A meeting of the Council of Governors

Thursday 13 December 2018 from 11.00 to 13.00 Connect Suite, ORTUS Learning Centre

AGENDA

The Director of Finance will be leading a pre- meeting (10.20 to 11.00 in the Buddy room) ahead of the full CoG for the benefit of Governors who would like learn more about Finance Reports, including how to read them and what to look out for.

Ref ITEM PRESENTER TIME PAGES

44 Introductions, apologies for absence

Chair 11.00

(15)

45 Declarations of interest

Chair

46 To agree the minutes of the meeting held on

13 September 2018

Chair 1-9

47 Action log Chair 10

UPDATES

48 Progress on Our CQC Improvement Plan and

our plans to improve patient flow – including

Multi-Agency Discharge Events

Followed by Q&A with the Non-Executive

Directors (NEDs)

Beverley Murphy

& Kris Dominy

NEDs

11.15

(10)

(10)

49 Trust updates from the Executive team:

Chief Executive Report

Finance Report

Performance and Quality Report

Nursing Vacancies and Agency costs

Followed by Q&A with the Non-Executive

Directors (NEDs)

Matthew Patrick

Gus Heafield

Beverley Murphy

& Kris Dominy

Beverley Murphy

NEDs

11.35

(30)

11-14

15-18

19-55

56-63

ASKING QUESTIONS OF THE NEDs

50 The work of the Mental Health Law Committee Geraldine

Strathdee

12.05

(10)

64-68

51 Report from the Chair Chair

12.15

(5)

69-75

FOR DECISION

52 Lead and Deputy Lead Governor elections Chair

12.20

(10)

76-77

53 Council of Governor meetings: amendment to

duration

Chair

78

FOR INFORMATION

54 Lead and Deputy Lead Governor report Jenny Cobley & 12.30 79-80

Brian Lumsden (5)

55 Working Group reports:

Quality

Planning and Strategy

Membership and Involvement

Bids

Reports to be taken as read. Opportunity for

Governor Q&A.

Rosie Mundt-

Leach

Angela Flood

Ermias Alemu

Simon Darnley

12.35

(15)

81-84

56 Readout from NED / Governor visits

Chair 12.50

(5)

FOR NOTING

57 NED / Governor meeting minutes, October

2018

Chair - 85-88

58 Governors’ Handbook: 2018 update Chair - 89

WRAP-UP

59 Date of next meeting:

Thursday 14 March 2019 in the ORTUS –

proposing to extend i.e. from 16.30 – 19.00

Conduct of meetings All attendees shall abide by the Governors’ Group Agreement, namely:

1. We will treat others with courtesy and respect. We will not raise our voices, make personal criticisms or behave in a threatening manner.

2. We will be kind, caring and polite:

We will support and encourage participation from quieter members of the group.

There is no such thing as a stupid question. If we are unsure, we will ask.

3. We will work within agreed timeframes, valuing the time of others:

We will start the meeting on time.

We will set mobile phones to silent and take calls only in an emergency.

We will help to keep discussions within the allocated time frame.

4. We will respect our differences, challenging the statement not the person

We will not personalise differences of opinion.

5. We will listen to others:

In discussions, we will indicate to the person chairing the meeting that we would like to speak and wait to be invited.

We will give other people the chance to speak.

6. Wherever possible, we will do what we say we will do

7. We will not discriminate against anyone on the grounds of their age, gender, disability, gender re-assignment, marriage, civil partnership, pregnancy, maternity, race, religion and belief or sexual orientation

8. We will not share personal information about other people without their permission.

Minutes of the meeting of the Council of Governors of the South London and Maudsley NHS Foundation Trust

Held on 13 September 2018, 15.00 – 17.00, at the ORTUS Learning Centre Present

Roger Paffard Chair Bobby Abbot Croydon CCG James Canning Public Governor Handsen Chikowore Public Governor Jenny Cobley Public Governor Simon Darnley Staff Governor Ed Davie Lambeth Council Helen Dennis Southwark Council Angela Flood Carer Governor Charles Gostling Lewisham CCG Kathryn Grant Service user Governor Jeannie Hughes Carer Governor Bert Johnson Rethink Mental Health Brian Lumsden Public Governor Rosie Mundt-Leach Staff Governor Ian Norman Kings College London (KCL) Susan Scarsbrook Carer Governor Gill Sharpe Public Governor Tutiette Thomas Service user Governor Emma Williamson Staff Governor

In attendance

Andy Bell Director of Finance David Blazey Member Beatrice Butsana-Sita Non-Executive Director Kris Dominy Chief Operating Officer Rachel Evans Director of Corporate Affairs Mike Franklin Non-Executive Director Jason Grant Member Duncan Hames Non-Executive Director Charlotte Hudson Deputy Director of Corporate Affairs Sarah Ironmonger Grant Thornton UK LLP Carrol Lamouline Member Gay Lee Unknown constituency June Mulroy Non-Executive Director Angela Paget Member Mark Price NHS Providers Matthew Patrick Chief Executive Gabrielle Richards Head of Occupation Therapy Elizabeth Rylance-Watson Member Carol Stevenson (CS) Membership Officer Anna Walker Non-Executive Director Kelvin Wheelan Member

Page 1 of 89

Apologies Ermias Alemu Staff Governor Mark Banham Service user Governor Sean Casey Service user Governor Giles Constable Staff Governor Janet Davies Public Governor Ian Everall Non-Executive Director Ruth Govan Public Governor Gus Heafield Chief Finance Officer Nancy Kuchemann Southwark Clinical Commissioning Group (CCG) Clara Martins de Barros Service user governor Beverley Murphy Director of Nursing Luke Sorba Lewisham Council Geraldine Strathdee Non-Executive Director

Did not attend

Christine Andrews Service user Governor Janet Avis Croydon Council Stella Branthonne-Foster Service user Governor David Dawson Kings College Hospital NHS Foundation Trust Harpal Harrar Lambeth Clinical Commissioning Group (CCG) Girda Niles Guys and St Thomas’ NHS Foundation Trust Phathiwe Ntini Service user Governor Zoe Rafah Service user Governor Michael Tinarwo Public Governor

Ref Issue Action

31 Welcome, introductions and apologies for absence (15.05)

Roger Paffard, Chair of the Council of Governors, welcomed everyone present, including an increased number of observers. He hoped that they would find the meeting interesting. Anyone with any queries after the meeting would be welcome to contact Charlotte Hudson (charlotte.hudson@slam.nhs.uk), Deputy Director of Corporate Affairs. Each table had been provided with a flag to be held up whenever a speaker may use “NHS speak” or an acronym that someone does not understand. Roger Paffard welcomed new Governors, including Tutiette Thomas, Cllr Helen Dennis and Cllr Ed Davie. Each introduced themselves and outlined their areas of interest. Béatrice Butsana-Sita, Non-Executive Director, was also introduced.

32 Declarations of interest (15.15)

There were no new declarations of interest.

33 To agree the minutes of the meeting held on 14 June 2018 (15.15)

The minutes of the last meeting were approved with no amendments.

34 Action log

The only item on the action log was the ongoing action of liaising with Black Thrive to identify a suitable time for the Council of Governors to receive an update on their continuing work with SLaM and local communities.

35 Report from the Chair and CQC update (15.16)

Page 2 of 89

Roger Paffard reflected that the last quarter had been heavily dominated by the CQC inspection. However, during that time there were some other important events and developments from his perspective. For example, he recently attended a Research Projects Day for CAMHS services, which consisted of a series of 15-minute presentations on things people are passionately doing to improve the position for children’s mental health. Some presentations were from front-line staff, some were from researchers doing work that will have an impact on children in all four boroughs that SLaM serves. There are at least another 100 projects going on across SLaM and IoPPN. He added that he had had the privilege to give out more SLaM Star awards, and hoped that Governors would be able to attend the Staff Awards on the day of the Annual Members’ Meeting (25 September). The Trust had recently undertaken its first inspection under the new CQC methodology. Five service lines were subject to announced inspections in July, with one additional unannounced inspection that month. There was a Well Led inspection in August. The Trust has so far received high-level, verbal feedback.

There are areas of work of which the Trust should be very proud, but there is work to do to ensure that every day, every service user receives the quality of care that they should. A Regulation 29A warning notice was issued by the CQC in July, with clear expectations and a timetable for the Trust to make improvements to its acute pathway, where the CQC found too much variation in quality. Governors have received a copy of the warning notice and the papers for September’s Board meeting set out the current position in terms of putting an improvement plan in place. Roger Paffard reflected that one of the reasons for the borough reorganisation had been to address issues in the acute care pathway, so in that sense the Trust is already on its way to addressing the variance in quality found by the CQC. However, there are other improvements to be made. There is incredible pressure on the acute pathway, which will not be fixed by the reorganisation. Demand is high, and the wards have been running at over 100% occupancy for over three years. The Trust cannot always admit people who really need to be admitted. Length of Stay benchmarking data shows that SLaM’s patients are inpatients for longer than in other Mental Health Trusts. Up to 40% of service users in acute beds should not have to be there. The Trust is looking at its own processes and practices to see where it may be at fault for delayed discharge, as well as holding external Multi-Agency Discharge Events (MADEs) with partners and stakeholders to find solutions to other blockers. There has already been a MADE in Southwark; Croydon’s is taking place soon and Lewisham and Lambeth are in the pipeline. Roger Paffard wanted to engage stakeholder governors to ensure that these events are effective. The warning letter is also clear that there is variation of standards of care between wards on the same site. The Trust is therefore also focusing on articulating very clearly the fundamental standards of care that any patient can expect. The Trust has been very open about the warning letter; it acts as a clarion call to work with others to make improvements at pace, and the executive has used it as an opportunity to drive change. An improvement plan – “Our Improvement Plan” – has been developed, focusing on key areas to be addressed including fundamental standards of care and governance.

Page 3 of 89

Brian Lumsden congratulated the Board on what appears to have been a mostly positive Well Led inspection but asked whether NEDs have confidence that middle management structures are effective e.g. is leadership responsible for not taking forward QI projects that would improve quality of care. Roger Paffard pointed again to the borough restructure as a key mitigation in ensuring that the span of control for each directorate management team is appropriate; previously, it was too broad. Management effort can now be focused in a reasonable operational area. Going forward, there will also be more emphasis on leadership and talent development. Staff cannot just be equipped with the skills to deal with pressure, but also feel supported. Good wards also have effective multi-disciplinary teams. He added that in respect of the point about QI projects, it is no coincidence that the teams that are doing well are those which are embracing QI. Anna Walker reflected that there is significant flow of information between “floor” and Board, but work is now focused on making sure that it is the right flow and that the Quality Committee does not just look at those teams which are flagged as having problems – the Committee should be looking at those who might be having issues. She stressed the importance of not just focusing on wards, but also on community teams which are crucial. Kathryn Grant remarked that the recent Extraordinary meeting of the Quality Working group had provided valuable insight into the work of the Board to tackle flow issues. A recent NED / Governor visit to a male acute ward had been overwhelming; she had sat in on a safety huddle and had been struck by the engaging and passionate consultant psychiatrist and an amazing ward manager. However, she had been concerned that the staff were exhausted and that this would have an impact on their wellbeing and that of the patients. Roger Paffard agreed and emphasised that 100% bed occupancy puts staff under constant pressure. Charles Gostling echoed Kathryn Grant’s observation that staff wellbeing and morale is critical to quality care and added that it is the responsibility of the whole system to address flow issues. He asked whether those wards which did less well during the CQC inspection are those which received red-rated QuESTT (Quality, Effectiveness and Safety Tool Trigger) scores; Anna Walker stressed that the tool is a good indicator of where there may be issues, but data has to be triangulated with other sources of information and experience. Angela Flood was interested in plans for joint training and development opportunities across key organisations; so far, the discussion is about what SLaM is doing internally, but there are other bodies e.g. the voluntary sector, social services, who have a part to play. Roger Paffard agreed that, in the long-term, alliances are probably the way to make sustainable improvements through system leadership.

36 Presentation and Q&A: Duncan Hames (Audit Committee) (15.55)

Duncan Hames, Non-Executive Director and Chair of the Audit Committee, provided an overview of the Committee and its work over the last year. It has taken quite a tour of the Trust via the internal audit plan, covering performance, finance, corporate affairs and quality.

Page 4 of 89

The Committee has been involved in the development of the Board Assurance Framework (BAF), which Deloitte flagged as an area of development three years ago. The BAF is now actively used and well-integrated into the governance of the Committees. A significant development has been being able to develop an understanding of the Board’s risk appetite, which is a hard thing to articulate. The Trust has been using new internal and external auditors for the last year, and they have bedded in well. Rosie Mundt-Leach (RML) asked if any of the work of the Audit Committee touches on clinical audit; Duncan Hames clarified that the Audit Committee does not work in isolation so while, for example, the Committee may look at the quality of information relied upon e.g. IAPT treatment targets, it does not comment on the performance itself, which would go to Quality Committee.

37 External Auditor’s report – Grant Thornton (16.06)

Sarah Ironmonger, Associate Director (Audit) at Grant Thornton UK LLP, attended to present the External Auditor’s report on the Quality Report to the Governors. The Quality Report is mandatory as part of the Annual Report. The aim is to encourage public accountability of the quality of care provided. NHS Improvement sets out what needs to be done for an auditor to give independent assurance. The term “limited assurance opinion” used does not mean that the assurance itself is limited, just that the process to gain assurance is necessarily limited. Sarah Ironmonger confirmed that SLaM’s Quality Report 17-18 meets the requirements set by NHS Improvements, the information within it was found to be consistent with other sources of data (e.g. internal audit, staff surveys), and tests against three particular indicators found nothing of concern. One of these indicators was chosen for audit by the Governors via the Quality Working Group. Like the Audit Committee, it is not the role of the external auditor to comment on the Trust’s performance against an indicator, but to check that the data is accurate. Jenny Cobley thanked Sarah Ironmonger for meeting a group of Governors during the summer to answer their questions about the role of the external auditor and the process of assuring the Quality Report. It was noted that the agenda noted this item for decision, when it was for noting.

38 Centre for Young People (16.16)

Those Governors who attended the Planning and Strategy Working Group in July had already received a presentation on the plans for the Centre for Young People (CYP). There will be further opportunities to learn more about it as the plans develop. Matthew Patrick outlined a national emergency in terms of children and young people’s mental health. 50% of adults in contact with mental health services had difficulties before they were 14 years old; 75% of those adults had identifiable antecedence before the age of 24. 1 in 10 children between 5 and 16 years old have an identifiable mental illness. Only 25% of those children and young people are accessing effective mental health services, while the aspiration set out in the Five Year Forward View is 35%, which cannot be acceptable. The situation is compounded by pressure on CAMHS budgets.

Page 5 of 89

The project for the Centre for Children and Young People’s Mental Health (CYP) started about two-and-a-half years ago. The then Dean of the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) felt that the time was right for a major fundraising campaign. Mental health comes second only to cancer in terms of the need for fundraising, and children and young people have a particularly high profile within mental health. Matthew Patrick stressed that the plan is for a social movement, not just a building. Although the Centre would provide inpatient services for Southwark, it will be for the benefit of young people in all four boroughs. It will be a hub for research and best practice. This is a huge story in mental health. Jenny Cobley asked whether the Centre will have somewhere for young people to go when they are in crisis; Matthew Patrick outlined the investment that the South London Partnership has made in the crisis care pathway and which is already being rolled out e.g. a new helpline. Tutiette Thomas recommended Nadine Burke Harris’ TED talk on how childhood trauma affects health, pointing out that Scotland and Wales have a strategy on trauma-informed approaches to mental health, but England does not. She suggested inviting Dr Burke Harris to SLaM to speak to members. Matthew Patrick thought this was an excellent idea. Matthew Patrick asked all Governors to give some thought to how they and their constituencies can spread the word about the Centre for Young People and to raise awareness of the neglect that children and young people are being subjected to; a 35% target rate for access to mental health services is not acceptable. Ed Davie sought assurance around the propriety of fundraising from drug companies; Matthew Patrick explained that Kings College London has an Ethics Board which scrutinises the sources of funds.

39 Lead and Deputy Lead Governor report (16.36)

Jenny Cobley asked for a show of hands from Governors if they wanted to be counted in a letter being sent to NHS England (copies provided) stating that the funding of mental health services, and particularly CAMHS, is unacceptable. Seventeen Governors asked to be counted (plus one who had emailed Jenny separately). Governors were encouraged to attend the Members’ Seminar on 12 October about the treatment of diabetes in psychosis. Brian Lumsden also encouraged Governors to attend the Annual Members’ Meeting and Staff Awards on 25 September. Technically, it is hosted by the Governors, so there should be a good turnout of Governor representatives. Kathryn Grant queried whether holding the AMM during an evening would increase attendance.

40 Working Group reports (16.41)

Quality Working Group Rosie Mundt-Leach reported on a stand-out extraordinary meeting of the working group to look at how the Trust is reducing length of stay and freeing up beds. The session answered a lot of the Governors’ questions.

Page 6 of 89

The group is interested in following up on the outcomes of the CQC inspection and how the Trust plans to support staff in implementing improvement plans arising from the Warning Notice in respect of the acute pathway. Rosie Mundt-Leach also flagged an outstanding question from Governors about the impact of hot weather on staff and patients and hoped that would be addressed soon. Planning and Strategy Working Group Angela Flood reported on July’s meeting of the group, which had included a follow-up on Governors’ questions about the Lambeth Alliance, as discussed at the last CoG. She thanked all those who attended, including NEDs and members of the Executive team. Bids Steering Group Simon Darnley thanked everyone who took part in the process of assessing bids; 74 awards have been made. Membership & Involvement Working Group Sue Scarsbrook reported that three Governors had attended very pertinent training the previous day, looking at the quality of engagement with people and making it possible for prospective Governors to get an idea of what it involves. It was also useful to meet Governors from across the country and see where there are shared concerns about engagement. Kathryn Grant asked whether it is a good idea for Governors to use social media for mental health activism and to raise awareness, and whether there are any rules about stating that one is a Governor through that medium. It was confirmed that Governors are welcome to use social media as a platform for their Governor work. Guidance on social media will be taken to the next Membership and Involvement Working Group meeting. Action: Provide Governors with guidance on using social media as a platform for their work as a Governor.

CS

41 Trust updates from the Executive Team (16.46)

Chief Executive’s update Matthew Patrick reported on a meeting with the family of Olaseni Lewis ahead of the launch of the Seni Lewis Award. The award will recognise the best collaborative initiatives between the police and health services, to showcase the importance of providing a multi-agency response to mental health crises. The sad deaths of Seni Lewis and Sean Rigg have cast long shadows and created an atmosphere of mistrust and fear in our communities. The Lewis family had to wait a tragically long time for a conclusion to the events surrounding Seni’s death and have been immensely impressive in their motivation to make sure that such an event never happens again. Matthew Patrick has met with them to talk about opportunities to work together towards that aim and as well as the award, they are working on a crisis management film. Tutiette Thomas asked what support there is for other families affected by tragic events such as this. Matthew Patrick explained that SLaM’s practice is to engage

Page 7 of 89

with every family during any investigation; some families may find it to painful to do so, but the trust will continue to make offers to them in case their feelings change. Jenny Cobley flagged that she had heard reports that staff do not feel particularly involved in the Trust reorganisation, particularly in community teams. She is aware that the Board have been visiting teams, but she felt that there could be more visibility. Matthew Patrick recognised that as well as the senior executive team, directorate senior management teams must also be part of the communication strategy. He stressed that the borough reorganisation only affects the management structure – everything else remains the same. Finance Andy Bell, Director of Finance, talked through the newly formatted report. The structure of the report has been changed following feedback from Governors and will continue to evolve as more feedback is received. In terms of the financial position, the Trust is roughly where it said it would be at this point, but there is significant pressure in bed overspill and nursing agency costs. There are other pressures outside of the Trusts control e.g. the national pay award settlement not covering the Trusts costs, and cuts to Research and Development funding. Jenny Cobley thanked the Finance team for a much-simplified report but asked what is meant by “one-off replacement savings” in respect of Cost Improvement Programmes (CIPs); Andy Bell explained that the “one-off” element was that the new savings identified would only apply in the current financial year and that the costs would return in the following year. The “replacement” element was that these were savings that are identified above and beyond the Trust’s planned CIPs in order to make up for planned savings that don’t deliver or to offset additional unexpected costs. 45% of the spend on bed overspill is in Lambeth; Andy Bell was asked how these costs are shared with Lambeth CCG? He explained that SLaM works very closely with them through the Lambeth Alliance and have a risk share agreement so that unexpected costs are shared. Brian Lumsden asked what recovery plans are in place to ensure that the control target is met. Roger Paffard said that the Board continues to review how tenable it is to meet the control target; the financial position is really beginning to hurt. There are no easy answers, but the Board is looking at alternative ways to meet it and to be flexible in approaches to resourcing activity. Helen Dennis asked whether agency spend is within SLaM’s gift to control? There are many issues at play e.g. affordable housing, but ultimately the highest levels of nursing vacancies are in London and in Mental Health. The South London Partnership is working on programmes to try to address a very big, systemic problem. It was agreed that the issues of agency costs, vacancies and recruitment / retention are important ones and should be looked at in more detail. Finance and Performance reports are often taken at the end of a meeting which means that they can run out of time and this should be addressed at the next meeting.

Page 8 of 89

Action: Schedule session on agency costs and Trust plans to address nursing vacancies for the next meeting of the Council of Governors. Action: Schedule Finance and Performance reports to be taken at the beginning of the next meeting of the Council of Governors. Performance The performance report was taken as read and Jenny Cobley reflected on the excellent extraordinary Quality Working Group meeting to look at bed pressures. Multi-Agency Discharge Events (MADEs) were discussed at that meeting, and she sought confirmation that the Trust is clear about how many people are waiting for beds. She has heard that Mental Health Assessments are still being cancelled owing to lack of beds. Kris Dominy, Chief Operating Officer, explained that there is a record held by the Acute Referral Centre (ARC) but added that there are other patients – not just those who need an assessment – who are waiting for beds. There are physically unwell people in acute trust beds who are also mentally unwell. At any given time, an assessment has to be made about who is at the greatest risk and prioritise accordingly. Ed Davie offered his services in raising housing issues related to delayed transfers of care / discharge with his colleagues in the housing arena. Angela Flood flagged that the Performance Management Office (PMO) is supporting a great deal of the Trust’s priority tasks and queried whether extra resourcing has been put in place to enable them to do that effectively. Brian Lumsden asked how many current inpatients should actually be discharged but cannot be owing to blockers to discharge outside of SLaM’s control. Kristin Dominy explained that this is what the external MADEs are finding out. Some patients cannot leave because there is nowhere safe or appropriate for them to go to continue their treatment in the community. Some do not have National Insurance numbers or bank accounts. Some have lost their tenancies. By bringing partners together, the agencies can collectively find solutions to unblock the system, ensuring that everyone is sharing the responsibility. Each time a blockage is found, a resource is being created as to how to unblock it (e.g. how to open a bank account; how to arrange a deep clean) as learning for future cases. Action: Schedule session on Multi-Agency Discharge Events at the next meeting of the Council of Governors.

CS

CS

CS

42 Any other business

There was no further business.

43 Date of next meeting

The next meeting will be held on 13 December, between 11.00 and 13.00 at the ORTUS Centre.

Page 9 of 89

Council of Governors Action Tracker December 2018

Meeting date

Item ref Description of action Lead Date for completion

Status / Notes / Evidence

RAG

14/12/17 MC1754 Liaise with Black Thrive regarding future Away-Day involvement.

CH September 2018

The most recent Away-Day focused, at the request of Governors, on relationships with CCGs, and the one scheduled for Spring 2019 will too. Black Thrive remains an area of interest and it is recommended that it remains on the forward work plan for consideration for future meetings / events, but is removed from the action tracker.

13/09/18 CoG1841 Provide Governors with guidance on using social media as a platform for their work as a Governor.

CS December 2018

Circulated with Governors’ newsletter

13/09/18 CoG1841 Schedule session on agency costs and Trust plans to address nursing vacancies for the next meeting of the Council of Governors.

CS December 2018

On December CoG agenda

13/09/18 CoG1841 Schedule Finance and Performance reports to be taken at the beginning of the next meeting of the Council of Governors.

CS December 2018

On December CoG agenda

13/09/18 CoG1841 Schedule session on Multi-Agency Discharge Events at the next meeting of the Council of Governors.

CS December 2018

On December CoG agenda

RAG ratings Green = action complete Amber = action on schedule for completion Red = action not on schedule for completion / overdue

Page 10 of 89

COUNCIL OF GOVERNORS – SUMMARY REPORT

Date of meeting: 11 December 2018

Name of Report: Chief Executive’s Report

Author: Matthew Patrick

Presented by: Matthew Patrick

Purpose of the report:

To keep the Council of Governors’ informed about key developments affecting the Trust.

1 – Seni’s Law

On 26th November, Michael Holland (Medical Director) and I attended an important

event at the House of Commons to celebrate “Seni’s Law”.

As a Trust, we welcome the Mental Health Units (Use of Force) Act 2018, which

received royal assent in early November. Under the new legislation, there are a

number of new requirements, which include staff training, transparency around

restraints data and the requirement for a nominated person with responsibility for this

area of work. SLaM is already compliant with almost of all of these standards and

has committed to reporting against them publicly to our Board on a monthly basis.

It was an honour to attend this very moving event, attended by a large number of the

Lewis family and Seni’s friends.

Page 11 of 89

2 – BME event with Yvonne Coghill

We had a very successful all-day event on the 13th November to explore the

experiences of our BME staff and to identify ideas for improvement. The event was

led by Yvonne Coghill, Director of Workforce Race Equality Standard (WRES)

Implementation at NHS England and was attended by the Board, our Governor

observers at the Equalities and Workforce Committee, BME staff and managers at

different levels.

It was a very worthwhile day. We had an open conversation about race and it

helped us all to understand more about the day-to-day experiences of our

colleagues. We spent some time considering the key indicators for WRES success

and what we needed to improve for the future. We received some good feedback

from Yvonne Coghill and her colleagues about our current WRES action plan, as

well as some ideas for further improvements. Our plan has been designed by our

‘Snowy White Peaks’ group involving the Chair of our BME Network as well as our

Non-Executive Director, Mike Franklin, as well as members of the executive team.

Thanks to the commitment of our s and the excellent facilitation and contribution by

Yvonne and her team, we ended the day with a real sense of optimism and energy

for driving this agenda forward and ensuring that SLaM is a great place for everyone

to work.

3 – Quality Improvement event

The first South London Partnership Quality Improvement conference took place on

Thursday 8 November at the KIA Oval. Attended by nearly 300 people including

staff, governors, service users, carers from the three organisations (SLaM, Oxleas,

and South West London and St George’s), it was a fantastic celebration of the

achievements of staff across the South London Partnership and an opportunity to

learn from each other through breakout sessions, poster submissions and

networking.

Page 12 of 89

External speakers included Johnathan MacLennon from NHS Tayside and Institute

of Healthcare Improvement who spoke about the importance of building the will,

starting small and learning from failure. Samantha Riley from NHS Improvement

spoke about the essential knowledge you need to get more from your data at her

session "Making data count". During the afternoon the emphasis was on the

importance of co-production and the value of lived experience in quality

improvement.

4 – South London Mental Health and Community Partnership leadership event

Senior Leaders from across the South London Partnership met on 12th November to

take stock of progress across the partnership and to discuss vision and future plans.

It was a chance for our leaders in each of the trusts to meet the new Oxleas Chief

Executive, Matthew Trainer, and to hear about the major programmes under way

and substantial benefits being delivered.

The event revealed a strong commitment across each of the Trusts to reap the

benefits of closer working across a range of different work areas with a view to

benefitting patient care and driving further improvements.

5 – Award Winning staff

I was delighted to be able to present the award for Psychiatric Team of the Year

(‘Working-age adults’ category) at the RCPsych Awards 2018 to our KHP Pathway

Homeless Team.

This fantastic multi-disciplinary team works to improve health and housing outcomes

for inpatients who are homeless or vulnerably housed. It provides holistic, integrated

care for homeless people attending King’s Health Partners trusts – Guy’s and St

Thomas’, King’s College Hospital and SLaM. The judges were particularly

impressed the way the team have supported a culture shift in the way homelessness

Page 13 of 89

is treated within the Trusts. They were also impressed by the rigorous evaluation of

the effectiveness of the service.

I would also like to congratulate Dr Graham Blackman, who was shortlisted for the

Core Psychiatric Trainee of the Year (CT1-CT3) award. Dr Blackman is Clinical

Research Fellow at the Institute of Psychiatry, Psychology & Neuroscience at King’s

College London, and was previously Academic Clinical Fellow at SLaM. His

research, supervised by Professor Anthony David, focused on the role of immune

dysfunction in neuropsychiatric disorders.

My warm congratulations to them all for their well-deserved success.

Dr. Matthew Patrick

Page 14 of 89

COUNCIL OF GOVERNORS – SUMMARY REPORT

Date of meeting: 13 December 2018

Name of Report: Finance Report – October (Month 7)

Author: Andy Bell, Director of Finance

Presented by: Andy Bell, Director of Finance / Gus

Heafield, Chief Financial Officer

Purpose of the report:

For Governors to note. This paper is intended to inform Governor’s about:

How well the Trust has performed financially against its plan in the four key financial

areas SLaM is measured against:

o Income and Expenditure (day to day spending e.g. paying staff each month)

o Cost Improvement (achieving SLaM’s agreed savings plan)

o Cash (readily available funds, physical money in the Trust’s bank accounts)

o Capital (spend on long term investments like buildings, equipment and IT

infrastructure)

What has caused any major variation in the four key areas (referred to as Key

Drivers)

What risks (or opportunities) have been identified in any of the four key financial

areas. These will be items that are not yet fully reflected in the Trust’s current

financial position but could be if certain things happen or conditions are met.

The finance team is continuing to work with Governors to ensure that the financials

presented are meaningful. Therefore, this papers sets out to:

Ensure technical references, jargon or terminology have been explained or simplified.

Focus on the most important areas of finance

Encourage Governors to ask any and all questions they have to help us improve the

reports.

In future iterations more visual, co-designed reports remain the ambition

Page 15 of 89

Headlines (key financial figures you need to be aware of)

Position

Reporting on plan (£0.7m deficit) but with significant operational pressures of £6.5m

CIP (Savings)

Reporting on plan (£16.4m) but with £1-2m delivery currently at risk

Cash

Levels will remain robust for the remainder of the year (£72m)

Capital

Expected underspend of £12.8m against an original plan of £28.6m. This is permitted by

nHS finance rules.

Key Financial Areas

Forecast

(up until 31st March 2019)

RAG Rating Risk Key (what do the Red Amber and Green colours mean in the graphic):

Red: significant risk that planned position will not be fully delivered.

Amber: Risk that planned position will not be fully delivered but with reasonable mitigation

Green: Minimal risk that the planned position will not be achieved

Month 7 Year to Date (How well we are doing financially after the first 7 months of the year up to the end of October compared to what we originally thought)

• The Trust is £0.2m favourable to (better than) plan.

• However, if costs proceed at the current rates then there will be significant forecast pressures (future unplanned increases in spending, reductions in income, or not delivering savings) which could be in excess of £6.5m.

• These pressures will require additional action in order to achieve the Trust’s Control Total (the financial amount we have to hit by the end of the financial year which for SLaM is a £0.7m deficit). Without significant mitigations (new funding or reductions in cost) this will be very difficult to achieve.

• Recovery plans are progressing but without significant mitigations (new funding or reductions in cost) full recovery will be very difficult to achieve.

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Cost Improvement Programme (CIP or agreed Trust savings plan)

• CIP is still expected to deliver £16.4m but worse than expected spend on Overspill (the use of private inpatient beds) will require replacement schemes.

• One off replacement savings (sometimes called “Lock Ins”) have now been identified in all areas of the Trust. These are subject to continued review to see if more can be done.

Cash (the physical amount of money SLaM has in the bank or readily available to spend).

This position remains healthy at £76m year to date.

Capital (defined as anything that costs more than £5k and lasts longer than 1 year. It refers to spend on items such as the Trust’s buildings, expensive equipment and IT infrastructure)

Capital spend is £6.0m year to date (£5.4m lower than SLaM’s original plan of £11.4m).

• The Trust’s planned Estates programmes which includes work on the National Autism Unit (NAU), Norbury ward, Douglas Bennett House, CAMHS Tier 4 & The Children’s and Young Person’s centre were always due to commence later in the year. However, other organisational priorities have meant there has been some delay in spending on Capital.

Key Drivers of SLaM’s financial position (what are the main causes of change in SLaM’s financial figures)

Unless other wise stated all of the financial amounts quoted below would be an impact for the entire financial year.

• Key areas driving SLaM’s spend above its plan in operational and clinical areas year to date are:

• Overspill – this is currently predicted to be £4.9m above plan but it could increase or decrease subject to operational pressures and the impact of the Trust’s Inpatient Flow Plan (e.g. opening 14 Inpatient beds in ELFT to increase capacity).

• Ward Nursing Costs – mainly Bank and Agency use - £2.9m run rate pressure (a financial prediction based on things carrying on as they have so far)

• Agency usage – which on average costs 20% more than our own SLaM staff pay rates - £3.2m run rate pressure

• Key areas driving overspend corporately are:

• Medical - Junior Doctors Costs and medical agency use - £0.9m

• Estates – facilities management contract costs (e.g.the provision of catering services) and utilities inflation (increasing costs in rent, rates, gas, electricity, water, waste management) - £0.3m

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• Human Resources - training income lower than expected and apprenticeship related costs - £0.6m

• Reduction in Research & Development income - £0.35m.

Key Risks in SLaM’s financial position (what are the potential financial issues that could emerge that are not currently included in the financial forecast)

• Southwark Local Authority fail to fund Complex Placements (£1.0m to £1.8m)

• SLaM are unable to mitigate longer term Overspill pressure (an additional £0.0m to £3.0m)

• SLaM are unable to deliver backloaded CIP requirement (more savings are scheduled towards the end of the year than the start of the year) - £1.0m to £2.0m average run rate increase per month.

Glossary

CAMHS Child and Adolescent Mental Health Services

CIP Cost Improvement Programme (agreed Trust savings plan)

IT Information Technology

NAU National Autism Unit

SLaM South London and Maudsley NHS Foundation Trust

Page 18 of 89

Council of Governors

13 December 2018

Name of Report Performance and Quality report

Author

Rod Booth, Director of Performance, Contracts & Operational Assurance Mary O’Donovan, Head of Quality

Presented by

Kristin Dominy, Chief Operating Officer and Beverley Murphy, Director of Nursing

Purpose

For update

Purpose of the paper

To update Governors on the Trust’s operational performance against a range of key national indicators and identify and analyse under-performance and report action plans.

Performance and Quality reports are prepared for the Trust Board on a monthly basis and are available in the Board papers which are circulated to Governors. They are also available on the Trust website.

Governors are asked to provide feedback on the format and content of this report to inform future iterations.

Executive Summary:

Since the last full Council of Governors (CoG) meeting in September 2018, the format and content of the regular Performance report has changed and is evolving. Previously, operational performance and quality issues were monitored at directorate level via two sets of monthly meetings: a PACMAN (Performance and Contract Management) meeting with the Chief Operating Officer, and a Quality Compliance meeting with the Director of Nursing. Following the CQC inspection over the summer and the subsequent work to address issues raised in the CQC’s report and warning notice, a decision was made to merge those two meetings from December 2018 and the related report to the Board as part of improved processes for “floor to Board” flow of information. Therefore, the report to the Council of Governors will from now on also be a joint Performance and Quality report. This means that additional performance indicators have been introduced to the report and, as such, it has grown. Work is underway to refine the report so that data is presented clearly, concisely and focuses on the key quality and performance data that will demonstrate the Trust’s direction of travel, particularly against Our Improvement Plan (the plan put in place to address the “Must Dos” and “Should Dos” flagged in the CQC’s inspection report). Additionally, and in recognition of feedback from Governors, whilst the CoG previously received a similar report to that which is taken to the Board the intention going forward is to present a more streamlined set of data that focuses on performance in key priority areas at a level of detail more appropriate to a quarterly meeting. Governors will continue to receive the full Board Performance and Quality Report as well. Key priorities Governors will be aware that the Trust is undertaking work (internally and in collaboration with external partners) to address ‘flow’. The flow of patients through the system, and ensuring that beds are

Page 19 of 89

managed properly, will help the Trust achieve its other goals and improvements and improve the patient experience. The main aims of this work are:

No 12 hour breaches in Emergency Departments (i.e. no-one waiting more than 12 hours)

No s136 breaches (i.e. a mental health assessment undertaken under s136 of the Mental Health Act should take place within time limits defined by the Act; if it isn’t, there is a ‘breach’)

No cancelled Mental Health Act assessments in the community

No inpatients sleeping anywhere other than a designated bed (this can happen, for example, when an inpatient has gone AWOL and returns to the ward voluntarily but their bed has been given to someone else in need)

To achieve this, the Trust is working to relieve bed pressures by addressing Length of Stay (how long someone is an inpatient) to ensure that people are discharged when it is medically the right thing to do. Sometimes, a patient is medically well but there are other barriers to them leaving a ward e.g. not having suitable housing. This is why the Trust is working with partners, such as local authorities, through Multi Agency Discharge Events (MADEs) to unlock those barriers. The Trust has set itself a Length of Stay target of 35 days. The bed pressures mean that there is continued usage of external overspill beds (i.e. beds in the private sector), which is not good for patients who may have to take a bed away from home. It is also an additional cost to the Trust. Each borough has a plan to reduce overspill to zero and these plans are reviewed at a weekly meeting chaired by the Chief Executive. Running parallel to this work is the implementation of what the Trust calls “Our Improvement Plan”, which is the programme of activity to address the issue of variability in quality of care in the acute pathway (as identified in the CQC’s warning notice to the Trust) and the “Should Dos” and “Must Dos” highlighted in the CQC’s inspection report.

1. Report Summary The following areas of the report contain noteworthy risks (detailed performance information is included in the appendices):

Pressure being experienced in adult acute inpatient activity

Growth in A&E Liaison presentations

Community activity – Wait times, caseloads 2. Trust Performance Dashboard, capturing data and Business Intelligence The Trust has launched its ‘performance dashboard’ (Deming) which means that anyone can see, at any time, and for any team, performance in relation to key indicators such as (but not limited to): the number of violent incidents; number of serious incidents; average inpatient length of stay; the number of readmissions to inpatient services within 30 days of discharge; community waiting times, and financial performance. There is a Business Intelligence (BI) team which, as well as developing Deming, is working alongside major projects in the Trust (e.g. Our Improvement Plan, Quality Priorities) to ensure that data is captured from the many different sources where it is found and turned into consistent performance management reporting and analysis mechanisms. It is recognised that improvements in quality and performance must be measurable, and informed by having accurate data available for consideration from floor to Board. The BI team has a focus on the ‘flow’ work at the moment, working with the Quality Improvement team and Chief Clinical Information Officer (CIO), to define list of measures and develop an initial prototype.

Page 20 of 89

There is a tool for inpatient wards (the Quality, Effectiveness and Safety Trigger Tool or ‘QuESTT’) which captures information about that ward (e.g. staff vacancy rates) and gives an early warning if there could be a cause for concern. A version for use in Community teams has been developed and will be rolled out in December 2018. Given significant demand, there is a risk around the sustainability of the BI team. Two new staff have been recruited, however they will need time to settle in, and an experienced member of the team left the Trust in September. 3. Operational Performance and Activity 3.1 Length of Stay With a Trust performance focus on patient flow within inpatient wards, Length of Stay (LoS) data for all Borough based adult inpatient wards is set out below for information (the Average Trust LoS over the past 18 months is 48.5 days against a target of 35 Days). Croydon Lambeth

Lewisham Southwark

Fig 1: Trust LoS Data from Power BI Trust Dashboard - inpatient wards

Patients with longer lengths of stay are reviewed weekly at clinical meetings. Longer lengths of stay can be attributed to delayed transfers of care, other reasons of social need and patient acuity. A review of the Croydon Multi-Agency Discharge Events (MADEs) that were held in September has been conducted to evaluate the impact of the event on the persistent pressure on the Trust’s cost due to external overspills. 49 patients over 50 days Length of Stay (LoS) were reviewed at the event with a total LoS of 11,135 days; 31 have been discharged with a total LoS of 5,389 days, which represents a MADE discharge rate of 61%. This is a significant reduction in bed utilisation equivalent to 179 patients’ worth of beds at an average length of stay of 30 days. It is even more significant considering that the MADE cohort comprises our most stranded patients. However, the 18 remaining from the original cohort include some of our ‘super-stranded’ patients who may need an alternative approach for discharge. The MADE discharges have also allowed Croydon to repatriate many private and out

Page 21 of 89

of area beds, which were not reviewed in the original cohort. A second MADE cycle will be carried out in Croydon in November with the internal event currently planned for 21st November and the external for 28th November. 3.2 Community Activity & Performance There is persistent increasing pressure in most areas of the community system. Appendix 4 reports on the pressures in A&E Mental Health Liaison and community teams respectively.

3.3 Child and Adolescent Mental Health Services (CAMHS) waiting times The figures for current cases waiting have been drawn from the CAMHS London data set and are correct as at end 30 September 2018. CAMHS waiting times at end of Q2: Borough 52 weeks + Croydon 5 Lambeth 11 Lewisham 96 Southwark 1 Overall, all CAMHS services are experiencing long waits within the neurodevelopmental services (e.g. autistic spectrum disorders, ADHD, and mood disorders) Croydon has three cases within the neuropsychiatry team; all of who have received opt-in letters or have an appointment booked. The service is looking at how they can reduce current waiting times of 11 months for this team and have employed a senior psychologist to lead on this work. The further two cases are due to one young person being in a long-term inpatient placement, and one l complex case which has required extensive partnership working. Lambeth has eleven cases all of whom have been risk assessed at referral, and sent resource packs to support the young person and family whilst waiting. Southwark has one case which is actually a recording error. Lewisham has 96 cases across the generic child and adolescent team (Horizon) and the neurodevelopmental teams. Work is continuing to review and action the cases that should have been closed. In addition, the team managers are electronically reviewing all of the cases that have been waiting for longer than 39 weeks to ensure that cases have a plan for further action by 12 November. The Deputy Director has requested that there is a senior review of all of the cases on current caseloads to ensure that there are robust plans for these and that we have maximum capacity available within the existing resources. This will allow for planning for further resource requirements to address the waiting times. 4. Quality Indicators Compliance This section outlines the compliance and performance against current quality and safety indicators. To note is the reduction in prone restraint being used in Lambeth (fig 11), the improvement in response and investigation timeframes with both complaints and serious incidents. Since July, the QuESTT tool scoring has resulted in an increase in action plans being received and monitored in the monthly Quality governance compliance meetings.

Page 22 of 89

4.1 Incidents

Fig 2: Total Incidents reported by week, Source; Datix

The Trust is amongst the lowest reporters in England; the aim is to drive up reporting so that we can be sure there is accurate reporting of all patient safety indicators. National Reporting and Learning System (NRLS) reporting All Trusts are required to report incidents on the National Reporting and Learning System (NRLS), but SLaM has been seeing a significant delay in the time taken for services to approve incident reports and therefore make them available for upload onto the national external reporting system. Going forward, the Performance and Quality meetings will be reviewing individual operational directorate performance data and holding Service Directors accountable though quality and performance reviews. 13,112 incidents reported incidents reported on Datix:

Severity of

incidents

01/11/17

–

31/10/18

October

2018

A - Death 556 38

B - Severe 134 21

C - Moderate 4012 563

D - Low 5422 396

E - No Adverse

Outcome

2988 215

Total 13112 1233

Fig 3: Total incidents by severity, Source: Datix

The top 5 reported categories were:

Category 01/11/17 – 31/10/18

October 2018

Assault By Patient 2441 251

Challenging Behaviour

1947 192

Patient Admission 884 62

Abscond - Sectioned Patient

741 53

Actual Self-harm 629 68

Total 6642 626

Fig 4: Total incidents by top 5 categories, Source: Datix

Deaths - A Oct

2018

Natural Causes 28

Probable Suicide 6

Death Due To Accidental Overdose 2

Homicide (Murder) BY Patient 1

Alleged Murder OF Patient 1

Total 38

Fig 5: Total reported deaths, Source: Datix Fig 6: Total reported ‘Death’ incidents by category (Oct 2018), Source: Datix

Page 23 of 89

4.2 Violence and aggression (Quality priority: Reducing violence by 50% over 3 years)

Fig 7: Total violence and aggression incidents, Source; Datix

4.3 Use of restraint (Quality priority: Reduction in restraint by 50% in over 3 years)

Fig 8: Total reported incidents of restraint, Source; Datix

Fig 9: Total reported incidents of prone

restraint, Source: Datix

Fig 10: Total reported incidents of rapid tranquilisation, Source; Datix

Whilst the graphs above do not show any indicators of change Trust-wide, there have been local areas of change which is outlined in the graph below.

Fig 11: Number of Prone Restraints in Lambeth services (excluding ES2 on Southwark Site)

Due to the Trust’s focus on restraint, we expect reporting to become more accurate and therefore expect the number of total reported incidents to increase before reducing again. We are closely monitoring any restraint over 10 minutes in duration and any prone over 5 minutes.

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This drop in the use of prone restraint was discussed at the Lambeth Quality Governance Compliance meetings. The points below are believed to have contributed to this decrease; it will require further monitoring to establish if this is a shift.

Improved engagement with 4 steps to safety

Sharing of good practice of exemplar ward (Luther King Ward)

Borough Executive oversight on all reported incidents

Review of PICU admissions- right care setting

Improved recruitment 4.4 Incidents of section 136 expiring

Fig 13: Total number of s135-s136 overstays, 30/04/2018-28/10/2018, Source; as reported by Central Place of Safety

When a patient is brought to a Place of Safety under s136 of the Mental Health Act, there is a set timeframe during which they must be assessed. This indicator shows where the timescale has been breached. 4.5 No bed available

Fig 14: Total reported incidents of ‘no bed available/additional bed used’, Source; Datix

‘No bed available’ refers to patients returning from AWOL or being admitted to an inpatient ward where

a bed is not available. We expect each incident to be reported and patients to be transferred to a ward

Page 25 of 89

where they have a bed. In October, this occurred on two inpatient wards – in both cases this was due

to patients not being discharged from the ward prior to new admissions arriving.

4.6 Mental Health Act (MHA) assessment cancellation

Fig 15: Total reported incidents of ‘MHA Assessment Cancelled’, Source; Datix

All MHA assessments that are cancelled are further categorised to detail the reasons for this. Below is a breakdown of these reasons (October 2018).

Type of incident

No Bed - In SLaM 11

No Police 3

Patient Not At Home 8

Total 22

4.7. Serious Incident (SI) investigations

Fig. 16: Number of serious incident investigations commissioned

Fig. 17: Average number of days for investigations to be completed

Serious Incidents are small in number and therefore small changes can appear significant when in fact they are simply variance over time. It should be noted that Southwark are very efficient at SI reports.

05

101520

18

/02

/…

25

/02

/…

04

/03

/…

11

/03

/…

18

/03

/…

25

/03

/…

01

/04

/…

08

/04

/…

15

/04

/…

22

/04

/…

29

/04

/…

06

/05

/…

13

/05

/…

20

/05

/…

27

/05

/…

03

/06

/…

10

/06

/…

17

/06

/…

24

/06

/…

01

/07

/…

08

/07

/…

15

/07

/…

22

/07

/…

29

/07

/…

05

/08

/…

12

/08

/…

19

/08

/…

26

/08

/…

02

/09

/…

09

/09

/…

16

/09

/…

23

/09

/…

30

/09

/…

07

/10

/…

14

/10

/…

21

/10

/…

28

/10

/…

Total reported incidents of 'MHA Assessment Cancelled

Page 26 of 89

4.8 Patient Experience – Complaints

Fig. 18: Number of Formal Complaints received

Fig. 19: Average number of days for complaint responses

Fig. 20: Number of Re-opened Complaints

Fig. 21: Number of Quality Alerts received

In Q2, 14% of complaints were reopened. In Q2, 25 closed complaints were not upheld, 34 were partially upheld and 31 were upheld. A Quality Alert is a mechanism by which partner agencies, such as GP practices or the Police, can raise issues with SLaM; these are systemic issues generally affecting a service, or the ability to deliver a high quality service.

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4.9 Patient Experience– PEDIC (Patient Experience Data Intelligence Centre) Scores

Fig. 22: PEDIC Scores (positive) Fig. 23: Family and Friends (FFT) scores (positive)

The Trust asks patients, carers and families to provide feedback on their experience. The Friends and Family Test (FFT) asks whether someone would recommend services to their friends or family should they need similar care or treatment.

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4.10 Inpatient Quality, Effectiveness and Safety Trigger Tool (QuESTT)

Table 2: QUESTT scores

The QuESTT is a self-assessment tool that gives an early warning of where there may be issues of concern on an inpatient ward. Scores are given in response to information such as (but not limited to) whether there have been two or more formal complaints that month, or a disciplinary investigation; staffing levels; whether clinical supervision has taken place.

Directorate Ward

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

De

c-1

6

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Jun

-17

Jul-

17

Au

g-1

7

Sep

-17

Oct

-17

No

v-1

7

De

c-1

7

Jan

-18

Feb

-18

Mar

-18

Ap

r-1

8

May

-18

Jun

-18

Jul-

18

Au

g-1

8

Sep

-18

Oct

-18

No

v-1

8

De

c-1

8

TOTAL NO REQ AP 15 10 13 14 14 12 12 13 8 9 9 13 16 14 13 18 18 14 17 13 20 19 18 16 20 15 16 0 0 0

Green 21 23 27 32 33 35 39 38 44 43 44 40 37 39 40 35 35 39 36 40 33 34 35 38 33 38 37 0 0 0

Amber 14 9 13 14 14 12 9 13 7 9 9 12 14 14 13 18 18 14 16 13 18 18 16 14 20 14 14 0 0 0

Red 1 1 0 0 0 0 3 0 1 0 0 0 2 0 0 0 0 0 1 0 2 1 2 2 0 1 2 0 0 0

Blue 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Croydon 5 4 5 3 3 2 2 3 3 3 3 2 4 6 4 7 6 3 4 5 6 4 4 3 7 6 7 0 0 0

Croydon Croydon HTT 9 6 6 9 4 7 9 10 4 6 6 6 6 12 12 12 12 12 12 4 10

Croydon Croydon PICU 5 7 7 6 5 9 9 9 9 7 5 8 8 10 10 5 7 7 10 8 7 7 12 14 16

CroydonTyson West 1

(Croydon Triage)9 7 7 7 7 7 7 9 7 7 5 5 7 7 7 7 7 7 7 6 9 6 6 12 12 11 11

Croydon Gresham 1 15 4 5 7 9 7 9 9 14 14 14 14 14 14 14 11 11 11 11 11 16 9 9 11 14 11

Croydon Gresham 2 4 6 6 4 4 6 6 6 4 6 7 7 4 4 2 5 7 7 7 11 9 11 6 6 12 12

Croydon Addison 13 13 9 9 14 9 7 12 7 9 7 9 9 11 9 9 7 6 10 15 11 9 9 8 13 13 13

Croydon Brook 7 7 2 2 2 2 2 5 6 7 7 5 5 5 5 5 5 4 2 2 0 8 7 4 4 5

Croydon Chaffinch 2 2 2 2 2 2 2 2 2 4 4 9 9 9 9 9 9 4 4 0 0 0 0 0 2 0 4

Croydon Effra 0 0 2 0 2 7 5 5 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Croydon Fitzmary 1 11 11 14 11 14 15 15 12 12 9 6 12 11 6 9 14 12

Croydon NAU 14 17 10 10 10 10 17 15 17 15 8 8 13 8 8 10 8 8 11 11 11 11 11 10 10 9 5

Croydon Norbury 14 14 14 14 10 1 8 8 6 7 9 9 9 4 5 8 8 5 6 8 8 9 9 2 2 2 2

Croydon NPU (Fitzmary 2) 12 9 12 9 9 0 9 12 15 6 9 6 6 6 6 6 14 6 6

Croydon Spring 10 10 10 8 8 5 5 5 5 3 3 3 8 3 3 3 3 3 3 3 3 4 4 4 4 4 4

Croydon Thames 9 9 10 10 8 10 9 9 11 10 9 6 5 5 5 5 4 3 3 2 2 2 2 2 2 2 3

Croydon Waddon 4 4 8 7 2 7 4 9 9 9 7 8 10 8 12 10 12 10 8 8 8 8 5 4 4 6 6

CroydonWard in the

Community3 3 7 8 9 7 5 5 5 5 7 7 7 12 12 12 7 7 9 7 4 4 4 4 4 4 4

Psychosis Westways 6 6 11 8 6 6 11 12 7 9 4 9 9 12 6 8 11 8 8 11 7 9 7 9 9 9 7

Lambeth 1 0 1 4 3 3 2 2 1 2 2 2 3 1 2 2 2 3 4 2 4 3 3 4 3 2 1 0 0 0

Lambeth ES2 8 11 11 9 8 8 11 11 11 12 20 9 7 6 6 14 11 8 8 4 7 7 7 6 6

Lambeth Lambeth Triage 9 7 12 14 10 10 12 11 3 3 3 9 11 11 7 7 7 7 10 12 10 14 12 10 7 9 9

Lambeth Lambeth HTT 4 4 4 4 4 4 10 7 4 4 6 6 4 4 4 4 4 4 4 4 4

Lambeth Luther King 7 4 11 13 11 12 9 9 6 4 4 0 0 5 3 0 5 2 0 5 3 8 6 6 3 3

Lambeth Nelson 6 4 4 1 1 0 1 1 1 1 1 5 2 6 6 6 6 6 6 13 16 18 14 14 12 12

Lambeth Eden (PICU) Lambeth 11 10 8 8 8 8 8 10 10 10 7 7 13 14 12 11 11 8 11 15 19 19 12 18 6

Lambeth LEO 5 5 5 10 7 11 4 5 9 9 7 0 15 10 12 16 12 12 14 7 9 19 12 7 5

Lambeth Tony Hillis 5 8 5 9 5 5 5 7 5 5 9 7 7 7 7 7 5 5 5 2 2 4 5 5 5

Lewisham 2 0 2 2 1 2 2 3 1 2 2 3 2 1 1 2 3 2 3 1 4 4 3 3 3 3 3 0 0 0

Lewisham Clare 4 9 9 8 11 11 11 16 12 14 14 11 9 7 8 11 11 12 9 12 11 13 13 14 16 16

LewishamJohnson PICU -

Lewisham11 10 11 8 8 8 15 8 7 7 15 12 15 11 11 14 16 12 9 19 17 14 14 16 16 17

Lewisham Heather Close 7 7 10 12 10 10 7 7 7 7 8 7 0 6 4 6 7 4 7 4 7 7 6 6 7 4

Lewisham Lewisham HTT 4 4 4 2 4 4 2 2 4 4 4 2 5 7 7 5 5 8 8 8 6

Lewisham Lewisham Triage 11 9 9 6 6 8 6 6 6 6 6 6 6 8 8 6 7 9 4 4 10 13 5 5 6 6 9

Lewisham Powell 14 9 9 6 6 4 4 7 7 4 4 6 6 6 4 4 4 4 6 6 9 9 5 4 2

Lewisham Wharton 9 7 7 9 9 13 8 14 10 10 4 7 8 15 11 9 17 14 17 14 11 14 11 10 12

Southwark 2 2 2 1 2 2 1 1 1 0 1 1 1 2 2 4 3 3 4 3 3 6 5 5 4 2 3 0 0 0

Southwark AL3 4 4 4 6 4 6 6 4 4 4 5 5 2 4 4 4 6 6 9 11 9 12 14 12 9 9 7

Southwark JBU 14 11 6 8 6 6 8 8 8 6 6 6 6 4 7 10 12 8 12 9 11 11 8 14 13 7 7

Southwark ES1 (PICU) Southwark 18 11 9 7 7 4 2 4 4 4 2 7 7 5 12 12 15 14 12 10 13 15 10 12 13 12

Southwark Ruskin 9 9 9 9 9 7 5 7 7 7 7 7 7 7 2 5 5 5 12 10 5 5 5 8

Southwark John Dickson 13 12 12 14 14 11 8 8 8 13 14 14 14 14 12 9 14 14 12 14 14 12 10 10 10 12

Southwark POS – Place Of Safety 13 13 9 11 11 9 9 5 7 10 10 10 10 12 12 9 7 11 11 11 10 9 18

Southwark Southwark HTT 6 6 4 4 0 0 0 4 7 5 2 4 6 6 6 7 4 5 7 7 7

CAMHS 4 2 1 2 2 2 3 3 1 1 1 5 5 3 3 2 1 1 1 1 2 1 0 0 1 1 1 0 0 0

CAMHS Acorn 13 9 5 8 8 8 10 10 5 5 7 10 10 10 10 12 7 4 4 4 4 0 5 4 7 7 7

CAMHS Ash 14 12 12 11 11 16 17 12 9 9 4 12 14 6 8 8 9 9 9 9 15

CAMHS BAU 12 7 9 9 9 9 9 9 4 4 12 10 10 7 9 11 7 3 5 5 5 0 6 8 10 8 10

CAMHS OAK 11 11 9 14 16 12 17 16 16 13 9 10 10 11 11 5 12 15 12 14 11

CAMHS CAMHS PICU 7 7 7 7 7 9

CAMHS KMAU 16 9 9 9 10 9

CAMHS SAU 7 7 7 7 4 4 9 9 9 9 9 25 18 15 11 8 8 7 9 9 9 0 6 6 9 9 9

PMOA 1 2 2 2 3 1 2 1 1 1 0 0 1 1 1 1 3 2 1 1 1 1 3 1 2 1 1 0 0 0

PMOA AL1 7 5 7 7 9 9 2 4 4 4 4 4 4 4 4 4 10 10 8 8 8 8 10 8 8 8 8

PMOA Ann Moss 9 7 7 7 7 7 7 7 7 5 5 5 5 5 9 9 9 9 9 7 7 7 7

PMOA Chelsham 7 7 7 12 12 9 9 5 7 4 4 7 4 4 4 4 7 7 7 9 7 5 7 5 7 5 5

PMOA Greenvale 5 7 7 7 7 7 7 9 9 9 9 9 7 7 7 7 5 5 7 7 7 7 5 7 7 5

PMOA Hayworth 8 10 10 7 7 4 4 4 4 4 7 7 7 5 5 5 5 5 7 7 7 4 2 2 2 2 2

PMOA ADRU 0 0 0 0

PMOA EDU 8 8 4 4 4 4 4 4 6 4 6 6 8 9 8 8 12 5 5 5 2 8 10 6 8 8 6

PMOA Lishman Unit 9 9 11 11 11 9 11 11 11 9 9 9 11 11 11 11 7 6 4 4 4 7 7 9 10 10 10

PMOA MBU 11 11 7 8 12 12 10 8 8 10 5 5 7 7 7 7 12 12 12 12 13 13 13 15 10 7 7

Level 0 (0-9)

Level 1 (10 - 16)

Level 2 (17 - 23)

Level 3(24 - 33)

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The scores are RAG rated (Red, Amber, Green) and any team with an amber or red score is followed up at monthly Quality Compliance meetings (soon to be merged Quality and Performance meetings).

Since July, the QuESTT tool scoring has resulted in an increase in action plans being received and monitored. Lambeth has seen a reduction of wards scoring high, whilst Croydon has seen an increase. The process of data submission and action plans has been smoother since the Trust restructure into boroughs.

4.11 Risk Assessment and Care Plan Audits

Fig. 24: Trust audit scores (inpatient and community)

Fig. 25: Percentage of care plans devised collaboratively with service users (inpatient)

Every patient, whether an inpatient or being cared for in the community, should have a care plan and risk assessment and this is monitored. There is a particular emphasis on care plans being devised collaboratively with the service user and there has been an improvement in this regard since October 2017, although that has dropped slightly since June 2018 (although that timing coincides with a reduction in the number of audits being carried out in this area as audit prioritisation was given to monitoring physical healthcare provided post-rapid tranquilisation, which was highlighted as an issue by the CQC). 4.12 Right Care Right Time – Quality Improvement/ICare All patients will have access to the right care at the right time in the appropriate

settingReduction in crisis readmissions by 10%

Fig 26: Right care at right time; Readmissions within 30 days- Source; Trust Dashboard

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Fig 27: Right care at right time; Community Services Average Waited Time - Source; Trust Dashboard

The waited time within the Trust dashboard is currently measuring all community service types. ICare is the name given to the Trust’s programme of work to improve care and outcomes for patients, families and carers. The aim is to provide the highest quality care in adult mental health services so that care is received in the right place at the right time and that the service is sustainably run by March 2019. This work is being co-designed with service users, carers and partners and aims to improve:

1. the provision of safe services 2. standardised ways of working 3. crisis care and relapse prevention plans 4. patient flow and capacity 5. team work across boundaries and with partners.

4.13 Staff Turnover The staff experience indicators and quality improvement work streams are also monitored in the Trust-wide Equalities & Workforce Committee.

Fig. 28: Reduce staff turnover; Source; Trust Dashboard

45.3

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I-Chart: Community Services:Average waited time for 1st Face to FaceAverage in days

Quality priroity Baseline and subsequent target to be agreed 17/18Yearly average 45.3 all community services

20.49 %

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Run Chart : Percentage Staff Turnover ( Rolling year)

Median

% Turnover

Quality Priroity: reduce to 10% over 3 yearsaim 18/19 15.73%

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4.14 Staff recommending the Trust as a place to work/receive treatment The Trust has set a quality priority to increase to 75% the proportion of staff recommending the Trust as a place to work. The Trust captures this information annually through the national Staff Survey and takes quarterly temperature checks through the Staff Friends and Family Test (FFT).

FFT Question Quality Committee Staff Experience target

Original Baseline

2018 Quarter 1 response

2018 Quarter 2 response

How likely are you to recommend this organisation to friends and family if they needed care or treatment?

75% (over 3 years) 61% (national survey)

72% 68%

How likely are you to recommend this organisation to friends and family as a place to work?

75% (over 3 years) 60% (national survey)

63% 60%

Fig. 29: Staff survey results; Source; Staff Friends and Family Test

It has been recognised that a slight dip in the percentage of staff saying that they would recommend the Trust as a place to work coincides with the CQC visit during the summer of 2018, a time of increased pressure. The Trust has set a target to reduce turnover by 10% over a three-year period. Recruitment and retention are a key risk for the Trust and actions to deliver significant improvement include:

Getting the basics right

Improving recruitment processes

Improving staff engagement

Enhancing the training and development offer

Redesigning roles

Developing our approach to talent management

Targeted recruitment campaigns

Improved preceptorship for newly qualified nurses

South London Partnership (SLP) Nurse development programme offering competence-based career progression for nursing staff

Career progression for health care support workers through Nursing Associates and Assistant Practitioners

Nurse degree and other apprenticeships

Passport offering ease of transfer between SLP partner Trusts. 5. Reviewing performance from floor to Board The focus of the Performance Team during the past month has been to deliver a Joint Performance, Quality, Finance and Workforce reporting framework to support and complement delivery of the CQC Trust Improvement Plan. This framework will ensure that the same data set is used at team level, directorate level, executive level and Board level. Previously, operational performance and quality issues were monitored at directorate level via two sets of monthly meetings: a PACMAN (Performance and Contract Management) meeting with the Chief Operating Officer, and a Quality Compliance meeting with the Director of Nursing. Following the CQC inspection over the summer and the subsequent work to address issues raised in the CQC’s report and warning notice, a decision was made to merge those two meetings from December 2018

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and the related report to the Board as part of improved processes for “floor to Board” flow of information. The format of the Quality and Performance Board Report will develop in line with a focus on quality improvement, patient flow and Clinical Commissioning Group (CCG) constitutional standards. This will include a new presentation for length of stay data, and reflections on learning from implementation of the new Trust performance dashboards The past month also saw delivery of a detailed action tracker for CQC “Must Dos” and “Should Dos” plus wider Trust plans on Leadership and Culture, Governance, Patient Flow and Fundamental Standards of Care. This tracker will ensure the Trust is able to performance manage and assure delivery of actions in a robust manner putting in place mitigating actions against risk areas as necessary. 6. Mandatory Training Compliance Overall, compliance has fallen slightly in October from 87.35% to 86.70%, which is in part to do with a glitch in the appraisal system and will be rectified when the end-of-year appraisals have been calibrated. Current compliance by directorate and by subject matter is shown in Appendix 5 of the Appendices section below. Work is continuing to review what we expect of staff, and how we deliver training, so that we can make keeping staff safe as efficient as possible. Recommendations made as a result of comparisons with the training requirements set by our SLP partners need to be reflected in policy changes, and in some cases, need a new approach to be adopted by subject matter experts. This work is being led by the Director of Nursing and supported by the E&D team. 7. Commissioning A South London Partnership (SLP) bid to South-East London (SEL) and South-West London (SWL) Sustainability and Transformation Partnership (STP) commissioners was successful in attracting a £1.24m investment into SLP partner winter plans. For SLaM, this investment is being used to support additional bed capacity at East London Foundation Trust, Social Care Discharge Teams, Risk Forums and enhanced Liaison Teams in Emergency Departments. These developments complement, and are part of, wider Trust plans to improve patient flow. Monthly contract meetings continue to be held with four borough commissioners and quarterly with NHS England commissioners to review activity and financial performance. In line with annual practice, projections on cost and volume activity and risk share levels on any over-performance are being shared with commissioners to support 2018/19 closedown. South East London STP is also undertaking a Commissioner and Provider alignment exercise to ensure all system partners are agreed on the level of activity delivered and any risk this poses to achieve an end of year financial balance. The level of activity delivered by the Trust and any associated demand above commissioned capacity is being shared as part of this exercise. A Quality, Innovation, Productivity and Prevention programme (QIPP) is a series of schemes required by the CCGs, and developed with SLaM, to help enhance services and improve their cost effectiveness. All QIPP and investment schemes are reviewed at contract meetings. A particular QIPP of note is the closure of Ann Moss in Southwark which was delivered earlier than target with quality pathway improvements and efficiencies fully realised. Mental Health Investment Standard developments have been agreed across the four commissioning boroughs with a risk review in place to ensure commissioner funding is allocated and spent in line with agreements prior to year-end.

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Adult acute inpatient service capacity continues to be a major discussion point given the ongoing heat in the system. Commissioners have confirmed their commitment to maintain the bed base (i.e. the number of beds) in 2018/19 and to plan to commission at 85% of those beds being used. The ICare programme to reduce length of stay continues to be a major focus in 2018 for commissioners as current plans indicate the potential for a ward closure early in 2019/20 which is based on SLaM activity trajectories and ICare plan. The current operational performance indicates that significant improvements must be achieved rapidly if the March 2019 targets are to be met. There is ongoing discussion with both Southwark Local Authority and CCG t about risk sharing, pooling resources and delegating certain NHS and local authority-related functions to other partners if it would lead to an improvement in the way those functions are exercised in respect of Child and Adolescent Mental Health Services (CAMHS) w. Whilst not formally signed off, there has been agreement from the review to communicate to CAMHS staff that whilst service developments are anticipated, there will not be a reduction to the CAMHS budget. Planning for the developments is now commencing. However, Southwark local authority has reduced its adult placements budget in 2018/19 by £1m to £2.1 million, putting the Trust at risk of non-payment of invoices once this level of expenditure is exceeded. The Trust is now reviewing this late decision to withdraw funding with Southwark Council and Southwark CCG. It should be noted the initially proposed reduction in CAMHS services, then withdrawn, was also £1m. 8. Lambeth and Croydon Alliances The Lambeth Alliance commenced in July 2018 and the Trust is working with Alliance partners in delivering the new model via the Lambeth Borough Team. Work has been successfully delivered on a new housing model with 6 new flats opening in January 2019 to support discharge from inpatient wards. Work also continues to develop with Black Thrive partners in Lambeth to support data requirement on ethnicity. The Croydon Alliance is now moving into a new phase of delivering Primary Care Hubs with SLaM front and centre with its new GP Advice Line service. This aligns with the alliance moving from older adults into a general population / all-ages model. 9. Conclusion The Trust continues to meet the NHS Improvement Single Oversight Framework indicators covered by this report (the framework is how NHSI monitors providers’ performance and considers whether they require support to meet the standards required in each area) Pressure across the adult acute pathway (inpatient and community) has increased and there is continued use of external overspill beds as a result. Multi-Agency Discharge Events (MADEs) continue, with a review of their effectiveness in place. In Croydon, of the 49 patients reviewed in September, 31 have been discharged. A second cycle of the Croydon MADEs took place in November. The Programme Management Office is now supporting the 18/19 oversight process for Cost Improvement Plans (CIP), Quality Innovation Productivity and Prevention (QIPP) programme and Commissioning for Quality and Innovation (CQUIN) programme. £3.8 million of the CIP programme is currently rated as high risk i.e. there is a risk that the Trust will not receive £3.8m of funding this year. The Trust is approaching the time of year when discussions take place with commissioners to negotiate funding for the forthcoming year. An approach has been agreed to evaluate the commissioners’ investment plans and commitment to the Five Year Forward View.

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We continue to work with both Southwark Local Authority and CCG in respect of CAMHS and the risk from the reduction in placements budget by Southwark Local Authority is being assessed. The Trust continues to focus on the development of a comprehensive data framework to support quality and performance improvements. Appendix 1 - Glossary

Abbreviation Description

AEP Accountable Emergency Officer

AfC Agenda for Change

Ascom Alarm / communications system supplied by Ascom UK, a telecommunications company

ASD / LD Autism Spectrum Disorder / Learning Disability

CAG Clinical Academic Group – bringing together clinical services, research and education and training into a single management grouping e.g. Psychosis

CAMHS Child and Adolescent Mental Health Services

CAT Clinical Assessment and Treatment

CBT Cognitive Behavioural Therapy (CBTp is CBT of psychosis)

CCG Clinical Commissioning Group – an NHS body responsible for the planning and commissioning of health services for their local area

CHS Croydon Health Services NHS Trust

CIP Cost Improvement Programme

CPA Care Programme Approach

CQUIN Commissioning for Quality and Innovation: A fund where payment is contingent on delivery on quality improvements and meeting milestones agreed with commissioners.

CYP Children & Young People

DBT Dialectical Behaviour Therapy

DTOC Delayed Transfers of Care

E&D Education & Development Department

EI Early Intervention: First Episode Psychosis

ePJS Electronic Patient Journey System: Clinical records system

EPM Emergency Planning Manager

EPRR Emergency Preparedness, Resilience and Response

GSTT Guys & ST Thomas’ NHS Foundation Trust

HTT Home Treatment Team

IAPT Improving Access to Psychological Therapies

I-Care Improving Care and Outcomes programme

ICD10 Diagnosis coding: International Classification of Diseases (World Health Organisation). Currently iteration ICD10

JOSC Joint Overview and Scrutiny Committee

LoS Length of Stay. The duration of an inpatient stay, usually measured in days. Can include or exclude leave and can focus on a stay on a particular ward or the full hospital admission.

LSLC Lambeth, Southwark, Lewisham & Croydon (CCGs)

LTC Long Term Condition

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MADEs Multi-Agency Discharge Events

MHA Mental Health Act

MHOAD Mental Health of Older Adults and Dementia

MHSDS Mental Health Services Data Set: National dataset submitted to NHS Digital (formerly known as the Health & Social Care Information Centre)

NHSE NHS England

NHSE(L) NHS England (London)

NHSI NHS Improvement: the new regulatory body overseeing all NHS providers as well as independent providers that provide NHS funded care

NHSP NHS Professionals

NICE National Institute for Health and Care Excellence: provides national guidance and advice to improve health and social care

NRLS National Reporting and Learning System: a central database of patient safety incident reports

OAP Out of Area Placement

OBD Occupied Bed Day – is a unit of currency used to measure the use made of a bed (e.g. 1 obd = 1 bed occupied for 1 day by a patient)

PACMAN Performance and Contract Management (meeting)

PICU Psychiatric Intensive Care Unit

PMF Performance Management Framework

PMO Programme Management Office

QIA Quality Impact Assessment

QIPP Quality, Innovation, Productivity and Prevention programme is a series of schemes required by the CCGs and developed with SLaM to help enhance services and improve their cost effectiveness

QuESTT Quality, Effectiveness and Safety Trigger Tool. An inpatient self-audit which enables pressures in inpatient wards to be quantified. In 2018 a simple community equivalent is being developed and introduced at SLaM.

SEL South East London

SI Serious Incident

SLP South London Mental Health and Community Partnership. A partnership of SLaM, Oxleas and SWLStG formed in 2015

SOF Single Oversight Framework: NHSI assurance and performance mechanism

SPC Statistical Process Control

STP Sustainability and Transformation Partnership

SWL South West London

SWLStG South West London and St George’s Mental Health NHS Trust

YTD Year to Date

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Appendix 2: NHS Improvement indicators (Access, Effectiveness and Quality indicators) NHS Improvement monitors certain indicators that providers must report their performance against.

Home Treatment Team Gatekeeping

Fig. 1 NHSI Indicators: HTT Gatekeeping.

This target refers to patients who require acute care receiving a gatekeeping assessment. The Trust continues to exceed the 95% target.

Early Intervention in Psychosis 2-week standard

Fig. 2 NHSI Indicators: Early Intervention in Psychosis

The access and waiting time standard for early intervention in psychosis (EIP) services requires that, more than 53% of people experiencing first episode psychosis will be treated with a NICE (National Institute for Health and Care Excellence)-approved care package within two weeks of referral.

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IAPT (Improving Access to Psychological Therapies) Waiting Times The Improving Access to Psychological Therapies (IAPT) programme aims to implement National Institute for Health and Clinical Excellence (NICE) guidance for people with common mental health problems. NICE recommends a range of psychological therapies to treat people with depression and anxiety disorders and bring them to recovery. 75% of people referred to IAPT services should start treatment within 6 weeks of referral, and 95% should start treatment within 18 weeks of referral.

Fig. 3 NHSI Indicators: IAPT 18-week Waiting Time Standard

The Trust continues to surpass the 18-week standard across all four boroughs in 2018/19. The Trust is judged by its regulators and NHS England based upon information produced by NHS Digital as opposed to the locally reported information. NHS Digital targets are represented by the red line in the chart, the most recent data being July 2018. Local figures (in blue) are a snapshot of the live system and there will always be minor variation due to rounding practices used by NHS Digital. Another source of variation is late data entry and changes to data by clinical services – these additional charts have highlighted areas where this could be addressed with the intention of assisting teams to reduce this source of variation. This additional cross-monitoring will continue to be reported.

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Fig. 4 NHSI Indicators: IAPT 6 week Waiting Time Standard – aggregate and detail

Trust maintains its high aggregate achievement for the 6-week standard at 92% in September, with similarly high achievements across the four boroughs. The individual borough performance is reported in Fig. 4, alongside the equivalent NHS Digital published data (red line) for each borough through to July 2018. There is a national target that IAPT services should be providing timely access to treatment for at least 15% of those who could benefit (people with anxiety disorders and depression). Southwark IAPT received £300k at the end of September to fund additional resource required to meet the national access target of 19% by the last quarter of 2018/19. A new publicity strategy has been launched at King’s College Hospital (KCH) and Guy’s & St. Thomas’ Hospital (GSTT) to increase the number of referrals from patients with long-term physical health conditions. The service has increased first consultation capacities in order to meet the new access target. Lambeth Talking Therapies Services achieved an access rate of 17.6% in Q2, against a commissioned target of 16.8%. Recovery rate was 48%, marginally below the national target of 50%. Waiting times are well below national targets, with 96% seen within 6 weeks (75% target) and 100% within 18 weeks (95% target) for first treatment session (triage). There is currently no agreed plan in place with CCGs regarding achievement of 25% access target by 2020/2. Although the CCG has provisionally approved some additional funding for Quarter 4 this will not be sufficient to raise the service from the previous 15.2% to reach 19% access for the full 2019 year. Other areas of major constraints include staffing, accommodation and funding. In the absence of investment in increasing provision for clients with long term conditions (LTCs), incremental development of service model is taking place, with initial focus on diabetes. Overall, the service is reviewing how it can tailor its treatment offer to the capacity that is funded, which may mean offering treatment to fewer clients.

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Access to Lewisham IAPT services is continuing to increase, with the highest number of referrals to the service occurring in October at 1,191. Service is on track to make the 19% access in Q4 as it remains well above target, achieving 17.7% at Q2. However this hampers the development of services for Long Term Conditions (LTCs) as more resources are being diverted to screening and triage. Nevertheless, some new activities are planned for Q4, piloting small collaborative services with targeted GP practices around Chronic Obstructive Pulmonary Disease (COPD) and diabetes.

IAPT Recovery There is a national standard that at least 50% of people who complete treatment through IAPT should recover.

Fig. 5 NHSI Indicators: IAPT Recovery Rate – aggregate and detail

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The Trust achieved the IAPT recovery rate at 51.87% in September 2018, above the 50% target. Croydon, Lewisham and Southwark services achieved the targets at 52.73%, 56.4% and 50.8% respectively, while Lambeth services performed marginally below the 50% target rate at 48.14%.

Seven Day Follow Up The standard used is that 95% of patients on a Care Programme Approach (CPS) will be followed up within 7 days of discharge from an inpatient mental health setting.

Fig. 6 NHSI Quality Account Indicator: Seven Day Follow Up

Performance remains low at September due to the small number of caseloads and small number of missed follow-ups recorded. Whilst Seven Day Follow Up is no longer a national target in the Single Oversight Framework, it remains an important measure and continues to be monitored and reported to the Board.

• Community Wait Times Community wait times reports on the length of time that service users had to wait for their first face-to-face contact with services following initial referral, and the number of service users still waiting after 12 months. Lewisham CAMHS remains at the highest level of waits over 12 months at 162 patients at the time of reporting; a significant drop from the 254 patients reported in October’s report. Croydon’s Personality Disorders and Psychological Therapies has marginally dropped to 121 patients from 150 patients but remains high, and Southwark Psychological Therapies remains high at 142 patients.

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Fig 7. Patients waiting over 12 months

Croydon psychological therapies service waiting times for Clinical Assessment and Treatment (CAT) assessments continue to be affected by long-term staff sickness. From November 2018, CAT assessment slots will be made available from other approaches and assessed by senior Psychologists and Psychodynamic Psychotherapists to help reduce the wait time. Psychodynamic waiting times and numbers have fallen significantly with new fixed-term post holders having commenced. The initiative predicts that waiting times at the end of the fixed term posts (August 2019) will be at 2 years and the audit is underway. Appendix 3: Operational Performance and Activity Inpatient Activity and Performance In order to improve the tracking of performance against contract, the following five run charts show the performance of the adult acute inpatient services for Lambeth, Southwark, Lewisham and Croydon (LSLC) patients against the LSLC contract values. In order to enable monthly comparison, the charts show the average number of occupied beds during the month. There are 340 beds across all adult acute wards (Early Intervention, acute, Psychiatric Intensive Care Unit), with approximately 20 beds being filled with non-LSLC inpatients. The charts show LSLC performance on a monthly basis from April 2017 to September 2018 with the contract trajectory included through to March 2019, aimed at reaching 85% occupancy. It can be seen that the contracted level of activity was revised upwards in October / November 2017 as part of the contract refresh negotiations with Lambeth and Lewisham. Figures include foreign patients for which a further accounting adjustment is made (usually reducing the activity by c.2%). The data excludes leave and includes all overspills. To support comparison, the y-axis scale for the four individual CCG charts has the same range (50 – 110 equivalent beds per month).

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0

50

100

150

200

250

300

350

Jun Jul Aug Sep Oct NovDec Jan FebMar AprMayJun Jul Aug Sep

Nu

mb

er

Admissions and Discharges (April 17 - Sept 18)

Discharges

Admissions

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Fig. 8 – LSLC Acute, EI and PICU performance against commissioned trajectory

Fig. 9 – External Overspill, August 2017 through to end of September 2018

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Length of Stay: Acute Care Pathway

Fig. 10 – Length of Stay Breakdown

Figure 10 clusters inpatients within the acute care pathway (as at the first week of November) by their length of stay at that point. The first colour is 0-30 days, then 31-60 days etc. and the final group is >180 days. The commissioners are in alphabetical order: Croydon, Lambeth, Lewisham, Southwark and “other”.

Patients with longer lengths of stay are reviewed weekly at clinical meetings. Longer lengths of stay can be attributed to delayed transfers of care, or other reasons of social need and patient acuity. Lambeth CCG still maintains the highest number of inpatients whilst both Croydon and Lambeth continue to have a high proportion of patients with longer lengths of stay.

LSLC Admissions The following charts show the admissions by CCG for each month Apr 17 – September 18 with planned levels through to March 2019. The planned level was based on historical performance in 2016 and was set at a flat, consistent rate. There was broadly a marginal fall in actual performance of admission levels in September 2018 except Lambeth where admission levels increased above planned levels.

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Fig. 11 – LSLC Admissions by month

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Delayed Transfers of Care The Trust makes a monthly submission to NHS England providing a snapshot of delays and lost bed days. The charts below plot these overall submissions alongside the most recent split across the different boroughs. The reporting is by local authority as the reason for delay can be attributable to NHS or social care. In September, the Trust recorded 572 bed days lost due to delayed transfers of care. This represents a 3% loss, which is slightly below the 3.5% target set from September 2017 by NHSE.

Fig. 12 – Delayed Transfer of Care lost bed days by month

Fig. 13 – Delayed Transfers of Care, Lost Bed Days by Local Authority

Figure 13 describes the number of days lost by local authority. The attribution of responsibility for delays is according to NHS England guidance and attribution process agreed in consultation with local authorities.

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Appendix 4: Community Activity & Performance

A&E Mental Health Liaison The number of presentations to A&E Mental Health Liaison teams was quite high and above plan for Lambeth and Southwark teams; Croydon was at plan whilst Lewisham was marginally below plan.

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Fig. 14 Mental Health Liaison Team Presentations

Community Teams The community redesign is taking place as part of the new delivery models in boroughs. These monthly snapshots of teams will continue to be provided in this report. The following graphs show the position at September, indicating continued growth in the caseload size of our Home Treatment team, and marginal reduction in that of the Early Intervention teams. The updated information to September 2018 is shown in Figs. 15 and 16.

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Fig. 15 Adult Home Treatment Team caseload, referrals and discharges Apr 16 – September 18

Fig. 16 Early Intervention caseload, referrals and discharges Apr 16 – September 18

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Appendix 5: Mandatory Training Compliance

Current Compliance Rates

Directorate September

2018 October

2018

Child & Adolescent Services 88.74% 88.73%

Clinical Support Services 73.47% 70.90%

Corporate Directorate 83.28% 81.83%

Croydon Directorate 90.37% 89.66%

Lambeth Directorate 84.29% 83.29%

Lewisham Directorate 88.74% 88.80%

PMOA 88.79% 89.48%

Southwark Directorate 87.39% 85.94%

Grand Total 87.35% 86.70% Fig. 17 – Mandatory training compliance rate by directorate

Core Subjects (Target 85%)

April 2018

April July 2018

October 2018

Basic Life Support –Group 1 90.57% 94.17% 95.21%

Basic Life Support - Group 2 66.57% 81.94% 81.64%

Equality, Diversity and Human Rights 87.64% 92.25% 90.98%

Fire Safety Awareness 80.78% 90.19% 86.14%

Health, Safety and Welfare 86.13% 90.19% 88.18%

Immediate Life Support [1 Year] 70.80% 78.99% 73.16%

Infection Control Level 1 89.46% 93.29% 91.98%

Infection Control Level 2 70.04% 79.47% 81.77%

Information Governance 78.70% 83.74% 86.03%

Moving and Handling - Loads - Group 1 91.24% 89.29% 97.69%

Moving and Handling - Loads - Group 2 78.57% 95.83% 95.65%

Moving and Handling - Loads - Group 3 87.15% 92.03% 91.55%

Moving and Handling - Patients - Group 1 73.23% 83.06% 87.50%

Moving and Handling - Patients - Group 2 84.84% 88.99% 88.38%

Moving and Handling - Patients - Group 3 82.05% 94.74% 97.22%

Prevent Awareness 89.52% 93.03% 93.37%

Prevent Workshop 86.67% 90.43% 90.44%

PSTS Awareness/Conflict Resolution 79.66% 84.47% 86.15%

PSTS Disengagement 66.72% 74.42% 74.72%

PSTS Team Work 81.43% 86.06% 87.48%

Safeguarding Adults Alerters 85.66% 90.01% 89.87%

Safeguarding Adults Alerters Plus 85.20% 89.69% 86.69%

Safeguarding Children Level 1 87.63% 91.93% 91.99%

Safeguarding Children Level 1 and 2 94.10% 97.54% 96.97%

Safeguarding Children Level 3 80.58% 88.80% 89.79%

Grand Total 81.94% 87.08% 86.70%

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Non-core – Mental Health Specific Subjects April 2018

July 2018

October 2018

Deprivation of Liberty Safeguards (DoLS) [3 Years] 84.95% 89.99% 86.85%

Mental Capacity Act (MCA) [3 Years] 85.72% 90.47% 85.89%

Mental Health Act Training [3 Years] 84.71% 88.44% 85.41% Fig. 18: Mandatory training compliance rates by subjects

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Appendix 6: Quality, Innovation, Productivity and Prevention (QIPP) programme The QIPP risk dashboard is below:

QIPP Ref CCG QIPP plan Progress Value (£)

RAG YTD Variance (£)

LAM-1819-005-Q

Lambeth Lambeth Adult inpatient - baseline as per 17/18

QIPP offset by investment.

835 418

STH-1819-003-Q

Southwark Swk Adult inpatient - baseline as per 17/18

QIPP offset by investment.

532 266

STH-1819-004-Q

Southwark QIPP gap - initiatives to be identified

Initiatives to be identified

559 112

LEW-1819-012-Q

Lewisham FYE - Lewisham Community Teams - A&L Team

Community teams budget (£42k) is in the baseline budget. Budgets will be monitored to track spend

42 21

LEW-1819-013-Q

Lewisham Placements reduction

New scheme, from former ERT £150k scheme.

55 0

LAM-1819-004-Q

Lambeth SHARP M1 variance of £33k 400 49

STH-1819-002-Q

Southwark Southwark Placements - CCG

Action plans being drafted

472 0

LEW-1819-005-Q

Lewisham QIPP Triage savings

Implementation in June 18

200 33

LEW-1819-014-Q

Lewisham

Primary care New scheme, from former ERT £150k scheme.

55 0

LEW-1819-015-Q

Lewisham Homelessness New scheme, from former ERT £150k scheme.

40 0

LAM-1819-006-Q

Lambeth ASD & ADHD C&V expenditure

QIPP being achieved subject to CCG confirmation.

150 0

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PMOA-1819-011-Q

Lambeth Greenvale - reduction in beds

QIPP being achieved 666 0

PMOA-1819-010-Q

Southwark Ann Moss Way

Service improvement 893 0

LEW-1819-007-Q

Lewisham FYE - IAPT (15% reduction)

QIPP being achieved 93 0

LEW-1819-011-Q

Lewisham FYE - LITT Team - move from Psychosis to primary (PMIC link)

QIPP being achieved 43 0

CRY-1819-010-Q

Croydon Croydon Adult inpatient - baseline as per 17/18

OBD are within the plan and QIPP should be achieved (based M1 performance)

2,333 155

CEN-1819-017- Q

NHSE NHSE Specialist Contracts

QIPP offset by investment - 17/18 baseline has therefore been retained

1,136

TOTAL 8,504 1054

Fig. 19: QIPP dashboard

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Cost Improvement Programme (CIP)

CAMHS Central Croydon Hub/Quality centre Lambeth Lewisham PMOA Southwark Total

HIGH 191 2,099 514 211 161 1,986 5,162

MEDIUM 813 1,671 79 1,463 190 385 262 487 5,350

LOW 230 4,358 70 758 55 345 5,816

Total 1,234 8,128 149 2,735 401 440 768 2,473 16,328

Fig. 20: Trust M6 CIP position

The chart above shows the summary of the Trust CIP schemes broken down by Operational Delivery Unit (ODU) and by risk as at M6. The table shows that of the 66 schemes at £16.4m in the Trust plan, £5.1m are at high risk. This is driven primarily by bed costs (overspill). £5.3m is rated medium for risk, driven primarily by overspends in inpatient nursing. The remaining £5.8m is rated as low risk.

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Council of Governors

13 December 2018 Name of Report Nursing vacancies and agency costs

Author Beverley Murphy, Director of Nursing

Presented by Beverley Murphy

Purpose Information

Purpose of the report:

The Council of Governors requested a paper addressing nursing vacancies and agency

costs.

This paper shares a significant amount of data. It is suggested that the data is used for the

Council of Governors to consider further and to raise specific questions or areas of focus

to be addressed.

1. Introduction

South London and Maudsley NHS Foundation Trust employs 5,338 people. Of this number, 604 are health care support workers and 1,274 are registered nurses. Additionally, the Trust employs a further 948 temporary staff across all services and staff groups1. The challenges to recruit and retain high quality staff is well recognised; London has additional difficulties given the significant costs of living and travelling within the capital and the dearth of good quality affordable housing. The following data indicates the success in recruitment of new staff in the past two years and also details the spend on agency staffing.

2. Vacancies The comparison of vacancy data (Table 1) from March 2016 to date for Health Care Support Workers (non-registered nurses) and Registered Nurses as a percentage may demonstrate that the recruitment of Registered Nurses has been successful. The percentage of vacancies for Health Care Support Workers (HSW) may suggest vacancies are broadly unchanged. However, tables 2, 3, 4 and 5 show that funded posts have not remained static over time, with HSW posts increasing slightly over time and Registered Nurse posts reducing. Another consideration is that finance, workforce and service data regarding vacancies has not been matched. The Trust has worked hard on this in the last 12 months and workforce data is more reliable and consistent than it has been. There is a possibility that some posts were inaccurately reported as vacancies previously.

1 Source: Annual Report 2017-18

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Vacancy Rate

Mar-16 Mar-17 Mar-18 Oct-18

Community HCA 15% 15% 15% 15%

Community Registered Nurse 26% 26% 17% 16%

Inpatient HCA 19% 22% 22% 21%

Inpatient Registered Nurse 28% 30% 18% 16% Table 1: Vacancy data - Registered Nurses and Health Care Support Workers (Mar 16 – Oct 18)

Mar-16

HSW Registered Nurse

Funded FTE Actual FTE Funded FTE Actual FTE

Community 50.62 42.83 542.57 403.18

Inpatients 487.28 396.18 791.35 571.06

Grand Total 537.9 439.01 1333.92 974.24 Table 2: Funded & Actual FTE - Registered Nurses and Health Care Support Workers (Mar 16)

Mar-17

HSW Registered Nurse

Funded FTE Actual FTE Funded FTE Actual FTE

Community 47.22 39.92 559.47 411.42

Inpatients 523.77 406.88 809.62 567.64

Grand Total 570.99 446.8 1369.09 979.06 Table 3: Funded & Actual FTE - Registered Nurses and Health Care Support Workers (Mar 17)

Mar-18

HSW Registered Nurse

Funded FTE Actual FTE Funded FTE Actual FTE

Community 33.30 28.32 535.40 444.43

Inpatients 542.44 421.28 759.79 620.07

Grand Total 575.74 449.60 1295.19 1064.50 Table 4: Funded & Actual FTE - Registered Nurses and Health Care Support Workers (Mar 18)

Oct-18

HSW Registered Nurse

Funded FTE Actual FTE Funded FTE Actual FTE

Community 42.10 30.93 529.48 444.76

Inpatients 536.12 422.00 750.99 628.33

Grand Total 578.22 452.92 1280.47 1073.09 Table 5: Funded & Actual FTE - Registered Nurses and Health Care Support Workers (Oct 18)

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3. Agency use

In 2017/2018, agency nursing was more or less on target (they financial year finished £100k over the ceiling of £8.9M). This year, we are forecasting to break the ceiling by £600k. The reasons why we are forecasting this are:

1. The agency ceiling was reduced by 11%. This is a national target set for us by the regulators, NHSI;

2. Agency nursing has reduced but not as much as the ceiling (8% reduction); 3. We are forecasting a run rate that includes the summer months’ usage traditionally

higher than winter, but this may be overly pessimistic.

Some of the factors that affect usage are: 1. Poor roster planning for summer leave; 2. Year-end substantive staff using up their leave; 3. Vacancies; 4. Community nursing has been traditional difficult to recruit permanent or bank staff to; 5. Difficult to recruit to posts, for example Kent Child & Adolescent services.

The following charts offer a comparison by borough (looking at year to date for both years), by staff grade with the top 5 increases and top 5 decreases in agency usage.

Figure 1: Nursing Expenditure by Staff Type (YTD 2017 - 2018)

Permanent 71.5% Permanent 72.5%

Bank 19.5%Bank 19.5%

Agency 9%Agency 8%

-

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

2017 2018

£ Nursing Expenditure by Staff TypeYTD 2017 v 2018

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Figure 2: Cumulative Nurse Agency Spend (2017/18 v NHSI plan)

Figure 3: Cumulative Nurse Agency Spend (2018/19 v NHSI plan)

-

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

1 2 3 4 5 6 7 8 9 10 11 12

Spend £

Fin Period

Cumulative Nurse Agency Spend2017/18 v NHSI plan

2017 Actual

2017 NHSI Plan

-

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

1 2 3 4 5 6 7 8 9 10 11 12

Spend £

Fin Period

Cumulative Nurse Agency Spend2018/19 v NHSI plan

2018 Actual

2018 Projected

2018 NHSI Plan

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Figure 4: Nurse Agency Usage and Vacancies by Year (2017-2018)

Figure 5: Agency Nursing Expenditure by Borough (YTD 2017 - 2018)

-200,000

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

£ Agency Nursing Expenditure YTD 2017 v 2018Comparison by borough

YTD 2017 YTD 2018

-

100

200

300

400

500

600

700

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1,000,000

1 2 3 4 5 6 7 8 9 10 11 12

WTE£

Fin Period

Nurse Agency Usage by Year Comparison with Nursing vacancies

2017 Agency 2018 Agency 2017 Vacancies 2018 Vacancies

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Figure 6: Agency Nursing Expenditure by Grade (YTD 2017 - 2018)

Figure 7: Top 5 Increases by Locality (YTD 2017 - 2018)

-500,000

-

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Band 2 Band 3 Band 4 Band 5 Band 6 Band 7 Band 8

£ Agency Nursing Expenditure YTD 2017 v 2018 Comparison by grade

YTD 2017 YTD 2018

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

LewishamCommunity

LambethCommunity

Prison Services Croydon Liaision Camhs KentServices

Top 5 Increases by LocalityYTD 2017 v 2018

YTD 2017 YTD 2018

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Figure 8: Top 5 Decreases by Locality (YTD 2017 - 2018)

4. Discussion points Recruitment of staff is time consuming for services and HR and is therefore costly. Excessive turnover of staff can be disruptive to providing high quality care. It is therefore essential that the Trust continues to mark itself out as an attractive place to work for registered nurses in London in order that we reduce turnover and continue to attract high quality nurses. The Board received a paper at the August 2017 setting out a detailed approach to this which focussed heavily on staff development, valuing staff as well as reducing violence. Engaging nurses in training is essential. If SLaM builds on its reputation as a good place to develop skills, then we are more likely to retain our commissioned students each year which is more than 100 nurses. It is also essential to provide good support for newly registered nurses as there is historical data showing that nurses leave within 18 – 24 months of joining the Trust. The Trust is moving to its second year of providing a bespoke support package for newly registered nurses (preceptorship) which has been highly evaluated by nurses and has been quality marked by Health Education England as part of the Capital Nurse framework. We need to ensure that services provide shift patterns or reduced hour contract roles that enable nurses to achieve a work-life balance. This is currently being explored with a pilot ward in each Operational Directorate trialling a 4-day per working week shift system. We have received feedback that we are not seen as a flexible employer. More than anything, the nursing workforce colleagues report that they want to matter to an organisation, feel that they can influence high quality care and be proud to be part of the organisation. The Trust engagement strategy is key as well as ensuring a good offer for BME

-100,000

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

Lewisham ComplexCare

SouthwarkCommunity

Croydon HomeTreatment

Asd InpatientServices

Lewisham Inpatient

Top 5 Decreases by LocalityYTD 2017 v 2018

YTD 2017 YTD 2018

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staff who currently report feeling that they are less able to develop at SLaM than their white counterparts. Roster planning requires improvement to ensure best use of the available resources across the year and to avoid high agency usage over peak holiday periods. E-roster and Safecare are key to this. SLaM needs to progress the implementation of new roles such as Assistant Practitioners and Nursing Associates as well as planning a strategic approach to the development of Peer Support Workers. Strategies are in place to tackle each of these areas and more, a discussion with the Governors is welcomed.

5. Conclusion SLaM has seen an improvement in vacancy rates, however continued focus is needed to ensure that vacancies continue to reduce and that there is a corresponding reduction in agency usage. A skilled and well engaged workforce who are valued and supported by an organisation is the key to unlocking consistent high quality care.

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Trustwide Mental Health Law Committee

The Committee:

• Meets four times a year.

• Monitors and reviews of the use of the Mental Health Act, Mental Capacity Act and other legislation e.g. Human Rights and Equalities duties.

• Reports to the Board of Directors on the Trust’s application of and use of the Mental Health Act 1983 (MHA) and Mental Capacity Act (MCA).

• Receives assurance that trust staff are trained in using the Acts and supported to apply best practice standards and use quality improvement methods.

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It also:

• Monitors the performance of clinical services in their responses to Care Quality Commission Mental Health Act visits.

• Prepares a forward work plan and keep track of actions arising within the agreed timescales.

• Monitors Trust risks allocated to the Committee by way of the Board Assurance Framework, focussing on the key risks and mitigating actions, and report to the Board.

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Board of Directors

Quality Committee Trustwide Mental Health Law Committee

Mental Capacity Act Sub-

Committee

Operational Delivery Unit Mental Health Law Committees

x 6

Lambeth, Southwark, Lewisham, Croydon and Forensic, PMOA,

CAMHS

Mental Health Law Committee Structure Page 66 of 89

Role of the Mental Health Act Office

• Write to persons detained under the MHA about –s132 information about their rights; dates when the sections start and end.

• Write to the nearest relative with the sectioned person’s consent

• Give advice to staff about the MHA or the MCA

• Provide training to clinical staff at regular training courses and provide subject specific training to ward and community teams

• Provide reports and statistical information for trust and directorate managers and committee meetings

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Role of the Mental Health Act Office (continued)

• Receive and check section papers to make sure they are legal

• Take action if section papers contain an error

• Place the section papers onto the person’s clinical record

• Remind clinical staff of key dates when MHA paperwork needs to be filled in

• Arrange appeal hearings for the Mental Health Tribunal and Hospital Managers

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COUNCIL OF GOVERNORS – SUMMARY REPORT

Date of meeting: 13 December 2018

Name of Report: Chair’s Report

Author: Roger Paffard, Chair

Presented by: Roger Paffard, Chair

Purpose of the report:

To update the Council of Governors on the Chair’s activities.

Summary Attached is a November 2018 diary summary as an illustration of my activity as Chair for a month. Highlights for September 2018 to November 2018 The main priorities for the Board this last quarter have been dominated by our response to the CQC improvement notice, and the need to address the challenges of patient and service user access and flow through our acute and crisis care pathway.

i) CQC service and Well-Led Inspection:

In July, the Care Quality Commission carried out an inspection of a number of services. These included our Acute inpatients services; our Psychiatric Intensive Care Units, our Older Peoples Community services; our Forensics service; and our Eating Disorders teams. They also undertook in August our first ‘Well-Led’ inspection since 2015. By October we knew that most of our services had fared well, that the Trust had been rated GOOD in our well-led inspection and that we had retained our Good rating overall. A pleasing result. However, the warning notice about unacceptable variation across our acute care inpatient wards was followed by an Inadequate rating for safety and responsiveness. The focus on developing, approving and implementing the improvement plan has been all-consuming since this time. We have set up a full governance structure to oversee this

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work – with an Oversight & Scrutiny Committee chaired by non-executive director Dr Geraldine Strathdee reporting to the Board on progress.

ii) Acute pathway pressure. The Board recognises that this recovery plan will only be sustainable in the longer-term if we address the unacceptable pressures in the system on both in-patient beds and community caseloads. Our improvement plan aims to achieve 85% bed occupancy (the international quality standard) and an acute length of stay of 35 days average (broadly the UK benchmark) – a reduction of a third in length of stay. An investment plan was approved by the Board in October to help achieve this.

iii) Community Partnerships. In the short-term this can only be achieved with the active support of community stakeholders – and the Multi Agency Discharge Events (MADE) in each of the Boroughs are the first step in that direction. In the longer term this will need more commissioned resources in the community pathway. A priority for me over this period has been to engage our Borough partners in this mission, and they have responded positively. This has involved meetings with CCG Chairs and Local Authority Leaders in each of the Boroughs; Attendance at Southwark & Croydon Health & Wellbeing Boards; Attendance at the Croydon Health & Social Care conference; Participation at the Croydon & Lambeth MADE events. The Borough re-organisation has been warmly received by our partners, and this has helped create fertile conditions for partnership working. The involvement of our Governors has also been well-received and has helped to highlight the pressures our services are facing.

“Golden moments” for me in the last three months have included:

i) Chairing the combined Annual Staff Awards and Annual Members Meeting on 25th September at the Oval for the third consecutive year. A truly inspirational insight into the amazing dedication and compassion demonstrated by our staff, volunteers & governors daily. Impossible not to feel moved on such an emotionally charged afternoon.

ii) Following up the successful visit this summer by Yvonne Coghill (National director of Workforce Race Equality Standard WRES) with a full day event on 13 November involving the full Board of directors, a cross section of managers and BME staff. An honest, constructive and hard-hitting dialogue about race, the day-to-day challenges and experiences of many of our staff and service-users, and the actions/leadership we need to commit to as a Board to make real improvement. A great way to set the tone for the future.

iii) I attended one of our first ever community MADE (Multi-disciplinary Discharge

Events) in Croydon aimed at improving the experience of our acute inpatient service-users once they are ready for discharge. There were over 50 people in the room from all the relevant agencies (Local Authorities; Social services; Housing; Primary Care; Voluntary sector) and many of our clinical staff. It was a

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joy to see so many barriers to smooth discharge being broken down and addressed in a constructive and collaborative atmosphere. 31 long-stay patients have already been discharged ahead of the second event on 28 November.

iv) Alongside several of our governors, we attended the first South London Partnership

Quality Improvement conference at the Oval on 8 November. All 3 South London Trusts were there in force (300 people!) demonstrating a range of great projects in a friendly but competitive environment. This partnership is already delivering great results and improved patient experience in forensics and CAMHS, but there is clearly a quality revolution going which is starting to attract national attention.

v) Accompanying Rachel Evans and Dr Michael Holland on Quality Improvement

Leadership walkabouts in community CAMHs services in Southwark & Croydon. Experiencing first-hand the pressures being experienced by our CAMHs staff with growing demand, constrained resources and the challenges of growing up in an increasingly hostile and violent environment.

Priorities for Dec 2018 – March 2019 This is always a very challenging time of year. There are 4 priorities for the Board to be focussing on in the next 3-4 months:

1) Finances. The pressures of high unplanned demand in our acute services are inevitably starting to impact on our finances, and we are increasingly likely to be forecasting a deficit versus our control totals. Recent board decisions to invest in the acute care pathway to maintain quality standards have contributed to this pressure – and inevitably this will lead to increased scrutiny from our regulators, and additional pressure on annual contractual negotiations with our commissioners. The focus must be both on navigating the short-term challenges and maintaining the long-term sustainability of our services.

2) Acute Services pressure. Addressing the need to improve the flow of service-users in crisis through our acute care pathway is our biggest challenge – and it is winter! We must reduce our in-patient length of stay by a third to national bench mark levels if we are going to make the whole system work for them. This will take heroic effort from front-line staff and our job is to make sure they are supported.

3) Community Support. We will need the support of our local stakeholders and partners more than ever through this period.

4) CQC re-visit next spring. The CQC warning notice on the acute care pathway variation gives until 1 April to address the issues identified. A comprehensive action-plan has been signed off by the board and will need close attention and monitoring to ensure we are ready.

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Diary Summary – Roger Paffard, Chair – November 2018

Date Meeting/Event Purpose Outcome

30th October Rachel Evans – Director of Corporate Affairs

Governance Progress Review

Beatrice Butsana-Sita, Non-Executive Director

Strategy & Governance Progress Review

Non Executives Meeting Strategy & Board Development

Agreement on Board Development priorities for 2019.

Non Executive/Governors Meeting Governor Relations.

See Minutes/Notes. Another constructive and challenging session. I feel these are working well – and I’m not aware of any other Trusts that do them.

Board Meeting Part I Strategy & Governance See minutes

31st October Agnelo Fernandes, Chair Croydon CCG; Steve Warren CCG director of commissioning; Dr Faisil Sethi Interim Service Director Croydon

Stakeholder Relations Introductory meeting with new interim service director for Croydon Dr Faisil Sethi and senior CCG leaders. Agree priorities for induction & hot topics.

QI Walkabout with Dr Michael Holland (Medical Director) & Dr Bruce French (Clinical Director CAMHS) Leadership Walk Around CAMHS Paediatric Liaison - 3 Teams Based at Christopher Wren House, Croydon

Staff Relations What an inspiring and positive team. Some great examples of innovation and Quality Improvement projects.

Lucy Canning, Programme director for Centre for Young People

Strategy Induction and introduction to new role to support the Centre for Young people programme board now that the Strategic Outline Business Case has been approved.

Matthew Patrick, Chief Executive Strategy & Governance Progress Review

1st November Lewisham Health & Wellbeing Board Meeting

Stakeholder Relations Agreed priority for improving BME access to CAMHS services

Donna Hayward-Sussex Interim Service Director Lewisham

Strategy & Governance Briefing on new Lewisham Borough progress

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6th November Rebecca Grey (Chief Executive of Maudsley Charity), Lucy Canning (Programme Director Centre for Young People)

Strategy & Governance Review of 4 conditions in the letter from Maudsley Charity confirming £10m grant for the Centre for Young People capital appeal. Agreed good progress on all 4.

Adrian McLachlan, Chair Lambeth CCG

Stakeholder Relations Agreement to support Multi Agency Discharge Event and Children & Young People Borough strategy

Jonty Heaversedge, Chair Southwark CCG

Stakeholder Relations Agreement to support Multi Agency Discharge Event and Children & Young People Borough strategy. Highlighted potential issues with Local Authority placement budget cuts.

7th November Geraldine Strathdee, Non-Executive Director

Strategy & Governance Progress Review

Research & Involvement Board Development Session Planning Dr Matthew Hotopf & Prof Ian Everall

Strategy & Board Development

Agreeing agenda for 27 November Board Development session

Jim Ellis, Involvement Register Manager

Staff & governor Relations

Briefing on Involvement Register challenges and opportunities

Rachel Evans – Director of Corporate Affairs

Governance Progress Review

8th November South London Partnership Quality Improvement Conference 2018

Staff & Stakeholder Relations

300 enthusiasts from all 3 Mental Health trusts in South London. Great National Profile speakers chaired by our own Dr Geraldine Strathdee; Lots of compelling Quality Improvement storyboards; Interesting Workshops; A great buzz and a “Golden Moment” for me.

Dr Faisil Sethi, Interim Service Director Croydon

Strategy & Staff Relations

Induction meeting. Agreement to support Croydon Health & Social Care events

12th November South London Partnership Senior Leaders Forum

Stakeholder & Staff Relations

Privilege to be the only Non-Executive Director to attend this Senior Leadership event celebrating the successes of this 2-year-old initiative - and exploring the potential next steps and clinical services for collaboration. Great atmosphere and encouraging clinical engagement.

13th November Matthew Patrick, Chief Executive Strategy & Governance Progress Review

SLaM Event – Yvonne Coghill National Director of Workforce Race Equality Standard (WRES)

Staff Relations Another “Golden Moment”. A challenging, honest and constructive day chaired by Yvonne Coghill that included a review of SLaMs WRES data (which shows significant scope for improving the experience of our BME staff); a Board session with honest feedback and challenge; a lively BME forum event with ideas for improvement; a cross-section of managers and a good plenary session. Hopefully a turning-point in o key priority for SLaM and the Board

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June Mulroy – Non-Executive Director & Deputy Chair

Strategy & Governance Progress Review

Council of Governors - Planning & Strategy Group

Governor Relations Well attended and lively governor working group with a very full agenda. Financial & Strategy reviews particularly relevant and timely.

Camberwell Community Council: Theme Health & Wellbeing

Stakeholder Relations A well-attended and not always comfortable evening community event! Invited to be on the panel with Jonty Heaversedge (Southwark CCG Chair); Peter John (Southwark Council Leader) and a number of active lobbyists. Good feedback on priority for CAMHs ahead of the Health & Wellbeing Meeting

14th November Agnelo Fernandes, Chair Croydon CCG

Stakeholder Relations Progress action plans and priorities

Centre for Children & Young People’s Mental Health Board (CYP)

Strategy & Governance Chairing CYP Programme Board. Delayed move to next stage until Kings College contribution confirmed.

Equalities and Workforce Agenda Planning Sally Storey (Interim HR Director) & Rachel Evans (Director of Corporate Affairs)

Strategy & Governance 27 November committee agenda agreed

15th November Rachel Evans – Director of Corporate Affairs

Governance Progress Review

Matthew Patrick, Chief Executive Strategy & Governance Progress Review

Informal Council of Governors Lead & Deputy Lead Meeting

Governor Relations Review of Governor Activity & Priorities – a useful meeting.

NHS London Region Dinner Strategy & Governance Insight into changes in Regulatory Regime and 10 year Forward View. International benchmarks on Integrated Care and Digital Health.

16th November IHI Meeting (Advisors on Quality Improvement); Matthew Patrick Chief Executive & June Mulroy Deputy Chair

Strategy Annual External Review of Progress on QI. Good and re-assuring benchmarking after 2 years. Ideas for Year 3.

Duncan Hames (Senior Independent Director) & June Mulroy (Deputy Chair)

Governance Executive Development Review mid-year

June Mulroy Governance Progress Review

19th November Dr Stephani Hatch (IOPPN BRC lead) & Lucy Canning

Strategy Briefing on Big Data population health work being undertaken by IOPPN and potential impact for Alliance working with Public Health officers.

Matthew Patrick, Chief Executive Strategy & Governance Progress Review

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20th November Croydon Health & Care Conference Stakeholder Relations Attended showcase event for One Croydon Health & Social Care Strategy.

21st November Southwark Health & Well-being board

Stakeholder Relations Invited by Chair (Peter John) to observe Children’s Review reversing decision to disinvest in CAMHs. Very positive meeting.

Stephen Swords, Chair Richmond & Hounslow community Health

Governance & Stakeholder relations

Follow up to inaugural Chairs meeting of South West London STP

Croydon Alliance Meeting Matthew Patrick Chief Executive; Gus Heafield finance Director; Dr Dan Harwood Clinical Director Older Adults; Dr Faisil Sethi;

Governance & Stakeholder Relations

Mapping Croydon Alliance structures and SLaM interfaces

Nominations Committee Governor Relations & Governance

Report to council of Governors in December.

Matthew Patrick, Chief Executive Matthew Patrick, Chief Executive

Progress Review

23rd November December Board Agenda planning Governance December Board agenda

27th November Equalities & Workforce Committee Governance & Stakeholder Relations

Non-Executive Director Meeting Board Development Executive Development Review

Board Development Meeting Board Development Research & Innovation review

Russell Mascarenhas Strategy & Governance Progress Review

Non Executive/Governors Meeting Governor Relations

Board Meeting Part I Strategy & Governance See minutes

Board Meeting Part II Strategy & Governance See summary

28th November Croydon MADE Bethlem Museum Stakeholder & Staff Relations

Second external MADE review

Matthew Patrick, Chief Executive Strategy & Governance Progress Review

29th November Ian Everall, Non-Executive Director Strategy & Governance Progress Review

Angela Flood Chair of Strategy & Planning Group

Governor Relations Informal catch up

Rachel Evans – Director of Corporate Affairs

Governance Progress Review

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Council of Governors 13 December 2018

Name of Report Lead and Deputy Lead Governor elections

Author

Charlotte Hudson, Deputy Director of Corporate Affairs

Presented by

Roger Paffard, Chair

Purpose

For decision

Introduction Since 2010, it has been a requirement that NHS Foundation Trusts like SLaM appoint a “Lead Governor”, primarily as a key contact between the Council of Governors and the regulator in the event that there are performance concerns about the Trust. Some Trusts give a wider remit than this to their Lead Governors and some, like SLaM, also appoint a Deputy Lead Governor. At SLaM, the role of the Lead Governor is to:

Be a point of contact for NHS Improvement;

Facilitate communications between Governors and the Board;

Be involved with setting the agendas for the Council and Away-Days;

Chair any Governor-only meetings and Away-Days;

Support the Chair in acting to remove a Governor due to unconstitutional behaviour.

Act as a point of contact for Governors and help to create a well-functioning and supportive atmosphere within the Council of Governors

The Lead Governor is not in competition with the Chair of the Trust, who will normally chair the Council of Governors and the Nominations Committee. The Lead Governor does not have a position on the Board of Directors. The role of the Deputy Lead Governor is to support the Lead Governor and deputise for him or her when necessary. It is recognised that the enormously proactive approach demonstrated by incumbents has been to the benefit of the Council and its relationship with the Board. It would be open to the successful candidate to continue this approach or to approach it differently. Constitutionally, there are no set guidelines for the process of appointing the Lead and Deputy Lead Governors. However, it is common practice at SLaM that Lead / Deputy Governors will be self-nominated, providing an outline of their relevant experience, and will be chosen by a ballot of Governors. Elections for Lead and Deputy Lead Governor at SLaM were last held in November / December 2017, with a view to the successful candidates being in post for a one-year term. As highlighted in the newsletter, we are proposing to slightly delay the launch of the elections this year so that the Council can discuss whether or not to add a second Deputy Lead Governor role.

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Proposal To reflect the responsibilities undertaken by the Lead and Deputy Lead Governors, and recognising that the Governors elected to these positions carry out their duties on an entirely voluntary basis, it is proposed that a new position is introduced, namely a second Deputy Lead Governor. Not only will this mean that the workload is shared, but that the Council of Governors will benefit from a “succession planning” approach, whereby there is more opportunity for Governors who may be interested in becoming Lead Governor to undertake some of the responsibilities associated with the role, gaining experience. This proposal has been developed following discussion with the current Lead and Deputy Lead Governor, and in recognition that other Trusts benefit from forward-thinking and succession planning in order to ensure a smooth handover when new Lead Governors are appointed. Governors are asked to approve:

The creation of a second Deputy Lead Governor role

The extension of the terms of the current Lead and Deputy Lead Governor to mid-January to allow time to undertake an election to the three roles

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Council of Governors 13 December 2018

Name of Report Council of Governor meetings: proposed amendment to meeting duration

Author

Charlotte Hudson, Deputy Director of Corporate Affairs

Presented by

Roger Paffard, Chair

Purpose

For decision

Introduction The September meeting of the SLaM Council of Governors was attended by Mark Price, Programme Manager – Governor Support, of NHS Providers, who kindly offered to give his informed feedback on the meeting from the standpoint of someone with considerable experience of attending Governor meetings and supporting Governors. He reflected that SLaM’s CoG meetings are relatively short when compared to other Trusts (there are currently four two-hour meetings per year, and eight hours per year is less than counterparts) and that the full agendas can lead to time over-running, particularly when there is a rich conversation and contribution from the Governors. This feedback was provided to the Lead Governor, Deputy Lead Governor and the Chairs of the Working Groups in November, who agreed that the following proposal should be put to the full Council. Proposal It is proposed that, from March 2019, the duration of the Council of Governors’ meeting is extended to 2.5 hours from 2 hours, with a 10-minute comfort break at the mid-way point of the meeting. The additional time given to the business of the meeting will therefore be 20 minutes. This additional time will give the Council more space to fulfil its responsibilities – such as holding Non-Executive Directors to account - but will also lend flexibility to the agenda where a topic has generated a rich discussion and more time is required than was anticipated. It was unrealistic to expect Governors to attend a longer meeting at short notice, which is why it is proposed that the change takes effect from the first meeting of 2019. Governors are invited to approve this proposal.

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Council of Governors 13 December 2018

Name of Report:

Lead and Deputy Lead Governor report

Author:

Jenny Cobley, Lead Governor

Presented by:

Jenny Cobley, Lead Governor

Purpose of the report:

For information

Governor elections Welcome to our four new governors: Ray Baker, Stephen Bawa and David Clugston (service user governors), and Professor Michael Kopelman (public governor), and welcome back to Brian Lumsden (public governor) and Simon Darley (staff governor), who have been re-elected. Welcome also to Heather Gilmour who is the new appointed governor from King’s College Hospital. Governor activities Working Groups. All governors are welcome to attend our four working groups and you are encouraged to attend at least one each quarter. It is important to have a good attendance, as we often have Non-Executive Directors, Executive Directors and other senior staff attending to provide information. The working groups will all be meeting in January or February. Site visits with the Non-Executive Directors (NEDs). These provide a valuable opportunity to see the wards and community services and to meet staff. These are advertised in the Governors’ Weekly Newsletter and it is necessary to have a DBS check in order to attend. Please contact Carol about a DBS check. The next site visit on 11 December is to Southwark Community Services in the Felix Post Unit on the Maudsley site (please note that you have to be booked to attend!). Other recent visits have been to the Ladywell Unit in Lewisham and wards on the Maudsley site. Governor Away-Day 23 October. This was held at Camberwell Library. We learned about the work of local Clinical Commissioning Groups (CCGs) from Rod Booth (Head of Performance and Contracts at SLaM) and received presentations from Lewisham CCG and Southwark CCG. We hope to hear from Croydon and Lambeth CCGs at our next Away-Day. We also had an update from Rachel Evans, Director of Corporate Affairs, on the inspection report from the Care Quality Commission (CQC). Meeting with the NEDs. We had our quarterly meeting with the NEDs on 30 October before the Board Meeting, when we raised questions about the current demand for beds and patient flow, and the Trust’s financial position.

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South London Mental Health and Community Partnership Quality Improvement (QI) conference – 8 November. Four governors attended this conference at the KIA Oval. It was a good opportunity to hear about projects to improve patient care in the three organisations. Meeting with Lambeth CCG. A group of governors will meet with members of the CCG on 5 Dec. Lead Governor meetings The Lead Governor and Deputy met with the Lead Governor from Oxleas NHS Foundation Trust at the QI conference. The Lead Governor will also meet with the Lead Governors from Guy’s and St Thomas’ FT (GSTT) and King’s College Hospital on 3 December and Lead Governors from other mental health trusts in the South East on 5 December. She has also been invited to a CQC workshop on 14 December with other experienced governors, to discuss how governors can interact with the CQC.

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COUNCIL OF GOVERNORS – SUMMARY REPORT

Date of meeting: 13th December 2018

Name of Report: Working Groups Report

Author: Working Group chairs, Carol Stevenson

Presented by:

Rosie Mundt-Leach (Quality)

Angela Flood (Planning and Strategy)

Membership and Involvement (Ermias Alemu)

Bids Steering Group (Simon Darnley)

Purpose of the report:

For information

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Quality Working Group report (Rosie Mundt-Leach) Governor involvement around quality issues since the last meeting has including the following activities: The Governor Away day on 23/10/2018 again focused on clinical quality matters by helping us to understand the relationships that commissioners have with the Trust and how they take decisions. Quality issues were discussed at the Governor/NED meeting on 30/10/2018 where there was again a strong focus on the systems that are being set up to enable the Trust to reduce Length of Stay in hospital for inpatients by preventing unnecessary delays in discharges and thereby giving acutely ill people to access beds. The Quality Working Group met on 7/11/2018. There were presentations by Gabrielle Richards who gave an update on the development of the Carers’ Strategy and by Dr Isabel McMullen on the pressures that exist in Psychiatric Liaison services in Emergency Departments in acute hospitals. The group also noted that a replacement Chair for the working group needs to be identified and interested governors should make themselves known to Jenny Cobley or Charlotte Hudson. Jenny Cobley attended the Trust Quality Committee on 13/11/2018 where the discussion included the importance of getting good data systems in place; the governance structures being put in place to ensure good floor-to-Board flow of information; delays in Mental Health Act assessments and there was a presentation about the IAPT (Improving Access to Psychological Therapies) pathway.

The next meeting will be on 24th January 2019, 16.00 to 17.30 in Maudsley Boardroom.

Planning and Strategy Working Group (PSWG) report (Angela Flood) Throughout 2018, the PSWG agendas have covered a range of key areas linked to Trust development and improvement plans: strategy and commercial development; financial business planning; the Lambeth Alliance; the organisational restructure from Clinical Academic Groups (CAGs) to boroughs; the Centre for Children and Young People’s Mental Health; Quality Improvement (QI) and operational, clinical and financial performance. Agendas are planned well in advance to ‘mirror’ the key stages of the Trust’s business cycle but, inevitably, have to allow for ‘hot topics’ to reflect the changes and, sometimes, more unforeseen issues caused by the dynamic internal and external environments in which the Trust has to operate. An example of this was the bespoke session for Governors in January 2018 in respect of commercial opportunities in Al-Amal. The PSWG last met on 13 November 2018, the final meeting of the current year, and was well attended by Governors from across all the Governor constituencies bringing wide-ranging perspectives to the discussions. Governor Observer reports: (Business Development and Investment Committee; Finance and Performance Committee; Audit Committee), providing insight into areas of the Trust that Governors might not normally have. Some matters raised questions – achieving a balance between increasing staff skills in business and management and using external consultants;

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the possible creation of wholly owned subsidiaries and potential impact on transfer of staff, employment rights and pension entitlements; the need for two-way flow of information and data between ‘floor and Board’ to monitor performance and the capacity and capability required to do this effectively. Financial (Chief Financial Officer). Despite the Trust currently being in the right place financially, significant and ongoing and emerging financial risks still need to be mitigated. Not achieving the Control Total would impact on sustainability and Cost Improvement Programme (CIP) funding. Bed usage, flow and use of agency staff also cause significant adverse impact. Focus has tended to be on agency nursing staff but Governors also raised concerns around the use of locums which is costly, creates turbulence in patient care and is disruptive for teams. Recruitment and retention, especially in mental health, remain a significant concern both across the Trust and nationally. Junior psychiatrists working at SLaM as part of their rotation are choosing not to remain on a permanent basis and some are choosing not to stay in medicine at all. The Department of Health and Social Care is sufficiently concerned that KCL has been asked to undertake a rapid review of possible reasons. Professor Ian Norman extended an invitation to Governors present (and SLaM Staff), to contribute to the review by attending a meeting at Kings College London on 20 November. Other related issues raised by Governors included high cost of living, key worker accommodation (this remains a key part of the overall Estates Strategy), the number of established staff who are retiring leaving groups of younger, less experienced staff, and a shortfall in respect of the pay award (the Trust continues to negotiate on this with NHSI). Changing Lives Strategy (Director of Strategy and Commercial). Governors welcomed the recognition for greater focus on quality as a primary aim. A supporting infrastructure has been built around delivery improvement, alignment with the operational strategy and linkage to the Annual Plan. There was debate around whether the strategy was too aspirational and whether it articulated the challenges enough, especially with regard to Service Users and Carers. Different mechanisms will be used for different audiences to communicate both challenges and the opportunities for positive change. Governors were encouraged by the involvement of young people in the SLaM communities and hoped this would both increase understanding of mental health and inspire future recruitment. Governors were concerned about the pressures of big caseloads and impact on quality of care. Staff needed to feel valued. If not, this impacted on working environments, the negative ‘messages’ being received by student nurses and future employment. In considering the self-assessment review (May 2018), the PSWG: has developed forward work plans; shared intelligence with the other Working Groups to support quality and service improvement; held informal discussions with the Membership and Involvement Working Group Chair regarding opportunities for collaborative working to support the Changing Lives Strategy. Next meeting: Tuesday, 7 February 2019, 17:00 – 18:30, Maudsley Boardroom. Membership and Involvement Working Group (Ermias Alemu) Members’ seminars The seminar on Diabetes and Psychosis held on 12th October was very successful.

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A list of potential topics for 2019 would be circulated and future evening seminars will be considered Mind and Body Programme At the working group meeting on 31st October 2018, Christine Andrews and her colleague presented about the Mind and Body programme and their role in it. Documents related to the subject were circulated to the members. Governor elections Congratulations to the following governors who have been elected Public: Brian Lumsden and Professor Michael Koplelman Service users (local boroughs): Ray Baker and David Clugston. The third elected governor was unable to take up their post so the first runner up, Stephen Bawa, has taken up the role. Staff: Simon Darnley. The other role remains vacant due to a lack of staff nominations. M&I Working Group priorities Members of the working group have agreed to focus on the following priorities in the coming year:

Engaging with staff to raise awareness of the Governor role with a view to increasing staff candidates at next year’s CoG elections;

Together with P&SWG to help the launch and delivery of the Changing Lives Strategy

Capturing Governors activity which demonstrates the duty to represent members and the public

Governor Expenses policy The working group have agreed the changes made in the expenses policy. Lobbying Letters have been sent to the Secretary of State for Health and Mental Health England. Dates of next meetings The next meeting of the group is on Tuesday 12th February 16.00 to 17.30 at the Maudsley

Boardroom.

Bids Steering Group (Simon Darnley) The last meeting of the Bids Steering Group was not quorate as only two governors were present. Attempts are being made to schedule a replacement meeting. All the bids awarded in 2018 have received their funding and planning for the next bids scheme in January 2019 is proceeding. New and existing governors are asked to consider joining this group which does very worthwhile work. Date of next meeting: 17th January 2019, 15.30 to 16.30pm in the room behind the Maudsley restaurant.

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Council of Governors 13 December 2018

Name of Report Notes of Governor questions to NEDs 30 October 2018

Author

Charlotte Hudson, Deputy Director of Corporate Affairs

Presented by

Roger Paffard, Chair

Purpose

For information

Governor questions to NEDs 30 October 2018 Present (Governors) Ermias Alemu (EA) Christine Andrews (CA) Jane Avis (JA) Jenny Cobley (JC) Angela Flood (AF) Jeannie Hughes (JH) Brian Lumsden (BL) Gill Sharpe (GS) Present (Non-Executive Directors) Roger Paffard (RP) Béatrice Butsana-Sita (BBS) Ian Everall (IE) Mike Franklin (MF) Duncan Hames (DH) June Mulroy (JM) Geraldine Strathdee (GS) Anna Walker (AW) Present (in attendance) Rachel Evans, Director of Corporate Affairs Charlotte Hudson, Deputy Director of Corporate Affairs Russell Mascarenhas, NExT Director 1. Delayed MHA assessments, waiting lists and beds Currently patients may have to wait for days in A&E before a bed is found and MHA assessments are also delayed. This puts considerable strain on both patients and staff. (a) Have you seen data on the number of SUs waiting for a bed and the number waiting for an MHA assessment?

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(b) Are you assured that SLaM has enough beds for the local population, given the growth both of population and mental health needs? 2. Multi Agency Discharge Events (MADEs)

Are you satisfied that the recent MADE events were effective and that the flow of patients through the system will be improved? Questions 1 & 2 were taken together as they are very closely linked.

Geraldine Strathdee (GS) confirmed that, as stated in the Board papers, there have been mental health assessments delayed owing to the lack of access to beds. This is part of the flow issue being tackled by Multi-Agency Discharge Events (MADEs) which are designed to identify barriers to patient discharge and which are already making a difference. She added that SLaM has one of the lowest levels of bed availability and in London and a lower level of resourcing (investement) in community teams, and these are linked. Jenny Cobley (JC) asked whether the Trust needs more beds; GS replied that at this stage it is important to know who are in the beds that the Trust already has and whether they should be there e.g. are they readmissions where the community support was insufficient. Flow is being added as a risk in the Board Assurance Framework. The Board papers should offer assurance to Governors that the Board is fully cognisant of the issues. Anna Walker (AW) set out the four measurements set to identify whether the efforts to improve flow are working:

No 12 hr breaches in Emergency Departments

No s136 breaches

No cancelled MHA assessments in the community

No inpatients sleeping anywhere other than a bed. Roger Paffard (RP) noted that never before has it been possible to have visibility of the number of patients waiting for a bed, but now that is reported daily. There are currently twelve. Brian Lumsden (BL) asked whether the MADEs are at the same stage across the four boroughs. GS explained that they are not, but that the first “round” has taken place in each borough and the second rounds are taking place over the next month or so. Southwark’s has already taken place (45-day follow-up). RP attended the Croydon MADE and was impressed by the level of engagement; all the senior figures were there making difficult decisions. Rosie Mundt-Leach (RML) thought it sounded positive asked if there is an anticipated date by which the flow issues will be solved. GS felt that there would be a better grip on this when the Improvement Plan is agreed with the CQC; although the warning notice relates to the acute pathway with a focus on inpatient environments, that pathway starters in the community and more needs to be done to understand that, including demand and quality standards. AW felt that there is a broader issue about waiting times and said that she would raise this at the Board meeting. As the Trust looks at flow, there should be information about waiting times because the danger is that in improving flow, it creates greater longer waits and waiting lists. At the moment, the data is not pulled together systematically, which is not the fault of the organisation but doesn’t mean that the Trust shouldn’t have a handle on it. Jeannie Hughes (JH) asked why SLaM has fewer beds than other Trusts, and whether this is due to lack of space, lack of funds or another reason. GS replied that there is always a question in mental health about the proportion of patients that should be treated in hospital and those

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who should be treated in the community. Twenty years ago, there were c.150,000 beds available nationally, now there are around 20,000. If there hadn’t been cuts in local authority funding, affordable housing and community asset building, then maybe the current figure would be appropriate. GS stressed that new benchmarking data against other Trusts will help SLaM find a balance between community and inpatient investment. JH had heard that the number of people waiting for a bed is 45 and felt that the Trust should increase its bed stock so that 45 vulnerable people do not have to wait. Duncan Hames (DH) explained that those 45 people are in beds, but not ones that SLaM is commissioned to provide i.e. SLaM is funding them in the private sector. SLaM has trained clinicians making decisions about patients which the Trust is not resourced to care for. There is clearly a gap. If the system as a whole is out of balance, SLaM cannot fix it by opening another ward and moving people back in to Trust beds, if it has built up latent demand and a community environment that patients cannot be discharged into. The flow work is about making sustainable change, or the Trust will just have the same problems while trying to run additional, unfunded services. Angela Flood (AF) asked whether the number of specialist beds in the Trust e.g. perinatal, eating disorders, means that resources are spread too thinly. GS explained that these are funded differently i.e. they are not beds that could otherwise be used in the acute pathway. Having specialist services attracts staff, and excellent research is being done on these units which will inform treatment. RP said that the average length of stay at SLaM is 62 days; the benchmark for the UK is 30-40. If the Trust could run on 40, all the pressures in the system would improve dramatically. The MADEs clearly show that about a third of beds are taken up by people who are medically fit and that is a system issue that must be addressed as a matter of priority. That is not to say that there are not internal issues which block discharge, but that is why the Trust checks its own barriers before taking external issues to MADEs. Red2Green is being trialled in two wards, which is a technique for management to proactively engage in getting people recovery-ready (a ‘green” day is one where proactive steps are taken towards discharge). MADEs will have to go through a number of cycles before it is clear how effective they can be, but RP expressed confidence that they are the right thing to do. GS reflected on practice twenty years ago, whereby medically-well patients who had no accommodation would be discharged and put in a taxi to the nearest homeless centre; SLaM is working to ensure that these patients are discharged in to environments where they can continue to be well. 3. Control Total

We understand that the Regulator would welcome a certain approach in its reporting of the Control Total. If this approach was taken, what are the potential advantages/disadvantages to the Trust (and the Regulator)? Can we be assured that the final decision would not adversely compromise the Trust? Jenny Cobley (JC) noted that the use of out-of-area beds must have an impact on finances. June Mulroy (JM) agreed and felt that the earlier conversation about flow demonstrated how much of a positive impact there would be on the finances if flow were improved / solved. However, the actions required to tackle flow will require investment and these costs were not taken into account this time last year when the budget was agreed. The Board will need to decide what the cap on that spend should be. The Board is not quite at the point where it can be positive about its view of the financial forecast or how far off the Control Total it is likely to be. There is significant planning underway, but it won’t be until the end of Q3 that there will be any meaningful clarity. Trusts are only

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allowed to change their financial forecast for the year at the end of a quarter and only once there is a rigorous process of governance and assurance from the Board to sign off the forecast and a recovery plan / mitigations. The Trust has already said that it cannot meet the requirements of the recent pay award (c.£1m) and other Trusts are likely to be in a similar position. If the Trust misses its Control Total, there is an impact on credibility (having said it would meet it, and then not) and also in cash terms. The Trust may need to bring in some short-term savings and the finance team has been tasked with identifying the options for that e.g. not doing planned estates work. Duncan Hames (DH) added that the Trust has met its Control Total, and therefore received payments from the STP (Sustainability and Transformation Partnership), for the last two years by relying on one-off income e.g. property disposals, but that is not sustainable. So few Trusts met their Control Totals last year that they still received STP payments. The Trust does not want to prioritise money over quality; if it has to spend the money to safeguard people, then it will. However, having inpatients who spend twice as much time on wards as they should do is a cost and quality issue that must be cracked as a priority. 4. How are NEDs involved in the CQC action (improvement) plan? An organogram showing the governance for the Improvement Plan was circulated; Governors who had attended the Away Day had had sight of it. Anna Walker is involved via Quality Committee; Duncan Hames is involved via Audit Committee; Geraldine Strathdee, Roger Paffard and Duncan Hames all sit on the Oversight and Scrutiny Committee. All NEDs will be part of the process as part of the Board. Geraldine Strathdee (GS) gave a summary of the role of the Oversight and Scrutiny Committee, which will have oversight of detailed plans and will report to the Board. They are currently working on ensuring the metrics for measuring success are right. She reported robust engagement from directorate management teams and felt that the borough restructure had been a positive step. She offered her confidence that the executive team could not be working harder. Her concern is whether the Trust has the capacity in the infrastructure to deliver by way of project management and informatics (i.e. processed data). Anna Walker (AW) reported on the extraordinary meeting of the Quality Committee which had received detailed improvement plans from all directorates (except CAMHS, which had not been inspected this summer with the other services, although the Quality Committee still has oversight of its plan) as well as Trust-wide actions. She felt that there are two areas outstanding: a clear view of how information flows from “floor to Board” (and vice versa) and a developed mechanism for monitoring statutory and regulatory compliance in community teams. She noted that the specialist services do well, so the focus is on inpatient and community services. Duncan Hames (DH) felt that the ‘Good’ rating has not resulted in complacency; the challenges of the warning notice have gripped senior management with focus and tenacity as if the rating were worse. They have not shied away from making difficult decisions. Ermias Alemu (EA) picked up on the capacity issue raised by GS; Roger Paffard (RP) explained that some of the actions are staggered – the priorities as identified will be addressed in the next six months – but changes must be sustainable. The Board will receive reports on progress in December, while the Quality Committee, Audit Committee and Oversight & Scrutiny Committee continue to meet in the meantime.

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Council of Governors 13 December 2018

Name of Report Review of the Governors’ Handbook 2018

Author

Charlotte Hudson, Deputy Director of Corporate Affairs

Presented by

Roger Paffard, Chair

Purpose

For noting

Introduction The Trust provides its Governors with a Handbook of core / key information to assist them in fulfilling their role. It includes (but is not limited to) practical information about the Trust (such as location and key contacts); an outline of the Governors’ key responsibilities; an introduction to members of the Board; the role of the working groups; how to claim expenses and processes for asking questions of the Non-Executive Directors. The Handbook is subject to annual review. Having taken into account feedback from Governors throughout the year, and recognising practical changes e.g. new members of the Board, the Handbook has been revisited to ensure that it remains up-to-date. Updates to the Handbook 2018 No substantive alterations have been made but there have been revisions for the purposes of clarity and ensuring information is accurate, including:

Updated Trust Board details;

Updated Governor details;

Amended expenses policy (as approved by the Membership & Involvement Working Group);

Removal of repeated text in the code of conduct;

Clarification of who Governors should contact depending on their query or issue;

Format updated to make it easier to read;

Request for Governors to alert the Corporate Affairs team if there is anything that needs to be taken into account to assist Governors fulfil their role e.g. access requirements;

Addition of the Annual Members’ Meeting to the “core” meetings that Governors are expected to attend, as agreed at the Chairs’ meeting;

Updated list of commonly used acronyms and their meanings. The updated Handbook will be circulated for the benefit of all Governors, not just the recently elected.

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