Board of Governors – Public Session public papers 011015.pdf · Board of Governors – Public Session . Meeting to be held at 12.30 on Thursday 1. st. October 2015 at the Rose Room,

Board of Governors – Public Session

Meeting to be held at 12.30 on Thursday 1st October 2015 at the Rose Room, Endeavour House, Russell Road, Ipswich IP1 2BX

Governors Please Note:

Governor informal Session (including Staff Governor feedback)– 10:00 to 10:30 Development Session 10:30 to 11:30

Governor / NED ‘getting to know you’ exercise 11:30 to 12:00

AGENDA

Time Item No

12:30 15.46

Chair’s welcome to new governors, notification of any urgent business and apologies for absence: Elizabeth Witt

i. ii.

Declarations of interest (all) Changes to governors (Robert Nesbitt)

Verbal Attachment A

12:40 15.47 To approve the minutes of the previous

public meeting held on 2nd July 2015

Attachment B

12:45 15.48 To address any matters arising from the minutes of the meetings in private and public held on 2nd July 2015

Attachment C

12:50

15.49

Governor feedback on new issues (Suffolk public, Norfolk public, Service User, Carer, Staff, Partner governors)

Attachment D

13:20

15.50

Items to close on the Governor’s issues log

Attachment E

13:40

15.51

Chief Executive’s report (Michael Scott)

Attachment F

15.52

Items for approval

13:55

i.

Extension of NED term to allow for handover (Gary Page)

Attachment G

14:05

ii.

Proposed changes to the Constitution (including principles for selecting reserve elected governors) (Robert Nesbitt)

Attachment H

Board of Governors – Public 01Oct 2015 - Agenda

Version 1.2 Author: Robert Nesbitt Department: Corporate

Page 1 of 3 Date produced: 04Sep2015 Retention period: 30 years

14:15 iii. Approval of Planning & Performance ToR (Robert Nesbitt)

Attachment I

14:20 iv. Dates for BoG meetings for 2016 (Robert Nesbitt)

Attachment J

15.53 Items for assurance or debate

14:25

14.40

i.

ii.

Quality improvement plan update (Michael Scott) Putting People First update (Leigh Howlett)

Attachment K

Presentation

14:50

BREAK

15:05 iii. Financial Recovery Plan update (John Doyle)

Presentation

15:20 iv. Workforce Strategy (incorporating staff wellbeing Min. 15.38) (Leigh Howlett)

Attachment L

15:40 v. Annual General Meeting arrangements 8th October 2015 (Norwich) (Robert Nesbitt)

Attachment M

15:45 vi. Notification of election arrangements for 2015/16 (Robert Nesbitt)

Attachment N

15:50 vii. Notification of lead governor election arrangements for 2016 and volunteers for “Code of Conduct” review (Robert Nesbitt)

Attachment O

15.54

Standing Item: Feedback from the sub-groups and committees

15:55 i. Service User and Carer Trust Partnership feedback 28th August 2015 (Guenever Pachent)

Attachment P

16:00

ii.

Membership and Communications subgroup Chair’s reports 16th July 2015 & 17th September 2015 (Andrew Good)

Attachment Q

16:05

iii.

Performance & Planning subgroup Chair’s report from 16th July 2015 & 17th September 2015 (Guenever Pachent / Catherine Wells)

Attachment R

16:10

iv.

Education subgroup Chair’s report from 11th August 2015 (Jane Millar)

Attachment S




16:15

v.

Nominations Committee Chairs’ report from 28th July 2015 (Guenever Pachent / Marion Saunders)

Attachment T

16:20

vi.

IPC Chairs’ report from 21st July 2015 & 24th August 2015 (Guenever Pachent)

Attachment U

16:25 15.55 Highlight report to members: to agree the

agenda items to be highlighted for members and the public (Andrew Good)

Verbal

15.56

Any other urgent business, previously notified to the Chair

15.57

Date, time and location of next meeting The next meeting of the Board of Governors will be held in Public on 7th January 2016 at Norwich City Council – Council Chamber, City Hall, St Peter’s Street, Norwich, Norfolk NR2 1NH

16:30

CLOSE




Report To: Board of Governors

Meeting Date: 1st October 2015

Title of Report: Changes to governors

Action Sought: For Assurance

Estimated time: 5 mins

Author: Robert Nesbitt: Company Secretary

Executive: Robert Nesbitt: Company Secretary

Executive Summary: Since the last BoG meeting in July 2015 we have been joined by Heather Passmore (UCS) and Elise Page (Suffolk Youth Council). Norfolk Youth Council have also nominated a governor who has just started a new job and so will be in touch when ready to take up the role. Board of Governors – at 21 Sept 2015 33 seats Public 13, Staff 4 Service User 4, Carer 2 = 23

Appointed10

Service User (4) Public – Suffolk (6) Norfolk Suffolk Norfolk Vacant Kevin James Suffolk Paul Gaffney Vacant

Paddy Fielder Vacant Jane Millar Guenever Pachent (Lead) Andrew Good Kathleen Ben Rabha

Margo Ononaiye – University of East Anglia

Cllr Sue Whitaker – Norfolk County Council

David Skevington – Suffolk Constabulary (covering for Norfolk Constabulary too)

Vacant (Norfolk CCGs rep)

Heather Passmore – University Campus Suffolk

Cllr Tony Goldson – Suffolk County Council

Vacant – Youth Council (Norfolk)

Elise Page – Youth Council (Suffolk)

Malcolm Blowers - Suffolk User Forum

Vacant - Suffolk Family Carers

Carer (2) Vacant (Suffolk) Mary Rose Roe (Norfolk)

Public – Norfolk (7) Sheila Preston Stephen Fletcher Ronald French Elizabeth Witt Vacant Catherine Wells Hilary Hanbury

Staff (4) Dr Nanayakkara De Silva Dr Karen O’Sullivan Howard Tidman Linda Weatherley

2015 BoG changes: 13.03.15 Margo Ononaiye – Partner governor appointed for UEA 23.03.15 Susie Enoch stood down as Public Governor Suffolk 17.05.15 Pat Southgate stood down as Public Governor Norfolk 18.05.15 Pip Coker / Julian Housing left BoG 05.06.15 Ann Donkin stood down stood down as N CCG governor 22.06.15 Siobhan Leviton stood down as SU Governor Norfolk 23.07.15 Heather Passmore appointed as partner governor for UCS 24.07.15 Elise Page appointed as partner governor for Suffolk Youth Council

Date: 01 October 2015 A Item: 15.46ii

Board of Governors 01Oct2015 Gov changes


Page 1 of 1 Date produced: 21Sept2015 Retention period: 30 years

Unconfirmed

Minutes of the Board of Governors – Public Session

Held on 2nd July 2015 at 12.30pm In the Council Chamber at City Hall, Norwich

Present:

Gary Page, Trust Chairman (Chair) Nanayakkara De Silva, Staff Governor Paddy Fielder, Public Governor, Suffolk Stephen Fletcher, Public Governor, Norfolk (in part) Paul Gaffney, Service User Governor, Suffolk Andrew Good, Public Governor, Suffolk Kevin James, Service User Governor, Norfolk Jane Millar, Public Governor, Suffolk Margo Ononaiye, Partner Governor, UEA Karen O’Sullivan, Staff Governor Guenever Pachent, (Lead) Public Governor, Suffolk Sheila Preston, Public Governor, Norfolk Mary Rose Roe, Carer Governor, Norfolk Michael Scott, Chief Executive Officer (in part) Howard Tidman, Staff Governor Catherine Wells, Public Governor, Norfolk (in part) Sue Whitaker, Partner Governor, Norfolk County Council

In attendance:

John Brierley, Non-Executive Director Claire Harber, Trust Administration (minutes) Peter Haylett, Membership Officer Dave Huggins, Lorenzo Programme Director (for item 15.37) Fraser McKay, Communications Officer Brian Parrott, Non-Executive Director Marion Saunders, Non-Executive Director Stuart Smith, Non-Executive Director

There was 1 member of the press and 1 service user present (for item 15.41i). The meeting commenced at 12.35pm.

Date: 1st October 2015 B Item: 15.47

BoG Public – 02Jul2015 – Unconfirmed Minutes Rev Unapproved

Version 1.0

Author: Claire Harber Department: Corporate

Page 1 of 10 Date produced: 03Jul2015 Retention period: 30 years

15.34 Chair’s welcome, notification of any urgent business and apologies for absence

Gary Page welcomed the governors and others present. Apologies for absence were noted from Kathleen Ben Rabha, Malcolm Blowers, Hilary Hanbury, Robert Nesbitt, David Skevington, Elizabeth Witt and Alan Yates. Governors were advised that no matters of urgent business had been received and that item 15.40i ‘Proposed changes to the Constitution’ would be taken after item 15.36.

i Declarations of Interest

No new interests were declared. ii. Changes to the Governors

The Board were informed that Pip Coker, Ann Donkin, Siobhan Leviton and Pat Southgate had stood down. Thanks to those governors was formally expressed.

15.35 To approve the minutes of the previous public meeting held on 2nd April 2015

It was agreed that Catherine Wells’ apologies are to be added and, under item 15.30vi, Catherine Wells is to be added as a member of the Improvement Plan Coordination subgroup With these additions, the minutes were approved as an accurate record of the meeting.

15.36 To address any matters arising from the minutes of the meetings in

private and public held on 2nd April 2015

Actions 15.23 and 15.25 were noted as complete.

Action 15.24: Michael Scott advised that communications to Suffolk have been sent and that communications to Norfolk are being drafted.

Item 15.40i was taken at this point.

15.40i Proposed Changes to the Constitution

Items 2.0 (Reducing the number of Non-Executive Directors and allocating an additional vote to the Chair), 4.0 (Name change to Council of Governors) and 5.0 (Name change to Company Secretary) required 16 Governors to be present for a quorum and, as only 15 were present, these items were not formally considered. However, it was agreed to discuss item 4.0 in order that the views of those Governors present could be heard.


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Changing the arrangement for the election of substitution governors

This item required 8 Governors to be present for a quorum to be achieved. The Board were reminded that when an elected governor stands down mid-term, there is currently no immediate election held to find a replacement. Instead, if a losing candidate had a substantial number of votes for that constituency, the Board of Governors has considered inviting them to step in until the next election round. This is often just for a few months. It is proposed to allow such governors to serve the rest of the full term (i.e. up to 3 years) to provide stability and reflecting the fact that it often takes new Governors some considerable time to get up to speed with the role. Stephen Fletcher joined the meeting at this point. It was confirmed that each individual case would be considered on its own merit and there would not be an automatic entitlement to a seat. It was agreed that a minimum threshold of votes, such as a percentage of the winning candidates vote, should be put in place before a nominee’s suitability could be considered. It was agreed to take a vote on the principle of the matter with a formal proposal coming to the next Board of Governors meeting proposing a minimum threshold. Twelve (12) governors voted in favour of the proposal that governors will in future vote on whether to allow an individual who narrowly missed out (formula to be proposed) on a seat at the previous election to become a governor for the remainder of the term. Two (2) governors voted against the proposal (Sheila Preston and Karen O’Sullivan) and one (1) abstained. The Chair informed the meeting that a proposal would be reconsidered at the next meeting to include a minimum threshold. The Chair advised that the meeting was not sufficiently quorate to approve the other changes to the Constitution but, at the request of the Lead Governor, asked for the informal views of those present on the following proposal. Changing the name ‘Board of Governors’ to ‘Council of Governors’ The Board were informed that the Trust adopted the name ‘Board of Governors’ on the basis that it reflected a ‘parity of esteem’ with the Board of Directors and that current guidelines suggest the use of the name ‘Council of Governors’. It was noted that ‘Council’ is a universal term to describe a group that holds people to account, which accurately describes the role of governors and that a change in name would prevent the confusion of having ‘two boards’. The following was an informal vote. Twelve (12) governors were in favour of a change in name from ‘Board of Governors’ to ‘Council of Governors’. Two (2) governors objected (Howard Tidman and Kevin James) and one (1) governor abstained from voting.


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Action 15.40i a. Trust Secretary to prepare a proposal to be presented to the next Board of Governors meeting on what the threshold of votes should be before allowing consideration for a governor seat. (Robert Nesbitt) b. ‘Proposed changes to the Constitution’ to be added to the agenda for the next Board of Governors meeting. (Kate Hope)

The meeting returned to item 15.37.

15.37 Governor Feedback on New Issues

It was confirmed that the Trust would move back to the old system of responding within one month due to the time between Board of Governor meetings. Norfolk Public Governors: Catherine Wells advised that unallocated cases remain a concern and requested a prompt response. Suffolk Public Governors: Guenever Pachent advised that the de-commissioning of 11 adult acute beds at Carlton Court is a major concern. It was confirmed that the matter has been fully reviewed by the Trust Board of Directors and the Great Yarmouth and Waveney Clinical Commissioning Group following a public consultation. Michael Scott confirmed that the closure is going ahead and that the Board believed that the increased capacity at Northgate would be adequate for demand in Yarmouth and Waveney. The Board were informed that further investment in enhanced community care in Great Yarmouth and Waveney would be made to help to avoid service users requiring hospitalisation. Concern was expressed that out of area placements will increase once the unit closes and place a financial burden on the Trust. Gary Page confirmed that the Trust is in dispute with the Central Norfolk CCGs regarding funding for out of area placements. It was agreed that the Board of Directors would receive a report on bed demand in Norfolk.

Action 15.37 Prepare report for public Board of Directors meeting considering bed situation and demand in Great Yarmouth and Central Norfolk and provide a model on how the closure of Carlton Court might affect the Trust’s finances. (Gary Page)

Service User Governors: Service users have asked whether the Trust can continue to cut its budget without cutting staff. Michael Scott responded that around 80% of the Trust’s costs are related to staffing, therefore it is impossible to make the required savings without cutting staff. It was stressed that front line and clinical staff will be prioritised.


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Staff Governors: It was noted that since the Lorenzo issue was submitted, the Lorenzo team have addressed many problems and provided extra training. However, some staff are still struggling to work with the new system effectively. Computer use has increased and issues such as eye strain have been reported. It was suggested that affected staff request a workplace assessment to ensure they are using their equipment in the healthiest way. Dave Huggins reported that now the volume of issues has reduced, the team can begin optimising the system. Dave Huggins left the meeting and Stephen Fletcher left the room at this point.

15.38 Items to Close on the Governors’ Issues Log

PNor18: The issue of temporary staffing will be presented to the next public session of the Board of Directors meeting. Close issue. Staff35: This issue was discussed under item 15.37. Close. Staff36: Gary Page confirmed that there will be an item on workforce strategy at the next Board of Governors meeting. Close issue.

Action 15.38 a. Ensure Workforce Strategy item due at the next Board of Governors meeting includes staff wellbeing. (Gary Page)

Staff37: It was confirmed that executive visits to localities are underway and communications to this effect are being arranged. Close issue. PSuf25: It was agreed to leave this issue open pending the result of the contract meeting. PSuf27: Issue to remain open. Stephen Fletcher returned to the meeting at this point.

PSuf28: It was agreed that ‘Insight’ be used more proactively to address stigma and there was a suggestion that there be more available work opportunities at the Trust for people with learning disabilities. It was agreed to close this item on the proviso that the actions below are completed.

Action 15.38 b. Inform governors the name of the person responsible for managing volunteers. (Michael Scott) c. Respond to governor queries on work opportunities for people with MH


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and LD issues. (Gary Page)

C28: Issue to remain open.

C32: This issue is to be re-opened as carer communication on the risks of the cessation of smoking whilst taking Clozapine need to be more robust.

Action 15.38 d. Gary Page and Bohdan Solomka to meet to discuss communicating to carers the risks of stopping smoking whilst taking Clozapine. (Gary Page)

C33: This issue is to remain open until clarification is given on the process by which service user and carer involvement in policy review can be embedded.

Action 15.38 e. Insert the words ‘as in’ before ‘the Triangle of Care’ in the issue description. (Gary Page)

C35: Governors were informed that the last Norfolk SU and Carer Locality meeting was devoted to discussing the Mind helpline and it included lead clinicians from South Norfolk, Louise Schofield, Clive Rennie and people that man the line. Chief Executives from the CCGs that have refused to fund the line will be invited to explain the reasons for the decision and what is planned to replace it. Catherine Wells left the meeting at this point. It was suggested that organisations such as the Samaritans could be contacted to explore the possibility of partnership working on a new service. The item was closed from the issues register and Gary Page made a commitment to the governors that further work will be carried out in this area. SU23: Close issue.

Action 15.38 f. Update governors on waiting lists once new data is available. (Gary Page) g. Investigate extra resources promised to South Norfolk DCLL in light of the transfer of North Norfolk DCLL to South Norfolk DCLL. (Michael Scott)

SU24: Close issue.

15.39 Chief Executive’s Update


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Michael Scott addressed the story in the Eastern Daily Press yesterday regarding the Alexander Report and explained that the Alexander Report was commissioned by the Trust 18 months ago with the purpose of ‘learning lessons’ from the Trust Service Strategy. During the preparation of this report, staff were consulted and promised confidentiality. The document was leaked earlier in the week after the Trust declined a Freedom of Information request to release the document on the grounds of staff anonymity. It was agreed that the coverage has been unhelpful for all concerned. Michael Scott reported that staffing remains a top priority, clinical vacancies are decreasing, as are staff sickness levels, and staff engagement work is ongoing. It was confirmed that the cost of recruiting locum psychiatrists is under review and that the Trust supports the government’s initiative to put a cap on agency costs. The Board were informed that the Deanery described finding ‘excellent training’ during their visit to the Trust last month. Some concerns were raised, and these are being addressed. It was confirmed that the feedback will be discussed verbally at the July 2015 public Board of Directors meeting with a written report to the August 2015 meeting. It will also be on the agenda of the Organisational Development and Workforce Committee on 30th July 2015.

15.40 Items for Approval

Item 15.40i was taken after item 15.36 (above). ii. Non-Executive Director Recruitment Plans

Attachment H was taken as read. The Board approved the recommendations set out in paragraph 4.0 of the report. Stephen Fletcher left the room at this point.

15.41 Items for Assurance or Debate i. Quality Improvement Plan (QIP) Update

Michael Scott reported that all data has been reviewed and returned for amendment where appropriate and that there is confidence that the level of scrutiny is optimum. Stephen Fletcher returned to the meeting at this point. Michael Scott gave an update on the staff wellbeing programme. There is a ‘healthy worker’ course which has received positive reviews, and ‘wellbeing weeks’ are being rolled out in localities. Michael Scott stressed that bullying and defamation are dealt with swiftly and severely throughout the Trust. A


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service user was present to discuss his recent experiences and sought confirmation from the CEO about the importance of staff wellbeing.

ii. Improvement Plan Coordination Subgroup Chair’s Reports 22nd April

2015, 27th May 2015 and 24th June 2015

The meeting were informed that the group analyse work being done around the QIP and send their analysis to the Chair and Non-Executive Directors, thus assisting in the triangulation process. Guenever Pachent expressed thanks to the members of the subgroup for their work. The meeting took a break between 3.00pm and 3.30pm.

iii. Financial Recovery Plan Update

Michael Scott introduced the financial performance report for month 2 and talked through the key headlines which show that the Trust is broadly meeting its plan to date. There is a marginal overspend due to equipment required for Lorenzo. Temporary pay is still high with medical and nursing areas prominent, largely due to a national shortage of qualified nurses. Temporary staffing costs in corporate areas should reduce now that restructuring work is complete. Stuart Smith, Chair of the Finance Committee, reported that the Committee are concerned that the planned £9.4m deficit is optimistic; if temporary staffing spend continues at current rates, it will contribute to a significant overspend. Additionally, out of area costs are not reducing as quickly as hoped after the opening of Thurne Ward. It was reported that the Trust is struggling to identify Cost Improvement Programmes to the value of the internal target of £11m. Additionally, costs are emerging as a result of the Trust being in special measures. Michael Scott explained that Quality Improvement Plan benefits are mostly in quality and are often a financial cost but, more positively, the balance sheet is strong, and if the Trust succeeds in arbitration, Central Norfolk CCGs will begin to fund out of area placements.

Action 15.41iii Ensure Human Resources are keeping a pool of ‘runner up’ candidates, particularly in relation to the band 6 role Stephen Fletcher was interviewer for three weeks ago. (Michael Scott)

iv. Service User and Carer Engagement

The Service User and Carer Involvement Strategy was tabled. Among the governors present, some dissatisfaction with the document was expressed, but it was agreed that the priority is to begin implementing the


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strategy. It was noted that the QIP for service user and carer engagement is currently rated red and there is urgency to move forward with the project. The Board were informed that the QIP Progress Report will be presented to the next Service User and Carer Trust Partnership (SU&CTP) meeting to be signed off.

Action 15.41iv a. Current definition of co-production on page 3 of the strategy to be replaced by the version proposed by SUF or the version used by the Recovery College, if it is possible to change the document at this stage. (Gary Page) b. Provide information on the job roles of service user and carer engagement team to governors. (Gary Page)

Michael Scott left the meeting and Stephen Fletcher and Mary Rose Roe left the room at this point.

v. Annual General Meeting Arrangements 8th October 2015

The Board noted the report. 15.42 Standing Item: Feedback from the Subgroups and Committees i. Service User and Carer Trust Partnership Feedback 26th June 2015

Governors were recommended to attend local group meetings. It was suggested by the group that all Trust interviews for new staff include service users and carers. Training would need to be completed before they could participate. It was also suggested that a service user and carer focus group could be created to consider Trust policies.

Action 15.42i Chairs updates from locality service user and carer meetings are to be included on SU&CTP agendas. (Gary Page)

ii. Membership & Communications Subgroup Chair’s Report 21st May 2015

The Board noted the report. Stephen Fletcher and Mary Rose Roe returned to the meeting at this point.

iii. Planning & Performance Subgroup Chair’s Report 21st May 2015


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The Board were informed that the subgroup are scrutinising the new operational model and were referred to paragraph 7.0 of the report (attachment O).

iv. Education Subgroup Chair’s Report 2nd June 2015

The report was taken as read. The Board noted the report. v. Nominations Committee Chair’s Report 26th May 2015

The report was taken as read. The Board noted the report. vi. Quality Governance Report

This item was withdrawn. 15.43 Highlight Report to Members: to agree the agenda items to be

highlighted for members of the public

It was agreed that the following items would be included in the highlight to members via ‘Trust Matters’:

1. Carlton Court: governors raised questions about the withdrawal of funding

for Carlton Court. 2. An update on Lorenzo. 3. The work of the Improvement Plan Coordination subgroup. 4. The increasing pace of the implementation of the Service User and Carer

Involvement Strategy. 15.44 Any Other Business

Appreciation was extended to the Non-Executive Directors and positive feedback was received on the Governor and Non-Executive Director networking event earlier in the day.

15.45 Date, Time and Location of Next Meeting

The next meeting of the Board of Governors in public will be held at 1.00pm on 1st October 2015 in the Rose Room at Endeavour House, Russell Road, Ipswich IP1 2BX.

The meeting closed at 4.30pm.

Chair: ……...…..…………………………

Date: ……....……………………………. BoG Public – 02Jul2015 – Unconfirmed Minutes Rev Unapproved

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Matters Arising from Public Board of Governors 2nd July 2015

Date: 1st October 2015 C Item: 15.48

Action 15.37

Prepare report for public Board of Directors meeting considering bed situation and demand in Great Yarmouth and Central Norfolk and provide a model on how the closure of Carlton Court might affect the Trust’s finances. (Gary Page)

Complete (see issues log)

Action 15.38

a. Ensure Workforce Strategy item due at the next Board of Governors meeting includes staff wellbeing. (Gary Page)

On Agenda

b. Inform governors the name of the person responsible for managing volunteers. (Michael Scott)

Actioned and complete

c. Respond to governor queries on work opportunities for people with MH and LD issues. (Gary Page)

d. Gary Page to meet Bohdan Solomka to discuss communicating to carers the risks of stopping smoking whilst taking Clozapine. (Gary Page)

Complete

e. Insert the words ‘as in’ before ‘the Triangle of Care’ in the issue description. (Gary Page)

Complete

f. Update governors on waiting lists once new data is available. (Gary Page)

Suffolk complete – awaiting data on

Norfolk

g. Investigate extra resources promised to South Norfolk DCLL in light of the transfer of North Norfolk DCLL to South Norfolk DCLL. (Michael Scott)

Central Teams (North & South DCLL) 2.0 wte x band 6 1.0 x wte band 5 1.0 x band 4 (this is a vacancy that will transfer on October to central) 1.0 x SAS Doctor

Central DIST 1.0 x band 6 1.0 x band 5

Action 15.40i

a. Trust Secretary to prepare a proposal to be presented to the next Board of Governors meeting on what the threshold of votes should be before allowing consideration for a governor seat. (Robert Nesbitt)

On Agenda

BoG Public – 01Oct2015 Matters Arising

Version 1.1 Author: Kate Hope Department: Corporate

Page 1 of 2 Date produced: Sep2015 Retention period: 30 years

b. ‘Proposed changes to the Constitution’ to be added to the agenda for the next Board of Governors meeting. (Kate Hope)

Complete

Action 15.41iii

Ensure Human Resources are keeping a pool of ‘runner up’ candidates, particularly in relation to the band 6 role Stephen Fletcher was interviewer for three weeks ago. (Michael Scott)

As part of the Recruitment and

Retention Strategy, we introduced an

appointable candidate talent pool

which means that where a manager

interviews someone who was very good

but, for example, they got pipped at the post

by someone else, with their consent, we put them in the talent

pool. This is ordinarily for up to six

months. These individuals can then

be accessed by other appointing managers in regard to their own

vacancies

Action 15.41iv

a. Current definition of co-production on page 3 of the strategy to be replaced by the version used by the NHS or the version used by the Recovery College, if it is possible to change the document at this stage. (Gary Page)

Complete

b. Provide information on the job roles of service user and carer engagement team to governors. (Gary Page)

Complete

Action 15.42i

Chairs’ updates from locality service user and carer meetings are to be included on future SU&CTP agendas. (Gary Page)

Complete

BoG Public – 01Oct2015 Matters Arising

Version 1.1 Author: Kate Hope Department: Corporate

Page 2 of 2 Date produced: Sep2015 Retention period: 30 years

Governor Feedback for Board of Governors 1st October 2015

BoG 1st October 2015 1

Date: 1st October 2015 D Item: 15.49

Norfolk Public governors’ feedback (1)

In Your Shoes Consultations How many people attended the In Your Shoes consultations and how much did the events cost?

Hellesdon Site Why is the property at Hellesdon not kept to an appropriate state, litter wise?

Dementia Sufferers I recently participated in a South Norfolk CCG workshop to help design a pathway for Dementia sufferers. Problems were highlighted, many arising from the messy interface between NHS and community care. Would our directors please explain what actions are being taken - and what results achieved – in engaging with users and CCGs in planning the pathways for Dementia/Alzheimer patients to ensure that users receive the care they need while at the same time achieving the increases in efficiency and effectiveness that are being demanded. Compiled by Liz Witt, Stephen Fletcher and Ron French for Norfolk Public Governors, 16 September 2015


Norfolk Public governors’ feedback (2)

Since the Trust disbanded the former SU and Carer Councils replacing them with locality groups, it appears that SUs and carers have disengaged. Those governors who attend locality groups and are in touch with SUs and carers believe SUs and carers have concerns about services but have lost confidence in the Trust's acknowledgement of their views and requirements. How will the implementation of the SU/Carer Strategy regain the trust of these service users and carers?

Compiled by Sheila Preston, Public Governor for Norfolk, 18 September 2015

Att BoG 03July2103 3

Suffolk Public governors’ feedback (1)

Communicating by telephone When the Trust staff make telephone calls, at least some of the calls come through as 'Witheld' on the recipients' phones. Many people do not answer 'withheld’ calls as they often come from unsolicited 'cold' callers. Some people use software to stop the calls coming through. And the Trust communicating itself as ‘Witheld’ is not necessarily the most accessible way of behaving. Please would the Board clarify the Trust's policy on how it engages with people who it is calling by telephone? Many thanks.

Loved ones being treated in specialist care outside the Trust Sometimes NSFT service users are treated at specialist hospitals outside the Trust, so that they can get the best possible specialist treatment. It seems that, sometimes, family carers are unclear as to who to approach to influence the service received at the non-Trust hospital, especially if the staff of that hospital do not seem to be listening. Please would directors clarify the process for carers contributing their views on their loved one’s treatment and care, when that treatment and care is being delivered outside the Trust. Thank you. Compiled by Guenever Pachent for Suffolk Public Governors, 16 September 2015


Suffolk Public governors’ feedback (2)

Service User and Carers on Interview Panels In Suffolk and across the Trust, governors are hearing complaints that service users (SU) and carers are not being given enough notice regarding attendance at interview panels, and sometimes they have no knowledge of the post. Sometimes they are not involved in shortlisting. Please would directors be able to say when this situation will have been resolved? In addition, how can governors be assured that policies within the SU and Carer Engagement Strategy find their way into current practice? Compiled by Kathleen Ben Rabha Suffolk Public Governors, 16 September 2015


Service User governors’ feedback (1)

Depot Clinics On the 24th September 2015 the Depot Injection Clinic in Mariner House in Ipswich was scheduled to close. Is similar happening to other depot clinics in NSFT and if so why? Compiled by Paul Gaffney, Service User Governor, 14 September 2015

Adult Recovery Team for Central Norfolk Feedback is being received from service users, Norfolk GPs and other voluntary and third sector organisations where GPs are not being informed that service users are being discharged back to primary care with an up to date care plan or a letter to say that that person has been discharged from services. Feedback is also being received that service users are not being told that they are being discharged. They are not receiving letters. Or they ring up to find out when their next CPA is and they are told that they are no longer under the care plan approach. Please would directors comment on this feedback and say how it is being addressed?

6


Consultation Fatigue Norfolk service users/GPs /voluntary and third sector organisations have reported consultation fatigue. They say that they don’t want to be involved in consultation primarily because the trust has consulted in the past and not delivered on what we have co-produced at listening events. The message being received from service users/Carers and GPs is ‘just get on with it’. Please would directors respond to this feedback?

Recovery Project Lyn Skipper (the lead for the Recovery Project) is retiring at Christmas – can the Trust confirm is her post going to be held open as a substantial post? Mind Support Line – when will conversations take place with CCGs, the Trust and other stakeholders as to how we are going to continue the service? An open conversation with the CCGs/users/Trust needs to take place – when will that be done?



Recovery College

We are relying on the goodwill of service users to co-produce courses and deliver them within our recovery college. We are asking them to be involved in the college but we are not paying them to do this. I am told that some people are therefore feeling like they are being used. I would suggest that the Trust needs need to pay some of the people we are relying on.

In addition, we are experiencing difficulties in getting managers to release staff to come to our central recovery forum and co-produce with us. We have a cohort of service users wanting to work together but staff are not turning up to the locality forum or the recovery forum and if we don’t have staff being released to come and work in partnership with us to help with building a life beyond illness then what are we meant to do? This needs to be embedded into team culture that IMROC and recovery project are part of the solution and reassurance is required from the Trust around that. Please would directors respond to this feedback?



Dual Diagnosis Service Please can we have an update for Norfolk for the provision of our dual diagnosis service? I understand that we need a staff member from mental health services to lead on that piece of work in Norfolk. As I understand it, the blockage is with mental health services and not NRP and so understand that this should be led by adult mental health services. Compiled by Kevin James, Service User Governor, 16 September 2015


Carer governors’ feedback

Answerphone Messages Need for “customer friendly” answerphone messages on Trust sites for carers and Service users. The current messages compare unfavourably with many commercial sites where personnel take care to make the caller feel that their call is valued.

Pace of Discharge It would be good if pace of discharge from Community Services could be graduated rather than leaving SU’s and their carers “cut off” from the Service.

Putting People First There is valuable and detailed feedback from the “putting people First” initiative. Carers and Service Users look forward to the Trust’s response. Compiled by Mary Rose Roe, Carer Governor for Norfolk, 16 September 2015


Staff governor feedback (1)

Lorenzo Still many (very frustrating) problems. Technical staff (IT and Lorenzo staff) slow to respond sometimes, even after issues Datixed. Fewer service users being seen because of time it takes to record information. Many staff working 1-2 hours at home on laptops to “keep up”. Anecdotal reports of strained relations at home and disturbed sleep from work being done late in the evening. Screens freezing. Work just “disappearing” after being typed. Huge amount of time searching for numbers to find notes.

E-Rostering Complaints from staff about equity, family-friendlyness. Staffing on wards variable and sometimes inefficient. Shifts/work patterns sometimes make no sense.


Staff governor feedback (2) Basic working conditions

There continues to be examples of availability of work stations, parking, parking permits for the City, lack of laptops and docking stations etc Small things but staff no longer have time to chase things endlessly and feel there is no support anymore, or identified people who have responsibility for day to day issues. Everything is so slow to be fixed. On a positive note:

In our shoes 1200+ staff took part. A listening exercise for what staff felt was wrong. Very cathartic and for once, many staff felt they were being heard. Many staff felt the environment was “safe enough” to express their frustrations with the service. We hope this will continue to be built on. Compiled by Karen O’Sullivan, Staff Governor, 17 September 2015


BOARD OF GOVERNORS ISSUES REGISTER

01/09/15

Date: 01 Oct 2015 E Item: 15.50

Agreed Process

1. Prior to the Board of Governors meeting, the Lead Governor approaches each constituency and asks the constituency governors to act together to prepare a maximum of five issues to be included in the papers for the next Board of Governors meeting.

2. At the Board of Governors meeting the previous Issues Register together with Trust Comments will be provided

as an agenda item. The Chair and the Lead Governor will have gone through the Trust Responses prior to the meeting and will have made a recommendation on the proposed status which will be included in the papers.

3. Governors will have the opportunity to respond to any of the Trust responses and to propose an alternative

status.

4. The new issues tabled and old issues that are still open will remain on the Issues Register. Within one month of

the Board of Governors meeting an initial Trust response will be circulated on all open issues.

5. Closed Issues are available on request from the Trust Secretary.

BOARD OF GOVERNORS MEETINGS ISSUES REGISTER

Raised by Issue Trust Response (responsibility) Status Norfolk Public Governors 2nd July 2015

PNOR19: Unallocated cases for each Locality: What is the number of unallocated cases currently in each locality? Are the NED’s satisfied that the current extent of unallocated cases is safe and constitutes an acceptable risk?

I have circulated the numbers for Suffolk which indicate we do not have a waiting list hence I am assured. The Norfolk numbers are not yet reliable given the introduction of Lorenzo but these will circulated as soon as I have them. However cases are being manually tracked to ensure that everyone who needs care is being seen. The waiting list in GY & W now stands at 32, West Norfolk Adult is 40. In Central Norfolk we are reviewing individually the unallocated cases and I will report on the waiting list at the next meeting. There is a high waiting list in West Norfolk Dementia Complexity Later Life (DCLL) which currently stands at 147. A review is underway to speed up assessments and I will report again at the next meeting. GP 13/08/15

Open

Norfolk Public Governors 2nd July 2015

PNOR20: Service User / Carer Involvement Strategy: When will the Trust SU/Carer Involvement Strategy be published and circulated to carers and users of the Trust? Are the NED’s satisfied that this will be timely and reconnect SU and Carer involvement? How will this be monitored?

The Involvement Strategy brochure is now ready for circulation and a series of workshops have been organised during August. I believe the execution of the strategy will address the disconnect between service users and carers and the Trust. It will be monitored at the Service User and Carer Trust Partnership which I chair. GP 22/07/15

Closed

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Raised by Issue Trust Response (responsibility) Status Norfolk Public Governors 2nd July 2015

PNOR21: Representation of Service User / Carer views: Are the NED’s satisfied with that the current locality groups are representing the views and involvement of SU’s and Carers adequately and how are the views expressed contributing to future Trust strategy?

It is fair to say that the locality groups in different parts of the Trust are not all functioning in the way that we would wish and attendance at some is poor. This in part will be addressed by the execution of the new strategy. However it should not be forgotten that there are many very effective groups which operate at ward and team level. Service users and carers actively participate in these forums and influence decisions which are taken. Not all service users and carers want to get involved in the more strategic issues. GP 22/07/15

Closed

Norfolk Public Governors 2nd July 2015

PNOR22: Carlton Court – Local bed requirements Governors understand that there has been a change in demand at Carlton Court since the CCG consulted on local bed requirements and that almost all beds are now used by local people rather than patients from Central Norfolk. There is therefore a concern about the prospect for a reduction in beds and Great Yarmouth & Waveney at a time when Out of area placements is still around 20. What is the Boards assessment of this issue and how does it plan to respond?

There was a change in demand experienced during May 2015 but it would appear that this was a spike rather than a trend as GY&W have been using on average 17 beds for local service users over the last few weeks which would mean that the reduction down to 20 in November would be adequate for their local population. Out of area beds have been steadily reducing and there are 7 adult out of area beds today, 2 of whom are Patient As who cannot be treated within the Trust. It would appear that a combination of Thurne ward opening and the recent focus on central Norfolk CRHT are helping to improve the situation. The board discussed the bed situation in Yarmouth and Waveney and continue to believe the proposed bed numbers are adequate. DW 4/8/15

Closed

4


Raised by Issue Trust Response (responsibility) Status Staff Governors 2nd July 2015

Staff38: Staffing: Continues to be very short in some areas, especially West Norfolk. Posts are filled in some areas, but basically the same pool of people so “fixing” one area results in a shortage in another. “Robbing Peter to pay Paul” is how the Trust seems to be existing.

I hope Governors can be assured that the OD&W Committee, of which Tim Newcomb, Gary Page and I are the non-executive members, always has a key priority the interrelated issues of staff vacancies, turnover and recruitment performance. We have welcomed Jane Millar (twice) and Howard Tidman (once) recently as observers at meetings of the committee. On the specific point about ‘Robbing Peter to pay Paul’, over the past 12 months the Trust has made the following external appointments to localities/services:

Locality Sum of FTE

Central Norfolk 139.55 Corporate 69.44 Great Yarmouth and Waveney 63.67 Secure Services 56.84 Suffolk Access and Assessment 19.00 Suffolk East 58.01 Suffolk West 65.23 Support Services 22.90 Substance Misuse 11.60 West Norfolk 40.49 Total 546.73

Internal staff do apply for posts elsewhere

Closed

5


Raised by Issue Trust Response (responsibility) Status

within the Trust; most notably recently for posts advertised on Thurne Ward. Of the current 21 staff appointed to work on Thurne Ward, 9 were appointed from elsewhere in the Trust (mainly from secure services). However, movement within the Trust does not appear to be abnormal elsewhere. Traditional career paths/job demands in the NHS often attract new recruits to work within inpatient settings after qualifying (band 5 roles are most common in inpatient areas) and then move into community based roles – often these roles reflect lifestyle changes and a desire to work within services that aren’t running 24/7. Promotion opportunities do exist within inpatient areas, but these would be to ‘charge-nurse’ roles at Band 6 or ‘ward manager’ roles at Band 7. The majority of roles within community teams are at band 6 reflecting greater autonomy of work and more assessment based duties. The Trust has recently been applying recruitment premiums to roles within hard to recruit to teams. These had been applied to both internal and external recruits, but in June the Executive’s Flexible Workforce Programme board felt it was prudent to cease premiums applying to internal staff. I trust this response is helpful in relation to both

6



the specific point raised and the wider recruitment context. Brian Parrott 10/08/15

Staff Governors 2nd July 2015

Staff39: Beds: Continues to be a serious concern to staff. Patients are still either being “held” at home, or going out of area. Staff feel they are left with the “risk”, rather than it being held by management / the organisation.

Managers have been very involved in the out of area process and concerns raised by inpatient areas. Out of area reports are received twice a day by senior managers as well as a daily Delayed Transfer of Care report and there is a weekly bed management meeting Chaired by the Associate Director of Operations for N&W. A recent example of listening to and acting on the concerns of staff is the decision to close 4 beds at Waveney Acute services in order to provide a safer service.

DW 4/8/15

Open BOG to discuss


Staff40: Lorenzo: An extensive list of staff concerns was raised please see Board of Governors papers for details.

Response to Staff Governor Karen OSull

LH 17/07/15

Closed


Staff41: Datix: There is a fairly universal experience that issues staff report are not responded to in any way. This varies from clinical issues to personal injury to shortages of staff. How can this be remedied?

The Governance team report that this is an ongoing issue they are trying to resolve with managers. Aside from the Policy and formal structures, managers are required to feedback to staff about Datix queries/ issues in a number of ways, safety newsletters, in the new Patient

Open BOG to discuss

7



safety guide for managers and via the locality forums.

It would useful if the Governors could provide specific details of where this is a problem to enable this to be targeted directly into the teams where there is a concern. In the July 2015 report to the Board a drop in reporting of Datix incidents has been highlighted. It is suggested the Board request the Directors of Operations to ensure the message is cascaded to their service managers about the importance of reporting and feeding back to staff as it appears the Trust are yet to get effective engagement with teams and to make sure this process is embedded in ‘business as usual’ practices. It would also be helpful to ensure feedback to staff if CTLs used the Datix dashboard at team meetings.

The Governance team have been looking at a way of evidencing that managers respond to the question on the form -‘Reporter wishes to receive feedback,’ if yes then there is a box for the manager to complete ‘Has feedback been given to the staff member?’ then there is a dropdown box of how it was given.

The Governance team are examining how to

8



identify a way of auditing the Datix records which will include the responses back to staff. This was initially tried through Health & Safety Committee, but the response was minimal.

In summary this is a performance issue which involves the Trust’s agreed procedure not being followed and not making the best use of the Datix system opportunities. This may imply further training and support is needed by teams and their managers.

JB 20/07/15

Suffolk Public Governors 8th January 15

PSUF25 Perinatal Mental Health: there has been a Suffolk wide inter agency pilot around Perinatal Mental Health, which has reached the implementation stage. NSFT has been very involved in all this work. We understand that prior to 2012 there was a Perinatal Mental Health Forum and, given the huge societal impact, wondered whether the BoG might receive an update on this, and whether the Forum could be re-instated? (FAO Chair of BoG and Executive Directors)

There were active Suffolk and Norfolk forums for perinatal MH. Clinical staff in Suffolk who are also involved in the perinatal MH pilot work have taken an action to renew contacts and recommence the forum, the proposal is that this should be trust wide and draw in the wide experience of clinical staff working across the two counties.

03/03/15 Alison Armstrong

We have tried unsuccessfully in Suffolk to resurrect this forum, which included providers and commissioners. This is due to be discussed at our next contract meeting at the end of July

Open Pending Forum Starting

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AA 16/06/15

I have asked our CCG mental health commissioners in East and West Suffolk via the contracts meeting for any update on this.

This should be covered in the Children and Young Peoples Mental Health Strategy which is currently being developed by Suffolk CC and CCG’s in conjunction with stakeholders.

The strategy was discussed at the HoSC in July; an implementation plan for strategy is currently being developed, including redesign where appropriate.

AA 20/07/15

Suffolk Public Governors 2nd April 2015

Psuf27 Lorenzo: There is uncertainty among some carers as to whether Lorenzo, before it goes live, is going to include information on carers, both generally, and in the care plans. Please could the Executive clarify the position, and please may we be assured that the Trust is communication with service users and carers about Lorenzo, as it affects them, to ensure clarity and understanding?

The care plan will include the necessary information on carers. There have been meetings with service user groups on Lorenzo and a service user/carer leaflet is available for further reading from the Lorenzo team.

15/05/15 – Leigh Howlett

We have a specific Carer’s Clinical chart. A clinical chart is a way of pulling lots of information together in one place – we only have 3, Care Process, Inpatient and Carers. In the Carer’s clinical chart there are the following

Open BOG to discuss

10



content options:

• A Carer’s Assessment (this is a bespoke CDC / Clinical Data Capture form)

• A Carer’s Clinical note (this is an approved Trust template)

• Uploaded docs (this is any additional scanned information)

So much more information than we had previously and in one place accessible to anyone involved in the SU care. In time we will be able to interrogate the system to see how much this is being used.

LH 22/07/15

Suffolk Public Governors 2nd July 2015

Psuf31: Safeguarding Patients Human Rights: We would like assurance regarding how the NED’s ensure that policy an practice within the Trust safeguards a patients Human Rights especially around Article 3 (right not to be subjected to degrading treatment), article 8 (right to respect for privacy and family life) and Article 5 (right to liberty and security). We understand that these rights are not absolute and be curtailed under special circumstances, but can we be reassured that patients are clearly told about their Human Rights and that staff know how they stand, if practice were to be questioned?

Staff do not have a duty to inform patients of their Human Rights (much like ignorance is no defence to breaking the law) but they have a duty to remind patients of their rights under the Mental Health Act which we monitor, monthly. Any concerns are escalated as per attached process. Art 3 is protected via Trust staff being registered with professional bodies and adhering to codes of practice to ensure good practice (ie no degrading treatment and a requirement to raise concerns if they see

Closed

11



degrading treatment from another unqualified staff member). If an issue of possible mistreatment is raised, the usual practice is for the staff member who is subject to the allegation (allegations can come from patients or other staff) is removed from clinical duties pending investigation. If investigation finds staff acted in contravention of trust policy and or their professional code (both of which embrace and have regard to art 3) then the staff member would be disciplined, get further training if necessary or further action may be taken such as dismissal or reporting to their professional body for investigation of their being able to continue to practice.

Art 8 is safeguarded by the Trust with the Data Protection act form for privacy/confidentiality. All patients are asked who (if anybody) information can be shared with. It is Trust vision and values to encourage recovery and for patients to take ownership of their own recovery, this includes encouraging as much time with family as possible (where appropriate). Obviously, for some inpatient units, patients’ rights under Art 8 and 5 are infringed but this is on balance and proportionate and the Trust safeguards that proportionality by use of the MHA and the strict

12



legislative framework in which that operates as well as the Code of Practice.

GP 05/08/15 (response provided by Maeve Heaney)


Psuf32: Withdrawal by CCG’s of Crisis funding from MIND in Norfolk: Following the withdrawal of funding for the crisis service operated by MIN in Norfolk, how does the Trust propose to meet the expectations and needs of users and people in crisis? Has the MIND pilot been evaluated and if so is this now available for NED’s and Governors?

The CCG’s have confirmed that they will not continue funding for the crisis line. NSFT have agreed to continue to fund the MIND support line for central and west Norfolk until 31/3/16. We will be working closely with MIND and commissioners to pursue funding options beyond this. Great Yarmouth and Waveney were already working with 111 at the time the Mind Crisis line was operational and are continuing this. Hence the Mind Crisis line is limited to Central and West Norfolk.

DW 4/8/15

Closed


Psuf33: Foreign Workers in NSFT: In view of the Government’s alleged plans to deport all foreign workers who have been in the UK for more than six years and earn less than £35,000pa, what plans do the Board have to cope with the possible imminent departure of any nurses who might fall into this group? This is particularly important because of the notoriously low pay they and the difficulties of recruiting staff.

There is a national review to look at increasing the Tier 2 (General) minimum salary threshold of £20,800 for the short-term category and £41,500 for the long-term category which is a level that better aligns with salaries paid to highly-specialised experts or individuals filling skills shortages. As such not all people who are in the UK and not earning £35k will be deported imminently. It would be difficult to stay in the UK for 6 years or more on a Tier 2 visa and most

Closed

13



people will apply for indefinite leave to remain in the UK or request to stay via other visa types. In terms of the NSFT position, we currently have 11 members of staff on a Tier 2 (General) migrant visa; 8 of these are medical staff that are considered to be highly skilled (doctors are on the national skill shortage list) and one nurse who is applying for indefinite leave to remain in the UK. The rest are linked to either research or training (pre-registration pharmacy) so are only here on a fixed term basis. So for us, although the immediate impact wouldn’t be significant, it will be for the wider NHS which may well have knock on effects for NSFT. For background information, it is quite difficult for overseas nurses to register with the NMC as a Registered Mental Health Nurse. The NMC require that migrants hold a specific mental health nursing registration in their own country before they can convert to NMC membership – however only a few countries worldwide have specific mental health nursing qualifications (most are dual qualifications), which limits the pool who are even able to enter the UK to work as a nurse specifically in mental health. Other professional bodies aren’t quite so strict in terms of registration in the UK.

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LH 16/07/15


Psuf34: Loss of funding for dementia advisors in Suffolk: Concerns were raised at the Dementia Meeting at Debenham attended by the national leads in dementia and ageing and frailty about the removal of finance, not by the Trust, from Dementia Advisors in Suffolk. These have only been in place for three years but have made a great impact locally. Alistair Burns (Dementia Lead) agreed with those present that money spent on psychiatric services might be better spent on the advisors, who only found out that they were redundant at very short notice. This is not directly related to the Trust, but none the less providing a valuable (anecdotal) service to patients for whom their removal will be detrimental. Does the Trust have a view on the removal of this service, and any plans to mitigate the impact on the Trust and its dementia patients?

Essentially, the funding for the service ran dry at the end of March. At the same time we were renegotiating our Strategic Partnering Agreement with Age UK Suffolk and agreed with them that that would develop their generic Information and Advice Service, which “will include advice workers with specialist knowledge of a range of support, including support for people with dementia”.

AA 16/07/15

Closed


Psuf35: Carlton Court, Closure of Beds: We understand that the Health East CCG is decommissioning mental health beds Carlton Court, because they are not needed in Yarmouth and Waveney. However, we perceive that the Central Norfolk CCG does need additional beds, because their mental health patients continue to be placed in other Norfolk and Waveney CCG areas or worse outside the Trust completely. This is distressing for the patients and staff, and wasteful of Trust funding. We don’t understand why the Trust is closing beds at Carlton court, when the beds are seemingly still needed by Central Norfolk patients. We are concerned that closing these beds at this stage will lead to unnecessary additional expenditure on beds outside the Trust, distress mental health patients when they are very ill, and needlessly damage the reputation of the Trust. Please would the Chair and Chief Executive explain why the closure of the Carlton Court beds is still being planned for, and demonstrate how this action will not lead to unnecessary additional expenditure and needless damage to the reputation of the Trust.

The closure of the acute beds at Carlton Court followed an extensive public consultation led by the CCG. The CCG’s conclusion, with which we agree, is that the enlarged wards at Northgate will be sufficient for Yarmouth and Waveney patients. You are correct in saying that we continue to see some OOA placements from Central Norfolk but numbers are much reduced showing the positive impact of changes we have made e.g. Thurne Ward and CRHT. The number as of today is 8 and had been consistently in single figures, we agree OOA should be avoided where ever possible because of the distress caused to patients and families. However

Closed

15



Central Norfolk will not commission additional beds and as you know we have gone to arbitration on the contract regarding risk sharing on OOA.

GP 13/08/15

Carer Governors 15th October 2014

C28: Communications with Carers: Communications with carers over e.g. locality forum meeting dates and locations. Does the Trust have a register/database of known carers? Are carer members of the Trust routinely contacted e.g. by email to inform them of locality forums etc? I am also raising this with the Service User and Carer engagement strategy

An involvement register for carers and services users has been identified as a priority and will be included in the strategy. This will be monitored by the Service User and Carer Trust Partnership.

Jane Sayer – 7th November 2014

All dates for forums and meetings are now on the internet and are being sent out to Trust members .We have a list of carers from the previous TSS meetings that is used in Norfolk as well as advertising through CAP (carers agency partnership) .The service user and carer list will be a piece of work to go through the PID that Lyn Skipper is leading on.

JS 08/06/15

Locality workshops will be underway in August. This will include discussion around a range of ways of identifying carers, and carers interested in becoming involved with service design

OPEN Pending date for creation of Carers register.

16



delivery and developments as active participants or who wish to be informed of specific events or opportunities.

This is likely to a database of some type, and will need to identify who holds it and updates it and accesses it.

LS 17.7.15

Carer Governors 8th January 15

C32 Clozaril: Carer from a Trust informs me that SU’s taking Clozaril who decide to stop smoking need to do this under medical supervision due to the interaction between nicotine and Clozaril. I believe Steve Bazire is aware of this potential risk. Are SU’ taking Clozaril, their GP’s, their family carers and relevant staff informed and monitoring this? (FAO Executive Directors)

There is a whole section (2page) on Action on Smoking Cessation (planned or admission to non-smoking ward) (page 2-3 of Clozapine Therapeutic Monitoring Guidelines attached). Advice is also in Clozapine Prescribing Guidelines (attached). It is a common knowledge among clinicians that patients should be informed of this prior to and during clozapine treatment. This is also included in choice and medication leaflet or other PIL which should be provided to patient before commencing treatment.

Clozapine Prescribing Guidelines.pdf

Clozapine Therapeutic Monitorin

BS – 25/02/15

I can confirm that this information can be

Closed

17

http://intranet.nsft.nhs.uk/corporate/Pharmacy/Pharmacy%20Documents/POLICIES%20AND%20GUIDELINES/Clozapine%20Therapeutic%20Monitoring%20Guidelines.pdf

http://intranet.nsft.nhs.uk/corporate/Pharmacy/Pharmacy%20Documents/POLICIES%20AND%20GUIDELINES/Clozapine%20Therapeutic%20Monitoring%20Guidelines.pdf



shared with Carers.

BS – 15/04/15

I have discussed the issue of how carers can be informed more effectively with the Medical Director. He has agreed that the guidance to clinicians will explicitly state that carers should be informed.

GP 22/07/15

Carer Governors 2nd April 2015

C33 Care Programme Approach (CPA) revision of paperwork: Carers have requested that “Carers views and knowledge sought” should be included as in the Triangle of Care Self-Assessment Tool, 1.3. Please would the Executive clarify if this is possible?

The new care plan form will have a section for carers views etc. – There were consultation events for service users and carers at our locality forums, as well as a separate meeting for carers and service users giving the opportunity for service users and carers to input in to the new design of the carer plan. Lorenzo team are due back to the locality forums throughout April and May – so we will be able to ensure that this request is actioned.

JS 15/04/15

Under the details section there is a section which will expand in the word document to capture carer’s views. At the end whether they have been offered a copy of the care plan.

Open BOG to discuss

18



Care Plan Mockup v1.2.docx

JS 18/06/15

We are currently looking for Service User and Carer views on review on CPA policy.

JS 17/07/15

Carer Governors 2nd July 2015

C36: Support for Carers as their loved ones health deteriorates: Carers experience a gap in services when aware that loved one’s mental health is deteriorating and SU seen as “in denial”. A feeling of helplessness and having to wait for the crisis. What can be done to advise and support carers in this situation, to whom should they turn to when GP is unhelpful?

If Service User is known to the service and has a care coordinator, they can ring and speak to a care coordinator directly. Otherwise, access is through the GP – if GP is not responsive, follow practice guidelines on raising a concern – usually through the practice manager.

JS 17/07/15

Closed


C37: Training for GP’s in Mental Health: Carers experience GP’s as often lacking in knowledge of mental health. Is the Trust able to extend further training to GP’s to follow the initiative already taken to offer training in dementia care?

The main way forward on this is the new clusters 1 -4 Wellbeing Service where a significant part of the medical role is to educate our GP colleagues.

BS 17/07/15

Closed


C38: Link workers in Norfolk and Waveney: Carers are vocal about the loss of link workers in Norfolk (still available in Suffolk). Having a mental health professional based with the GP was valued. It is felt that this role is not covered by the Well-being Service. Was this a decision made by Commissioners, and did the Trust

The decision to lose link workers was made by NSFT as part of the service strategy not Commissioners. The new Primary Care Mental Health service which goes live in

Closed

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challenge it, and is it still an agenda item in discussions with Commissioners?

Norfolk and Waveney on 1/9/15 includes a named clinician role which is similar to the linkworker role and will be based in GP surgeries. Although the PCMHS is for clusters 1 to 4 we are working on plans at present to increase our presence in GP surgeries for clusters 5 to 17 also.

DW 4/8/15


C39: Communication with Carers: Communication with Carers is an on-going issue. We often have to take the initiative to get information from staff. We look forward to the development of the Triangle of Care.

Govs issues july 2015.doc

JS 17/07/15

Closed

Service User Governors 2nd July 2015

SU25: NSFT Budgets: Since the merger of the two Trusts which led to the creation of Norfolk and Suffolk Foundation Trust in 2012 what has the total budget been for the Trust in each financial year to the present day and what will it be going forward for the foreseeable future?

Total operating budgets 12/13 - £210.2m 13/14 - £208.5m 14/15 - £202.4m 15/16 - £211.9m 17/07/15 AH

Closed

Service User Governors 2nd July 2015

SU26: Employee Costs: Further what impact has the cost cutting had on the Trusts largest single cost: employee costs and what will that be for the foreseeable future?

Total Employee Costs 12/13 - £162.4m - actual 13/14 - £162.1m - actual 14/15 - £159.7m - actual 15/16 - £162.0m - plan 17/07/15 AH

Closed

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Title of Report: Chief Executive’s Report


Estimated time: 10 minutes

Author: Michael Scott, CEO

Director: Michael Scott, CEO

Executive Summary:

This report provides an update on the main issues, insights, observations and activities undertaken by the Chief Executive over the past two months.

1.0 Monitor

1.1 There have been two monthly assurance meetings with Monitor; these were held on the 19th August and 16th September 2015. Additionally, some of the Board where invited to meet with Monitor at their London office to update them on the financial position. A verbal update will be given at the meeting.

2.0 Directorial Changes

2.1 Following the resignation of our Director of Finance and Deputy Chief Executive, Andrew Hopkins; we appointed an Interim Director of Finance, John Doyle who you will have met during the summer period. John is seconded from Merseyside Health Care and is likely to be with us until we appoint a new Director of Finance and Deputy Chief Executive. Interviews for this position were held on the 24/25 September 2015.

3.0 Nottinghamshire Health Care Trust

3.1 You will be aware that NHCT are our buddy trust. I am pleased to confirm that Julian Eve has joined us on a part-time basis working on the organisational development strategy and leadership

3.2 Some of the Board visited NHCT last month to attend their Board meeting for observation purposes. This was an informative visit which will help with our Board

Date: 1st October 2015 F Item: 15.51

Board of Governors 1Oct15 CEO’s Update

Version: 1.3

Author: Carol Carter Department: Corporate


agendas. The Chief Executive’s report also took a more strategic focus which I will be adopting in future.

4.0 Year End Financial Position: 4.1 The Trust has an Income and Expenditure deficit of £4.5m to August 2015 and

must deliver its planned deficit of £9.4m by March 2016. To achieve this, the Trust must identify and deliver additional schemes totalling £3.7m during October to March 2016 on top of the £6.6m CIP currently being delivered. Schemes being be introduced include reducing Temporary staffing/Agency costs, procurement saving and schemes which will reduce general everyday spend. All schemes identified will be assessed using existing Quality Impact Assessments to ensure that Service User safety is not compromised.

The Trust is also introducing further cash management controls to ensure that cash levels are adequate for continuing service operation.

5.0 Clinical Strategy Delivery 5.1 Clinical Strategy Development has commenced. In July, Locality teams were sent

a template for collecting background information about their areas’ population and mental health needs and the current resources available to meet those needs. Lead Clinicians within these teams are the leads for this, but widespread staff involvement is essential. Workshops are in place during October and November to start to build the clinical strategy for the next 5 years in each locality, based on the background information, forecasted needs, Trust Values and financial sustainability. The workshops are an initial part of the process, locality teams will seek to engage stakeholders in as many ways as possible. The development of this model for delivering mental health care will involve all stakeholders: staff, service users and carers, commissioners and other providers in the care pathways. By the end of December 2015, each Locality will have a clinical strategy prepared to implement from April 2016

6.0 Care Quality Commission:

6.1 I met with the CQC and their new local manager; I explained to them where the Trust has improved and where we have further work to do.

7.0 Governance Review:

7.1 We have tasked Foresight with a follow up review which has commenced this month with internal and external stakeholders participating in surveys. In addition, Mike Smith will be observing the Finance, Governance and Board meetings. Feedback sessions are likely to be held in November.


Version: 1.3



8.0 Lorenzo: 8.1 The Lorenzo team have completed a series of visits with Locality senior

management teams to identify prevalent issues, resolutions to which are being sought through escalation to CSC, support from ICT and further communication of best practice as is appropriate. The principal issues experienced are;

• The performance (i.e. speed) of the system in some areas – ICT and CSC are

investigating and seeking to resolve these issues • Access and training – New training courses have been designed and temporary

access cards provided to wards to alleviate access issues, ‘bitesize’ videos on many areas of functionality are now available through the intranet as is a user forum to encourage sharing of best practice

• Productivity impacts – The programme team are working with staff to identify and implement efficiencies in the new processes and procedures

• Availability of reporting – Commissioning datasets have now been provided and operational data made available in order to review and improve data quality

8.2 Calls to the service desk have diminished and anecdotal feedback from users indicates that they are becoming more comfortable using the system. The Lorenzo User Group and a supporting Change Advisory Group are now in place to manage ongoing requests for change

9.0 Meetings and visits:

9.1 The Chair and I met with our local MP Clive Lewis who is very interested in the Trust and supporting mental health services.

9.2 I visited the wellbeing service in Kings Lynn to hear about their concerns and

hopes for our new primary care mental health services.

9.3 On visiting Carlton Court, I heard an excellent presentation to show how services can be taken forward in a cost effective way that improves service users experience and rewards staff for their skills. This was led by Nurse Prescribers who have been able to create a more stream-lined, user focussed service.

9.4 Meeting with the GMC in London with Dr Solomka in preparation for their inspection visit to the Trust in November. This will be an important visit and preparations are well in hand.

9.5 I met the staff and residents at Chilton House. I was able to hear the great work

that they are doing under their new leadership to move to a more progressive model of care.


Version: 1.3



9.6 I visited Norfolk Recovery Partnership based at Hellesdon and Norwich City

Centre. This team has raised both contract performance and staff morale by focussed leadership.

9.7 I took the opportunity to visit St Clements Hospital whilst in Ipswich. I also saw the

excellent new accommodation which will be the new training suite in the grounds. 9.8 As you are probably aware I try to attend every staff induction and the induction on

the 14th September was a particularly busy 26 enthusiastic new recruits coming into the Trust from around the country and sometimes around the world who have joined our organisation.

9.9 I also joined the team in Central Norfolk looking at how we better organise the

process of referral to discharge in our community teams, improvements to the process were identified and it highlighted our belief that the people best able to improve a process are those who do the job on a day to day basis.

9.10 I attended the Clinical Cabinet around our policy for rapid tranquilisation. This

needs to be amended in light of new NICE guidance and link closely with our new approach to PMS training. These taken together mean changes for staff but most importantly a less restrictive response to our service users.

10.0 Risks / mitigation in relation to the Trust objectives

10.1 None.

11.0 Recommendations

11.1 The Board is asked to note the content of this report.

Michael Scott Chief Executive


Version: 1.3





Title of Report: Proposal to extend term of office of NED

Action Sought: For Approval


Author: Robert Nesbitt: Trust Secretary

Director: Gary Page: Chair

Executive Summary: The Nominations Committee has started the process of recruiting to two forthcoming NED vacancies. One of these is the Chair of the Audit and Risk Committee which is a keystone of the governance system for any FT. In order to provide a smooth transition it is proposed that the current Chair of Audit and Risk has an extension to their term to 30th April 2016.

1.0 Reason for proposal to extend NED term of office

1.1 John Brierley and Stuart Smith are coming to the end of their terms as non-executive directors and so the Nominations Committee has been making arrangements to recruit to these roles.

1.2 John Brierley is the Chair of the Audit and Risk Committee. The Audit and Risk Committee is one of the most important committees and is one of the few that all FTs (and listed companies) are required to have. The committee meets bi-monthly and has a wide-ranging set of responsibilities which require both breadth and depth of understanding of the Trust’s work. One of these is the oversight of the annual accounts and report.

1.3 The new appointee will need time to learn about the work of the Trust and role of the Committee in relation to the Trust’s governance structure. Assuming that the appointment process is successful the earliest date that the new appointee could start would be 1st November 2015. John Brierley’s current term of office ends on 9th November 2015.

Date: 01 October 2015 G Item: 15.52i

Board of Governors, 1st October 2015, Nom Ctte Report

Version 0.1 Author: Robert Nesbitt Department: Trust Corporate


1.4 The proposal is therefore that we extend John Brierley’s appointment to 30th April

2016. This will allow a smooth transfer of role and will also take the appointment to the end of the financial year. This is within the maximum nine years appointment period set out in the Constitution.

2.0 Recommendations

2.1 The Board of Governors is asked to approve the extension of John Brierley’s current term of office to 30.04.16.

Background Papers / Information None.




Report To: Board of Governors – Public


Title of Report: Proposed changes to the Constitution




Executive: Robert Nesbitt: Trust Secretary

Executive Summary: The Board of Governors considered a number of changes to the Constitution at its meeting on 01 July 2015. The meeting was unable to vote on the changes as the higher quoracy threshold required for changes to Standing Orders was not met. In addition, governors requested more detailed guidance on how the substitute governor arrangements would operate in practice. As a result, this paper is returning to the Board of Governors to be considered again. This paper sets out the rationale for four proposed changes to the Trust’s Constitution: 1. Amending the Board of Directors’ membership. 2. Changing the arrangements for the election of substitute governors (when a governor stands down mid-term and the Board of Governors exercises its discretion to appoint the next governor from the election result list). 3. Changing the name ‘Board of Governors’ to ‘Council of Governors’. 4. Changing the post title, ‘Trust Secretary’ to ‘Company Secretary’. The rationale and advantages and disadvantages of each proposal are set out in the paper. Any changes made to the Constitution also have to be approved by the Board of Directors before taking effect.

1.0 Statutory framework

1.1 It is good practice to keep the Constitution of the Trust under review and to update it from time to time to make sure that it reflects the needs of the organisation and the expectations of local people. Some elements of the Constitution are fixed by statute, but others are for local agreement.

Date: 1st October 2015 H Item: 15.52ii

BoG Public – 01Oct2015 Constitution Proposals



1.2 At the time of writing there are 33 governor seats, 8 of which are vacant, meaning

that there are 25 governors in post. Most changes to the Constitution require that the meeting is quorate (i.e. allowing for rounding one third of the governors in post must be present (8.3 = 8)), except for changes to the Standing Orders (where two-thirds must be present (16.6 =17)).

All the changes proposed in this paper, with the exception of the change for substitute elected governor terms, require changes to the Standing Orders and so 17 governors must be present for these to be approved.

2.0 Amending the Board of Directors’ membership

2.1 What is proposed?

2.1.1 Reducing the number of NEDs by one and allocating an additional vote to the Chair.

2.1.2 Currently the Constitution requires that,

22. Board of Directors Constitution

“22.1 The Trust is to have a Board of Directors, which shall comprise both Executive and Non-Executive Directors. At least half the Board excluding the Chair shall comprise Non-Executive Directors determined by the Board to be independent.”

This means that the non-executive directors are in a voting majority on the BoD (in line with good practice). However, it is possible to achieve the same end by allocating an additional vote to the Chair.

The proposal is therefore that the number of NEDs be reduced by one, but that the voting majority of NEDs remains in place by allocating an additional vote to the Chair. The wording of the Trust’s Constitution would be changed so that the second sentence of the paragraph above (22.1) would be removed, so that it reads,

“22.1 The Trust is to have a Board of Directors, which shall comprise both Executive and Non-Executive Directors”.

and the following sentence inserted,

“22.8 In the event that the number of Non-Executive Directors (including the Chair) is equal to the number of Executive Directors, the Chair (and in his or her absence, the Deputy Chair), shall have a second and casting vote at meetings of the Board of Directors in accordance with the Standing Orders for the Board of Directors”.

In addition, Annex 8, the Standing Orders would be amended as follows:

“21 Voting




21.1 Save as provided in SO 22 - Suspension of Standing Orders, and SO 23 -

Variation and Amendment of Standing Orders, every question put to a vote at a meeting shall be determined by a majority of the votes of members present and voting on the question. In the event that the number of Non-Executive Directors (including the Chair) is equal to the number of Executive Directors, the person presiding the meeting shall have a second vote. In the case of an equal vote, the person presiding (ie: the Chair of the meeting) shall have a second, and further casting vote.”

2.2 Rationale / advantages of the proposed change

2.2.1 At 15 people, the Board of Directors is quite large and this proposal provides an opportunity to reduce the size of the board. A smaller board can make deliberation easier. Whilst not a primary motivation, the reduction does also represent a modest saving to the cost of the board of £11k pa. plus expenses. We have checked with Bevan Brittan who confirm that the additional vote arrangement is not uncommon and consistent with the legal framework.

2.3 Possible disadvantages

2.3.1 The reduction in NEDs reduces overall NED capacity although it should be noted that following the rationalisation of the committee structure in 2014 there are fewer committees to chair / attend. The Trust will need to explain why it has adopted this approach as part of the ‘comply or explain’ requirement of the Monitor Code of Governance in the annual report.

3.0 Changing the arrangements for the election of substitution governors


3.1.1 At present, when an elected governor stands down mid-term, the Board of Governors has the option of appointing the next candidate for that constituency from the last election (assuming a contested poll). If the next candidate accepts the offer they then have to stand again at the next election and so in practice they serve less than 12 months and this could be as short as 6 months. It is proposed to change this provision so that the substitute candidate can be appointed for the remainder of the 3 year term of that election.

When this proposal was discussed at the meeting of the Board of Governors in July 2015, governors requested that the principles for exercising this option be included. At present the Constitution gives this discretion but does not provide any principles.

3.1.2 The current arrangement is set out in Annex 9 (Further provisions) as follows,

“14. When a vacancy arises for one or more Elected Governors, the Board of Governors shall have the option to take from the list of members who stood for election at the most recent election of Governors from the class or constituency in question whichever member who was not elected as a Governor at the recent election but had secured the next most votes at that time. This procedure, which




shall be an uncontested election for the purposes of the Model Rules for Elections as they apply to the Trust, shall be available to the Governors on two occasions within twelve (12) months of the previous election. Governors appointed in this way shall hold office for a minimum of six (6) months from their appointment but, subject thereto, shall hold office until the earlier of the conclusion of the next election of Governors and (except where the vacancy arose through expiry of a term of office) the date on which would have expired the term of office of that Governor whose cessation of office gave rise to the vacancy”.

3.1.3 The wording of the final sentence in the above paragraph would be amended to read as follows,

“Governors appointed in this way shall hold office for the remainder of the term of office for those governors elected at the most recent election.”

3.1.4 Principles for exercising this option. Simply taking the next person from the election result list can have anomalous effects (for example, in one recent election the next candidate received 471 (27%) votes but the one below that received 76 (4%).

The substitute governor should have a sufficient electoral mandate (relative to the elected governors) so that they have credibility in their role. As a simple way of gauging this it is proposed that the substitute governor should have received at least 66% of the number of votes of last elected governor on the list.

In the examples below, the last elected governor in Election 1 (B) received 516 votes, so the threshold to be reached is 341. This would allow candidate C to be substituted but not candidate D. The last elected governor in Election2 (O) received 483 votes so the threshold to reach is 319. Candidates P could substitute but not candidates Q or R. Examples:

Election 1 No.

Votes %age outcome Threshold of 66% of 516

Candidate A 632 37 elected Candidate B 516 30 elected 341 Candidate C 471 28 Could substitute Candidate D 76 4 Could not substitute total 1695 100

Election 2 No.

Votes %age outcome Threshold of 66% of 483

Candidate M 631 24 elected Candidate N 577 22 elected Candidate O 483 18 elected 319 Candidate P 342 13 Could substitute Candidate Q 316 12 Could not substitute Candidate R 271 10 Could not substitute total 2620 100




The board of governors would retain the provision as an option (so it would always be subject to a vote by the full board) which it can choose to exercise if it wished.

However, the 66% rule would act as a constraint on the Board of Governors’ powers if included in the Constitution.

3.2 Rationale / advantages of the proposed change

3.2.1 New governors often comment that it takes several months to become familiar with the role and so elected governors who are substituted part-way through the year are at something of a disadvantage in having missed the induction process. Whilst individually tailored programmes are arranged, by the time such governors have got into their role they find themselves having to stand for election again. Extending the appointment to the remainder of the 3 year term allows them to ‘find their feet’ and provides continuity for the constituency.


3.3.1 There is a risk that applying a 66% rule is somewhat arbitrary but the examples shown above seem to indicate that the outcomes are reasonable. This is also mitigated by the fact that the facility remains an option for governors to exercise at their discretion and whilst, if adopted, a candidate not reaching the threshold would not be appointable, there would be no requirement for governors to automatically appoint a candidate who did meet the 66% rule.

4.0 Changing the name ‘Board of Governors’ to ‘Council of Governors’


4.1.1 Before the Health and Social Care Act (2012), FTs tended to use two main names, “Board of Governors” or “Council of Governors.” The Act tried to encourage the use of the name Council of Governors although it stopped short of insisting that all FTs standardise to “Council of Governors”. At that time, Norfolk and Waveney Mental Health NHS FT decided to continue to use the name “Board of Governors” on the basis that it reflected a ‘parity of esteem’ with the Board of Directors.

4.1.2 It is proposed that we now come into line with the legislation and with most other FTs and change the name to the Council of Governors. The following paragraph would be changed within the Standing Orders the Constitution,

“1.2.2 “Board of Governors” means the Board of as constituted in accordance with this Constitution, which has the same meaning as the Council of Governors in the 2006 Act;”

To read,

“1.2.2 “Council of Governors” has the same meaning as the Council of Governors in the 2006 Act;”




And all references to the Board of Governors would be changed to Council of

Governors.

4.2 Rationale / advantages

The shorthand reference to ‘the Board’ has the potential to cause confusion and the name change avoids this. In addition, the term Council (with its connotations of elected representatives who represent, deliberate and advise) arguably more closely reflects the governor role. The way in which the Board of Governors has developed in recent years means that the parity of esteem argument is no longer so relevant.


There may be come confusion in the changeover process and it will need to be explained that the functions remain the same. This will require careful communication. All documents will need to be brought into line in due course so that they reflect the new name.

5.0 Changing the role title ‘Trust Secretary’ to ‘Company Secretary’.


That the role title ‘Trust Secretary’ be changed to ‘Company Secretary’.

This would mean that in the Standing Orders, the term would change,

“1.2.6 “Trust Company Secretary" means a person appointed to act independently of the Board of Directors to provide advice on corporate governance issues to the Board of Directors, Board of Governors and the Chair, and monitor the Trust’s compliance with the law, its terms of authorisation, binding guidance issued by Monitor, the Trust’s Standing Orders.”

And all references to the term Trust Secretary would be changed in the document.

5.2 Rationale / advantages

The professional body for Company Secretaries in the UK (ICSA) has an NHS FT Company Secretaries’ section, examination and textbook and recognises experience in an NHS FT role for associate membership accreditation.

The current post-holder is a qualified Company Secretary and is able to draw on this membership of ICSA to access governance materials and guidance which is beneficial. The title ‘Trust Secretary’ has no legal meaning. Many FTs use the term Company Secretary for this reason and as the Trust is an independent entity, able to form legally binding contracts, it is arguably more appropriate to use the correct professional title.





There may be some initial confusion or concern that the move represents a more commercial approach, although of course the Trust uses other professional terms such as accountant and solicitor.

6.0 Financial implications (including workforce effects)

6.1 There are no financial or workforce effects of these proposals

7.0 Quality implications

7.1 There are no implications for the quality of care provided by the Trust,.

8.0 Equality implications

8.1 There are no equality implications.

9.0 Recommendations

9.1 Governors are asked to consider each of the four proposals and decide whether or not to approve the amendment. Those approved will be presented to the Board of Directors’ meeting in October 2015 for approval.

Robert Nesbitt Trust Secretary Background Papers / Information None .




Planning & Performance Sub-Group Terms of Reference – amended 16th July 2015 by P&P group for BoG

approval on 1st October 2015 1.0 Role of Sub-Group

To contribute to holding the Non-Executive Directors collectively to account for the performance of the Board of Directors

To consider information on the performance of the Trust To provide a perspective on Trust performance to the full Board of Governors

in order to support the responsibilities of the Governors in terms of challenge and in reflection of the needs of the Governors’ constituencies

To be involved in the review and development of forward plans for the Trust and any significant changes to the Trust’s business plan

To consider and recommend how governors should be involved in service reviews and planning.

2.0 Composition / Attendance Chair and Vice-Chair to be reviewed annually The core membership is made up from each constituency:

• Public Governor – Norfolk

• Public Governor - Suffolk

• Partner Governor

• Staff Governor

• Service User Governor

• Carer Governor Open to any Governor At least two Non-Executive Directors will be in attendance at each meeting Other Trust staff by invitation

3.0 Quoracy One member (who should be the Chair or Vice-Chair of the sub-group) and

two other Governors from the core membership

4.0 Relationship with, and reporting to, the Board of Governors

Date: 1st October 2015 I Item: 15.52iii

Planning & Performance ToR V3 Approved at P&P 16Jul2015 For Approval at BoG 1Oct2015

Via the notes of meetings or written or verbal updates from the Chair / Vice

Chair No executive powers unless specifically mandated by the Board of Governors To make recommendations to the Board of Governors

5.0 Secretarial support To be provided by Trust Secretariat

6.0 Frequency of meetings To meet no less than four times per annum, but as necessary.

7.0 Review Terms of Reference Annually, next review due July 2015, unless otherwise required

Planning & Performance ToR V3 Approved at P&P 16Jul2015 For Approval at BoG 1Oct2015



Title of Report: 2016 Meeting Dates



Author: Lucy Want: Committee & Meetings Secretary

Director: Robert Nesbitt: Trust Secretary

1.0 Proposed meeting dates for 2016

BoG – 13:30-16:30 – all public meetings across NSFT 1st Thursday quarterly meetings – Jan, Apr, July, Oct (amended from Wednesdays to avoid clashes with Exec meetings) 2 x development sessions will be held – March, Sept – dates TBC Papers due midday on … Meeting date Venue / room booked Weds 30th December 2015 Thursday 7th January 2016 Norwich TBC TBC March – Development

Session

Weds 30th March 2016 Thursday 7th April 2016 Ipswich Weds 29th June 2016 Thursday 7th July 2016 Norwich TBC TBC September –

Development Session

Weds 28th September 2016 Thursday 6th October 2016 Ipswich

2.0 Recommendations

2.1 The Board is asked to approve the dates above.

Lucy Want Committee & Meetings Secretary Background Papers / Information None

Date: 1st October 2015 J Item: 15.52iv

BoG– 1st Oct 2015 – 2016 mtg dates

Version 0.1

Author: Lucy Want Department: Trust Secretariat

Page 1 of 1 Date produced: 22nd Sept 2015 Retention period: 30 years



Title of Report: PMO Programme - Progress Report


Estimated time:

Author: Abdul Parkar – Interim PMO Programme Manager

Director: Michael Scott (Chief Executive)

Executive Summary: This Progress Report highlights the progress made on the Quality and Cost Improvement Plans that are being managed by the PMO. Currently there are 24 QIP projects of which 14 are Green and 9 are on Amber status and 1 on Red Status. During the last month 2 new QIPs were added (Q0041, Q0042). One on developing Learning Disabilities and Autism Strategy and the other on Statutory and Mandatory Training. Four QIPs have been closed as completed. An overview is given in appendix 1. The key achievements during the month have been:

• Business Case for improving the physical environment at Norvic Clinic has been presented to the Finance Committee.

• Average monthly number of Restraints and Seclusions are reducing compared to last year.

• Workshops have been conducted on the implementation of the Service User and Carer Involvement Strategy – 124 people attended these workshops of which 49 (40%) were service users and carers

• We have seen significant improvements in checking of emergency equipment, drug storage and personal alarm availability in ward areas

• All in-patient areas now have their ligature audit action plans and estates are costing any works needed

A Trust and CCG level Quality Dashboard has been developed. A QIP level Dashboard has also been developed which will track the progress towards achieving the KPIs against each QIP. The next stage of development of these dashboards is to get them populated with the data. There are currently 20 active CIPs and 2 Cost reduction schemes – 6 Green (£878k), 8 Amber (£1819k) and 8 Red (£6614k).[Financial values are budgeted, forecast values are shown within appendix 2 CIP Tracker] At the end of August, the year to date achievement of the CIPs was £2.9M against a target

Date: 1st October 2015 K Item: 15.53i

Board of Governors 1st October 2015 PMO Programme Progress Report

Version 0.2

Author: Abdul Parkar / Stuart Clifton Department: PMO

Page 1 of 6 Date produced: 16 September 15 Retention period: 30 years

of £1.53M, an over achievement of £1.3M. A substantive Head of PMO has been appointed and has taken post from 14th September 2015.

1.0 Introduction

1.1 The Transformation Programme Board (TPB), meeting weekly, is devoting alternate weeks to assuring ‘delivery’ of the active programmes and reviewing ‘pipeline/development’ of new ideas for CIP and QIP.

1.2 The PMO is currently staffed with a Head of PMO, 3 Interim Project Managers, 1 Project Support Administrator, A Head of Quality and an Interim Quality Improvement Consultant.

1.3 A substantive Head of PMO has taken office from 14th September 2015.

1.4 The PMO is currently managing 24 QIP projects and 20 CIP and 2 Cost reduction Schemes.

2.0 Current Progress

2.1 QIP Plans:

2.1.1 There are 24 QIP Projects active. 14 are on Green status, on target to achieve their deliverables. 9 are on Amber status, slightly behind schedule to achieve their deliverables and 1 Red. [QO024 Physical Health Monitoring, which has been discussed in detail at TPB 9th September. Red status as a result ongoing problems with reporting on compliance and staff training and the potential loss of CQUIN monies. Mitigating action: collect manual data and awaiting executive decision on turning on the competencies module within staff pathways.

2.1.2 During the month, 4 QIPs were closed:

• QO002 Ligature Risks and QO003 Line of Sight: Risk assessments on Ligature Risks and Line of Sight have been completed and an action plan has been developed and discussed with Estates. Estates are in the process of developing an implementation plan with associated costs.

• QO005 Mixed Sex Accommodation: assessment completed and an action plan developed. This QIP is related to QO006 Poppy and Avocet for which funding has been approved and is awaiting planning permission before building works can commence.

• QO039 Multi-agency Suicide Prevention: this QIP was considered to be outside the control of the Trust and should be managed by the local Public Health authorities with input from the Trust.

2.1.3 During the month 2 new QIPs were approved by the Transformation Programme Board:


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• QO041 Learning Disability and Autism Strategy - this QIP will be implementing the nationally recommended Greenlight Toolkit

• QO042 Statutory and Mandatory Training – this QIP’s key aim is to improve the Trust’s take up of Statutory and Mandatory Training

2.1.4 QO17 Service User and Carer Involvement Strategy - Workshops were held in each locality to develop an implementation plan for the Service User and Carer Involvement strategy. 124 people attended the workshops of whom 49 were service users and carers (40%). The next stage is to analyse the outputs from the workshops and set up Project Groups to implement the Service User and Carer Involvement Strategy in each locality.

2.1.5 QO035 – Secure Services Improvement Plan - Designs and costing have been received from the Architects. The Executive Team have approved in principal £2. 8M for the works. A business case for the improvements to be made at Norvic Clinic has been presented to the Finance Committee. The next stage after getting the necessary approvals is to get planning permission before the works can commence.

2.1.6 QO013 24/7 Dementia Intensive Support Services- A draft working protocol has

been produced for the Dementia Intensive Support Team & Norfolk Swift Response to jointly provide a seamless 24/7 crisis service through a single referral process for people with dementia or complexity in later life. This is currently with key stakeholders awaiting feedback

2.1.9 QO036 – Community Care Service Development - The WAVES model for

personality disorder will commence in Norfolk on 12th October 2015. 2.1.10 QO024 – Physical healthcare Monitoring - Lead clinicians and NSFT pharmacy

leads are working with CCG pharmacy leads to develop shared care arrangements for prescribing and monitoring side effects of relevant drugs

2.2 CIP Schemes: 2.2.1 As can be seen from table 1, the CIP delivery for month 5 is ahead by £1.3m but is

mainly due to £1.9m of non-recurrent savings. It is worth noting that this table is monitoring the CIPs against a full year target of £6.6m as opposed to £8.5m. However, the recurrent saving is making a smaller impact on the variance and is an indication of the vulnerability of the delivery of the CIP delivery over the rest of the financial year.


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Table 1 – 2015/16 CIP Schemes Year to Date Delivery

2.2.2 Table 2, shows that as at the end of month 5, £4.8m has been removed from the

budgets thus guaranteeing delivery of that amount in 2015/16. The future months show the planned amounts that will be removed to achieve the £8.5m identified. It can be seen that the savings are skewed into the latter months which increases the risk of non-delivery. Please note that the £1m contingency is not factored into the figures shown.


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Table 2 – 2015/16 CIP Progress

2.2.3 CIP032 –Enhanced Specialist Placements- Norfolk and Waveney patients in

external placements are now being reviewed with a view to ending the placements, moving them to more suitable placements or bringing those patients back to our care

2.2.4 CIP027 Shorter Handover periods-The consultation period for shorter handover

periods in Norfolk wards is about to commence with an anticipated start date on 9th November

2.3 The QIP and CIP Exception Reports presented to the Transformation Programme Board on 9th September 2015 are attached at Appendix 1. The overall QIP and CIP Delivery Trackers are attached at Appendix 2.


3.1 The PMO Risk Log, reviewed at the Transformation Programme Board on 9th September is attached at Appendix 3.

3.2 The main risks are:

• 2015/16 CIPs are not delivered in order to meet the £8.9m target.

• The savings in the outer years which are dependent on transformational change do not happen in a timely manner to achieve financial sustainability.

• Two new risks added:

o Risk 33,Mitigating actions needs to be agreed with executive team

o Risk 34, Mitigation agreed within the PMO.

Progress Report: CIP Schemes

CIP Target £11m

CIP Identified to Date £8.534m

Unidentified £2.466m

Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total Risk TotalScheme Number Scheme Name £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

CIP Schemes Banked 4,816.2 4,816.2 4,816.2

0.0 61.6 115.4 115.4 169.3 115.4 115.4 169.3 861.9 861.9

0.0 100.6 404.8 404.8 404.8 404.8 404.8 404.6 2,529.3 2,529.3

0.0 6.3 53.4 53.4 53.4 53.4 53.4 53.4 326.8 326.8

Total 4,816.2 168.5 573.7 573.7 627.5 573.7 573.7 627.3 8,534.1 8,534.1

CIP Schemes Already Banked as at 31 August 2015CIP 005, 008, 009, 011, 013, 015, 016, 018a, 018, 019, 024, 026, 027, 029, 030, 038, IG002These are schemes where the budgets have already been removed before 31 July 2015 even if the savings are profiled to be delivered over the year due to the phasing of the budgets.

Medium Risk Schemes

High Risk Schemes

See List Below

Low risk schemes but not yet banked


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4.0 Recommendations

4.1 The Board is asked to note this report.

Michael Scott - Chief Executive


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APPENDIX 1

TO BE COMPLETED BY THE PROJECT LEAD FOR EACH PROJECT THAT IS RAG RATED RED & AMBER BY THE PMO, AND PRESENTED BY THE EXECUTIVE SPONSOR AT THE TRANSFORMATION PROGRAMME BOARD

Project @ Risk 04/09/2015Red

Project Name / NumberCIP015 Corporate Savings Commercial Director

Project Lead & Executive SponsorJane Parris / Leigh Howlett

Where slipped?

End of consultation

Why slipped?

Exec Sponsor on annual leave - CIP015 not handed over to new PMO Manager. Actions to fix?

Time to green

No meetings between PMO and the Project Lead have been possible to date. Workbook not updated. The following Milestones scheduled for completion in March are now missed:

Feedback from the Project Lead urgently required - will liaise with Exec Sponsor and project lead w/c 7/9/15

18/09/2015

Organise staff 1-2-1's

Receive expressions of interests and work through logistics

Review of financial impact of changes following consultation

Formal sign off by execs

Selection process - top down process

Confirm people in post

updated



Project Number and NameCR001- Nursing Agency and Temp spendFY15/16 Target:

YTD: Project Lead and Executive Sponsor

Sue Miller/ Alison Armstrong

Where slipped?

Where slipped?

PID requires development - this is underway. Financial input required to identity cost improvement. KPI clarification required.

Actions to fix?

Time to green

Data collation and analysis completed however delayed. PID received requiring further development.

* Finalisation of the CIP workbook (including PID) - Financial input underway to identify cost improvement* Make contact with Trust lead for recruitment and retention project – Sarah Ball. Understand work already in progress and incorporate into overall action plan* Evaluation of current approach to ‘specialling’ on the wards. Identification of opportunities for new ways of working to reduce demand. Set up meeting with PICU consultant to discuss.* Norfolk locality manager workshop to agree action plan for Norfolk teams with high demand* Arrange meeting with Abbeygate team to explore their high demand and develop action plan to reduce

31-Oct-15

updated



Project Number and NameCR002- Medical Locum and Agency spendFY 15/16 Target: £600KYTD: zero

Project Lead and Executive SponsorJune Johnson/ Bodhan Solomka

Where slipped?

Why slipped?

Actions to fix?

Time to green

Gathering information on the areas of high cost locums and also on difficult to fill positions has taken longer than expected. This information is required in order to develop an action plan on the timescales and the areas to be targetted to reduce the Medical Locum and Agency costs.

Data has been collected and is currently being analysed. Once the analysis has been completed, will enable the PID and Workbook to be completed. Expected to be green by end of August

31-Dec-15

The following actions are being planned to rduce locum spend:1. To query whether on-calls can be covered elsewhere or by internal staff. We may not be able to stop all locums undertaking on-calls but can hopefully reduce the number. - feedback to the project group on 4th September2. June to send Business accounts the names of locums appointed, the start and end dates and the rate. - by 28th Aug.3. Jo to revise the forecasted figures and circulate together with the current forecasts to be able to compare if there is any difference. Monthly forecasts to be sent to June. 4. . June to investigate if this is in the SLA agreement. - feedback by 4th September5. To reduce number of junior doctors positions - Suffolk have already converted 2 medical posts - June to look into this - initial proposals on 4th September.6. There are potential saving in Kings Lynn if we can recruit to the substantive posts using an R&R incentive.. potential savings of £300K p.a. This is a long term solution which June is working on - Plan by 31 Dec. 2015..

updated

TO BE COMPLETED BY THE PROJECT LEAD FOR EACH PROJECT THAT IS RAG RATED RED & AMBER BY THE PMO, AND PRESENTED BY THE EXECUTIVE SPONSOR AT THE TRANSFORMATION PROGRAMME BOARDProject @ Risk 07/09/2015

Amber CIP006 – GY&W after CCG consultation implementationFY15/16 Target: £450k (£225k in Q3 & £225k in Q4)YTD: Nil - however looking at being £77k short of £450 because of reasons listed belowProject Lead & Executive SponsorGill Morshead, Debbie WhiteWhere slipped?

Why slipped?

Actions to fix?

Time to green

The saving for Q3 was expected to be £225k. A potentital 2 week delay in building works will cost around £37k (confirmed by Mark

Building works have been delayed. The initial staffing complement will have some Band 6 staff in Band 5 roles as the Directorate decided to avoid redundancy and down-banding.

The Clinical Team Leader and Consultant Psychiatrist are reviewing the expected discharge dates for the remaining 9 patients at Waveney acute services. The possibility of closing all beds at the end of September is being considered. This would have benefits in reducing temporary staffing spend as well as achieving the allocated CIP for October. The consequence to the overall Trust of having 5 fewer beds overall for 2 weeks is being evaluated also. A further update on this decision will be reported on 10th September. Forecast overspend on staff will improve with natural turnover of staff.

Overspend on staff will improve with staff turnover. Awaiting update on 10th September regarding 5 fewer beds


Project @ Risk 29/09/2015Amber

Project Number and NameCIP 012 - Corporate Savings Medical and PharmacyFY 15/16 Target: £393KYTD ( August 2015) : £36K

Project Lead and Executive Sponsor

Esther Johnston / Bodhan SolomkaWhere slipped?

Why slipped?

Actions to fix?

Time to green

various schemes have been proposed which have not been approved or agreed by the Exec Team. These include stopping out of hours Pharamcy call-out, centralising the Pharmacies, bring dispensing in-house.

The Chief Pharmacist is looking at a number of ways in which costs could be reduced - stopping prescribing cod liver oil to new patients and review use for existing patients. Look at supplying starter packs which are much cheaper. These need to be approved by the Drugs and Therapeutic Committee on 17th September and the Medicines Advisory Committee on 13th October. Potential savings in the region of £40 - 100K p.a.A meeting between the Chief Phamacist, Finance and PMO has been scheduled for 8th September to discuss ways in which to achieve the savings target.PMO to present Pharmacy savings proposal a thte next TPB.

31-Oct-15

The Schemes have not been fully explored and costed. Some of the scheme require discussiosn with CCGs such as stopping the supply of physical health drugs once the pateint has left NSFT care, getting clinicans on board to prescribe cheaper alternatives and to stop precribing drugs with no clinical value.



Project Number and NameCIP023 - Corporate Savings - Management costsFY 15/16 Target: YTD: Project Lead & Executive SponsorLeigh Howlett

Where slipped?

Why slipped?The Benchmarking report has been received but there is a significant lack of detail nor any methodology as to what is included in each category.Actions to fix?

Time to green

This project is based on the comparison of NSFT figures with other Trusts and is awaiting the MH Benchmarking Club data before identifying specific areas of potential savings. Milestones that had been predicted had slipped but, without the data required, could not be revised or completed at this stage.

Benchmarking report received - review of content required - meetings being arranged to address and progress.

18/09/2015

updated


Project @ Risk 07/09/2015Project Number and Name AmberCIP032 – Enhanced specialist placementsFY15/16 Target: £325kYTD: -49k at end of month 4

Project Lead & Executive SponsorDebbie White, Micki Munro

Where slipped?

Why slipped?Staff sicknessActions to fix?

Time to green

This project is intended to ensure that there is an effective process in place by the Trust for agreeing/reviewing/ending an external placement for service users. We have identified two experienced Practitioners to review current placements. Both of these staff members are now on sick leave delaying the reviews. However, the £23k overspend in month 1, and £31k overspend in month 2 have been followed by £3.5k in month 3 and £1.5K in Month 4, thereby reducing the increasing trend of overspend. The Project Lead has now identified a replacement lead to review the out-placed patients. Month 5 figures due this week

Continuation of work to review the outplaced patients prioritised by cost

09/10/2015 (Monthly updates on situation available at of first week of following month)


Amber CIP037 – Shorter handover periods FY15/16 Target: £826kYTD: NilProject Lead & Executive SponsorDebbie White, Veno SunghutteeWhere slipped?

Why slipped?

Actions to fix?

Time to green

PMO asked for a review of CIP figure - calculations came back significantly lower than the target of £826K.

Two parallel workstreams have been identified;-1) To achieve the 220k saving, the staff consultation process has been commenced regarding the implementation process for the shorter handover period. Dependent on the outcome of the consultation, the new shift systems to achieve the shorter handover period will be implemented from 9th November 2015.2) Work is now in progress to review current team establishments and/or skill mix. This is awaiting executive decision, and will allow for the calculation of associated savings.

27-Nov

Potential savings from the introduction of the shorter handover period within current staffing establishments will be the region of £220k. This leaves a gap in savings from the full potential saving initially identified with the PID (£826k). Closure of the savings gap is dependent upon a review of team establishments and/or skill mix. The skill mix/establishment model to achieve the savings has not yet been agreed.


Project @ Risk 04/09/2015Green

CIP004 - ProcurementFY15/16 Target: 74.0YTD: 55.1

Project Lead & Executive SponsorDonna-Marie Newman, John Doyle

Where slipped?

Why slipped?

Actions to fix?

Time to green

Savings behind plan - 75% level of purchasing through procurment is not being met by localities

Travel policy (hotel bookings) is going to September TPM so slightly behind plan. Anticipated that this will be rolled out for 1 October. Room hire policy - still working on this as part of 75% total. List of places is with Procurement team - trying to challenge some bookings but many go outside of procurement process. Policy go-ahead will bring scheme on target.

01-Nov

Principal example is bookings for hotels and meeting rooms being placed by localities directly rather than through procurement office, leading to higher prices being paid.

APPENDIX 1



QO013 – 24/7 Dementia Intensive Support Services

Project Lead & Executive SponsorMarcus Haywardm, Debbie White Where slipped?

Why slipped?

Actions to fix?

Time to green

The aim of this project is to produce a working protocol for DIST & NRS to provide a seamless 24/7 crisis reponse through a single referral process. We are anticipating an overall 2 week delay with completion date.

There was a delay in producing draft guidance as the project lead was awaiting a workshop to take place to help inform said guidance

Draft guidance has now been produced and Project lead is awaiting feedback from stakeholders (Project lead returned from leave on 1st September)

The project close date is currently 07/09 - it is now anticipated to close on 21/09

updated


Project @ Risk 04/09/2015

Project Number and Name AmberQO016 - Community Caseload Management

Project Lead & Executive SponsorDebbie White, Veno Sunghuttee

Where slipped?

Why slipped?

Actions to fix?

Time to green

Milestones need to be reviewed in light of paper by Del Mitchell (review of caseload management). Had initial meeting to discuss 03/08 and waiting on RTT information. Transition to Lorenzo system, and the new data warehousing process, have required temporary suspension of current Abacus system. It is expected that more detailed real-time information will be available by mid-October

Norfolk uses allocated/unallocated data while Suffolk uses a waiting list approach. Norfolk is going to move to a waiting list approach based on the above mentioned paper. PID currently with project group

Met on 2nd September to discuss new milestones to reflect change to 56 day RTT rather than allocated/unallocated - currently updating workbook.

15th October, to be in line with Abacus system being able to reflect caseloads in real time.

updated



Project Number and NameQO017 - Service User Carer StrategyProject Lead & Executive SponsorLyn Skipper / Jane SayerWhere slipped?

Why slipped?New approach takes longer to organise; requires engagement and event planning with key stakeholders. Actions to fix?

Time to green

Change of consultation approach; decision made to run locality based workshops instead of meeting with project team members on a 1:1 basis.

• 5 Locality Workshops held with representation of Staff, Service lines, Service users/Carers partners - 124 attendees of which 49 were service users and carers.• Outputs of the workshops are being analysed and will be fedback to the workshops participants by the end of September 2015. • Recruitment to band 6 post successful, awaiting HR checks. Admin in place.• One Listening event has been held in North Norfolk and another one planned for South Norfolk to increase Service User/ carer particaption in the implementation of the Service User and Carer Strategy• The next steps are to set up Working Groups and develop deliverables and milestones for each working Group by the end of October 2015.

30/09/2015



Project Number and Name AmberQO030 – Additional Capacity at Carlton Court

Project Lead and Executive SponsorDebbie White, Andy GoffWhere slipped?

Why slipped?

Actions to fix?

Time to green

Project has been on track for contractors to be on site 05/10. Option was costed and agreed by Board at end of May. Now told that 2 new options are being drawn up to be discussed at start of September (this meeting has not yet happened) . This will inevitably delay start of building works.

To decide upon agreed option as quickly as possible (meeting early September but no date fixed yet) and revise milestones with AG. AG to update after 1-1 with DW on 04/09

25th September

Original plan had option signed off by Board in May - this is now being reconsidered

updated



Project Number and Name AmberQO024 – Physical Health care forms & Monitoring

Project Lead & Executive SponsorBohdan Solomka, Sara Fletcher

Where slipped?

Why slipped?

Actions to fix?

Time to green

All milestones on track – however, confirmation that patients are receiving checks is not yet recorded on Lorenzo. Assurance was given at recent steering group that the form would be on Lorenzo by 7th August got delayed to late August - this is now indefinitley delayed as of 25th August. Additionally it is proving difficult to report on numbers of staff trained as this is not at present a mandatory training item.

Recording of the physical health form on Lorenzo is now indefinitley delayed. Unable to report definitively on numbers of staff trained as this is not a mandatory training item

Jane Sayer has directed the training department to make Physiological workbook training mandatory (this may decrease compliance with Mandatory training KPI). Stat/Man training PID approved by TPB on 26th August. Paper audits are recording compliance with physical health checks - to be completed montly from September by Matrons/Audit department

2nd October

no update



Project Number and Name AmberQO031 – Review of Inpatient bed requirement

Project Lead & Executive SponsorDebbie White, Veno Sunghuttee

Where slipped?

Why slipped?

Actions to fix?

Time to green

Project mirrors CIP003 (curtail demand to services) – was awaiting progress report on CIP003 before deciding on merging 2 projects.

Micki Munro working on PID to re-launch and organising meeting with Ops Directors, contracts, finance and PMO. Waiting for all to get back to her

18 September 2015

Delay in decision on how to proceed with CIP003. Decision made to relaunch and look for alternative saving schemes. Counties discussing their joint work to date on Patient Flow, and Operations Directors will discuss additional steps that can be taken.

no update


AmberProject Name and NumberQO034 - Provision of S136 Suites

Project Lead and Executive SponsorVeno Sunghuttee / Debbie White

Where slipped?

Why slipped?Awaiting UEA interim report

Actions to fix?

Time to green

There is an academic evaluation of the use of our S136 suites that was expected to produce an interim report by now with the full report due in November. We are waiting on this report (and have asked Terri Cooper-Barnes for copy) but this delays us being able to calculate the potential demand on S136 suites in the future. Also potential issues with S136 suites being used for S135 clients.

Chasing report from TCB

Awaiting update on report

no update


Project @ Risk 29/09/2015Project Name and Number GreenQO005 - Mixed Sex Accommodation

Project Lead and Executive SponsorNeil Paull / Jane Sayer

Where slipped?

Why slipped?Submission of Planning Application

Actions to fix?

Time to green

The assessments have been completed. Estates have not submitted a planning application and this may lead to a delay in the completion of works. the Trust had 4 events last year and therefore 1 event would make the Trust non-compliant with 100% target. The works are planned to be completed by September 2015

Planning permission has been submitted and approval is expected by the end of September.Once approval has been received then the tender for works can be released and works started.Other areas of non-complianace have been identified for which a PID is being developed.

31 October 2015

closed


Project @ Risk 29/09/2015Green

Project Name and NumberQO035 - Secure Services Improvement Plan

Project Lead and Executive SponsorIan Young / Debbie WhiteWhere slipped?

Why slipped?The design of the options produced by the architects have been deemed not feasible during staff consultations. New designs have been received which statisfy all stakeholders.Actions to fix?

Time to green

Staff consultations of the options have shown that none of the options will meet the requirements for seclusion room sizes. The architects have been asked to produce other options in consultation with the staff. This is likely to delay the project. The presentation of the options to the Executive Team has been postponed by 2-3 weeks, depending on when the new options are ready.

Designs and costings have been received from the Architects. The Execs have approved the costings in principal - £2.8M. Business case is scheduled to be presented to the Finance Committee for approval on 15th September. Following this the Business Case will be to be approved by the Trust Board before planning permission documentation can be submitted.Work is ongoing on the development of the Clinical Strategy - due to be completed by 31 Dec 2015. and the Culture of Care Barometer which is expected to be piloted by end of Sept 2015. Equality and Diveristy strategy is in place and is being rolled out in all secure Services. Training is currently taking place.Actions to reduce restrictive interventions have been implemented with beteer recording of seclusion data and

30-Sep-15

APPENDIX 2Date updated 29/09/2015

CIP Delivery TrackerMilestones Finance KPI Risks RAG Explanation

CIP001 Estates Rationalisation Capturing the revenue savings from the implementation of the 5 year estates strategy.

Leigh Howlett, Director of Strategy and Resources

Mark Kittle 470 125 Amber Green Red Green Green Karen Rix's team has been moved from the Octagon to Magpie Lodge. It is hoped that this will create sufficient space for the staff from Meadowland to re-locate.

CIP003 Curtail demand to services

Undertaking a review of all services across NSFT, to understand demand for and income from each service

Alison Armstrong, Director of Operations (Suffolk)

Alison Armstrong 250 75 Amber 0 Red 0 0 Suffolk has identified £75K potential. No PID has been submitted yet.Alison to share the learnings of Suffolk with Debbie. Debbie to review and see if the Suffolk model can be applied to Norfolk. Alison to email Abdul with outcome of discussions with Debbie.

CIP004 Procurement Improving volume of orders through the e-procure system, to ensure best value is achieved.

Andrew Hopkins, Director of Finance

Donna Newman 200 200 Amber Green Green Green Amber The volume of financial analysis required is too high to be performed monthly. Savings behind plan - 75% level of purchasing through procurement is not being met by localities. £68.1k ytd - on track for target. Travel policy in for review which may see further increase.

CIP005 Lorenzo - Patient Administration System

The implementation of Lorenzo as an electronic patient record system across all NSFT secondary mental health services


Dave Huggins 70 220 Green Green Green Green Green Completed roll-out. Clinical Portal is not a dependency

CIP006 GY&W after CCG consultation

Reduction in adult acute beds in GY&W following public consultation in 2014

Debbie White, Director of Operations (Norfolk & Waveney)

Gill Aspinall 450 425 Amber Amber Amber Green Green All milestones on track (linked to QO33) – possibility of delay which would endanger the 225k for Q3 – delay will cost approx. £37k. GM to get update on potential delays from MK. Also the staff costs are approx. £40k over budget where staff have been slotted in. It is anticipated that turnover of staff will reduce this overspend.

CIP007 Extension of Non-Medical Staff review

Review of difficult to recruit to medical posts, to identify areas in which non-medical responsible can be utilised to reduce staffing costs.

Bohdan Solomka, Medical Director

Bohdan Solomka 100 25 Amber Green Red Green Green ANP Job descriptions have been sent to HR for Banding. Once banding has been completed then job adverts can be released. Loooking at placing a ANP in Waveney Ward. Bodham to speak to the Consultant on faciltating this. Abdul to speak to Micki Munro on which position to fill with ANP. Another one would be in West Norfolk. Bohdan to speak to June Johson on this. Abdul to speak to Alison/Sue on Nurse Consultant posts in Suffolk. Debbie and Alison to be invited to the next project group meeting.

CIP008 Domestic Service Tender

Outsourcing of Norfolk & Suffolk domestic services.


Jane Parris 200 220 Green Green Green Green Green QIA now signed off - Project Complete

CIP009 Corporate Savings: Service Governance & Training

Restructure of service governance and training department

Jane Sayer, Director of Nursing, Quality and Patient Safety

Dawn Collins 58 16 Amber Green Amber Green Green YTD to August £6K achieved against an annual target of £58K

CIP010 Corporate Savings: Service Governance & Training

Identification of non-recurrent savings Jane Sayer, Director of Nursing, Quality and Patient Safety

Dawn Collins 291 225 Amber Green Amber Green Green YTD to August £137K achieved against an annual target of £291K

CIP011 Corporate Savings: Medical Director & Pharmacy

Restructure of pharmacy department Bohdan Solomka, Medical Director

Esther Johnston 106 106 Green Green Green Green Green Complete

CIP012 Corporate Savings: Medical Director & Pharmacy

Identification of non-recurrent savings Bohdan Solomka, Medical Director

Esther Johnston 331 150 Red Red Red Red Amber Data from Refine can provide information that can track the savings. Chief Pharmacist is looking at finding more savings.The Chief Pharmacist is looking at a number of ways in which costs could be reduced - stopping prescribing cod liver oil to new patients and review use for existing patients. Look at supplying starter packs which are much cheaper. These need to be approved by the Drugs and Therapeutic Committee on 17th September and the Medicines Advisory Committee on 13th October. Potential savings in the region of £40 - 100K p.a.

CIP013 Corporate Savings: Chief Executive

Reduction in chaplaincy posts, CNST savings and exec costs

Robert Nesbitt, Trust Secretary

Robert Nesbitt 232 232 Green Green Green Green Green A meeting between the Chief Phamacist, Finance and PMO has been scheduled for 8th September to discuss ways in which to achieve the savings target.

CIP014 Corporate Savings: Chief Executive

Identification of non-recurrent savings Robert Nesbitt, Trust Secretary

Robert Nesbitt 131 120 Green Amber Amber Amber Amber PMO to present Pharmacy savings proposal a thte next TPB.

CIP015 Corporate Savings: Commercial Directorate

Restructure of commercial management and comms team


Jane Parris 680 680 Red Red Red Red Green This project may well be on track but no meetings between PMO and Project Lead have been possible. PMO documentation shows slippage. Picked up by PMO (PT) 04/09/15

CIP016 Corporate Savings: Estates Maintenance

Restructure of estates and facilities management team and facilities team


Mark Kittle 325 325 Green Green Green Green Green Completed - money received

CIP017 Corporate Savings: Estates Maintenance

Identification of non-recurrent savings Leigh Howlett, Director of Strategy and Resources

Mark Kittle 402 200 Green Green Green Green GreenProject on track - Milestones updated and risks updated.

CIP018a

Corporate Savings: Finance

Restructure of finance team Andrew Hopkins, Director of Finance

Kathy Walsh 85 218 Green Green Green Green Green On track & delivering

CIP018b

Corporate Savings: Finance Commercial Development

Identification of non-recurrent savings Andrew Hopkins, Director of Finance

Oli Matthews 125 110 Green Green Amber Green Green On track & delivering

CIP019 Corporate Savings: HR Restructure of HR team Leigh Howlett, Director of Strategy and Resources

Sarah Ball 169 169 Green Green Green Green Green Finance information updated - on track

CIP020 Corporate Savings: HR Identification of non-recurrent savings Leigh Howlett, Director of Strategy and Resources

Sarah Ball 28 28 Green Green Green Green Green On track & delivering

CIP021 Corporate Savings: ICT Identification of non-recurrent savings Leigh Howlett, Director of Strategy and Resources

Darren Adams - - Red Red Red Red Red TPB on 8th July agreed to take this off the CIP. Leigh Howlett to discuss with Cynthia Conquest on alternative savings

CIP022 Corporate Savings: ICT Mobile

Restructure of ICT department Leigh Howlett, Director of Strategy and Resources

Jane Parris 100 78 Green Green Amber Green Green Complete but money will be coming out in monthly increments and monitored by Finance

CIP023 Corporate Savings: Management Costs

Identification of further management cost savings


Leigh Howlett (Director of Strategy & Resources)

783 - Red Amber Red Amber Amber Benchmarking report has been received but is lacking in detail. Awaiting feedback from finance on Benchmarking Club ratification. Service Managers meeting scheduled for 21/07 to discuss potential CIP schemes. Benchmarking data received - team meeting to be arranged to address and progress.

Project ID

Executive SponsorProject Name Project Lead Overall RAGProject Description Forecast Budgeted CIP £

Milestones Finance KPI Risks RAG ExplanationProject ID

Executive SponsorProject Name Project Lead Overall RAGProject Description Forecast Budgeted CIP £

CIP024 Corporate Savings: Direct Clinical Services Senior Operational Team (SOT) savings

Restructure of senior operational team Debbie White, Director of Operations (Norfolk & Waveney)

Debbie White 133 133 Green Green Green Green Green £126 savings identified. The balance of £7k to be found non-recurrently in 2015/16 – will be found by end of June (assured by accountant)

CIP026 Norfolk Central UEA Post

Removal of vacant band 9 post Debbie White, Director of Operations (Norfolk & Waveney)

Micki Munro 110 110 Green Green Green Green Green complete - confirmed by Micki Munro - Financial tracking only required

CIP027 Norfolk Central Older People Acute

Review of users in external private placements Debbie White, Director of Operations (Norfolk & Waveney)

Micki Munro 40 40 Green Green Green Green Green The workbook for CIP032 details the milestones for review of these patients.CIP lead (CC) confident thatt this is now delivered

CIP029 GY&W Band 8a post Removal of Band 8a post in GY&W Debbie White, Director of Operations (Norfolk & Waveney)

Gill Aspinall 50 50 Green Green Green Green Green Complete - confirmed by Gill Morshead - Financial tracking only required

CIP030 GY&W Band 8b post Removal of Band 8b post in GY&W Debbie White, Director of Operations (Norfolk & Waveney)

Gill Aspinall 70 70 Green Green Green Green Green Complete - confirmed by Micki Munro - Financial tracking only required

CIP031 GY&W Staff grade post Removal of 0.5 WTE post Debbie White, Director of Operations (Norfolk & Waveney)

Gill Aspinall - - Amber Amber Amber Amber Amber Lead met with Dr Abuya on 10/06 and discussed removal of a different post from the original PID (with a similar saving). This is an LD post and the project lead is in discussions with the CCG

CIP032 External Specialist Placements (Norfolk)

Review of all external specialist placements to consider what level is most appropriate and if any cost savings can be achieved.


Micki Munro 100 - Red Amber Red Green Amber Reviews have been delayed because of staff sickness with 2 members of staff. 23k overspend in month 1, 31k overspend in month 2, 3.5k underspend in month 3 and 1.5k underspend in month 4.

CIP033 External Specialist Placements (Suffolk)

0 Alison Armstrong, Director of Operations (Suffolk)

Paula Clarke - - 0 0 0 0 0 0

CIP034 E-Rostering & Recruitment

Implementation of e-rostering system Leigh Howlett, Director of Strategy and Resources

Denise Zandbergen - - Green Green Green Green Green To be combined with Temp Staffing as an enabler. Original savings target £420K - now transferred to CIP43

CIP035 Photocopying & printing wastage

Reduction in the usage of photocopying and printing, resulting in a subsequent cost saving.


Jane Parris 100 15 Red Green Red Green Amber YTD August is £5K against a annual target of £48K

CIP037 Shorter Handover Periods & Use of Band 2s

Review of handover periods, and implementation of standardisation, that will result in a cost saving from staff costs.


Veno Sunghuttee 900 450 Red Amber Red Green Amber Various shift options were presented to the executive team. The scheme was originally costed as per ‘option 6’. The shift pattern described in the workbook (which was also reported to TPM) does not match these costings . Had meeting on 12/08 and decided to implement shorter handover periods from 12/10 (possibly earlier in some areas) and also review skill mix. National safe staffing guidance is poor. Next meeting 24/08

CIP038 West Norfolk Band 8a Removal of Band 8a post in West Norfolk Debbie White, Marcus Hayward 77 77 Green Green Green Green Green Complete - confirmed by Marcus Hayward - CR001 Non-recurrent pay

savings (Add line for each locality)

Reduction in the use of nursing agency and temp staffing

0 0 3,120 - Red Red Red Red Red Target savings includes transfer of £420K from CIP034 on e-rostering. PID is under development - expected w/c 1/9/15. Data has been collected and analysed for both counties. Once data analysis has been completed then the PID and Workbook will be completed.

CR002 Medical Locum and Agency Spend

Reduction in Medical Locum spend Bohdan Solomka, Medical Director


600 100 Red Red Red Red Red The following actions are being planned to rduce locum spend:1. To query whether on-calls can be covered elsewhere or by internal staff. We may not be able to stop all locums undertaking on-calls but can hopefully reduce the number. - feedback to the project group on 4th September2. June to send Business accounts the names of locums appointed, the start and end dates and the rate. - by 28th Aug.3. Jo to revise the forecasted figures and circulate together with the current forecasts to be able to compare if there is any difference. Monthly forecasts to be sent to June. 4. . June to investigate if this is in the SLA agreement. - feedback by 4th September5. To reduce number of junior doctors positions - Suffolk have already converted 2 medical posts - June to look into this - initial proposals on 4th September.6. There are potential saving in Kings Lynn if we can recruit to the substantive posts using an R&R incentive.. potential savings of £300K p.a. This is a long term solution which June is working on - Plan by 31 Dec. 2015.7. Look at the feasibility of using part-time locums instead of full time. and Also on doubling up of

CIP044 Outsourcing supply of drugs to community team

To outsource the delivery of medicines to the community teams via Polarspeed


Esther Johnston 120 120 Green Green Green Green Green This is now a Cost Reduction scheme. YTD August cost avoidance of £35K

CIP045 Norfolk Central 8c 0 Debbie White, Director of Operations (Norfolk & Waveney)

Micki Munro 72 72 Green Green Green Green Green 0

11,078 5,184

Red 6,614 1,395Amber 1,819 1,091Green 2,645 2,698

Check Check

APPENDIX 2

QIP Delivery Tracker Date updated 29/09/2015

Milestones Finance KPI Risks RAG Explanation

QO001 Safer Ward Environments Identification and removal of Ligature Risks, Environmental quality including fixtures and fittings, decor and furnishings, availability of Personal Alarms to staff and all who need them, Medical Equipment is in a state of readiness for emergencies, Drug administration policy is fully compliant.


Veno Sunghuttee Green Green Green Green Amber 5 key elements (ligatures, environment, personal alarms, emergency equipment, drug storage) all milestones on track. Was Amber because July spot audits highlighting some problems with; signing personal alarms in and out, drug storage (unlocked fridges), checking of emergency equipment. Early re-audits in August are looking more promising. Awaiting assurance that quarterly estates meetings have been set up (if not assuarnce rceived by 18/09/15 status will go amber)

QO002 Ligature Audit Action Plan To reduce ligatures in the ward environment. In line with Safe Environment, identified ligatures should be removed or mitigated.


Neil Paull Amber Amber Green Green Green Assessments have been sent to CTLs and Matrons. Meeting with Estates has taken place. Estates to develop an Action Plan and timescales for the completion of the works. Awaiting Action Plan from Estates

QO003 Line of sight Action Plan To reduce risks where there are poor lines of sight. To have a robust ligature policy for which the Trust has a measurable way of demonstrating its ongoing application in a systematic and defendable way.


Neil Paull Amber Amber Green Green Green Assessments have been sent to CTLs and Matrons. Meeting with Estates has taken place. Estates to develop an Action Plan and timescales for the completion of the works. Awaiting Action Plan from Estates

QO004 Norvic Clinic Reconfiguration of Drayton & Thorpe wards to address the concerns raised in the CQC report.


Mark Kittle Green Green Green Green red 4 options drawn up - selected option costs have been provided - Debbie White to take to Trust - awaiting a decision. To merge with Q035

QO005 Mixed Sex Accommodation

To reduce the number of mixed sex accommodation areas across the Trust


Neil Paull Green Green Green Green Green JS and LH have agreed to close as all original areas addressed. New project PID in development, to be reviewed 16/09/15

QO006 Poppy and Avocet Female Only Plan

Addressing concerns that there are no quiet facilities at Woodlands on Poppy and Avocet Wards for female patients.


Mark Kittle Green green Green Green red MIlestones now realistic - all on track. Needs senior operational input to progress upcoming milestones. Planning application has been submitted.

QO007 Seclusion Facilities To address areas of particular concern, lack of CCTV outside seclusion rooms, not all seclusion suites have en-suite facilities and there were also instances where male and female service users shared an area.


Mark Kittle Amber Amber Green Green Amber On track at presentDependency: Service Managers to feed back to Mark on requirements. Milestone slippage - Plans have been developed, agreement with service managers taking longer than expected. Slipped from end 08/15 to end 09/15.

QO008 Seclusion data and governance review

Review of the data and governance review around Seclusion


Sue Barratt Green Green Green Green Green This is now merged with QO010

QO010 Reducing restrictive interventions

To reduce the number of restrictive interventions that occur across the Trust


Michele Allott Green Green Green Green Green YTD ( August)Average monthly seclusions are 49 which are well below the same period last year.., which were 61.YTD (August) Average number of occasions when restraints were used were 201 against a baseline of 219 for last year.YTD ( August) average monthly prone restraints are 57 against a baseline of 76 for last year.

QO012 Community Care - Policy Compliance

To ensure that there are robust policies and procedures that keep staff and patients safe in the community, with particular regard to management of community based appointments.


Gary Hazelden Amber Green Green Amber Green Responses now received from Suffolk – all milestones on track. Original KPIs were monthly with an expectation that Lorenzo could report on DNAs, cancelled appointments and crisis plans. KPIs have been reviewed. PMO comment - amber - as DNA audit for August '15 only showed 64% compliance. Audit report distributed to relevent leads for action.

QO013 24/7 Dementia Intensive Support Services

To establish 24/7 crisis / emergency response provision for people with dementia or complexity in later life (DCLL) which includes frail elderly with co-morbid mental illness.


Marcus Hayward (DIST)Andy Goff (CAMHS)

Amber Green Green Amber Green Draft guidance now done and circulated 13/08). All milestones are on track. Amber as expecting a 2 week delay with producing the final guidance because of the delay in send out the draft. KPI's not yet proposed because of missed milestone in July '15.

QO014 Safety Incidents - Learning Lessons

The Trust will strengthen the current systems to provide feedback and learning from incidents and complaints by implementing an improved system of cascading and embedding learning.


Michele Allott Green Green Green Green Amber KPIs have been developed.1. Reduction in the re-occurrence of themes – this can be collected via RCAs completed2. Lessons learned discussed at Quality Governance and Clinical Team meetings – data to be collected via meeting agendas.3. Lessons Learned posters displayed in a clinical areas - data to be collected via QIVs and spot audits.

QO015 Locality Governance Embed and monitor delivery of quality standards within locality based governance arrangements to achieve parity across the organisation.


Sue Barrett Green Green Green Green Green Probably need to review the whole thing as there is a good deal of overlap with QO10 and QO14. In the meantime I have feedback from 7/9 localities that they are using the template=77% - PMO comment - need to clarify whether current compliance 7/9 localities is sufficient to close project

QO016 Community Caseload Management

The Trust will ensure that there are sufficient community staff at all times to provide care to meet patients' needs, and ensure that community patients are supported to remain in their own home environment.


Veno Sunghuttee Amber Amber Green Amber Green Milestones need to be reviewed in light of paper by Del Mitchell (review of caseload management). Had initial meeting to discuss 03/08 and waiting on RTT information. Transition to Lorenzo system, and the new data warehousing process, have required temporary suspension of current Abacus system. It is expected that more detailed real-time information will be available by mid-October

QO017 Service User and Carer Strategy

Service User Carer Strategy was agreed by the Board March 2015. The project will produce an implementation plan for the delivery of the 6 objectives laid out in the strategy.


Lyn Skipper Amber Amber Green Amber Amber • 5 Locality Workshops held with representation of Staff, Service lines, Service users/Carers partners - 124 attendees of which 49 were service users and carers.• Recruitment to band 6 post successful, awaiting HR checks. Admin in place.• Norfolk evaluation by Equal Lives completed• Co produced interview training developed and on time table of Recovery College - first 2 courses fully booked• Service User/Carers identified for Stories to the board.Challenges:* Reaching hard to reach individuals and groups in its first phase of Co production.* Service Users/ carers and Peers have been involved in the Policy Review Group, review of inudction training, in Restrictive Practices Group, in training for managers.* One Listening event has been held in North Norfolk and another one planned for South Norfolk* Trust has won an Award from the CPA Association for its Peer Support Training

QO018 Staff supervision and appraisals

To ensure that all staff receive regular supervision and annual appraisals, and ensure all nursing staff will be revalidated.


Dawn Collins Green Green Green Green Green Work on standardising Clinical Supervision training to 2 days is ongoing. Sue Bridges is piloting group supervision sessions. Policy has been reviewed and has been presented to the OD&W Committee. Revalidation of Nursing competency has been added to the PID. Poster to staff has been developed for ensure staff are aware of revalidation. A website has also been developed on revalidation. Dawn is looking at setting up an electronic portfolio to manage the revalidation. Also revalidation will be added as a separate field on the e-rostering system. Jane Sayer taking paper on policy to the Board. Appraisal process is being redesigned to incorporate validation. Looking at how to measure the quality of appraisals, possibly using an electronic tool. Also looking at relaunching and rebranding the policy. Dawn is running portfolio management training to 40 staff, who will become portfolio champions, to help staff manage their portfolios and revalidation.Sarah Ball is reviewing and redesigning the Appraisal documentation to align it with the "Putting People First" project.

Overall RAGProject DescriptionProject ID

Project Name Executive Sponsor Project Lead

QO019 Lorenzo implementation Implementation of the Lorenzo system across the Trust


Dave Huggins Green Green Green Green Green This project links to CIP005

QO022 Practitioner quality framework - Clinical Strategy

The aim of the project is to coproduce with staff, service users and stakeholders a clinical strategy that practitioners use to support their practice, and that is used as a framework for clinical quality governance processes.


Bohdan Solomka Green Green Green Green Amber Dates for 4 of the localities have been set - Secure Services , West Norfolk and North/ Central Norfolk in October.

QO023 Physical healthcare form completion

Redesign and implementation of the physical healthcare forms and ensure completion of forms


Veno Sunghuttee Amber Amber Amber Amber Amber All milestones on track. Lorenzo and LARA problems keep this project at Amber (to be merged with QO024)

QO024 Physical healthcare monitoring

To ensure that every service user has a physical health assessment and appropriate interventions (organised or conducted) annually, but in addition on admission and consistently as directed through their care plan.


Sara Fletcher Red Red Amber Amber Amber Assurance that patients are having checks however not yet on Lorenzo. Received assurance at steering group that form would be on Lorenzo by 7th August but now reported as potentially delayed to late November. Additionally it is proving difficult to report on staff trained as this isn't a mandatory training item. Possible loss of CQUIN money

QO029 CYP out of area placement review

This project focusses on reviewing the accessibility of NHSE commissioned CAMHs Tier 4 beds for children and young people in Suffolk and Norfolk.

Alison Armstrong, Director of Operations (Suffolk)

Sue Miller Green Green Green Green Amber Met with Norfolk Lead and will be working alongside him on the 3 year strategy so that it becomes a trust wide position, timetable for this is November 2015. Awaiting information re; use of adult beds; in Suffolk we are reviewing the child and youth pathway to remodel where we can input intensive support. Further work with Suffolk commissioners around specific areas of youth pathway delivery eg Connect, PMHWs. We are also part of a wider piece of work with commissioners around the children’s health and wellbeing strategy.

QO030 Additional 5 beds at Carlton Court

Expansion of Carlton Court capacity to include an additional 5 beds


Andy Goff Amber Green Green Amber Green No outstanding milestones – however at meeting on 06/08 it was decided to prepare 2 options for tender and a decision will be made on which of these to proceed with at start of September. This is likely to delay the building works from 05/10

QO031 Review of In-Patient Bed Requirement

Provision of inpatient beds (including secure services) to ensure that there is sufficient capacity across the Trust.


Veno Sunghuttee Amber Amber Green Amber Green On hold following decision at TPB 09/09. This will form part of the Clinical Strategy which is under development.

QO032 Medicines Management The Trust will ensure that medicines prescribed to patients who use the service are stored, administered, recorded and disposed of safely.


Esther Johnston Amber Green Green Green Green The project is on track. All milestones have been achieved to date. KPIs have been agreed with Christina Walters. Changed to amber 15/09/15 as result of quality governance committee recommendation on 25/08/15. PMO to chase progress.

QO033 Post GY&W Consultation - Implementation of Inpatient Beds

15 beds currently provided for acute adults at Waveney Acute Services, Carlton Court are expected to close in October 2015.


Debbie White/Gill Aspinall

Green Amber Green Green Green All milestones on track – (Linked to CIP006) – possible 2 week delay in starting building works that won’t affect the QIP elements but will affect the CIP element.

QO034 Provision of S136 Suites Review of the evaluation findings and recommend how many place of safety units are needed based upon evidence regarding the impact of the pilot projects & consider how to resource extensions of the pilot project work.


Veno Sunghuttee Amber Amber Green Green Green There is an academic evaluation of the use of our S136 suites that was supposed to have produced an interim report by now with the full report due in November. We are waiting on this report (have asked Terri Cooper-Barnes for copy) but this delays us being able to calculate the potential demand on S136 suites in the future. Also potential issues with S136 suites being used for S135. Jane Sayer to look at activity levels and any overlaps. RAG status to be advised after review of the data.

QO035 Secured services improvement plan

To coordinate within a single plan the existing and future initiatives to improve the quality of secure services across NSFT.


Ian Young Amber Green Green Green Amber Designs and costings have been received from the Architects. The Execs have approved the costings in principal - £2.8M. Business case is scheduled to be presented to the Finance Committee for approval on 15th September. Following this the Business Case will be to be approved by the Trust Board before planning permission documentation can be submitted.Work is ongoing on the development of the Clinical Strategy - due to be completed by 31 Dec 2015. and the Culture of Care Barometer which is expected to be piloted by end of Sept 2015. Equality and Diveristy strategy is in place and is being rolled out in all secure Services. Training is currently taking place.Actions to reduce restrictive interventions have been implemented with better recording of seclusion data and this has been shared with CTLs. On review there are a number of variables such as clinical strategy modelling which is holding RAG at amber. As variables defined will go to green.

QO036 Community Services - Service Development

Implement the Flexible assertive community treatment (FACT) model to localitiy to provide more intensive support that is responsive to risk.


Del Mitchell Green Green Green Green Green Project has 3 elements. FACT model (green), Waves model (green), The crisis support telephone line in Norfolk available through collaboration with MIND (green following funding decision) Overall project is (green). MIND will be delivering the WAVE model (commissioned by NSFT) They met on 07/08 to present the suffolk model and discuss how to operate in Norfolk. It was agreed to start in Norfolk on 12/10

QO037 CYP out of hours arrangements

Joint project with other providers to improve out of hours arrangements


Andy Goff 0 0 0 0 0 Project on hold pending discussions with CCG, Norfolk CC. Estimated on hold until Autumn

QO038 Youth Councils Developing Youth Councils in order to engage CYP


Emma Corlett Green Green Green Green Green PID and QIA have been signed. Project Team is being set up with Service User involvement to design the Welcome Pack. Initial meeting with the Graphic Designer has taken place and work scope out. Need Head of Comms to approve time of Graphic Designer to do this work. Funding to come from Service User Involvement Budget. Project Lead has been on leave for the past 2 weeks and as such there have been no updates.

QO039 Multi-agency suicide prevention

Establish a multi agency working group to improve suicide prevention across Norfolk and Suffolk


Jane Sayer Green Green Green Green Green Project closed following TPB decision as this is a public health project and not a stand alone NSFT project

QO040 BME community response To better understand the diversity of Suffolk communities (beyond the top level census data) with insights into how under-represented groups conceptualise mental health and perceive NSFT. To identify and address barriers to access through practical changes which can be evaluated.

Robert Nesbitt, Trust Secretary

Ravi Seenan Green Green Green Green Amber Project Lead is developing the worksbook with milestones, KPIs, Risks. First phase is to recruit Local LD champions and then hold a qworkshop with the champions on the implementation of the Greenlight Toolkit.

QO041 Learning disability and autism strategy

To make the Trust compliant to the Learning Disabilities legislation, including the Autism Act 2009. To roll-out the Greenlight toolkit throughout the Trust. To have all Trust service users/ carer documents available in 'easy read' format


Sue Bridges Green Green Green Green Green 0

QO042 Statutory & Mandatory Training

To achieve 90% compliance with Stat / Mand training


Dawn Collins Green Green green Green Green Approved at TPB 26/08 PID, QIA & workbook developed. On Track

Last updated: 16 September 2015

LOW1 - 3

MOD4 - 6

SIGN8 - 12

HIGH15 - 25

# Risk identified Date Identified Risk Owner Probability Impact Score Status Mitigating ActionRevised

probabilityRevised impact

Revised score

Review Date

1 Lack of clinical capacity to deliver improved care may impact on delivery 15-Jun-15 Michael Scott 4 5 20 Open Detailed review initiated of skill mix and workforce development needs. Recruitment and retention strategies in place (although these will take time to bear fruit).

4 4 16 30-Oct-15

2 Delays in identifying or progressing Cost Improvement Projects of sufficient scale or deliverability

01-Jun-15 Michael Scott 5 4 20 Open Active and regular monitoring by PMO and TPB, with regular review by the Board. Further work required to identify appropriate corrective action on existing schemes, and new schemes to bridge gap

4 4 16 30-Sep-15

3 PMO developing capacity to support the large complex programmes; may impact on delivery

15-Jun-15 Leigh Howlett 4 4 16 Open PMO almost fully staffed, and recruiting to cover gaps. While interims are in post, and new to organisation, handover to substantive staff needs to be planned. Budgets to reflect dual running during handover

2 4 8 30-Oct-15

4 Management capacity for transformational change may impact on delivery 15-Jun-15 Leigh Howlett 4 4 16 Open Out to advert for Head of Strategy and Transformation and Head of Organisational Development. Executive fast-track development process under consideration

2 4 8 30-Sep-15

5 The Board's wish to strengthen the clear ‘organising principle’ / ‘inspiring vision’ for the Trust may slow down the organisational capacity for change

15-Jun-15 Michael Scott 4 4 16 Open Board and executive team are developing the vision but it is not fully articulated yet. Links to staff engagement work 4 4 16 30-Oct-15

6 Lack of suitable project managers across the Trust, with capability, competency and capacity to deliver schemes

05-May-15 Leigh Howlett 5 3 15 Open The Trust has a need for flexible resource to be available so it can be allocated to projects as and when required. Varying levels of resource have been made available in different localities. Whilst the Trust has capacity to deliver transactional CIPs, large transformational CIPs may need additional resource investment. The current size of the PMO may not be sufficient to provide the necessary project management support going forward. 3 managers recruited in N & W; ongoing effort to recruit in Suffolk

There may be opportunities to reallocate some individuals from other projects that are coming to a conclusion (e.g. Lorenzo) and this should be reviewed as an option rather than recruit externally. To be reviewed by Exec sponsors for

4 3 12 30-Sep-15

33 What will be the governance and reporting framework for the initiatives for the Finance Recovery Plan (FRP), introduction of any new clinical care model and corporate strategy be?

16-Sep-15 Leigh Howlett (TBC)

4 5 20 Open Review and scope current capacity and capability within the PMO to support the FRP, corporate strategy and any changes to the model of care. If not PMO, agree and publish governance and accountability framework. It needs to be agreed at Board level that this is the correct mitigation and scored accordingly.

7 Quality, operational and potential ‘political’ challenges may detract focus away from QIP & CIP delivery

05-May-15 Michael Scott 3 4 12 Open This risk is to be managed by executive directors, to ensure that focus remains on QIP and CIP in the transformation programme and staff are not distracted by other issues.TPB to build and maintain rigour on highlighting need for pace on both CIP and QIP development and delivery.

2 4 8 30-Oct-15

8 Trust are not targeting the maximum possible opportunity i.e. only targeting the more "transactional" opportunities.

05-May-15 Michael Scott 3 4 12 Open Executive sponsors and the Transformation Directors are responsible for ensuring the Trust go after the maximum opportunity. To be managed at Transformation Board. A CIP and transformation pipeline is in place to ensure on-going delivery and ensure that all ideas are captured and moved forward.

2 3 6 30-Oct-15

9 Lack of longer term quality strategy 05-May-15 Leigh Howlett 3 4 12 Open Trust to put in place a plan to develop a longer term quality strategy - exec team and Board to review overview of strategy and resulting implementation plans during June and July 2015.

3 4 12 30-Sep-15

10 Trust staff display a lack of urgency and pace in developing and implementing CIP & QIP schemes

05-May-15 Michael Scott 2 5 10 Open Executive sponsors will be required to report and be challenged at the transformation board on delivery of projects through exception reporting.

Any slippage will be captured by the PMO from milestone, KPI and financial reports, which will then be escalated to executive sponsor and the transformation board.

Clear action logs are also taken at each TPB to drive ownership and accountability.

1 4 4 30-Sep-15

11 Costs to implement QIP and meet issues raised in CQC report 05-May-15 Jane Sayer 5 2 10 Closed QIP lead to monitor resource requirements and costs of the QIP programme with support of the PMO.Finance to approve spending and act as "gatekeeper" for funds to be allocated.

3 2 6 01-Sep-15

12 Lack of staff engagement and understanding with/of Transformation process 05-May-15 Leigh Howlett 3 3 9 Open Communication plan in place and presented (successfully) to Monitor. Lead identified and process for information sharing in place. Putting People First engagement work in hand; communication messages for staff developed after each TPB

3 3 9 30-Sep-15

13 Lack of ownership shown by project leads whilst PIDs and workbooks are being developed, or once project delivery is underway

05-May-15 Leigh Howlett 3 3 9 Closed Executive sponsors are responsible for ensuring that project leads fully own all projects they are assigned to. Any slippage in delivery will be reported to the TPB as will any shortfall on CIP identification.

2 2 4 01-Aug-15

14 Delays to the collection and analysis of service data, following the introduction of Lorenzo, may result in delays to the monitoring of project KPIs, and inaccuracies when comparing to baseline data.

20-Jul-15 Leigh Howlett 3 3 9 Open Active engagement with the Lorenzo team to understand the roll-out programme for training; encouragement to key teams to collect data accurately, and regular monitoring; setting of target end-dates for accurate collection and analysis; engagement between project-lead and key service-areas

2 2 4 01-Oct-15

15 QO01 - Capacity of the Estates Department to carry out surveys/implement works action plan.

09-Jul-15 Debbie White 4 4 16 Open Monthly communications with Estates and alignment with other QIPs 3 3 9 01-Sep-15

21 QO07 - Access to areas not possible 15-Jul-15 Leigh Howlett 3 5 15 Open Make use of other seclusion rooms on the site. 2 4 8 31-Oct-15

22 QO14 - High number of staff vacancies 15-Jul-15 Jane Sayer 4 4 16 Open Ongoing recruitment process. Development of AP roles, flexible training programmes, nursing academy 4 3 12 30-Oct-15

23 QO17 - Insufficient resource, financial and human to undertake the work. 15-Jul-15 Jane Sayer 4 4 16 Open Additional Staff requested will increase the ground that can be covered, maintain links with communities and agencies. Admin will ensure communication is effective.

4 1 4 30-Oct-15

24 QO17 - NSFT Localities Trust management do not buy in to this significant cultural shift and do not support it with time, money or prioritise the work, due to existing pressures.

15-Jul-15 Jane Sayer 4 4 16 Open Project lead, existing and new resource to align with localities and depts. to ensure project is on every radar. IMROC project to work closely with the project. Partnership meeting to be regularly updated on progress or problems.

3 2 6 30-Oct-15

25 QO22 - The Clinical Strategy is not acceptable to the CCGs 15-Jul-15 Bohdan Solomka

3 5 15 Open CCG Involvement in the shaping of the clinical strategy and regular meetings with the CCGs 3 3 9 23-Dec-15

26 QO24 - Loss of related CQUIN monies through non-achievement of goals 15-Jul-15 Bohdan Solomka

4 4 16 Open Target physical healthcare team to areas that require additional support 4 3 12 01-Dec-15

27 QO24 - Lorenzo documentation does not support physiological observation monitoring

15-Jul-15 Bohdan Solomka

4 4 16 Open Purchase additional clinical observations module for Lorenzo 3 3 9 30-Oct-15

28 QO29 - Young people will continue to be accommodated in adult beds 15-Jul-15 Alison Armstrong

3 5 15 Open (i) Discussion with NHSE on how local risk will be managed. (ii) Work with local commissioners to champion access. (iii) Ensure that local community teams are reaching into any admission episode to expedite discharge

3 4 12 01-Nov-15

29 QO35 - Insufficient funding to achieve environmental improvements. 15-Jul-15 Debbie White 4 4 16 Open Engaging commissioners with plans. 3 3 9 30-Sep-15

32 QO40 - Lack of engagement by a locality team to run the pilot due to competing priorities means that the learning from the survey work cannot be applied.

15-Jul-15 Robert Nesbitt

4 4 16 Open Work closely with operational directorates to identify a team that has equality lead(s) so as to support the pilot team. This work will take place by September 2015.

2 4 8 30-Sep-15

34 QO006 - Capacity within Estates Department to design and project manage the scheme may be insufficient

01-Jun-15 Leigh Howlett 5 5 25 Open Use external architects to perform the work, which will require funding. 1 1 1 01-Oct-15

Programme Risks Log APPENDIX 3



Title of Report: DRAFT OD & Workforce Strategy 2016 TO 2020

Action Sought: For Debate


Author: Sarah Ball, Head of OD & HR

Director: Leigh Howlett, Director of Strategy & Resources

Executive Summary:

Attached is a first draft of the proposed Organisational Development and Workforce strategy. It has been reviewed by the lead for OD at the NHS England and our buddy Trust who have provided positive input and guidance. Ahead of the Board of Governors, it will be discussed in detail at the OD&W Committee on September 21st and the Board of Directors (BoD) on 24th September 2015. The Board is asked to consider the content of this report, does it include all aspects needed and if there is anything missing. Post a clear direction from the BoD this document will be refined and then go out for wider consultation with staff, service users, carers and health partners ahead of final ratification by the BoD.

1.0 Report contents 1.1 The Trust has had a number of disjointed Organisational Development and

Workforce (OD&W) plans over recent years. This has led to a lack of direction for the Trust and its staff. It was recognised by the CQC that this was one of the key missing elements from our overall strategic plans. This strategy aims to bring all those elements together into one clear overall strategic plan.

1.2 The back ground to this is an organisation that has undergone/ still undergoing significant organisational change, while operating within a very challenging financial environment and under considerable regulatory scrutiny.

1.3 The strategy takes account of the significant learning that has been gained over the last four years. This includes the importance of listening to our staff and patients and acting upon their feedback and ideas in an open and timely way. It also recognises the benefits of involving our staff and patients in the design of our services and how we deliver changes as well as the value of sharing learning and embedding best practice in a consistent and sustainable manner.

Date: 1st October 2015 L Item: 15.53iv

BoG – 1st Oct 2015 -Draft OD&W Strategy

Version 0.1

Author: Leigh Howlett Department: Strategy & Resources

Page 1 of 2 Date produced: 17/09/15 Retention period: 30 years

1.4 The strategy also takes account of the known and anticipated challenges and

opportunities that shape our organisational development and workforce priorities over the next four years including ongoing financial constraints, national skills shortages and the drive for more integrated working with partner organisations as set out in the Five Year Forward View (2014).

1.5 The strategy has been reviewed by the NHS England’s lead for OD and our buddy Trust, both of whom have provided feedback and guidance which has influenced the report.

1.6 The overall ethos for this strategy is that through challenges we believe comes opportunity for innovation and improvement and this is a thread that runs throughout the strategy.

2.0 Financial implications (including workforce effects) 2.1 Described in the strategy, to be defined on completion.

3.0 Equality implications / summary of consultation 3.1 The strategy is written to be inclusive and a fuller consultation will be undertaken

once the BoD have agreed the overall direction is correct.

4.0 Recommendations 4.1 The Board is asked to consider and discus the content of this report, does it

include all aspects needed and if there is anything missing.

Leigh Howlett

Director of Strategy & Resources

BoG – 1st Oct 2015 -Draft OD&W Strategy

Version 0.1

Author: Leigh Howlett Department: Strategy & Resources


“PUTTING PEOPLE FIRST” DRAFT ORGANISATIONAL DEVELOPMENT

AND WORKFORCE STRATEGY

2016 TO 2020

Version draft 0.5

1

1. INTRODUCTION

What is ‘Organisational Development’?

‘Organisational development’ means many things to many different people. For the purposes of the Trust’s Organisational Development Strategy, it is essentially about a planned whole Trust (and wider systems) approach to the sustained improvement of our organisational capability through the involvement of our staff and patients and the development of our leadership and workforce potential.

What is our Organisational Development Model?

The following diagram illustrates the organisational development model that we have developed for our Trust which forms the basis of our Strategy.

This model is based on the strong evidence base that links excellent workforce capability with excellent organisational capability and higher levels of staff experience with higher levels of patient experience1. The focus of how we achieve this is based on developing a more engaged, skilled and flexible workforce. These elements therefore form the three core domains of the strategy with the enabling strategies (shown as pillars on the diagram) underpinning the delivery.

1 ‘Employee Engagement and NHS Performance’, Michael A West and Jenny? F Dawson, (2012); ‘The link between the management of employees and patient mortality in acute hospitals’, M A West, C Borril, J Dawson, J Scully, M Carter, S Anelay, M Patterson, J Waring, (2002)

2

What is the background to this strategy?

The backdrop to this strategy is an organisation emerging from a period of significant organisational change that is operating within a very challenging financial environment and is under considerable regulatory scrutiny. Through challenges, however, we believe comes opportunity for innovation and improvement and this is a thread that runs throughout the strategy.

The strategy takes account of the significant learning that has been gained over the last four years. This includes the importance of listening to our staff and patients and acting upon their feedback and ideas in an open and timely way. It also recognises the benefits of involving our staff and patients in the design of our services and how we deliver changes as well as the value of sharing learning and embedding best practice in a consistent and sustainable manner.

The strategy also takes account of the known and anticipated challenges and opportunities that shape our organisational development and workforce priorities over the next four years including ongoing financial constraints, national skills shortages and the drive for more integrated working with partner organisations as set out in the Five Year Forward View (2014).

What is our vision?

We have a workforce that has been commended for its care of our patients2. We appreciate and are proud of the commitment and contribution of every doctor, nurse, allied health professional and corporate and support staff that works for the Trust. We want our staff to be equally proud to work for the Trust, acting as positive ambassadors of the Trust as a provider of services and a desirable employer, recognised locally, regionally and nationally. We want our staff to feel fulfilled and valued in their roles, recognising the important contribution each of them makes day to day and to be engaged in positively shaping the services they provide and the culture of the Trust they work in.

This strategy complements and is critical to supporting and enabling the delivery of the Trust’s Vision “…be a champion for mental health services; building trust with local people by providing safe, effective, needs-led services, together with our partners”. It is our ambition to be recognised as a leading provider of mental health, learning disability and substance misuse services. We want to be renowned for the high quality and safe services we provide and the positive differences we make to the lives of our patients. In achieving this, we want everyone working for the Trust live our values of “Working together, respectfully, positively, for better mental health”. These values have been developed by our staff and patients through a programme known as ‘Putting People First’. Our Organisational Development and Workforce Strategy adopts this name and builds upon this significant step in our journey forward.

2 CQC Inspection 2014

3

2. OUR FUTURE DIRECTION

What are we going to do?

As set out in Part 3 below, ‘Putting People First’, sets out our organisational development and workforce ambitions for the Trust. These ambitions have been tested with our staff and patients. ‘Putting People First’ means ensuring our patients and our staff are at the centre of what we do - attracting, developing, leading, valuing and retaining engaged, skilled and flexible staff who care for, involve and empower our patients to recover and lead the best possible lives that they are able to.

Through the delivery of this Strategy, we believe we can create a sustainable and thriving organisation with an excellent reputation for high quality patient care and experience. We are, however, realistic that there is a lot to deliver and that it is likely to take some considerable time to fully realise the impact from this strategy in terms of consistent and sustainable improvements across our organisation from the current baseline position. Our approach has therefore been to set an ambitious but realistic framework and pace to this Strategy. This will be supported by a four year implementation plan; key milestones are highlighted in Appendix 1. This is, however, a ‘living’ strategy and will therefore require regular refresh in light of changing external drivers and internal needs.

Who is responsible for the strategy?

Whilst Executive Directors have overall accountability for the delivery of the strategy, due to the critical relationship between our workforce and the delivery of high quality patient care, it is important to emphasise that the strategy belongs to every person in our workforce – doctors, nurses, allied health professionals, corporate and support staff - each having a valuable role to play in its delivery and in its success. Appendix 2 sets out a diagram that describes the organisational development cycle that will be used to embed, monitor, test and continuously improve our organisational development strategy and the role of everyone connected with our organisation in relation to this. Part 3 below sets out the Executive Director lead for each aspect of the strategy. In addition to delivery against the implementation plan, Appendix 4 sets out a number of quantitative and qualitative indicators that will be used to assess performance and success. True success will be demonstrated by consistent achievement across the indicators within all areas of the Trust. These indicators will therefore be monitored at Locality as well as Trust level.

With overall leadership from the Executive Director of Strategy and Resources, the strategy will be managed as a transformational programme of work, monitored by the Board of Directors via the Organisational Development and Workforce Committee.

The enabling strategies and supporting implementation plans will be led by the Head of Organisational Development and Human Resources and the Deputy Director of Nursing (the latter in regard to Education, Training and Development) on a day to day basis. We commit to the ongoing training and development of these teams, particularly in the development of increasing the expert base in organisational development as an essential requirement in the delivery of this strategy.

4

3. ‘PUTTING PEOPLE FIRST’ – OUR ORGNISATIONAL DEVELOPMENT AND WORKFORCE STRATEGY

AN ENGAGED WORKFORCE

Our aim is that our staff will:

• Be proud to work for the Trust, acting as positive advocates for the Trust as an employer and provider of services.

• Live our values and demonstrate these on a day to day basis.

• Feel fulfilled and valued in their roles, recognising the important contribution they make each day in supporting our patients to live the most positive lives they are able to.

• Be engaged in positively shaping the services we provide and the culture of the environment they work in.

This will be delivered by:

Developing a culture of empowering, resilient and adaptable leadership and management capability at all levels of the organisation, including clinical leadership

• The Board of Directors, in particular the Executive Leadership Team, will set out a clear vision and direction of travel for the Trust. They will have a consistent leadership story and communicate this clearly to staff at all levels and in all roles across the organisation. (Chief Executive)

• We will offer a portfolio of informal and formal leadership and management development tools, training and other development opportunities to ensure we equip our managers and leaders (including clinical leaders) at all levels of the organisation to have the skills and behaviours to make sound decisions, empower others to do their jobs effectively and to be supportive managers. This includes developing a culture of coaching. (Director of Strategy & Resources)

• Managers will engage staff in reviewing and acting upon learning lessons (from positive and more negative experiences). (All Directors)

• Managers and leaders at all levels of the organisation will not only listen to but will hear the views and ideas of our staff, patients and carers. Appropriate and timely action will be taken in response to feedback. (All Directors)

Having a clear values and behaviours framework that is embedded across the organisation

• Our policies and processes throughout the employment lifecycle will be aligned to our values, including the implementation of values-based recruitment and appraisals. (Director of Strategy & Resources)

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Improving the wellbeing of our staff

• We will offer a range of tools, training and development to support staff to take responsibility for their own health and to support the wellbeing of their colleagues. (Director of Strategy & Resources)

• We will offer a range of tools, training and development and empower our managers to champion staff wellbeing and deliver safe and healthy work environments. (Director of Strategy & Resources)

• We will work to meet the standards of the Employer’s Wellbeing Charter. (Director of Strategy & Resources)

• We will champion ‘A Time to Change’ to reduce the stigma of mental ill health. (Director of Strategy & Resources)

Recognising the value of our staff

• We will recognise high performance and staff loyalty in a fair and timely way at a local and organisational level holding regular Trust-wide award events. We will also nominate for awards and celebrate the successes of our staff at regional and national levels. (Director of Strategy & Resources)

A SKILLED WORKFORCE

Our aim is that:

• We will be a desirable training provider and employer attracting, developing and retaining a skilled workforce that provides consistently good quality of care to our patients.

• We will work collaboratively with partner organisations and through integrated teams where this is in the best interests of our patients and we will develop new roles to meet changing service needs and support our staff with the knowledge, skills and confidence to operate in dynamic environments.

• Our staff will be experts in their own professional areas but will have opportunities to develop their broader transferable skills and experience meaning we have an identified and ready succession of talented staff with opportunities across a variety of career pathways.

• Our staff will take ownership for their professional and personal development and we will support this through a variety of innovative and flexible educational and development pathways.

This will be delivered by:

Having a robust recruitment and retention strategy

• We will regularly benchmark and review our employment proposition to ensure we are competitive within the recruiting markets. (Director of Strategy & Resources)

6

• We will proactively engage with the local, regional and national labour markets through a variety of innovative media and events and a combination of generic and targeted campaigns. (Directors of Operations)

• We will ensure our recruitment process is as efficient as possible. (Director of Strategy & Resources)

A flexible approach to role design and career pathways

• We will develop new roles to support current and emerging clinical need e.g. Non-Medical Prescribers, Advanced Practitioners, Graduate Health Workers. (Director of Nursing, Quality & Patient Safety / Medical Director)

• We will commit to establishing career pathways to identify progression, development, training and education needs, including movement between clinical and managerial roles. (Director of Nursing, Quality & Patient Safety / Medical Director)

• In line with the strategy set out in the Five Year Forward View (2014), we will work collaboratively with partner organisations to integrate our workforces and systems and share premises where this is in the best interests of our patients. (Directors of Operations)

Future focused workforce planning influencing educational commissioning

• Recognising national skills shortages, we will have an increased focus on ‘growing our own’ staff. This will be supported by the ‘Talent for Care’ strategy to develop the Bands 1 to 4 support workforce (Apprenticeships through to Assistant Practitioners) as well as exploring more innovative approaches to access registered level training. (Director of Nursing, Quality & Patient Safety)

• We will work collaboratively with Health Education East, the Deanery and educational providers to identify emerging needs and solutions to meet workforce demands and skills requirements. (Director of Strategy & Resources / Director of Nursing, Quality & Patient Safety / Medical Director)

• We will review our offerings, support and processes to develop our reputation as an excellent place to receive clinical training (medical, nursing, allied health professionals and other professional training). (Director of Nursing, Quality & Patient Safety / Medical Director)

• We will deliver workforce planning led recruitment plans.

Innovative and flexible approaches to the delivery of staff education, training and development

• We will review our mandatory training requirements in line with national NHS core competencies and ensure that these are relevant to individual staff roles. (Director of Nursing, Quality & Patient Safety)

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• We will develop more flexible and innovative training and development interventions (face to face and electronic) supporting more local delivery and learning within the workplace. (Director of Nursing, Quality & Patient Safety)

Developing a succession and choice of capable staff through a robust talent management and succession planning framework

• A clear framework for talent mapping and cohesive succession planning at all levels of the organisation will be developed and rolled out to identify workforce capacity gaps and risks and to inform strategic and operational planning. (Director of Strategy & Resources)

• Talent management will support staff to be the best they possibly can in their own roles as well as supporting career development for those who are interested and have the competency, values and demonstrate the necessary behaviours for this. (Director of Strategy & Resources)

A FLEXIBLE WORKFORCE

Our aim is that:

• Our workforce will be agile enough to respond, in a timely way, to changing strategic and operational needs supporting there being the right staff, in the right place, at the right time according to those needs.

• We can deploy our staff as effectively as possible in order to deliver safe, effective services, operating as a system rather than isolated units.

• Our staff will support our patients to remain at home wherever possible. To enable this, we will provide resources, train and develop staff to work in new more flexible ways of working, including mobile working.

• We are able to draw upon additional resource to supplement our core workforce when operationally necessary. Our temporary workforce will be capable, supported and engaged in line with robust governance requirements.

• We increase and develop our peer support and volunteer workforces.

• We maximise our use of the Electronic Staff Record (ESR) capabilities so every employee can view their core employment data and information to support them in their work and managers can have easy access to information and technological support to better equip and empower them to do their jobs.

This will be delivered by: Agile organisational design and role flexibility • We will design our services and supporting workforce structures so that these are

adaptive to changing operational needs, maximising the efficiencies of technological enablers. (Directors of Operations)

8

• Where needs are identified, we will train and develop staff so that they have more flexible and transferable skills and are able to operate in different environments, including integrated teams with partner organisations. (Director of Nursing, Quality & Patient Safety / Director of Strategy & Resources)

An enabling employment proposition • Our contractual arrangements, policies and procedures will support a more agile

workforce. (Director of Strategy & Resources)

• New ways of working including portfolio working will be explored and introduced for roles such as project management and specialist skills. (Director of Strategy & Resources)

The implementation and benefits realisation of electronic rostering across the whole workforce • Starting with inpatient areas, electronic rostering will be rolled out across the whole

workforce. (Director of Strategy & Resources)

• Management information will be used to inform the efficient planning of our valuable staff resource. (Director of Strategy & Resources)

A move to more mobile working • ICT will be used to support an increased level of mobile working to enable more

effective and efficient working amongst community based teams leading to an increase in face to face patient contact. (Director of Strategy & Resources)

Developing more responsive, higher quality and more cost-effective temporary staffing arrangements. • Temporary staffing arrangements and providers will be reviewed in line with NHS

procurement frameworks and current contractual arrangements to ensure robust governance and value for money. (Director of Strategy & Resources)

• Terms and conditions for bank workers will be regularly benchmarked to ensure

these remain competitive. (Director of Strategy & Resources) Increasing and developing and Peer Support workforce • We will increase and continue to develop our Peer Support workforce and raise the

profile of the valuable contribution staff who have themselves experienced mental ill health can make in supporting our patients (and our staff) achieve the best possible outcomes. (Director of Nursing, Quality & Patient Safety)

Expanding and developing our volunteer workforce • We will ensure arrangements are in place for the co-ordination, management and

development of our volunteer workforce across a variety of roles. (Director of Nursing, Quality & Patient Safety)

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• We will significantly increase the size of our volunteer workforce, including volunteers who are or have been service users or carers and we will raise the visibility and profile of our volunteer workforce in the valuable contribution it makes to supporting our clinical and support services. (Director of Nursing, Quality & Patient Safety)

• We will ensure our volunteer workforce is recognised and rewarded for its

contributions through involvement in the wider staff awards events. (Director of Strategy & Resources)

Electronic Staff Record (ESR) • All employees will be supported in the familiarisation and effective use of the

Electronic Staff Record (ESR) including self-service, learning and talent management. For managers, this will include having direct access to management information and business intelligence reporting. (Director of Strategy & Resources)

Sarah Ball

Head of Organisational Development and Human Resources

(Jul15/ODWkfceStratv05)

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APPENDIX 1

‘PUTTING PEOPLE FIRST’ – ORGANISATIONAL DEVELOPMENT AND WORKFORCE STRATEGY HIGH LEVEL MILESTONE PLAN

11

12

APPENDIX 3 – SUCCESS INDICATORS

Indicator Target

Engaged Workforce Language used by staff and patients at ‘Putting People First’ listening events is increasingly in line with the Trust’s values and behaviours

Improving trend of more positive indicator words than negative indicator words using ‘wordles’.

Year on year improvements to the staff engagement score for the Trust in the annual NHS Staff Survey

Staff engagement score in NHS Staff Survey to be in the top 20% of Mental Health/Learning Disability Trusts by April 2020.

Sustained improvement in Staff Friends and Family Test (SFFT) results for net promoter scores for the Trust as an employer and as a provider of services

SFFT results to be in the top 20% for Mental Health/Learning Disability Trusts by April 2020.

Sustained improvement in Patient Friends and Family Test (PFFT) results

Year on year improvement in PFFT

Year on year improvements in NHS Patient Survey results to being involved in decisions about their care.

Year on year improvement in NHS Patient Survey.

Leaders and managers have received leadership and management training or other development relevant to their needs

By April 2020, all senior leaders and managers have accessed leadership and management development support relevant to their needs with the participants and their line managers reporting positive outcomes.

Reduced sickness absence To 4.5% by end March 2015 and to sustain a rate within the lower quartile for mental health Trusts

Increase in number of internal and external awards delivered

High quality entries made in all major external awards processes; Year on year increase in number of occasions shortlisted, finalists and winners.

All eligible staff who report having had a quality appraisal within the last 12 months

70% by April 2018 and 85% by April 2020

Staff Survey results In top 20% for in excess of 50% of key findings

Skilled Workforce Reduced turnover A healthy and stable voluntary turnover not exceeding 10%

Vacancies Vacancy rate reduced to 8% by April 2017

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Time to hire Reduced to 8 weeks (advert to unconditional offer) by April 2017

Career pathways All professions have a clearly defined career pathway by April 2020

Increase in workforce planning led recruitment

Year on year decrease in reactive recruitment activity (‘one in one out’) with increased focus on annual collaborative recruitment plans

Increased ‘grow our own’ pathway Year on year increase in Apprentice to Assistant Practitioner to accelerated nurse training numbers

Reputation as a clinical training provider Year on year improvements in Health Education and Deanery quality assessments

Mandatory training 95% compliance by April 2018

Succession planning Succession plan for all key job roles by April 2020

Flexible Workforce Rostering efficiency Year on year improvements in rostering efficiency

Face to face clinical contacts Year on year increases in face to face clinical contacts

Reduced temporary staffing demand Year on year decreases in temporary staffing demand

Bank to agency ratio Year on year improvements in bank to agency ratios

Number of volunteers Year on year increase in number of active volunteers

Number of timesheets and P forms processed

All timesheets processed electronically by April 2017. Number of P forms processed reduced significantly by April 2017.

14



Title of Report: AGM arrangements





Executive Summary: This paper updates the Board of Governors on arrangements for the Annual Members’ Meeting / AGM which takes place on 08.10.15 to cover the year 2014/15. The venue for the meeting alternates between Norfolk and Suffolk and this year will be held in Norwich.

1.0 Purpose of the Annual Members’ Meeting / AGM

1.1 Under the Trust’s constitution we are required to hold an Annual Members’ Meeting / AGM. The formal business is to receive and approve the Trust’s annual report and accounts for the year 2014/15. This is part of the line of accountability back to members and local people for a Foundation Trust.

1.2 Changes made to the Constitution by the Board of Governors must also be presented to the meeting and members given the opportunity to vote on whether they approve the amendments, but this applies only to changes,

“in relation the powers or duties of the Board of Governors (or otherwise with respect to the role that the Board of Governors has as part of the Trust)” (S.46)

In 2013/14 there were no changes and for 2014/15 the changes primarily related to the introduction of the electronic voting option. These amendments will be notified to the meeting but not put to a vote.

2.0 Demonstrating achievements

2.1. Although not part of the formal business the event also provides an opportunity to explain the work of the Trust to local people and partners and to demonstrate achievements.

Date: 01 October 2015 M Item: 15.53v

BoG Public – 01Oct2015 AGM arrangements



2.2. The programme for this year’s event is as follows:

14:30 – 14:45 Tea / Coffee 14:45 – 15:40 AGM 15:40 – 16:20 Putting People First 16:20 – 16:45 Service User and Carer strategy launch 16:45 – 17:10 Refreshments 17:10 – 17:40 Nursing Academy Presentations 17:40 – 17:45 Closing comments and thanks

6.0 Financial implications (including workforce effects)

6.1 There are no financial or workforce effects of these proposals

7.0 Quality implications

7.1 There are no implications for the quality of care provided by the Trust.


8.1 There are no equality implications.

9.0 Recommendations

9.1 Governors are asked to note the arrangements for the Annual Members’ Meeting / AGM.

Robert Nesbitt Trust Secretary Background Papers / Information None AGM agenda: .




Annual General Members’ Meeting

Meeting to be held on Thursday 8th October 2015 from 14.45 – 15.40

The Great Hospital (Birkbeck Hall) Bishopgate, Norwich, Norfolk NR1 4EL

AGENDA

Time Item No

14:45 A15.01 Chair’s welcome, notification of any urgent business and apologies for absence

Apologies:

14:50 A15.02 To approve the minutes of the Norfolk & Suffolk NHS Foundation Trust Annual General Members’ Meeting held on 19th September 2014

Attachment A

i. To approve the release of the minutes in accordance with the Freedom of Information Act

A15.03 To address any Matters Arising from the minutes of the previous meeting, not covered by the agenda

14:55 A15.04 To receive the 2014-15 Annual Report (Michael Scott)

Presentation

15:10 A15.05 To receive the 2013-15 Annual Accounts (John Doyle)

Presentation

15:25 A15.06 Questions from the floor to the directors and governors

A15.07 Motion to approve the Annual Report and Accounts 2014-15 (Gary Page)

15:35 A15.08 Changes to the Constitution made in 2014-15 (Robert Nesbitt)

Attachment

15:40 CLOSE






Title of Report: Notification of election arrangements for 2015/16




Executive: Robert Nesbitt: Trust Secretary Executive Summary: This paper notifies the Board of Governors of the seats that will be up for election this year for the new intake of governors from 01.02.16.

1.0 Seats that are for open for election in the 2015/16 round 1.1 Elected governors serve three year terms (to a maximum of nine years per

governor). 1.2 Seats coming up for election (10)

Public – Norfolk (3)

• Stephen Fletcher (served 6 years to end of this term) • Catherine Wells (served 3 years to end of this term) • Vacant (formerly Pat Southgate)

Public – Suffolk (1)

• Vacant (formerly Susie Enoch)

Service User – Norfolk (1)

• Vacant (formerly Siobhan Leviton)

Service User – Suffolk (1)

• Vacant (not contested at last election)

Carer – Norfolk (1)

• Mary Rose Roe (served 6 years to end of this term)

Carer – Suffolk (1)

Date: 1st October 2015 N Item: 15.53vi

BoG Public – 01Oct2015 Election arrangements 2015/16



• Vacant (not contested at last election)

Staff (2) • Dr Karen O’Sullivan (served 8 years to end of this term) • Linda Weatherley (served 3 years to end of this term)

2.0 Indicative timetable

2.1. The timetable can be seen below and the intention will be to time the results in such a way as to provide a period for preliminary induction before the newly elected governors take up their seats on 01.02.16.

ELECTION STAGE 41 days Trust to send nomination material and data to ERS Tuesday, 20 Oct 2015 Notice of Election / nomination open Tuesday, 3 Nov 2015 Nominations deadline Wednesday, 18 Nov 2015

Summary of valid nominated candidates published Thursday, 19 Nov 2015 Final date for candidate withdrawal Monday, 23 Nov 2015 Electoral data to be provided by Trust Wednesday, 25 Nov 2015

Notice of Poll published Monday, 7 Dec 2015 Voting packs despatched Tuesday, 8 Dec 2015 Close of election Wednesday, 30 Dec 2015

Declaration of results Thursday, 31 Dec 2015

3.0 Recommendations

3.1 Governors are asked to note the arrangements for the next elections.

Robert Nesbitt Trust Secretary Background Papers / Information None

BoG Public – 01Oct2015 Election arrangements 2015/16





Title of Report: Lead governor election arrangements for 2016 including review of Lead Governor role profile





Executive Summary: This paper sets out the plans for the lead governor elections for 2016 and requests governor volunteers to carry out the annual review of the governor role profiles, lead governor role profile and code of conduct.

1.0 Role of the Lead Governor

1.1 Monitor requires Boards of Governors to nominate a lead governor in order to act as a link point between the regulator and Foundation Trusts (since it would be impractical for Monitor to try to relate to every governor individually, and since it is sometimes appropriate to make contact with the lead governor rather than the Chair).

1.2 The current role profile for the lead governor is shown in the appendix.

2.0 Process

2.1. The Nominations Committee approved a process for the election of the lead governor in 2012 which is shown below:

Date: 1st October 2015 O Item: 15.53vii

BoG Public – 01Oct2015 Lead Governor election arrangements



Proposed process for election of lead governor (approved by Nominations Committee on 28.11.12)

1.1 A simple majority vote will be used (rather than the more complex single transferrable vote system). The process will mirror the rules used by ERS for governor elections but will be held in-house.

1.2 Stage one – call for nominations

All governors will be invited by email to nominate themselves to stand as lead governor. To do so they need to complete a nomination form which includes a statement of up to 175 words stating why they wish to take on the role. The nomination must be received before the deadline. The same rules on word counting will apply as used in the ERS process. If there is only one nomination then they will be offered the role without a ballot. Nomination forms can be sent by email or post.

1.3 Stage two – issuing of poll

All governors will receive an email link to an online ballot. Governors may use a paper ballot paper if preferred.

The online and paper ballot will list the names of all of the candidates.

Governors using the online ballot will be asked to indicate their preferred candidate electronically.

Governors using the paper ballot method will be asked to mark their preferred lead governor with an X online and to return the ballot paper in the supplied envelope before the deadline.

1.4 Stage three – counting votes

The count will be conducted by the Trust Secretary in the presence of the Chair. Any governor may be present at the count. In the event of more than one candidate receiving the same number of highest votes cast, the decision will be made by drawing lots.

1.5 Stage four – pre-announcement communications

The governor with the highest number of votes will be contacted to confirm that they are willing to take on the role. If they have decided to withdraw then the governor with the next highest number of votes is elected. If the




governor accepts the role then the other candidates will be contacted to tell them that they have been unsuccessful.

1.6 Stage five – announcement

All governors will be contacted as soon as practical after stage four to inform them of the outcome. The full list of nominations and votes cast will be available on request. Monitor will be informed of the outcome using their online form.

2.0 Timescale

2.1 Nominations invited from 9am 3rd December to Friday 21st December at 5pm.

2.2 Poll runs from 7th January to Monday 21st January 12 noon.

2.3 Count and announcement takes place as soon as practical after close of poll.

Robert Nesbitt Trust Secretary

29.11.12

3.0 Updating this process

3.1 Assuming that the Board of Governors wishes to follow the same approach, then the above process can be updated with the following timescales:

o Nominations Committee signs off the updated lead governor role profile 24th November 2015.

o Nominations invites from 9am on Monday 6th December 2015 to Friday 24th December at 5pm.

o Poll runs from 11th January to 18th January at 12 noon.

o Count and announcement completed by Friday 21st January.

4. Review of role profiles and code of conduct

Volunteers are requested to carry out the annual review of the above documents (we usually do this as a telephone conference call in October)

5. Recommendations

Governors are asked to note the proposed timescale for the lead governor election.




Governors are asked to volunteer to assist with the review of the role profiles and

code of conduct.

Robert Nesbitt Trust Secretary Background Papers / Information None .






Title of Report: Chairs report – Service User and Carer Trust Partnership 28th August 2015

Action Sought: For Information


Author: Guenever Pachent

Executive Summary:

This report highlights the key issues arising out of the Service User and Carer Trust Partnership meeting on 28th August 2015

1.0 Key Issues

1.1 Quality Improvement Plans (QIPs) – we reviewed the Progress Reports for the three Plans allocated to the Partnership. We asked for more detail to be provided on the Key Performance Indicators (KPIs) for the Report on the Service User and Carer Involvement Strategy. The other two projects were signed off as presented. The Red Amber Green (RAG) ratings were supported.

1.2 Trust-wide ‘Mock’ CQC Visit – Service User (SU) and Carer involvement in the visit, week beginning 30th November, was discussed and agreed.

1.3 Service User and Carer Involvement Strategy – The launch of the Strategy at the AGM on October 8th was discussed and it was agreed that it should be led by SUs and Carers who had been involved in its co-production. It was recommended that Chris Curry, Chair of West Suffolk Locality Forum should be asked to introduce the Strategy, and Governor Kevin James offered to present part of it. The focus will be on the recognition of a more responsive approach from the Trust on SU and Carer engagement and some examples of good practice.

1.4 Service User and Carer Interview Training – Co-produced interview training will be given in new courses being run in Norfolk and Suffolk. Courses are fully booked and there has been an enthusiastic response from Service Users and Carers.

Date: 1st October 2015 P Item: 15.54i

Board of Governors 1st October 2015

Version 0.1

Author: Guenever Pachent Department: Governor


1.5 Attendance at Quality Governance (QG) Committee – SU and Carer

involvement in QG was discussed following recent confusion about who attended, and the role of SU and Carers at the Committee. It was accepted that SU and Carers should not use QG to raise issues of concern about services, because there are other forums for this. Instead, they should use their experience to help Board members gain assurance about Quality Governance in the Trust. It was agreed to continue with 2 carer and 2 service user representatives but the Chair will review the functioning of this in 3 months.

1.6 Review of effectiveness of the SU and Carer Trust Partnership – members felt the meetings were effective and necessary to drive forward Trust wide initiatives like the Involvement strategy, but that better attendance from Executive staff responsible for SU and Carer engagement was important. The Executive staff should be able to give assurance on the three QIPs allocated to this group: the SU and Carer Involvement Strategy; the Youth Councils; and the Open Mind Black and Minority Ethnic (BME) Mental Health.


2.1 The meeting asked for on-going assurance on the BME QIP, thus minimising any potential inequality.


3.1 More effective Service User and Carer Involvement is a key trust Objective. This committee has an important part to play in monitoring the extent to which the new Involvement strategy is being implemented and the quality of engagement is improving.

4.0 Recommendations 4.1 The Board is asked to note the Report.

Guenever Pachent Lead Governor 14th September 2015 Background Papers / Information None

Board of Governors 1st October 2015

Version 0.1

Author: Guenever Pachent Department: Governor




Title of Report: Membership and Communications Sub Group

Action Sought: For information


Author: Andrew P Good - Chair

Director: Not applicable Executive Summary: This report is a short summary of the main issues discussed at the last two sub group meetings on 16th July and 17th September. Some issues will appear on the agenda of today’s meeting.

1.0 Membership database tender

1.1 The specification for the tender has been approved and a number of Governors

have volunteered to be on the selection panel to receive bids.

2.0 Stand up for mental health 2.1 The sub group is keen to develop a campaigning theme which “stands up for mental

health” and can be used as an approved Trust brand and strap line for communications and recruitment of members. A project plan has been approved but is dependent upon Trust Officers being available to work up the proposals and design suitable materials. It was hoped to launch this at the AGM but that is now unlikely.

3.0 Governor Networks

3.1 Most Governors have completed the wheel of engagement which has been designed to show the extent of Governor involvement in related networks. The conclusion reached by the group is that there is extensive experience and knowledge being deployed by Governors across an impressive range of groups who are involved in mental health in some way. The wheel also demonstrates the user, carer and voluntary organisations and forums attended by Governors.

3.2 It was noted that the only area not covered appeared to be the business community where we need to influence thinking around employment opportunities and the training of shop and retail staff re dementia.

Date: 1st October 2015 Q Item: 15.54ii

BoG - Public 1st Oct 2015 Membership & Comms Subgroup

Version 1.0

Author: Andrew Good Department:

Page 1 of 2 Date produced: 22 Sept 2015 Retention period: 30 years

3.3 An item is on the BoG agenda to discuss this. 4.0 Insight

4.1 The sub group was delighted with the relaunched issue of Insight. There had been no discernible criticism about the need to move over to on line delivery. It was noted that Members could still request a hard copy and copies were available at all Trust premises and community locations including GP surgeries.

5.0 Member matters 5.1 It was noted that member lectures had been well received and that plans were

progressing for the Governor hosted conference at Ipswich on 30th October. 5.2 The member survey had attracted only 11 responses. A very poor response but one

which was overall quite positive. The sub group will consider at a later date whether the exercise should be repeated or combined with a request for feedback on the content of Insight

5.3 The information provided to people interested in becoming Governors was

approved with some minor amendments about the role. It was noted that the last round of elections did not deliver a Carer Governor in Suffolk and Staff Governor positions were not contested.The sub group agreed to ask Gary Page to produce a personalised letter to members in October encouraging people to stand. It was noted that the next issue of Insight would be carrying a feature on Paddy Field and his work as a Governor. It was also agreed that the CEO should restate to staff that Staff Governors would be given protected time in order to carry out their duties. A flyer about the role of Governors would be in the delegate pack for the October conference.

6.0 Change of name to Council of Governors

6.1 It was noted that at the last Board of Governors there were insufficient Governors present to decide upon the proposal to change the name to Council of Governors in line with other Foundation Trusts. The sub group was unanimously in favour of the change to better reflect the representative role and to reserve the title of Board to the Board of Directors. This should avoid confusion and make communication more meaningful outside of the Trust

Andrew P. Good Chair of Membership and Communications sub group Background Papers / Information None BoG - Public 1st Oct 2015 Membership & Comms Subgroup

Version 1.0

Author: Andrew Good Department:

Page 2 of 2 Date produced: 22 Sept 2015 Retention period: 30 years

Report To: Board of Governors Meeting - Public


Title of Report: Performance & Planning Subgroup Chair’s report

Action Sought: For Information

Estimated time: 5 Minutes

Author: Guenever Pachent: Lead Governor

Director: Robert Nesbitt: Trust Secretary

1.0 Summary of Report:

1.1 This report is a summary of the main issues discussed at the Planning and Performance Subgroup meeting held on 16th July 2015.

2.0 The New Operating Model

2.1 The new Operating Model was approved by the Board of Directors (BoD) and completes one of the key action points arising from the Foresight Report. It will bring a single structure to all localities; key staff that will be present in each locality are Lead Clinicians (one medical and one non-medical), Modern Matrons and Locality Managers. There will be two deputy Medical Directors – one based in Norwich and the other in Suffolk. The number of management layers remains an issue as in some areas seven tiers still exist.

2.2 Gary Page confirmed that further work is required to strengthen middle management and equip them to deal with difficult situations e.g. holding staff to account for poor performance. The impact of the new model on staff should be minimal although they are expected to notice improvements in decision making, governance and opportunities for clinical input.

3.0 Lorenzo and Operating Processes

3.1 Dave Huggins was in attendance to report on the implementation of Lorenzo. His feedback was balanced and acknowledged some areas that could have gone better e.g. IT dependencies should have been delivered earlier. It was recognised that there is a difference in perspectives and mixed feedback has been received from staff.

Date: 1st October 2015 R Item: 15.54iii

Board of Governors Meeting - 1st October 2015 – P&P Subgroup Report

Version 0.1


Page 1 of 2 Date produced: 8th Sept 2015 Retention period: 30 years

4.0 Annual Review of Terms of Reference

4.1 The Terms of Reference was approved subject to a minor amendment and has been submitted to the Board of Governors (BoG) for approval.

5.0 Financial Position

5.1 The group questioned the confidence of the Executive Team in achieving the financial improvements required. Stuart Smith provided assurance that significant work was being done and the mediation outcome and CIP achievement are areas of focus which it is hoped will lead to an improved position.

6.0 Alexander Report

6.1 Concerns were raised regarding the Alexander Report and that governors only became aware of this when it was made public at the same time as the July 2015 BoG meeting. Gary Page advised that the BoD had not commissioned the report and had never discussed it. The first time most Board members had heard about the report was when the press story broke. Members of staff participated in the production of the report on the understanding that it would remain confidential, hence the reluctance to release the report until first getting the approval of the staff involved.

7.0 Recommendations

7.1 The Board is asked to note the report.

Board of Governors Meeting - 1st October 2015 – P&P Subgroup Report

Version 0.1


Page 2 of 2 Date produced: 8th Sept 2015 Retention period: 30 years

Report To: Board of Governors - Public


Title of Report: BoG Education Subgroup Chair’s Report

Action Sought: For Information and approval


Author: Jane Millar, Public Governor Suffolk, Chair of Education subgroup

Director: Jane Millar, Public Governor Suffolk, Chair of Education subgroup

Summary: This report is a summary of the main points discussed at the Education Sub-group meeting held on 11th August 2015.

1.0 The main points from the meeting are:- 1.1 DBS checks

A revised process has been agreed to ensure all governors register and complete an up to date DBS check by 1st October 2015.

1.2 Governors training programme • A three part induction/refresher programme for all governors, together with two

half day development sessions, has been organised for the first half of 2016. All of these sessions have been constructed taking into account feedback from last year’s events.

• Governors wish to record their thanks to the Non-Executive Directors who took part in the "getting to know you" session, which was so informative and helpful.

1.3 Shared training and development

We are pursuing links with local governing bodies to share learning and to consider joint training sessions. Contacts also established to share experience and learning with buddy trust and other trusts who have successfully exited special measures.

Date: 1st October 2015 S Item: 15.54iv

Board of Governors – Public 1Oct2015, BoG Education Subgroup Chair’s Report

Version 1.0

Author: Jane Millar Department: Governor


1.4 Board of Governors Self-evaluation

• The 2015 self evaluation survey has been issued to all governors for

completion. The feedback will inform further training and development needs. • Further evaluation of the work of the Board of Governors will be sought from

the Board of Directors and members of the Trust.

2.0 Recommendations

2.1 Governors are asked to note the report.

Jane Millar Public Governor (Suffolk), Co-Chair of BoG Education Subgroup

Board of Governors – Public 1Oct2015, BoG Education Subgroup Chair’s Report

Version 1.0

Author: Jane Millar Department: Governor




Title of Report: Nominations Committee Chair’s Report

Action Sought: For Assurance For Approval of NED remuneration rates



Director: Marion Saunders: Chair of Nominations Committee (SID)

Executive Summary: The Nominations Committee oversee the appointment and remuneration of the Non-executive Directors (NEDs) including the Chair on behalf of the Board of Governors. This report provides a summary of the meeting held on 28th July 2015. The Board of Governors is asked to approve the remuneration rate for the Chair of the Audit and Risk Committee and mileage rates for NEDs and the Chair.

1.0 NED Recruitment

1.1 John Brierley and Stuart Smith are coming to the end of their terms as non-executive directors and so the Nominations Committee has been making arrangements to recruit to these roles. Following a presentation from two providers the committee has appointed an external recruitment company (Gatensby Sanderson) to assist with the process. One of the posts is the Chair of the Audit and Risk Committee (currently held by John Brierley). In addition to the core NED competencies, the Chair of the Audit and Risk Committee must have recent relevant financial experience.

1.2 The vacancies have been advertised from 17th August to 17th September 2015 and a subgroup of the Nominations Committee will shortlist on 8th October 2015. The plan is for interviews to take place in October with a view to a recommendation coming to the BoG meeting on 30th October 2015 (on the morning of the member event at University College Suffolk, Ipswich).

1.3 To enable a smooth handover for the role of Chair of Audit and Risk, a separate paper on today’s agenda proposes that John Brierley’s term be extended.

Date: 1st October 2015 T Item: 15.54v




2.0 Remuneration

2.1 The committee carried out its annual review of NED and Chair remuneration using benchmarked data from comparable Foundation Trusts. Although the benchmarking information shows that the current level of £11k and £45k for the Chair is slightly below sector average, the committee agreed that the current levels should be maintained.

For the role of Audit and Risk Chair, it is common for an additional payment to be made in recognition of the significant additional work and responsibility that this role carries. The committee agreed that the post should be advertised at £14.5k which is in line with the sector average for the role and slightly below the current remuneration level of £16k. The committee recommends this change to the Board of Governors for approval.

2.2 In relation to expenses, the committee recommends that the mileage rate payable to non-executive directors be aligned with the HMRC non-taxable rate of 45ppm (to 10,000 miles then 25ppm). This is a change from the current NHS Agenda for Change mileage rate of 56ppm (to 3,500 then 20ppm) and has the advantage of simplifying tax arrangements.

3.0 Time commitment

3.1 In drafting the advert for the NED vacancies the committee discussed the time commitment (currently described as a minimum of 4 days per month). The committee recognised that NEDs sometimes commit more time than this and also acknowledged the importance of NEDs maintaining their independence. The committee decided not to vary this but to keep the matter under review in line with the terms of reference for the nominations committee

4.0 Recommendations

4.1 The Board of Governors is asked to note that the remuneration levels for NEDs and the Chair remain unchanged and to approve the (slightly reduced) remuneration level of £14.5k for the role of Chair of the Audit and Risk Committee.

4.2 The Board of Governors is asked to approve the change of mileage rate for NEDs to 45ppm (to 10,000 miles then 25ppm) as set out above.

Background Papers / Information None.






Title of Report: Improvement Plan Coordination Sub-group Report



Author: Guenever Pachent: Lead Governor

Governor: Guenever Pachent: Lead Governor

Executive Summary: The Improvement Plan Coordination Sub-group (IPC) was set up by the Board of Governors (BoG) following Monitor’s decision to put the Trust into special measures in February 2015. The BoG approved the terms of reference for the IPC in March 2015. This report provides a summary of the July and August 2015 IPC meetings.

1.0 Summary of concerns and issues

1.1 At the meeting held on 21st July 2015 the group concluded the following, and as a result the Lead Governor wrote to, and received the reply from, the Chair.

Recruitment strategy – although activity is taking place there is no clear written strategy and therefore it is difficult to assess whether the activity is successful. Additionally feedback from frontline staff indicates that progress is not as good as the recruitment figures suggest. There continues to be a lack of clarity around the interview process and the involvement of service users and carers. It is important to establish how the Non-Executive Directors (NEDs) are assured that recruitment activity is taking Norfolk and Suffolk NHS Foundation Trust (NSFT) in the right direction of being properly and safely staffed.

Feedback from Board Committees – positive feedback was given on the Quality Governance Committee (QGC) and Finance Committee. It was felt that the Organisational Development and Workforce (OD&W) Committee would benefit from greater clarity around responsibilities and a more robust follow up of unsatisfactory answers to questions.

Feedback from Monitor Stakeholder Assurance meeting – recruitment has been highlighted as the key area to focus on. Additionally the pace of progress is now of vital importance.

Date: 1st October 2015 U Item: 15.54vi

Board of Governors, 1st October 2015, IPC report

Version 1.0 Author: Lucy Want Department: Trust secretariat


Quality Improvement Plan (QIP) plan report – the governors agreed to seek assurance around the number of QIP projects signed off by the relevant committees as this was unclear from the papers received. A lack of documentation relating to the transformational projects was also raised as a concern.

1.2 At the meeting held on 24th August 2015 the governors concluded the following, and as a result the Lead Governor wrote to the Chair and received a response.

Feedback from Board Committees - With regards to both the QGC and Audit & Risk Committee (A&RC) meetings, their chairs are requiring further evidence in the form of actions being followed through to satisfactory outcomes. Concerns were raised with regards to the OD&W Committee as it was felt that focus has been given to explanations of why work has not been done, rather than the actions that will be taken to rectify this. It was felt that the NEDs could be stronger in seeking assurance. Additionally it appears the QIP projects overseen by the OD&W Committee have not yet been reviewed and signed off and it was agreed that this would be followed up.

Update on visit to Basildon Trust – Governors Catherine Wells and Sheila Preston visited Basildon Trust along with Non Executive Director John Brierley. There were several learnings that could be beneficial within NSFT including Executive Directors or senior managers being available to staff on a daily or weekly basis, an increase in visits to the wards, and presentations from services at Board of Director (BoD) meetings of work that has gone well. The IPC group agreed that governors should be more involved with community team and ward visits and agreed to take this forward as an action.

Feedback from a discussion between Guenever Pachent and Rebecca Farmer (Monitor) - Monitor provided feedback that more work needs to be done to progress the transformational projects. Clear documentation with timescales and outcomes needs to be in place.

Review of papers from August 2015 Stakeholder Meeting - The service user and carer strategy has moved from a ‘red’ rating to ‘amber’. The level of input from service users and carers is low in some areas, particularly central Norfolk. Therefore in light of this assurance needs to be sought as to how sustainable the ‘amber’ rating is. Mandatory training is reported at just over 70% and the group agreed that this should be questioned to ensure plans are in place to address this.

Feedback from the Buddy Trust - Robert Nesbitt updated the group on interactions with the Buddy Trust. The Human Resources (HR) and Secure Services departments have been working together. Several members of the BoD were due to attend a BoD meeting on 27th August 2015 at the buddy Trust as observers. Lynn Skipper is leading on some work looking at the exchange of service users between the Trusts although no date has yet been identified. Julian Eve, Nottinghamshire Healthcare Trust’s Associate Director of Learning & Development, will be joining NSFT in w/c 7th September for 1 day a week until December 2015.




2.0 Recommendation

That governors assure themselves that the work of the IPC is satisfactory. Background Papers / Information None.


