Workforce

Person Centred

Effective

Safe

Our Vision, Values,

Aims and Strategy

Standards and

Guidelines of Care

The State HospitalsBoard for Scotland

Foreword

The State Hospita

ls Boa

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or S

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and

AnnualReport2019/20

Safe and Secure Care, Treatment and Recovery

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01 Foreword 2

02 The State Hospitals Board for Scotland 3

03 Standards and Guidelines of Care 4

04 Our Vision, Values, Aims and Strategy 5

05 Safe 6

06 Effective 9

07 Person Centred 13

08 Workforce 20

APPENDICES

Appendix 1 – Board Members’ and Senior Managers’ Register of Interests 2018/19Appendix 2 - Board Governance Committees 2018/19Appendix 3 - At a Glance ‘Key Performance Indicators 2018/19’

Contents

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1. ForewordIt goes without saying that we are in difficult times as we face a second major surge in Covid-19. It now seems a very long time ago but nevertheless it is pleasing to be able to report on the many positive developments which took place in 2019/20. We have spoken for some time about the importance of values and behaviours within an organisation. We are committed to investing in staff and recognising them for the great work which they do. 2019/20 saw the launch of the Staff Excellence Awards and Long Service Awards. These initiatives, which were long overdue, were very well received and no doubt will feature at The State Hospital long into the future. iMatter saw The State Hospital achieve a 79% response rate, which was the fifth highest out of the 22 Health Boards. Furthermore, the Employee Engagement Index of 77 was slightly higher than the national score. We can take pride in the way we have taken iMatter on board and for the diligent manner of our participation in this important staff experience process. Great work occurred throughout the year in reviewing and developing the Clinical Model. Staff were consulted widely at every stage of development and the Board endorsed a revised model in October 2019. The implementation plans were put on hold because of Covid-19. However, there is a widespread view that the new approach will result in better care for our patients and improved ways of working for our staff. We look forward to full implementation of the model in the near future. For a number of years, the challenges arising from staff absence have been referred to in this Foreword. It is therefore pleasing to note the significant improvements which have taken place in 2019/20. These have resulted from a great deal of hard work throughout the organisation. Team Leaders, Managers, Staff Side, Occupational Health and HR staff have played a particularly significant role in these efforts. Our thanks are due to them and to all of our staff for helping to turn this around. Once again we achieved financial balance while at the same time maintaining the highest standards of patient care. This is not easy to do against a background of financial constraint with the ongoing requirement to achieve savings. Our thanks are due to everyone throughout the organisation for achieving this first class result.

The last large scale event in the Hospital in 2019/20 was the Patient Learning Awards Ceremony on 11 March 2020. This has always been one of the Hospital’s premier events and this year’s ceremony was no exception. Those in attendance heard of the tremendous efforts made by patients in order to gain their awards. A few patients addressed the audience and recalled their personal feelings around the joys and challenges of the learning process as well as acknowledging their sincere thanks for the support which they received from staff. Little did we know that life in The State Hospital and throughout the world would change dramatically shortly thereafter due to the Covid-19 pandemic. NHS Scotland was put on an emergency footing and a strict Covid-19 national lockdown commenced on 23 March 2020. In response, we immediately activated our Incident Command Structure. A full report on the impact of the pandemic on the Hospital will be included within next year’s annual report. It is good to note however, that the general consensus to date, is that the whole process has been professionally and sensitively managed at The State Hospital. Our highly committed staff have worked very hard to ensure that our patients have received the highest quality of care throughout this extremely difficult time. We are most grateful to them for their magnificent efforts. Finally, we wish to acknowledge the retiral of Maire Whitehead, Non-Executive Director in January 2020, and express our thanks for the great contribution she has made over the years. Our sincere thanks also to Kay Sandilands who served as Interim HR Director prior to undertaking the full-time role of HR Director with NHS Lanarkshire. Last but not least, we are pleased to welcome back John White who has once again taken up the role of Interim HR Director.

Gary JenkinsChief Executive

Terry CurrieChair

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Other NHS Hospitals

Prisons

Courts

Patient Death

Administrative Services

Allied Health Profession

Medical / Dental

Nursing / Midwifery

Other Therapeutic

Senior Managers

Support Services

2. The State Hospitals Board for Scotland

Patient Discharges 2019/20 (34)

Patient Admissions 2019/20 (38)

Other NHS Hospitals

Prisons

Courts

Community

Located in South Lanarkshire in central Scotland, The State Hospital is the high secure forensic mental health resource for patients from Scotland and Northern Ireland. The principal aim is to rehabilitate patients, ensuring safe transfer to appropriate lower levels of security.

There are 144 high-secure beds for male patients requiring maximum secure care: 12 beds specifically for patients with a learning disability, and four for emergency use. Wards are in four units (hubs and clusters) with each unit comprising three 12-bedded areas (i.e. 36 beds per hub).

A range of therapeutic, educational, diversional and recreational services including a Health Centre is provided.

Patients

• Patients are admitted to the Hospital under The Mental Health (Care and Treatment) (Scotland) Act 2003 / 2015 and other related legislation because of their dangerous, violent or criminal propensities. Patients without convictions will have displayed seriously aggressive behaviours, usually including violence.

• During 2019/20 there were 38 patient admissions and 34 patient discharges.

• The majority of admissions were from Courts and Prisons.

• The majority of discharges were to Other NHS Hospitals and Prisons.

• 70% of patients are ‘restricted’ patients within the jurisdiction of Scottish Ministers. That is a patient who because of the nature of his offence and antecedents, and the risk that as a result of his mental disorder he would commit an offence if set at large, is made subject to special restrictions without limit of time in order to protect the public from serious harm. This number also includes patients undergoing criminal court proceedings who are also subject to the supervision of the Scottish Ministers.

• All patients are male, with an average age of 40. The most common primary diagnosis is schizophrenia. The current average length of stay is around six years, with individual lengths of stay ranging from less than one month to over 30 years.

Staff

• As at 31 March 2020, 656 staff worked at The State Hospital.

Staff Headcount as at 31 March 2020 (656)

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2020 Vision

Triple Aim Quality of Care Health of thePopulation

Value andFinancial

Sustainability

QualityOutcomes

Independentliving

Services are safe

Engagedworkforce

Positiveexperiences

Healthier livingEffective

resource use

2020 Vision / Quality AmbitionsSafe, effective and person-centred care which supports people

to live as long as possible at home or in a homely setting.

3. Standards and Guidelines of CareIn February 2018, the Scottish Government replaced the Local Delivery Plan (LDP) with an Annual Operational Plan (AOP). The AOP focuses primarily on performance, high-level finance and workforce - drawing together key planning assumptions which reflect local priorities.

The only national two LDP standards directly relevant to The State Hospital are Psychological Therapies Waiting Times and Sickness Absence. Additional local Key Performance Indicators (KPIs) are reported to the Board and included in this report. There are 15 KPIs in total. The following two KPIs are being replaced:

• Patients will engage in meaningful activity on a daily basis.

• Hubs have a monthly community meeting.

Performance Management Task Force has been set up to review all the current KPIs and refresh the performance framework. Four models are being worked on at present as part of this piece of work.

Performance targets have been aligned with the three Quality Ambitions in the national NHSScotland Healthcare Quality Strategy: safe, effective and person centred. Outcomes are measured against agreed targets, and achieved through an incremental continuous improvement approach by way of the existing governance structure, e.g. Board and Committee Structures / Executive Appraisal. This annual report is structured around the three quality ambitions.

This report also covers work relating to the NHSScotland 2020 Workforce Vision:

“We will respond to the needs of the people we care for, adapt to new, improved ways of working, and work seamlessly with colleagues and partner organisations. We will continue to modernise the way we work and embrace technology. We will do this in a way that lives up to our core values. Together, we will create a great place to work and deliver a high quality healthcare service which is among the best in the world.”

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4. Our Vision, Values, Aims and Strategy

Vision

“To excel in the provision of high secure forensic mental health services, to develop and support the work of the Forensic Network, and to strive at being an exemplar employer.”

Values and Aims

The State Hospital has adopted the core values of NHS Scotland which are:

• Care and compassion.• Dignity and respect.• Openness, honesty and responsibility.• Quality and teamwork.

Primary twin aims are:

• Provision of high quality, person centred, safe and effective care and treatment.

• Maintenance of a safe and secure environment that protects patients, staff and the public.

Strategic Priorities and Objectives

A strategy session takes place annually to review and re-confirm or amend the long-term direction of the Hospital. Our three-year Service Strategy (2017/20) was developed, identifying three strategic priorities critical to the success of the organisation and ensuring high quality care:

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

A set of strategic objectives (aligned to State Hospital Quality Ambitions) was established to support these three strategic priorities:

• Reduce obesity and increase physical activity.• Complete implementation of the “Patients’ Day”

project.• Reduce the use of additional hours.• Optimise efficiency in clinical practice and clinical

service delivery.• Transform services to optimise efficiency whilst

maintaining quality.• Identify ways of generating more income.• Promote attendance and reduce sickness absence.

• Support a forward looking culture.• Create conditions for supporting quality assurance,

quality improvement and change.• Look at ways of better utilising technology to support

the national digital agenda.• Explore more cost effective stewardship of assets and

resources.• Develop effective workforce and succession planning

strategies and measures that will address identified rapid turnover in the future.

• Explore options for effective shared services and resilience building through enhanced collaborative working both internally and externally.

• Ensure opportunities to develop the whole workforce are maximised; focussing on leadership development and the review of workforce models to ensure a sustainable, skilled and competent workforce.

State Hospital’s Clinical Model

During the year, the Clinical Model was reviewed involving consultation and engagement both internally and externally. In October 2019 the Board endorsed a 10 ward model with eight major mental illness wards and two intellectual disability wards. There is no plan to increase the number of patients with an intellectual disability. The increased provision is to enable a quieter environment with fewer patients, which would not be achieved if numbers were increased. A detailed planning and implementation process was developed and presented at the Board in December 2019. The process included the establishment of a Clinical Model Oversight Board which met three times between January and March 2020, making good progress in relation to the following work-streams: • Workforce• Clinical Delivery• Culture, values, behaviours and leadership• Finance• Security and Environment• Communication and Engagement The implementation of the Clinical Model will be delayed until 2020 as a result of the Covid-19 pandemic.

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Reception (Security Building)

5. Safe

“There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate clean and safe environment will be provided for the delivery of healthcare services at all times.”

5.1 HIGH QUALITY PATIENT CARE AND TREATMENT

Clinical Governance

The underlying principle of effective clinical governance is that systems and processes provide the framework for patients to receive the best possible care.

The Clinical Governance Committee is supported by the Clinical Governance Group which has a quality assurance / improvement remit, and the Clinical Forum which continues to act as a professional advisory group.

The Clinical Governance Annual Report for 2019/20 provides a comprehensive overview of clinical governance activity.

Forensic Network Medium and High Secure Care Review Visit – Action Plan

By February 2020 there were 10 actions outstanding from the original 37 with work planned to progress these in 2020/21.

Clinical Governance Group

As well as overseeing the reports that go to the Clinical Governance Committee, in 2019/20 the Group ensured:

• The Patients’ Day Project was progressed and will continue into 2020/21.

• The review of the Clinical Model was robust and engagement was at the forefront of the project.

• The next phase of the Supporting Health Choices Plan would include a workshop to agree new recommendations.

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• The RSM Audit results were progressed through Skye Activity Centre data.

• A discussion forum for digital inclusion within The State Hospital was created.

• A review of the Psychological Therapies Service to enable service improvement and development.

• All action plans were closed in a timely manner through more regular progress updates.

Risk and Resilience

Risk management continues to be embedded within all functions and disciplines across the organisation through the effective monitoring of risk information by groups and committees, regular monitoring of patient-specific risks by clinical teams, and sharing learning from incidents with local action being taken to minimise recurrences.

Areas of good practice during 2019/20 related to continued development of the Corporate Risk Register with risk owners and associated enhancement of local departmental risk registers, testing of resilience plans through resilience exercises, learning from incidents through effective incident reporting, close scrutiny of health and safety control book audits including workplace inspections, and the delivery of staff training and education aimed at reducing risk.

Work-steams relating to the Scottish Patient Safety Programme for Mental Health (SPSP-MH) were progressed:

• Review and update of the Improving Observation Practice policy.

• Ongoing delivery of Post Incident Debriefs with work planned for 2020/21 through the Senior Charge Nurse development programme around training for those leading the debriefs.

• Weekly undertaking of Pre-Weekend Safety Briefings.• Programme of Leadership Walk-rounds and review of

associated documentation.

Highlights of resilience measures strengthened during the year include State Hospital representation at the Beyond EU Exit: Integrating Resilience Across Health & Social Care event on 21 January 2020, and Golden Hour training for new Senior Charge Nurses (SCNs) on 28 January 2020.

Additional resilience activity included the review and testing of contingency plans and the Incident Command Structure by way of a multi-disciplinary pandemic influenza table top exercise on 5 December 2019 with resultant Loss of Staff plan review, and a Scottish Fire and Rescue Service (SFRS) exercise held on 20 January 2020 involving three fire appliances on scene.

Child and Adult Protection

The protection of children and adults from harm remains a key priority for The State Hospital, with clearly defined responsibilities for staff from all disciplines. This work is led by the Child and Adult Protection Forum within The State Hospital and as part of South Lanarkshire Council’s Multi-Agency Child Protection Framework. The State Hospital has Corporate Parenting responsibilities for all patients, up to and including the age of 25, who were looked after by their local authority at any point up to their 16th birthday. A three-year Corporate Parenting Plan is in place. During the year one patient met the identified criteria and liaisons with the relevant local authority took place to ensure that corporate obligations were satisfied. In the year: • Five patients who were parents of children had some

form of child contact.• 26 patients had contact with children.• 78 children were approved to have some form of

contact with a State Hospital patient.• There were two Child Protection referrals.• Three Adult Support and Protection (ASP) inquiries

were responded to. Infection Control

The Hospital’s Infection Control Committee promotes the highest standards of practice within the organisation for infection prevention and control, ensuring compliance with the Healthcare Improvement Scotland (HIS) Healthcare Associated Infection (HAI) 2015 standards. The Board noted the following achievements in 2019/20:

• As per previous years, the results of quarterly audits undertaken as part of the NHS Scotland National Cleaning Services Specification, were in the ‘green’ category indicating a result of 90% or above.

• A significant increase in the total number of flu vaccinations from 35.8% in 2018/19 to 43.9%. In addition, there was an increase in uptake among nursing staff from 26.8% in 2018/19 to 41.8%.

• Blood Borne Virus (BBV) testing was incorporated into admission blood screening, resulting in a high uptake by patients.

• 27 exposure incidents of infection control issues were cited as secondary; a decrease from 53 the previous year.

• Significant improvement in compliance with the Management of Loose Stools Policy.

• 100% compliance for the management of Healthcare Waste pertaining to sharps; consistent with the previous year.

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• High levels of hand hygiene compliance across the hubs ranging from 80% to 98% with nursing staff consistently achieving in excess of 90% and the Health Centre consistently achieving 100%.

• Continued promotion of food hygiene and food safety online training modules with positive results.

Infection prevention and control remains a high priority for The State Hospital and is monitored through the Board’s Risk and Governance Structure. During March 2020 the Hospital’s Incident Command Structure was enacted in response to the Covid-19 pandemic, with the Senior Nurse for Infection Control becoming a key member of the Covid-19 Support Team.

Information Governance

Focus over the course of the year was on improving Information Governance standards and practices across the Hospital to ensure compliance with the national Information Governance Framework. Matters relating to data protection, records management, Caldicott issues (including incident reporting), and mandatory training remained a top priority as did the monitoring of Freedom of Information (FOI) and Subject Access Requests.

Additionally, Information Governance Walk-rounds took place to staff and patient areas, and work associated with the Electronic Patient Record (EPR) system and the outcomes of the FairWarning system (together with ad hoc issues such as record retention and email scams) were all addressed.

In 2019/20:

• There were 21 Information Governance Risk Assessments on the Risk Register; 14 were at or below their target risk rating of medium, with action plans in place to reduce or eliminate the remaining seven risks.

• Levels of compliance for mandatory training continued to be high as in previous years.

• There were 16 recorded personal data breaches; none of these required notification to the Information Commissioner’s Office.

• A review of the Records Management Plan was undertaken between January and March 2020 with actions arising being addressed.

• For the third year, the Scottish Information Commissioner’s Self-Assessment Toolkit was used to assess FOI management at the Hospital and indicated a trend of continuing improvement.

• Subject Access Requests doubled with requests being evenly split between staff and patients (past and present); from 22 in 2018/19 to 49 in 2019/20.

• Forty eight policies were delivered through the MetaCompliance cyber security, training and compliance awareness platform; a rise of 26%.

• MyCompliance, a complimentary system to MetaCompliance, was introduced in the fourth quarter providing staff with a mechanism for acknowledging policies prior to MetaCompliance enforcing a response.

• There were no Category 1 or Category 2 investigations related to Information Governance.

Information Technology

Information systems were enhanced during the year, with the development of new dashboards for the Tableau Business Intelligence platform, to help frontline staff better understand data and use it to inform decisions. At the annual national Tableau ‘Vizathon’ event, the Information Team won (following a public vote) the ‘top dashboard award’ with their Christmas themed viz. The RiO Electronic Patient Record (EPR) was also further developed with a range of new modules, and numerous new RiO reports were established to capture data for new daily and weekly monitoring reports.

The year also saw upgrades to the infrastructure including servers and networks. Security

Maintaining a safe and secure environment for patients, staff, volunteers and visitors is a key component of effective patient care and treatment. During the year:

• Work to upgrade the Hospital’s security systems was taken forward through the Security Refresh capital project.

• A Security Governance Group was established with representation from a variety of disciplines.

• Multi-disciplinary involvement in the review of Security policies and procedures increased.

• State Hospital Negotiators attended the Police Training College at Tulliallan to support Police Scotland deliver national training for Police Negotiators.

• In line with environmental and safety improvements, a mock Modified Strong Room (MSR) was built with over 100 staff participating in the ‘MSR layout’ consultation.

• Visits were made to the English high security hospitals to further strengthen relationships and enhance information sharing.

The Hospital has its own Security Standards which are aligned to the national High Secure Care Standards. The next audit is not due until 2021.

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Patient Accommodation

6. Effective

“The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated.”

6.1 EFFICIENT AND EFFECTIVE USE OF RESOURCES

Corporate Governance and Accountability

The State Hospitals Board for Scotland is accountable to Scottish Ministers, through the Scottish Government, for the quality of care and the efficient use of resources. The Board consists of a Chair, six Non-Executive Directors, and four Executive Directors.

The role of the Board is to provide strategic leadership, direction, support and guidance to the Hospital and promote commitment to its core values, policies and objectives. The Chair has a particular duty to ensure that Board members are provided with timely, accurate and clear information in order to fulfil their duties, as well as facilitating effective contributions from Non-Executive Directors.

The main functions of the Board are to establish strategic direction, aims and values, ensure accountability to the public, and assure that the Hospital is managed with integrity. The Board allocates resources, delegates operational matters to management, monitors organisational and executive performance, and oversees senior management arrangements and appointments.

Corporate governance arrangements are set out in Standing Orders, Standing Financial Instructions and the Scheme of Delegation.

The Board is supported by a Board Secretary and a number of Committees to advise and help carry out its duties. Clinical governance, staff governance and corporate governance are overseen by the Clinical Governance Committee, Audit Committee, Staff Governance Committee and the Remuneration Committee.

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The Board met publically six times during the year and each governance committee met four times.

In 2019/20, following a self-assessment, an improvement plan to support key corporate governance priorities was developed as part of the Blueprint for Good Governance. This focused on setting the direction, holding to account, assessing risk, engaging stakeholders, and influencing culture. The improvement plan was reviewed by the Board during each of its meetings during 2019/20. Of particular note, the Board focussed on assurance of information including performance metrics as well as engagement of stakeholders and the wider public.

See Appendix 1 for Board Members’ and Senior Managers’ Interests 2019/20, Appendix 2 for Board Governance Committees 2019/20, and Appendix 3 for ‘At A Glance’ Key Performance Indicators 2019/20.

Audit Committee

The Audit Committee oversees arrangements for internal and external audit of the Board’s financial and management systems and considers the Board’s overall systems of internal control.

The Internal Audit Plan from RSM for 2019/20 was approved in June 2019. The plan, which was kept under constant review, was designed to target priority issues and structures to allow the Chief Internal Auditor to provide an opinion on the adequacy and effectiveness of internal controls to the Committee, the Chief Executive (as Accountable Officer) and the External Auditors.

Details of activity can be found in the Annual Report of the Audit Committee 2019/20.

Remuneration Committee

The Remuneration Committee seeks to support the Board’s aim to be an exemplar employer with systems of corporate accountability for the fair and effective management of all staff.

The Remuneration Committee Annual Report 2019/20 outlines the key achievements and key developments overseen by the Committee. The stock-take also includes the Committee’s Terms of Reference, reporting structures and work programme which is largely determined by the requirement to implement Executive and Senior Managers’ pay with reference to relevant Scottish Government instruction and performance appraisal. In addition, oversight of the application and award of discretionary points is a routine consideration of the Committee as is consideration of ad-hoc issues relating to remuneration.

Financial Targets

The Board operates within three budget limits:

• A revenue resource limit - a resource budget for ongoing operations.

• A capital resource limit - a resource budget for capital investment.

• A Cash requirement – a financing requirement to fund the cash consequences of the ongoing operations and the net capital investment.

During the financial year ended 31 March 2020, the Board was within all three of its statutory financial targets and reported a carry-forward of £21k on its revenue resource limit.

The table below illustrates the Board’s performance against agreed financial targets. The limit is set by the Scottish Government Health & Social Care Directorates.

LimitAs Set

ActualOutturn

Variance(Over) /Under

£000 £000 £000

Revenue Resource Limit- Core- Non Core

34,676 2,538

34,655 2,535

21 3

Capital Resource Limit- Core

225 225 -

Cash Requirement 34,393 33,393 -

Revenue Resources

The Statement of Comprehensive Net Expenditure provides analysis in the annual accounts between clinical, administration and non-clinical activities. Excluding the effect of annually managed expenditure, net expenditure in 2019/20 increased by £1,971k from the previous year.

Capital Resources

The Board’s Capital Programme for 2019/20 focused on improving Hospital security, maintenance of the estate and improvements to eHealth systems.

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Collaborative Working

NHS Scotland national Boards are required to work together to identify ways to collectively standardise and share services to reduce operating costs by £15m (a recurring target from 2018/19) so this can be reinvested in frontline NHS Scotland priorities.

The work in delivering the target has focused on four key work-streams:

• Transformation to deliver quality improvements and efficiencies across NHS Scotland to support the Health and Social Care Delivery Plan.

• Delivery of reduced operating costs through a critical review of support services to deliver sustainable savings.

• Delivery of cash releasing efficiency savings for territorial Boards.

• Management of non-recurring spend and collaborative initiatives to deliver the target for 2019/20 whilst the work plans in the first two bullets deliver more sustainable quality improvements and reduced costs.

Sustainable Economic Growth

The Board is committed to the continuous delivery of a high quality professional service based on the principles of sustainable development and their relevance to State Hospital activity. As in previous years, an equitable balance continued to be sought between meeting the needs of patients, staff and the community; delivering value for money; and minimising environmental impacts and ensuring protection of environmental resources within the Hospital’s sphere of control.

Efficiency and Productivity

The Hospital is committed to supporting the drive for efficiency and productivity. Savings targets have been met in each of the recent years.

In future years, it is very likely that the Hospital will have increasing difficulty generating the same level of cash releasing savings. In order to ensure that service delivery can continue to improve and develop, the focus will need to move to improvements in operational productivity. This will require new approaches to driving and monitoring efficiency and productivity.

The Hospital’s vision is to incorporate the essential elements of the Sustainability & Value Programme, 2020 Vision, and the Health and Social Care Delivery Plan.

Current challenges include:

• Physical health inequality of our patients. • Redeployment of resources to meet the needs of

patients and drive out inefficiencies. • Requirements for recurring savings. • Excessively high levels of staff sickness. • High proportion of staff reaching retirement age. • Proactively support the national strategy in relation to

national Boards through collaborative working.

Fraud

The State Hospital continues to take a zero-tolerance approach to fraud. In 2019/20 the Hospital reviewed its top ten fraud risks, completed a Counter Fraud Assessment Tool, and saw the e-learning fraud module being completed by staff.

Annual Review

The Scottish Government monitors the Board’s performance (in relation to the quality of care and the efficient use of clinical, financial and people resources) through a process known as the Annual Review. Staff and members of the general public can attend as observers, and ask questions of Scottish Government officials and the Board Chair. The 2019/20 Annual Review is arranged for 10 November 2020. Annual Review meetings have been very positive and productive, with only a number of actions to follow up each year.

6.2 HIGH QUALITY PATIENT CARE AND TREATMENT

Clinical Quality Strategy

This year’s highlight was once again on Quality Improvement (QI) via the TSH3030 QI initiative. Building on last year’s success, TSH3030 was launched in September 2019 with 28 teams qualifying for the awards ceremony on 19 December 2019. Overall 146 staff and 64 patients were engaged with over 20 QI methods utilised. Projects ranged from increasing patient engagement & activity and staff health & wellbeing, to improving processes in the Hospital, and raising awareness of services and activities. Two days QI training was offered to teams by QI mentors prior to projects commencing.

Evaluation was positive with teams highlighting the benefits of multi-disciplinary working and the support provided to projects from across the Hospital.

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The organisation’s QI focus was recognised externally with the TSH3030 QI Project Team having been shortlisted for the ‘Psychiatric Team of the Year: Quality Improvement Award’ by the Royal College of Psychiatrists. The project was also commended by the Scottish Government Service Reform Team in their publication “Finding a Way Forward”.

Clinical Supervision and Values Based Reflective Practice (VBRP) for Ward-based Nurses

The Clinical Supervision and Values Based Reflective Practice (VBRP) for Ward-based Nurses policy was implemented with a standard of six sessions of supervision per year.

Monitoring and Measuring Care Quality

Assurance that clinical service delivery is safe, effective and person centred was enhanced in 2019/20 through the introduction of Excellence in Care, a nationally agreed set of clearly defined key measures / indicators of high-quality nursing care. These core and mental health specific nursing quality measures were introduced as part of the national assurance framework, focusing on areas such as culture, leadership, safety, effectiveness, person centredness and quality improvement.

Nursing representatives from The State Hospital played a key role in developing these measures during the year, working alongside other territorial boards and the Mental Welfare Commission for Scotland.

Work on a Care Assurance Information Resource (CAIR) dashboard progressed well, with information analyst time being funded to support this work.

Clinical Audit

During 2019/20, 23 clinical audit projects were undertaken (25 in 2018/19). These aim to provide feedback and assurance to a range of stakeholders that clinical policies are being adhered to. All clinical audit reports contain recommendations to ensure continuous quality improvement and action plans are discussed at the commissioning group.

Standards and Guidelines

In 2019/20, 184 publications (pieces of guidance / reports / standards) were issued setting out the priority areas for quality improvement in health and social care, compared to 206 in 2018/19. Of these, 42 had some relevance to the Hospital and 13 underwent a full evaluation with identified areas for improvement being embedded within relevant work-streams.

Research

Throughout 2019/20 research activity continued to focus on both conducting research and on implementing research findings into practice. Over the year, 13 studies were completed with 10 new studies approved to commence within the Hospital, giving a total of 27 studies ongoing at year end.

The annual State Hospital and Forensic Network Research Conferences were both conducted with considerable contribution from State Hospital staff, and very positive feedback from those who attended.

The Research Committee Annual Report 2019/20 notes 15 published journal articles, and the delivery of 31 research focused presentations across local, national and international events.

Campus

Campus

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Skye Centre Building(patient therapy and activity)

7. Person Centred

“Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communications and shared decision making.”

7.1 ACCESS TO SERVICES

Referrals, Admissions and Transfers

The Care Programme Approach (CPA) is a structured process for the management of risk and the care and treatment planning of patients. There is a target of 100% of all discharges and transfers from The State Hospital to be managed by the CPA process which includes Transfer / Discharge CPA meetings, CPA Reviews and CPA Contingency Planning meetings – including those convened under the Early Discharge Protocols. Furthermore, there is a need for the transfer pathway and risk management arrangements to be facilitated by the CPA process and / or Multi-Agency Public Protection Agency (MAPPA) for a relatively small number of high profile patients.

Key Performance Indicator (KPI)Patients are transferred / discharged using CPA.

All patients were discharged / transferred using the Care Programme Approach (CPA). This year’s 100% compliance was an increase on last year’s performance of 97%.

Campus

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Appeals Against Excessive Levels of Security 2019/20 (23)

Successful

Not Upheld

Cancelled/ Withdrawn

Appeals Against Excessive Levels of Security

The Mental Health Tribunal gives patients the right of appeal against excess security. In 2019/20 there were 23 appeals: 19 successful, one not upheld, and three cancelled / withdrawn.

7.2 HIGH QUALITY PATIENT CARE AND TREATMENT

Care and Treatment Planning

Treatment planning processes within the Hospital are well established. There is a co-ordinated approach to annual and intermediate reviews, the Care Programme Approach (CPA), clinical risk assessments, Integrated Care Pathways (ICPs), and to ensuring that the Hospital meets national guidance and legislation relating to treatment planning and discharge processes.

Within a safe and secure setting, expert and high quality, care and treatment is delivered by multi-disciplinary teams comprising psychiatry, nursing, occupational therapy, pharmacy, psychology, activity and recreation, social work and security.

Key Performance Indicator (KPI)Patients have their care and treatment plans reviewed at six monthly intervals.

Performance decreased in 2019/20 with 88% of patients having their care and treatment plans reviewed at six monthly intervals compared to 96% achieved in 2018/19. The target is 100%. An increase in compliance is predicted for 2020/21.

Key Performance Indicator (KPI)Patients will have their clinical risk assessment reviewed annually.

Performance remained only slightly below the 100% target throughout the year. The average figure for this indicator in 2019/20 was 97.68%.

Attendance by Clinical Staff at Case Reviews

In addition to multi-disciplinary clinical teams, all patients are assigned a Key Worker on admission to the Hospital. The Key Worker is an experienced Registered Nurse who, in collaboration with the patient, is responsible for the assessment, planning, implementation and evaluation of the day to day care of the patient. As the identified practitioner for a small group of patients, the Key Worker will develop a positive, caring, and therapeutic relationship over time with each of their patients and their family or carers. The Key Worker is supported by an Associate Worker.

Key Performance Indicator (KPI)Attendance by clinical staff at case reviews.

The table below provides comparative data on the extent to which professions met their attendance target.

Attendance at Case Reviews by Clinical Staff Target 2018/19 2019/20

Responsible Medical Officer (RMO) 90% 90.9% 90%

Medical 100% 97% 96%Key Worker (KW) / Associate Worker (AW) 80% 63.6% 78.3%

Nursing 100% 96.5% 97.8%

Occupational Therapy (OT) 80% 64.2% 86.3%

Pharmacy 60% 59.4% 61.3%

Clinical Psychologist 80% 84.3% 71.3%

Psychology 80% 84.5% 87.8%

Security 60% 41.2% 52.5%

Social Work 80% 80.8% 73.8%

Dietetics tbc 23.6% 60.8%

Skye Centre Activity tbc 1.1% 2.3%

Hospital Wide n/a 65.6% 71.5%

Medicines Management

The State Hospital’s Pharmacy services continue to be provided from NHS Lothian which includes medicines supply from St John’s Hospital, Livingston plus a specialist on-site Clinical Pharmacy Service. This ensures all patients have a regular review of both their physical and mental health medicines, and supply challenges around medicine alerts and shortages are dealt with effectively.

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Through a local multi-disciplinary Medicines Committee three main work-streams are overseen. These include Medicine Management, Clinical Effectiveness, and Safe Use of Medicines. Key activities over the last 12 months have focused on policy development, quality improvement initiatives from clinical audit projects, resilience planning, and a proactive approach to reducing medication incidents. The introduction of electronic prescribing in collaboration with NHS Lothian remains a main objective supported through the Scottish Government’s eHealth Strategy.

Psychological Therapies Service (PTS)

Psychological therapies and assessments promote psychological wellbeing and reduce the risk of harm. Interventions help patients to understand how and why their mental health problems developed, the link between mental health and offending behaviour, what they need to learn about themselves and their situation to promote recovery and wellbeing, and how they can manage and prevent themselves from harming others in the future. The number of referrals to group therapies remains high. During the reporting period of January to December 2019: • There were 86 new referrals (compared to 80 in

2018/19).• 115 patients received individual highly specialist

interventions i.e. offence focused work, specialist psychological assessments and individualised therapy in recognition of the highly complex problems and needs of patients.

• Psychological therapy nurses delivered 14 group supervision sessions and 18 individual sessions to the nursing staff group.

• Two new interventions were developed to support the reduction of patient obesity.

• Active engagement took place with patients to encourage them to participate in psychological therapies.

• Two audits were undertaken to support clinical practice: (1) a formulation quality audit comparing formulations to the ideal, and (2) an audit of all research activity for the previous five years including the number of studies published.

Key Performance Indicator (KPI)Patients will be engaged in psychological therapies.

Performance over the course of the year was above target, with the exception of Quarter 2 which fell below the 85% target, however remained in the green zone.

Key Performance Indicator (KPI)Patients will commence psychological therapies <18 weeks from referral date.

All but one patient commenced treatment within this timescale in the course of the year.

Skye Centre Activities

The Skye Centre service is defined by four Activity Centres (Patient Learning, Sport & Fitness, Craft & Design, and Gardens & Animal Assisted Therapy) and also includes an Atrium where patients can access the Activity Group Room, Café, Library, Shop and Bank. A variety of groups and services are facilitated in the Skye Centre including the Patient Partnership Group, Christian Fellowship Group, Multi-faith services, Psychological Therapies groups and Allied Health Professions groups. In 2019/20, seven volunteers supported activity within the Skye Centre.

The Skye Centre Annual Report 2019/20 provides an update on patient activity from 1 June 2019 to 31 May 2020. Key pieces of work undertaken and future developments are also highlighted within the report. Key achievements during the year included delivery of the Patient Day Project, successful pilot and subsequent roll-out of the RiO patient timetable, and induction for new patient admissions. Key Performance Indicator (KPI)Patients will be engaged in off-hub activities.

This indicator has seen a slight improvement from 81.7% in 2018/19 to 83% in 2019/20. The target is 90%. There was slight fluctuation during the year that was mainly due to patient discharges and new admissions not being approved by the clinical team to attend activity at the Skye Centre within the agreed timeframe.

7.3 PERSON CENTRED IMPROVEMENT

Person Centred Improvement Service (PCIS)

The Person Centred Improvement Service (PCIS) supports services across The State Hospital through its diverse work-streams, namely:

• Person-centred specific improvement projects.• Meaningful stakeholder involvement: patients,

carers, volunteers and the public (limited to external regulatory / supporting bodies and third sector partners).

• Volunteer services. • Carer / Named Person / visitor support.• Spiritual and Pastoral Care. • Equality agenda. • Supporting the role of the Patients’ Advocacy Service

(PAS).

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The Person Centred Delivery Plan 2018/21 builds on the national commitment to provide services developed through “mutually beneficial partnerships between patients, their families and those delivering healthcare services, which respect individual needs and values and which demonstrates compassion, continuity, clear communication and shared decision making.”

The Person Centred Improvement Steering Group (PCISG) met regularly during the year to ensure compliance with legislative requirements and to support the service to respond to national drivers and enhance local practice.

Extensive partnership working with external stakeholder groups took place in 2019/20 including the Scottish Government Person Centred Stakeholder Group, Volunteer Scotland, Scottish Health Council, Health Improvement Scotland, and Carers’ Trust (Scotland).

Key pieces of work undertaken during the year include:

• Service review informing successful recruitment to vacant post.

• A new and improved feedback database to support a more effective approach to identifying themes and trends and to strengthen associated monitoring.

• Delivery of the person-centred ‘What Matters to You?’ (WMTY) initiative.

• Patient engagement in the Clinical Care Model Consultation process.

• Development of a process to enable patients to engage in the Staff and Volunteer Excellence Awards.

• Patient engagement in the TSH3030 quality improvement initiative.

• Addition of the ‘Building Thoughts, Connecting Blocks’ feedback mechanism to the patient feedback toolkit.

• Carers’ event as part of the national ‘Getting Carers Connected in their Communities’ initiative.

• Volunteers’ event as part of the national ‘Time to Celebrate’ initiative.

• Increased opportunity for the Board to hear stakeholder feedback through use of ‘Emotional Touchpoint’ presentations.

• Completion of the tendering process for the Patients’ Advocacy Service.

Further detail is captured in the PCIS Annual Report 2019/20 covering the period 1 November 2018 to 31 October 2019.

Stakeholder Feedback

The Board, staff and volunteers have a unique and long-term relationship with patients, carers and stakeholders. Emphasis is on actively gathering feedback, listening to patients and carers, and importantly, taking appropriate action in response. The ‘Patient Voice’ is embedded in the work of the Clinical Governance Committee and the wider Board.

The Datix system is used to record complaints. Feedback is recorded within a locally tailored database developed to support analysis through which person-centred themes are identified aligned to national initiatives including Excellence in Care, Realistic Medicine and What Matters to you?

Complaints accounted for 16% of the overall feedback received in 2019/20 compared to 15% in 2018/19 and 35% in 2017/18.

In 2019/20:

• 52 complaints were received from 21 complainants.• Seven (13%) complainants made one or more

complaints, compared to 35 (77%) complainants in 2018/19.

• Three carers submitted 21 complaints (1) (4) & (16) respectively, accounting for 40% of all complaints received. Although there was a decrease in the number of carers who made a complaint this year compared to the previous year (9), there was an increase in the number of complaints received from carers compared to the previous year (16).

• One carer accounted for 76% (16) of the total number of complaints made by carers. Of the 16 complaints received, 14 were closed in this reporting year, two of which were fully upheld and five partially upheld.

• The independent Patients’ Advocacy Service (PAS) continued to support patients who wish to make a complaint but do not wish to do so directly. This year PAS supported 48% (25) of all complaints received, similar to 46% (28) in the previous year.

Complainants who remain unhappy with The State Hospital’s response to their complaint can ask the Scottish Public Service Ombudsman (SPSO) to review their complaint. During 2019/20 two complaints were referred to the SPSO.

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7.4 HEALTH IMPROVEMENT

Within The State Hospital, patients are encouraged and supported to adopt a healthy lifestyle particularly in relation to smoking, activity, and nutrition. The State Hospital is a smoke free environment and has its own on-site Health Centre to meet the primary healthcare needs of patients, and a Sports & Fitness Centre which includes a sports hall and gym. The Supporting Healthy Choices group is well established and drives forward improvement.

As in previous years, the greatest challenge during the year related to the management of levels of obesity and its related physical health problems.

Mental Health

Improving mental health is The State Hospital’s core business within the requirements of the Mental Health (Care and Treatment) (Scotland) Act 2003 / 2015. The ultimate aim is to meet patients’ mental health needs, enabling, when appropriate, a move onto another setting.

Diagnosis is through assessment and formulation of patient risks and needs (psychological, physical, functional, social and spiritual). Each member of the multi-disciplinary clinical team contributes. The aim is to address identified treatment needs to support recovery from mental disorder and reduce the risk of future offending.

Partnership working with South Lanarkshire Council is well established and provides social work services for patients and their families in addition to liaising with patients’ designated Mental Health Officers (MHOs) across the country. Well-developed relationships exist with the Mental Health Tribunal Service for Scotland and the Mental Welfare Commission for Scotland, and good partnership working is in place across the Forensic Network to ensure patients are transferred as required. As an organisation committed to learning, The State Hospital continues to share its experience with other NHS mental health services and interested groups.

A strong relationship with the Open University was maintained, with five State Hospital Nursing Assistants enrolling in OU Mental Health Nursing qualifications in 2019. This is not only an excellent career and personal development opportunity for staff, but also contributes to the supply of Registered Nurses nationally. Interest in the programme is high, with four more successful applications for the 2020 intake.

Work-streams from the Scottish Patient Safety Programme (Mental Health) continued to be implemented across the Hospital, patient Integrated Care Pathways (ICPs) brought about improvements in patient care, standards and guidelines continued to be reviewed, and through psychological therapies patients were helped to improve their mental health, and to reduce and manage any future risk they may present to others (and / or themselves).

Over the reporting period of 1 November 2018 to 31 October 2019, key pieces of work delivered by the Mental Health Practice Steering Group (MHPSG) included:

• Monitoring of the outcome measures with improvement plans agreed where appropriate.

• Implementing updated patients’ admission guidance aimed at supporting the earliest possible engagement in activity for all newly admitted patients.

• A small scale test of change (as part of the TSH3030 quality improvement initiative) to trial a process to more effectively tailor Care Programme Approach (CPA) meetings to the needs of patients.

• A shift from quality assurance to quality improvement in terms of Advance Statements for patients.

• Supporting the delivery of Realistic Medicine within the Hospital.

• Ensuring that the development of any clinical practice takes cognises of the ‘What Matters to Me’ feedback.

Focus from 1 November 2019 included identifying opportunities to support continuity of clinically relevant 2019 TSH3030 projects, informing the developmentof the Implementation Plan for the new Clinical Care Model, contributing to the development of the new Carers’ Policy, and supporting the Triangle of Care assessment and emerging work-streams.

Physical Health

Patients often have very significant physical health needs related to risk taking behaviours such as substance misuse; or consequences of treatment over a prolonged time in institutional care; or are living with the effect of long term conditions.

The Physical Health Steering Group (PHSG) is responsible for the delivery of five key work-streams. Developments and progress against these work-streams are captured in the PHSG 12 month rolling report covering the period of 1 October 2018 to 30 September 2019.

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Highlights are provided below:

1. Primary Care Service (including long term conditions)

The Health Centre provides patients with a range of clinics and services focusing on health, disease prevention, and the monitoring and management of physical health conditions including:

• GP Service• Optician Service• Podiatry Service • Blood Monitoring• Dental Service• ECG Clinic• Physiotherapy Service• Practice Nurse and Triage Clinics

As per routine practice, all patients were offered an Annual Health Review (AHR), the Seasonal Flu Vaccination, and Colorectal Screening for patients aged between 50-74.

The number of days from patient admission to Sports & Fitness Induction decreased over the year, with 50% of admitted patients receiving their induction between 21 and 50 days. Although this is above the pathway target for access to Sports & Fitness, there has been a steady increase over the last two years in the number of patients able to complete the induction within one to 10 days following admission.

Key Performance Indicators (KPI)Annual Physical Health Review and Access to Primary Care. Patients requiring primary care services will have access within 48 hours.

The Health Centre consistently meets its targets. In 2019/20 the annual physical health review averaged at 98.48% and access to primary care was 100%. The 48-hour access statistics are based on access to the appropriate healthcare professional, not solely the GP. Currently this would include the Practice Nurse, General Practitioners, Junior Doctors, Physiotherapist, Optician, Dental Team and NHS24.

Key Performance Indicator (KPI)Healthier BMI.

The percentage of patients who have a healthier BMI decreased to 8.75% in 2019/20 from 13.7% the previous year.

2. Weight Management and Food, Fluid and Nutritional Care (FFCN)

In December 2019, rates of overweight and obesity were 89%. This data represents an ongoing decline in those patients who have and maintain a healthy weight (87.3% in 2018). Electronic monitoring of weight statistics is now in place through RiO and the Tableau database. Phase 2 of the Supporting Healthy Choices initiative commenced in January 2020.

As part of the FFNC standards, all patients need to be nutritionally screened and have a nutritional care plan in place - the latter approach has developed into holistic Health and Wellbeing Plans (HWP) for patients. In December 2019, 99% of patients had a Nutritional Screening Tool completed and 91% a HWP.

By 31 March 2020, patients newly admitted during 2018/19 gained on average 18.1% of their initial weight in the first year of admission, compared with 13.1% the previous year.

Various strands of weight management interventions exist. New for 2019 was the delivery of the adapted Healthy Living Group for patients with an intellectual disability, and the initiation of a Counterweight programme.

3. Physical Activity

Physical health inequalities for State Hospital patients is significant. Reducing obesity and increasing physical activity are key outcomes in addressing these inequalities.

Throughout the year, the Sports & Fitness Centre facilitated a range of both indoor and outdoor physical activities including table tennis, bowling, football and badminton. These were enhanced with the introduction of four challenges such as ‘cross bar’ and ‘high jump’ to maintain patient motivation and increase both interest and variety. Patients were also supported to use the gym equipment in the Sports & Fitness Centre and within ward areas.

Patient inductions took place both on the ward and within the Sports & Fitness Centre with every effort being made to encourage and involve ‘hard to reach’ patients.

There was an increase in the number of patients participating in moderate physical activity through the month of November 2019. This was due to numerous TSH3030 quality improvement initiatives focused on increasing patient physical activity levels. The majority of these activities took place in the evenings and at the weekends.

Certificates and trophies were presented to patients at the end of the year as part of the annual Sports & Fitness Awards.

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Additionally, during the year, six patients completed Level 4 of the Sports Leadership Course and three patients completed Level 5. Nine patients participated in the ‘Bikeability’ cycling proficiency programme and three patients became Sports Volunteers thus providing peer to peer patient support.

Key Performance Indicator (KPI)Patients will undertake 90 minutes of exercise each week.

The target for this indicator is 80% and the overall average for 2019/20 was 60.7%.

Quarter 1 saw the activity levels average at 64.2% which was an increase from the end of 2018/19 Quarter 4 data being 59.3%. Quarter 2 increased again to 66.4%, however there was a steady reduction through Quarters 3 and 4 being 59.2% and 53% respectively. Contributing factors to this decrease related to department closures over the Christmas public holidays and reduced grounds access due to diminishing light.

4. National Clinical Guidelines and Standards

Over the last 12-month period the Physical Health Steering Group was involved in the review of 77 guidelines / standards of which 59 were deemed to be either not relevant or were covered by a similar guideline. Of the remaining 18, 15 had varying degrees of relevancy to physical health services within The State Hospital and were sent out for information purposes, two awaited feedback from the GP, and one was subject of a recommendation review.

5. Training

The following provides an overview of health improvement related training completed in 2019/20 by staff:

Training Staff Completions

Guide to Healthy Eating online module 54

Healthy Eating in Forensic Settings online module 34

Physical Health Issues in Forensic Care online module 115

REHIS Food & Health Certificate course 8

Supporting Health Behaviour Change – MAP Training Programme 7

Two Health Champions Update Workshops

7 attending each

6. Education and Patient Learning

Within The State Hospital education and learning are widely recognised as important elements in promoting individual health and wellbeing, e.g. improvements in self-confidence and self-esteem, personal development and self-fulfilment, enhanced life and social skills, social inclusion and behavioural change.

Learning provision includes both accredited and non-certificated programmes and the Hospital has ‘approved centre’ status with a number of qualification awarding bodies including the Scottish Qualification Authority (SQA), the British Computer Society (BCS), the Royal Environmental Health Institute of Scotland (REHIS), and Sports Leaders UK.

At 31 December 2019:

• 72 patients had engaged in formal or accredited learning.

• 24 new referrals to the Patient Learning Centre were processed.

• 23 patients ceased attendance (mainly due to leaving the Hospital).

• 100 patients (95% of the patient population) had been invited to complete the core skills screening process. Of these, 87 patients (87%) completed the screening process, nine declined to take part (9%) and four were unable to participate due to poor mental health (4%).

• Seven patients engaged in the literacy programme.• Two patients participated in open / distance learning

programmes.• One patient was awarded a ‘Certificate of Higher

Education in Psychology’.• Eight vocational programmes were delivered and 43

vocational qualifications were successfully achieved.• 12 patients regularly took part in the weekly Patient

Reading Group.• Six patients took part in the Reading Ahead national

library initiative.• 52 patients completed a learning evaluation

questionnaire (an increase of 24% from the previous year).

At the Staff and Volunteer Excellence Awards Ceremony in October 2019, three individuals were recognised by both staff and patients for their commitment toproviding patient learning activities: one staff member from the Craft and Design Centre and two volunteers from the Patient Learning Centre.

The Patient Learning Annual Report 2019 provides full details of activities and achievements over the 12-month period covering January to December 2019.

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Campus showing Staff Offices

8. Workforce

2020 Workforce Vision

Everyone Matters is the workforce policy for NHSScotland. It supports the 2020 Vision for Healthcare in Scotland and the NHSScotland Healthcare Quality Ambitions of person centred, safe and effective.

The 2020 Workforce Vision Everyone Matters sets out the core values of NHSScotland which are:

• Care and compassion• Dignity and respect• Openness, honesty and responsibility• Quality and teamwork

“We will respond to the needs of the people we care for, adapt to new, improved ways of working, and work seamlessly with colleagues and partner organisations. We will continue to modernise the way we work and embrace technology. We will do this in a way that lives up to our core values. Together, we will create a great place to work and deliver a high quality healthcare service which is among the best in the world.”

The five priorities within the implementation plan are:

• Healthy organisational culture• Sustainable workforce• Capable workforce• Integrated workforce• Effective leadership and management

The implementation plan for the 2020 Workforce Vision continues to inform the planning process for the Staff Governance action plan. In 2019/20 focus was on:

• Embedding iMatter as a continuous improvement tool to improve staff experience with emphasis on responding to feedback, improving leadership visibility and staff engagement.

• Taking action to promote health, wellbeing and resilience.

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• Working across organisational and professional boundaries to share good practice in learning and development, evidence-informed practice, and organisational development.

• With our partners, developing workforce planning capacity and capability in the integrated setting.

• Delivering actions within the overview paper “Executive Level Leadership and Talent Management in the NHS in Scotland” published May 2017.

Particular attention was given to the launch of Long Service and Staff Excellence Awards. Both initiatives were very well received across the organisation.

Staff Governance

The Board recognises that its most valuable resource is undeniably its staff, and acknowledges the importance of staff governance as a feature of high performance which ensures that all staff have a positive employment experience in which they are fully engaged with both their job, their team, and their organisation.

The Staff Governance Standard sets out what each NHSScotland employer must achieve in order to improve continuously in relation to the fair and effective management of staff. It highlights the need for staff to be valued, shows that investment in staff is a direct investment in patient care, and specifies that staff are entitled to be:

• Well informed• Appropriately trained • Involved in decisions which affect them• Treated fairly and consistently• Provided with an improved and safe working

environment

Measurement of organisational success is against the elements of the Standard through iMatter and the use of the national Annual Monitoring Return.

Fitness to practice governance arrangements are in place for professional registration, continuous professional development, and clinical supervision.

In 2019/20, the Staff Governance Committee continued to focus its monitoring activities in respect of the above. The Committee members recognised their obligations to support a culture where the delivery of the highest possible standard of staff management is understood to be the responsibility of everyone working within the organisation and is built upon the principles of partnership. The Committee met on four occasions during the year in line with its terms of reference: 23 May 2019, 29 August 2019, 28 November 2019 and 20 February 2020.

The main priority area in terms of Staff Governance performance management continues to be the pursuit of the Attendance Management target of 5% absence.

The Staff Governance Annual Report 2019/20 provides full details of activity during the year.

Workforce Plan

In October 2019, the Board endorsed a new Clinical Model and the Implementation Plan for this provides the framework for the Workforce Plan going forward together with the Common Staffing method defined by the Health and Care (Staffing) (Scotland) Bill.

Attendance Management

One of the key achievements during the year was the significant reduction in sickness absence. The end of year average monthly absence percentage was 5.92%; an improvement of 2.34% from the 2018/19 figure of 8.26%. Also on a positive note, compliance with notifying absence to EASY (Early Access to Support for You) was 90%. The EASY service provides early intervention and support to employees who have reported absent for work. Key Performance Indicator (KPI)Sickness Absence. As detailed above, the rate of absence was 5.92% in 2019/20 compared to 8.26% the previous year; a reduction of 2.34% enabling a move from the red zone in 2018/19 to the green zone in 2019/20. This target is 5%

Staff Experience (iMatter and Dignity at Work)

The State Hospital’s response rate of 79% in 2019 (77% in 2018) was the fifth highest across NHS Scotland for the Health and Social Care Staff Experience Report 2019 which describes how NHS Scotland performed on iMatter, the Staff Experience survey. Overall, The State Hospital compared favourably with NHS Scotland colleagues with the average response rate for NHS Scotland being 62% for 2019 (59% in 2018). Additionally in 2019, The State Hospital achieved a score of 77 on the Employee Engagement Index (EEI), compared with the national score of 76.

In 2019/20 there were four Dignity at Work cases (three in 2018/19) and one Whistleblowing case (zero in 2018/19).

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Fitness to Practise

In 2019/20 all professional staff were registered and fit to practise with no lapses in registration.

Principles of Sturrock Review

In response to the report to the Cabinet Secretary for Health and Sport into cultural issues relating to allegations of Bullying and Harassment in NHS Highland that was carried out by John Sturrock QC, a programme of work was established to take forward the following themes within The State Hospital: Communications and Engagement, Leadership and Management, Human Resources, Culture and Behaviours, Staff Support, and Governance.

This included a staff survey, results of which formed a presentation that was discussed at various meetings and then rolled out to staff through focus groups led by Heads of Departments. The feedback and learning from the meetings and focus groups was incorporated into the Culture, Values, Behaviours and Leadership work-stream.

Values and Behaviours

The Board is committed to investing in staff and recognising them for the great work that they do. To this end, staff recognition was the number one priority during 2019/20 with the launch of the Staff Excellence Awards and Long Service Awards. Around 100 staff, volunteers, patients, and guests from the Scottish Government, NHS Lanarkshire, Community Engagement and the Mental Welfare Commission gathered for the celebration. The event received positive feedback from the many attendees.

Additionally, every effort was made throughout the year to increase visibility across the site of The State Hospital’s core values: (1) care and compassion, (2) dignity and respect (3) openness, honesty and responsibility, and (4) quality and teamwork.

In February 2020 work commenced to create a sustainably improved:

• Organisational culture.• Level of staff engagement, morale and sense of value.• Team approach and fidelity to the values of the

organisation.• Sense of worth and empowerment for all staff

Hospital-wide.• Leadership and development model for The State

Hospital.

Knowledge and Skills Framework (KSF)

All staff covered by Agenda for Change (AfC) - modernised NHS pay system - are required to take part in an annual review against a KSF post outline. As at 31 March 2020, 99.5% of posts had a validated KSF outline assigned, 46.3% of staff had a live Personal Development Plan (PDP) in place, and 84.1% of staff had an annual review undertaken and recorded on the Turas Appraisal system during the previous 12 months.

Key Performance Indicator (KPI)Staff have an approved PDP.

The PDR compliance level at 31 March 2020 was 84.1% against a target of 100% compared to 80.9% in 2018/19.

Mandatory and Statutory Training

Organisational compliance levels for statutory and mandatory training at 31 March 2020 were 94.5% compliance for statutory training and 85.9% for compliance for mandatory training.

Healthy Working Lives (HWL)

The State Hospital has held the Healthy Working Lives Gold Award since 2008. Driven by the HWL Group, activities undertaken during the year related to smoking, mental health, drug and alcohol misuse, physical activity, healthy eating, and health, safety and wellbeing.

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• 14 Fitech fitness and lifestyle assessments were undertaken with either advice being given or onward referrals made to their GP as appropriate for follow up.

• 526 staff were screened for fitness to participate in Prevention and Management of Violence and Aggression (PMVA) training; a 53% increase from last year.

• 108 Hepatitis B vaccines were administered or bloods taken.

• The overall uptake of the flu vaccine was 278 (43%); an increase of 40 from last year.

• Similar to previous years, there were 133 new physiotherapy referrals.

• 17 employees accessed the Time for Talking Employee Assistance programme.

• Demand for referrals to the Keil Centre decreased to 10 from 24 last year.

Carer Positive Scheme

Accreditation relating to the Carer Positive Scheme remained at Level 1 (Engaged) in 2019/20. This means the organisation has awareness of carers within the workforce and has made a commitment to support carers through workplace policies / working practices, there is some evidence that systems and processes have been developed to support this, and carers are supported to identify themselves as carers and can access support within the organisation to help them manage their work and caring responsibilities.

Disability Confident Scheme

The State Hospital has achieved Level 2 of the Disability Confident Scheme (which demonstrates that the Hospital is positive about employing people with a disability) and is working towards achieving Level 3.

Of particular note:

• Go with Flo’ was run for the second time and ‘Quit Your Way’ was promoted.

• Suicide awareness was promoted, 10 staff yoga sessions took place, two workshops on Developing Personal Resilience were delivered, and Time to Talk day (February 2020) was promoted.

• The Drug and Alcohol Misuse Policy was reviewed.• The ‘Daily Mile’ staff walking initiative and local

park runs were promoted as was staff use of Sports facilities, six places were funded at the Glasgow Santa Dash, and a Manual Handling Quiz was undertaken in October 2019 with prizes of a Misfit stepper tracker or a posture assessment and back massage.

• Through the Supporting Healthy Choices initiative, information on key health conditions that were prevalent in the Hospital were promoted, Health Champions remained in key locations across the organisation, Dietitians’ Week (June 2019) was promoted and supported, access to healthy eating recipes was provided via the Intranet, and information on nutrition and hydration continued to be made available at health fayres.

• The Healthy Living Plus Award was retained, a healthy meal option in the staff dining room was provided daily, healthy eating promotional days were featured regularly, services provided by Occupational Health were promoted, our Staff Excellence Awards including Long Service Awards were launched, a ‘You’ve Been Mugged’ initiative took place, MacMillan Coffee Mornings were held, and BackCare Awareness Week in October 2019 was promoted and supported.

Feedback from all these events was positive.

Occupational Health Service

The Occupational Health Service continued to promote and maintain the physical, mental and social wellbeing of staff through the provision of a confidential advisory service on issues concerning health and work, health surveillance, immunisation, follow up of injuries / traumatic incidents, training, workplace assessments, health promotion activities, counselling and policy formation.

Within the 2019/20 reporting period:

• There were 216 management referrals (259 in 2018/19) and 37 self-referrals (a reduction of around 48% from the previous year).

• 99 pre-placement health assessments were carried out; an increase of 24 (25%) from 2018/19.

• Vision screening tests remained the same as last year – a total of nine.

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Board Members’ and Senior Managers’ Register of Interests 2019/20

Name Interest

T CurrieChairperson

Deputy Lieutenant, LanarkshireChair, St Ambrose High / Buchanan High Site Recovery Group

W BrackenridgeNon Executive None

T HairEmployee Director Director of Drumchapel Community Credit Union

N JohnstonNon Executive Chief Executive, Educational Competencies Consortium Ltd

D McConnellNon Executive None

B MooreNon Executive(from 1 February 2020)

Board Member, NHS Lanarkshire Trustee of NHS Lanarkshire Endowment Fund Voluntary Management Committee member of Clydesdale Housing Association

M WhiteheadNon Executive (to 29 February 2020)

None

G JenkinsChief Executive

Chair of Scottish Healthcare in Custody Network including Police Care Network and Prison Care Network

E AndersonActing Interim HR Director (16 December 2019 to 31 March 2020)

None

R McNaughtFinance & Performance Management Director

Member, Audit Committee, Mental Welfare Commission for Scotland

M RichardsDirector of Nursing & AHPs Professional Advisor to Scottish Public Sector Ombudsman

K SandilandsInterim HR Director (to 31 March 2020)

None

L ThomsonMedical Director

Medical Director, Forensic Mental Health Services Managed Care NetworkProfessor of Forensic Psychiatry, The University of Edinburgh

D WalkerDirector of Security, Estates and Facilities

None

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Board Governance Committees 2019/20

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Clinical Governance CommitteeMembership Role

N Johnston (Chair)D McConnellB Moore (from 1 February 2020)M Whitehead (to 29 February 2020)

To ensure that clinical governance mechanisms are in place and effective throughout the Board, and to ensure that the principles and standards of clinical governance are applied to the health improvement activities of the Board. It met four times during 2019/20.

Audit CommitteeMembership Role

D McConnell (Chair)W Brackenridge T HairB Moore (from 1 February 2020)M Whitehead (to 29 February 2020)

To oversee arrangements for external and internal audit of the Board’s financial and management systems and to advise the Board on the strategic processes for risk, control & governance. It met four times during 2019/20.

Staff Governance CommitteeMembership Role

W Brackenridge (Chair)T HairN JohnstonB Moore (from 1 February 2020)M Whitehead (to 29 February 2020)

To ensure that the Board has an effective system of consistency of policy and equity of treatment of staff, including remuneration issues, where they are not already covered by existing arrangements at national level. And to encourage, support and monitor partnership working. It met four times during 2019/20.

Remuneration CommitteeMembership Role

T Currie (Chair)W Brackenridge T HairN Johnston D McConnellB Moore (from 1 February 2020)M Whitehead (to 29 February 2020)

To consider performance-related pay in respect of Senior Managers and employees of the Board, to consider and agree appraisal outcomes of Executive Directors to be submitted to the national Performance Management Committee, and to consider and approve the award of Consultants Discretionary Points. It met three times during 2019/20.

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THE STATE HOSPITAL

AT A GLANCE 2019/20Key Performance Indicators (KPIs)

GREEN (G) - Achieved / ExceededAMBER (A) - Working TowardsRED (R) - Needs Improvement

THE STATE HOSPITAL

AT A GLANCE 2019/20Key Performance Indicators (KPIs)

GREEN (G) - Achieved / ExceededAMBER (A) - Working TowardsRED (R) - Needs Improvement

Patients have their care and treatment plans reviewed at six monthly intervals.

Target 100%

RESULT 91.73%A

Patients will be engaged in psychological therapies.

RESULT 87.93%G

Target 85%

Patients will be engaged in off-hub activity centres.

Target 90%

RESULT 83%A

Patients will be offered an annual physical health review.

Target 90%

RESULT 98.48%G

Patients will undertake 90 minutes of exercise each week (Annual Audit).

RESULT

60.7%R

Target 80%

Patients will have a healthier Body Mass Index (BMI).

RESULT 8.75%R

Target 25%

Staff have an approved Personal Development Plan (PDP).

Target 80%

RESULT 86.68%G

.......... AT A GLANCE 2019/20

SUMMARY

12 x Key Performance Indicators (KPIs)

Of these: 7 x green, 3 x amber and 2 x red PLUS

Responsible Medical Officer (RMO)Medical Key Worker (KW) / Associate Worker (AW)NursingOccupational Therapy (OT)PharmacyClinical PsychologistPsychologySecuritySocial WorkDieteticsSkye Centre Activity* Hospital Wide

* Only attend Annual Reviews

Target

90%100%

80%100%80%60%80%80%60%80%n/an/an/a

2019/20

90% G96% A

78.3% A97.8% A86.3% G61.3% G71.3% R87.8% G52.5% R73.8% R60.8%2.3%71.5%

Attendance at Case Reviews by Clinical Staff

For further information please contact:The State Hospital, Carstairs, Lanark ML11 8RPTel: 01555 840293 Email: tsh.info@nhs.net Web: www.tsh.scot.nhs.uk

Target 5%

Sickness absence (National HEAT stardard is 4%).

RESULT 5.92%A

Target 100% Patients will have their clinical risk assessment reviewed annually.

RESULT

97.68%G

Patients are transferred / discharged using the Care Programme Approach (CPA).

Target 100%

RESULT 100%G

Target 100% Patients requiring primary care services will have access within 48 hours.

RESULT 100%G

Patients will commence psychological therapies <18 weeks from referal date.

Target 100%

RESULT 99.78%G

27App

endi

x 3

App

endi

x 3

Staff have an approved Personal Development Plan (PDP).

Target 80%

RESULT 86.68%G

.......... AT A GLANCE 2019/20

SUMMARY

12 x Key Performance Indicators (KPIs)

Of these: 7 x green, 3 x amber and 2 x red PLUS

Responsible Medical Officer (RMO)Medical Key Worker (KW) / Associate Worker (AW)NursingOccupational Therapy (OT)PharmacyClinical PsychologistPsychologySecuritySocial WorkDieteticsSkye Centre Activity* Hospital Wide

* Only attend Annual Reviews

Target

90%100%

80%100%80%60%80%80%60%80%n/an/an/a

2019/20

90% G96% A

78.3% A97.8% A86.3% G61.3% G71.3% R87.8% G52.5% R73.8% R60.8%2.3%71.5%

Attendance at Case Reviews by Clinical Staff

For further information please contact:The State Hospital, Carstairs, Lanark ML11 8RPTel: 01555 840293 Email: tsh.info@nhs.net Web: www.tsh.scot.nhs.uk

Target 5%

Sickness absence (National HEAT stardard is 4%).

RESULT 5.92%A

Target 100% Patients will have their clinical risk assessment reviewed annually.

RESULT

97.68%G

Patients are transferred / discharged using the Care Programme Approach (CPA).

Target 100%

RESULT 100%G

Target 100% Patients requiring primary care services will have access within 48 hours.

RESULT 100%G

Patients will commence psychological therapies <18 weeks from referal date.

Target 100%

RESULT 99.78%G

The State Hospita

ls

Board

for

Sco

tlan

d

The State Hospitals Board for ScotlandCarstairs, Lanark ML11 8RPTelephone 01555 840293Email: tsh.info@nhs.scotwww.tsh.scot.nhs.uk

Safe and Secure Care, Treatment and Recovery