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Board of Directors 26 October 2016 Public
www.sussexpartnership.nhs.uk
BOARD OF DIRECTORS MEETING IN PUBLIC
To be held on 26 October 2016 at 10.00 Board Room, Trust HQ, Swandean,
Arundel Road, Worthing, West Sussex, BN13 3EP
AGENDA Please note: we are planning to live stream this meeting onto social media and upload
the footage to our public webpage – the public audience will not be intentionally
filmed.
TBP 36 /16 INTRODUCTION
10.00 TBP36 .1/16 Chair’s Welcome and Introduction
10.01 TBP36 .2/16 Apologies for Absence & Declaration of Interests
10.02 TBP36 .3/16 Minutes of the Board of Directors meeting held on 28 September 2016
A
10.03 TBP36 .4/16 Questions from Members of the Public
TBP 37/16 STRATEGY
10.05 TBP 37.1/16 Developing a Clinical Model and Strategic Work Programme (Kay Macdonald, Clinical Academic Director)
Presentation
10.15 TBP 37.2/16 2017/19 Business Plan (Sam Allen, Executive Director of Strategy and Improvement) B
10.25 TBP 37.3/16 Smoke Free Environment – Update (Diane Hull, Executive Director of Nursing and Patient Experience) C
10.30 TBP 37.4/16 Eliminating Mixed Sex Accommodation – Feasibility Study (Lorraine Reid, Executive Director of Service Delivery & Performance Management)
D
TBP 38/16 ASSURANCE (QUALITY & PERFORMANCE)
10.40 TBP 38.1/16 Chief Executive Report (Colm Donaghy, Chief Executive) E
10.50 TBP 38.2/16 To discuss the Thematic Review (Colm Donaghy, Chief Executive) Verbal
11.00 TBP 38.3/16 To receive the Quality & Performance Report (Lorraine Reid, Executive Director of Service Delivery & Performance Management)
F
11.20 TBP 38.4/16 CQC Task and Finish Group - Update (Tim Ojo, Executive Medical Director & Director of Quality)
G Verbal
11.25 TBP 38.5/16 To receive an update on Safe Staffing (Diane Hull, Executive Director of Nursing & Patient Experience) H
11.30 TBP 38.6/16 To receive a report on the last meeting of the Quality Committee (Professor Gordon Ferns, Non-Executive Director) I
11.35 TBP 38.7/16
To receive a report on the last meeting of the Finance and Investment Committee (Richard Bayley, Independent Non-Executive Director)
To receive the Finance Report (Sally Flint, Executive Director of Finance & Support Services)
J
K
TBP 39/16 GOVERNANCE
11.45 TBP 39.1/16 Board Assurance Framework Q2 (Sam Allen, Executive Director of Strategy and Improvement) L
11.50 TBP 39.2/16 Emergency Preparedness Resilience and Response Procedure Update (Sally Flint, Executive Director of Finance and Support Services)
M
12.00 TBP 39.3/16 To receive a quarterly notification of Board Site Visits (Caroline Armitage, Chair) N
12.05 TBP 39.4/16 To receive the Quarterly Notification of Sealed Documents (Caroline Armitage, Chair) O
12.10 TBP 39.5/16 Board Members Action Points following the Council of Governors meeting (Caroline Armitage, Chair)
P
12.20 TBP 39.6/16 Action Points from the meeting held on 28 September 2016 (Caroline Armitage, Chair) Q
12.25 TBP 40/16 ANY OTHER BUSINESS
Date and Venue for Next Meeting: 30 November 2016
Training Centre, Swandean, 85 Arundel Road, Worthing West Sussex, BN13 3EP
To adopt the motion: “That representatives of the press and other members of the public be excluded from the remainder of this meeting,
having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest ”
(Section 1(2) Public Bodies (Admission to Meetings) Act 1960)
NB Those present at the meeting should be aware that their name will be issued in the notes of
this meeting which may be released to members of the public on request
Page 1 of 11
Sussex Partnership NHS Foundation Trust
Board of Directors: 26 October 2016 - Public Agenda Item: TBP36 .3/16
Attachment: A For: Decision
By: Rebecca Huth, Corporate Governance Administrator
SUSSEX PARTNERSHIP NHS FOUNDATION TRUST
Minutes of the Board of Directors held in public on Wednesday
28 September 2016 at 10.00 in the Training Centre at Swandean, Arundel Road, Worthing
Present Caroline Armitage, Chair Anne Beales, Non-Executive Director Colm Donaghy, Chief Executive Diana Marsland, Non-Executive Director Diane Hull, Executive Director of Nursing and Patient Experience Lewis Doyle, Non-Executive Director Lorraine Reid, Executive Director of Performance Management and Service Delivery Professor Gordon Ferns, Non-Executive Director Richard Bayley, Non-Executive Director Sally Flint, Executive Director of Finance and Support Services Sam Allen, Executive Director of Strategy and Improvement Tim Ojo, Executive Medical Director and Director of Quality In Attendance Peter Lee, Head of Corporate Governance Sue Esser, Director of Human Resources and Organisation Development Rebecca Huth, Corporate Governance Administrator (minutes) Observers Mark Hughes, Carer Governor Elizabeth Hall, Lead Governor Simon Street, Complaints Manager and Staff Governor Dan Charlton, Director of Communications Dave West, Performance Director Cassandra Blowers, Equality & Diversity Business Advisor Justine Rosser, Interim Director of Nursing Standards and Safety Professor Sube Banerjee, Director of Centre for Dementia Studies, Brighton & Sussex Medical School (until end of item CDStudies) Tanya Telling, Assistant Director for Research and Development and Centre for Dementia Studies, Brighton and Sussex Medical School (until end of item CDStudies) Two members of the public
ITEM NO ITEM
TBP31 .1/16 Chair’s Welcome and Introduction
1 Caroline Armitage welcomed all present to the meeting.
TBP31 .2/16 Apologies for Absence & Declarations of Interest
2 Martin Richards, Non-Executive Director
Kay Macdonald, Clinical Academic Director
Page 2 of 11
TBP31 .3/16 Minutes of the Board of Directors meeting held on 27 July 2016
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Caroline Armitage advised that she has a new declaration; she is now Chair of Raven Housing Trust.
Colm Donaghy added that he has two new declarations; he is a Board member of NHS Employers National Policy Board and a member of the Chief Executives Advisory Group.
Caroline and Colm both confirmed that their declarations have been formally noted with the Company Secretary.
Minutes of the public Board of Directors held on 27 July 2016 were approved as an accurate record.
Caroline confirmed that actions would be picked up throughout the meeting and revisited at the end to confirm completion.
TBP31 .4/16 Questions from Members of the Public
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Caroline Armitage advised that there were no questions submitted by members of the public prior to the meeting, and asked for any additional questions to be raised now.
A member of public requested an update on the security of eCPA, a question she has raised previously. Caroline advised that this question would be covered during a scheduled agenda item.
TBP32 .1/16 Annual Review of the Staff Health and Wellbeing Strategy
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Caroline Armitage welcomed this item, noting the importance of this area.
Sue Esser introduced the item and opened up for discussion, highlighting that large amounts of investment has been put into our staff health and wellbeing, and she hopes to see a lot of progress in the future.
Richard Bayley noted that we’ve invested £0.5m on sport related health and wellbeing, and queried how effective that investment has been. Sue advised that the contract is due for renewal and this question will form part of the review.
Colm Donaghy wished to add that evidence now demonstrates that we deliver better quality care and maintain staff retention when our staff health and wellbeing is good and effective. Colm added that it may be useful in the future to evidence this in a report. Richard Bayley agreed, noting that this evidence is not visible today.
Diana Marsland advised that she’s unclear of what is specifically being done to reduce stress for staff, adding that when we deal with stress, it’s reactive rather than proactive. Diana also queried how equip our front line managers are in dealing with stress amongst staff. Sue advised that as part of our CQUIN this year we’ve investing into stress for staff and we’re looking at specific training for this area. We’ve also invested in our general development of managers, including skills to pick up on staff morale. Sue added that our health and wellbeing area within the staff survey has improved and hopes to see this improve again this year. Colm Donaghy added that Sussex Mindfulness Centre has become really well regarded and we provide training to staff here at Swandean, yet we’re looking to roll this out further. Diana acknowledged the on-going good work, however added that it would be good to see this reaching larger areas of staff.
Anne Beales commented on disability and engagement, advising that staff are less engaged if they’re disabled and queried how we can raise the profile of our Disability Reference Group. Sally Flint, Chair of the Disability Reference Group, advised that the work we’re doing around CQUIN is being taking this through the group and we’re looking at other health and wellbeing programmes to implement, particularly including how to engage our disabled staff.
Caroline Armitage stated that there appears to be a lack of awareness of the benefits available to staff. Sue Esser advised that she’s been working with Communications to create
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a Staff Benefits Booklet.
Sam Allen informed members that evidence shows the role of the line manager and the relationship with the employee really makes a difference to staff health and wellbeing, and we need to think of ways to encourage and support our line managers, reminding them that solutions are found within teams.
Tim Ojo praised the Mindfulness training, advising that it addresses our emotional states in real time. In terms of engagement with staff and line managers, Tim advised that all medical trainees and juniors have weekly contact with their managers/leaders.
Diane Hull stated that the Leadership Development Programme has been really well received by staff, adding that staff can easily become stressed if they feel they don’t have the right skills for the workforce.
Caroline Armitage advised that she’s recently spent time with our Trust Chaplain and was very impressed with the spiritual services he is providing to staff members.
Lewis Doyle queried whether staff fully use the Salary Sacrificed Scheme. Sue Esser advised that this is used well, particularly for child care vouchers and lease cars, however the awareness of this could be raised more. Lewis went on to ask if this can be linked with staff engagement. Sue said yes, advising that the Trust’s investment into GCC’s Get the World Moving Global Challenge has demonstrated engagement really well, we had 67 teams of 7 register for the challenge throughout the Trust.
Caroline Armitage advised that the Board of Directors are fully behind this strategy.
Caroline advised that Sue Esser will discuss the actions within the report with Peter Lee.
TBP32 .2/16 Centre for Dementia Studies - Progress
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Professor Sube Banerjee thanked the Board and those present for welcoming him, advising that he’s going to update on the work being done at the Trust and the University.
[Sube spoke to his presentation]
Sube highlighted specific areas throughout his presentation including:
- Development of the Centre for Dementia Studies - Changing healthcare education – Time for Dementia - Developing a memory service for people with HIV – Orange Clinic - Management of agitation in dementia – SYMBAD Trial - Measuring the quality of life of carers of people with dementia – C-DEMQOL - Analysis of quality in dementia care
Caroline Armitage thanked Sube for his great presentation and opened up for comments.
Lewis Doyle felt that the presentation was fascinating, and asked Sube how many Clinical Academic posts they would need to make a real difference. Sube advised that he’s currently at capacity with projects, however would like to make two more posts available, which would be open to a vast area of professionals. Caroline Armitage advised that we can look into this when planning our funding within our business plan. Sally Flint echoed Caroline’s comments of including this in our business planning and service delivery.
Sam Allen highlighted that one of our strategic goals is to put research into practice, adding that it’s great to hear of the work taking place. Sam asked what it would take to put this research and work into practice. Caroline Armitage asked what the stats are on the use of anti-psychotic drugs within the Trust, and Richard Bayley asked what one recommendation Sube would make to us as a Trust. Sube advised that we’ve arranged for a Senior Consultant within the Trust to work with us for two years, to run an interface between the Centre for Dementia Studies and the Trust. Sube added that this will help our translation into practice and will aid the building of structures for older people within the Trust. Sube highlighted that to make these structures work, the Trust will need to invest in quality improvement for older people’s services.
Caroline Armitage advised that the Board of Directors accept the challenge of improving older people’s services. Richard Bayley wished to go one step further, and challenge the
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Board to become the lead executioner of this research.
Gordon Ferns noted that this goes beyond our organisation into primary care, and queried how we’re managing the outreach. Sube advised that this is happening through our Dementia Fellowship Programme, which 95 people across Kent, Surrey and Sussex have completed, which aids our dissemination through to primary care.
TBP33 .1/16 Chief Executive Report
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Colm Donaghy wished to highlight that during the recent CQC Inspection the inspectors were very complimentary of the attitude of our staff. They have raised some concerns which we will be dealing with, and they are continuing to undertake unannounced inspections. The unannounced inspections that have already taken place have gone fairly well. Colm advised that we should receive our first draft report in December.
Tim Ojo advised that the key challenge for us now will be to continue momentum throughout the Trust. Tim added that the CQC were very helpful in identifying challenges that we face, yet we’re continuing to use our fundamental standards as a way to continuously generate quality in our care.
Richard Bayley queried how we’re going to continue a focus on areas between now and the report. Tim Ojo advised that we’re not dispending the CQC Project Group and they worked with enablers and CDSs to focus on specific areas. We’re completing regular audits on areas with concern, checking regularly that we’re compliant and we’re continuing to improve physical health.
Colm Donaghy advised that we’re implementing a task and finish group which will focus on the areas raise by the CQC. We also have a physical health strategy which should assist us in improving the physical health of our patients. Colm wished to add that the CQC didn’t alert us to any areas of concern that we were not aware of.
Action: CQC Task and Finish Group update to come to October Board of Directors.
Sam Allen wished to thank all of our staff, patients, carers and stakeholders for the continuous hard work which went into the preparation for the week of inspections.
TBP33 .2/16 To receive the Quality & Performance Report
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Lorraine Reid advised that the CQC suggested that we change the language of this report, to Quality and Standards as it’s more engaging. We’re in the process of implementing this.
Lorraine discussed the highlights of the report, advising that CDSs now produce their own trajectories for performance, however this is still being embedded. Lorraine added that we’re not entirely convinced that our performance will change the CDSs ratings. Lorraine advised that her and her team have been looking at all areas of struggles, including CPA and 7 day follow up, and they’ve recently thoroughly reviewed all Adult Services performance. A medium view of performance is now included in the report, to show the patterns of increase and decrease. With regards to 7 day follow-up, the issues of performance in this area relate mostly to the change in definition.
Caroline Armitage asked Lorraine how our patients must feel by not having a follow-up. Lorraine advised that there are a lot of issues that often go into someone not being followed-up, such as patients not answering their phones, or cancelling the appointment. It’s a small percentage that could feel lost during this time.
Lorraine advised that following discussions with auditors, we’ve agreed to implement some exceptions for 7 day follow-ups, regarding foreign nationals and contact with care homes. Lorraine added that she’s uncertain these will make a huge improvement, however this will improve our clarity of the target. Most CDSs have moved towards either daily or weekly monitoring of 7 day follow-ups and we’re reviewing the quality of interaction at these meetings. There has been some additional pressure on the acute pathway which has had an impact on the 7 day follow-up.
On a separate issue, Lorraine advised that we’ve had an increase over the summer of people being held in police custody as opposed to a place of safety. This was mostly due to
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bed pressures in Coastal West Sussex. Our length of stay and gender segregation issues also had an impact on this. In addition to this, there were two unusual cases in July which were difficult to find complex beds for. Lorraine added that Sam is working with the police and they’ve agreed to take a patient to any place of safety in Sussex, not just locally. Lorraine advised that it’s a very unfortunate time nationally with bed pressures but she wished to assure the Board that this is moving forward.
Caroline Armitage acknowledged that this has been really hard work for your staff and wished to congratulate the teams who have assisted with these pressures.
Gordon Ferns advised he’s pleased to see that mandatory training has improved.
Diana Marsland advised that she’s aware of the bed pressures and listened into a bed call, and felt Shakil was very encouraging. Diana noted that agency staff appear to be high all over the Trust, however Brighton and Hove are managing their area well, and wondered if their learning can be shared. Lorraine advised that Brighton and Hove created a plan where they recruited to their maximum headroom for ward staff (not allowing any headroom for maternity cover, etc) and this has worked really well for them. Lorraine added that she’s working with Diane Hull on Trustwide staffing issues, however we need a longer term plan.
Gordon Ferns queried what the value of reporting is for supervision an annual appraisals. Caroline Armitage advised that from the CQC’s inspection feedback, they were able to verify on the wards that we are compliant at a good level, however this is not translating through our data. Sue Esser advised that for supervision, we don’t have a central process for reporting this as it’s the responsibility of the managers to hold this information, however Kay is looking at the possibility of a platform for this within the system. In terms of appraisals, we record this on MyLearning and we’re working with Operational Services to record their information with regular reports of compliance. Sue thanked Diane for her comments regarding the teams in Brighton and Hove, adding that they’ve worked really hard in the management of their rotas, staff and booking of agency. Sue added that they started this work two years ago, so this should pick up soon in other areas.
Lewis Doyle noted the really good results on the patient indicators and friends and family test. Lorraine advised that they’re looking to do something a bit more robust in the future. Lorraine also added that in terms of Governance, we need to make clear links between the quality committee and standards in the wards.
Sam Allen advised that at the Quality Improvement workshop she and Lorraine held, many areas of safety were discussed, including MRSA, and the CDSs are absolutely committed to meeting 100% of their patient safety targets.
Anne Beales advised that if we’re looking at development plans, she’s keen to see the impact on the patients that can show what the real outcomes are for patients.
TBP33 .3/16 To receive an update on Safe Staffing
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Diane Hull advised that she’s soon meeting with someone from another Trust to share their learning and report for Safe Staffing.
Diane advised that over-fill rates are due to enhanced observations and mixed-sex accommodate, and under-fill rates are due to registered nurses being supplemented for non-registered nurses. Diane added that she’s reviewing the policy and going forward wished to implement some training focusing on observations.
Diane acknowledged that we have to strengthen nurse leadership, and we need leaders and managers who are clinically focused on wards, to create more alternative ways of caring for people who require close attention. Diane added that she’s confident that once our mixed-sex wards are completed, this will reduce the impact on observations.
Diane informed members that last week she recruited an Associate Director of Patient Safety, and she’s introducing weekly meetings with each ward team to look at the management of rostering.
Anne Beales advised that we need to ensure our ward areas are emotionally safe, so even if observations are in place, we need to ensure that people’s emotions are still being cared for.
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Diane fully agreed with Anne, adding that the engagement of observations are also being thought of.
TBP33 .4/16 Complaints Annual Report
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(Simon Street joined the table)
Diane Hull advised that we’re now examining the last three years of data, looking at CDSs per year and cross referencing. We want to see an improvement in complaints and we want to look for early resolution. Diane added that we need to increase the learning and to think about what we can do to help our key issues.
Caroline Armitage thanked Diane and Simon for an much more improved report. Simon Street advised that he and Andrea Byles have aligned our work nationally, including removing communication and odd themes to show much more complex themes.
Lewis Doyle advised that he’s interested to see what the response is of the person making the complaint, querying whether it’s possible to feedback whether they were happy, unhappy or satisfied with the response they received.
Anne Beales advised that she’s been involved in two specific complaints and believes that clinical robustness is not as good as it could be when dealing with complaints. Simon advised that we’re working with all staff to train them to resolve complaints quickly at a local level. Simon acknowledged that we need to raise the profile of complaints to our staff. Tim Ojo wished to note that medical staff are not exempt from answering complaints in a specific time frame. Colm Donaghy added that this is a cultural issue as much as a process issue, and we’re moving to a more reactive way of working.
On another point, Diana noted the complaints received by MPs, and queried why people go to MPs. Simon advised this happens for a number of reasons, such as those who are dissatisfied with their original response, or for those who think they’ll receive a response sooner. Diana felt it would be useful to keep track of these reasons.
Colm Donaghy advised that recently he asked for an analysis of MP letters and from this we’ve created a plan for the particular problem areas. Colm believes that the main issue for complaining to an MP is frustration towards a first response, however their contact with an MP doesn’t necessarily change the original response.
Diane Hull advised that if a complaint is not upheld, we need to work on our feedback in these cases. Sue Esser advised that we’re linking this to values within the organisation and we’re recruiting staff with our values for complaints.
Tim Ojo advised that unfortunately some of our response come across to other people as a very difficult language to sometimes understand, and our responses may not be clear for who we’re addressing them too.
Action: Complaints Annual Report 6 monthly update at March Board.
TBP33 .5/16 Serious Incidents Annual Report
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(Justine Rosser joined the table)
Justine Rosser advised that we’ve looked at the system we’re currently running and where we want to go in the future, and the information we receive from services is really helpful. We’re looking at how we can disseminate our learning through services in a meaningful way and we’re looking at further useful information to provide.
Gordon Ferns advised that we need to think about best practice, as the CQC felt that our learning is available locally, but not widely.
Diane Hull advised that we’re looking at how other organisations share their learning, such as with workshops, although we’re also thinking about simulation training and incorporating learning into inductions and core training. We want to have people set up in particular areas to share learning and to make it live.
Anne Beales advised that after an incident staff receive a debriefing, and it would be good to
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see service users debriefed when an incident takes place in shared or residential accommodation. Justine Rosser advised that we have a stress management policy which covers exactly that.
Colm Donaghy wished to note that this work will form part of the Executive’s Task and Finish group. Colm added that the CQC feedback showed that there was discussions of learning from SIs throughout teams, however learning throughout the organisation was patchy. They acknowledge our learning, but could not see this being monitored to cover the whole organisation, and we’ll therefore be ensuring this is a part of staff supervision and appraisal.
Action: 6 monthly update on SI annual report – progress to March board.
TBP33 .6/16 Workforce, Race, Equality Standard Report
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(Cassandra Blowers joined the table)
Sue Esser advised the report provides an overview of the WRES actions throughout the Trust. Sue added that the Board reviewed the submission (Appendix 1) and continues to support this area. Cassandra Blowers highlighted some areas within the report, including that our submission doesn’t include our ‘White Other’ staff due to how information is requested, therefore this does not include European staff affected by Brexit (Britain’s decision to leave the European Union). Cassandra added that from data collected in the Staff Survey shows that 41% of BME (Black, Minority & Ethnic) staff report bullying from patients, relatives and staff. In relation to employment, 1500 BME staff applied for positions within Sussex Partnership in 2015, of those only 83 were appointed. Cassandra felt that there is progression throughout the organisation and we have been praised at NHS England’s WRES event regarding our equality.
Caroline Armitage noted her concern at the level of bullying. Diane Hull acknowledged that it’s very distressing and we need to emphasise our zero tolerance of this. Colm Donaghy advised that we’ve implemented a plan with Sussex Police to ensure violence towards staff is effectively reported and dealt with.
Sue Esser advised that in her experience of mental health she’s seen a reluctance of staff reporting abuse because of their compassion and professionalism towards staff. Sue added that only 10% of our Leadership Development Programme attendees are BME staff, and we need to work more to support them.
Caroline Armitage advised that the Board of Directors have formally noted the report.
TBP33 .7/16 To receive an update on the Audit of GP Letters
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Tim Ojo advised that this audit was prompted following concerns regarding the compliance against patients receiving copies of clinical letters using the Trust’s old Clinical Information System, eCPA. Tim added that compliance has now reached 60% and asked the Board of Directors to continue supporting the direction of travel with on-going audits using Care notes.
Caroline Armitage advised that she is concerned with the correspondence function within Care notes and feels that our compliance level is unacceptable. Sam Allen echoed Caroline’s concern in that our compliance level is not good enough and this should be an automated function.
Tim Ojo advised that this is 60% compliance within a time frame, and not 60% overall, however acknowledged that we need to improve this functionality within Care notes.
Action: Clinical letter function within Care notes to be investigated.
Caroline Armitage wished to note the progress being made, however also noted the disappointment of the functionality within Care notes.
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TBP33 .8/16 CQC Mental Health Act Seclusion Inspection Report
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Tim Ojo advised that a top level summary of this audit is included, and noted that there are on-going issues, including concerns about our calming rooms following a visit to one of our Psychiatric Intensive Care Units (PICUs).
Caroline Armitage advised that she’s pleased that this is actively being monitored.
Action: Seclusion Audit information to be included in future Quality Committee Summaries.
Lorraine Reid felt that this needs to be a Trustwide approach, adding that Diane Hull is working on a quality improvement project to reduce violence which should have an impact on our seclusions. Diane Hull added that our new Associate Director of Patient Safety will be looking at restrictive practice and using a quality improvement initiative across all CDSs.
Lewis Doyle raised a concern that one action target date is scheduled for June 2017, and requested that this be brought forward.
Action: Tim Ojo to work with Colm Donaghy on an earlier target date.
TBP33 .9/16 To receive a report on the last meeting of the Quality Committee
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Gordon Ferns wished to highlight that at the meeting on 04 August 2016 the issue of buddying was discussed and this is being taken forward by the Clinical Senate. Gordon highlighted another issue which was raised by a member of the public as a previous question to the Board, and asked Sally Flint to discuss the matter. Sally advised that this issue was reported through the Information Governance Group Committee which then reported through the Quality Committee and was in regards to the security of eCPA. Sally explained that when the Trust transferred from eCPA to Care notes, there was a two week period where staff access to patient notes were not monitored and this was raised as a concern. Sally confirmed that a review of access during this period has been completed and there were no breaches during this time.
In relation to SIs, Gordon advised that there’s been a 50% increase and in terms of delay’s in completion, the large backlog is now down to 8 reports. The expectation is that this will reach 0 by next week.
Caroline Armitage noted that we’re performing poorly with unexpected deaths, and would like clarity on the work in this area. Tim Ojo advised that since Diane Hull’s arrival we’re meeting weekly to review and analyse levels of unexpected deaths and the learning from these, by looking at every case individually. Tim added that he hopes to report sustainability of this area soon as we’re now clearer of expected mortality and anticipation.
Colm Donaghy explained that as a Board suicide prevention is one of our quality priorities, however we recognise that this needs to be a community approach as opposed to organisational, adding that we’re looking at what work we can do with local partners in the community.
Anne Beales advised that she’s aware of a small grant available to organisations to support cancer patients in specialist services who refuse life-saving treatment, and she’s having a call about the grant today.
Tim Ojo wished to note that we’re reviewing all areas of death before accepting certain causes such as Dementia to ensure no learning is missed.
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TBP33.10/16
To receive a report on the last meeting of the Finance and Investment Report
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Richard Bayley advised that the committee last met on Friday 23 September 2016, with one governor, Michael Decker present. Richard outlined the committees discussions, including the concern about the deterioration of the financial performance since July and how we can improve our planning and implementation. The committee tasked Sally and Lorraine to gain traction on the financial recovery plans, and an additional meeting has been called in October to focus on planning and implementation, for this year and two years ahead. Richard noted that the lack of delivery against our plans is affecting the delivery of our 2020 Vision.
Sally Flint discussed August's finances, advising that In Month 5 the Trust's financial position deteriorated further and is now reporting a year to date deficit of £2,446k and we're reporting a financial sustainability rating of 2. Sally reminded members of our best, mid and worst case forecast positions. Sally explained that to improve our finances and care we provide, we're looking at standardising consistency and delivery within Adult Services. Sally reported that NHS Improvement (NHSI) have requested our draft plan for 2017/18 by end of November 2016, adding that they're becoming less tolerant of Trust's that are not performing financially and they're concerned over our agency usage.
Diana Marsland noted that most of the Adult Services CDSs are dependent on the care model, and queried whether this will be implemented in time to perform against. Sally advised that we are looking at the care model, however we don't need to wait for this to improve our performance now. In addition, we are offering care pathways for different diagnoses and we're implementing standards for management within wards.
Anne Beales queried whether the CDSs can report against their progress with the Carter Work Stream. Sally confirmed that we can start to look at performance within this area now.
Colm Donaghy explained that between now and the end of the year our planning process will be focussing on our care model and looking at our here and now performance. Colm added that we'll be holding a planning focused workshop with the CDSs and Sally has included our recovery plan within this.
With regards to the clinical model, Lorraine Reid felt that this has been over-complicated with too many work streams and our CDS model doesn't sit well within these. Lorraine added that we're looking at the parameters of the model with the inclusion of CDSs and what our staffing levels within these models should look like. Lorraine noted that whatever we wish to implement, this must stay within the commissioning logistics of services.
Following the recent CQC inspection, Lorraine advised that she felt very proud of our staff during the inspection week and going forward, we need to support our CDSs with their difficult challenges, including agency spend.
Richard Bayley advised that these comments from Lorraine and Diane were also part of the discussions at the Finance and Investment Committee on Friday 23 September, and wished to note that our work is very positive and we acknowledge the on-going hard work, we just need to gain more traction on the delivery of our plans.
TBP33.10/16 To receive the Finance Report
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TBP33.11/16 To receive a report on the last meeting of the Audit Committee
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Lewis Doyle advised that this Audit Committee meeting reported was observed by one Governor, Claire Quigley, who participated in the meeting and was very constructive. Lewis advised that the committee requested a plan for Roster Pro, as this is currently being done on an informal basis with poor control on rostering management. Lewis added that we need to demonstrate that we’re spending our overspend in the right areas, as at present we cannot do this.
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Caroline Armitage stated her concern that the Rostering policy is not being used. Sally Flint noted the concern and advised that NHSI questioned this area too, adding that rosters should be planned 6 weeks in advance, including annual leave where possible. Lorraine Reid wished to add that these wards are not sufficiently staffed due to other pressures and we can’t decline annual leave because of this. Lewis Doyle advised that he’s asked Corin Anstead to look at areas of good practice with rostering.
Caroline Armitage wished to note that the issue of rostering is the use of the system, not the existence of it. Sue Esser wished to add that some wards are using this very well, where as some aren’t planning well enough in advance, especially those with vacancies.
Action: Executive’s to ensure a 6 week planning policy for Roster Pro is implemented.
Lewis Doyle advised that at the meeting the IT team gave a very good update, including their struggles of engagement within the organisation. Lewis added that good progress is being made in this area but traction is a problem, and there appear to be operational issue here too.
Anne Beales queried whether there’s been an impact assessment on CDS Improvement Plans. Lorraine Reid advised that the top 5 risks within each CDS are known and Peter has been doing a lot of work in this area. Lorraine added that she’s including these risks within the monthly performance meetings so the CDSs are fully aware. Lewis Doyle advised that this was a concern for him but he acknowledged that this is being closely reviewed by the Executive team.
TBP34 .1/16 To receive the performance against Business Objectives
106
107
Caroline Armitage advised that she has nothing further to add and the Board are cited on all of the issues.
Richard Bayley noted that a few areas do not include an update, such as 4.3 and 4.4, and asked for completeness, for updates for all issues to be included going forward.
TBP34 .2/16 Medical Revalidation Annual Report
108
109
110
111
112
Tim Ojo advised that the General Medical Council will confirm the continuation of a doctor’s licence to practice and ensure the organisation is fit for practice by using clinical appraisals as a standard of medical revalidation. Tim outlined the process of the appraisals.
Tim explained that we’re not high in comparison with other Trusts against national standards, however we’ve made about 7% progress against last year’s figures. Tim added that there were a number of non-approved appraisals, and this was due to a change in guidance part way through the process. Tim advised that he’s satisfied that we have sufficient processes in place, however need to continue to work towards improvements.
Caroline Armitage advised that the Board of Directors approve the statement of compliance.
Sam Allen queried whether we review this information for sources of assurance. Caroline Armitage asked Lewis Doyle to review the sources of assurance at the Audit Committee.
Action: Lewis Doyle to review sources of medical revalidation assurance at Audit Committee.
Page 11 of 11
TBP34 .3/16 To receive an update on the last meeting of the Charitable Funds Committee
113
114
Anne Beales advised that the Charity is looking to develop partnerships with other organisations, and we’re working towards CDSs approving suggested fundraisers and becoming aware of the Charities’ priorities. Anne advised that the Charity will no longer be spending it’s funds on minor areas, such as garden improvements and maintainance, but the funds will be spend on areas such as service user leadership. Anne added that it’s really important that the CDSs think about unseen areas to invest in.
Caroline Armitage wished to say a huge thanks to Anne for her energy, experience and encouragement with the Charity.
TBP34 .4/16 Actions Points from the meeting held on 27 July 2016
115 Caroline Armitage confirmed that all action points have been completed.
TBP35 .1/16 Any Other Business
116
117
118
Live-streaming Board Meetings
Caroline Armitage advised that we’re expecting as of October Board of Directors to live stream the meetings online. Caroline explained that there are relatively few other Trust’s doing this yet they’re very popular. Caroline added that the view of the meeting will be focussed on the Board table and not the public, however will remind the public at each meeting the possibility of being filmed if they move in view of the camera.
Goodbye to Peter Lee
Caroline Armitage advised that this is Peter’s last Board of Directors meeting as he will be leaving the Trust on Friday and moving to South East Coast Ambulance Service. Caroline advised that Peter has provided immense support and leadership, and he’s helped the Trust through a vast amount of changes, including the Board Governance Review. Caroline added that Peter has personally supported her into the role of the Chair and has been a real key member of the team.
Colm Donaghy also wished to praise Peter, explaining that his name within the Executive team was ‘The Enforcer’ as he always ensured that actions and follow-ups were completed by all team members. Colm added that he will be very much missed as a member of the Executive Team and a friend, and wished him the very best of luck from the Board of Directors.
Date and Venue of the next Board of Directors meeting
Wednesday 26 October 2016
1000 – 1230
Boardroom, Trust Headquarters, Swandean
Arundel Road, Worthing, West Sussex, BN13 3EP
Signed………………………………………………………. Date…………………..
Caroline Armitage, Chair
Sussex Partnership NHS Foundation Trust
What do we want to achieve?
• Consensus on future shape of our clinical services
• What are the components of the Clinical Model
• How we manage the programme of work
STP and CCG Plans
What we look like now
2020 Vision
Clinical Model
Accountable Payment/PBR Programme
Board
Business Planning
Carter Workstreams
CDS Plans and Operations CAGs
Others
The Clinical Model 1. Mental Health Promotion: Supporting emotionally
healthy and emotionally resilient communities Programme: • To define & operationalise our social value • To build a healthy staff community – staff wellbeing strategy • To offer wellbeing support to other organisations • To offer consultation, advice and support to local
communities • To build resilience in the community
Early Intervention 1. Primary Care Mental Health Programme: • To be the one stop front door for all services • To more effectively pull people into services • To cover all ages – developing youth pathways • To support integrated pathways of care with the third sector
and physical healthcare providers – ensuring all resources are used more effectively
• To support primary care directly – and be part of the solution in transforming models of care
• To dramatically increase use of online interventions and community based interventions
Early Intervention 2. Integrated Physical and Mental Health Programme: • To take a leadership role – and articulate our vision • To be a prime provider of services (e.g. Pain Management in
MSK East) with the expertise to deliver on this • To be the provider of choice for specialist integrated services
(e.g. MUS services in Brighton) • To draw on current infrastructure - e.g. increasing from 15 –
25% prevalence within IAPT • To ensure mental health remains a key part of the STP plans
Early Intervention 3. Recovery and Wellbeing Colleges Programme: • To integrate Recovery and Wellbeing colleges into our care
pathways and service offer • To clearly articulate the core place of these services and cost
savings that can be achieved from them • To articulate the role of Wellbeing and Recovery colleges in
supporting people back into health
Core Services Programme: • Single point of access in partnership with third sector • Development of supported communities • Define roles of care coordinator, associate care coordinator
and peer navigator • To define service offer according to cluster and pathway of
care – integrating pathways with third sector • To describe, recruit and train new workforce • Build on CDS care models – including development of Youth
Pathway • To deliver key work-streams e.g. Carter review • To be seen as the leaders of developments – underpinned by
CAGS, R&D, and E&T • To achieve flow – with third sector pulling people out of
services
CareHome +
Children & YP
PC & W
LD
East Sussex
Forensic Healthcare
Brighton & Hove
West Sussex
2020 Vision Clinical Strategy
Engine Room & Design Team
Pathways, Clustering
& Currency
Integrated Physical &
Mental Health
Single Point of Access
Core Services
& Models
Recovery &
Wellbeing Colleges
CCG & STP
Mental Health Promotion: Supporting emotionally healthy and emotionally
resilient communities
Primary Care
Mental Health
Mental Health Five Year Forward View • A 7 day service – right care, right time, right quality • An integrated mental & physical health approach
• Promoting good mental health and preventing poor mental health – helping people lead better lives as equal citizens
What do we do next?
• Resource the ‘Engine Room’ and the ‘Design Team’ • The ‘Engine Room’ to be led by the Transformation Director, as a full
time function, supported by Head of Strategic Planning and a senior Clinician.
• Senior Clinicians role has to be defined and resourced. • The ‘Design Team’ to consist of representatives from all key
stakeholder groups – including service users and carers. • To facilitate a series of workshops in Q3 with a range of stakeholders
(including service users and commissioners) to shape the model and strategy.
• Engage with CDSs on the model and strategy to promote developments and innovation that align with the model.
• In Q4 establish the workstreams to deliver the model and strategy ensuring synergies and interdependencies between CDS plans and enabler workstreams.
Board of Directors: 26 October 2016 - Public Agenda Item: TBP37 .2/16
Attachment: B For Information
Presented by: Sam Allen, Executive Director of Strategy and Improvement Report Author: Tony Sharp, Head of Strategic Planning
Business Planning Process 2017/19
SUMMARY & PURPOSE
The purpose of this paper is to provide an update on the business planning process for 2017/19. It takes into account the new national NHSI timetable which has been brought forward by three months.
LINK TO OUR 2020 VISION
The Business Plan is a mechanism for delivering and linking our 2020 vision goals, our values and our quality priorities.
Our strategic goals are:
Safe, effective, quality patient care
Local, joined up patient care
Put research, innovation and learning into practice
Be the provide, employer and partner of choice
Live within our means
Our values are:
Respect and dignity
Commitment to the quality of care
Compassion
Improving lives
Working together for patients and with patients
Everyone counts
Our quality priorities are:
Care Plans
Suicide prevention
Physical health
Staff health & wellbeing
ACTION REQUIRED BY THE BOARD OF DIRECTORS
To note the timetable, process and progress
SUMMARY OF PROCESS
The planning process will commence in September, be complete by 31 December and will be
implemented from 1 April 2017.
Summary of business plan development process
Sep & Oct 16 1 Nov 16 30 Nov 16 31 Dec 16 From 1 April 17
Engagement: BoD, CoG &
CDS workshops
Draft CDS plans
distributed
Submit draft
trust plan to NHSI
Submit final trust
plan to NHSI
Implement and set
staff objectives
2
Milestones:
Individual CDS workshops – September and October
Board Away Day – 12 October
Integrated CDS planning session – 20 October
Overarching CDS workshop - 28 October
Draft CDS plans shared – 1 November
Corporate department SIP planning session – 1 November
Second Integrated CDS Planning session – 3 November
Council of Governors workshop – November (being set up)
Draft trust business plan to November Board of Directors
Draft trust business plan to NHSI – 30 November
Final trust business plan to December Board of Directors
Final trust business plan to NHSI – 31 December
Further engagement and communications to ensure implementation from 1 April 2017
CDS workshops
Brighton and Hove Gurprit Pannu 4 October
East Sussex Neil Waterhouse & Dr Isaac Mokhtar 6 local workshops set
Coastal West Sussex Jo Scott & Dr Brian Solts 29 September (WSx)
North West Sussex Jonathan Beder & Dr Mihaela Bucur 27 September – NWSx 29 September (WSx)
Primary Care and Wellbeing Dr Nick Lake 12 October
Children and Young People Ruth Hillman & Dr Rick Fraser 11 October
Learning Disabilities Vikki Baker 19 October
Carehome Plus Sue Turner 30 September
Forensic Healthcare Rebecca Hill & Dr Richard Noon 11 October
All of the CDS workshops have now taken place and Service Directors are drafting their CDS
plans. There are some key cross cutting themes emerging that cannot be solved by individual
CDSs. These are physical healthcare, being clearer about the relationship between the trust
strategy, clinical model, CAGS and CDSs, estates, workforce modernisation and new opportunities,
improving the business partner model and demand and capacity planning.
Alongside the CDS plans we have a number of trust wide projects. These were developed by
applying the learning from the Carter Review into NHS efficiency (Operational Productivity and
Performance in English NHS Acute Hospitals: Unwarranted Variations; Department of Health
2015). These projects are in the process of being reviewed and they may change if we can
rationalise and simplify.
CONCLUSION
We are on track with our planning process even though the process was brought forward nationally
by three months. We will be able to give a view on the assurance position on the delivery of our
financial and service plans following the detailed plans being produced on 1 November. This will
enable us to move to the next formal stage of the process which is the production of the draft trust
plan by 30 November.
3
Annex: Summary Planning Process and the Trust’s Work Programme 2017/19
Sussex Partnership’s Work Programme April 2017 – March 2019
Plan Status Lead
1. West Sussex On track. Draft plan due by 1/11 Jo Scott / Jonathan Beder
2. Brighton and Hove On track. Draft plan due by 1/11 Gurprit Pannu
3. East Sussex On track. Draft plan due by 1/11 Neil Waterhouse
4. Learning Disabilities On track. Draft plan due by 1/11 Vikki Baker
5. Care Home Plus On track. Draft plan due by 1/11 Sue Turner
6. Primary Care and Wellbeing On track. Draft plan due by 1/11 Nick Lake
7. Children and Young People On track. Draft plan due by 1/11 Ruth Hillman
8. Forensic healthcare On track. Draft plan due by 1/11 Rebecca Hills
9. Reducing agency spend Milestones to be set by 1/11 Michael Mergler
10. Transforming Care Pathways in Community Services
Milestones to be set by 1/11 Michael Mergler
11. Procurement and non-pay Milestones to be set by 28/10 Simone Button
12. Use of Estate Milestones to be set by 28/10 Lee Richardson
13. Review of Corporate services Milestones to be set by 28/10 Tony Sharp
14. Efficient and Effective Use of Administrative Services
Milestones to be set by 28/10 Tony Sharp
15. Enabling digital technology and information systems
Milestones to be set by 28/10 Karl Goatley
16. In-patient staffing and the Model Ward
Milestones to be set by 28/10 Simone Button
17. Medical Staffing Milestones to be set by 28/10 Shakil Malik
18. Prescribing Milestones to be set by 28/10 Shakil Malik
CDS Plans
West
Sussex
Brighton and Hove
East
Sussex
Learning
Disabilities
CareHome
Plus
Primary Care and
Wellbeing
Children
and Young People
Forensic
Healthcare
2020 Vision & Clinical Model
CAGs
The needs of the people we serve; direction from regulators; and national and local plans
Cross cutting projects
1
Board of Directors: 26 October 2016 - Public Agenda Item: TBP37 .4/16
Attachment: E For Decision
Report Author: Michael Mergler, Transformation Director – Operational Services
Eliminating Mixed Sex Accommodation
Feasibility Study Report
SUMMARY & PURPOSE
This paper serves to report on the feasibility study that has been carried out in relation to the viability of moving to single gender wards across the Trust’s adult, functional and dementia services. The paper links to an initial paper (June 2016) that addressed issues of assurance and future planning around the requirement for eliminating mixed sex accommodation (EMSA).
LINK TO OUR 2020 VISION
1. Safe, effective, quality patient care 2. Local, joined up patient care 3. Put research, innovation and learning into practice 5. Live within our means
ACTION REQUIRED BY TRUST BOARD
For discussion and decision on recommendations
2
Eliminating Mixed Sex Accommodation – Feasibility Study Report
1.0 Executive Summary
It had been identified, by the CQC, that the trust had achieved slow progress in eliminating mixed sex accommodation on inpatient adult, functional and dementia wards. Immediate actions were taken across older people’s services to achieve compliance, while a long term estates solution has been developed to achieve sustainability. A series of improvement measures were put in place across all wards during the first two quarters of 2016 to support overall compliance of EMSA. These were outlined in the paper, Eliminating Mixed Sex Accommodation - Inpatient Units, June 2016. One of the key recommendations of the paper was to undertake a feasibility study into the possibility of going single gender across the adult, functional and dementia inpatient units. This recommendation was endorsed by the Board and the study was carried out in Q2 2016. The study explored the following options: Option A – mixed sex accommodation with appropriate, managed segregation (no change) Option B – single sex wards Option C – single sex wards with dementia and functional mix for older people The recommendation of the study is that the Trust proceeds, in principle, with a plan to introduce single sex wards in line with option B. The advantages of option B are:
Provides a safer and improved environment for patients, particularly female patients
Meets the set standards for EMSA
Efficient to manage
Fits with Place Based Plans
Significantly reduces the spend required to reconfigure estates
Will eliminate the potential for EMSA breaches
Possibly create additional bed space if required
Likely to save staff time on patient observation relating specifically to segregation
Significantly lower estates costs
Staff observation time managing split reduction The interdependencies and challenges of option B are:
Discussion and agreement will need to be sought from Brighton & Hove, East and West Sussex HOSCs and appropriate CCGs.
Will impact on the current Business Plans and Service Improvement Plans for some CDSs.
Will create travel for some patients and carers which can be mitigated by providing transport to cover visiting, transfers and discharges.
Requirement to travel may have an impact on the service user and carer experience.
Distance to travel may exceed recommended distances
Surrey & Borders purchase of 13 beds on Coral ward would need to be considered in terms of the contractual obligations.
Patient flows and bed management will have to be mapped, managed and coordinated.
3
2.0 The Feasibility Study
Method of Inquiry The existing wards configurations were mapped ‘as is’ and ‘to be’ in a broad sense and the options discussed with approximately 30 individuals including; a small number of Service Users; Ward Managers; Nursing staff; Health & Safety; Matrons; Directors and Executive Directors; and Finance. Additionally, Estates Project Managers involved closely in the works currently planned to configure wards to accommodate mixed sex patients and Finance informed the discussions. It should be noted that consultation was limited given constraints. Maps used are included (appendix 1) though it should be noted that these were to inform discussion only at this point. Current Situation
The Trust’s compliance with EMSA regulations is currently determined by two factors:
Estate configuration and environment
Management and practice of treating patients safely on each ward.
Forensic Healthcare is fully compliant and no changes are planned for CAMHS. A number of the adult, functional and dementia wards are compliant and some need improvement to ensure they are fully and sustainably compliant with EMSA requirements. Those requiring improvements are:
Beechwood
Heathfield
Oaklands
Orchard
St Raphael
The Burrowes
Iris
Brunswick
Woodlands The approved budget to undertake the required works is £1,856,000 and estimates to date equate to £2,838,877. Since the CQC inspection of older people’s wards in January 2016 a number of these wards have become single gender wards. The improvement works will provide sustainability for these wards to maintain high standards of compliance and make the units safe. The wards that are now single gender are:
Brunswick - male
Grove – male
Iris - female
Heathfield – female
Bodium – male Reporting of potential breaches Reporting of gender mix breaches is nationally mandated. Daily reporting gender-mix on wards has been introduced on the daily ICD1 call in Q2 2016. The requirement is for each CDS to report where genders are mixed and confirm whether the risk and safety plans are in place to mitigate. In addition, where these mixed wards are operating, a plan is in place
4
to use an interactive white board that includes a dashboard and room overview. This will be available for inspection in real time and will inform reports available to the Trust. Since further gender separation was introduced this year, no complaints have been received at all relating to travelling to our wards as a response to creating single gender wards for dementia.
Travel Patients and carers are currently travelling to wards outside their own local area. Where appropriate they are assisted with the cost of travel. Taxis are often used for patient visits, transfers and at the point of discharge. The estimated cost of staff travel this year is in the region of £35,000 in addition to the cost of taxis for patient use and in addition to secure transports costs.
Learning from other trusts Nationally other trusts have transitioned to single sex wards. For example, Hertfordshire Partnership NHS Foundation Trust¹ re-organised two wards into two single sex wards and transitioned with relatively few problems. Differences described included males becoming calmer and female wards more disruptive. The overall conclusion in Hertfordshire suggested single sex wards are just as effective if not, in some respects, better. Research there revealed four strongly repeated themes: ward rounds and time management; single gender specific aspects of care; levels of disturbance; and transitional issues.
Ward rounds - increased as doctors needed to see patients on both wards. The number of rounds increased but they were shorter and it was acknowledged that this could be managed more effectively.
Single gender specific aspects of care - male staff commented they could work more confidently on male wards without worry of allegations of sexual abuse from female patients. Similarly for female staff, they feared violence on the male ward. On the female wards, females reported being more able to discuss female issues. Male patients reported missing females initially after the change but that soon stopped once new patients were admitted.
Levels of disturbance - strong impression that the male wards became much quieter and calmer environments after the change (not attributed to clinical profiles). Contrary to staff expectations, female wards became more hectic and noisy with more verbal aggression. Incident reports partly agreed, male incidents did not increase, female incidents more than doubled.
Implementation and transitional issues - staff reported that the change happened too quickly though regarded the changes as having gone well. The opinions, six months following the change, were that the arrangements were satisfactory.
1 Nursing Times, The effect of single sex wars in mental health, Nov 2013 available at:
https://www.nursingtimes.net/the-effect-of-single-sex-wards-in-mental-health/5065923.article
Hertfordshire summarised and suggested there were no compelling results to support or refute transition to single gender environments.
5
In the East London NHS Foundation Trust, seventeen wards transitioned (with a further two recently) and in Luton and Beds seven wards transitioned during a three week period. It is reported that due to safeguarding alerts being raised frequently, The wards across East London and Luton and Beds the moves occurred swiftly upon the decision being made. Reportedly the biggest hurdle in achieving the change to single sex was reluctance from staff, particularly at consultant, level however that was overcome and the transitions successful. Leicestershire Partnership NHS Trust transitioned to single sex accommodation and reported a small increase in incidents of violence/aggression on the male wards which appeared to decrease on the female wards².
3.0 Options for Consideration
A number of options have been mapped to inform initial discussions, described below. Option A - Mixed sex on the majority of wards (current configuration) The continued provision of segregated mixed sex accommodation. This would include the use of swing beds and the relocation of Brunswick and Iris wards to Promenade and Dove wards. This involves significant estate related improvements to a number of wards (as highlighted in the capital plan). The plan reconfigures the wards to ensure gender specific areas within each ward to be managed in line with guidance, with the provision of en-suites where possible, gender specific bathrooms and designated female lounge space. The two areas can be appropriately managed by staff and locked/ separated where necessary.
2British Journal of Mental Health Nursing, Transitioning to Same Sex accommodation, available at:
http://www.magonlinelibrary.com/doi/10.12968/bjmh.2015.4.2.83
Table 1: Approved budget and cost estimates received to date (in relation to older people’s wards)
Ward Approved Budget
Estimate (cost plan) Option A
Orchard 5000 5000
Grove 5000 5000
Larch 5000 5000
Burrowes 110,000 141,000
Promenade 1,200,000 1,907,877
Meridian 40,000 40,000
Heathfield 5000 5000
St Raphael 250,000 400,000
Beechwood 120,000 176,000
Opal 1000 1000
Dove 110,000 153,000
Total 1,856,000 2,838,877
6
There is no significant spend anticipated on working age acute or PICU wards at this point in time. Option B – Single sex accommodation on all wards This option brings the Trust totally in line with national requirements for singe sex wards. This option involves additional travel for patients, carers and families due to bed availability for a particular gender. No distances exceed the 30 mile guide. There is wider discussion within the Trust relating to the cost of travel for patients and carers and it is possible that the Trust will consider provision of travel to negate external costs. Option C – Single sex on all wards and with mixed sex accommodation on dementia and functional This option also brings the Trust in line with national requirements for single sex wards. By mixing dementia and functional patients, the option ensures there is a ward for each gender in each area but with a mixed patient group. The exception would be Beechwood, which would remain mixed sex with gender specific areas (as in Option A) until the intended move to St Gabriel is complete.
4.0 Option Impact Summary
Option A The total cost in relation to Estates is high, at £2,838,877. The cost is allocated to the improvement works that will be necessary to ensure long term compliance and sustainability. The likelihood of breaches is higher and demands on ‘swing’ beds are likely to continue. Staff will need to continue to manage the mixed sex environments despite the re-configuration of the wards in order to avoid breaches. Additional staff resources will be required to provide a safe service. Option B The Trust would be compliant with national guidelines and regulations regarding the elimination of mixed sex accommodation. Staff capacity, currently spent on observation and other activities, to specifically monitor in relation to compliance would be gained. There would be a significant reduction in the estate works required to the older people’s wards (shown in table 2) which highlights a potential saving on spend of £1,552,177. Care hours or observation time would likely be saved on each ward however it is difficult to quantify that in terms of whole time equivilent. The actual saving would be valuable to ward staff giving them more time to care. The transition to single sex wards would remove the potential for breaches completely. Travel for patients and carers would increase in some cases. The Trust could explore provision of its own transport, work is currently in process. Whilst travel will be necessary, the plan is in line with ‘Place Based Care’, working with the resources we have to provide the best possible care³. There would also be an opportunity to put existing space to better more therapeutic use. Further work will be required to plan the full single sex options for Psychiatric Intensive Care Units.
7
3 Public Health England, Guidance, Placed-based services of care, May 2016. Available at:
https://www.gov.uk/government/publications/place-based-services-of-care/placed-based-services-of-care
Surrey & Borders NHS Foundation Trust purchase 13 beds located in Coral ward at LGH. There are a number of options that could be employed to provide gender separation and discussion with SABFT is recommended. This option would require carefully phased implementation. Option C As in Option B, the Trust would be compliant with guidelines though there would remain the need for closer observation due to differing needs of the two patient groups (functional and dementia). There would be a continuing cost associated with this configuration; however transition time would be shorter in comparison with Option 2, which is dependent on the completion of the Dementia improvements in East Sussex. NHS Commissioning Guidance suggests that where possible, separate ward space for functional and organic disorders. The ward configuration though could allow segregation of functional and organic in a similar way to Option A above, segregation appropriately managed by staff. The Joint Commissioning Panel for Mental Health guidance suggests that the needs of older people with functional mental health illness and/or dementia can be treated together4. The Royal College of Psychiatrists however maintains that provision should remain separate and dedicated. Staff consulted largely agree, that the needs of the two patients groups differ and may require a higher level of observation5. 4 Joint Commissioning Panel for Mental Health , Guidance for Commissioners, Older People’s Mental Health Services,
available at: http://www.jcpmh.info/wp-content/uploads/jcpmh-olderpeople-guide.pdf
5 Faculty of Psychiatry, Faculty Report FR/OA/I: Inpatient care for older people within mental health services, available
at: http://www.rcpsych.ac.uk/pdf/fr_oa_1_forweb.pdf
The overall cost implications for each ward where estates works are required is shown below. Table 2: Older people – 170 beds – options comparison of potential costs Ward Approved
Budget Estimate (cost plan) Option A
Estimate (cost plan) Option B
Estimate (cost plan) Option C
Orchard 5000 5000 5000 5000
Grove 5000 5000 5000 5000
Larch 5000 5000 5000 5000
Burrowes 110,000 141,000 7050 * 7050 *
Promenade 1,200,000 1,907,877 1,200,000 1,200,000
Meridian 40,000 40,000 2000* 2000*
Heathfield 5000 5000 5000 5000
St Raphael 250,000 400,000 20,000* 20,000*
Beechwood 120,000 176,000 9000* 9000*
Opal 1000 1000 1000 1000
Dove 110,000 153,000 27,650** 27,650**
Total 1,856,000 2,838,877 1,286,700 1,286,700
*5% design costs incurred to date only / ** 5% design and re-decoration
8
5.0 Options Summary
Option Approved
Budget Cost Plan Estimate
WTE / Obs time saved if gender specific
Travel Implications**
Estates Reportable Breach Likelihood
Advantages Key Interdependencies and challenges
A £1,856,000 £2,838,877 -- No change but some patients travel more than 30 miles
Provision of female lounge on all wards / female assisted bathroom
Very likely a) Managed compliance with guidance
a) Ensuring patient safety b) Difficult to manage c) Significant potential for
breaches d) Some patients need to
travel e) Costly in staff observation
time f) Significant spend
required on our Estates to meet requirements
B £1,286,700 £467,000 Max travel 36 miles for far East to Uckfield – majority less than 30 miles
Potential to use female specific rooms for other purposes (inc beds)
Very unlikely
a) Provides a safer environment for patients, particularly female patients b) Meets the national set standards for single sex provision c) Efficient to manage d) Fits with Place Based Plans e) Significantly reduces the spend required to reconfigure estates f) Will eliminate the occurrence of reportable breaches g) Possibly create additional bed space if required
a) Discussion and agreement will need to be sought from Brighton & Hove, East and West Sussex HOSCs and appropriate CCGs.
b) Will impact on the current Business Plans and Service Improvement Plans for some CDSs.
c) Will create travel for some patients and carers which can be mitigated by providing transport to cover visiting, transfers and discharges.
9
h) Divides the additional observation for Surrey patients across two wards i) reduces the level of staff observation required to managed mixed sex environments
d) Requirement to travel may have an impact on the service user and carer experience.
e) Distance to travel may exceed recommended distances
f) Surrey & Borders purchase of 13 beds on Coral ward would need to be considered in terms of the contractual obligations.
g) Patient flows and bed management will have to be mapped, managed and coordinated.
C £1,286,700 -- Max travel 36 miles for far East to Uckfield – majority less than 30 miles
Retains the need for separate areas for dementia and functional patients
Very unlikely
a) Clinical evidence base not strong
b) Two different patient groups with differing needs
c) The need to separate the patient groups might well remain
d) Staff largely against this option, seen as a backward step
10
Table 3: **Travel implications – longest journey:
Between Miles
Fernhurst to Worthing 30
Gatwick to Hove 27
South Harting to Worthing 30
Walderton to Worthing 27
West Wittering to Worthing 28
Wadhurst to Eastbourne 30
Camber to Eastbourne 33
Camber to Uckfield 36
Frant to Eastbourne 29
6.0 Recommendation/Action Required
National guidance is clear that the Trust should eliminate mixed sex accommodation. Whilst the Trust is managing to retain mixed sex wards through estate configuration and environment and management and practice of treating patients safely on each ward, this comes at a cost. A number of options were considered within the study; remaining mixed sex; single sex; and single sex with dementia and functional mix. The options were mapped and discussed with a relatively wide mix of staff roles, though limited in number, provided a clear feedback against each option. The recommendation of the study is to, in principle, follows Option B. Single sex wards, is the preferred option, being safer for the patients, fully compliant with no breaches, potential to reduce reliance on observation and create a better environment for therapeutic activity. Outlined below are an initial set of action areas that will be addressed to take forward the delivery. There are a number of key interdependencies related to travel, patient flows, estates, finance, local CDS plans and workforce, which will impact on delivery. The Project Group will produce a Delivery Plan that take account of the interdependencies and thoroughly rates the associated risks. These risks will influence the date by which the Trust will operate single gender wards. The aim will be to deliver our ambition in a phased approach where the mitigated risks allow us to move to single gender environments where and when appropriate. We will ensure that where we continue to operate mixed sex accommodation, this will be delivered to the highest standards ensuring patient safety is paramount.
11
Area of actions Lead By when
1 Establish a task and finish project group to develop a Delivery Plan. The plan will encompass the interdependencies and rate the risks, which will support the determination of delivery timeframes.
Transformation Director
Establish Project Team by November 2016
Risk rated Delivery Plan in place by end of January 2017
2 Begin discussions with SABFT to resolve gender separation on Coral ward.
CDS leadership Q3 2016/17
3 Develop a communications plan to engage with service users and carers, local communities and commissioners and other stakeholders.
Transformation Director and CDS leads
Q3 2016/17
4 Implementation of the Delivery Plan.
Transformation Director and CDS leads
Commence in Q4 2016/17
Appendix One: Service Maps
OPTION ASussex Older People’s Inpatient Wards
Mixed sex wards to be
Orchard (Func)0 male / 9 female
3 swing
Heathfield (Func)0 male / 18 female
0 swing
Grove (Dem)10 male / 0 female
0 swingMeridian (Func)
10 male / 9 female0 swing
Promenade (Dem)6 male / 9 female
Inc 2 swing
The Burrows (Dem)3 male / 7 female
0 swing
Dove (Dem)6 male / 6 female
Inc 2 swing
Beechwood (Dem)7 male / 10 female
3 swing
Opal (Func)7 male / 9 female
3 swing
Larch (Func)6 male / 8 female
4 swing
St Raphael (Func)12 male / 0 female
5 swing
EMSASussex Other wards as is
BodiumWAMHS18 mixed
CoralAMHS
19 mixed
JadeAMHS
19 mixed
AmberleyAdult acute18 female
MapleWAMHS18 mixed
RowanWAMHS18 mixed
RegencyWAMHS Acute
20 male
PavillionWAMHS10 male
CaburnWAMHS
20 female
OaklandsAcute
22
AmberPICU
12 mixed
WoodlandsAcute
23 mixed
Option BEMSA
Sussex Older People’s Inpatient Wards to beSingle sex wards / No Dementia/Functional mix
Orchard (Func)12 female
Heathfield (Func)0 male / 18 female
0 swing
Grove (Dem)10 male
Meridian (Func)19 female
Promenade (Dem)15 femaleThe Burrows (Dem)
10 female
Dove (Dem)12 male
Beechwood (Dem)7 male / 10 female
3 swing
Opal (Func)19 male
Larch (Func)18 male
St Raphael (Func)12 male / 0 female
5 swing
24 m
27 m
27 m
21 m
21 m
26 m
St GabrielEmpty will be
Dem DICUMixed
Option BEMSA
Sussex Other wards to be
BodiumAcute
18 male
CoralAMHS
19 male
JadeAMHS
19 female
AmberleyAcute
18 female
MapleWAMHS18 male
RowanWAMHS
18 femaleRegency
WAMHS Acute20 malePavillion
WAMHS10 male
CaburnWAMHS
20 female
OaklandsAcute
22
AmberPICU
12 mixed
WoodlandsWAMHS23 mixed
18 miles
SeldenLD
6 male / 4 female
OPTION CSussex Older People’s Inpatient Wards
Single sex wards / mixed Dementia/Functional to be
ChichesterOrchard 12 male / Grove 10 female
EastbourneHeathfield 18 female
Brighton & HoveMeridian 19 male / Promenade 15 female
CrawleyDove 12 male/ Opal 19 female
MIXED - Beechwood7 male / 10 female
3 Swing
WorthingLarch 18 male / The Burrowes 10 female
HastingsSt Raphael 17 male
Page 1 of 3
Board of Directors: 26 October 2016 – Public Agenda Item: TBP38 .1/16
Attachment: E For information and discussion
By: Colm Donaghy, Chief Executive
CHIEF EXECUTIVE REPORT
1. Introduction
In this report I outline some of the most recent issues since the Board last met in September 2016.
2. Key Issues
Thematic Review The independent review published on 18 October 2016 related to incidents which had devastating consequences for those affected. I realise this brought back painful memories for them. I also understand that some, if not all, will feel angry about our services. On behalf of the Trust, I offered my sincere apology and condolences.
You will know we commissioned this review jointly with NHS England at our own request because we want to make sure we have done everything possible in response to these tragic incidents. We have a responsibility to the patients, families and local communities we serve to ensure this. We have investigated each of the incidents individually. We also wanted independent, expert advice about any common themes which may link them.
Sometimes, as is the case across the NHS, we need to improve processes, policies and training in response to incidents involving our services. But that isn’t enough on its own. This review has given us a strong message about the need to identify and embed learning when things go wrong in a way that changes clinical practice and behaviour. This goes beyond action plans; it’s about organisational culture, values and leadership.
Another key focus of the report is how we work with patients and families. This is something we don’t always get right. We’re doing a lot to improve this. But we need to keep at it and keep talking to patients and carers about what we can do better. That includes being prepared to listen to, reflect upon and respond to critical feedback in a positive way. We have appointed people with lived experience of using mental health services to our new, senior Patient and Carer leader roles to help us do this.
We are also introducing Family Liaison Officer roles to provide a single point of contact and support for families affected by a homicide involving someone known to our services. This is something which was recommended to us by families who have been through this tragic experience themselves.
It’s important to reiterate that our staff work really hard to provide the best possible care to patients. They make difficult and complex clinical decisions every day and often get things right. I want us to be an organisation which learns when things go wrong and which does something about it, rather than one where people get blamed when they make a mistake. This approach is in the best interests of patients because it will help us continue to improve. It is also why we commissioned this review with NHS England.
Above all, we have a duty to patients, their families and the public to provide the best possible care in the safest way for the people who need our services. I give you my commitment as Chief Executive that we will continue to do everything possible to achieve this.
Page 2 of 3
Care Quality Commission Inspection The Care Quality Commission (CQC) has now concluded their planned hospital inspection. The Chair and I received positive feedback from the CQC about the progress we have made since the last inspection and the CQC highlighted to us areas that require immediate improvement. These include:
- Documentation of risk in community services. - Medicines management - Sharing learning is good in teams but patchy across the organisation - High occupancy rates in our inpatient services - Physical health monitoring in adult inpatient services and post use of rapid
tranquilisation - Langley Green Hospital is a hot spot e.g. high use of agency due to vacancy levels - Data quality requires improvement
The Care Delivery Services have undertaken immediate action in a number of these areas, including a Trust-wide audit of Medicines Management and reviewing documentation for risk assessment in our community services. I anticipate we will receive a draft report from the CQC, with further detail, in the next few months. In the interim we are taking immediate steps, with Care Delivery Services, to address the areas above. Changes to the executive team You will be aware that I have recently announced my retirement from the NHS. Having served 38 years in the NHS I have decided now is the time for me to retire and return to be closer to my family in Northern Ireland at the end of March 2017. Lorraine Reid, Executive Director of Performance and Service Delivery has also advised me she plans to retire in March 2017 and our Executive Medical and Quality Director, Dr. Tim Ojo, has taken the decision to step down from his post next year and will remain with us as a Consultant Psychiatrist following seven years in the role.
The Chair and I are aware the announcement of three members of the Executive Team moving on, through retirement or to other roles in the Trust, will require a careful period of transition. I am confident we have a plan in place to mitigate potential risk and each member of the team remains focused on delivery of Our 2020 Vision during this time. Financial Performance At the last Council I provided an update on our financial performance for Q1, which was very disappointing. Performance remains challenging with the position at month At the end of month six the Trust is £2.6m in deficit, compared to the planned surplus of £0.4m, therefore £3.0m off plan. The main reasons for this are overspending inpatient services, high agency usage, and some non-delivery of service improvement projects. The issues and our mitigation of these will be discussed in more detail through our performance reports at Trust Board.
The Care Delivery Services continue to focus on delivery of the service improvements plans alongside working on our operating plans for 2017/19. Leadership Development I am pleased to report that we have launched a new programme for Emerging Leaders. This targets staff in roles that are Band 2 – 6 and compliments our already successful leadership development programme for staff Band 7 and above that 250 staff have completed. These courses will support our work on retention, succession planning and embedding our values and behaviours.
Page 3 of 3
Sustainability & Transformation Plan (STP)
The latest submission of the Sussex and East Surrey STP was made to NHS England on 21 October. I have established a mental health sub-group of the STP Programme Board that has met to review the place based plans, of which there are three (Coastal Care, Central Sussex and East Sussex Better Together) to ensure mental health and delivery of the Five Year Forward View for Mental Health priorities will be delivered.
3. Recommendations
Members of Trust Board are invited to note the contents of this report, comment and ask questions.
Board of Directors: 26 October 2016 - Public Agenda Item: TBP38 .3/16
Attachment: F For Information
By: Lorraine Reid, Executive Director Service Delivery and Performance Management
Trust Quality and Performance Report – September 2016
SUMMARY & PURPOSE
The Trust Performance report, attached, provides a summary of Trust performance against an agreed set of performance indicators related to Quality, People, Finance, and those set by NHS Improvement and CCG Commissioners. The Executive Summary, at the front of the report highlights the current key risks and emerging issues. The Trust Board is asked to:
Review the performance of the organisation as reported.
LINK TO ANNUAL PLAN
The Annual Plan areas this paper relates to –
1. Quality and Experience of patients 2. Finance Information and Performance 3. People
ACTION REQUIRED BY COMMITTEE MEMBERS
The Trust Board is asked to:
Review the performance of the organisation as reported.
1.0 Introduction
The Trust Quality and Performance report is attached to this paper. This report is laid out as described in Appendix B. A number of indicators related to the Trust’s strategic quality priorities have been added in the section labelled “Quality Account”.
2.0 Report
2.1 NHS Improvement Indicators The Trust has achieved the following NHS Improvement indicators at the end of September 2016 (Quarter 2): Delayed Transfers of Care, Early Intervention waiting times, Gate-keeping of Inpatient Admissions, Access to Healthcare for people with a Learning Disability, Mental Health Minimum Dataset (completeness) and Mental Health Minimum Dataset (Outcomes) and IAPT18 week and 6 week waiting times. The following indicators have not been achieved at the end of September.
CPA Reviews: 86% of patients on CPA have had a review in the last 12 months. Whilst North West Sussex has achieved this quality standard in the month other CDSs have not. Learning from the areas where most improvement has been made suggests that focused support provided by the data quality agents, regular personal updates on when CPA reviews are due, together with the work on demand and capacity modelling, which involves data cleansing is the most effective approach. This learning has been shared with CDSs and we are reviewing how further training support on Carenotes can be provided to support clinicians. CDSs have been asked to review their existing action plans to improve effectiveness and revise the recovery trajectory to achieve this indicator as soon as possible, within the next quarter. In addition a personalised dashboard system is being piloted which will remove the need for manual prompts, this has been extremely well received by clinicians.
7 day follow ups: Performances against the 7 day follow up indicator remains under target in the current quarter. 91.4% of patients were followed up within 7 days in this period. This equates to 261 of 284 discharges followed up within 7 days of discharge in September.
Each CDS has a comprehensive action plan in place to address these issues and performance has improved significantly in the month, however using the QI methodology we plan to focus more on trends (at daily, weekly and monthly intervals) to determine the effectiveness of these interventions.
The Trust proposed a number of exceptions to our auditors KPMG and also to NHS Improvement which relate to areas where the Trust is not in a position to impact on performance. In terms of governance, these exceptions are being signed off by the Executive Assurance Committee in October. The exceptions are:
Patients with Dementia discharged to a care home setting. Follow up will be completed with the care home staff.
Patients who are discharged overseas
Patients who are readmitted to a Mental Health acute ward in 7 days
Patients who are discharged to private CQC registered hospitals (Run charts for 7 day follow up performance are included as Appendix B)
The Trust performance against 7 day follow ups, once these exception are removed was 92.9% for Q2 and 92.6% for September. 2.2 Performance of the CDSs against the agreed Quality and Finance ratings
Appendix A describes how each CDS is performing against the Quality and Finance ratings agreed in the CDS Accountability Framework. The table describes the current performance against the finance and quality ratings. An adjusted quality risk rating is provided for each CDS which is based on the level of assurance provided by the action plans provided. The table also describes the Governance actions which have been suggested by the Executive Assurance Committee. 2.3 Quality Account Indicators The Trust has agreed a number of quality indicators to underpin the 4 strategic quality priorities of care planning, suicide prevention, physical health and staff well-being and development. Reporting mechanisms are planned to be in place by the end of Q2 (Q3 for the self-harm measure). Reports have been produced for all the key measures. (Adult reports are in the process of being tested and are expected to be reported at the November Board meeting) The figures reported for child and adolescent risk assessments represent the proportion of patients, who have had at least one assessment contact, that have a valid risk assessment completed on Carenotes. The reports show that 54% of patients have a current risk assessment, on the Carenotes standard form. Audit has identified that a number of risk assessments are held on Carenotes as uploaded documents which is not appropriate as these are not always easily available to other practitioners.. The services have robust plans in place that aim to ensure that all risk assessments are complete on Carenotes by the end of November; a 30% improvement has been achieved in the first week. The CDS is also reviewing risk assessment training, supervision arrangements, Carenotes training and overall leadership in relation to maintaining and providing better assurance on this quality standard.
2.4 Patients accommodated in police custody and places of safety Appendix C shows the number of patients held in custody each month compared to those who are held in a place of safety. Patient flow and capacity in inpatient services has improved in the last month, and use of custody is reducing and has been noted by Sussex Police colleagues. There have, however, been a few occasions when the 136 Suites have not been available due to demand, but on the whole the trend is positive.
3.0 Recommendation/Action Required
The Trust Board is asked to review the performance of the organisation as reported.
4.0 Next Steps
The performance of the organisation is reviewed each month at CDS level and by the Executive Director of Service Delivery and Performance through quality and performance review meetings where the CDSs have amber or red quality ratings, or where the financial ratings require it.
APPENDIX A CDS
Quality Rating Finance Rating Governance Actions
Rating Adjusted Risk Rating
Frequency of Monitoring
Rating Commentary Frequency of Monitoring
East Sussex Red
Amber Reporting Monthly more frequently
2a Level of risk is material but stable
Reporting Monthly / Meeting Monthly
Bi-weekly financial scrutiny Weekly 7 day follow up reporting scrutiny
North West Sussex Red Red Reporting Monthly / Meeting more frequently
1 Significant Risk Reporting Monthly / Meeting more frequently
Additional management support in place. Bi-weekly financial scrutiny meetings. Weekly 7 day follow up reporting scrutiny
Coastal West Sussex Red Amber Reporting Monthly / Meeting more frequently
2b Material Risk Reporting Monthly / Meeting Monthly
Facilitated planning approach with North West Sussex. Bi-weekly financial scrutiny Weekly 7 day follow up and CPA review scrutiny
Brighton & Hove Red Red Reporting Monthly / Meeting more frequently
2a Level of risk is material but stable
Reporting Monthly / Meeting Monthly
Additional management support will be put in place and bi-weekly financial scrutiny Weekly 7 day follow up and CPA Review reporting scrutiny, close monitoring of quality actions.
Primary Care & Wellbeing
Green Green Reporting monthly / meeting Quarterly
4 No evident concerns
Reporting Monthly / Meeting Quarterly
N/A
Forensic Healthcare
Green Green Reporting monthly / meeting Quarterly
4 Reporting Monthly / Meeting Monthly
CDS is now performance meeting to enable quality actions to be closely monitored.
Children & Young People’s Service / EIS
Amber Amber Reporting Monthly / Meeting Monthly
3 Emerging or minor concerns potentially requiring
Reporting Monthly / Meeting Quarterly
Support regarding demand and capacity in Hampshire.
APPENDIX A CDS
Quality Rating Finance Rating Governance Actions
Rating Adjusted Risk Rating
Frequency of Monitoring
Rating Commentary Frequency of Monitoring
scrutiny
Learning Disability – Red Amber Reporting /meeting monthly
4 No evident concerns
Reporting Monthly / Meeting Monthly
Fortnightly review of action plan progress monitoring with Operations Director.
APPENDIX B
0
50
100
150
200
250
60%
65%
70%
75%
80%
85%
90%
95%
100%
105%
d
i
s
c
h
a
r
g
e
s
P
e
r
c
e
n
t
a
g
e
Coastal West Sussex discharges and % followed up in 7 days
% followed up in 7 days Median Discharges Linear (Discharges)
0
50
100
150
200
250
60%
65%
70%
75%
80%
85%
90%
95%
100%
105%
d
i
s
c
h
a
r
g
e
s
P
e
r
c
e
n
t
a
g
e
East Sussex discharges and % followed up in 7 days
% followed up in 7 days Median Discharges Linear (Discharges)
0
50
100
150
200
250
60%
65%
70%
75%
80%
85%
90%
95%
100%
105%
d
i
s
c
h
a
r
g
e
s
P
e
r
c
e
n
t
a
g
e
North West Sussex discharges and % followed up in 7 days
% followed up in 7 days Median Discharges Linear (Discharges)
0
50
100
150
200
250
60%
65%
70%
75%
80%
85%
90%
95%
100%
105%
d
i
s
c
h
a
r
g
e
s
P
e
r
c
e
n
t
a
g
e
Brighton & Hove discharges and % followed up in 7 days
% followed up in 7 days Median Discharges Linear (Discharges)
APPENDIX C PLACES OF SAFETY / CUSTODY
0
2
4
6
8
10
12
14
16
18
20
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Patients held in custody vrs place of safety - Crawley
Place of Safety
Median
Police Custody
Median
0
5
10
15
20
25
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Patients held in custody vrs place of safety - West Sussex
Place of Safety
Median
Police Custody
Median
0
5
10
15
20
25
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Patients held in custody vrs place of safety - Eastbourne
Place of Safety
Median
Police Custody
Median
0
2
4
6
8
10
12
14
16
18
20A
pr-
15
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Patients held in custody vrs place of safety - Hastings
Place of Safety
Median
Police Custody
Median
0
5
10
15
20
25
Ap
r-1
5
Ma
y-1
5
Jun
-15
Jul-
15
Au
g-1
5
Sep
-15
Oct
-15
No
v-1
5
De
c-15
Jan
-16
Feb
-16
Ma
r-16
Ap
r-1
6
Ma
y-1
6
Jun
-16
Jul-
16
Au
g-1
6
Sep
-16
Patients held in custody vrs place of safety - Brighton
Place of Safety
Median
Police Custody
Median
Appendix D The top level Trust dashboard shows the performance of the Trust as a whole against NHS Improvement (NHSI) indicators, Local Indicators, Workforce Indicators, Finance Indicators and Patient Indicators. A number of quality indicators have been agreed and are being developed to underpin the Trust quality goals.
NHS Improvement (NHSI) section: The circular info graphic describes whether each of the NHSI indicators are achieved or not (red or green) in the prior quarter. The three letter codes on each section link to the table of indicators on the right hand side of the section. Within this table the current period’s performance is stated against the target with an arrow to represent the trend over the last 12 months. The spark line, (little bar chart), shows the performance for each quarter over the past twelve months.
Local indicators are presented in a similar way showing the actual, performance and trend.
Workforce Indicators: The staffing section shows the agency costs and temporary costs against the target. Where there is a red box this shows that the target is now achieved. The sickness section shows the sickness absence performance for the period. The mandated training performance is shown pictorially through a wheel. The Inner dark blue wheel show the percentage of Core training courses completed and the outer light blue wheel shows the percentage of all courses.
o Patient Indicators: The proportion of friends and family tests that are positive
is represented through the faces info graphic. The table also shows how many responses were made. The serious incidents section describes the proportion of SI reports that were completed on time alongside a graph which shows the number of level 1 and level 2 (more serious) incidents in the last quarter, compared to the prior year. The duty of Candour section shows how many serious incidents met the criteria for duty of candour and the percentage. The complaints section shows how many complaints were received compared to the same period last year, and how many were responded to on time.
o Finance Indicators: The finance section shows the budget variance: The graph shows the variance between the year to date budget and actual. The SIP graph described the SIP achieved (bar) against the target (line).
Care Delivery Service Dashboards: Each CDS has a quality assurance dashboard included in the report, followed by a narrative. Each CDS is assigned two quality ratings.
The main quality rating, which is based on the actual performance observed. Non achievement of less than 4 indicators is a green rating, Non- achievement of more than 4 indicators leads to an amber rating and non-achievement of more than 8 indicators leads to a red rating. Other qualitative information may also be taken into account to influence the rating awarded. The top level Trust dashboard shows the performance of the Trust as a whole against Monitor indicators, Local Indicators, Workforce Indicators, Finance Indicators and Patient Indicators. A number of quality indicators have been agreed and are being developed to underpin the Trust quality goals
The mitigated quality rating is calculated as above, but where the review group is convinced that quality written action plans are in place, the ratings are reduced to amber for each indicator. Amber rated indictors are only scored a half a point which then impacts on the overall mitigated quality score. On the dashboard, the small diamond or round shapes indicate the mitigated score for each indicator.
CDS Quality Assurance Dashboard
www.sussexpartnership.nhs.uk
September 2016
Trust Total Reporting Period: Jul-Sep 2016
NHSIKey
7DF 7 Day Follow Ups ≥ 95% 91.4%
C12 CPA reviews in 12 months ≥ 95% 85.5%
GTK Gatekeeping ≥ 95% 98.8%
DTC Delayed Transfers of Care ≤ 7.5% 5.2%
IA6 IAPT 6 Week Waits ≤ 75% 76.6%
IA18 IAPT 18 Week Waits ≤ 95% 98.3%
EIW EIS 2 Week Waits ≤ 50% 72.7%
IDN MHSDS Completeness Identifiers ≥ 97% 97.6%
OUT MHSDS Completeness Outcomes ≥ 50% 75.4%
LOCAL INDICATORS KeyCurrent
Period
Refer to individual CDS Dashboards for performance against PBR PBR Reassessments ≥ 95% 76.3%
other local indicators
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 120,204
YTD Variance -1,846
Mandatory TrainingSIP YTD against Plan
YTD Plan 5450
YTD Achieved 2403
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test73.8%
Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95%
85% Positive Response RateSuicide Prevention
1300 Number of Responses 7 Day Follow Ups ≥ 95%
Patients with a Risk Assessment ≥ 95%
Serious Incidents CPA Patients with a Crisis Plan ≥ 90%
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90%
Inpatients Physical Health Assmt ≥ 95%
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Annual Appraisals ≥ 90%
£ '000s
YTD Actual 122,050
Target12mth
Trend
TargetCurrent
Period
12mth
Trend
58 Serious Incidents
meeting criteria for
Duty of Candour
£ '000s
4 Breaches in period
Performance against I&E
Budget
Complaints responded to
on timeTarget
32%Completed and submitted to
commissioners in 60 days
93%Compliance in period
-2,500
-2,000
-1,500
-1,000
-500
0
500
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
2,000
4,000
6,000
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
15.2%
7.9%
0% 5% 10% 15% 20%
Temporary
Costs
Agency
Costs
Current Period
Target
78%73%
Core Courses All Courses Target
4.2%
175 180 185 190 195 200
Same Period
Last Year
Current Period
Number of Complaints Received
0 20 40 60
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
7DF
C12
GTK
DTC
IA6
IA18
EIW
IDN
OUT
0%100%
Target
75%
85%95%
Under development
91%95%
Under development
Under development
Under development
Under development
4.2%
Under development
Under development
SUSSEX PARTNERSHIP TRUST WIDE AND EXECUTIVE SUMMARY QUALITY STANDARDS FRAMEWORK The Trust is monitoring Care Delivery Services (CDSs) performance against the quality standards described in the attached dashboards. CDSs are actively applying the principles of quality improvement and incrementally embedding learning to their action plans to improve effectiveness. ACHIEVEMENTS IN MONTH Early Intervention in Psychosis: The Trust continues to achieve the new Early
Intervention in Psychosis waiting times targets. 72% of patients were treated in 2 weeks against the national target of 50%
IAPT Waiting times. The service has achieved the quarterly waiting times target as required by NHS Improvement. The 76.6% of patients achieved the 6 week waiting times target against the 75% target and 97.8% of patients achieved the 18 week waiting times target against the 95% target.
Delayed Transfers of Care: Performance remains below the NHSI target. 5.6% against a target of less than 7.5%, which is helpful in stabilising recent pressures in the acute care pathway.
Duty of Candour: The management of 96% of relevant incidents met the Duty of Candour requirements in the quarter, which represents 2 breaches out of 53, where late completion (between 1 and 5 days) resulted in breaching the regulation. This demonstrates a positive trend of improvement
AREAS OF CONCERN Quality Account / Clinical Supervision: The Trust has agreed a number of quality indicators to underpin the 4 strategic quality priorities of care planning, suicide prevention, physical health and staff well-being and development. Reporting mechanisms are planned to be in place by the end of Q2 (Q3 for the self-harm measure). Reports have been produced for all the key measures. (Adult reports are being tested and are expected to be reported at the November Board meeting) The figures reported for child and adolescent risk assessments represent the proportion of patients, who have had at least one assessment contact, that have a valid risk assessment completed on Carenotes. Audit has identified that a number of risk assessments are held as uploaded documents in Carenotes and a proportion not confirmed. The services have robust plans and a focused approach in place ensure all risk assessments are complete on Carenotes by the end of November. The CDS is also reviewing risk assessment training, supervision arrangements, Carenotes training and overall leadership in relation to quality standards.
Financial Performance: At the end of Month 6 the Trust is reporting an overall deficit of £2,587k. Although there was a reduction in the deficit in month to £141k, this was due to a one off benefit in month rather than a real improvement in the underlying position. These results provide the Trust with a Financial Sustainability Risk Rating of 2, with ratings of 1 for all of the metrics relating to the income and expenditure plan, off-set by a rating of 4 for liquidity. The Trust is currently £1,397k off a rating of 3, compared to the planned rating of 4. Given the Month 6 position and forecast deficit, NHSI are now in dialogue with the Trust regarding the actions that need to be taken to deliver the best case forecast and delivery of the control total for 2017/18. Based on the Trust’s Month 6 position it is now accepted that the Trust will not meet its control total this year. The current forecasts based on the best, worst and mid case are set out below.
Best Case Deficit £2.3m Mid Case Deficit £4.3m Worst Case Deficit £5.2m
However, following reporting a best case forecast deficit of £2m to NHSI in Month 5, the Trust is now being held to delivering this position. The Trust is also being asked to submit detailed action plans that support this position and to schedule a meeting with NHSI to discuss the plans to provide assurance on their delivery. 7 day follow ups: Performance against the 7 day follow up indicator remain under target in the current quarter. 91.4% of patients were followed up within 7 days in this period. This equates to 261 of 284 discharges followed up within 7 days of discharge in September. Each CDS has a comprehensive action plan in place to address these issues and performance has improved significantly in the month, however using the QI methodology we plan to focus more on trends (at daily, weekly and monthly intervals) to determine the effectiveness of these interventions. The Trust proposed a number of exceptions to our auditors KPMG and also to NHS Improvement which relate to areas where the Trust is not in a position to impact on performance. In terms of governance, these exceptions are being signed off by the Executive Assurance Committee in October. The exceptions are:
Patients with Dementia discharged to a care home setting. Follow up will be completed with the care home staff.
Patients who are discharged overseas Patients who are readmitted to a Mental Health acute ward in 7 days Patients who are discharged to private CQC registered hospitals
The Trust performance against 7 day follow ups, once these exceptions are removed was 92.9% for Q2 and 92.6% for September.
Care Programme Approach reviews: 86% of patients on CPA have had a review in the last 12 months. Whilst North West Sussex has achieved this quality standard in the month other CDSs have not. It has been noted that areas where most improvement has been made is where focused support has been provided by the data quality agents to clinicians with multiple reviews outstanding. The Trust is reviewing how further training support on Carenotes can be provided to support clinicians to get used to the new system. CDSs have been asked to review the learning from their existing action plans to improve the effectiveness of actions and revise the recovery trajectory to achieve this indicator as soon as possible but within the next quarter. Mandated training: Mandated training remains a Trust-wide priority. Trust wide 78% of staff have completed the Core Courses and 73% of staff has completed all of the required training. CDSs are developing plans to address this paying particular attention to teams who have not completed the Core Courses and learning from those areas where performance is good. We are monitoring the uptake of classroom based training - with regular updates to CDSs. The CDSs education partners are working closely with teams to ensure that there is operational capacity to release staff and that training is targeted to manage identified risks for example in standalone wards. The figures reported exclude staff who work exclusively on the bank. Payment by Results: The Trust is working closely with Commissioners to prepare for the introduction of an accountable mental health currency in 2017/18. The Trust has agreed a programme of work with Commissioners to achieve this. The key objectives are:
Packages of care must be specified by cluster and agreed by CCGs with variants as appropriate
Pathways of care should become standardised (as far as clinically possible) Clustering quality must be adequate for planning and contractual purposes Data on patient contacts must be accurately and comprehensively recorded in
Carenotes Outcomes must be specified, and measured by cluster.
The programme is focusing on early intervention in psychosis service in October, alongside clustering for patients in acute services and a number of assessment and treatment teams across the Trust. Following the “all adult” performance meeting in September CDSs are in the process of revising their actions plans to bring about a step change in performance over the next two months. A workshop has taken place with Early Intervention services to train senior clinical and managerial staff. The service has agreed to review the caseload and re-cluster all patients by the end of October. Further training has also been planned to take place during team meetings as a priority.
Agency Costs: Agency costs remain high at 7.9% of the total pay bill. The new NSHI Single Oversight Framework will be rating the Trust’s progress against the agency ceiling. NHSI have also offered to provide the Trust with help in reducing use of agency staff. Performance is varied across CDSs; plans are in place in each CDS to manage this. Weekly resourcing conference calls are in operation in adult and specialist older adult wards, a specialist older adult governance group has also been convened. It is of concern that most operational areas are using in excess of 15% of temporary staff, with particular concerns in North West Sussex, where temporary staffing level are up to 20%, of which 15% is agency staff. The use of agency staff in community settings has undergone a carefully managed reduction process and is due to cease in October. Responding to Serious Incidents: The Trust is required to complete a review and report to Commissioners within 60 working days of an incident occurring. 32% of incident reports were completed in the required timeframe in the last quarter. Each CDS has an action plan in place to respond to this where required. The response to the new trust wide team of clinical reviewers has been extremely positive and as predicted is reducing the burden on management capacity, while improving the quality and learning from the reviews.
Coastal West Sussex CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
7DF 7 Day Follow Ups ≥ 95% 93.0% 4WK 4 week waiting times ≥ 95% 97.2%
C12 CPA reviews in 12 months ≥ 95% 83.3% PBR PBR Reassessments ≥ 95% 75.2%
GTK Gatekeeping ≥ 95% 99.4% 5DY 5 day Urgent Care ≥ 95% 100.0%
DTC Delayed Transfers of Care ≤ 7.5% 8.6% ETH Ethnicity Completeness ≥ 90% 90.5%
IND MHSDS Completeness Identifiers ≥ 97% 97.9%
OUT MHSDS Completeness Outcomes ≥ 50% 79.0% Note: 5 day urgent care data does not yet include July figures due to late returns
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 15,809
YTD Variance -808
Mandatory TrainingSIP YTD against Plan
YTD Plan 901
YTD Achieved 43
PATIENT INDICATORS Complaints QUALITY ACCOUNTTarget: 85%
Friends & Family Test 84.6%Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95%
87% Positive Response RateSuicide Prevention
240 Number of Responses 7 Day Follow Ups ≥ 95%
Patients with a Risk Assessment ≥ 95%
Serious Incidents CPA Patients with a Crisis Plan ≥ 90%
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90%
Inpatients Physical Health Assmt ≥ 95%
Compliance in periodStaff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 8 FINANCE RATING: 2b
MITIGATED QUALITY RATING: 6.0
13%Completed and submitted to
commissioners in 60 days
100%
Serious Incidents
meeting criteria for
Duty of Candour
Target
12
0 Breaches in period
12mnth
Trend
Performance against I&E
Budget
Complaints responded to
on time
Current
PeriodTarget
Mitigated
RiskTarget
Current
Period
Mitigated
Risk
12mth
Trend
£ '000s
YTD Actual 16,617
£ '000s
-900
-600
-300
0
300
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
200
400
600
800
1,000
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
13.8%
7.2%
11.3%
0% 5% 10% 15%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
77%
70%
Core Courses All Courses Target
4.2%
0 50
Same Period
Last Year
Current Period
Number of Complaints Received
0 5 10
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
4WK
PBR5DY
ETH7DF
C12
GTKDTC
OUT
IND
0%100%
Target
75%
83%95%
Under development
93%95%
Under development
Under development
Under development
Under development
4.2%
63.3%
3.5%
80%
Under development
Under development
COASTAL WEST SUSSEX CDS ACHIEVEMENTS IN MONTH Friends and family test: 87% of patients gave a positive response to the friends and
family test. There were 240 responses in the quarter. Duty of candour: 100% meet duty of candour requirements. Routine waiting times: 97% of patients had an assessment within 4 weeks of referral. Urgent waiting times: 100% of patients on the urgent pathway were assessed in 5 days. Ethnicity completeness: 91% of patients have ethnicity recorded. Complaints response rates: The CDS responded to 85% of complaints in the quarter.
The services are using the safeguard system to run local reports and review progress through the local clinical audit group.
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Action plans to make improvements in areas that are under target have been reviewed by an Executive lead group in October. 7 day follow ups: The CDS followed up 93% of patients in 7 days in the last quarter and
have achieved the 93% target in September. In addition to a comprehensive action plan, the CDS are reviewing each breach to ensure that learning is embedded.
Agency Spend: Coastal CDS continues to have cost pressures in the use of agency staff, with 7.2% of the pay bill in the quarter, 7.6% in the month related to agency spend. Rowan ward has seen an increase in sickness in September related to vacancies and cover of long term sickness cases. However the ward has been successful in recruitment and staff is returning from sickness which will reduce agency spend.
CPA Reviews: 83% of patients have had a CPA Reviews in the last 12 months at the end of September. The Bognor team is taking longer than expected to deliver the outstanding CPA reviews due to the pressures on the team to review social care packages for patients on their caseloads. Support provided by the Data Quality Agents is helping the teams to improve their data quality and understand how to use Carenotes effectively.
Mandatory Training: 70% of staff has completed all of the mandated training against the 75% target, which is an improvement in the month. 77% have attended the core courses. Most teams in the service are on target but there are a notable few teams that are behind, particularly in the Chichester area. The service has a number of actions in play to give staff the time to complete the mandatory training and to ensure that the system is reporting accurate information.
Sickness Absence: Sickness absence continues to improve. The CDS and is reporting 4.2% in the quarter. Actions in place to improve the health and wellbeing of staff include regular drop in sessions with HR advisors, bite sized training in relation to health and wellbeing and embedding wellbeing and have a robust approach to annual appraisal process in place.
AREAS OF CONCERN / AREAS UNDER REVIEW CPA Reviews: 83% of patients have had a CPA Reviews in the last 12 months at the end
of September, pace in the Bognor Team is a concern that is being addressed Serious Incidents: 13% of serious incident reports were completed on time in the period.
Coastal are increasing the number of trained and available reviewers by rolling out root cause analysis to band 7 staff, and have established a clinical team to support services to respond to serious incidents and ensure that learning is embedded.
Delayed transfers of Care. Discharge from acute wards was delayed for 8.6% of patients in the period. The areas causing most pressure for Coast relate to rehabilitation and dementia services. For both these services there is a lack of suitable move on accommodation. As the situation also impacts on our partners, it is being raised with the system resilience groups and also with local commissioners, with a view to receiving a share of the available resilience funding. Commissioners are provided with a daily position statement on bed availability.
Payment by Results: 75% of patients’ reviews were completed in the required timeframe. The CDS is using learning from other areas The plan is being updated to encourage staff engagement as this is the area where the CDS has experienced the greatest challenge.
North West Sussex CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
7DF 7 Day Follow Ups ≥ 95% 88.7% 4WK 4 week waiting times ≥ 95% 92.2%
C12 CPA reviews in 12 months ≥ 95% 95.0% PBR PBR Reassessments ≥ 95% 57.2%
GTK Gatekeeping ≥ 95% 98.8% 5DY 5 day Urgent Care ≥ 95% 100.0%
DTC Delayed Transfers of Care ≤ 7.5% 6.9% 5DY Ethnicity Completeness ≥ 90% 86.6%
IND MHSDS Completeness Identifiers ≥ 97% 98.3%
OUT MHSDS Completeness Outcomes ≥ 50% 61.0%
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 7,349
YTD Variance -1059
Mandatory TrainingSIP YTD against Plan
YTD Plan 0
YTD Achieved 0
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test68.4%
Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95%
77% Positive Response RateSuicide Prevention
353 Number of Responses 7 Day Follow Ups ≥ 95%
Patients with a Risk Assessment ≥ 95%
Serious Incidents CPA Patients with a Crisis Plan ≥ 90%
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90%
Inpatients Physical Health Assmt ≥ 95%
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 10 FINANCE RATING: 1
MITIGATED QUALITY RATING: 9.5
24%Completed and submitted to
commissioners in 60 days
£ '000s
Breaches in period0
100% Compliance in period
Serious Incidents
meeting criteria for
Duty of Candour
5
12mnth
Trend
Performance against I&E
Budget
Complaints responded to
on time
Current
PeriodTarget
Mitigated
RiskTarget
Current
Period
Mitigated
Risk
12mth
Trend
£ '000s
8,409
Target
YTD Actual-1,200
-800
-400
0
400
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
50
100
150
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
24.4%
14.9%
20.9%
0% 10% 20% 30%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
76%
67%
Core Courses All Courses Target
6.6%
20 25 30
Same Period
Last Year
Current Period
Number of Complaints Received
0 5 10
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
4WK
PBR5DY
ETH7DF
C12
GTKDTC
OUT
IND
0%100%
Target
75%
95%95%
Under development
89%95%
Under development
Under development
Under development
Under development
6.6%
84.3%
3.5%
80%
Under development
Under development
NORTH WEST SUSSEX ADULT CDS ACHIVEMENTS IN MONTH 5 day urgent care, delayed transfers of care and gatekeeping of admissions to inpatient
units remains on target. The CDS has achieved the CPA review target in the period with 95% of patients having
had a review in the past 12 months. The service has implemented a new reporting system in their community service, with
support from the Trusts clinical care intelligence team. The objective of the system is to enable better clinical accountability through transparency of each clinician’s caseload and performance against key KPI’S.
A new caseload dashboard, on Carenotes, developed by the clinical care intelligence team, is being trialled in North West Sussex to support clinicians to manage their caseload, PBR and CPA reviews more easily. The dashboard has been designed specifically to encourage clinical accountability of the system information.
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE 7 day follows ups: The CDS followed up 89% of patients in 7 days in the last quarter.
The performance in September. A daily review process is in place to ensure timely actions are taken and learning is embedded in their action plan.
KEY AREAS OF CONCERN / AREAS UNDER REVIEW 4 week wait waiting times: 92% of patients had an assessment within four weeks. The
CDS are developing a plan to bring about improvements. Payment by Results: 57% of patients in this area have a valid cluster. Improvements
have been seen in a number of teams in the month, but performance remains low in Crawley community teams. The CDS have forecast that the team will achieve 95% by Christmas using the new reporting processes in place. In addition these teams are being fast tracked for developments on the Trust accountable currency development programme which is being jointly managed with Commissioners.
Agency Spend: The service is experiencing high levels of agency expenditure, 14.9% of the pay bill, which is occurring in both acute and community services. A comprehensive action plan is in place; however there has been some delay in achieving the actions planned which is being followed up with the service Director.
Sickness Absence: Sickness absence has remained high over the last 4 months. The service has agreed for the senior HR advisor to work with team to renew focus on short term sickness and ensure the policy is followed.
Mandated training: 67% of all courses have been completed and 76% of the core training is complete. The CDS is in the process of describing a recovery trajectory to achieve 85% by the end of December.
Timeliness of responses to complaints: 68% of complaints have been responded to in agreed timeframes. Management of complaints has been delegated to team managers.
Serious incident reporting: 24% of serious incident reports were submitted on time. Overdue reports are being followed up each week.
Brighton & Hove CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
7DF 7 Day Follow Ups ≥ 95% 90.0% 4WK 4 week waiting times ≥ 95% 89.9%
C12 CPA reviews in 12 months ≥ 95% 80.5% PBR PBR Reassessments ≥ 95% 78.8%
GTK Gatekeeping ≥ 95% 99.1% 5DY 5 day Urgent Care ≥ 95% 95.4%
DTC Delayed Transfers of Care ≤ 7.5% 8.7% ETH Ethnicity Completeness ≥ 90% 80.9%
IND MHSDS Completeness Identifiers ≥ 97% 97.9%
OUT MHSDS Completeness Outcomes ≥ 50% 74.3%
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 10,085
YTD Variance -328
Mandatory TrainingSIP YTD against Plan
YTD Plan 301
YTD Achieved 181
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test84.4%
Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95%
94% Positive Response RateSuicide Prevention
52 Number of Responses 7 Day Follow Ups ≥ 95%
Patients with a Risk Assessment ≥ 95%
Serious Incidents CPA Patients with a Crisis Plan ≥ 90%
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90%
Inpatients Physical Health Assmt ≥ 95%
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 11 FINANCE RATING: 2a
MITIGATED QUALITY RATING: 9.5
12mnth
Trend
Performance against I&E
Budget
Complaints responded to
on time
Current
PeriodTarget
Mitigated
RiskTarget
Current
Period
Mitigated
Risk
12mth
Trend
£ '000s
YTD Actual 10,413
28%Completed and submitted to
commissioners in 60 days
18 Serious Incidents
meeting criteria for
Duty of Candour
£ '000s
89% Compliance in period
2 Breaches in period
Target
-450
-300
-150
0
150
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
100
200
300
400
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
10.9%
2.9%
7.5%
0% 5% 10% 15%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
78%
72%
Core Courses All Courses Target
4.2%
20 25 30
Same Period
Last Year
Current Period
Number of Complaints Received
0 5 10 15
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
4WK
PBR5DY
ETH7DF
C12
GTKDTC
OUT
IND
0%100%
Target
75%
81%95%
Under development
90%95%
Under development
Under development
Under development
Under development
4.2%
83.2%
3.5%
80%
Under development
Under development
BRIGHTON ADULT CDS A personalised information dashboard is being piloted in Brighton and Hove CDS. It provides prompts to clinicians about actions that are required. It has been very well received by clinicians. ACHIVEMENTS IN MONTH Gatekeeping of inpatient admissions: The service is achieving the target to meet
Gatekeeping is on target in the period. Friends and family test: 94% of patients gave a positive response to the friends and
family test and the response rate has increased to 89 in the period. Recruitment and retention: The CDS has been successful in recruiting to inpatient
vacancies and the positive situation is being maintained. Sickness Absence rates: The sickness absence rate for the service is 4.2% which is the
lowest in adult services.
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Completion of Serious Incident reports: 28% of serious incident reports were
completed on time. Mandated training: 79% of staff has now completed the Core courses and 72% all
courses. Plans are in place to ensure that desktop computers are available and training is monitored in supervision. A nurse development practitioner is maintaining a review in acute services.
Serious Incidents: a significant amount of work is underway at Mill View to support and improve practice around physical healthcare and observations in line with the learning from two serious incidents this year.
AREAS OF CONCERN / AREAS UNDER REVIEW Further support is now being provided to Brighton CDS, in line with the Accountability Framework. 4 week waiting times: 90% of patients received an assessment within 4 weeks of referral
to the service. A recovery plan and trajectory is in place. This includes the promotion of the use of the Trust DNA policy to ensure that low risk patients that do not attend are discharged and focusing on medical recruitment.
CPA Reviews in 12 months: 80.5% of patients have had a CPA review in the last 12 months. The CDS plan includes ongoing cleansing of data, medical recruitment in the West Assessment and treatment service, caseload reviews and more detailed reporting to clinicians for review in supervision. The CDS has been asked to review this action plan as the current actions were not delivering against trajectory
Payment by Results (PBR): 79% of patients have had a current PBR review. The CDS is looking to provide further training on PBR to engage the clinicians in the benefits of carrying out PBR reviews. Team and service benchmarking reports have been delivered to the CDS by the clinical care intelligence team to better engage clinicians.
7 day follow ups: 90% of patients received a follow up in 7 days in the quarter. Over the past month all clinicians have been made aware of the revised guidance and the business manager is reviewing the process for follow up between acute and community services.
Delayed Transfers of Care: Delays have increased to 8.7% in the quarter. Issues relate to waiting for suitable internal rehabilitation places or supported accommodation. The Trust Clinical Director is supporting the service to review the risks for patients whose discharge is delayed with a view to finding alternative accommodation options.
Agency expenditure: There has been a sustained improvement in recruitment in the service which has had a positive impact on agency usage. (2.9% in the quarter), however much of the current agency spend relates to unsocial hours and this issue is being investigated to further minimise the use of agency staff.
East Sussex CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
7DF 7 Day Follow Ups ≥ 95% 91.8% 4WK 4 week waiting times ≥ 95% 97.1%
C12 CPA reviews in 12 months ≥ 95% 91.4% PBR PBR Reassessments ≥ 95% 86.1%
GTK Gatekeeping ≥ 95% 98.1% 5DY 5 Day Urgent Care ≥ 95% 99.0%
DTC Delayed Transfers of Care ≤ 7.5% 2.7% ETH Ethnicity Completeness ≥ 90% 87.4%
IND MHSDS Completeness Identifiers ≥ 97% 96.8%
OUT MHSDS Completeness Outcomes ≥ 50% 84.2%
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 13,772
YTD Variance -637
Mandatory TrainingSIP YTD against Plan
YTD Plan 820
YTD Achieved 273
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test59.4%
Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95%
86% Positive Response RateSuicide Prevention
121 Number of Responses 7 Day Follow Ups ≥ 95%
Patients with a Risk Assessment ≥ 95%
Serious Incidents CPA Patients with a Crisis Plan ≥ 90%
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90%
Inpatients Physical Health Assmt ≥ 95%
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 9 FINANCE RATING: 2a
MITIGATED QUALITY RATING: 6.5
1 Breaches in period
YTD Actual 14,409
24%Completed and submitted to
commissioners in 60 days
94% Compliance in period
17 Serious Incidents
meeting criteria for
Duty of Candour
£ '000s
Target
12mnth
Trend
Performance against I&E
Budget
Complaints responded to
on time
Current
PeriodTarget
Mitigated
RiskTarget
Current
Period
Mitigated
Risk
12mth
Trend
£ '000s
-750
-500
-250
0
250
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
200
400
600
800
1,000
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
17.1%
5.8%
15.7%
0% 5% 10% 15% 20%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
76%73%
Core Courses All Courses Target
5.3%
20 30 40
Same Period
Last Year
Current Period
Number of Complaints Received
0 10 20
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
4WK
PBR5DY
ETH7DF
C12
GTKDTC
OUT
IND
0%100%
Target
75%
91%95%
Under development
92%95%
Under development
Under development
Under development
Under development
5.3%
57.1%
3.5%
80%
Under development
Under development
EAST SUSSEX ADULT CDS ACHIVEMENTS IN MONTH Routine and priority waiting times, delayed transfers of care and gatekeeping of
admissions to inpatient units remains on target.
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Mandated training: Mandated training is discussed at team and managerial level.
Performance has improved. 76% of staff has completed the core mandated training and 73% have completed all courses. The requirement for mandated training is discussed with staff in supervision and managers use Mylearning to review performance.
Serious Incident reporting: 24% of serious incidents were completed in the required timeframe. SI’s are reviewed by the responsible general managers. The service has no outstanding SI reports.
Ethnicity reporting: 88% of patients have recorded ethnicity. This is marginally below the target and the service has plans in place to improve performance.
7 day follow ups: 92% of discharges have received a follow up in the month. The CDS is continuing to monitor performance weekly.
Payment by Results: 86% of patients have received a review in the required timeframe in the period. Reporting is being used to focus attention on areas where reviews have not been completed and support is being provided in using Carenotes
AREAS OF CONCERN / AREAS UNDER REVIEW CPA Reviews: 92% of CPA reviews have been completed in the timeframe. The service
has a number of actions in place including: updated guidance, circulating information reports to clinicians with prompts to action and regular reviews of performance with the service managers. Specific support is being provided to clinicians at High Weald Lewes and Havens and Eastbourne recovery teams where performance is weakest.
Sickness Absence: The service is reporting 5.3% sickness in the period. Overall 3.5% relates to long term sickness. The services are reviewing their approach to supporting staff with wellbeing initiatives specifically tailoring to their needs.
Complaints – The service responded to 59% of complaints in required timeframe, which is below the target. Complaints are reviewed by the general managers that are responsible for ensuring the reviews are carried out. Some delays resulted from the changes of process which involved uploading complaints to the safeguard system. Training is being reviewed with the complaints team
Primary Care & Wellbeing CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
IA6 IAPT 6 Week Waits ≥ 75% 76.6% IAR IAPT Recovery Rates ≥ 50% 54.4%
IA18 IAPT 18 Week Waits ≥ 95% 97.8%
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 292
YTD Variance 88
Mandatory TrainingSIP YTD against Plan
YTD Plan 192
YTD Achieved 124
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test100.0%
Care Planning
Care Plans signed by Patient ≥ 65% Under development
CPA Reviews in 12 months ≥ 95% Under development
95% Positive Response RateSuicide Prevention
55 Number of Responses 7 Day Follow Ups ≥ 95% Under development
Patients with a Risk Assessment ≥ 95% Under development
Serious Incidents CPA Patients with a Crisis Plan ≥ 90% Under development
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90% Under development
Inpatients Physical Health Assmt ≥ 95% Under development
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 2 FINANCE RATING: 4
MITIGATED QUALITY RATING: 1.0
100%
Completed and submitted to
commissioners in 60 days
Nil Return Compliance in period
Serious Incidents
meeting criteria for
Duty of Candour
0
£ '000s
Complaints responded to
on time
0 Breaches in period
Target
YTD Actual 204
TargetCurrent
Period
12mth
Trend
Mitigated
RiskTarget
Current
Period
12mnth
Trend
Mitigated
Risk
Performance against I&E
Budget
£ '000s
-200
-100
0
100
200
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
50
100
150
200
250
A M J J A S O N D J F M
SIP
Y
TD
'00
0s
YTD Achieved YTD Plan
11%
3%
5%
0%
0%
2%
-5% 0% 5% 10% 15%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
78%
70%
Core Courses All Courses Target
3.6%
0 2 4
Same Period
Last Year
Current Period
Number of Complaints Received
0 0.5 1
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
IAR
IA6IA18
0%100%
Target
75%
3.6%3.5%
Under development
Under development
PRIMARY CARE AND WELLBEING ADULT CDS ACHIVEMENTS IN MONTH 97.8% of treatment is provided within 18 weeks, meeting the NHSI indicator for the 18
week target. 95% of patients responded positively to the friends and family indicator in the period. (45
responses were received). The IAPT recovery rate has improved in the last quarter. 54.5% are demonstrating
recovery in the period meeting the expectations of local commissioners. 100% of complaints were responded to within the agreed timeframe in the quarter.
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE 70% of staff have completed all the Core Training requirements. The service is putting in
plans to ensure all staff complete Mandatory training. Sickness absence is well managed. The service achieved 3.6% which was marginally
above the target of 3.5%.
ChYPS CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
C12 CPA reviews in 12 months ≥ 95% 77.6% 4WS 4 week waiting times - Sussex ≥ 95% 94.9%
EIW EIS 2 Week Waits ≥ 50% 72.7% 4WH 4 week waiting times - Hants ≥ 95% 44.1%
IND MHSDS Completeness Identifiers ≥ 97% 97.5% 4WK 4 week waiting times - Kent ≥ 95% 52.9%
OUT MHSDS Completeness Outcomes ≥ 50% 71.2% PBR PBR Reassessments - EIS ≥ 95% 71.4%
DTC Delayed Transfers of Care ≤ 7.5% 0.0%
ETH Ethnicity Completeness ≤ 90% 95.9%
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 19,325
YTD Variance 442
Mandatory TrainingSIP YTD against Plan
YTD Plan 739
YTD Achieved 548
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test74.3%
Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95%
85% Positive Response RateSuicide Prevention
330 Number of Responses 7 Day Follow Ups ≥ 95% Under development
Patients with a Risk Assessment ≥ 95%
Serious Incidents CPA Patients with a Crisis Plan ≥ 90% Under development
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90% Under development
Inpatients Physical Health Assmt ≥ 95% Under development
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 7 FINANCE RATING: 4
MITIGATED QUALITY RATING: 5.0
72%Completed and submitted to
commissioners in 60 days
50%Compliance in period
Serious Incidents
meeting criteria for
Duty of Candour
2
YTD Actual 18,883
TargetCurrent
Period
12mth
Trend
Mitigated
RiskTarget
Current
Period
12mnth
Trend
Mitigated
Risk
Performance against I&E
Budget
£ '000s
£ '000s
Complaints responded to
on time
1 Breaches in period
Target
54%95%
-150
0
150
300
450
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
200
400
600
800
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
14.5%
11.8%
7.6%
0% 5% 10% 15% 20%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
81%77%
Core Courses All Courses Target
3.5%
0 20 40 60 80
Same Period
Last Year
Current Period
Number of Complaints Received
0 5 10
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
4WS
4WH
4WK
PBRDTC
ETHC12
EIWIDN
OUT
0%100%
Target
75%
78%95%
Under development
3.5%
0%
3.5%
80%
Under development
ChYPS SERVICE ACHIVEMENTS IN MONTH Waiting times: The Early Intervention service has achieved the NHSI indicator for waiting
times for treatment. 73% of patients received a treatment in 2 weeks from referral. Sickness Absence: Sickness absence in the period was at 3.5% Friends & Family: 85% of patients gave a positive response to the friends and family test
The number of responses has increased from 112 to 330 in the period. Waiting times to assessment: The targets were achieved in Sussex where 95% of
patients were assessed in 4 weeks. Mandatory Training: 81% of the core training and 77% of all courses have been
completed in ChYPS services. Reports are being used to identify areas where greater uptake is required
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Medical Staffing – The service continues to find medical recruitment challenging and is
developing a new medical staffing model with a view to ensuring that medical resources are shared equitably across the service. This work is being led by the Clinical Director and will report back to the November quality standards meeting.
Waiting times performance Hampshire: Given the lack of progress which has been made in reducing the waiting lists, the service has focused on finalising a number of waiting times trajectories for each team. The high vacancy rate in the service has meant that despite a number high number of agency staff the net capacity is only just over establishment. The service has been canvassing agency staff to join as permanent staff where possible. A number of options are being presented to Commissioners to reduce the waiting times, which involve additional funding or adjustments to the service model to address the current level of demand which exceeds estimates predicted in the tender.
Waiting times performance Kent: Waiting times in Kent have improve in some areas due to waiting times initiatives funded by Commissioners. 53% of patients were seen in 4 weeks in Kent. The service has demonstrated that they are maintaining their capacity and activity levels, and waiting lists remain static. The Kent service is current going through the competitive dialogue stages of the re-procurement of the service.
Serious incident reviews: 72% of serious incident reports were completed in 60 days. Outstanding serious incidents are being reviewed weekly.
Responding to complaints: 74.5% of complaints were followed up in the required time in ChYPS in the last quarter, a slight reduction in September.
AREAS OF CONCERN / AREAS UNDER REVIEW CPA Reviews for Early Intervention patients: 77% of patients have had a CPA reviews
in the last 12 months in Early Intervention services in Sussex. The CDS is reviewing the existing actions which have not been effective in achieving the target to date.
Payment by Results for Early Intervention patients: 72% of Payment by Results reviews were completed in the required timeframe. Additional support and training have been provided to the team. The service expects to review the caseload and re-cluster all patients by the end of October.
Risk Assessments – there is a robust plan in place to ensure that every person receiving treatment and care has a risk assessment and management plan in place on Carenotes, all staff are engaged in this process.
Forensic Healthcare CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
DTC Delayed Transfers of Care ≤ 7.5% 1.5% ETH Ethnicity Completeness ≥ 90% 99.1%
IND MHSDS Completeness Identifiers ≥ 97% 98.6%
Local Indicators under development
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 8,073
YTD Variance -176
Mandatory TrainingSIP YTD against Plan
YTD Plan 516
YTD Achieved 350
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test60.0%
Care Planning
Care Plans signed by Patient ≥ 65%
CPA Reviews in 12 months ≥ 95% Under development
89% Positive Response RateSuicide Prevention
62 Number of Responses 7 Day Follow Ups ≥ 95% Under development
Patients with a Risk Assessment ≥ 95% Under development
Serious Incidents CPA Patients with a Crisis Plan ≥ 90% Under development
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90% Under development
Inpatients Physical Health Assmt ≥ 95% Under development
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 3 FINANCE RATING: 4
MITIGATED QUALITY RATING: 2.5
54%Completed and submitted to
commissioners in 60 days
100% Compliance in period
3 Serious Incidents
meeting criteria for
Duty of Candour
YTD Actual 8,249
TargetCurrent
Period
12mth
Trend
Mitigated
RiskTarget
Current
Period
12mnth
Trend
Mitigated
Risk
Performance against I&E
Budget
£ '000s
£ '000s
Complaints responded to
on time
0 Breaches in period
Target
-200
-150
-100
-50
0
50
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
200
400
600
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
17.7%
4.1%
19.2%
0% 5% 10% 15% 20% 25%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
86%80%
Core Courses All Courses Target
4.7%
0 5 10
Same Period
Last Year
Current Period
Number of Complaints Received
0 5 10
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
INDDTC
0%100%
Target
75%
ETH
Under development
4.7%
81.7%
3.5%
80%
Under development
Under development
Under development
FORENSIC HEALTHCARE CDS ACHIEVEMENTS IN THE MONTH Delayed Transfers of Care: The service has achieved the delayed transfer of care
indicator in the period Essential training: 86% of staff have completed the core training and 80% of staff have
completed all courses. Actions in place include all staff attending induction, a programme of My Learning compliance and study days and a focus on PMVA training to reflect the needs of staff on shifts. Assistance is being sought from the PMVA team to find available slots.
Recording ethnicity: The service has achieved 99% AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE
Care Planning: The service is working to a target for Care Plans to be reviewed every six
months. Currently 96.9% of care plans meet this target which is an improvement in the month. The nurse consultant has undertaken a review of the quality and content of these plans and is supporting clinicians to achieve the 100% target.
Agency Expenditure: Agency expenditure was 4.1% in the period. Additional agency costs were incurred at Hellingly as a result of enhanced observations and long term segregation in Willow ward. Actions in place to avoid the use of agency staff, which includes seeking authority for agency booking, better management of sickness and a better spread of training activity.
Sickness Absence: Sickness is 4.7% in the quarter. Stress / anxiety and depression continue to be the main reason cited for sickness across the service and continues to be a main area of focus. A key aim of the health and well-being plan is to identify stressors within the workplace and work with staff to reduce and/or improve these areas. The stress assessment tool will help identify areas of stress for individuals and team and focus action plans to support staff.
Response to complaints: 60% of complaints are responded to in the agreed timeframe. The service is looking to put controls in place to achieve the target routinely.
Serious Incidents: Actions have been taken following a death in the inpatient service at HMP Lewes, to ensure a robust and thorough approach is taken to risk assessment and management from onwards including transfer and discharge. The CDS have put a steering group in place to track and oversee the changes and ensure that they are firmly embedded in practice and behaviour.
Learning Disabilities CDS Reporting Period: Jul-Sep 2016
NHSI LOCAL INDICATORS
Inner Wedge: Current performance Inner Wedge: Current performance
Outer Rim: Mitigated Risk Outer Rim: Mitigated Risk
Key Key
DTC Delayed Transfers of Care ≤ 7.5% 33.8% 4WK 4 week waiting times ≥ 95% 91.9%
IND MHSDS Completeness Identifiers ≥ 97% 98.0% ETH Ethnicity Completeness ≥ 90% 84.6%
Additional Local Indicators under development
WORKFORCE Sickness FINANCE
Target: 3.5%
Staffing
YTD Budget 2,408
YTD Variance -41
Mandatory TrainingSIP YTD against Plan
YTD Plan 198
YTD Achieved 39
PATIENT INDICATORS Complaints QUALITY ACCOUNT Current Period
Target: 85% Target
Friends & Family Test50.0%
Care Planning
Care Plans signed by Patient ≥ 65% Under development
CPA Reviews in 12 months ≥ 95% Under development
100% Positive Response RateSuicide Prevention
87 Number of Responses 7 Day Follow Ups ≥ 95% Under development
Patients with a Risk Assessment ≥ 95% Under development
Serious Incidents CPA Patients with a Crisis Plan ≥ 90% Under development
Target: 90%Physical Health
Duty of Candour Inpatients height, weight & BMI ≥ 90% Under development
Inpatients Physical Health Assmt ≥ 95% Under development
Staff Wellbeing and Development
Sickness levels ≤ 3.5%
6 weekly supervision - all staff ≥ 80%
Inpatient Supervision only ≥ 80%
Annual Appraisals ≥ 90%
QUALITY RATING: 7 FINANCE RATING: 4
MITIGATED QUALITY RATING: 6.5
100%
Completed and submitted to
commissioners in 60 days
Nil Return Compliance in period
Serious Incidents
meeting criteria for
Duty of Candour
0
YTD Actual 2,450
TargetCurrent
Period
12mth
Trend
Mitigated
RiskTarget
Current
Period
12mnth
Trend
Mitigated
Risk
Performance against I&E
Budget
£ '000s
£ '000s
Complaints responded to
on time
0 Breaches in period
Target
-60
-40
-20
0
20
40
60
A M J J A S O N D J F M
Bu
dg
et
Va
ria
nce
£0
00
s
Variance '000s Target
0
50
100
150
200
250
A M J J A S O N D J F M
SIP
Y
TD
'0
00
s
YTD Achieved YTD Plan
11%
3%
5%
15.4%
6.6%
17.2%
0% 5% 10% 15% 20%
Temporary
Costs
Agency
Costs
Vacancies
Current Period
Target
78%70%
Core Courses All Courses Target
6.0%
0 5 10
Same Period
Last Year
Current Period
Number of Complaints Received
0 1 1 2
Level 1
Level 2
Serious Incidents reported
Current Period
Same Period Last year
4WKETHINDDTC
0%100%
Target
75%
6.0%
100%
3.5%
80%
Under development
Under development
LEARNING DISABILITIES CDS The Trust provides services for people with learning disabilities across Sussex. ACHIEVEMENTS IN MONTH Supervision: All teams are able to evidence that supervision is in place. Friends and family: The service has received 100% positive feedback relating to patient
experience.
AREAS OF IMPROVEMENT OR WHERE ROBUST PLANS ARE IN PLACE Complaints: 50% of complaints were responded to in the agreed timeframe. The one
complaint that fell outside the trust timeframe for response was part of a system complaint and not specific to the service.
Routine waiting times: 89% of patients had an assessment within 4 weeks of referral to the service in East Sussex. This relates to the West Sussex specialist assessment service where demand outstrips the service commissioners. Discussions are in process with commissioners.
Essential training: 78% of staff have completed core training and 70% of staff all training. Service Managers are linking with my learning and business partners to address ongoing reporting anomalies with the system. The approach to training used at Lindridge, with an intensive induction period in the first four weeks is being adopted at the PDCA.
The Partnership Domiciliary Care Agency (PDCA) is operated by Sussex Partnership and is registered as a Social Care Domiciliary Care provider (i.e. it is inspected independently of other Sussex Partnership services by CQC). The PDCA provides domiciliary support to 14 adults with Learning Disabilities (and with a range of complex challenges) who rent flats at Mayfield Court and Acorn House. Our partners in the project are Southdown Housing Association, who are the social landlords for the 14 tenants.
Each tenant has an individualised package of care and support, which is spot-purchased by a care manager (local authority or CCG) and is delivered within their own rented flat. This support can alternatively be commissioned within a person’s family home, but we do not have any such clients at present.
The target client group is those people who might otherwise be at risk of long term hospitalisation, or who have been in hospital in relation to their learning disability and challenging needs, and is therefore a key plank in the local Transforming Care initiative, as it offers a bespoke community based approach to their needs. Nationally, there are few services operating this model as the PDCA works to manage significant risk presented by its clients in a strongly community-oriented way (as opposed to the more usual ‘communal’ residential care model). PDCA clients generally struggle to share space with others, which is why the model seems to be yielding generally positive outcomes for people.
Some of the more recent clients of the PDCA have previously been inpatients at the Selden Centre, which is a specialist Learning Disability Inpatient assessment, and Treatment Unit, and whose care managers have often struggled to find suitable services in the community.
Quality concerns at the PDCA: The service has significant staffing issues with high
sickness. Recruitment has been very challenging, which puts additional pressures existing substantive staff, however with HR and team leader ownership this is improving and the service is attracting candidates whose values and attitudes are aligned with those of the service. Interviews for a new registered manager post are scheduled to take place in the next couple of weeks.
Ethnicity recording: The service has a plan in place to improve the recording of
ethnicity. 85% of patients have recorded ethnicity against a national target of 90%
1 of 3
Sussex Partnership NHS Foundation Trust Board of Directors: 26 October 2016 - Public
Agenda Item: TBP38 .6/16 Attachment: J
For: Information By: Gordon Ferns/Diana Marsland Non-Executive Directors
QUALITY COMMITTEE SUMMARY REPORT
1.0 Introduction
The Quality Committee met on the 18th of October 2016; chaired by Diana Marsland Non-Executive Director in the absence of Prof. Gordon Ferns who had sent apologies [other apologies received are in the minutes of the meeting available on boardpad. There were no new declarations of interest.
2.0 Report
The meeting opened with the chair inviting comments on the findings of the Independent Thematic review of Homicides that had been published that morning. There was a discussion about the finding that the Trust needed to do more to evidence the embedding of learning. Additionally it was noted that the Trust needs to listen to patients, carers and other stakeholders and that responsibility for doing this had been stated. It was also noted that the report contained some of the theme that Trust governors had been concerned about too. Nevertheless there was acceptance that the homicide rate by Trust patients was not higher than those of comparable mental health providers. Monitoring of progress against stated actions will continue through the relevant subgroups of the Quality committee as well as the Executive Assurance committee. Under matters arising the issues of notes were about safeguarding information on care notes and the need for more information about how themes emerging from the SI and complaints annual reports were being taken forward. The next part of the meeting dealt with summary reports and matters for escalation from the sub-committees of the feed up into the Quality committee. Health & Safety – concerns about uptake of fire safety training. However a number of relevant policies had been ratified. Next meeting scheduled for end of October Suicide & Homicide prevention – concerns about how robustly the Trust was responding to the recent slew of Prevention of Future Deaths [PFD] HM coroner letters recently. It was agreed that CDS representation at future meetings would help in giving assurance. Terms of reference for the group were approved subject to regular review Mortality & SI review – the benefits of the weekly mortality reviews were discussed. However it was acknowledged that our level of incident reporting was still quite low and work need to continue to improve this Information Governance – ongoing concerns about volume of subject access requests and impact on staff re managing demand. Further discussion ensued about dealing with misfiling of records on Carenotes The committee also considered the Quality and Patient safety report which was very detailed. There was consensus around the need to address staff assaults and the need to work through the relevant Trust groups to get staff appropriately trained to help patients de-escalate The CDS Quality dashboards highlighted increased activity in Hampshire CHYPs as well as improvement in baseline performance on 7 day follow-up and quality improvement plans.
2 of 3
The clinical audit plan was reviewed and identified areas for improvement were noted and discussed. An update on progress on the 2016/17 Quality priorities was received and a fuller update was requested for the next meeting. The Patient experience report was tabled and discussion about the findings and what steps were being taken to address the issues of concern was had. There is a plan for a task and finish group with a QI perspective to address some of the more pressing issues.
QUALITY COMMITTEE
Agenda
Date: 18 October 2016
Time: 1400 - 1630
Duration: 2.5 hours
Venue: Board Room, Trust Headquarter, Swandean
Chair: Professor Gordon Ferns, Non-Executive Director
1 Welcome & Introductions
Verbal Gordon Ferns
1a Declaration of Interests Verbal All
1b Minutes from the meeting of 4 August 2016
Paper Gordon Ferns
1c Action Points & Matters Arising
Paper All
SUB-COMMITTEE REPORTS
2
3
4
Information Governance Group (8 Sept 2016)
Suicide & Homicide Group (7 October 2016)
SI & Mortality Review Group (7 October 2016)
Paper
Paper
Paper
Peter Lee
Tim Ojo
Tim Ojo
SAFE, EFFECTIVE, QUALITY PATIENT CARE
5
5a
CDS Quality & Performance Dashboard
&
CDS Performance Exception Report
Paper
Lorraine Reid
3 of 3
6 Clinical Audit Plan Review Paper
Kay Macdonald
7 Quality Priorities Review
Paper Tim Ojo
PATIENT EXPERIENCE
8 Patient Experience Report Paper
Bryan Lynch
STAFF HEALTH & WELLBEING
9 Workforce Strategy – Staff Health & Wellbeing Programme &
Year 2 Priorities
Paper Sue Esser
RISK MANAGEMENT
10 Board Assurance Framework & Strategic Risks
Paper Peter Lee
11 AOB
Verbal All
12 Date, Time & Venue of Next Meeting:
13 December 2016
1400 – 1630
Elm Room, Aldrington House
All
NB: Those present at the meeting should be aware that their name will be issued in the notes of this meeting which may be released to members of the public on request.
Contact: Jane Wells, EA to Executive Director of Nursing & Patient Experience
Email: [email protected]
Tel: 01903 845714
Distribution
Professor Gordon Ferns Non-Executive Director, Chair
Diana Marsland Non-Executive Director,
Dr Tim Ojo Executive Medical Director & Director of Quality, Jt Exec Lead
Diane Hull Executive Director of Nursing & Patient Experience, Jt Exec Lead
Lorraine Reid Executive Director of Service Delivery & Performance
Sam Allen Executive Director of Strategy & Improvement
Dr Kay Macdonald Clinical Academic Director
Sue Esser Director of Human Resources & Organisational Development
Justine Rosser Director of Nursing Standards & Safety
Dr Shakil Malik Senior Clinical Director
John Rosser Quality & Improvement Director
Bryan Lynch Deputy Director of Patient Experience
Head of Risk & Safety
Nikki Jones Head of Quality & Compliance
Scott Hunt Council of Governors Representative, East Sussex (observing)
Copy for Information:
Colm Donaghy Chief Executive
Caroline Armitage Chair
Corin Ansted Audit Committee Members distribution
Sally Flint Executive Director of Finance & Support Services
Head of Corporate Governance
Board of Directors: 26 October 2016 - Public Agenda Item: TBP38 .7/16
Attachment: K For Information
By: Richard Bayley, Non-Executive Director & Chair, Finance and Investment
FINANCE AND INVESTMENT COMMITTEE SUMMARY REPORT
1.0 Executive Summary This report provides a summary of the papers and discussions held at the Finance and Investment Committee meeting held on the 23rd September 2016 in order to provide the Board with assurance on the Trust’s financial and operational performance and investment decisions.
This report provides a summary of the papers and discussions held at the Finance and Investment Committee meeting held on the 23rd September 2016. It should be noted that Michael Decker was the Governor Representative at the meeting. The Committee Received papers on a number of current topics including:-
Month 5 Financial position and Financial Recovery Plan
Update on the Service Improvement Programme for 2016/17
Update from the Carter Work Streams
Options Appraisal for Supply of Temporary Staff
Single Oversight Framework
Capital Expenditure Report and Update on Disposal Programme for 2016/17
Contract Update
Commercial Report
2.0 Introduction
The purpose of this Committee is to drive excellent financial performance and ensure that the Trust has an investment strategy that supports the business and is financially deliverable. The Committee is responsible for ensuring that robust scrutiny is in place, taking action to commission further work as required in the achievement of this objective. The main focus of the September Committee was the year to date financial position and to gain assurance on the work being undertaken to address the issues. The Committee also received updates on the capital programme and contract and commercial reports. As well as being briefed on the Single Oversight Framework published by NHS Improvement. It should be noted that a summary of the Finance and Investment Committee is reported to the Board on a monthly basis and the paper is public part of the Board and therefore the paper is available on the Trust’s website. It should also be noted that the full minutes of the meeting are circulated to all members of the Board for information.
The Finance and Investment Committee meet in the week before the Board meeting, the next formal meeting of the Committee is due to be held on the 25th November, however given the Trust’s current financial position an extraordinary meeting has been called for 21st October 2016.
This report provides a summary of the meeting held on the 23rd September 2016, the main areas of discussion are set out in the body of the report below.
3.0 Report
Month 5 Financial Report and Delivery of the Cost Improvement Plan and Financial Recovery Plan for 2016/17 Given the Trust’s current financial position, this was the main area of discussion at the September meeting. The Committee received a report on the financial performance for month 5 noting that the financial position deteriorated further in September and the Trust is now reporting a year to date deficit of £2,446k. The main area of concern continues to be around the Adult Service CDSs, which overspent by £265k in Month 5, and £2,379k year to date. The main issues relate to the overspend in the Adult Service inpatient units, the shortfall in the delivery of Service Improvement Plans (SIP) schemes and in addition, the Trust has continued to experience bed pressures, with £70k spent on external placements in the month, although this position had improved during the first half of September. The Committee held a robust discussion on the actions being undertaken by the executive team to address these issues, with the discussions focusing on the following areas:-. Adult Service Care Delivery Services (CDSs) – the Committee discussed whether the CDSs had the right level of support to help them delivery their SIP plans. The proposals were outlined for next year’s planning round with the Adult Service CDSs working together to focus on standardising services, with particular attention being paid to the community pathway with the implementation of a single point of access and electronic referrals. This Committee noted that this work links closely to the recommendations of the Carter Review with the development of the model ward. This principle is also being extended to develop a model community and crisis team. This work will also be underpinned by the work being undertaken on recording activity, capturing data for mental health Payment by Results and reviewing the demand and capacity of community teams. To address this year’s financial position, regular meetings are being held with the Adult Service CDSs to help them meet their control totals, which is focusing on managing vacancies, addressing agency usage, patient flows and managing the overspend in the in-patient units. The Committee also discussed use of agency staff noting that at the end of August the Trust had spent £5.5m on agency staff and is forecasting a spend of £13m against the agency ceiling of £7.1m. The Committee discussed the actions that were being taken to address use of agency staff and requested that the agency dashboard and roster planning report is discussed with matrons and ward mangers. It was noted that the Trust’s new Executive Director of Nursing and Patient Experience will be taking forward these discussions. The Committee received an update on the work being undertaken to deliver the Carter Work Streams, which will help make savings this financial year, and will be the basis of service improvement plans for next financial year. The Committee acknowledged that with the CQC inspection behind us it is now essential that the Trust gives more attention to its financial position if it has any chance of turning this position around for this year and developing robust plans for the next two years. The main issue is not the lack of plans to address the financial challenge but the fact that these need to be translated into detailed delivery plans and have strong governance arrangements around them to ensure that they are now delivered at pace. Based on the current position the Committee were informed that the Trust’s was currently forecast a best case year end position of a £2m deficit, with mid or worst case position of a deficit £3.9m and £5.9m respectively.
Given the Committees concerns around the Trust’s financial position and that the next formal Committee meeting is not due to be held until November, the Committee Chair requested an extraordinary meeting in October, with a view to reviewing detailed plans to address this year’s position and plans for next year. Options Appraisal for Supply of Temporary Staff The Committee received a paper setting out the current position relating to the Trust’s in-house bank provision for temporary staffing and provided options for future provision. The Committee supported the proposal to develop the internal bank service further and to centralise all agency and bank bookings. This is also in line with the recommendation from NHS Improvement, who have a see up to 20% savings on agency staff in Trust’s that have centralised bookings. Single Oversight Framework The Committee received a briefing paper setting out the new Single Oversight Framework published by NHS Improvement (NHSI). The Committee noted the key changes between the new framework and the current Risk Assessment Framework for foundation trusts, in that there will be fewer and some new performance metrics and new metrics for finance and use of resources. The main implications for the Trust where noted to be the inclusion of indicators for physical health and clinical coding and monitoring of performance against the agency ceiling set by NHSI. The Committee also noted that the principle underpinning the framework aligns well the Trust’s CDS accountability framework in its aim to identify where providers may benefit from, or require improvement support. Capital Expenditure Report and Update on Disposal Programme for 2016/17 The Committee received a report on the capital programme for month 5, noting that the year to date expenditure on the capital programme totalled £1,234k, which is £2,174k under plan. It was noted that during August the Estates and Facilities Team met to review and prioritise the capital programme for the remainder of the financial year, particularly taking into account work identified during the preparation for the CQC visit, for example the scheme at the Woodlands Unit in Hastings to create two single sex wards. Further to this review, it is still anticipated that this year’s capital programme will be delivered in full. Contract Update The Committee were updated on the current contract position, which included an update on progress being made to deliver CQUIN schemes, contract variations, monthly contract challenges and mandated service improvement schemes. The Committee also noted the tight timetable for this contracting round, with 2 year contracts required to be signed by the end of December 2016. Commercial Report The Committee received the Commercial Report that provided an update on current bids and tenders, as well as providing an overview of the Trust’s business planning process for 2017/18.
4.0 Recommendation/Action Required
The Board is asked to note the contents of this report and ask any questions of the Chair of the Finance and Investment Committee.
5.0 Next Steps
An Extraordinary meeting of the Finance & Investment Committee is due to be held on 21st October 2016 and the Chair of the Committee will be able to provide a verbal update on the discussions held at the October Committee meeting, highlighting any matters for action or ratification by the Trust Board.
Board of Directors: 26 October 2016 - Public Agenda Item: TBP38 .7/16
Attachment: K For: information
By: Sally Flint, Executive Director of Finance & Support Services
FINANCE REPORT MONTH 6 & FINANCIAL RECOVERY PLAN
1.0 Executive Summary
In Month 6 there was an improvement in the Trust’s financial position, with the monthly deficit reducing to £141k, taking the year to date deficit to £2,587k. However, it should be noted that the improvement in the month was due to a one off benefit rather than there being a real improvement in the underlying position. This provides the Trust with a Financial Sustainability Risk Rating of 2, which is £1,397k off a rating of 3, compared to the planned rating of a 4. Given the current position and forecast deficit, NHS Improvement (NHSI) are now showing a keen interest in the Trust’s financial position and have requested a detailed action plan that provides them with the assurance that the best case forecast or better will be delivered by the end of the financial year. This paper therefore sets out the current issues and addresses the work that is being undertaken to provide the Finance & Investment Committee and the Board that there is a detailed action plan and commitment to deliver this out-turn, with a view to sharing this work with NHSI in due course. As part of this work, it will be important to demonstrate that the Trust has plans in place to reduce its expenditure on agency staffing. The imperative being to improve the Trust’s shadow rating in this area by reducing expenditure on agency from currently being 90% over the agency cap, to under 50% over the cap. In real terms this means reducing the use of agency by at least half the current spend over the remaining six months of the year. The main area of concern continues to be around the Adult Service CDSs, which overspent by £453k in the month and £2,832k year to date. The position in the Specialist Services CDS’s improved in the month, with an under spend of £191k. However, the position in Corporate Services deteriorated in the month reporting an overspend of £89k. The areas of concern and the work being undertaken to address these issues are set out in the body of the report, together with the details of the overall financial position.
2.0 Introduction
The Finance Report sets out the Trust’s financial position for Month 6, setting out the main issues and the work being undertaken to address the Trust’s financial position.
3.0 Report Overall
At the end of Month 6 the Trust is reporting an overall deficit of £2,587k. Although there was a reduction in the deficit in month to £141k, this was due to a one off benefit in month rather than a
real improvement in the underlying position. These results provide the Trust with a Financial Sustainability Risk Rating of 2, with ratings of 1 for all of the metrics relating to the income and expenditure plan, off-set by a rating of 4 for liquidity. The Trust is currently £1,397k off a rating of 3, compared to the planned rating of 4. Given the Month 6 position and forecast deficit, NHSI are now in dialogue with the Trust regarding the actions that need to be taken to deliver the best case forecast and delivery of the control total for 2017/18. Based on the Trust’s Month 6 position it is now accepted that the Trust will not meet its control total this year. The current forecasts based on the best, worst and mid case are set out below.
Best Case Deficit £2.3m
Mid Case Deficit £4.3m
Worst Case Deficit £5.2m However, following reporting a best case forecast deficit of £2m to NHSI in Month 5, the Trust is now being held to delivering this position. The Trust is also being asked to submit detailed action plans that support this position and to schedule a meeting with NHSI to discuss the plans to provide assurance on their delivery. Income In September income was £96k over plan reducing the year to date shortfall to £177k. The main reason for the favourable variance is the additional funding for the Hampshire Children and Young People’s Service. However, there was also an improvement in the occupancy levels in all cost per case services, with the overall under performance across these services reducing to £34k in the month, compared to a year to date adverse variance of £319k. The main contributor to the in-month and year to date shortfall in income is the rehabilitation service at Crawley Road, which is £19k under plan in the month and £238k year to date. Occupancy levels in the unit have now increased, with 20 of the 24 beds occupied in September. It should also be noted that the new manager for the unit is now in post. Pay Pay was overspent in the month by £177k (Month 5: £447k), increasing the year to date overspend to £1,775k. Pay costs in the Adult Services CDSs are overspent by £1,909k, which is off-set in part by underspends in the other CDSs and Corporate Services. . The level of temporary staffing remains high, accounting for £2,286k (13.6%) of the pay bill in September, of which £1,193k (7.1%) related to agency staff, which is significantly over the year to date percentage of the annual agency ceiling of £7,110k. The new Single Oversight Framework will be rating the Trust’s progress against the agency ceiling, with performance assessed against the percentage of expenditure over the ceiling. Year to date expenditure on agency staffing is currently £6,763k, which is 90% over the agency ceiling, with a forecast of £13,534k, which is also 90% over the ceiling. To improve the Trust’s rating for agency, the forecast position needs to reduce to below 50% over the ceiling, i.e. to below, £10,665k. In order to achieve this expenditure on agency staff for the remainder of the year needs to be below £3,902k, the equivalent of £650k per month. NHSI have also offered to provide the Trust with help in reducing use of agency staff. In addition the Trust is requesting that the cost of agency staff attributable to the additional staffing in Children and Young People’s Services to meet waiting times is removed from calculation, this request is being considered.
Non-pay Non-pay was overspent in the month by £205k (Month 5: £181k), increasing the year to date overspend to £1,393k. Of the year to date overspend, £325k relates to drug costs, £274k to patient transport and taxis and £209k due to the cost of external placements. The cost of drugs and use of patient transport and taxis are now two of the Carter work streams. A summary of the income and expenditure position is set out in the table below. . Financial Sustainability Risk Rating - The financial position for Month 3 provides the Trust with an overall Financial Sustainability Risk Rating of 2. Details of the ratings are set out in the table below.
Care Delivery Services In September Care Delivery Services (CDS’s) were overspent by £225k (Month 5: £245k). This takes the year to date overspend to £2,669k, of which £2,832k relates to the Adult Service CDSs and of this £1,867k relates to the overspend across the two Adult Services CDSs in West Sussex.
Income and Expenditure Account
Budget Actual Variance Budget Actual Variance
£000's £000's £000's £000's £000's £000's £000's
Revenue from Activities
Total operating Revenue (242,944) (20,818) (20,915) (96) (122,819) (122,641) 177
Operating Expenses
Total Pay Costs 193,894 16,580 16,758 177 98,169 99,944 1,775
Total Non Pay Costs 37,438 3,270 3,475 205 18,850 20,243 1,393
Total Operating Costs 231,332 19,850 20,233 382 117,019 120,187 3,168
Reserves 0 0 (100) (100) 0 (600) (600)
EBITDA (11,612) (968) (782) 186 (5,800) (3,055) 2,746
Retained Surplus For the Year (720) (60) 141 201 (354) 2,587 2,941
Non Trading (Gains)/Losses (792) (170) (297) (127) (692) (741) (49)
Retained (Surplus)/ Deficit For the Year (1,512) (230) (157) 74 (1,046) 1,846 2,892
ANNUAL
BUDGET
In Month - Sep-16 Year to Date - Sep-16
It should be noted that work has been undertaken in the month to align the expenditure on external placements for the first six months of the financial year, with the cost of the placement being reallocated to the CDS where the bed pressure originated. This work has seen a significant shift of costs (£110k) from Brighton to North West Sussex CDS. The other areas of concern in Adult Services continue to be the overspend on the inpatient wards and non-delivery of service improvement plans, partly off-set by an underspend in community services. An analysis of the year to date position across the CDSs is set out in the table below.
CDS
YTD Overspend
/ (Underspend)
£'000 SIP Shortfall Inpatients Community Income Shortfall
- Brighton 328 119 314 (52) (53)
- East 637 547 397 (308) 1
- Coastal 808 857 431 (540) 60
- North West 1,059 0 524 535 0
- Primary Care & Welbing (88) 69 0 (169) 12
- ChYPS (445) 191 0 (586) (50)
- Forensic 176 166 (16) (212) 238
- Learning Disabilities 41 159 123 (238) (3)
- Nursing Home 10 13 (87) (0) 84
- Operational Management 142 8 0 134 0
TOTAL 2,669 2,129 1,686 (1,435) 289
Reasons for Overspend / (Underspend)
Corporate Services It is disappointing to report that Corporate Services were overspent by £89k in the month, after reporting an underspend in August of £42k. This increases the year to date overspend to £693k. The finance team continue to work closely with all Corporate Services to deliver the finance recovery plan, either directly by reducing costs in their area or indirectly by working more closely with the CDSs to release savings through operational service improvement plans. The table below sets out the details of the Month 6 and year to date position for each Corporate Service.
Corporate Service
M6 Overspend /
(Underspend)
YTD Overspend
/ (Underspend)
£'000 £'000 SIP Shortfall
Over /
(Underspend)
- Chief Executive (3) (11) 8 (19)
- MSK 0 0 0 0
- Director of Nursing 49 258 94 164
- Human Resources (30) (33) 15 (48)
- Estates & Facilities (1) 43 412 (369)
- Finance & IT (12) (140) 134 (274)
- Medical Director 66 376 213 163
- Clinical Academic Director 11 198 27 171
- Strategy & Improvement 8 2 16 (14)
TOTAL 89 693 920 (226)
Reasons for Overspend /
(Underspend)
Service Improvement Plan (SIP)
The Trust continues to gain traction in the delivery of SIP plans particularly in Adult Services. The Trust only achieved recurrent savings of £452k in Month 6, taking the year to date shortfall to £3,647k. This is off-set in part by non-recurrent savings of £705k which increased in the month by £454k, mainly as a result of additional for the Hampshire Children and Young People’s Service. A summary of the planned and actual recurrent savings year to date savings are shown in the table below.
Way Forward and Financial Recovery Plan A number of approaches are being taken to improving the in-year position and to address the underlying issues by taking a stronger line on performance management through the CDS Assurance Framework, developing detailed financial recovery plans and implementing the recommendations of the Carter Review. In addition, good work is being undertaken to develop the clinical strategy for Adult Services which will provide the context for future financial plans. Performance Management – The actions to address performance as set out in the CDS Assurance Framework is now being implemented for those CDSs where there are concerns regarding financial performance, including:- More frequent meetings – Fortnightly meetings are now being held with all Adult Service CDSs,
with the purpose of the meetings being to seek assurance that recovery plans are in place to deliver
agreed control totals and also to provide support and additional resources where needed. To date
meetings have been held with East and North West Sussex. Through these meetings we have
already seen a reduction in agency usage in East Sussex. Meetings have now also been scheduled
for Brighton and Coastal west Sussex.
Requests for More Information - the Adult Services CDSs are now receiving weekly staffing
reports for in-patient services, which are being discussed in detail at the fortnightly financial
performance meetings. In addition, given the Trust’s high agency usage, meetings are being
scheduled with the matron’s from each Adult in-patient units, with the intention of starting a daily
staffing call from the last week of October.
Other work that is being undertaken in preparation for planning for next financial year includes helping the Adult Service CDSs to better understand their cost base. The finance team are meeting with CDS management teams to go through their Service Line Reporting setting out the level of funding received and how this is currently spent on operational costs, the cost of their estate and contribution to support services. These sessions will help prepare the CDS for discussions with commissioners regarding the level of service that can be provided within the available funding and what services will need to be stopped if no further funding is available for next year.
Sharing expertise and resources across CDSs – the CDSs are now starting to work together to
share expertise and resources. Good examples of this are now starting to take effect, for example
the work that is being undertaken to manage dementia beds across the Trust.
Review of CDS viability - the work being undertaken with Coastal and North West Sussex to
develop a federated model is now being taken forward, drawing on the best expertise and
experience from each CDS to provide the overall leadership, whilst still maintaining local identity
which is particularly important for both staff and commissioners. Discussions have been held with
commissioners who are supportive of this approach.
Development of formal recovery plans – given the request from NHSI, all areas will need to
review their financial recovery plans to ensure their robustness to deliver their revised control totals.
Where plans are not deemed to be robust or able to be implemented within the required timescales,
alternative plans will need to be put into place.
Financial Recovery Plans – In August the CDSs and Support Services developed their financial recovery plans based on the revised control totals and a number of pieces of work were identified to help CDSs deliver these plans, these include:-
work on reducing the level of observations on the wards
review of medical staffing
a call to action to staff Langley Green Hospital using nursing staff from across the Trust
whilst vacancies are filled
development of joint plans across Coastal and North West Sussex
However, this work is slow to start and needs to be prioritised to ensure that the Trust delivers its financial recovery plan this year. The other areas of focus for the Adult Service CDSs need to be around the design and effectiveness and efficiency of the Community Teams and medicines management. In addition a number of other actions are being implemented that will help deliver financial recovery plans. These areas are estimated to save £822k.
Corporate vacancy freeze
Reduction in the use of bank staff in support services
Reduction in the use of agency and admin staff in clinical services
Reduce travel costs
Reduction in the levels of discretionary spend
Carter Workstreams - The third Carter Implementation Group was held in early October. The focus of the meeting was to identify the areas of work that will realise savings this financial year and to align the workstreams into a programme of work to support business plans for 2017/18. It should be noted that project management has now been put into place to support this work. Other Areas Capital Programme – In September expenditure on the capital programme was £347k, taking the year to date spend to £1,581k, which is £2,306k under plan. The main expenditure in the month was on the Hellingly and Carenotes projects. Further to the Trust’s CQC inspection, the capital programme is being review and prioritise to take account of work identified, for example the scheme at the Woodlands Unit in Hastings to create two single sex wards. Further to this review, it is still anticipated that this year’s capital programme will be delivered in full. The Trust’s disposal programme is also still on track to deliver the planned £4.1m capital receipts this year.
It should also be noted that the Trust has been awarded £275k funding from the Department of Health as part of the crisis care concordat to enhance the Trust’s places of safety, which includes schemes in East Sussex, Brighton and Langley Green. Cashflow – at the end of September the Trust is reporting a cash balance of £28.6m, which is £2.1m under plan, with the deficit accounting for the adverse variance. The year end cash forecast is £29m, which is £2.3m under plan and is based on the best case forecast of a deficit of £2m. Summary and Conclusion In Month 6 there was an improvement in the Trust’s financial position, with the monthly deficit reducing to £141k, taking the year to date deficit to £2,587k. However, it should be noted that the improvement in the month was due to a one off benefit rather than there being a real improvement in the underlying position. This provides the Trust with a Financial Sustainability Risk Rating of 2, which is £1,397k off a rating of 3, compared to the planned rating of a 4. Given the Trust’s current position and forecast deficit, NHS Improvement (NHSI) are now showing a keen interest in the Trust’s financial position and are requested a detailed action plan that provides them with assurance that the Trust is in a position to deliver the best case forecast or better for 2016/17. This paper therefore sets out the current issues but also addresses the work that is being undertaken in order to assure the Finance & Investment Committee and Board that there is a detailed action plan and commitment to deliver this out-turn and that these plans will be shared with NHSI in due course. As part of this work, it will be important to demonstrate that the Trust has plans in place to reduce its expenditure on agency staffing. The imperative being to improve the Trust’s shadow rating in this area by reducing expenditure on agency from currently being 90% over the agency cap, to under 50% over the cap. In real terms this means reducing the use of agency by at least half the current spend over the remaining six months of the year. The main area of concern continues to be around the Adult Service CDSs, which overspent by £453k in the month and £2,832k year to date. The position in the Specialist Services CDS’s improved in the month, with an under spend of £191k. However, the position in Corporate Services deteriorated in the month reporting an overspend of £89k.
4.0 Recommendation/Action Required The Board is asked to note the performance for Month 6 and work being undertaken to address the Trust’s underlying deficit and to deliver at least the best case forecast position of a £2m deficit for 2016/17.
5.0 Next Steps Progress on the delivery of the Trust’s financial position will continued to be monitored through the Finance and Investment Committee, the Executive Assurance Committee, as well as the monthly Performance meetings with the CDSs. Capital expenditure will continue to be monitored through the Estates & Facilities Executive Group and reported to the Finance & Investment Committee. In addition, the governance framework for CDS has now been implemented and the Carter Governance Group has been established to oversee the implementation of the recommendations set out in the Carter Review.
Board of Directors: 26 October 2016 - Public Agenda Item: TBP39 .1/16
Attachment: L For decision
Report Author: Peter Lee, Head of Corporate Governance
Q2 Board Assurance Framework 2016/17
1.0 Introduction
It is the overall responsibility of the Board of Directors to ensure controls are in place to sufficiently mitigate the principal risks to the achievement of the organisation’s objectives. The Board Assurance Framework (BAF) sets out the principal risks to the achievement of the annual objectives, which themselves align to each the goals set out in ‘Our 2020 Vision’. The BAF is therefore a key mechanism which the board uses to reinforce strategic focus and better manage risk. It is a dynamic tool, which reflects the extent to which risks change and risk treatment is effective. Over the summer, the Head of Corporate Governance has worked with the executive leads on the options and treatment plans of each risk, as reflected in this version of the BAF (section 4.0). The Executive Assurance Committee regularly receives the BAF and monitors progress against the stated actions. Each risk is rated in accordance with the grading matrix (section 4.0) with a risk rating given pre control and post control (residual risk). In addition, this version sets out the option taken to treat the residual risk1, the risk treatment, benefits expected and the target risk rating. The Board will use this information to confirm its appetite and tolerance for risk. On 25 October 2016, the Executive Assurance Committee reviewed the Board Assurance Framework following the publication of the Thematic Review and made amendments to the risks. These amendments can be viewed on Appendix 1.
2.0 BAF overview
Figure 1 below illustrates how each risk is rated pre and post control and gives the associated target risk. The Board is asked to specifically consider the target risk ratings and confirm the extent to which it accepts these risks.
1 Treatment options include: Accept; Eliminate; Reduce; Transfer
Figure 1 Risk ratings
Figure 2 (Extreme risks)
Figure 2 confirms the risks post control which are rated extreme; both relate to Goal 5 of Our 2020 Vision.
Trust Risk Reference
Objective Residual Risk Rating
Target Risk
7941 5.1 Maintain sound financial performance 16 12
7942 5.2 Deliver service improvement plans
20 20
3.0 Board Assurance Framework v2
Key: SD – Executive Director of Service Delivery and Performance
MD – Executive Medical Director and Quality
FD – Executive Director of Finance and Support Services
SI – Executive Director of Strategy and Improvement
NP – Executive Director of Nursing and Patient Experience
CAD – Clinical Academic Director
HR – Director of Human Resources and Organisational Development
4.0 Likelihood Risk Rating
Likelihood Rating is a matter of personal judgement; the table below provides some structure to aid thinking.
Likelihood x Consequence/Impact = RISK RATING
CONSEQUENCES / IMPACT
Insignificant
(1)
Minor
(2)
Moderate
(3)
Major
(4)
Catastrophic
(5)
L
IKE
LIH
OO
D Certain (5) 5 10 15 20 25
High probability (4) 4 8 12 16 20
Possible (3) 3 6 9 12 15
Unlikely (2) 2 4 6 8 10
Very unlikely (1) 1 2 3 4 5
Low Moderate High Extreme
1 – 3 4 – 6 8 – 12 15 – 25
5.0 Recommendation/Action Required
The Board of Directors is asked to consider the BAF and the principal risks to achieving the trust’s objectives, and satisfy itself in relation to the controls and actions currently in place. Specifically, the Board is asked to confirm that it accepts the target risk related to each objective.
Likelihood (of not meeting the objective) Score
Certain 5
Probable 4
Possible 3
Unlikely 2
Very unlikely 1
Appendix 1 Amendments to the Board Assurance Framework following the Thematic Review (Amendments are highlighted in blue)
1 – Safe, Effective, Quality Care
Objective Principal Risk Key Controls
1.1 provide a focus on our four quality priorities to deliver improved outcomes and experience through Quality Circles: 1. Care Plans 2. Suicide Prevention 3. Physical Health 4. Staff Health and Wellbeing Within this, a priority is to embed the learning for the independent, thematic review (published October 2016) in a way that changes clinical practice and improves patient / family experience.
Insufficient framework to ensure adequate coordination and focus on each quality priority. Focus on policy, process and training delivers insufficient change / improvement to clinical practice for patient benefit.
Quality Priorities are included in CDS annual plans. CDS accountability framework (performance reviews) includes each priority. Review of QI Strategy outputs underway. Further joint working with NHS England Mental Health Homicides Team and the “Making Families Count” Collaborative to identify ways to embed learning from incidents in a way that changes practice. Learning fora across all clinical services to provide opportunity for staff to reflect upon their practice and review learning from incidents. Introduction of new family liaison roles. Appoint of Patient and Carer Leaders to improve the way we work with and involve patients / families. Work with families involved in previous incidents to embed learning and improve care.
Board of Directors: 26th
October 2016 - Public
Agenda Item: TBP39 .2/16
Attachment: N
By: Sally Flint, Executive Director of Finance & Support Services
Emergency Preparedness Resilience and Response (EPRR) Core Standards Submission 2016/17
1.0 Executive Summary
The Trust has recently undertaken the annual Emergency Preparedness Resilience and Response (EPRR) assurance process for 2016/17 against the NHS Core Standards. The Trust is required to provide evidence to NHS England, through the Local Health Resilience Partnership, that the Trust’s Board of Directors is sighted on the levels of compliance achieved against the NHS Core Standards for EPRR and the resulting action plan to address gaps in compliance. The process has confirmed that a number of compliance gaps and risks continue to exist with the Trust’s EPRR and Business Continuity capacities and that arrangements currently in place are non-compliant with the NHS Core Standards that the Trust is expected to achieve.
2.0 Introduction
EPRR is a core function of the NHS and a requirement of the Civil Contingencies Act 2004. This requires NHS organisations to show that they can continue to operate safe patient care during emergency situations whilst maintaining essential services. The NHS needs to plan for, and respond to, a wide range of incidents and emergencies that could affect health or patient care. These could be anything from extreme weather conditions to an outbreak of an infectious disease, a major transport accident or a terrorist incident. The NHS England Core Standards for EPRR set out the minimum EPRR standards that NHS providers must meet. The EPRR Assurance self-assessment for the Trust for 2016/17 shows only partial assurance of compliance with the Core Standards, with a number of areas requiring review and improvement, including:-
the Trust’s overarching EPRR framework and risk approach;
the need for formalised annual work and training programmes to mitigate against key risks and
the resourcing of EPRR (currently there is no dedicated Trust role for EPRR)
3.0 Report
As part of the national EPRR assurance process for 2016/17 the Trust was required to self- assess itself against the NHS England Core Standards. This self-assessment was completed by the Director of Estates and Facilities and submitted to the Coastal West Sussex Clinical Commissioning Group EPRR Lead on 2 August 2016. Coastal West Sussex CCG and NHS England have assessed the Trust as non-complaint due to the majority of core standards rated as amber. The outcome of the self-assessment has shown that of the 43 core standards applicable to the Trust, the Trust is:
Fully compliant with 13 of the standards (green), i.e. 30%;
Non-compliant with 28 of the standards, but with evidence of progress and in the EPRR work plan for the next 12 months, i.e. 65%;
Non-compliant with 2 of the standards (red) and not in the EPRR work plan for the next 12 months, i.e. 5%.
The results are a small improvement on the previous self-assessment made for 2015/16. However, it should be noted that following the 2015/16 assurance submission an external assessment of the Trust’s EPRR compliance position was commissioned which highlighted further gaps which are reflected in the 2016/17 self-assessment. For the 2016/17 assurance submission the Trust was also required to undertake a self-assessment into business continuity planning with a focus on organisational fuel use and supply. The two areas assessed as being non-compliant (red) and are not currently in the EPRR work for the next 12 months 6 is are around business continuity planning are as follows:-
(i) the Trust has not as yet undertaken risk based Business Impact Assessment of services it delivers, taking into account the resources required against staffing, premises, information and information systems, supplies and suppliers,
that the Trust has identified interdependencies within its own services and with other NHS organisations and 3rd party providers; and
the risks identified thought the Business Impact Assessment are present on the organisations Corporate Risk Register.
(ii) The Trust has identified its Critical Functions through the Business Impact
Assessment and that maximum tolerable periods of disruption have been set for all functions - including the critical functions
It is recommended that the Trust declares itself non-compliant against the EPRR Core Standards, as arrangements currently in place do not appropriately address 11 or more core standards that the Trust is expected to achieve. Alongside the self-assessment the Trust was required to submit an action plan to set out how it plans to address the core standards for which full compliance cannot be evidenced, this is attached as Appendix 1. The action plan will be monitored on a quarterly basis in order to demonstrate future compliance.
4.0 Recommendation/Action Required
The Board is asked to:-
(a) note the statutory and regulatory obligations on the Trust in respect of EPRR and Business Continuity;
(b) note the results of the Trust’s 2016/17 self-assessment against the NHS England Core Standards for EPRR and the levels of compliance achieved, including the deep dive into fuel use and supply;
(c) approve the action plan for achieving compliance.
5.0 Next Steps
Recommended next steps are contained in the attached report and 2016/17 work plan. Progress to deliver the work plan will be monitored through the Estates & Facilities Executive Group, which will report back to the Board with an update before the Trust completes its self-assessment for 2017/18.
Emergency Preparedness, Resilience and Response (EPRR) action plan 2016/17Version 1 September 2016
Action to be taken Lead Timescale
Governance
2
Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response. Appoint dedicated role to EPRR 1.0 WTE and business continuity
management. Develop programe and roll out supporting network of champions across CDS and corporate services to support the assessment, planning, embedment & validation of EPRR/BCM. Establish programme of training & exercising for EPRR/BCM.
Director of Estates & Facilities Mar-17
3
Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response.
Full review and update of the overarching framework to align with NHSE 2015 EPRR Framework and Core Standards, including Emergency & BC Response Plan and annexes on outbreak response, severe weather, heatwave, cold weather, fuel isruption, Hazmat/CBRN, evacuation, pandemic influenza plan.
Executive Director Finance & Support Services Mar-17
4
The accountable emergency officer ensures that the Board and/or Governing Body receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standards.
Report to Board on EPRR and resource requirements and EPRR related activity including planning, training and preparation across the Trust.
Executive Director Finance & Support Services Nov-17
Duty to assess risk5
Assess the risk, no less frequently than annually, of emergencies or businesscontinuity incidents occurring which affect or may affect the ability of theorganisation to deliver it's functions.
Review of risk register to identify risks having potential for causing EPRR/BCM risk, annual review of EPRR/BCM risks to support prioritisation of the workplan.
Director of Estates & Facilities Mar-17
6
There is a process to ensure that the risk assessment(s) is in line with theorganisational, Local Health Resilience Partnership, other relevant parties,community (Local Resilience Forum/ Borough Resilience Forum), and nationalrisk registers.
Risk of emergencies or business continuity incidents to be aligned to the National and Sussex Community risk registers. Carry out compatibility checks with other local provider plans.
Executive Director Finance & Support Services Aug-17
7
There is a process to ensure that the risk assessment(s) is informed by, andconsulted and shared with your organisation and relevant partners.
To assess the National and Sussex Community Risk Registers, and where appropriate assess the risks to the Trust and its estate and site locations.
Executive Director Finance & Support Services Aug-17
Duty to maintain plans – emergency plans and business continuity plans
Full review & update of the overarching framework to align with NHSE 2015 EPRR Framework and Core Standards. Establish programme to review all plans required, working with CDS & corporate services network across the Trust.
Aug-17
9Ensure that plans are prepared in line with current guidance and good practice which includes:
Update plans in line with current guidance. Director of Estates & Facilities Aug-17
10
Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources.
Improve cascade arrangements and training to meet the expectations of the switchboard, to include training and testing. Executive Director
Finance & Support Services Aug-17
12Arrangements explain how VIP and/or high profile patients will be managed. To be reviewed. Executive Director
Finance & Support Services Aug-17
13Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content
Develop business impact assessments & business continuity plans for all services/ buildings across the Trust. Director of Estates &
Facilities Aug-17
Command and Control
16Those on-call must meet identified competencies and key knowledge and skills for staff.
Review Directors on call training to include DH Leadership in Crisis training and training and exercising programme.
Director of Estates & Facilities Aug-17
17
Documents identify where and how the emergency or business continuity incident will be managed from, ie the Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist .
All on call staff to meet the relevant National Occupational Standards (NOS) for their role level. Review nominated ICC locations, resources and staffing and training. Director of Estates &
Facilities Aug-17
19
Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response.
Arrangements to be reviewed to ensure they follow the common process.
Director of Estates & Facilities Aug-17
Core Standard
Executive Director Finance & Support
Services
8
Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity.
Emergency Preparedness, Resilience and Response (EPRR) action plan 2016/17Version 1 September 2016
Action to be taken Lead TimescaleCore StandardTraining And Exercising
34
Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents
Training needs analysis to be undertaken. Develop testing programme of exercises to include: communication exercise min. 6 monthly; table top exercise min. 12 monthly; live play exercise 3 yearly; command post exercise 3 yearly.
Head of Operations, Education and Training Aug-17
35Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work.
Lessons learnt - gaps in communication exercising and command post exercising.
Director of Estates & Facilities Aug-17
36Demonstrate organisation wide (including oncall personnel) appropriate participation in multi-agency exercises
Develop training programme for on call managers beyond their local service. Director of Estates & Facilities Aug-17
37Preparedness ensures all incident commanders (oncall directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation.
Further development required. Executive Director Finance & Support Services Aug-17
Deep Dive DD1 Organisation has undertaken a Business Impact Assesment Develop a toolkit to support CDS to undertake business impact assessment and review of corporate risk register; risk assess and develop business continuity plans for local resilience.
Executive Director Finance & Support Services Aug-17
DD2 Organisation has explicitly identified its Critical Functions and set Minimum Tolorable Periods of disruption for these
Develop a toolkit to support CDS to undertake business impact assessment and review of corporate risk register; risk assess and develop business continuity plans for local resilience.
Executive Director Finance & Support Services Aug-17
DD3 There is a plan in place for the organisation to follow to maintain critical functions and restore other functions following a disruptive event.
Plan, responsibilities and communications to be reviewed Executive Director Finance & Support Services Aug-17
DD4 Within the plan there are arrangements in place to manage a shortage of road fuel and heating fuel
Plan, responsibilities and communications to be reviewed Executive Director Finance & Support Services Aug-17
DD5 The Accountable Emergency Officers has ensured that their organisation, any providers they commission and any sub-contractors have robust business continuity planning arrangements in place which are aligned to ISO 22301 or subsequent guidance which may supersede this .
to be reviewed
Executive Director Finance & Support Services Aug-17
Preparedness 38 There is an organisation specific HAZMAT/ CBRN plan (or dedicated annex) Plan to be developed. Executive Director Finance & Support Services Aug-17
39 Staff are able to access the organisation HAZMAT/ CBRN management plans. Plan to be developed. Executive Director Finance & Support Services Aug-17
40 HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate to the organisation.
Plan to be developed. Executive Director Finance & Support Services Aug-17
42 Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/ CBRN incident and this specialist advice is available 24/7.
Current arrangements to be reviewed. Executive Director Finance & Support Services Aug-17
Decontamination Equipment
43 There is an accurate inventory of equipment required for decontaminating patients in place and the organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff.
Model from London CCN to be rolled out within the Trust. Executive Director Finance & Support Services Aug-17
Training 49 Internal training is based upon current good practice and uses material that has been supplied as appropriate.
Current arrangements to be reviewed. Executive Director Finance & Support Services Aug-17
51 Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant.
Current arrangements to be reviewed. Executive Director Finance & Support Services Aug-17
B:\ASSISTANT CHIEF EXECUTIVE\Meetings\Board\Board of Directors\2016 Board of Directors\2016-10-26\PUBLIC\TBP39 .3.16 - Board Director Site Visits.docx
Board of Directors: 26 October 2016 – Public Agenda Item: TBP39 .3/16
Attachment: N For Information
Presented by: Caroline Armitage, Chair
BOARD DIRECTOR SITE VISITS FOR Q2
1.0 Executive Summary
CQC identify in their "Well Led" domain that direct senior knowledge of services will contribute to high quality and good governance. Direct engagement with staff enables board directors, in particular independent non- executive directors, to verify for themselves the issues being highlighted to them through reports. It also enables staff at all levels to have access to the board. For these reasons board members are actively encouraged to regularly visit services across the trust. During Q2, executive board members also continued their ‘back to the floor’ programme.
2.0 Site Visits
The below table lists the site visits undertaken by board directors during the last quarter. Site CDS/Service
Caroline Armitage – Chair
Early Intervention in Psychosis – New Park House
North West Sussex/Community
Linwood Community Mental Health Centre
North West Sussex/Community
Lighthouse Recovery Support Centre Brighton & Hove
Twisleton Court, Dartford Children and Young People/Community
St Anne’s Centre, Hastings East Sussex/Community
Chanctonbury, Swandean Coastal West Sussex/Community
Colm Donaghy – Chief Executive
Eating Disorder Services - Chalkhill Children and Young People/Community
Community Forensic Team, Hellingly Secure and Forensic/Community
Langley Green Hospital North West Sussex/Acute
Lorraine Reid – Executive Director of Service Delivery & Performance
Hampshire Urgent Assessment and Home Treatment Service
Children and Young People/Community
Kay Macdonald – Clinical Academic Director
Eating Disorder Services - East Brighton Community Mental Health Centre
Children and Young People/Community
Health in Mind – Secure and Forensic Services, Hellingly
Secure and Forensic/Community
Diane Hull – Executive Director of Nursing and Patient Experience
Hellingly, Secure and Forensic Healthcare
Secure and Forensic/Community
Meadowfield, Swandean Coastal West Sussex/Community
Mill View, Brunswick Ward & Lindridge Centre, Hove
Brighton & Hove/Acute & Nursing Home
Bedale Centre, Bognor Regis Coastal West Sussex/Community
Department of Psychiatry, Eastbourne East Sussex
Knightrider House, Maidstone Children and Young People
Georges Turle House, Canterbury Children and Young People
Chalkhill, Haywards Heath Children and Young People/Community
Sue Esser – Director of Human Resources and Organisation Development
Bedale Centre, Bognor Regis Coastal West Sussex/Community
Mental Health Liaison Team, Brighton General Hospital
Brighton & Hove /Acute & Crisis
Sally Flint – Executive Director of Finance and Support Services
Rutland Gardens, Hove Brighton & Hove
Department of Psychiatry, Eastbourne East Sussex
Anne Beales – Non-Executive Director
Amberstone, Hellingly Secure and Forensic/Community
The Firs, Hellingly Secure and Forensic/Community
Diana Marsland – Non-Executive Director
Langley Green Hospital North West Sussex/Acute
3.0 Recommendation/Action Required
Board directors are asked to note the contents of this report.
Board of Directors: 26 October 2016 – Public Agenda Item: TBP39 .4/16
Attachment: O For: Information
By: Caroline Armitage, Chair
NOTIFICATION OF SEALED DOCUMENTS
Q2 REPORT
1.0 PURPOSE AND RECOMMENDATION
Standing Order 8.3 requires the Board of Directors to receive a report each quarter, on all sealed documents. This is the Q2 summary report of sealed documents between 01 July 2016 and 30 September 2016.
2.0 SEALED DOCUMENTS
No. Date Document
313 09.08.16 License to carry out minor works relating to Ground Floor Office Suite, Advertiser House, 24-32 London Street, Andover between (1) Burebrook Properties Limited and (2) Sussex Partnership NHS Foundation Trust. This relates to the newly acquired leasehold property for the CAMHS team (Advertiser House) and grants Landlord consent for the trust to undertake the necessary fit-out works.
314 09.08.16 Lease relating to Ground Floor Office Suite, Advertiser House, 24-32 London Street, Andover between (1) Burebrook Properties Limited and (2) Sussex Partnership NHS Foundation Trust. This relates to the newly acquired leasehold property for the CAMHS team (Advertiser House) and is the lease which has been negotiated for the trusts occupancy.
315 10.08.16 Land registry transfer relating to 26 Ditchling Road, Brighton between (1) Sussex Partnership NHS Foundation Trust and (2) 7-9 George Square LLP. This relates to the sale of 26 Ditchling Road and is the document required by the Land Registry to transfer the ownership of the property to 7-9 George Square LLP (the new owner).
Page 1 of 1
Sussex Partnership NHS Foundation Trust
Board of Directors: 26 October 2015 - Public Agenda Item: TBP39 .5/16
Attachment: P For: Information
By: Rebecca Huth, Corporate Governance Administrator
MATTERS ARISING: ACTION POINTS FROM THE COUNCIL OF GOVERNORS MEETING HELD IN PUBLIC ON
MONDAY 17 OCTOBER 2016
Date of Action
Min. No. Action Points from previous meeting Lead Action Taken
17.10.2016 CG 32.2/16 Phyllida’s question to be referred to the Mental Health Act Committee and to be reported back to the Council in January 2017
Martin Richards Complete: Mental Health Committee administrator aware and update scheduled on forward look
17.10.2016 CG 32.2/16 Briefing for Governors on STPs in November Sam Allen
17.10.2016 CG 32.2/16 Medications action plan to come to January 2017 Council of Governors.
Tim Ojo Complete: on forward look
17.10.2016 CG 32.2/16 Share Langley Green Hospital plan with Governors and bring an update to January 2017 Council of Governors.
Lorraine Reid Complete: LGH plan requested by Corporate Governance Office and update scheduled on forward look
17.10.2016 CG 33.3/16 Lewis Doyle to ensure Inpatient and Community Activities are included in the Audit Plan.
Lewis Doyle Complete: Audit Committee administrator aware
17.10.2016 CG 34.5/16 Sam Allen to pass issue of discharge information and post-diagnosis information to Diane Hull and Tim Ojo, and report back in April 2017.
Sam Allen, Diane Hull and Tim Ojo
Complete: Updated scheduled on forward look
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Sussex Partnership NHS Foundation Trust Board of Directors: 26 October 2016 - Public
Agenda Item: TBP39 .6/16 Attachment: Q For: Decision
By: Rebecca Huth, Corporate Governance Administrator
MATTERS ARISING: ACTION POINTS FROM THE BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 28 SEPTEMBER 2016
Action Date
Minute Reference
Action Points Lead Action Required
26.09.2016 TBP33 .1/16 CQC Task and Finish Group update to come to October Board of Directors.
Peter Lee/ Tim Ojo Complete: on agenda
26.09.2016 TBP33 .4/16 Complaints Annual Report 6 monthly update at March Board.
Peter Lee/ Diane Hull
Complete: on forward look
26.09.2016 TBP33 .5/16 6 monthly update on SI annual report – progress to March board.
Peter Lee/ Diane Hull
Complete: on forward look
26.09.2016 TBP33 .8/16 Seclusion Audit information to be included in future Quality Committee Summaries.
Tim Ojo Complete: Quality Committee administrator aware
26.09.2016 TBP33 .8/16 Tim Ojo to work with Colm Donaghy on an earlier target date.
Tim Ojo/ Colm Donaghy
26.09.2016 TBP33 .11/16 Executive’s to ensure a 6 week planning policy for Roster Pro is implemented.
Executive team
26.09.2016 TBP34 .2/16 Lewis Doyle to review sources of medical revalidation assurance at Audit Committee.
Lewis Doyle Complete: Audit Committee administrator aware
