quality risk may be higher, e.g. dispersed or isolated teams, those working in stressful environments, teams with high/low


Report on the outcome of the Quality SEEL to the Clinical Quality Committee. Evaluation of the Quality Strategy to date.

May 2013 June 2013

Reporting of this will be incorporated into the Balanced Scorecard

HJR Clinical Quality Committee

4

Appendix A

turnover and/or high sickness rates. 11 Clinical Audit at Audit Committee

(low priority) The Audit Committee also has a role in reviewing some information on quality, focusing on clinical audit monitoring and the production of annual Quality Report. How this role ties into wider quality governance assurances is not clearly defined and would benefit from being revisited.


The Audit Committee currently approves the annual Clinical Audit programme and receives progress and assurances against clinical audit results and actions plans as a result of completed clinical audit via the quarterly report. The Clinical Audit Programme for 2013/2014 includes audit identified by the implementation of the SEEL assessment and national audits required by the Quality Account.

July 2013 Action to be revisited by Chair of the Committee and Medical Director.

MM Clinical Quality Committee Audit Committee

12 Engagement with Commissioners (low priority) Monitoring of quality by Commissioners is likely to be strengthened following Francis Two. We would recommend that the Trust proactively engages with CCGs as their new Commissioners and with CCG patient focus groups as the focus of CQUINs is likely to become more and more patient focussed as the CCG landscape evolves.


The Head of Contracts engages with Commissioners and links with the Quality and Governance Directorate and Networks regarding proposed CQUIN and Quality Contracts.

April 2013 HJR Clinical Quality Committee

13 Quality of information provided to Networks (low priority)


This will be addressed in year 2 of the Quality Strategy (2013/14) through the

2013/14 HJR Clinical Quality Committee

5

Appendix A

Information delivered at network level and below should be pre-analysed in a way that enables rapid focus on key issues and avoids wasting clinical time.

introduction of Team Information Boards (TIBs).

14 Comparative data at Network level (low priority) Network staff should be enabled to obtain and analyse data at a team or ward level for comparative purposes.


As above – year 2 of the Quality Strategy.

2013/14 HJR Clinical Quality Committee

15 Skills in data analytics (medium priority) The Trust should seek assurance that more junior staff being required to perform increasing amounts of data handling and interpretation have the appropriate skills and improve these skills where required.

Fundamental Standards

Modular training programme by the Lean Development Team to address data interpretation issues (initial training dates - May 2013)

2013/14 LG Network Workforce

16 Assurance to Support Self Certification (medium priority) The Trust should secure an independent review of the adequacy of its evidence to support compliance with the Quality Governance Framework on an annual basis. This will ensure that their systems and processes to assure good quality governance are independently assessed in line with best practice and

Openness Transparency and Candour

There is a current programme of internal audit to include audit of the Quality Governance Framework.

2014 HJR

Internal Audit

6

Appendix A

recommendations to drive further progress are made.

17 Data Quality Kite-marking System (low priority) Whilst the Trust received a mixture of general and piecemeal assurance over the data quality of some of the indicators it relies on the Monitor Quality Performance, there is no single data kite-marking system which allows Board to quickly identify the level of assurance over all indicators. This is relevant as some indicators are inherently less reliable and comprehensive than others. The Trust should consider implementing a data kite-marking system which quickly identifies the level of assurance over all indicators.


2013/14

18 Great use of real-time data (low priority) Currently data presented to Board is of varying age and some takes several weeks to collate. The work to review and update the quality report and implementation of the balanced scorecard will ensure more real time data. The first two phases of implementation aimed at increasing


Quality Strategy 2 will enable teams to have quality information at team level through the Team Information Boards and the quality map.

2013/14 HJR/MM Clinical Quality Committee

7

Appendix A

the use of quality information at team/ward level should be prioritised by management.

19 Use of information at the frontline (medium priority) One of the primary focuses of the Quality Strategy is to increase the availability and use of quality information across and throughout the organisation. As noted the Trust has some way to go before staff delivering care are able to analyse and use information that is relevant to them. Work will be required around both systems and culture to enable this to happen in a sophisticated way. A programme of training and coaching should be rolled out to those delivering care to encourage the active proportionate use of data.

Accurate Useful and Relevant Information Fundamental Standards

This is a priority of year 2 of the Quality Strategy. Modular training programme by the Lean Development Team to address data interpretation issues (initial training dates - May 2013.)

2013/14 HJR/MM Clinical Quality Committee

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LINK TO VALUES: Accountability

LINK TO PRIORITIES: 2. To improve value for money and productivity to achieve efficiency savings of 20% across the Trust over the next five years.

LINK TO NHS CONSTITUTION: Not Applicable

LINK TO BOARD RISK REGISTER:

4. Sustain a viable business model



EXECUTIVE SUMMARY

The Trust must determine the identity of its Chief Operating Decision Maker (CODM) and

the segments in which the Trust operates.

It is the interpretation and advice of the Director of Finance that the Board is the CODM

and the Trust operates in the single segment of healthcare

1.0 BOARD ACTION

Endorse the recommendation that the Board remains the CODM and that the Trust

operates in the single segment of healthcare

2.0 INTRODUCTION

International Financial Reporting Standards (IFRS) require organisations to

“disclose information to enable users of its financial statements to evaluate the

nature and financial effects of the business activities in which it engages”. In

short this means that information should be segmented and reported in line with

the substance of how it manages, resources and develops its business. A key

factor in determining this is the identity of the CODM

This paper identifies relevant issues so that the Board can determine the

identity of the CODM and relevant operating segments for reporting purposes


AGENDA ITEM: Chief Operating Decision Maker (CODM)/Segmental Reporting


PREPARED BY: Director of Finance



REVIEW DATE: 30/04/2014

3.0 BACKGROUND

It was previously agreed that this matter would be referred to the Board

periodically for determination

4.0 ISSUE

The Board should determine the identity of the CODM

The Board should identify the operating segments


The Interpretation of the Director of Finance is that the Board is and remains the

CODM:

• It has overall responsibility for providing leadership and for delivering the

activities of the Trust

• It determines information requirements necessary to facilitate proper and

robust discussion and to reach informed decisions

• It sets the performance monitoring regime and tracks agreed actions

• The level and nature of operational risk information subject to Board

scrutiny has been determined and the Board receives regular reports on the

status of those risks

• There is little evidence to suggest any alternative body as the CODM

The criteria of aggregation into a single operating segment is as follows:

• Segments have similar economic characteristics

• Are similar in nature of the products, services and production processes

• Have similar type or class of customer for their products and services

• Have similar methods used to distribute their products or provide their

services

• Have similar regulatory environment

• For each reportable segment an entity shall report a measure of profit or

loss, total assets and liabilities

The interpretation of the Director of Finance is that, while there is a direction of

travel which will eventually lead to Networks or Service Lines being determined

as operating segments in their own right, there is insufficient evidence for them

to defined as operating segments at the current time

The nature of the Trust’s approach to Service Line Management is such that

there will be a clear determinant established of what constitutes a discrete

operating segment and that until that determination, it is the interpretation and

advice of the Director of Finance that the Trust operates in the single segment of

healthcare

6.0 RECOMMENDATION

Confirm that the Board remains the CODM and that the Trust operates in the

single segment of healthcare

LINK TO VALUES: Accountability LINK TO PRIORITIES: 1. To improve compliance, performance and quality by

strengthening our organisational delivery and assurance systems.

LINK TO NHS CONSTITUTION: Not Applicable LINK TO BOARD RISK REGISTER:

1. Balance organisational aspirations



EXECUTIVE SUMMARY The Plan is being populated based on documents and resourcing strategies considered and endorsed in earlier months by the Board, and the views of the Council of Governors have been sought and built into plans.

As previously reported verbally, the monitoring arrangements relating to The Harbour transaction require careful consideration in preparing the financial elements of the submission to Monitor. It is anticipated that these will be in line with previous forecasts and allow us to deliver a Financial Risk rating of at least 3 and a Continuity of Services Rating of 4. 1.0 BOARD ACTION

Endorse the approach for preparing the Annual Plan and approve the proposed Corporate Governance Statement and its submission to Monitor

2.0 INTRODUCTION This paper summarises progress with the development of the Annual Plan and

its submission to Monitor and details the supporting evidence on which the Board can rely when considering the Corporate Governance Statement

3.0 BACKGROUND

On 1 April 2013, the provider licence came into effect for all NHS Foundation Trusts. The Licence replaces the Terms of Authorisation and incorporates a set


AGENDA ITEM: Annual Plan 2013/14






of requirements covering governance and financial viability. Monitor intends to introduce a Risk Assessment Framework to replace the current Compliance Framework, in order to make a more specific assessment of the risk of financial failure and to retain oversight of the governance of Foundation Trusts. The framework will assess risk in two areas of the licence:

• The Continuity of Services condition 3 - which requires all NHS providers to ensure they remain a going concern

• Foundation Trust Governance licence condition 4 – which lays out Monitor’s definition of good governance

For the first half of 2013/14, Monitor has adapted the current Compliance Framework to assess the risks of compliance with the above licence conditions, whilst the Risk Assessment Framework continues to be finalised. The Compliance Framework for 2013/14 introduces the Corporate Governance Statement which includes Board statements relating to Quality, Finance and Governance and a Joint Ventures & Academic Health Science Centre Statement. It also confirms the annual planning cycle requirements

4.0 ISSUE

It is imperative that we can deliver a financial performance which will result in a Financial Risk rating of at least 3 and a Continuity of Services Rating of 4; it is also important that there are robust governance arrangements in place that allow us to ensure compliance with the new Provider Licence


The Plan is being populated based on documents and resourcing strategies considered and endorsed in earlier months by the Board, and particularly the information that was presented to the Board in April

The views of the Council of Governors have been sought and built into plans The evidence supporting the Corporate Governance Statement and the Joint

Ventures or Academic Science Centre Statement is attached for consideration and approval by the Board as part of the Annual Plan submission

Monitor has recently published templates for completion of the Annual Plan. Key leads have been identified to complete the documentation for review and submission by 31 May

As previously reported verbally, the monitoring arrangements relating to The Harbour transaction require careful consideration in preparing the financial elements of the submission to Monitor. These are unlikely to be completed until the second half of May and will be circulated to Board members outside of the meeting. It is anticipated that these will be in line with previous forecasts and allow us to deliver a Financial Risk rating of at least 3 and a Continuity of Services Rating of 4

6.0 RECOMMENDATION

Endorse the approach for finalising the Plan Approve the Corporate Governance Statement

Corporate Governance Statement 2013/14

Quality

Evidence

1 The board is satisfied that, to the best of its knowledge and using its own processes and having assessed against Monitor’s Quality Governance Framework (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), its NHS foundation trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of health care provided to its patients.

In November 2012 the Director of Nursing presented a paper to the Board detailing the progress of the implementation of the Quality Strategy and the Quality SEEL (Safety; Effectiveness; Experience; Leadership) tool. In February 2013 the Board were advised of the outcome of the review to align the current governance structures to the delivery of the Board and Executive responsibilities. The Board approved the structures which have been put in place for 2013/14. This strengthens the reporting into Board in relation to assurances against key risks. KPMG have recently audited the Quality Governance Framework and provided helpful feedback.

2 The board is satisfied that plans in place are sufficient to ensure on-going compliance with the Care Quality Commission’s registration requirements.

The Trust has systems and processes in place to support compliance with the Essential Standards. Each service line is responsible for ensuring that evidence is available against each outcome and this is monitored on a regular basis. Regular reports are received through Network Governance Committees and Executive Management sub-committees. The Quality SEEL tool also measure compliance against CQC outcomes.

3 The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements.

The Trust secured a Green status of compliance in October 2012 with the NHS Revalidation Support Team Organisational Self-Assessment Tool. This provides assurance that the policies, procedures and systems are in place to support revalidation.

Finance

4 The board anticipates that the trust will continue to The plan will be prepared on the basis of maintaining a


maintain a financial risk rating of at least 3 over the next 12 months.

financial risk rating of at least 3 for at least the next year. As long as we achieve the required CIP then we will achieve the required position and as explained in papers to the Board, there is considerable headroom available as contingency to support this position. The financial report produced each month for the Board includes a forecast of outturn against the plan and should there be a risk of a risk rating of 3 not being achieved this will be drawn to the attention of the Board and remedial action identified and agreed.

5 The board is satisfied that the trust shall at all times remain a going concern, as defined by relevant accounting standards in force from time to time.

Our external auditors provide assurance that our statements and expectations can be substantiated as part of auditing annual financial statements. A financial risk rating of 3 can be taken as sufficient evidence of compliance with the ‘going concern’ assessment and therefore the evidence available under the above statement also substantiates the confirmation of statement.

Governance

6 The board will ensure that the trust remains at all times compliant with its licence and has regard to the NHS Constitution.

The Board receives a monthly performance report that provides details of compliance with its terms of authorisation. The report is structured to provide assurance in relation to the following areas;

• Monitor – targets and indicators Delivery of the Quality Strategy – patient safety,

patient experience and clinical effectiveness. Delivery of Commissioned activity and targets • Workforce • Membership


• Information governance The report is supplemented on a monthly basis with exception reports in respect of those areas that are rated as red and amber. The quarterly Workforce report and the annual Staff Survey provide assurances that the Trust is committed to meeting the rights of staff.

7 All current key risks to compliance with the trust’s licence have been identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues – in a timely manner.

Through its Enterprise Assurance Management approach to risk the Board has identified the main areas of risk to its licence. The Board has a robust Board Assurance Framework which identifies the high-level risks to compliance with the Trust’s licence and provides the Board with sight of the controls and assurances around the management of these risks. The newly formed Executive Risk Management Committee will provide assurance that the Risk Management strategy is being effectively deployed throughout the organisation. Where there are emerging issues, such as the in-patient facility for older adults at Ribbleton Hospital, in-depth and detailed analysis is undertaken to resolve concerns on a prioritised basis including immediate resolution of critical risk areas. The Trust maintains robust oversight of these to ensure that it is satisfied by the progress against the resultant action plans and a longer term approach is taken for lessons learnt.

8 The board has considered all likely future risks to compliance with its licence and has reviewed appropriate evidence regarding the level of severity, likelihood of a

The Board identified all of the risks to its strategic objectives and priorities within the Annual Plan. These include the risks to compliance with its licence and as mentioned above, are


breach occurring and the plans for mitigation of these risks to ensure continued compliance.

recorded within the Board Assurance Framework. The Executive Risk Management Committee will identify and bring to Board’s attention any emerging risks that ought to be escalated onto the Board Assurance Framework. There is a clear strategy and process that defines the level of risk that should be escalated to the Board as tolerance levels have been signed off by the Board across key areas of business activity.

9 The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily.

The Board receives a monthly performance report that provides data based on achievement or compliance against the following • Licence and Compliance Framework; • Delivery of Commissioned activity and targets; • Delivery of the Trust integrated business plan; • Delivery of the Quality Strategy. Performance data is reviewed on a weekly basis by the Executive Team. A further in depth review of each Network has been conducted through the Chief Executives Challenge; which provides the Executive Team with further opportunity to test the assurances given and establish that risks have effective controls in place to mitigate them. There is a clear programme of review in place to ensure that all Networks receive robust scrutiny. Steps are being taken to ensure that there is sufficient capacity to establish the effectiveness of our assurance systems. These arrangements have been reviewed and there is a number of new Executive Committees substantiating governance in this area. This will also lead to an adaptation of the Chief Executive’s Challenge, which will strengthen the review process.


The Trust has undertaken an Enterprise Assurance Management approach to risk management which means that risks to the Trust’s strategic objectives are proactively identified and monitored on an on-going basis. Gaps in control and assurance have clear corrective actions to address them and these are reviewed on a regular basis. Where there is significant work required to provide greater control this informs the planning cycle and provides a dynamic approach to risk management. The Clinical Audit function provides reports to the Audit Committee, which scrutinises the work and development of Clinical Audit in the same way as it would for the Internal and External Auditors. There is a clear process in place to address recommendations arising from Internal Audit that ensures that all actions have been closed off appropriately. These are overseen by the Company Secretary.

10 An Annual Governance Statement is in place pursuant to the requirements of the NHS Foundation Trust Annual Reporting Manual, and the trust is compliant with the risk management and assurance framework requirements that support the Statement pursuant to the most up to date guidance from HM Treasury (www.hm-treasury.gov.uk).

An Annual Governance Statement is currently being prepared in support of the audited annual report and accounts, as it was for 2011/12. This is supported by a robust risk management and assurance process.

11 The board is satisfied that plans in place are sufficient to ensure: on-going compliance with all existing targets (after the application of thresholds) as set out in Appendix B; and a commitment to comply with all known targets going forwards.

The Board receives a monthly performance report that provides data based on the achievement or compliance of all existing targets. Current performance demonstrates achievement of all targets.

12 The board is satisfied that its NHS foundation trust can operate in an efficient, economic and effective manner.

The Board has established a Cost and Resource Effectiveness Committee to support them in their


responsibilities for sustainability and value for money and to ensure that the Trust is as effective as it can be in the use of public money. In considering value for money the Committee will take into account aspects of Economy (careful use of resources to save expense, time or effort), Efficiency (delivering the same level of service for less cost, time or effort) and Effectiveness (delivering a better service or getting better return for the same expense, time or effort).

13 The board will ensure that the trust will at all times operate effectively within its constitution. This includes: maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors; that all board positions are filled, or plans are in place to fill any vacancies; and that all elections to the board of governors are held in accordance with the election rules.

Board members are required to declare an interest in any agenda item at the start of every Board meeting and a register of interests is maintained by the Company Secretary in accordance with the Trust’s Business Conduct Procedure. Appointments to the Council of Governors are determined by the rules set out in the constitution. Elections are undertaken via a transparent and independent process run by the Electoral Reform Society. A register of appointments which sets out the terms of office for members of the Board and Council of Governors is maintained and regularly reviewed in order to ensure timely succession planning.

14 The board is satisfied that all executive and non-executive directors have the appropriate qualifications, experience, training and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.

Appointments to the board of directors are subject to an agreed formal recruitment process against a written role description and informed by the outcomes of a review and gap analysis of the generic and specific skill sets needed to fulfil the role. In relation to the appointment of NED’s, it has been the practice to use eternal consultants to provide expert and objective process and advice to the Nominations Committee

15 The board is satisfied that: the management team has The Chief Executive has reviewed the skills required at


the capacity, capability, training and experience necessary to deliver the annual plan; and the management structure in place is adequate to deliver the annual plan.

Executive level to deliver the annual plan and plans are in place to recruit an Executive Director with the skills to lead the delivery of the Innovation and Transformation Programme. The Network and Corporate management structures have been established and tested as part of the Annual plan process. Resources have been identified to provide additional capacity and capability to support delivery of the Annual Plan.

16 For an NHS foundation trust engaging in a major Joint Venture, or Academic Health Science Centre (AHSC), the board is satisfied that the trust has fulfilled, or continues to fulfil, the criteria in Appendix C4.

See Below

17 The board is satisfied that plans are in place to ensure that the trust will at all times comply with its statutory requirements

The Annual Planning process has provided assurance on compliance with statutory requirements.

For NHS foundation trusts: (i) that are part of a major Joint Venture or AHSC; or (ii) whose boards are considering entering into either a major Joint Venture or an AHSC The following statement should be made:

Criteria Evidence The board is satisfied it has or continues to:

ensure that the partnership will not inhibit the trust from remaining at all times compliant with the conditions of its licence;

The JV only exists to support the Trust’s existing strategies, priorities and plans.


have appropriate governance structures in place to

maintain the decision making autonomy of the trust; The JV Business plan and relevant decision making processes have been agreed by Trust Board.

conduct an appropriate level of due diligence relating to the partners when required;

Due diligence was conducted as part of the procurement of a partner for the JV.

consider implications of the partnership on the trust’s financial risk rating having taken full account of any contingent liabilities arising and reasonable downside sensitivities

At this stage the financial results/implications of the JV have no significant impact on Trust risk ratings.

consider implications of the partnership on the trust’s governance processes;

The JV governance arrangements have no significant impact on the Trust’s governance processes.

conduct appropriate inquiry about the nature of services provided by the partnership, especially clinical, research and education services, and consider reputational risk;

In terms of the JV this was discussed within the context of papers and items brought to attention of Board. All services were covered within JV business plan which was considered and endorsed by Board.

comply with any consultation requirements

Not applicable.

involve senior clinicians at appropriate levels in the decision-making process and receive assurance from them that there are no material concerns in relation to the partnership, including consideration of any re-configuration of clinical, research or education services;

In terms of the JV this criteria is not relevant as it does not impact on clinical, research or education services

have in place the organisational and management capacity to deliver the benefits of the partnership;

The JV has a dedicated Chief Executive with the management capacity to deliver the relevant benefits.

address any relevant legal and regulatory issues (including any relevant to staff, intellectual property and compliance of the partners with their own regulatory and legal framework);

JV compliant with all relevant legal and regulatory issues..


ensure appropriate commercial risks are reviewed;

Risk analysis relating to inpatient reconfiguration and those associated with JV were considered by Board.

ensure that the Principles and Rules for Cooperation and Competition are considered and where appropriate the CCP is consulted;

Not relevant

maintain the register of interests and no residual material conflicts identified; and

Not relevant. JV designed to support aims of Trust. Directors sitting on JV Board do not have pecuniary interest and are there to protect Trust interests.

engage the governors of the trust in the development of plans and give them an opportunity to express a view on these plans.

The COG has been engaged in the development of the Trust’s annual plan which the JV supports.

In addition, before entering into an accredited AHSC or other major Joint Venture, boards of NHS foundation trusts are required to certify that they have received external advice from independent professional advisers with appropriate experience and qualifications and that they have taken into account the best practice advice in Risk Evaluation for Investment Decisions by NHS Foundation Trusts or comment by exception where this is not the case.

The JV does not represent a major joint venture. This is driven by the transaction tests (i.e. over 10%/25% of existing Trust, which the JV isn’t). Nevertheless the attached evidence has been included for completeness. The Trust is hosting a Academic Health Science Network (AHSN) as distinct from an AHSC. This does not need to be covered in this statement.

LINK TO VALUES: Accountability LINK TO PRIORITIES: 1. To improve compliance, performance and quality by

strengthening our organisational delivery and assurance systems.

LINK TO NHS CONSTITUTION: Quality of Care & Environment LINK TO BOARD RISK REGISTER:

8. Maintain an effective system of internal control


The report provides new/on-going assurance around an existing risk; no change to risk scoring

EXECUTIVE SUMMARY The Trust Board receives a monthly integrated report on Quality and Performance. The report for March 2013 is attached.

• Integrated Quality & Performance Framework – Appendix 1a • Quality Account – Appendix 1b

1.0 BOARD ACTION

The Board is asked to: i) Note the overview of performance provided in the report.

2.0 INTRODUCTION The attached report details the performance of the Trust for March 2013.

3.0 BACKGROUND

The Integrated Quality and Performance Report provides the Board with a monthly overview of performance and aims to give the Board assurance that the level of reporting across the organisation is sufficient to ensure that the Trust is operating effectively, efficiently and economically.


AGENDA ITEM: Integrated Quality and Performance Report DATE OF MEETING: 02/05/2013

PREPARED BY: Head of Performance

FOIA STATUS: No exemption Choose an item.



The framework promotes accountability for performance at a number of levels across the organisation and has been structured to provide assurance in relation to the following areas:

• Monitor – Terms of authorisation and Compliance Framework • Assurance and Accreditation • Delivery of NHS Mental Health, Community and Specialised services

Contracts • Delivery of the Quality Strategy – Patient Safety, Patient Experience and

Clinical Effectiveness • Information Governance • Membership • Workforce

The frequency of reporting to the Board for each indicator has been developed to reflect the timescale by which progress can be meaningfully demonstrated. A number of indicators will only report on a quarterly or annual basis and where this is the case and a performance indicator is not due to be reported, the indicator is shaded grey in the framework. The report is supplemented with exception reports in respect of those areas that are rated as red or amber and also to highlight other key issues to the Board. The red, amber and green (RAG) metrics have been informed by either nationally prescribed targets where they exist, or by locally developed targets. The locally developed targets will be reviewed on a regular basis to ensure that the thresholds that have been developed reflect the right level of assurance to the Board.

4.0 ISSUES

Quality and Performance

The Board’s attention is drawn specifically to the following: 4.1 Monitor Compliance Framework 2012/13 The Trust has declared full compliance against the Monitor indicators for the final

quarter of 2012-13. 4.2 Financial Risk Rating All figures at this stage must be considered with caution as they are subject to

adjustment as part of annual accounts process and audit. However, they are in line with previous trends and indicate performance in line with or better than plan.

4.3 Patient Safety Health Care Acquired Infection- C-Difficile:- There has been one reported case in

December 12 of C-Difficile, this caused the Trust to exceed the 11/12 outturn of zero cases.

Health Care Acquired Infection- MRSA:- There has been no reported MRSA colonisations for March 13 for Mental health and Community services.

Falls which result in a Fracture:- There have been 10 reported incidents of a fall resulting in a fracture since April 12, with one incident being reported in March13.

Pressure Ulcers in the Community:- There was a single grade 4 pressure ulcer within BwD in quarter 4 12-13.

Incidences of Violence:- The Accident Incident Rate (AIR) for the reported violent and aggression incidents shows the Quarter 4 position is 22.9 a small reduction on the Quarter 3 figure. The classification of violent incidents allows the Trust to monitor incidents involving physical violence and incidents of aggression where there is no physical violence against service users or staff; there is a higher rate of physical incidents when compared to the Non-physical incidents. During March 2013 there were 114 reported incidents of physical violence, with a classification of no injury occurring in 63.2% (72 incidents) of cases, ‘Low injury’ (short term injury/first aid given) occurring in 36% (41 incidents) of cases and moderate injury (medical treatment required e.g. X-ray/broken bones) occurring in 0.4% (1 incident) of cases. March’s figure of 114 incidents is a reduction on cases reported in February (189). The clinical areas with the identified decreases in violence are the Acquired Brain Injury Service ABI (42.8) and Psychiatric Intensive Care Units (PICU) (36.8). The AIR for non-physical incidents has increased on February 13 by an AIR 3.6. Out of the 171 reported incidents 97.7% (167) of the cases where classified as ‘No Injury’, with 2.3% (4 incidents) being classified as ‘low injury’. The category of the incidents showed that 49% consisted of verbal abuse or verbal threats and 30% attempted assault by patients on staff. The Trust is also specifically monitoring the number of ‘patient on patient’ and ‘patient on staff’ physical violence incidents. Out of the 103 incidents reported, 25.2% (26) were ‘patient on patient’ incidents and 74.8% (77) were ‘patient on staff’ incidents.

4.4 Patient Experience Younger People Admissions: Since April 12 there have been 18 reported incidents

of a young person being admitted to an Adult ward. There has been one admission in March 13.

The process for out of hour’s admissions to The Platform is now much clearer and the commissioning for out of area placements is now centralised through the North West Specialised Commissioning Team. This has enabled a more streamlined process for accessing out of area beds when required, which has contributed to the reduction in the use of Adult Mental Health Beds for 16/17 year olds. The CAMHS Tier 4 Outreach Service is also providing a regular update to on-call managers every Friday afternoon, which indicates the availability of CAMHS beds and CAMHS intensive care beds across the North of England, to support the managers in finding appropriate placements when these are required, which, reduces the need to use AMH beds. There has been a nationwide shortage of CAMHS Tier 4 beds (especially PICU beds) over recent months, which has resulted in the need to manage at least three young people in The Platform who required support in a more intensive environment but there was no availability. These situations required significantly increased

staffing levels to maintain a safe therapeutic environment and resulted in increased use of restraint and property damage. This highlights the potential difficulties in admitting high risk young people to CAMHS units, where the pathway to PICU (if required) is not always available locally or at all. There remains occasions were young people are transferred great distances placing pressure upon families and creating isolation.

National Indicators for Quality Improvement that deals with young persons’ admission:- Number of hospital occupied bed days on adult psychiatric wards of patients aged under 16, on admission, under the care of a psychiatric specialist- There have been no OBDs occurring for a young person under the age of 16 at the Trust

Number of hospital occupied bed days on adult psychiatric wards of patients aged 16 or 17, on admission, under the care of a psychiatric specialist. The number of young person admissions has decreased on the previous quarter (Quarter 3 12/13), from 6 to 1 admission. This has led to a decrease in the number of occupied bed days from 11 to 2. The average occupied bed day per patient has decreased from 2.29 days to 2 days.

Compliments and Complaints:- During Quarter 4 there have been 43 complaints, 155 concerns, and 636 compliments. This is a 40% reduction in complaints and an increase of 30% in concerns from the previous quarter. There has again been an increase in the number of compliments received. There has been a 100% achievement of the standard relating to acknowledging complaints within 3 working days of receipt. The primary subjects of complaints have been recorded from and the top themes identified which are similar to those identified in previous quarters. Each network has been provided with data which relates to that network. From the complaints that have been completed during the quarter there are 11 significant complaints and 2 extreme complaints across the organisation. These relate to privacy and dignity, cancellation of appointments, medication, referrals and communication. The relevant services have action plans in place following these complaints. There has been a slight rise in the number of compliments, the majority of these are given to services directly and then passed through to Customer Care for collation. For those compliments received directly by the Customer Care department these will be forwarded to the relevant services where identified. The nature of the compliments is varied and currently the main types are not identified individually but the main themes are Compassionate Care, working with and helping families, comments on positive attitudes and behaviours of staff and thank you to individuals or teams. In the quarterly network reports examples of compliments pertinent to each network are picked out and included – usually those which give an indication of aspects of care which are valued (rather than general thanks). Work is ongoing to understand comments included within compliments which give valuable insight into the aspects of care which are valued by patients, service users and carers.

Inpatient Surveys- In comparison to 12/13 Quarter 3 outcomes, Quarter 4 results show that three of the nine indicators exceeded the previous quarter’s results. The three greatest increases were ' Was the Ward Clean?' ‘Could I get a hot drink when I wanted?’ and ‘I was satisfied in how I was involved in planning my discharge'.

Five indicators saw a percentage point decrease. ‘I got as much information as I wanted about my treatment' which saw the biggest fall by 18 percentage points, ‘I knew how to make a complaint if I needed to' which saw an 11 percentage point decrease.

4.5 Workforce and Organisational Development e-PDR: To support the current business planning process and ensure individuals

understand their role in supporting the delivery of network plans and organisational priorities, it was agreed that all PDR ‘objectives only’ should be completed by the end of June 2012. The Trust achieved 80.4% against this target, using the new system for 12/13. To improve the e-PDR system the plan is to simplify and amend sections in the electronic system. In addition an e-PDR focus group involving staff, managers, staff side will look at ideas on how to further improve the system/process. From the middle of April 2013, managers will be able to access on-line reporting to monitor network or team compliance and supporting documentation will be available to explain how and what the data is showing. The Learning & Development team will continue to work closely with the Networks and Teams to provide on-going system support, advice and training to their staff and managers.

Spend on Bank and Agency staff has increased since last month by £570,511. The highest users of agency are currently IT and Information and highest bank usage is Learning Disability Service Supported Living. Turnover for March stands at 8.30%. This reflects a small increase since last month. The In Month Sickness Absence Rate has decreased since last month, from 5.51% in February to 5.16% in March.

4.6 Information Governance

Following approval by the Senior Information Risk Owner the Annual Information Governance Training Assessment was submitted 27th March 2013. The Trust has maintained a Satisfactory rating (above 65%) and an improved position for 12/13. The overall final result was 85%. This is an 11% increase on the July 2012 Baseline position. The toolkit comprises of 6 initiatives which are aggregated to provide the final score. The following is a breakdown down of attainment for each initiative: Information Governance Management 93%, Confidentiality and Data protection 87%, Information Security Assurance 88%, Clinical Information Assurance 80%, Secondary User Assurance 83%, Corporate Information Assurance 66%.

SUMMARY AND CONCLUSIONS The integrated Quality and Performance report details the performance of the Trust for March 2013.

4.7 RECOMMENDATION The Board is asked to: i) Note the overview of performance provided in the report.

No Indicator Title Description of metricOrganisation

al Priorities

Care Quality

Commission

requirement

Community or

Mental Health

Contract

requirement

Executive Lead Data Source

Trend from

previous

reporting

period

Frequency of

Report

Red Amber Green

1 Care Programme ApproachPatients receiving follow up contact within 7 days of

discharge from hospital - target 95%3 Director of Finance

National Care Records

System (NCRS) &

Electronic Care Record

(ECR)

<90% <95% 96.20% Monthly

2 Care Programme ApproachPatients having formal review within 12 months-

target 95%3

Director of Finance NCRS & ECR <90% <95% 97.30% Monthly

3Minimising mental health delayed

transfers of care

The percentage of non-acute patients age 18 & over

whose transfer of care was delayed summed across

13 weeks of the quarter - target ≤7.5%

3 Director of Finance NCRS & ECR >10% 7.5%-10% 7.30% Monthly

4

Admissions to inpatient services had

access to crisis resolution home treatment

teams

The percentage of gate-kept admissions to inpatient

services requiring access to crisis resolution home

treatment teams - target 95%

3 Director of Finance NCRS & ECR <90% <95% 98.10% Monthly

5Meeting commitment to serve new

psychosis cases by early intervention

Level of performance against contracted activity -

target 95%3 Director of Finance NCRS & ECR <90% <95% 152% Monthy

6 Mental Health Data Completeness Patient Identifiers - target 97% 1 Director of Finance NCRS & ECR <90% <97% 99.70% Monthly

7 Mental Health Data CompletenessOutcomes for patients on CPA - target 50%

1 Director of Finance NCRS & ECR <45% <50% 75.50% Monthly

8Access to Healthcare for people with

Learning Disabilities

Certification against compliance with requirements

regarding access to healthcare for people with

Learning Disabilities

3 Director of Nursing Greenlight ToolkitNon Compliant/

Breaches

Moving to

complianceCompliant Quarterly

9 NHS Litigation Authority Plan to achieve Level 1 standards in year 1 Director of Nursing Director of NursingNon Compliant/

Breaches

Moving to

complianceCompliant Annual

10Referral to treatment times - Consultant-

led

Maximum time waited for non-admitted patients

(threshold 18 weeks) completed pathway

- target 95%

1 Director of Finance NCRS & ECR <95% 100% Monthly

11Referral to treatment times - Consultant-

led

Maximum time waited for non-admitted patients

(threshold 18 weeks) incomplete pathway

- target 92%

1 Director of Finance NCRS & ECR <92% 100% Monthly

12Community Information Dataset (CIDS)

CompletenessReferral to treatment times (50% target for 12/13) 1 Director of Finance NCRS & ECR <45% <50% 97.6% Monthly

13 CIDS CompletenessReferrals

(50% target for 12/13)1 Director of Finance NCRS & ECR <45% <50% 100% Monthly

14 CIDS CompletenessCare Contact Activirty

(50% target for 12/13)1 Director of Finance NCRS & ECR <45% <50% 74.3% Monthly

15 CIDS Completeness

Patient Identifier Information

(this indicator, with a target of 50% is not currently

within the compliance framework, but may be

introduced during 12/13)

1 Director of Finance NCRS & ECR <45% <50% 50% Monthly

Performance Framework - position as at March 2013 Appendix 1a

MONITOR COMPLIANCE FRAMEWORK

Thresholds

16 CIDS Completeness

Patients Dying at Home/Care Home

(this indicator, with a target of 50% is not currently

within the compliance framework, but may be

introduced during 12/13)

1 Director of Finance NCRS & ECR <45% <50% 50% Monthly

Adult - target to be agreed in line with transition plan 36.4 days

Older Adult - target to be agreed in line with

transition plan58.5 days

Adult - target to be agreed in line with transition plan 100.8%

Older Adult - target to be agreed in line with

transition plan86%

19 Overall Risk Rating 2 Director of Finance Finance ledger <3 3 >3 Monthly

20 Achievement of Plan EBITDA Achieved (of plan)2

Director of Finance Finance ledger <70% 70%-85% 118.3% Monthly

21 Underlying Performance EBIDTA Margin2

Director of Finance Finance ledger 4.7% 5%-9% >9% Monthly

22 Financial Efficiency Return on assets2


23 Financial Efficiency I&E surplus margin2


24 Liquidity Liquidity Ratio (Days)2

Director of Finance Finance ledger <15 days 15-25 days 31 days Monthly

25 Care Quality Commission Maintain compliance with standards

1

Director of NursingNon Compliant/

Breaches

Moving to

complianceCompliant Monthly

26 Quality Governance Framework Maintain compliance with framework

1

Director of NursingNon Compliant/

Breaches

Moving to

complianceCompliant Monthly

27 CQUIN Delivery of CQUIN indicators 3 Director of Finance Network DirectorsNon Compliant/

Breaches

Moving to


28 Schedule 3 / Quality Schedule Delivery of Schedule 3 3 Director of Finance Network DirectorsNon Compliant/

Breaches

Moving to


29 Performance Improvement Notices Performance issues identified by commissioners 1 Director of Finance Lead Commissioner Notice receivedNo performance

notices receivedMonthly

30 Health Care Acquired Infections Cumulative number of incidents reported for C-DIFF 3 Director of NursingInfection Prevention &

Control dept.>2011/12 OT On target <2011/12 OT Monthly

31 Health Care Acquired InfectionsCumulative number of incidents reported for

colonised MRSA3 Director of Nursing

Infection Prevention &

Control dept.>2011/12 OT On target <2011/12 OT Monthly

32 Falls resulting in a FractureCumulative number of incidents of falls resulting in

fractrue3 Director of Nursing Datix >2011/12 OT On target <2011/12 OT Quarterly

33Pressure Ulcers in the Community - Central

Lancashire localityReported number of Category 3 and 4 pressure sores 3 Director of Nursing Datix

Increase on

previous

quarter

On target

Decrease on

previous

quarter

Quarterly

34Pressure Ulcers in the Community -

Blackburn with Darwen localityReported number of Category 3 and 4 pressure sores 3 Director of Nursing Datix

Increase on

previous

quarter

On target

Decrease on

previous

quarter

Quarterly

FINANCIAL RISK RATING

NHS MENTAL HEALTH & COMMUNITY CONTRACTS

PATIENT SAFETY

ASSURANCE & ACCREDITATION

IN-PATIENT ACTIVITY

17

18

Length of Stay on Discharge

Bed Occupancy

1

1

Director of Service Delivery &

Transformation

Director of Service Delivery &

Transformation

NCRS

NCRS

Monthly

Monthly

35 Incidences of Violence Accident Incident Rates 5 Director of Nursing Datix>Quarter 1

12/13 baselineOn target

<Quarter 1

12/13 baselineMonthly

36 Violent Incidents Against StaffCumulative Incidences of Violence on Staff Members

by Service Users5 Director of Nursing Datix >2011/12 OT On target <2011/12 OT

37 Medicines ManagementReduction in the number of prescribed hypnotics and

anti-psychotics per network2 Director of Nursing Chief Pharmacist

Increase on

previous monthOn target

Reduction on

previous monthUnder Review Monthly

38 Staff Questionnaires: Patient Safety % Staff witnessing errors, near misses or incidents in

last months that could hurt service users5 Director of Nursing CQC

< below

national

average

Improvement

on previous

year score

> national

average

Annual on

publication of

results

39 Staff Questionnaires: Standards of Care% of staff that feel satisfied with quality of work and

patient care being delivered5 Director of Nursing CQC

< below

national

average

Improvement

on previous

year score

> national

average

Annual on

publication of

results

40

Staff Questionnaires: Percentage of Staff

with Appraisal completed within last 12

months

% Staff with a completed appraisal within last 12

months5

Director of Workforce &

ODCQC

< below

national

average

Improvement

on previous

year score

> national

average

Annual on

publication of

results

41 Mandatory trainingPercentage of Staff with Mandatory Training

Completed 75% annual target1


ODTraining department <70% 70%-75% 76.04% Monthly

42 PDP/PDRPercentage of Staff with PDP/PDR Completed 100%

annual target1


ODTraining department <80% 80.40% 100% Quarterly

43 Younger People AdmissionsCumulative number of young persons admissions to

adult wards3 Director of Nursing Datix >2011/12 OT On target <2011/12 OT Monthly

44

National Indicators for Quality

Improvement that deals with young

persons admission

CF-01 Number of hospital occupied bed days on

adult psychiatric wards of patients aged under 16, on

admission, under the care of a psychiatric specialist

3 Director of Nursing NCRS

Increase on

previous

quarter

On target

Reduction on

previous

quarter

Quarterly

45

National Indicators for Quality

Improvement that deals with young

persons admission

CF-02 Number of hospital occupied bed days on

adult psychiatric wards of patients aged 16 or 17, on

admission, under the care of a psychiatric specialist

3 Director of Nursing NCRS

Increase on

previous

quarter

On target

Reduction on

previous

quarter

Quarterly

46 Compliments Number of compliments received per quarter 5 Director of Nursing Datix

Reduction on

previous

quarter

On target

Increase on

previous

quarter

Quarterly

47 Complaints Number of complaints received per quarter 5 Director of Nursing Datix

Increase on

previous

quarter

On target

Reduction on

previous

quarter

Quarterly

48 Inpatient Surveys Outcomes of the Internal Inpatient survey 5 Director of Nursing Clinical Governance

Reduction on

previous

quarter

On target

Increase on

previous

quarter

Quarterly

492011 Mental Health Inpatient Service

Users Survey

Results from the 2011 Mental Health Inpatient

Service Users Survey undertaken by Quality health5 Director of Nursing CQC

< below

national

average

Improvement

of previous

year score

> national

average

Annual on

publication of

results

502011 Community Mental Health Service

Users Survey

Results from the 2011 Community Mental Health

Service Users Survey undertaken by Quality Health5 Director of Nursing CQC

< below

national

average

Improvement

of previous

year score

> national

average

Annual on

publication of

results

PATIENT EXPERIENCE

51 Carers Assessments Under Development Director of Nursing

52 PEAT Assessment

Patient Environment Action Teams (PEAT) report

published by the National Patient Safety Agency rates

Trusts on hospitals treat their patients in cleaner,

better maintained environments.

4 Director of Finance NPSADeterioration

last review

Standard

Maintained

Improvement

on last reviewAnnual

53 Advancing Quality- PsychosisPercentage pass rate on the achievement of meeting

the 3 indicators for Advancing Quality3 Medical Director ECR < 90.09% Target On target > 90.09% Target Monthly

54 Advancing Quality- DementiaPercentage pass rate on the achievement of meeting

the 5 indicators for Advancing Quality3 Medical Director ECR < 71.25% Target On target > 71.25% Target Monthly

55 Information Governance ToolkitOverall Attainment Score

National Target 65%1 Director of Finance IG Toolkit ≤64% 85% Quarterly

56 Growing representative membership Target membership - 12827 members 5 Director of Workforce &

ODCompany Sectretary

>2% Below

target

<2% above

target14268 Monthly

56A Growing affiliate membership Target affiliate membership - 250 members 5Director of Workforce &

OD

Stakeholder Engagement

Manager

>2% Below

target

<2% above

targetAbove target

Every six

months

56B Regular cycle of membership engagementTarget engagement cycle - 6 membership exercises

annually5

Company Secretary and


OD

Stakeholder Engagement

Manager

4 or fewer

exercises

annually

5 exercises

annually

6 or more

exercises

annually

Annually

57 Use of Bank & Agency Staff

Total cost of Bank & Agency staff (includes all Bank

payments made through payroll and all invoiced

agency costs that include agency doctors)

2 Director of Workforce &

ODGeneral Ledger 1,953,622

>£1m-

≤£1.5m≤£1m Monthly

58 Turnover Rate (total new organisation)Number of Leavers over a 12 month period (FTE) /

Staff in Post (FTE) *1002


ODESR ≥17% >13%-<17% 8.30% Monthly

59 Sickness absence rate - monthlyFTE Days Lost / FTE Days available * 100 – for current

month2


ODESR >5.5% 5.16% ≤5% Monthly

60Sickness absence rate - cumulative

position for year to date

FTE Days Lost / FTE Days available * 100 – for year to

date2


ODESR >5.5% 5.31% ≤5% Monthly

Trend Key

Above target improving performance

Above target deteriorating performance

Below target improving performance

Below target deteriorating performance

Worse than target performance unchanged

Better than target performance unchanged

MEMBERSHIP

WORKFORCE & ORGANISATIONAL DEVELOPMENT

ADVANCING QUALITY

INFORMATION GOVERNANCE

Appendix 1b

Falls Which Result in a Fracture

Health Care Acquired Infection (HCAI)

PATIENT SAFETY

Trust Board Report for March 2013

0 01 2

34

5 6 6 6 6 6

0

5

10

15

20

25

Ap

r-1

2

May-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Mar-

13

Cu

mu

lati

ve

MR

SA

re

po

rte

d c

ase

s

Month/Year

Cumulative MRSA Activity against 2012/13 Target

Cumulative YTD Target 12/13 (15 cases)

0 0 0 0 0 0 0 0

1

0 0 0

0

1

2

3

4

5

Ap

r-1

2

May-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Mar-

13

Cu

mu

lati

ve

C-D

Iff

rep

ort

ed

ca

ses

Month/Year

Cumulative C-Diff Activity against 2012/2013 Target

Target 12/13 (0 cases) Cumulative YTD

01 1 1 1

2

55

6

7

910

0

2

4

6

8

10

12

14A

pr-

12

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

Cu

mu

lati

ve

re

po

rte

d c

ase

s

Month/Year

Cumulative Falls Activity against 2012/13 Target

Cumulative YTD Target 11/12 (13 cases)

Falls which result in a FractureThere have been 10 reported incidents of a fall resulting in a fracture since April 12, with one incident being reported in March13. The incident occurred on an Older Adult ward. Overall the graph shows that there has been a lot of variance in the number of reported fractures which is due to the low numbers involved.

The second graph shows the cumulative number of falls resulting in a fracture against the 11/12 out turn. 2012/13 out turn did not exceed the 11/12 out turn of 12 cases.

Detailed analysis is being undertaken and will be included in the SUI six monthly review report.Falls are a preventable harm in Harm Free Care, and is a CQUIN target and a Trust priority.

(Source: Datix)

Mandatory Surveillance - Operating Framework 2012/13

National targets for MRSA bacteraemia and Clostridium difficile infections (CDI) are set for Acute and Primary Care Organisations on an annual basis based on data from the previous year. The Trust is not set a target by the Commissioners however if an MRSA bacteraemia or CDI is reported as a community or Mental Health acquired infection the Community IPC Team are contacted to perform an RCA if the organisation is implicated (following the initial RCA performed by the Commissioning IPC Team) i.e. staff have provided care for the individual or they have been an inpatient in one of the wards.Clostridium difficile infections (CDI)There have been no reported cases of C-Diff in March 13 within Mental Health services. The second graph shows the cumulative number of reported Mental Health C-Diff cases against the 11/12 out turn. LCFT commissioners have not set a target but LCFT have set their own target based on the previous years out turn. The single case in December 12 has caused the Trust to exceed the 11/12 out turn of no reported cases.MRSA Screening:Longridge Community Hospital report rates for MRSA screening for inpatients as per local and national policy. This is reported via the IPC Assurance Framework on a quarterly basis and monitored via the IPC team on a weekly basis. The target is set for 100%compliance with the policy. From April 12 they have achieved 100% compliance.MRSA bacteraemia or colonisation:In March 13, there have been no reported cases of an MRSA bacteraemia or colonisation within the Mental or Physical Health services of Lancashire Care.

The second graph shows the cumulative number of Mental Health reported MRSA cases against the 11/12 outturn; no target has been set by the commissioners but as with CDI above LCFT has set their own target. 2012/13 out turn of 6 cases did not exceed the 11/12 out turn of 15 reported cases.

(Data Source: Infection Prevention & Control dept.)

0

1

2

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Mar-

12

Ap

r-1

2

May-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Mar-

13

No

of

Re

po

rte

d c

ase

s

Month/Year

SPC Chart for C-Diff

Data Average UCL LCL

0

1

2

3

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Mar-

12

Ap

r-1

2

May-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Mar-

13

No

of

Re

po

rte

d c

ase

s

Month/Year

SPC Chart for MRSA

Average Data UCL LCL

0

1

2

3

4

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

No

of

Re

po

rte

d c

ase

s

Month/YearAverage Data UCL LCL

LCFT Quality Account - February 2013 Trust Board Report Page 1

Appendix 1b

National Reporting and Learning System National (NRLS) patient safety reports

Incidences of Violence and Aggression

Serious Untoward Incidents (SUI)

1015 18 17

26 22

37 3327 30

25 27

10 10 1 2

2 7

5 13

6

14

5

0

10

20

30

40

50

Qrt

1

Qrt

2

Qrt

3

Qrt

4

Qrt

1

Qrt

2

Qrt

3

Qrt

4

Qrt

1

Qrt

2

Qrt

3

Qrt

4

10/11 11/12 12/13

To

tal c

ase

s re

po

rte

d

No of Incidents Reported in 48 hours by Quarter and Financial Year

Not reported in 48 hours

Reported in 48 hrs.

18 16 18 18

3023

26

3128

25 2318

76 2 3

2

45

43

31

1

0

10

20

30

40

Qrt 1 Qrt 2 Qrt 3 Qrt 4 Qrt 1 Qrt 2 Qrt 3 Qrt 4 Qrt 1 Qrt 2 Qrt 3 Qrt 4

10/11 11/12 12/13

To

tal r

ep

ort

s co

mp

lete

d

No of Reports completed in 45 Days by Quarter and Financial Year

Reports not completed within 45 DaysReports completed within 45 Days

90%89%

96%

95%

0%

20%

40%

60%

80%

100%

120%

12/13 Quarter 1 12/13 Quarter 2 12/13 Quarter 3 12/13 Quarter 4

% Reports completed in 45 days against 2012/13 Targets

% Reports completed in 45 days 90% Target

82%

97%

86%

84%

0%

20%

40%

60%

80%

100%

12/13 Quarter 1 12/13 Quarter 2 12/13 Quarter 3 12/13 Quarter 4

% incidents reported in 48 hours against 2012/13 Targets

% incidents reported in 48 hours 90% Target

Serious Untoward Incidents (SUI)

The figures only relate to Mental Health. An integrated reporting system became operational on 2nd July 12. The SUI Quarterly Report has been changed to a bi-annual report and will allow the Trust time to do in-depth data analysis and compile action plans. The Policy for the Reporting, Management and Investigation of Incidents has been reviewed following service transformation and the change to one organisation wide Datix system and the new policy and guidance will launch in April 2013. The new Policy for the Reporting, Management and Investigation of Incidents includes serious incidents formally known as SUI’s or (serious untoward incidents). The organisation intends to remove the term ‘untoward’ and in future will call these serious incidents as the term applies to all serious incidents and this is in line with current national guidance. This reviewed serious incident reporting and management procedure has been piloted in Adult Mental Health Network and learning from this pilot has been integrated into the new process in preparation for implementation.

Incidents reported in 48 hours Quarter 4 shows a 2% decrease on quarter 3 on the number of incidents reported within 48 hours representing a 6% short fall on the commissioning target of 90%.This decrease relates to some instances where there has been a delay in reporting in Network.Alongside this increase there have been some issues in the reporting process interface between the system development as part of the pilot and the transition and progress to new ways of working. This has been raised in Network and is being addressed and further training is being provided.

Reports completed in 45 days Quarter 4 has seen a 1% increase on quarter 3 on the number of incidents completed within 45 day. Quarter 4 exceeds the commissioning target of 90% by 5%.

(Source: Head of Risk and Datix)

The graphs show the Accident Incident Rate (AIR) for the reported violent and aggression incidents during April 12 to March 13 across all Inpatient Mental Health Units. The graph above benchmarks the Trust against the AIR as of Quarter 1 2012/13. The Quarter 4 position is 22.9 which is a 2.63 reduction on Quarter 3.

The classification of violent incidents allows the Trust to monitor incidents involving physical violence and incidents of aggression where there is no physical violence against service users or staff. The second set of graphs show a higher rate of physical incidents when compared to the Non-physical incidents. During March 2013 there were 114 reported incidents of physical violence, with a classification of no injury occurring in 63.2% (72 incidents) of cases, ‘Low injury’ (short term injury/first aid given)occurring in 36% (41 incidents) of cases and moderate injury (medical treatment required e.g. X-ray/broken bones) occurring in 0.4% (1 incident) of cases. March’s figure of 114 incidents is a reduction on cases reported in February (189). The clinical areas with the identified decreases in violence are the Acquired Brain Injury Service ABI (42.8) and Psychiatric Intensive Care Units (PICU) (36.8). Further analysis shows the ABI ward that has the greatest reduction of incidents is Bleasdale Ward (15) and PICU ward with the greatest reduction is Burnley PICU (24 incidents). The AIR for non-physical incidents has increased on February 13 by an AIR 3.6. Out of the 171 reported incidents 97.7% (167) of the cases where classified as ‘No Injury’, with 2.3% (4 incidents) being classified as ‘low injury’. The category of the incidents showed that 49% consisted of verbal abuse or verbal threats and 30% attempted assault by patients on staff.

The Trust is also specifically monitoring the number of ‘patient on patient’ and ‘patient on staff’ physical violence incidents. Out of the 103 incidents reported, 25.2% (26) were ‘patient on patient’ incidents and 74.8% (77) were ‘patient on staff’ incidents. (Source: Datix)

The data has been taken from the National Reporting and Learning System National (NRLS) patient safety reports, with the latest results being April to September 2012. The reporting rates are higher than average which represents a maturing safety culture and the Trust remains in the top percentile of reporters (NRLS, 2013) in the current comparable cluster of Trusts. The incident reporting data is reviewed and quarterly reports are provided organisation wide alongside a 6 monthly thematic report of serious incidents.


Appendix 1b

Pressure Ulcers in the Community

Quality Priority 1 Safety: Compliance with the harm free care national priority

Safety Thermometer: Harm Free Care

Young People Admissions

1

34

7

10

11

15

17 17 17 17

18

0

2

4

6

8

10

12

14

16

18

20

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Ma

r-1

3

Cu

mu

lati

ve

re

po

rte

d c

ase

s

Month/Year

Cumulative incidents of young persons against 2012/13 Target

Cumulative YTD 2011/12 Cumulative Out turn (9 incidents) 2011/12 Out turn profile

A focus on the delivery of harm free care is a key priority within the 2012/13 CQUIN encompassing community services, community hospitals, old age mental health inpatient and community services, learning disability inpatient and community services and prison services. Harm Free Care focuses around 4 harm areas; Pressure Ulcers (PU), Falls, Urinary Tract Infections in patients with a catheter (UTI) and Venous Thromboembolism The Trust participates in the national data via the NHS Safety Thermometer. The safety thermometer supports measuring the incidence of harm and focusing on prevention and protection from avoidable harm ’. A steering group and four sub-groups have been established to support implementation. The number of sites now reporting is currently 45. The DoH recommends that the first six months data should be taken as baseline data. 2013/14 figures will be used as a future baseline.

All applicable teams are on track to submit from April 2013 as required by CQUIN.

(Source: Quality & Governance Directorate)

92% 95% 94% 91% 91% 91% 91% 90% 90% 91%91% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

% of patients that have received harm free care

Harmfree Aspirational Target (95%)

0

1

2

3

4

5

6

Jun

-11

Jul-

11

Au

g-1

1

Se

p-1

1

Oct

-11

No

v-1

1

De

c-1

1

Jan

-12

Fe

b-1

2

Ma

r-1

2

Ap

r-1

2

Ma

y-1

2

Jun

-12

Jul-

12

Au

g-1

2

Se

p-1

2

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Fe

b-1

3

Ma

r-1

3

No

of

ad

mit

tan

ces

of

yo

un

g p

oe

ple

Month/YearData Average UCL LCL

Pressure Ulcers in the Community

The first graph shows the number of category 3 and 4 pressure ulcers by provider for Community services. The second and third graphs show where the pressure ulcer was acquired by category. A new process has been agreed following changes to StEIS guidance in April 12 which means that only avoidable pressure ulcers and those acquired within the Trust are reported. Quarter 4 shows there was a single grade 4 pressure ulcer within BwD. In Mental Health services there has been one hospital acquired pressure ulcers since April 12.This occurred in November 12 and was a Grade 3 pressure ulcer at Ward 20 Burnley General Hospital. An investigation was undertaken and findings shared with all clinicians involved.Work to prevent avoidable pressure ulcers is continuing within the Trust and includes standardisation of reporting systems, implementation of training programmes for clinical staff and care homes and development of a pressure ulcer prevention strategy to embed the harm-free care agenda locally. A pressure ulcer prevention harm-free care group has been established as a sub-group of the Harm free care steering group. This group will drive forwards implementation of a strategy for pressure ulcer prevention within the Trust and will oversee triangulation of data between the Safety Thermometer data, incident data and SUIs for pressure ulceration which is collated within the Trust. (Data Source: Datix and Tissue Viability Nurses)

1

2 2 2

1 1

1

3

2

0

1

2

3

4

5

6

Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13

BWD Central

No

of

ca

ses

Categories of Pressure Ulcers by Provider by Quarter during 2011/12

Category 3 Category 4

1 1 1 1

1 1

2

0

1

2

3

Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13

BWD Central

No

of

Ca

ses

Quarter /Year by Area

Setting of Acquired Pressure Ulcer- Category 3

Residential Care home Pt's Home

1

1

1 1

2 2

0

1

2

3

4

Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13

BWD Central

No

of

Ca

ses

Quarter /Year by Area

Setting of Acquired Pressure Ulcer- Category 4

Residential Care home Pt's Home


Appendix 1b

Occupied Bed Days

0 2011/12 Q 4 3 4

2011/12 Q 3 0 0 2011/12 Q 3 0

0

2011/12 Q 1 0

0

2011/12 Q 4

1

2012/13 Q 3 11

Year/ Quarter No of patients

2011/12 Q 2 0

16 7

2012/13 Q 1 0 0 2012/13 Q 1 9

0 2011/12 Q 2 30 4

0 2011/12 Q 1 1

No of patients Year/ Quarter Occupied Bed Days

4

0 2012/13 Q 22012/13 Q 2 0

62012/13 Q 3 0 0

2012/13 Q 4 0 0 2012/13 Q 4

National Indicators for Quality Improvement that deals with young persons admission

2 1

Young People Admissions

Since April 12 there have been 18 reported incidents of a young person being admitted to an Adult ward. There has been one admission in March 13.

The process for out of hour’s admissions to The Platform is now much clearer and the commissioning for out of area placements is now centralised through the North West Specialised Commissioning Team. This has enabled a more streamlined process for accessing out of area beds when required, which has contributed to the reduction in the use of Adult Mental Health Beds for 16/17 year olds.The CAMHS Tier 4 Outreach Service is also providing a regular update to on-call managers every Friday afternoon, which indicates the availability of CAMHS beds and CAMHS intensive care beds across the North of England, to support the managers in finding appropriate placements when these are required, which, reduces the need to use AMH beds.There has been a nationwide shortage of CAMHS Tier 4 beds (especially PICU beds) over recent months, which has resulted in the need to manage at least three young people in The Platform who required support in a more intensive environment but there was no availability. These situations required significantly increased staffing levels to maintain a safe therapeutic environment and resulted in increased use of restraint and property damage. This highlights the potential difficulties in admitting high risk young people to CAMHS units, where the pathway to PICU (if required) is not always available locally or at all. There remains occasions were young people are transferred great distances placing pressure upon families and creating isolation.

The second graph shows the cumulative incidents of young persons admitted to adult wards, compared with the 11/12 out turn. It can be seen that the Trust has exceed the 11/12 out turn of 9 cases, with a 2012/13 out turn of 18 cases. As stated above the trust has worked with the specialist commissioners to resolve that problem as far as possible. (Data Source: Datix and Assistant Network Director Children’s and Families Network)

0

5

10

15

20

25

30

35

Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4

2011/12 2012/13

Occu

pie

d B

ed

Da

ys

Year/Quarter

CF-02 Number of hospital occupied bed days on adult psychiatric wards of patients aged 16 or 17, on admission, under the care of a psychiatric

specialist

The NHS Information Centre, the Department of Health and NHS professionals have identified Indicators for Quality Improvement (IQI). These indicators describe the quality of a broad range of service.

These two graphs display the Indicators for Quality Improvement that represents young persons admission. It has been included to monitor the number of Occupied Bed Days (OBDs) that an under 16 and 16-17 year old person has spent on Adult wards. They include new admissions and transfers prior to discharge. This indicator does not have a target.

The first graph shows there have been no OBDs occurring for a young person under the age of 16 at the Trust.

The second graph shows the number of young person admissions have decreased on the previous quarter (Quarter 3 12/13), from 6 to 1 admission. This has led to a decrease in the number of occupied bed days from 11 to 2. The average occupied bed day per patient has decrease from 2.29 days to 2 days.

(Source: http://www.ic.nhs.uk/services/measuring-for-quality-improvement and LCFT Information systems)

CF-01 Number of hospital occupied bed days on adult psychiatric wards of patients aged under 16, on admission, under the care of a psychiatric specialist

CF-02 Number of hospital occupied bed days on adult psychiatric wards of patients aged 16 or 17, on admission, under the care of a psychiatric specialist

0

0.5

1

Q 1 Q 2 Q 3 Q 4 Q 1 Q 2 Q 3 Q 4

2011/12 2012/13

Occu

pie

d B

ed

Da

ys

Year/ Quarter

CF-01 Number of hospital occupied bed days on adult psychiatric wards of patients aged under 16, on admission, under the care of a psychiatric

specialist


Appendix 1b

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

92% 91% 98% 94% 94% 98% 93% 95% 98% 91% 96% 96% 95% 92% 93% 98%

68% 77% 81% 79% 84% 85% 85% 85% 92% 93% 88% 93% 93% 95% 93% 98%

88% 78% 81% 81% 71% 83% 78% 84% 77% 80% 80% 84% 83% 84% 83% 82%

77% 71% 75% 71%

68% 68% 61% 73% 79% 77% 78% 88% 82% 76% 76% 71% 55% 54% 64% 53%

83% 79% 81% 78%

88% 77% 81% 72% 78% 78% 77% 83% 88% 83% 80% 87% 83% 90% 88% 87%

80% 77% 82% 84%

7 8 7 7 7 7 8 7 8 8 7

66 97 52 85 69 80 60 116 66 71 49 45 41 62 44 45

887 939 971 879 989 904 889 918 977 901 800 840 819 853 765 760

7% 10% 5% 10% 7% 9% 7% 13% 7% 8% 6% 5% 5% 7% 6% 6%

Quarter

1

Quarter

2

Quarter

3Quarter 4

6 9 11 9

22 10 49 25

44 17 56 35

1 6 15 11

0 0 0 2

6 9 11 9

20 6 18 8

24 28 60 33

23 9 47 32

Quality Priority 2 Patient Experience: To increase service user involvement through the National Institute for Health and Clinical Excellence (NICE) Clinical Guidelines

LCFT Internal Inpatient Surveys

2009/10 2010/11 2011/12

Adult & Older Adult Inpatient Surveys

Was the Ward Clean?*

Could I get a hot drink when I wanted?*

The Ward felt a safe place to be in?*

I got as much information as I wanted about my

treatment +78% 86% 86%

Internal Survey

Compliments & Complaints

Top 5 Topics from upheld and partially upheld

complaints for Quarter 4

Assessed risk

Care and Treatment

Moderate Privacy

5 9 10Withdrawn

Upheld

Partially Upheld

Quarter 4

All Networks

Significant

Extreme

Not upheld

Complaint referred to the Ombudsman

No of patients who

referred their

complaint to the

Ombudsman

Quarter 1 Quarter 2 Quarter 3 Quarter 4

17

Quarter 2 Quarter 3Overall Outcomes

of ComplaintsQuarter 1

Withdrawn

Low

2012/13

83% 86% 88% 76%

53%52% 57%

I knew how to make a complaint if I needed to +

I was satisfied with how I was involved in

planning my hospital care +80% 84% 80%

Medication

Staff attitude and behaviour

Communication

90%

Discharges per quarter

Response Rate

51% 57% 55%

Would you recommend us to a friend?

Sample size

78%

My privacy was respected*

I was satisfied in how I was involved in planning

my discharge +81% 83% 87%

88% 84% 76% 46%

59%

59% 56% 69% 51%80% 80% 62%86% 86%

86%

Patient, service user and carer experience is a key component of the Quality Strategy where each team within the organisation will have an understanding of the experience of people who use the service. Building on the descriptions of a quality experience provided by the Nice Guidelines, teams have identified the types of feedback they have from their patients and service users as part of their service self-assessments using the Quality SEEL tool. This information will become a key component of the Experience Quadrant of the Team Information Boards which are being developed with every team. (Source: Head of Service User and Carer Involvement and Experience)

Internal Inpatient Survey

In comparison to 12/13 Quarter 3 outcomes, Quarter 4 results show that three of the nine indicators exceeded the previous quarter’s results. The three greatest increases were ' Was the Ward Clean?' which saw a 5 percentage points matched by ‘Could I get a hot drink when I wanted?’ which saw a 5 percentage point increase and finally ‘I was satisfied in how I was involved in planning my discharge' which saw a 4 percentage point increase. Five indicators saw a percentage point decrease. These include ‘I got as much information as I wanted about my treatment' which saw an 18 percentage point decrease, ‘I knew how to make a complaint if I needed to' which saw an 11 percentage point decrease and 'I was satisfied with how I was involved in planning my hospital care' which saw a 4 percentage point decrease. The remaining two both saw a 1 percentage point decrease.

N.B. * Scores for answer 'always/mostly'+ Aggregated scores for answers 'good' and 'satisfactory'

Sample size relates to the number of questionnaires responded to and not all questions are completed within the questionnaire.

A steering group has been established to review the "Family and Friends Test” and to identify how this can be implemented within the Trust. The National "Family and Friends Test” focuses on asking a simple question "whether they (the service users) would want a family or friend to be treated by the Trust in their hour of need ".Further work is being undertaken in line with the new quality strategy to review methods of data collection for patient experience data.

(Source: Quality and Governance. Team and Clinical Audit )

Grade of Complaint: From the complaints completed by Network, the breakdown of significance based on the risk rating within the investigation report is as follows:

Compliments & ComplaintsDuring Quarter 4 (1 January 2013 to 31 March 2013) there have been 43 complaints, 155 concerns, and 636 compliments. This is a 40% reduction in both complaints and an increase of 30 % in concerns from the previous quarter when there were 78 complaints and 102 concerns. This reflects a drive to have increased contact with complainants and to respond in accordance with the wishes of the complainant. There has again been an increase in the number of compliments received. There has been a 100% achievement of the standard relating to acknowledging complaints within 3 working days of receipt. The primary subjects of complaints have been recorded from and the top themes identified which are similar to those identified in previous quarters. Each network has been provided with data which relates to that network.From the complaints that have been completed during the quarter there are 11 significant complaints and 2 extreme complaints across the organisation. These relate to privacy and dignity, cancellation of appointments, medication, referrals and communication. The relevant services have action plans in place following these complaints. There has been a slight rise in the number of compliments, the majority of these are given to services directly and then passed through to Customer Care for collation. For those compliments received directly by the Customer Care department these will be forwarded to the relevant services where identified. The nature of the compliments is varied and currently the main types are not identified individually but the main themes are Compassionate Care, working with and helping families, comments on positive attitudes and behaviours of staff and thank you to individuals or teams. In the quarterly network reports examples of compliments pertinent to each network are picked out and included – usually those which give an indication of aspects of care which are valued (rather than general thanks). Work has commenced on making more use of the comments included within compliments which give valuable insight into the aspects of care which are valued by patients, service users and carers.

(Source: Customer Care Department)

195 186164

132

62

134169

144

230 236 234

345

487

577 583

636

49 47 34 227 9

8 236

5536 39

92

111

784344 47

3161

8 12 722

61 62 60 72

113 121102

155

0

100

200

300

400

500

600

700

Quarter 1

12/13

Quarter 2

12/13

Quarter 3

12/13

Quarter 4

12/13

Quarter 1

12/13

Quarter 2

12/13

Quarter 3

12/13

Quarter 4

12/13

Quarter 1

12/13

Quarter 2

12/13

Quarter 3

12/13

Quarter 4

12/13

Quarter 1

12/13

Quarter 2

12/13

Quarter 3

12/13

Quarter 4

12/13

Adult MH Childrens and families Adult Community and Specilaist Services Trust Wide Position

Compliments Complaints and Concerns by Network and Trust Total

Compliments Complaints Concerns

Overall Outcomes of Complaints: From the complaints completed by Network, the following table shows the outcomes from the complaints and the Top 5 Topics for the Trust


Appendix 1b

Effectiveness Metrics

Quality Priority 3 Effectiveness: To reduce time on non-value added activity.

EFFECTIVENESS

Advancing Quality (AQ)

Advancing Quality provides Trusts with a list of key measures which should be delivered to every patient to ensure they receive the highest standard of care. If every hospital achieves the measures set out by Advancing Quality, it will help to reduce admissions, reduce complications and decrease the length of time patients have to spend in hospital. The Trust participates in two areas; Dementia and First Episode Psychosis. Data is submitted monthly in accordance with the timescales set by Advancing Quality Alliance (AQuA).

Psychosis Dementia

Psychosis had a 12/13 CQUIN stretch target (percentage pass rate) of 90.9% for 12/13. The Target is applied to the existing measures only. November's submission showed the Trust achieved 93.8% pass rate, which exceeded the target by 2.85%. The year to date position (April to November 12) showed the Trust exceeded the 90.9% CQUIN target by 3.8%.

There has been an introduction of two new measures since April 12. The first indicator is the combined ‘Positive and Negative Syndrome Scale (PANSS) assessment and review the Duration of Psychosis (DUP)’. The PANSS and DUP indicator has a 15.8% pass rate for November which is a increase on October’s 5.9% submission. A review of the PANSS element of the indicator shows high pass rates, however the DUP element has a very low pass rate and work is on-going to implement this in clinical practices. This includes reviewing the guidance and determining training needs.

The second indicator is the ‘offering of psychological therapies within 6 months of acceptance’. October’s indicator has been submitted with a pass rate of 70.6%, which when combining with the PANSS/DUP indicator has a combined pass rate of 38.2%. These are being reported in 'shadow format' to AQuA and are not subject to targets during 12/13.

The auditing of the submitted figures took place in March 13 by Grant Thornton who replaced the defunct Audit Commission. Early indication is the Trust exceeded the 80% CQUIN target, although the final report has yet to be received from the Auditor.

(Source: LCFT information systems)

Dementia had a 12/13 CQUIN stretch target (percentage pass rate) of 71.25% for 12/13. The Target is applied to the existing measures only and December’s submission shows the Trust achieved 92.5% pass rate, which exceeded the target by 21.2%. The year to date position (April to December 12) showed the Trust exceeded the 71.25% CQUIN target by 22.9%.

There has been an introduction of three new measures since April 12 which include assessment for nutritional need, assessment of pain and a discharge care plan review to ensure that care plans are still appropriate post discharge. These are being reported in 'shadow format' to AQuA and are not subject to targets during 12/13. The shadow indicators have a 44.4% pass rate for December. Work is on-going to embed the assessments/review into current practice. Raising awareness of the new measures by visits to team meetings on the ward is still on going.

The auditing of the submitted figures took place in March 13 by Grant Thornton who replaced the defunct Audit Commission. Early indication is the Trust exceeded the 80% CQUIN target, although the final report has yet to be received from the Auditor.

(Source: LCFT information systems)

This quality priority is a key part of the transformation programme and quality strategy and is an integral part of the transformation strategy in terms of lean. A presentation was given at the Standards and Assurance Committee on 27th November 12. Case studies were presented to show how the Lean Team had worked within staff at Guild Lodge and Sexual health Service to look at specific processes in order to reduce waste and improve services. Waste can be defined as any aspect of an activity, task or process that adds no value to the final service and if waste is eliminated there is more time for value adding work. An end of year report will be presented in the Annual Quality Account.


LINK TO VALUES: Accountability

LINK TO PRIORITIES: 2. To improve value for money and productivity toachieve efficiency savings of 20% across the Trust over the next five years.

LINK TO NHS CONSTITUTION: Not Applicable

LINK TO BOARD RISK REGISTER:

4. Sustain a viable business model



EXECUTIVE SUMMARY

At the time of writing, the Finance Department are in the midst of preparing year end

accounts. Late transactions and adjustments are always likely to arise as a result of

actions by third parties. The figures presented herein are subject to significant change and

must therefore be treated with extreme caution. An update will be provided at the Board

meeting.

The Trust is expected to significantly over perform against plan (£6.7m surplus before

exceptionals v £4.1m plan). Exceptional items of £2.7m relate to write offs after revaluation

of fixed assets and are not taken into account in the calculation of financial risk ratings. An

overall risk rating of 3 has been achieved for the year as a whole with all metrics

marginally down since February, though this gives little cause for concern

The net over performance includes the under achievement of CIPs (£1,029k), though the

variance against the risk adjusted plan is £1,133k positive.

1.0 BOARD ACTION

None

2.0 INTRODUCTION

The report explains the actual and forecast financial performance and position of

the Trust, the implications and any proposed management action


AGENDA ITEM: Finance Report March 2013






3.0 BACKGROUND

Planned surplus – Full year £4.1m

Planned overall financial risk rating – Full year 3

Planned CIP – Full year £14.4 m

4.0 ISSUE

Actual surplus before exceptional items – £6.7m v Plan £4.1m

Actual FRR – 3 v Plan 3

Actual CIP – £13.4m v Plan £14.4m. There are net under spends elsewhere

helping to mitigate this variance by £3.6m


The Trust is expected to over perform significantly against plan though the

financial risk rating of 3 is constrained by the EBITDA margin, following

acquisition of community services in June 2011

The under achievement of CIPs was the only significant issue

6.0 RECOMMENDATION

Note the expected financial performance for the year

EXECUTIVE SUMMARY

NB At the time of writing, the Finance Department are in the midst of preparing year end accounts. Late

transactions and adjustments are always likely to arise as a result of actions by third parties. The figures

presented below are subject to significant change and must therefore be treated with extreme caution. An

update will be provided at the Board meeting.

Target Year to date Notes

EBITDA £’000 £15,212 v AP £12,855 1

Surplus before exceptionals £’000

£6,710 v AP £4,139 1

Surplus after exceptionals £’000

£4,003 v AP £4,139 1

CIP £’000 £13,378 v AP £14,408 2

Cash Balance £’000 £33,285 v AP £16,162 3

Capital Expenditure £’000 £16,510 v AP £12,750 4

Cumulative BPPC

Compliance %

NHS Volume TBC

Value TBC v Target 95 5

Non NHS Volume TBC

Value TBC v Target 95

Financial risk rating 3 v AP 3 6

Notes 1 ‘Exceptionals’ of £2.7m relate to write offs following revaluation of assets

Performance is judged on surplus prior to exceptionals for the purposes of financial risk ratings

Main driver of variance is income over and above plan (£8.4m), though this is offset by relevant additional expenditure of £6.0m, generating the net variance of £2.4m in EBITDA

2 CIP outturn is £36k less than anticipated last month, though there have been positive movements on a number of schemes over the last month

The outturn compares favourably with the risk adjusted plan of £12.2m

3 The closing cash balance is substantially better than anticipated though it contains a number of transitional gains

4 More than £10m was spent in March, with a significant element relating to IT, inpatient reconfiguration (land, etc) and/or technical expenditure

5 No issues

6 Score of 3 against plan of 3, constrained by EBITDA margin following acquisition of community services in June 2011

1. INCOME & EXPENDITURE PERFORMANCE

The draft outturn is a net surplus before exceptional items of £6.7m against a plan of

£4.1m. Exceptional items relate to write offs following revaluation of fixed assets and are

not taken into account when calculating financial risk ratings.

Whilst improved, there remains an under achievement of CIPs (£1,029k). This is more than offset by net under spends elsewhere of £3.6m.

£0.0m

£1.0m

£2.0m

£3.0m

£4.0m

£5.0m

£6.0m

£7.0m

£8.0m

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Cumulative Surplus £'m

Plan Actual Best Forecast Downside

Income and Expenditure

Actual Plan Variance

£'m £'m £'m

Income 321.736 313.354 8.382

Pay (238.874) (238.093) (0.781)

Non Pay (67.650) (62.406) (5.244)

Total Costs (306.524) (300.499) (6.025)

EBITDA 15.212 12.855 2.357

P/L on Disposals 0.003 0.000 0.003

Capital Charges (8.096) (8.423) 0.327

Interest Receivable 0.013 0.053 (0.040)

Interest Payable (0.422) (0.346) (0.076)

Net Surplus before Exceptional Items 6.710 4.139 2.571

Exceptional items (2.707) 0.000 (2.707)

Net surplus / (deficit) 4.003 4.139 (0.136)

EBITDA margin 5% 4% 1%

Year To Date

2. ANALYSIS BY DIRECTOR Analysis of results given the potential impact of late audit adjustments and third party

transactions has not been prepared.

NB The analysis as included in the February report is repeated here for information.

Clinical Services

Under spend of £1,248k, 0.6% (Q1 £400k, 0.7%; Q2 £147k, 0.1%; Q3 £589k, 0.3%) against net budget of £208m. £2,180k under spend on pay. Adult Mental Health is over spent by £425k, exclusively driven by Out of Area costs as a result of ward closures. Adult Community has recovered the position to a £617k underspend. Secure is delivering a deficit of £446k, mainly driven by high use of bank and agency on the ABI unit and an unfunded Assistant Network director post. Children and Families has had additional funding confirmed in Health Visiting which improves their position to £1,245k favourable.

Director of Nursing

Under spend of £112k 3.1% (Q1 £55k, 5.7%; Q2 £122k, 6.2%; Q3 £133k, 4.5%) against budget of £3.6m. Under spend relates to having 8 staffing vacancies primarily relating to reduced hours, maternity leave and pending recruitment.

Chief Executive

Over spend of £168k (Q1 under £2k; Q2 over £148k; Q3 over £89k) against budgeted net

income of £884k Main variance is in respect of the extension to the Inpatient Programme

(£31k), Non Executive recruitment costs (£43k).

Director of Finance

Under spend of £207k 0.7% (Q1 £165k; 1.9%, Q2 £83k, 0.5%; Q3 £273k, 1.1% all adverse) against budget of £30.8m. Main variances are due to under-recovery of interest receivable (£55k); revised Finance savings post TCS (£120k) and SLA savings (£180k).

Director of Workforce and Organisational Development

Over spend of £636k 14.3% (Q1 £234k, 19.8%; Q2 £452k, 19.6%; Q3 £492k, 13.5%) against budget of £4.5m. Main variance due to authorised non-recurrent spends on ESR Self Service (£182k), E-Rostering (£168k) and the Transformation Project (£120k) which were not allowed for in budget. Human Resources is £39k overspent on pay and £99k over on non-pay, mainly due to consultancy.

Medical Director

Under spend of £556k 19.5% (Q1 £106k, 13.0%; Q2 £274k, 17.5%; Q3 £505k, 21.5%) against budget of £2.8m. Main variances are drug underspends (£370k) following some drugs becoming generic and underspends on medical vacancies (£104k)

3. COST IMPROVEMENT PROGRAMME

Savings of £13.4m have been achieved for the year as a whole, against a Plan of £14.4m

and a Risk Adjusted Plan of £12.2m. Variance against plan is 7.1% adverse (Q1 19.5%,

Q2 14.2%, Q3 12.9%) and against Risk Adjusted Plan is 9.9% positive (Q1 4.3% adverse,

Q2 1.2% positive, Q3 2.6% positive). The underperformance of £1.0m is more than offset

by other gains of £3.6m. Savings in February are substantially above the trend from

previous months (£1,791k savings v average of £1,053k).

There is a good degree of achievement against the programme for 2012/13:

141 schemes out of the 166 planned schemes were on track, a number of which over performed

3 additional schemes were identified

25 schemes under performed, with 18 of these by £10k or more

Delays were experienced in some Estates schemes due to the timing of ward closures.

The Childrens and Families and Adult Community Networks under performed (by 23% and

20% respectively), reflecting to an extent their background within PCTs, where the

robustness of planning was questionable. Both networks identified offsetting savings

elsewhere during the year and delivered annual under spends (£725k and £904k

respectively including the under achievement of CIPs).

At an overall Trust level, there is an under performance of £1,029k (7.1%); there is an over

performance of £1,133k (9.3%) against the Risk Adjusted Plan.

The final outturn on planned CIP schemes for 2011/12 was £14.0m (2010/11 £9.6m).

The Cost & Resource Effectiveness Committee continues to review the programme with

the focus now turning to future developments and considering the most appropriate and

effective way to identify savings and efficiencies. The need to robustly manage schemes

and source compensatory schemes where there is any shortfall has been communicated

to managers as a priority.

CIPs

Plan Actual Variance

£'000 £'000 £'000

Income &Expenditure CIP14.4 13.4 -1.0

Year to Date

4. BALANCE SHEET

Fixed assets show the impact of substantial expenditure during March, including land

acquisition for The Harbour development, offset by write offs following the revaluation of

properties.

The closing cash balance is substantially better than anticipated though it contains a

number of transitional gains.

Balance Sheet

Year To Date


£'m £'m £'m

Fixed Assets 130.856 123.187 7.669

Stock 0.249 0.208 0.041

NHS Debtors 5.600 6.634 -1.034

Other Current Assets 5.333 3.957 1.376

Cash 33.285 16.162 17.123

Current Liabilities -35.836 -22.728 -13.108

Working Capital 8.631 4.233 4.398

Long Term Assets 0.691 0.448 0.243

Provisions and other Long Term Liabilities -1.799 -2.605 0.806

Loans -11.311 -2.825 -8.486

127.068 122.438 4.630

Taxpayers Equity

PDC 100.889 100.265 0.624

I&E Reserve 6.436 6.253 0.183

Other Reserves 19.743 15.920 3.823

127.068 122.438 4.630

5. CASH AND WORKING CAPITAL

Historic trends suggest a working capital ‘buffer’ in the system relating to the speed of settling

liabilities (accruals, etc). An ‘adjusted’ forecast has been shown in the chart which allows for this

‘buffer’, estimated at around £3m, this is expected to reduce over time and will be reassessed

after the NHS reorganisation.

£0.0m

£5.0m

£10.0m

£15.0m

£20.0m

£25.0m

£30.0m

£35.0m

Apr-12 Jul-12 Oct-12 Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15

Month End Cash £'m

Plan Actual/Forecast Best Downside Adjusted

Cashflow


£'m £'m £'m

Surplus/(deficit) after tax 4.003 4.139 (0.136)

Non Cash Flows 11.209 8.716 2.493

Operating Cash Flows before WC 15.212 12.855 2.357

Changes to WC 2.781 (8.275) 11.056

CF from operations 17.993 4.580 13.413

Capital and Investment Activities (17.678) (12.186) (5.492)

Financing and Other 5.644 (3.558) 9.202

Net cash inflow/outflow 5.959 (11.164) 17.123

Opening cash balance 27.326 27.326 0.000

Closing cash balance 33.285 16.162 17.123

Year To Date

6. CAPITAL PROGRAMME NOT AVAILABLE AT THIS STAGE

7. FINANCIAL RISK RATING

Figures remain subject to change, but it is considered certain that a final overall risk rating

of 3 will be achieved for the year.

The constraining factor is EBITDA margin, which is adversely impacted by the acquisition

of community services without relevant assets being transferred from PCTs.

10 months

to January

2013

11 months

to February

2013

12 months

to March

2013

EBITDA margin % 4.5% 4.8% 4.7%

2 2 2

EBITDA % v Plan 114.8% 119.5% 118.3%

5 5 5

Return on assets % 7.7% 8.3% 7.9%

5 5 5

I&E surplus % 1.8% 2.1% 2.1%

3 4 4

Liquidity days inc WCF 30.3 32.0 30.7

4 4 4

Weighted average 3.6 3.8 3.8

Overriding rules rating 3 3 3

Key Rating <3 Rating = 3 Rating >3

LINK TO VALUES: Accountability LINK TO PRIORITIES: 1. To improve compliance, performance and

quality by strengthening our organisational delivery and assurance systems.

LINK TO NHS CONSTITUTION: Not Applicable LINK TO BOARD RISK REGISTER: 8. Maintain an effective system of internal control IMPACT ON THE RISK SCORE OR ASSURANCES IN PLACE:


EXECUTIVE SUMMARY Attached are the unconfirmed minutes of Cost and Resource Effectiveness (CARE) Committee held on 3rd April 2013.

1.0 BOARD ACTION The Trust Board is asked to note the unconfirmed minutes of CARE Committee.

2.0 RECOMMENDATION The Trust Board is not required to take any action as a result of this report.

AGENDA NUMBER: TB 074/13 AGENDA ITEM: Trust Board Sub-Committee Minutes

DATE OF MEETING: 02 May 2013

PREPARED BY: Jo Alker, Executive PA



REVIEW DATE: 02 May 2013

Cost and Resource Effectiveness Committee

Minutes of the meeting held on 3rd April 2013 at 10.00am

PRESENT: Steve Jones (Chair) Peter Ballard, Non-Executive Director Derek Brown, Non-Executive Director Chris Heginbotham, Non-Executive Director

Mark Hindle, Director of Service Delivery and Transformation Jim Taylor, Non-Executive Director Heather Tierney-Moore, Chief Executive

IN ATTENDANCE: Dominic McKenna, Financial Management Director Emma Foster, Transformation Director

Diane Halsey, Company Secretary Jo Alker, Executive Board Support Officer

CARE 010/13 APOLOGIES FOR ABSENCE

Apologies for absence were received from the Director of Nursing, Hazel Richards.

CARE 011/13 MINUTES OF THE MEETING ON 29 JANUARY 2013

The minutes of the meeting held on 29th January 2013 were confirmed as a true and accurate record.

CARE 012/13 ACTION TRACKER

Committee members noted that all items from the action tracker had been closed off. Two additional items were identified. The Director of Service Delivery and Transformation explained that demand management would be picked up in the work being done around service line management and described the work currently ongoing across the Trust. The Transformation Director added that this had been highlighted in the transformation programme capability and capacity review. This would inform the Chief Executives proposition to the Board regarding organisational development support. The Chief Executive agreed to schedule an informal Board session discussion regarding this. A second item relating to CIPs which were potentially hindered by current contractual arrangements was discussed. This would also be discussed at Board and the overall intelligence regarding relationships with CCGs would be factored into the Board away day in June.

UNCONFIRMED

CARE 013/13 VALUE FOR MONEY

The Chair introduced the subject of value for money in the context of the business planning process. The Financial Management Director introduced his paper by describing a maturity matrix approach to evaluating where Networks are in terms of value for money in order to highlight what support is needed to ensure that processes are in place that will drive value for money in the organisation. It was acknowledged that value for money should be embedded in everything that the Trust does. Some issues of clarity and understanding around what value for money means had been surfaced and it had been a helpful discussion. The exercise was intended to provide a baseline view. Discussions followed around the extent to which the exercise represents another initiative and whether this detracts from the main focus for value for money within business planning and effective execution. Aspiring to ensure we get value for money should be at the forefront of all managers’ agendas and the intention is not to create a burden of work but to create an understanding of the journey and a structure that facilitates the achievement of value for money. Ownership of the principle is the key message and this is part of what Excellence means in practice in the organisation. It was noted however that there remains a duty for the Trust via the Audit Committee to report on its approach and performance in relation to value for money agenda and the Cost and Resource Effectiveness Committee is charged with this responsibility on their behalf. In summary the Chair acknowledged the need for light touch oversight of this agenda and the need for appropriate tools and support for managers in achieving it but that this needed to be linked to the existing programmes around business planning which are the true drivers of value in the organisation. The balance between getting the best service in a cost effective manner is the ultimate aim and we need to ensure that communication is appropriately targeted to the right people. The control over resource utilisation at the front line because of the nature of the work and this is where value in its widest sense needs to be understood. It was agreed that there was a need to undertake some value for money evaluation in order to report back to the Audit Committee in line with the reporting requirements and the Chief Executive was to give some further thought about how this was achieved in practice. The Chair of Cost and Resource Effectiveness Committee would meet with the Chair of Audit Committee to agree the value for money reporting requirements to Audit Committee.

CARE 014/13 PROCUREMENT AND VALUE FOR MONEY The Financial Management Director reminded the Committee that he had agreed to bring a paper back that followed up the move to an in-house procurement service and the realisable benefits achieved in terms of value for money. He highlighted the key messages noting that this was still an immature initiative and further work was being done to ensure organisational understanding about how procurement expertise can influence cost. A discussion followed on the robustness of contracts, the access to budgets and catalogues on line and the alignment of procurement to budgets on line. The longer term aims for procurement, how they link to other strategies and how this aligns to the IM&T investment strategy and is tracked through to the CIP performance were explored. Examples in Drugs and Therapeutic budgets where significant savings have already been achieved through attention to procurement were noted. Some of the risks inherent with the NHS contracts moving into the future were surfaced and discussed at high level. The majority of these were contained within the Estates and Facilities agenda and these would be discussed as part of the Estates Strategy that is due to come to the Board in April. The drive to save money from non-pay budgets was noted and a proposition requested on how savings can be achieved in this area through procurement and what investment is needed to achieve that position. The Chair commented on the number of areas where real savings had been achieved since the change in arrangement and these were to be commended. It was agreed that a paper would be brought to the committee at the next meeting having been considered by the Executive Team. This should include an analysis of the non-pay spend, a proposition around some of the savings that could be achieved and the investment needs to get there quickly together with a summary of key risks and opportunities associated with them.

CARE 015/13 CIP REPORT

The Financial Management Director introduced the CIP report which provided an update on the finalised position following the business planning process. The risk rating against schemes was noted and there was confidence around the outturn position. Differential CIPs was discussed in the context of the initial work that had been undertaken. The risks relating to achieving inpatient savings for Commissioners was noted in the context of the need to be able to close wards without impacting on safety. This £1.4m was therefore at risk but negotiations were ongoing to mitigate this on a non-recurrent basis. Future reporting arrangements were considered and it was proposed that a quarterly report is produced on progress to date on schemes including where necessary, a recovery action plan and that this would be produced by the Network Directors. It was noted that the network plans and progress would now be tracked in detail through the new governance structures at EMT level and Non-Executive Directors were aligned to these structures. Any issues

arising out of these meetings would be escalated to the Committee and or the Board as appropriate. The progress against business plans and CIPs would be reported back to the Cost and Resource Effectiveness Committee to consider a proposition. It was noted that this might impact the pattern of meetings moving forward. The differential CIPs plan was discussed and in response to a question it was noted that the outcomes had been aligned to the service line reporting plans. Further questions about the potential for double counting on CIPs plans in service re-design were raised and assurances provided about the extent to which these had been tested to ensure that this is not the case. Further information relating to targets and the extent to which these are stretch targets was also provided. Clarity in reporting at Board level about the areas where we are investing to save or investing to support activity was requested and would be included as part of future reports.

CARE 016/13 DATE AND TIME OF NEXT MEETING The next meeting was scheduled to take place on 14th August 2013 but the Chief Executive would review this and confirm to Committee members shortly.

LINK TO VALUES: Accountability LINK TO PRIORITIES: 5. To engage positively and meaningfully with our

patients, service users, carers, staff, partners and commissioners.

LINK TO NHS CONSTITUTION: Not Applicable LINK TO BOARD RISK REGISTER: 7. Maintain the organisational reputation

EXECUTIVE SUMMARY The attached minutes from the Council of Governor meeting held on 13th March 2013 are provided to keep the Trust Board informed about the activity of the Council of Governors and any issues arising from their discussions. 1.0 BOARD ACTION

To note the attached minutes.

2.0 INTRODUCTION The attached minutes are provided to keep the Trust Board informed about the activity of the Council of Governors and any issues arising from their discussions. Copies of their agenda and papers are available by following the link on the Trusts website. Papers exempted from publication under the Freedom of Information Act are available on request from the Company Secretary.

3.0 BACKGROUND Trust Board have received previous minutes detailing activity from Council of Governor meetings.

4.0 ISSUE Any issues are detailed within the attached minutes.


AGENDA ITEM: Council of Governor Minutes

DATE OF MEETING: 02 May 2013

PREPARED BY: Diane Halsey, Company Secretary



REVIEW DATE: 02 May 2013

COUNCIL OF GOVERNORS Minutes of the meeting of the Council of Governors held on 13th March 2013 Present Steve Jones (Chair)

In Attendance Heather Tierney- Moore (Chief Executive)

Public Governors Blackburn with Darwen Brian Spencer Blackpool Linda Jones Central Lancashire Mike Marsden Selvizhi Subramanian Brian Taylor East Lancashire Catherine Dobson Tom Lawman Alan Ravenscroft Mike Wedgeworth Hilary Whitworth North Lancashire David Jackson Christina McKenzie-Townsend John MacLeod Nominated Nigel Harrison Steve Sansbury Staff Graham Ash Barbara Hummer Caroline Johnson Andrew Kirkby Paul Morris Linda Ravenscroft

Diane Halsey (Company Secretary) Bev Pickover (Head of Communications) Lynne Robinson (Project Support to Council of Governors) Trudi Dewey (Learning & OD Facilitator) Clive Taylor (Equality and Diversity Lead) Anne Allison (Programme Lead, Clinical Safety and Effectiveness)

CG033.13 WELCOME AND OPENING COMMENTS

The Chair welcomed everyone to the meeting and confirmed that the meeting was quorate. The Chair highlighted the booklets tabled about the New Inpatient Mental Health and noted how useful they are. The Chair informed the Council that Mark Lunney had resigned from his post as Nominated Governor and Lead Governor due to a change of job role and

Council of Governors

noted the Council of Governors wished him well. Governor opinions had been canvassed regarding a new Lead Governor and Chair for the Membership Committee and the Chair proposed Catherine Dobson for Lead Governor and Linda Jones for Chair of the Membership Committee. The Council of Governors agreed unanimously that Catherine Dobson become Lead Governor and Linda Jones become the Chair of Membership Committee. Catherine Dobson and Linda Jones confirmed they are happy to accept the positions. It was noted that if any Governor has an interest in becoming a chair should discuss with current chairs and arrange to shadow them.

CG034.13 APOLOGIES FOR ABSENCE AND DECLARATIONS OF INTEREST Apologies had been received from Tahir Khan, David Jones, Jane Kay and Valerie Wilson. No declarations of interest were noted.

CG035.13 MINUTES OF COUNCIL OF GOVERNOR MEETING HELD ON 19th FEBRUARY 2013 The part 1 and part 2 minutes of the last meeting held on 19th February 2013 were confirmed as a true and accurate record.

CG036.13 MATTERS ARISING AND ACTION TRACKER UPDATES Items on the action tracker were noted. CG126/12 – The Chair highlighted that the Francis II report will be covered at April Council of Governors meeting and it is now unlikely that Sir Stephen Moss will be attending a meeting.

CG037.13 THIS AGENDA Governors were given the opportunity to raise issues arising out of reports issued for information. The Chair noted two questions had been raised by Governors prior to the meeting, one relating to Atos and the confidentiality of patient’s records and the other around troubled families. The Chief Executive responded to the Atos question by highlighting that only the appropriate persons should be accessing records, and control of access was currently being strengthened. A Governor requested that this be added to the frequently asked questions to reassure the public. The Chairman responded to the troubled families question and confirmed that the Trust is engaged. The focus is on a relatively small group of families that have disproportionate needs that impact across the public sector. Full written answers to both questions will be circulated in due course.


No other questions were raised.

CG038.13 GUIDED CONVERSATION UPDATE The Learning and Organisational Development (OD) Facilitator presented the paper and reminded the Governors of the pilot and stressed the importance of this year’s feedback which contained some really useful suggestions and comments. It was noted that the Appreciative Enquiry approach had been used in the Guided Conversation to give the Governors a flavour of the Trust’s culture, however the language used in future documentation will be more user friendly and not cause a barrier. A discussion took place following a question from a Governor about any development required following the Guided Conversation and the Learning and OD Facilitator noted that the Company Secretary’s team would be collating the information any emerging themes would be addressed.

CG039.13 EQUALITY AND DIVERSITY REPRESENTATIVE The Equality and Diversity Lead introduced the paper and highlighted the four goals within the Equality Delivery System (EDS) and the ‘Opportunity Knocks’ events that have taken place over the last twelve months. The Governors were informed of the EDS scoring framework which is based on the ‘Protected Characteristics’ as set out in the Equality Act and for a Trust to score ‘Excellent’ it must demonstrate that it is addressing all 9 Protected Characteristics proactively across services at all levels. The Equality and Diversity Lead explained the role a Governor would take and asked for volunteers. Four public Governors – Linda Jones, Brian Spencer, Mike Marsden and John MacLeod volunteered. A Governor asked how feedback would come back to the Council of Governors with the Equality and Diversity Lead confirming reports would be fed back through the Company Secretary’s team to circulate.

CG040.13 MONITORING QUALITY The Programme Lead, Clinical Safety and Effectiveness gave an overview of how Quality is measured and highlighted the Quality SEEL and how it builds a picture from team level to Board level. Forty teams have been validated to date with the rest of the Trust following shortly; all risks will be recorded on the risk register. Some Governors have been trained around the Good Practice visits with one visit having taken place. Further training will be provided later in the year. A discussion took place around the Quality SEEL being incorporated into care homes with the Chief Executive noting that it will only apply to the care our District Nurses provide however, if they saw poor care the Trust would expect it to be reported with the support of their managers.


It was noted by a staff Governor that the Quality SEEL was showing as being a really useful tool. Following a Governors question around the external validation of our Quality Measures and how does the Trust ensure quality of the highest standard. The Chairman assured the Council of Governors that improvements are taking place to raise standards and noted that although that the Francis II report highlighted that at Mid Staffordshire there were not enough checks in place to make improvements quickly enough, the evidence at LCFT was that the Trust acts quickly when problems arise. The Trust ensures it has the best possible chance of compliance by keeping the best staff, having high minimum standards and identifies what quality means to them. The Chief Executive added the prevailing culture of the Trust is linked to the values of all employees and noted that the Trust listens and acts quickly, has a lack of tolerance of poor care and identifies what excellence looks like. Staff Governors highlighted that the Quality SEEL will show areas where the Trust is doing well and success can be celebrated but also show areas where improvement will be required. The Chairman noted that an extra Council of Governors session on the Francis II Report is taking place following April’s Council of Governors meeting.

CG041.13 CHIEF EXECUTIVE ASSURANCE REPORT The Chief Executive Assurance Report had been circulated to the Council of Governors for Information and Assurance. The Chief Executive informed the Council of Governors that the Care Quality Commission (CQC) had recently visited Coniston Ward at Ribbleton Hospital whilst a Quality SEEL exercise was taking place. The CQC have reported that they have seen lots of very good care however some processes including Mandatory Training where not in place. The conclusions from the Quality SEEL exercise highlighted the same issues. An investigation commenced and has identified significant management issues and as a result of this, some staff have been suspended. The Chief Executive reminded the Governors of the briefing that had been cascaded to them on 8th March about Coniston Ward and provided assurance to the Governors that the Trust had acted quickly in the interest of patients. New staff have been brought into the ward establishment with further staff being recruited with the hope that the ward can be re-opened in September as a centre of excellence. Support is being provided to staff that have been re-deployed to other environments along with support to patient’s families.


The CQC report will be in the public domain and themes from the investigation can be brought back to the Council of Governors. A Governor asked if the investigation would uncover why the problems had not come to light sooner and the Chief Executive and the Chairman confirmed that Trust Board had discussed this and assured the Governors that the issues identified by the Quality SEEL and the CQC will be addressed. A staff Governor highlighted that there had been similar issues at Parkwood; however important on-going work entitled ‘energising for excellence’ is being sustained along with staff engagement. The Chair noted that although the vast majority of staff are compassionate and do understand the importance of quality, it is the areas that are less than perfect that are discussed and the Chief Executive described the celebration of success at a recent World Café event where staff talk about what they do well and how things can be made better.

CG042.13 INTEGRATED PERFORMANCE AND QUALITY REPORT The Chief Executive Assurance Report had been circulated to the Council of Governors for Information and Assurance.

CG043.13 GOOD PRACTICE VISITS The Programme Lead, Clinical Safety and Effectiveness covered this item under CG040.13.

CG044.13 ANY OTHER BUSINESS Caroline Johnson, Staff Governor, informed the Council of Governors of her

resignation from the Board of Directors at the Foundation Trust Governors Association (FTGA) and provided the reasons for her resignation. The Council of Governors acknowledged these reasons and supported the decision.

The Company Secretary noted that a number of Trusts are ceasing to

subscribe with the FTGA and our Council of Governors must decide before August whether they wish to continue with the subscription fee or not.

CG045.13 DATE AND TIME OF NEXT MEETING 16th April 2013, 10.00am, Wellington Park Hotel, Leyland.

Bev Pickover, Clive Taylor, Anne Allison, Brian Taylor and Brian Spencer left the meeting.

CG046.13 THEMATIC REVIEW SCOPING

The Company Secretary introduced the paper which scoped out the Thematic Reviews for the coming year and reminded the Governors that these emerged from the breakout groups at March’s Council of Governors meeting. It was noted that the presentations may change as the year


progresses. The Thematic Review Template was introduced to the Council of Governors, this will be given to colleagues delivering the Thematic Reviews to give guidance around the assurances Governors require. The Company Secretary highlighted the wording on page 75 of the papers around Raising Concerns and noted that ‘although there is no formal mechanism for feeding intelligence up the organisation’ it should say there isn’t a systematic process for gathering information, however work is being carried out around this issue and there mechanisms for raising concerns do exist. The Chairman noted that although eleven themes had been chosen by Governors, there may not be enough time to cover all of them.

Mike Wedgeworth left the meeting.

THEMATIC REVIEWS

CG047.13 STAFF GOVERNOR ROLE Staff Governor, Linda Ravenscroft, delivered a presentation around the role of Staff Governor, which highlighted; An overview of Staff Governors Introduced the Staff Governors Details of the Staff Governor role including acting in the best interest

of members, seeking assurance around the services the Trust delivers and engaging with members

Staff Governors skills and attributes including well developed communication and interpersonal skills and honesty

Selvizhi Subramanian left the meeting. The difference between a Staff Governor role and a Trade Union

Representative Examples of the work Staff Governors are involved in within the Trust

She reminded the Council of Governors that following meetings where other Trusts attended, the good relationship that our Council of Governors has with Trust Board was clearly evident.

CG048.13 BREAK OUT SESSION

Following the above presentation, the Governors views were captured around the role of the Governor and will be fed back before the next Council of Governors meeting for information.


Documents

A G E N D A Board/Trust Board... · 2014-08-27 · A G E N D A Item Number Item FOIA Exempt Presenting PART ONE TB 061/13 . Welcome and opening comments/celebrating success : Chair