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Annual Report2017/18

The State Hospitals Board for Scotland

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Section Title Page Number

1 FOREWORD 3

2 THE STATE HOSPITALS BOARD FOR SCOTLAND 4

3 STANDARDS AND GUIDELINES OF CARE 5

4 OUR VISION, VALUES, AIMS AND STRATEGY 6

5 PERSON CENTRED 7

5.1 ACCESS TO SERVICES 5.2 HIGH QUALITY PATIENT CARE AND TREATMENT 5.3 INVOLVEMENT, ENGAGEMENT AND FEEDBACK 5.4 HEALTH IMPROVEMENT

6 SAFE 14

6.1 HIGH QUALITY PATIENT CARE AND TREATMENT

7 EFFECTIVE 19

7.1 EFFICIENT AND EFFECTIVE USE OF RESOURCES 7.2 HIGH QUALITY PATIENT CARE AND TREATMENT

8 WORKFORCE 23

APPENDICES 27

Appendix 1 - Board Members’ and Senior Managers’ Register of Interests 2017/18 Appendix 2 - Board Governance Committees 2017/18

INDEX

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1. Foreword

Jim Crichton, Chief Executive and Terry Currie, Chairman

The Annual Report is an opportunity to share with the public the tremendous work undertaken by our staff on a daily basis. Their commitment and enthusiasm across all areas of the service is a testament to their skill, compassion and courage. As the outgoing Chairman and Chief Executive, we celebrate their success while recognising the significant areas of improvement that must be achieved. Our Patients Maintaining our focus on targeting health inequalities among our patient group has been a primary objective. The Healthy Choices Task Group has led the way on this initiative by taking forward the Board Action Plan on improving healthy eating. This included improving the healthy choices available from the Hospital shop and ending access to external food orders. In tandem, a range of initiatives were initiated to increase access to physical activity for patients. We were pleased to be able to maintain a smoke free environment following the outcome of the Supreme Court Appeal Hearing. Respiratory and cardiovascular related illnesses had previously played a significant role in reduced life expectancy of our patients. Our focus on rehabilitation has been maintained and is illustrated through over half of our patients being discharged into lower levels of NHS Forensic Care.

Our Staff Supporting our staff to do the job well and ensuring good team work is essential if our quality care is to be maintained. The iMatter Survey provides staff with an opportunity to feedback on their experience within the organisation. We achieved a response rate of 78% compared with an average of 63% for NHSScotland. We were delighted to achieve the Healthy Working Lives Gold Award for the 11th year running with a sustained effort to create the conditions for a healthy and safe working environment. In the past year alone we have seen the introduction of EASY to support staff who are unable to be at work, physical activities delivered at the Sports & Fitness Centre, the Eat Safe Award for Excellence in Food Hygiene, flu clinics, and training in mental health related areas. Our Challenges The level of staff absence continues to be the major area of concern. The adverse effect upon our service and quality of care has been significant. We are all working tirelessly to ensure that everyone and every day counts. The achievements in this report are a tribute to the outstanding commitment of all staff. Their dedication and hard work often in the most challenging circumstances are what allow us to make progress and we greatly value and appreciate all they do.

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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 140 high-secure beds for male patients requiring maximum secure care: 12 beds specifically for patients with a intellectual disability. 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 2017/18 there were 30 patient admissions and 33 patient discharges.

• 75.9% of the 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.

• The majority of admissions and discharges were from / to the prison service and other NHS hospitals.

• All patients are male, with an average age of 42. The most common primary diagnosis is schizophrenia. The current average length of stay is six years, with individual lengths of stay ranging from less than one month to over 30 years.

Staff

• As at 31 March 2018, 643 staff worked at The State Hospital.

Patient Admissions (30)

Other NHS Hospitals

Prisons

Courts

Community

Police

Staff Headcount as at 31 March 2018 (643)

Administrative Services

Allied Health Profession

Medical / Dental

Nursing / Midwifery

Other Therapeutic

Senior Managers

Support Services

2. The State Hospitals Board for Scotland

Patient Discharges (33)

Prisons

Other NHS Hospitals

Courts

Community

Police

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NHS boards are expected to abide by national service standards and guidelines. This includes meeting Local Delivery Plan (LDP) standards. The LDP sets out the strategic plan for the Board and is the product of an inclusive planning process with integration of risk management with service, financial and workforce planning. Success is measured against a set of Key Performance Indicators (KPIs). Most LDP standards are former ‘HEAT’ targets, with HEAT being an acronym relating to four key objectives:

• Health Improvement.• Efficiency and Governance Improvements.• Access to Services.• Treatment Appropriate to Individuals.

The only national LDP standards directly relevant to The State Hospital are Psychological Therapies Waiting Times, GP Access, and Sickness Absence.

The LDP is being replaced by an Annual Operational Plan for 2018/19 focusing primarily on performance, finance and workforce - drawing together key planning assumptions which reflect local priorities.

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.

Performance targets have been aligned with the three Quality Ambitions in the national NHSScotland Healthcare Quality Strategy: person centred, safe and effective. 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.”

3. Standards and Guidelines of Care

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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 NHSScotland 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. Following the 2017 session, a 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) has been 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.

The State Hospital’s Clinical Model

Care and treatment in the Hospital follows a well-established Clinical Model based on nine principles:

• Integration. • Patient-Focused Care. • Individualised Care Pathways. • Positive Therapeutic Milieu. • Supporting Staff. • Strengthen Multi-Disciplinary Working. • Violence Risk Assessment and Management. • Comprehensive Mental & Physical Health Care and

Treatment. • Clinical Governance Strengthens and Informs Care.

4. Our Vision, Values, Aims and Strategy

Campus

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“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.”

5.1 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. As part of the Local Delivery Plan (LDP), there is a target of 100% of all discharges and transfers from The State Hospital to be managed by the CPA process. This includes transfer / discharge, CPA meetings, CPA Reviews and CPA Contingency Planning meetings.

Additionally, 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.

A CPA / MAPPA Annual Report covering the period 1 July 2017 to 30 June 2018 has been produced. During the review period, 31 patients were transferred or discharged with the LDP target being achieved in 97% of cases.

All patients are invited and encouraged to attend their CPA transfer / discharge meeting. During the year 87% of patients attended which was a slight increase from the previous reporting period.

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

97% of patients (30 out of 31) were discharged / transferred using the Care Programme Approach (CPA) against a target of 100%, which is a decline on last year’s performance of 100%. The circumstances around the absence of a CPA for one patient resulted in a Significant Untoward Incident (SUI) review and learning points have been agreed.

Skye Centre(patient activitiesand therapies)

5. Person Centred

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Key Performance Indicator (KPI)80% of patients attend their Annual Care Programme Approach (CPA) Review Meeting.

Given the nature of the patient group, there are a number of reasons which may impact on a patient’s ability to attend CPA Meetings, including concentration skills and positive symptoms of mental illness. Data therefore reflects whole or partial attendance, as a tailored approach to individual preference is encouraged. Data illustrates that 68% of patients attended their CPA Review Meeting. Attendance continues to be reported via the Variance Analysis Tool and Clinical Outcomes process, with one of the current Equality Outcomes dedicated to improving performance around patient involvement.

New Key Performance Indicator (KPI)The percentage of patients attending annual and intermediate CPAs.

This high level data will be reported to the Board as a trend over time given the difficulty in determining a hard target at this point (i.e. the ability, appropriateness or willingness of patients to attend full review etc). However, the comparative data across hubs that is already produced (and demonstrates significant differences in practice) is now being fed into the newly established Hub Leadership Teams for their consideration and response.

Appeals Against Excessive Levels of Security

The Mental Health Tribunal gives patients the right of appeal against being detained in excessive security. In 2017/18 there were eight appeals: six successful and two cancelled.

5.2 HIGH QUALITY PATIENT CARE AND TREATMENT

Care and Treatment Planning

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. When appropriate, the aim will be for the patient to move on, whether that is return to prison, transfer to a lower security hospital, or, in rare cases, discharge into the community. This takes on board best practice recovery models and approaches. Risk assessment and management is integral.

Services for patients with an intellectual disability tend to be more intensive, at a slower pace, and have a greater need for consistency, communication and engagement.

A significant number of patients have one or more risk factors for cognitive impairment, secondary to longstanding severe schizophrenic illness, substance misuse (including alcohol) and acquired brain injury. Such impairment may impact on patients’ understanding of, and compliance with, treatment. Assessments are carried out on admission and include specialist assessments for areas of specific identified difficulties. This should lead to services being tailored to meet individual need.

The requirement for processes to be in place to support early detection of dementia is addressed through cognitive screening as part of the psychology assessment undertaken on admission; and by multi-disciplinary clinical teams being alert to patients who present a reasonably high index of suspicion (certain patient groups are more susceptible). When required, a specialist neuro-psychology assessment is conducted.

Treatments and activities are provided within high secure conditions, and are tailored to meet the requirements of individual patient risk assessment and management plans.

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

Performance improved in 2017/18 and the figure for March 2018 was 95.4% compared to 91% in the previous year against a target of 100%. More robust systems are now in place with a future audit being planned to ensure the system is working efficiently at all points in the process.

New Key Performance Indicator (KPI)All patients will have a minimum of a weekly one to one discussion with their key worker documented in their records.

A function has now been introduced to RiO (electronic patient record) to capture key worker 1:1 discussions.

The current programme of audit only covers evidence of ongoing discussion between the patient and key / associate worker about the patient’s care and progress. Work has commenced to adjust the audit to ensure monitoring and reporting is aligned with this KPI.

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

Performance has remained only slightly below the 100% target throughout the year. The figure for March 2018 was 99.1% with only one out of date, compared to 97% in March 2017. The system put in place from April 2017 has worked well over the past year and clinical risk assessments are now being completed timeously and in line with significant dates for each patient (e.g. date of renewal of detention or annual report).

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Attendance by Clinical Staff at Case Reviews

Multi-disciplinary clinical teams comprise a wide range of highly skilled professional staff in the fields of psychiatry, nursing, occupational therapy, pharmacy, psychology, activity and recreation, social work and security.

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.

New 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 Local Delivery Plan (LDP) attendance target.

Clinical Staff Target 17/18 16/17 Increase / Decrease

Responsible Medical Officer (RMO)

90% 94.8% 96.8% -2.2%

Medical 100% 97.5% 99.5% -2.0%

Key Worker / Associate Worker

80% 75.2% 71.8% 3.2%

Nursing 100% 96.4% 97.3% -0.9%

Occupational Therapy 80% 65.5% 47.9% 17.6%

Pharmacy 60% 57.2% 74.5% -17.8%

Clinical Psychologist 80% 69.6% 72.3% -2.7%

Psychology 100% 90.8% 96.2% -5.4%

Security 60% 59.8% 59.6% 0.2%

Social Work 80% 79.9% 75.5% 4.4%

Medicines Management

The Medicines Committee oversees all aspects of medicine throughout the Hospital including their effective and economic use, policies and clinical audit.

A Medicines Committee report covering the period 1 October 2016 to 30 September 2017 has been produced. Key areas of work during this period included updates of three major medicine policies, approval of guidance on the use of unlicensed intra-muscular clozapine and implementation of a pharmacist prescriber in line with an agreed framework.

The report noted an extensive programme of Clinical Audit projects has continued (both local and national) as well as working with the Patient Safety Group on local medicine topics.

The supply of medicines to The State Hospital switched from The Royal Edinburgh Hospital to St John’s Hospital, Livingston in June 2017. The transition went smoothly.

Psychological Therapies Service (PTS)

The purpose of psychological services at The State Hospital is to provide assessments and interventions that promote psychological wellbeing in a safe, efficient and effective way and to reduce the risk of harm.

The psychology therapies service includes psychology assessments (e.g. admission assessments, risk assessment, cognitive assessment and formulations), the provision of psychological therapies, enhancing the therapeutic milieu, multi-disciplinary working within clinical teams, training, evaluation, and research.

The Psychological Therapies Service Annual Report covering the period January to December 2017 is centred on the six quality dimensions of the NHSScotland Healthcare Quality Strategy. Key service developments during 2017 included the Connections programme; Safety and Stabilisation training; sustained focus on healthy living via National Education for Scotland (NES) funded health psychology trainees; sharing practice and updates with the Forensic Matrix Implementation Group; delivering external training and producing a referral and guidance booklet.

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

Performance over the course of the year was consistently close to or above target.

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.

Rehabilitation Therapies

The Skye Centre service is defined by four Activity Centres, and an Atrium where the patients can access the activity group room, café, library, shop and bank.

There are also a variety of other groups facilitated in this environment including the Patient Partnership Group (PPG), Christian Fellowship, Multi Faith Services, Psychological Therapy groups and Allied Health Professions staff.

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The Patients’ Advocacy Service also facilitate their annual AGM, held outside the Hospital, via video link and Board meetings in the Skye Centre both of which include patient representation. The Health Centre is an integral part of the service and operates closely with the wider activity centres and Atrium.

Group interventions available to patients attending the Skye Centre include:

• Crafts & Creative Expression. • Education & Learning. • Life Skills. • Physical Health & Fitness. • Recreation. • Mental Health & Recovery. • Vocation & Working Activities.

The interventions are available at varying degrees of complexity to meet patient needs and are delivered in a variety of formats. Additionally, there are regular ongoing group activities such as animal care, crafts or sports, and general learning sessions for which there is no restricted time limit. In contrast to this, there are a number of planned, time limited groups such as SVQ qualifications i.e. Sports Leadership, Creative Arts. The Crafts staff also work collaboratively with the Art Therapist delivering group interventions in the Craft & Design Centre.

A Skye Centre Annual Report (June 2016 to May 2017) details service activity levels and key achievements. Key pieces of work undertaken during these 12 months focussed on:

• Vocational Qualifications / Courses. • Patient Active Day Project.• Review of Supervision Model. • Sickness. • Social Events. • Carer Involvement.

A Rehabilitation Therapies Annual Report (1 October 2016 to 30 September 2017) has also been produced presenting an overview of the rehabilitation interventions that are available across the Hospital. This work is mainly attributed to the Allied Health Professions (AHPs) and Skye Centre, and includes clinical assessments, the provision of group and individual treatment interventions and multi-disciplinary working within clinical teams.

Key Performance Indicator (KPI)Patients will be engaged in off-hub activities.

The average figure for 2017/18 was 78.7% against a target of 90% compared to the previous year’s figure of 79.3%. These figures represent static performance for this target.

The availability of activity was affected during the last quarter of the year by additional departmental closures as a consequence of the financial delivery plan and adverse weather conditions, which resulted in restrictions in patient movements for several days in March 2018.

Key Performance Indicators (KPIs)Patients will engage in meaningful activity on a daily basis. Hubs have a monthly community meeting.

During the year, it was agreed that these two KPIs be replaced. New indicators and business processes are in development and will be reported on to test out their validity as measures.

5.3 INVOLVEMENT, ENGAGEMENT AND FEEDBACK

Involvement and Equality Service (IES)

Stakeholder involvement and engagement, volunteering, equality and diversity, and spiritual and pastoral care workstreams are embedded within the Local Delivery Plan (LDP) ambitions, closely aligned to fulfilling the person centred aspirations within the NHSScotland Healthcare Quality Strategy.

The Involvement and Equality Steering Group (IESG) 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.

The group has a comprehensive workplan, which includes a wide range of quarterly monitoring reports:

• Patient and Visitor experience.• Volunteering input.• Spiritual and Pastoral Care input.• Equality Outcomes monitoring.• Advocacy input.• Health equalities.• Learning from Feedback (including Complaints).

Key pieces of work undertaken during the year included:

• Participation Standards self-assessment. • The State Hospital Annual Review stakeholder

presentation. • Person centred ‘What Matters to You?’ initiative. • Implementation of tailored NHS Model Complaints

Handling Policy and Procedure. • Publication of Equality Outcomes.

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• Development of a tailored version of Triangle of Care Tool.

• Development of a Patients’ Advocacy Service (PAS) self-assessment tool.

• Implementation of the new Discharge / Transfer Care Programme Approach (CPA) Feedback templates.

• A Patient Partnership Group (PPG) led Advance Statement Workshop.

• Implementation of a new Patient Welcome Pack.

The year has seen an increasing focus for the service on supporting stakeholders to share their views in response to a range of external consultations, including the PAS independent feedback initiatives, the Scottish Health Council (SHC) service review and draft Carers’ Charter. Stakeholder forums have also been proactive in terms of contributing to internal reviews relating to service change, including the Supporting Healthy Choices implementation workstreams, temporary ward closure, CCTV outline business case, as well as discrete service feedback initiatives including psychological therapy services and pilot projects including the Active Patient Day model.

The policy consultation process also promotes the opportunity for stakeholders to contribute to the way in which services are developed.

Key Performance Indicator (KPI)100% of Hubs have representation at all Patient Partnership Group (PPG) Meetings.

The PPG was facilitated 47 weeks of the year; closures correspond with Christmas, New Year, Easter and Autumn public holidays, in addition to one further week where, due to inclement weather, the Skye Centre was closed at short notice. A ward outreach service was facilitated on that occasion.

During this year, one hub was not represented on one occasion (due to the patient’s physical health issues) and another hub on four occasions (coinciding with a decline in mental health). Members of the IESG met with this patient on a 1:1 basis within the ward environment to ensure continuity of input. Attendance data therefore reflects a figure of 94% to the KPI of 100% hubs representation at all PPG Meetings.

Stakeholder Feedback

The State Hospital aims to create an organisational culture in which stakeholders are recognised and meaningfully involved as equal partners in service delivery. Feedback is welcomed from patients, carers, staff and volunteers, as this data enables the Board to improve its understanding of what we are doing well, what we are not doing so well, and what we could do better.

This year the Board introduced stakeholder ‘stories’ as a regular feature of the Board Meeting Agenda, through the use of a wide range of medium including Emotional Touchpoints, and creative feedback models such as the River Model.

The new NHS Model Complaints Handling Procedure (CHP) was introduced on 1 April 2017. The main focus was to take a consistently person centred approach to complaints handling across NHSScotland, implement a standard process, ensure staff and people using NHS services have confidence in complaints handling and to encourage NHS organisations to learn from complaints in order to continuously improve services.

The State Hospital’s Annual Complaints and Feedback Report has been published, providing details of feedback and complaints received during the period 1 April 2017 to 31 March 2018. This report demonstrates meaningful stakeholder involvement at The State Hospital and evidence of feedback driving change and improvement across all areas.

As in previous years, key themes arising from complaints related to clinical treatment and staff attitude.

Main Issue Raised in Complaint 2016/17 2017/18

Staff Attitude / Behaviour 15 27

Policy / Procedures 5 27

Clinical Treatment 17 17

Aids, Appliances and Equipment 2 13

Staff Shortage / Availability 3 13

Patient Privacy / Dignity 5 7

Patient Property / Expenses 1 5

Communication (Oral / Written) 4 4

Policy and Commercial Decisions 2 4

Catering Services 3 2

Complaint Handling 0 1

Premises / Access / Transport 0 1

Admission / Transfer / Discharge Procedures 1 0

Cleanliness / Laundry 0 0

Patient Status / Discrimination 1 0

Total 59 121

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The new CHP five day local resolution stage has been a positive step in encouraging the resolution of issues quickly, empowering frontline staff to respond to feedback in real time.

Outcomes of complaints are categorised as Upheld, Partially Upheld, Not Upheld and Withdrawn. The majority of complaints dring the year were Upheld or Partially Upheld.

88% of complaints closed at Stage 1 within five working days, and 93% complaints closed at Stage 2 within 20 working days.

5.4 HEALTH IMPROVEMENT

The ultimate aim is to meet patients’ mental health needs, enabling, when appropriate, the patient to move onto another setting. 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. There are many contributory factors involved such as lack of exercise, obesity, complications of psychotropic medication, and the consequences of a self-selected poor diet. For some years now, the Hospital has been a smoke free environment.

The State Hospital played a leading role in the organisation of the two-day 5th Health and Justice Summit (November 2017) and a number of staff delivered workshops at the event.

Mental Health

In response to a recommendation from the Medium & High Secure Care Standards Peer Review Audit, a Suicide Awareness and Prevention Policy was developed during the year.

Physical Health

The Hospital remains committed to ensuring that patients are encouraged and supported to adopt a healthy lifestyle particularly in relation to smoking, activity, and nutrition. Proactive assessment of significant risk factors can lead to improved outcomes for long term conditions.

An approach which supports self management is crucial to a better long-term outcome, which means that education plays an important part in improving health.

The Physical Health Steering Group (PHSG) governs food, fluid and nutrition, weight management, physical activity and physical health services on behalf of the Board. The PHSG Annual Report covers the period 1 October 2016 to 30 September 2017. Activity undertaken during the year related to six key areas. For each of these areas (outlined below), all Local Delivery Plan (LDP) targets were met:

1. Primary Care Service (including long term conditions)

The GP continues to undertake an annual medicines management review for all eligible patients. An annual physical health summary is provided to the multi-disciplinary clinical teams.

There has been an overall percentage increase in patients accepting flu vaccination. In 2017, the uptake was 66%. A study undertaken in September 2017 aimed to improve understanding about the factors influencing vaccination intention and behaviour among patients.

A fully functioning electronic system for the management of blood results is now operational.

Over the last 12 month reporting period, there were 20 patients with diabetes, 10 patients with asthma (and a further three patients on inhaler therapy requiring further review), and seven patients with symptoms of Chronic Obstructive Pulmonary Disease (COPD).

Key Performance Indicator (KPI)Annual Physical Health Review and Access to Primary Care.

The Health Centre consistently meets its targets. The 48-hour access statistics are based on contact with an appropriate healthcare professional. Currently this would include the Practice Nurse, General Practitioners, Physiotherapist, Optician, and NHS24. In the year, 100% of patients requiring primary care services had access within 48 hours. Of the 95 patients eligible, 86% attended their Annual Health Review. Of the 31 patients eligible, 26% returned their bowel screening test.

Upheld

Partially Upheld

Not Upheld

Withdrawn

2017 / 18 Complaint Outcomes

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Key Performance Indicator (KPI)Healthier BMI.

Patients with a healthier BMI increased from 13.6% in 2016/17 to 15.8% in 2017/18.

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

The percentage of patients with a normal body weight slightly increased, with a significant increase in those overweight and a decrease in those obese. Overall overweight levels have increased from 28.5% to 34.6%, despite two six month periods showing a reduction in this area. However, this could be reflected in a positive shift in those that were obese (a reduction from 58.1% to 53.7%) moving to the overweight category. Obesity figures, despite much ongoing intervention, remain above national averages, with 85.5% of patients being overweight or obese. This is 20% higher than the average national figure (Scottish Health Survey 2014), and on average, patients gain 13.5% of their body weight in the first year of admission.

There are 13 Health Champions spread across the Hubs and Skye Centre. Training on the six physical health priority areas identified in the Physical Health Education Plan took place, namely, diet and nutrition, blood borne viruses, oral health, physical activity, and foot care. In addition sessions on motivational interviewing and basic cognitive behavioural therapy were delivered.

Compliance with the National Catering and Nutritional Specification (Food in Hospitals) continues to be excellent. An audit of Nutritional Screening Tools (NSTs) and Nutritional Care Plans (NCPs) took place in September 2017 - 100% of patients had a NST and 99% had an NCP. Additionally, during the year the external procurement of food items ceased (October 2017), the Hospital shop was re-modelled with stock (now being 80% compliant), five patients took part in a pilot of the Health and Wellbeing Plans, and consideration was given to buying outdoor equipment for hard to reach patients.

3. Physical Activity

The Board sees physical activity as an extremely important part of overall physical healthcare. There is a target for all patients to engage in 90 minutes of activity per week.

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

During the year a Physical Activity Monitoring System was piloted ensuring a minimum of two entries were recorded daily for each patient. In the longer term, the data will provide reliable insights at both population and individual levels into whether patients are meeting the current target and inform the development of new targets.

A new report providing personalised analysis for individual patients was also piloted, and subsequently incorporated into the weekly Clinical Team Meeting so that appropriate interventions could be set.

4. National Clinical Guidelines and Standards

Over the last 12 months, 48 guidelines / standards were reviewed by the PHSG. Of these, 30 were deemed to be either not relevant or were covered by a similar guideline. Of the remaining 18 guidelines / standards, 14 had varying degrees of relevancy to physical health services within The State Hospital and were sent out for information purposes.

5. Training

During the year the Food Safety training was completed by 36 staff, the Guide to Healthy Eating training by 38 staff, and the Healthy Eating in Forensic Setting training by 18 staff.

A mandatory physical health online training module was launched in June 2017 for staff. The online ‘Healthy Eating’ and ‘Healthy Eating in a Forensic Setting’ modules were updated during the year and completed by 77 staff.

The ‘REHIS’ Food and Health Course for Carers of Adults with a Learning Disability was delivered in 2017 with 27 staff in total attending three courses. A number of health awareness events for patients took place during the year including cholesterol and heart disease awareness, sun awareness and skin cancer, bowel screening, slim and trim, testicular cancer awareness, foot care awareness and flu vaccination.

6. Education and Patient Learning

Patient learning programmes are delivered within the Patient Learning Centre, Patient Library, Skye Access Centre, Gardens & Animal Assisted Therapy Centre, Sports & Fitness Centre, and the Craft Centre. Learning provision includes accredited and non-certificated programmes and the Hospital has ‘approved centre’ status with a number of qualification awarding bodies: the Scottish Qualification Authority (SQA), the British Computer Society (BCS), the Royal Environmental Health Institute of Scotland (REHIS), and Sports Leaders UK.

The Patient Learning Annual Report (January to December 2017) details service activity levels and key achievements. In 2017, 68 patients were engaged in formal learning programmes, 129 formal qualifications were attained including 62 core skill qualifications, 60 vocational qualifications, and seven Open University qualifications. In relation to the Local Delivery Plan (LDP) target to support improvement in patients’ educational attainment and life skills through enhancement of literacy and numeracy skill levels, there were 13 core skill progressions during 2017. The Patient Learning Achievement Awards took place in February 2018.

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“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.”

6.1 HIGH QUALITY PATIENT CARE AND TREATMENT

Clinical Governance

Clinical governance has been defined as:

“A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”

Each year the Committee undertakes a review of clinical governance arrangements, consisting of:

• A review of reporting structures within the Hospital.• A review of the Committee’s work programme for

forthcoming years.• A review of the Committee’s Terms of Reference.

• An annual report summarising the work of the groups and departments that report to the Clinical Governance Committee.

Patients are entitled to expect the care they receive to be safe, effective and tailored to their needs. They also expect services will treat them with dignity and respect. A key part of clinical governance is the setting and meeting of standards for good quality care.

Clinical Governance Committee

The main objectives of the Clinical Governance Committee are to provide the Board with the assurance that clinical governance mechanisms are in place and effective within The State Hospital; and that the principles of clinical governance are applied to the health improvement activities of the Board.

Over the last 12 months, the ‘Patient Voice’ has become increasingly embedded in the work of the Clinical Governance Committee and the wider Board.

Patient Accommodation

6. Safe

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The Clinical Governance Committee Annual Report 2017/18 summarises the work of the Committee and highlights particular areas of good practice along with matters of concern that have been discussed throughout the year.

Risk Management

An integrated and inclusive approach to the management of risk continued during the year, encouraging and empowering each member of staff to take an active interest in this area of activity; embedding risk management tools in operational management, and in strategic planning, decision making, reporting and performance management.

In 2017/18 quarterly risk management reports provided an overview of risk management activity across incidents, enhanced reviews, complaints and claims.

Risk Management Annual Reports are well established.

Health & Safety

The Board acknowledges that the minimum acceptable standards of health and safety are those contained in legislation. The Hospital’s Health, Safety and Welfare Committee met regularly throughout the year and was supported by a suite of occupational health and safety policies.

The table (below) shows the ‘Top 10’ Health & Safety (H&S) incidents in 2017/18. As with previous years, the most commonly reported incidents relate to behaviour, verbal aggression and attempted assault:.

Category Number % of total H&Sincidents

Behaviour 377 31%

Verbal Aggression / Abuse 213 17%

Attempted Assault 112 9%

Slip / Trip / Fall - Patient 65 5%

Assault 52 4%

Staff / Patient Injury 42 3%

Sexual 30 2%

Contact 22 2%

Struck 16 1%

Slip / Trip / Fall – Staff / Other 13 1%

Arrangements for managing health and safety continue to be integrated into the Hospital’s Risk Management Strategy through departmental H&S Control Books which provide the infrastructure to manage health and safety arrangements across the Hospital.

During the year, 28 H&S Control Books were audited, and in addition to regular health and safety training days, three H&S Control Book training sessions were delivered.

Incident Reporting

There was an increase in incidents compared to the previous year; from 1,897 in 2016/17 to 2,310 in 2017/18. Incident types are shown below.

Incident Type 2017/18 2016/17

Health & Safety 1,219 974

Security 325 324

Direct Patient Care 270 269

Other 231 58

Equipment / Facilities / Property 175 166

Communication / Information Governance 67 70

Infection Control 23 36

Totals 2,310 1,897

Average Patient Population (based on average bed complement at end of each quarter)

109 114

Investigations

The year saw a change in terminology. From January 2018, Critical Incident Reviews (CIRs) became known as Category 1 investigations and Serious Untoward Incidents (SUIs) changed to Category 2 investigations.

In 2017/18; there were two Category 1 investigations and nine Category 2 investigations were commissioned.

Category 1 investigations

Category 2 investigations

CIR 17/01: Attempted Suicide (four recommendations implemented)

17/02: Review Self Harm 17/03: Generator Failure17/04: Restricted Item17/05: Network Replacement17/06: Patient in Bedroom 17/07: Prohibited Items 17/08: Detention Paperwork18/01: Pre Court Contingency Planning 18/02: Attempted Suicide

CIR 17/02: Assaults (three recommendations implemented)

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Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR)

RIDDOR requires employers to report incidents that arise out of or in connection with work resulting in the death of any person, specified injury to any person or hospital treatment to non-employees, employee injuries resulting in over seven day absence from work, dangerous occurrences, and specified occupational diseases. The number of RIDDOR reports have almost doubled since last year; from 19 in 2016/17 to 37 in 2017/18. This is the highest annual RIDDOR total since 2008/09 when 38 RIDDOR reports were submitted.

Training

The Board ensures relevant health and safety training is made available to all staff so that individuals and groups can fulfil their role effectively and safely. Health and safety training for staff is mandatory.

Resilience

The Resilience Committee continued to meet regularly during the year. Resilience plans are well established. In addition, a Board development session was undertaken in August 2017 to allow a discussion on two elements of resilience: “organisational resilience” in terms of the services ability to deliver on its strategic objectives and “leadership resilience” related to forthcoming non-executive and executive turnover in positions.

Patient Safety

Participation in the Scottish Patient Safety Programme for Mental Health (SPSP-MH) continued. Work is co-ordinated via a multi-disciplinary steering group which met three times during the year. Locally, steady progress was made across all five of the agreed national workstreams:

• Leadership and Culture.• Communication at Transitions.• Safer Medicines Management.• Least Restrictive Practice. • Risk Assessment and Safety Planning.

Our efforts in this area during 2017/18 suggest a positive impact on practice as evidenced in The State Hospital’s Scottish Patient Safety Programme Report covering the period July 2017 to June 2018:

• The year’s programme of Leadership Walkrounds commenced in June 2017 with a revised question set. By February 2018, four walkrounds had taken place. A range of improvement ideas were discussed with some already being put into action.

• A laptop has been introduced for use when a patient is boarding out overnight at a general hospital. This allows staff to send shift reports back to The State Hospital three times daily. The DASA (a structured professional judgment tool which will support decision making regarding how patients are supported on a day to day basis) is also completed and emailed back to the Hospital. Both these allow staff back at The State Hospital to prepare for the patient returning i.e. equipment, medication, diet etc.

• Psychotropic PRN medication documentation (‘8 rights’) spot check completed in December 2017 with median completion of 7.9 against the ‘8 rights’; with one administering less than 10 PRN medications during the week of the spot check.

• In 2017 a decision was made to implement a form within the electronic patient record that would capture the 8 rights information. The form is currently being piloted within the Intellectual Disability ward and will be rolled out in September 2018 to all wards.

• A sustained improvement with the medicine reconciliation forms across the full Hospital has ensured newly admitted patients are having their medication reviewed on admission.

• Post incident debrief tools were implemented for intramuscular injection medication, seclusion and post physical interventions. It was agreed that a generic debrief will be implemented that can be used for any type of debrief rather than staff completing more than one for any incident. The most recent data is showing that the debriefs are not being completed consistency across the Hospital.

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. An integrated approach to Child and Adult Protection is now embedded into practice. Work continues to be driven forward in an inter-agency manner to promote the safety and wellbeing of children, both within the Hospital and as part of South Lanarkshire Council’s Multi-Agency Child Protection Framework.

A Child and Adult Protection Annual Report has been produced covering the period 1 April 2017 to 31 March 2018. The report highlighted:

• For those patients’ who are parents of children, four have some form of contact. There were 101 child visits to the Hospital.

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• At the end of the reporting period, 36 children were approved to have some form of contact with a State Hospital patient.

• The State Hospital published its Corporate Parenting Plan (CPP) in February 2018.

Clean Environment

In 2017/18 the Hospital achieved an above 90% compliance / satisfaction rate for both national audit systems for cleanliness and estate monitoring.

Infection Control

The State Hospital is not considered to be high risk for infection or cross infection; however the employment of evidence based protocols to assist clinical practice to ensure a clean and safe environment is an integral part of our overall clinical governance agenda. Throughout the year the following areas were addressed:

• Healthcare Environment Inspectorate (HEI) recommendation regarding the wearing of wrist watches – this resulted in a full uniform review in February 2018.

• Review of the procuring of patient equipment.• Review / audit of patient carry out meals. • Water Safety Group review of the risk assessment. • Development of Acute Boarding Out Leave (ABOL)

protocol.• Incorporating Blood Borne Virus (BBV) testing into

admission blood screening.

The results of various infection control audits demonstrate sustained improvement in practice and motivate staff and patients to maintain this improvement.

During the year, the Clinical Waste and Sharps Audit was combined with the Health and Safety eControl book.

The compliance for the management of Healthcare Waste was consistent at 100% throughout the year. In terms of hand hygiene compliance, the Health Centre consistently achieved 100% and the ward environment nursing staff constantly attained over 94%.

Raising compliance levels within the Skye Centre patient activity areas remains a priority.

The State Hospital has a three year Healthcare Acquired Infection (HAI) Education Training Plan which is reviewed every six months. In addition to online learning, training continued to be delivered throughout the year for new and existing staff.

During the year there were 24 infection control incidents; a decrease of 12 from 2016/17.

Information Governance

The State Hospital takes confidentiality, privacy and security seriously with a firm commitment to the lawful, ethical and responsible handling of personal information. During the year a new post was created ‘Information Governance and Data Security Officer’ to strengthen information governance by supporting the Hospital’s activities and ensuring compliance with duties. This included defining uses of information and policies / practices for governing the use of personal information.

A Records Survey was also undertaken to ascertain what records were held in various areas, as well as looking at how these were managed, accessed, stored and retained / destroyed. Additionally, bulk shredding of clinical notes and other confidential information Hospital-wide, was undertaken in February 2018.

In May 2018, the Data Protection Act 1998 was replaced by the Data Protection Act 2018 and the EU’s General Data Protection Regulation (GDPR). Much work was undertaken during the year in preparation of the Regulation coming into force.

In 2017/18:

• The Hospital ensured compliance and development of Information Governance overall as monitored by the Information Governance toolkit.

• Issues relating to data protection and health records including structure, filing, storage, and archiving were addressed.

• Caldicott issues including monitoring incident reports and ensuring relevant training for staff were attended to.

• A forum was provided for the various staff groups to raise any Information Governance issues and to receive feedback from Information Governance on such matters.

• Requests made in relation to Freedom of Information (FOI) and Subject Access Requests were monitored.

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Information Technology

Key eHealth projects completed in 2017/18 include:

• Patient Moving & Tracking System (PMTS). • Network replacement, network firewall, web filter and

additional network security controls.• Anti-malware protection to all computers.• Mobile Device Management for the control and

security of mobile devices. • Secured iPad for use with patient care and recovery. • Ground work for Windows 10 & Office 2016

deployment.• Cyber Resilience.

Security

The Hospital’s secure environment is provided by three domains of security:

• Physical security - provided through high quality physical barriers and sophisticated electronic detection and observation systems.

• Procedural security - provided through policies, procedures and working practice.

• Relational security - provided by clinical staff working closely with patients to deal with illness and offending behaviour.

The Clinical Model sets out how the Hospital delivers safe and effective relational security as an integral part of its clinical work. To assist in this the Security Department has Clinical Security Liaison Managers working as an integral part of multi-disciplinary clinical teams.

The Hospital has its own Security Standards, which are aligned to the national High Secure Care Standards produced by the Forensic Network and adopted as national policy.

Compliance with Security Standards is audited by the Forensic Network and an external advisor.

During the year, when the UK threat level was raised to critical electronic items were placed in a separate tray prior to bags being X-rayed. This significantly improved the inspection of bag contents and the identification of contents. As a result, a decision was made to continue with this practice which strengthened the searching process.

Forensic Medium and High Secure Care Standards

Every three years, The State Hospital is assessed against the Forensic Medium and High Secure Care Standards relating to assessment, care planning and treatment, physical health, risk management, physical environment and teams, and skills & staffing. The next assessment takes place in April 2018.

Staff Offices

Perimeter Physical Security

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“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.”

7.1 EFFICIENT AND EFFECTIVE USE OF RESOURCES

Corporate Governance and Accountability

The State Hospitals Board for Scotland allocates resources and monitors organisational and executive performance, delegates operational matters to management and oversees senior management arrangements and appointments.

In line with good governance, transparency and accountability, public notices advertising Board Meetings are placed on The State Hospital’s website alongside Board agendas, papers and minutes.

The Board met six times during the year (in public) to progress strategy and review performance. See Appendix 1 for Board Members’ and Senior Managers’ Interests 2017/18.

Governance and Management Arrangements

The Board’s statutory responsibility embraces the three strands of statutory governance: Clinical Governance, Staff Governance and Corporate Governance which are overseen by the Clinical Governance Committee, Audit Committee, Staff Governance Committee and the Remuneration Committee. See Appendix 2 for Board Governance Committees 2017/18.

Management is based around multi-disciplinary clinical teams, reporting to the Senior Management Team.

During 2017/18:

There is a range of supporting frameworks, strategies and action plans in place to ensure delivery of high standards of governance. Corporate governance arrangements are set out in Standing Orders, Standing Financial Instructions and the Scheme of Delegation. Each Committee produces an annual report in line with its Terms of Reference.

PatientAccommodation

7. Effective

– 20 – – 21 –

• Leadership walkrounds continued.• Corporate document standards were in place to help

streamline the flow of documentation.• Group and committee structures within the Hospital

were regularly reviewed to streamline, rationalise and simplify meeting arrangements so that these were fit for purpose.

• The corporate Risk Register was reviewed annually by the Board and quarterly by the Audit Committee. A full review will be undertaken in 2018/19. In addition, local departmental risk registers are now in place, from which any identified high risk item is given consideration for the requirement to be reflected in the corporate Risk Register.

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 (internal auditors) for 2017/18 was approved in June 2017. The plan was kept under review for the remainder of the year. The plan 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.

During financial year 2017/18, the Committee met on three occasions. Details of activity can be found in the Annual Report of the Audit Committee 2017/18.

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 Committee met on four occasions during the year.

The Remuneration Committee Annual Report 2017/18 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 is required to operate 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 2018, the Board was within all three of its statutory financial targets and reported an under spend of £5k 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

32,0121,384

32,0071,384

5-

Capital Resource Limit- Core 750 679 -

Cash Requirement 33,292 33,292 -

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 2017/18 increased by £86k from the previous year.

Capital Resources

The Board’s Capital Programme for 2017/18 focused on improving Hospital security, maintenance of the estate, improvements to eHealth systems and the purchase of vehicles.

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Collaborative Working

Special / National Health Boards were tasked by the Scottish Government Health and Social Care Directorate (SGHSCD) to work together to identify ways to collaborate services with a target to reduce the operating costs of Special Boards by £15m in 2018/19 so that this could be reinvested in frontline NHSScotland priorities.

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

• Transformation to deliver quality improvements and efficiencies across NHSScotland 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 2018/19 whilst the workplans in the first two bullets deliver more sustainable quality improvements and reduced costs.

The National Boards met their commitment to reduce costs by £15m in 2017/18. This will be a recurring target for 2018/19 and beyond.

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 strategy, which is under review currently, will 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

Special Boards through collaborative working.

Fraud

The State Hospital continued to take a zero-tolerance approach to fraud. In 2017/18 the Hospital reviewed its top ten fraud risks, completed a Counter Fraud Assessment Tool and participated in the National Fraud Initiative exercise which is carried out bi-annually. In 2017/18 the non-mandatory e-learning fraud module was replaced by a mandatory module which was completed by 357 staff.

Annual Review

The State Hospitals Board for Scotland is the governing body of the Hospital. It is accountable to Scottish Ministers, through the Scottish Government, for the quality of care and the efficient use of resources.

Every year an annual review of performance is undertaken by the Scottish Government. The Board completes and submits a composite assessment report to the Scottish Government. A review meeting between the Board and the Scottish Government then takes place. Members of the general public can attend if they so wish.

Thursday, 28 September 2017 was the date of the 2016/17 Annual Review of The State Hospitals Board for Scotland. This was a non-ministerial review. Monday, 14 January 2019 is the date of the 2017/18 Annual Review. This will be a ministerial review.

Annual Review Feedback Letters are placed on the Board’s website.

Mental Welfare Commission (MWC) Annual Meeting

The annual meeting with the Mental Welfare Commission for Scotland was held in February 2018 providing an opportunity to share information on key issues for the MWC both locally and nationally. An update was also provided on priority issues within the service including implementation of Healthy Choices and changes to the management of tobacco products.

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7.2 HIGH QUALITY PATIENT CARE AND TREATMENT

Clinical Quality Strategy

The Board is committed to fostering a forward-looking and “can do” organisational culture. Focus on continuous improvement underpins all activities and a working environment rich in educational and staff development opportunities. Quality care is underpinned by person centred values and placing a high value on research and audit. Improvements in the quality of clinical care are best led by multi-disciplinary teams providing frontline services. Leaders and managers in all areas have particular responsibility as role models and enablers in the promotion of safety, quality and person centeredness and must demonstrate this through their everyday actions and behaviours. All individuals and teams are responsible for applying quality assurance and improvement into practice through:

• Professional codes of practice.• Continuous professional development.• Performance and appraisal review process.• Revalidation.• Improvement activity and measurement.• Audit.• Evidence based practice.• Personal reflection.• Learning from adverse events, complaints and

feedback.

The Clinical Quality Strategy 2017/20 was produced during the year setting out the direction, aims and ambitions for the continuous improvement of clinical care within The State Hospital. Seven goals have been identified to ensure the focus remains on delivering the Hospital’s quality vision:

• Setting and delivering ambitious quality goals to support the provision of high quality care and services to patients and carers.

• Engaging staff, patients, carers, volunteers and other stakeholders in improving quality of care.

• Ensuring that everyone in the organisation understands their accountability for quality and are clear about the standards expected of them.

• Gaining insight and assurance on the quality of care.• Ensuring access to and understanding of

improvement data to build a positive momentum in relation to quality improvement.

• Evaluating and disseminating results.• Building improvement knowledge, skills and capacity.

Clinical Supervision

With the overall aim of improving quality of care, clinical supervision is recognised as a supportive way to facilitate learning from experience. Throughout the year, clinical supervision continued for clinical staff across all disciplines through a mixture of 1:1 and group sessions.

Clinical Audit

Clinical audits provide assurance that clinical policies are being adhered to within the Hospital. During 2017/18 a total of 17 audits were completed enabling performance to be reviewed and continuous quality improvements to be made.

Standards and Guidelines

During the year there were 284 publications (pieces of guidance / reports / standards) issued. Of these, 81 had some relevance to the Hospital and five underwent a full evaluation with identified areas for improvement being incorporated into relevant Hospital plans of work.

Research

2017/18 has seen a continued focus on the implementation and dissemination of a wide range of research and evaluation conducted by staff including the ongoing popularity of both The State Hospital Research & Clinical Effectiveness conference, and the national Forensic Network Research conference. The dissemination of State Hospital research has also won several awards at international conferences and events. During the year, 12 research studies were completed.

The Research Committee and Research Funding Committee Annual Report 2017/18 notes 14 published journal articles, the delivery of 53 presentations and the achievement of three research awards.

Eat Safe and Healthy Living Awards

The Hospital has achieved a number of major awards:

• Healthy Retail Standard. • Eat Safe Award for Excellence in Food Hygiene.• Healthyliving Award and Healthyliving Award Plus for

Promoting Healthy Eating.• Health Facilities Scotland’s, Innovations Award and

“The Paul Taylor” overall winner award.• Healthy Working Lives Gold Award.

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“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.”

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.

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.

Staff Development and Conference Centre

8. Workforce

– 24 – – 25 –

Staff Governance

The Staff Governance Action Plan for 2017/18 focused on outcomes relating to the five priorities of the implementation plan of Everyone Matters 2020 Vision. The main priorities and actions addressed during 2017/18 related to:

• Implementing Cycle 3 of iMatter.• Embedding NHSScotland values within the Board.• Improving performance in attendance management.• Tackling bullying and harassment within the workplace

and ensuring all staff are treated with dignity and respect.

• Ensuring effective communication with staff and involvement in changes which affect them within the organisation.

• Addressing issues relating to the health, safety and wellbeing of staff.

• Participating in the National Shared Services agenda as appropriate.

• Scoping progress with regard to the review of PIN policies.

The Human Resources and Partnership Working Group (comprising a range of operational managers, staff side representatives and HR staff) continued to work closely with Partnership Forum colleagues to develop and approve policies relating to staff governance.

The Staff Governance Committee Annual Report 2017/18 evidences that the Committee met in line with its Terms of Reference, fulfilled its remit with adequate and effective staff governance arrangements in place throughout the year, and all processes relating to statutory requirements were undertaken within the necessary timescales.

The State Hospital’s Staff Governance Standard ‘National Annual Monitoring Return 2017/18’ was submitted to the Scottish Government in line with process.

Values and Behaviours

An organisational conversation commenced in January 2018 with the aim of involving all teams and patients in the discussion around ‘what our values mean to us’. This feedback will be used to improve the way decisions are made, communication and interaction with one another.

Workforce Strategy

A Workforce Strategy has been developed for 2016/21 to support the workforce profile for the current and future Hospital environment. The workstreams identified have been progressed as follows:

Sustainable Workforce • To review nursing workforce capacity in relation to

core workforce requirements – completed.• To review Allied Health Professions (AHP) workforce

and leadership arrangements – ongoing. • To review the Clinical Model / Patient Day – ongoing. • To improve Staff Attendance – ongoing.

Capable Workforce• To develop a Leadership Programme to nurture

leadership skills and support workforce capability – commenced in respect of Senior Charge Nurse development with principles being implemented across all leaders within the organisation.

• To develop secondment opportunities within the Forensic Network – ongoing.

Quality Improvement Skills • To Develop a Quality Improvement Strategy –

ongoing.

Effective Leadership• To develop recommendations to improve the nursing

management and leadership arrangements – completed.

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Attendance Management

Sickness absence has been a major area of concern across multiple departments in the Hospital. As a result, during the year, a unique telephone-based sickness absence management service entitled “EASY” (Early Access to Support for You) was implemented. Phase 1 was launched in April 2017 followed by Phase 2 in June 2017. The EASY service supplements existing absence policies and enables telephone communication between the absentee, their line manager, and the EASY service from the first day of absence and referral to Occupational Health Services at day ten.

In addition to EASY, staff training, rigorous monitoring and constant scrutiny remained high on the agenda all year. However, despite these efforts, the Hospital’s sickness absence level continued to be above the national target of 5% resulting in sustained pressure on staffing.

Key Performance Indicator (KPI)Sickness absence.

The 2017/18 end of year average absence percentage was 8.52% compared to 8.35% in 2016/17. The principal reasons for absence were consistent with the previous year, with the two most common reasons for absence being anxiety / stress / depression and musculoskeletal conditions. This has impacted negatively on the requirement for additional hours, with a subsequent pressure on frontline staff to fill shifts, demands on staff to work additional hours, and a detrimental impact on budget. This has been an area of concern, with a new approach required to enhance governance and assurance in relation to these areas.

An improvement plan was launched in August 2017 instigating a range of improvement measures.

Staff Experience(iMatter and Dignity at Work)

iMatter is the NHSScotland Staff Engagement continuous improvement tool designed to help individuals, teams and health boards understand and improve staff experience. The State Hospital’s 2017 iMatter report showed a response rate of 78% compared with an average of 63% for NHSScotland. The Employee Engagement Index (EEI) score was 76% (national average was 75%).

The Board remains committed to ensuring that all staff are provided with a safe working environment, free from all forms of bullying and harassment.

In supporting the right of all staff to be treated with dignity and respect, the year saw the delivery of training and a review of the Hospital’s ‘Dignity at Work: Preventing and Dealing with Bullying and Harassment Policy’. This policy makes it clear that behaviour involving the bullying and harassment of any member of staff, for any reason and in any form, is unacceptable, and will not condoned or tolerated.

In addition, a Dignity at Work Survey was issued in November 2017. Findings were summarised in the Health and Social Care Staff Experience Report 2017 which was published in March 2018.

In the year 2017/18 there were two Whistleblowing cases and three Dignity at Work cases.

Knowledge and Skills Framework

The NHS Knowledge and Skills Framework(KSF) applies to all staff who are employed under Agenda for Change (AFC) terms and conditions. It is a broad framework which supports a fair and consistent approach to Personal Development Planning and Review known (PDP&R).

Turas Appraisal - a new national electronic system for recording details of the KSF PDPR meetings - will be in place for 2018/19.

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

The 2017/18 average monthly completion rate was 84.5% compared to 75.15% in 2016/17. The target is 80%.

Mandatory and Statutory Training

Organisational compliance levels for statutory and mandatory training at 31 March 2018 were noted as 86.6% compliance (reduced 3.5% from March 2017) for statutory training and 75.3% compliance (reduced 0.3% from March 2017) for mandatory training.

Leadership

The year saw further investment in leadership development. The Board carried out a Board Diagnostic (self-assessment) for the first time, and the Senior Charge Nurse (SCN) leadership development programme was launched and delivered. Both initiatives received very positive feedback.

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Partnership Working

The Board has well established partnership working arrangements within regard to the formal structure of the Partnership Forum and any associated sub-groups. During the year, a number of issues were progressed in partnership with staff representatives including Promoting Attendance, Job Evaluation, Working Longer and the Workforce Review where there is a common understanding that these are matters which need to be progressed with this mutual approach.

Fitness to Practise

In 2017/18 all professional staff were registered and fit to practice.

Healthy Working Lives (HWL)

The Board promotes a healthy working environment that takes staff wellbeing seriously. For the 11th successive year, the HWL Gold Award has been rightfully earned. Some examples of activity in 2017/18 include:

• A Staff Information Day (November 2017) with representation from a range of organisations including Citizens Advice, Fraud Team (Police Scotland), Money Advice, Salus, Credit Union, Home Energy Scotland. Some taster sessions in acupuncture were also on offer.

• Sponsorship for staff participating in the 10k Christmas Walk (December 2017) in Edinburgh.

• A Pamper Day for staff (January 2018) with massage, Hopi Ear and other alternative therapies being on offer.

• Ten week ‘Weigh to Go’ (weight loss programme) commenced February 2018.

• Various opportunities were available throughout the year to participate in physical activities. For example, Metafit, Badminton, Yoga, and the Daily Mile.

• Flu vaccine campaign.• Lifestyle checks for male and female staff.• Information on various health and wellbeing issues.• Quizzes with prizes.

Occupational Health Service

NHS Lanarkshire, via Salus, continues to provide an Occupational Health Service (OHS) to The State Hospital. The purpose of the service is to promote and maintain the physical, mental and social wellbeing of all staff. The 2016/17 OHS Annual Report was published in November 2017, reporting on a range of services including health surveillance, immunisation, follow up of injuries / traumatic incidents, training, workplace assessment, health promotion activities, counselling and policy formation. The 2017/18 report will be presented to the Hospital in November 2018.

Carer Positive Scheme

During the year, The State Hospital is registered at Level 1 (Engaged) of the Carer Positive Scheme. 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.

• Carers are supported to identify themselves as carers and can access support within the organisation to help them manage their work and caring responsibilities.

The two other levels are: Level 2 (Established) and Level 3 (Exemplary).

Disability Confident Scheme

Level 2 of the Disability Confident Scheme was achieved in July 2017 demonstrating that the Hospital is positive about employing people with a disability. The scheme, which replaces the Double Tick scheme, has three tiers of commitment: Level 1, Level 2 and Level 3. The State Hospital is currently working towards achieving Level 3.

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NAME INTEREST

T CurrieChairperson Deputy Lieutenant, Lanarkshire

W BrackenridgeNon Executive Chairman, Scottish Legal Complaints Commission (until 31 December 2017)

E CarmichaelNon Executive

National Council Member, Scottish Association for the Study of Offending.Board Member, Corra Foundation (previously Lloyds TSB Foundation Trust)

A GillanEmployee Director None

N JohnstonNon Executive

Chief Executive, Educational Competencies Consortium LtdTrustee, Abertay University Dundee Students Association

M WhiteheadNon Executive

Non Executive Director, NHS Golden Jubilee Hospital (until September 2017)Trustee, City of Glasgow College Foundation

J CrichtonChief Executive Non-Executive Member, SACRO

D IrwinSecurity Director None

R McNaughtFinance & Performance Management Director

Non-Executive Member, Audit Committee, Water Industry Commission for ScotlandMember, Audit Committee, Mental Welfare Commission for Scotland

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

L ThomsonMedical Director Professor of Forensic Psychiatry, The University of Edinburgh

J WhiteInterim HR Director (from 1 April 2017)

None

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Board Members’ and Senior Managers’ Register of Interests 2017/18The interests of the Board and senior managers for the year were:

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CLINICAL GOVERNANCE COMMITTEE

Membership Role

N Johnston (Chair) E CarmichaelM Whitehead

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. The Committee met four times during 2017/18.

AUDIT COMMITTEE

Membership Role

E Carmichael (Chair)W Brackenridge A GillanM Whitehead

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 and governance. The Committee met three times in 2017/18.

STAFF GOVERNANCE COMMITTEE

Membership Role

W Brackenridge (Chair)A Gillan N JohnstonM Whitehead

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. Also to encourage, support and monitor partnership working. The Committee met four times during 2017/18.

REMUNERATION COMMITTEE

Membership Role

T Currie (Chair)W Brackenridge E CarmichaelA Gillan N Johnston M Whitehead

The Remuneration Committee considers senior management performance and pay related issues. It met four times in 2017/18.

Board Governance Committees 2017/18

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The State Hospitals Board for ScotlandCarstairs, Lanark ML11 8RP

Tel: 01555 840293 Fax: 01555 840024Email: tsh.info@nhs.netwww.tsh.scot.nhs.uk

October 2018