Dec 2014 Public Board papers PDF version2014/12/02 · 10.5 Mental Health Act Scrutiny Committee’s Chair’s Report Assurance Dr Hill Enc 11 1.50pm 10.6 Management Executive Team

PUBLIC MEETING OF THE TRUST BOARD

1pm, Wednesday 3rd December 2014Boardroom, Canalside House, Walsall

AGENDA

Culture and Conduct ProtocolWe are a values-led Board. We place quality of care and safeguarding the needs of our patients at the heart of

everything we do. We work consciously as a team to support and constructively challenge each other in the best interests of service users, their carers and families. We champion the interests of staff and acknowledge that they are

working well in challenging times. We seek to ensure value for money at all times through efficient use of our resources in the delivery of services and achievement of standards. We welcome the rigour of debate with fellow

Board members, drawing upon a range of different experiences and perspectives and applying the Nolan principles of Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership.

ITEM Purpose Board Lead Format Timings

1. Apologies Oral 1pm

2.

Minutes of the Previous Meeting

To approve the minutes of the Board meeting held onWednesday 5th November 2014

Approval Ms Oum Enc 1

3. Summary Report of Confidential session of Trust Board held on Wednesday 5th November 2014 Information Ms Oum Enc 2

4. Matters Arising Continuity Ms Oum Enc 3

5. Notification of Items of Any Other Business Oral

6.Declarations of Interests For Board members to declare any relevant interests in items on the agenda.

All Enc 4

7. Questions from Members of the Public Oral

8. Chair’s Comments Information Ms Oum Enc 5 1.10pm

9. Chief Executive Officer’s Overview (including written summary of strategic publications and headlines) Information

Mr Graham Enc 6 1.15pm

10. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

10.1

Trust Integrated Performance Dashboard (Month7)Performance ReportQuality Governance ReportFinance ReportWorkforce Report

Assurance

Mr Axcell/Ms Pugh/Ms Ingram

Enc 7 1.20pm

ITEM Purpose Board Lead Format Timings

10.2 Board Statements for Monitor and TDA - Month 7Approval (following Chair’s action)

Mr Axcell Enc 8 1.35pm

10.3 Governance and Quality Committee Chair’s Report Assurance Dr Gutteridge Enc 9 1.40pm

10.4 Finance and Performance Committee Chair’s Report Assurance Mr Higgs Enc 10 1.45pm

10.5 Mental Health Act Scrutiny Committee’s Chair’s Report Assurance Dr Hill Enc 11 1.50pm

10.6 Management Executive Team Chair’s Report Assurance Mr Graham Oral 1.55pm

10.7 Service Experience Desk Report Quarter 2 AssuranceMs Ingram (Ms Adams in attendance)

Enc 12 2pm

11. LEADERSHIP, CULTURE & WORKFORCE

11.1 Medical Directors’ Update AssuranceDr Weaver/Dr Gingell

Oral 2.10pm

11.2 Nurse Director Update Assurance Ms Pugh Oral 2.15pm

11.3 Monthly Ward Staffing Report and Bi Annual Ward Staffing Report Assurance

Ms Pugh(Ms Musson in attendance)

Enc 13 2.20pm

11.4Wider Staff Engagement Work and Focus GroupHeadlines, plus Bullying and Harassment action plan

Assurance/Discussion

Ms Ingram(Mr Johnson in attendance)

Presentation 2.30pm

12. STRATEGIC DEVELOPMENT & DIRECTION

13. ANY OTHER BUSINESS

3pm

14. DATE AND TIME OF THE NEXT MEETING

Wednesday 7th January 2015, 1pm, Trafalgar House, Dudley

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MINUTES OF THE TRUST BOARD MEETING OFDUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST

Held on Wednesday 5th November 2014Village Hotel, Dudley

PUBLIC SESSION

Present

Ms D Oum Chair Mr G Graham Chief Executive OfficerMs M Ingram Director of People and Corporate Development/Deputy CEOMs W Pugh Director of Operations, Nursing and EstatesMr M Axcell Director of Finance, Performance, IM and TDr M Weaver Joint Medical DirectorDr S Hill Non Executive DirectorMr D Matthews Non Executive Director Dr R Gutteridge Non Executive Director Mrs G Cooper Non Executive DirectorMr M Higgs Non Executive Director In Attendance

Ms M Edwards FT Project/Company Secretary ConsultantMiss H King Minute TakerMs H Attwood Personal Assistant to Service Transformation Programme Director

(observation purposes)

305. APOLOGIES ACTION

Apologies were noted from Dr Kate Gingell, Joint Medical Director.

The Chair highlighted the culture and conduct protocol on the agenda which had been agreed at the Board Development Session on 22nd

October 2014. She asked if the Board wished to make any final amendments to the protocol.

Mr Higgs asked that some additions be made to the protocol to include reference to the quality protocol, and the safeguarding protocol, and the focus on service users and carers. He also asked that a statement be included that referenced the Trust’s financial obligations, and sustainable financial position.

It was agreed that the protocol would be amended in line with the above comments. Mr Axcell would draft an appropriate form of words regarding the Trust’s financial obligations.

Ms Edwards/Mr Axcell

306. MINUTES OF THE PREVIOUS MEETING

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The minutes of the meeting held on 1st October 2014 were agreed as an accurate record.

The minutes were approved and would be signed by the Chair.

307. SUMMARY REPORT OF CONFIDENTIAL SESSION OF TRUSTBOARDThe Board noted a summary of the business transacted in the confidential session of the Trust Board held on 1st October 2014.

308. MATTERS ARISING

The schedule of matters outstanding was noted.

Ms Pugh provided an update on action 286.1 regarding the report on the deep dive being completed on staff well-being and incidents across operations, looking at Occupational Health and Health and Safety. The report would be presented to the next Health and Safety Committee, and then submitted to Trust Board in the New Year.

309. NOTIFICATIONS OF ITEMS OF ANY OTHER BUSINESS

No items of any other business were noted.

310. DECLARATIONS OF INTERESTMembers were asked to disclose any interest they may have, direct orindirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item.

No interests were declared in addition to those already recorded on the Register of Interests.

311. QUESTIONS FROM MEMBERS OF THE PUBLIC

No members of the public were present.

312. CHAIR’S COMMENTS

The Chair advised that her focus over the past month had been mainly outward facing, meeting stakeholders and partners. She had however begun to visit a few internal services.

The Chair highlighted that her main message for the Board was to increase focus on partnership working.

The Board received the Chair’s update for information and assurance.

313. CHIEF EXECUTIVE OFFICER’S OVERVIEW

Mr Graham took the Board through the key points of the strategic overview and horizon scan paper. The following was highlighted:

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- Staff Friends and Family Test quarter 2 results were currently being benchmarked against the national results. The Trust had been in the top quartile for quarter 1, and if benchmarking was stillthe same it was hoped that the Trust would still be in the top quartile for quarter 2.

- The publication of the consultation document for the 2015-16national tariff payment system had been delayed by three weeksto the end of December 2014.

- The first ever waiting time standards for mental health had been announced by the Department of Health. Mental health would work to the 18 week wait standard. First views were that it would not be a problem for the Trust. Appropriate arrangements would be put in place to ensure mandated waiting times were adhered to.

- The NHS Five Year Forward View would form a significant part of the Trust’s Clinical and Social Care Vision. The view offered a menu for the LHE to choose from. Relevant matters would be brought to Trust Board for consideration if necessary.

- The CQC had identified a variation in care quality. Mr Graham highlighted that the Trust was the only one of the mental health pilot sites that the CQC had given explicit sign off to continue through to the Monitor assessment phase.

The Board received the CEO’s overview for information and assurance.

314. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

314.1 Trust Integrated Performance Dashboard – Month 6

Mr Axcell took the Board through the key points, issues, and risks, as set out within the Dashboard Report and the Performance Report. The following additional information was noted:

- CPA figures were on target on the dashboard, but were highlighted as they had seen a slight deterioration in October; it had been challenging to meet the target. The Associate Director of Operations and the operational teams were working on improving the figures.

- Activity against contract was still a concern, but had improved. The financial risk had reduced to £310.6K from a previous figure of £570K. Action plans were in place to address the shortfall, and underperformance was being closely monitored by the Finance and Performance Committee. The Chair queried whether the improvement had been due to managed performance, or whether it was simply a natural spike. Mr Axcell clarified that the majority was due to managed performance, and capacity issues, which had been resolved.

- Mr Graham highlighted the staff engagement work, which had been undertaken so far, which had uncovered that some staff were unaware that they had targets to meet, this was a management issue which needed to be resolved. It was also

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highlighted that some staff were not aware of the bigger picture, and therefore when the pressure was applied for targets they didnot know what was happening or the reasoning behind it.

- CIP against plan (full year effect) was on track.

The Chair stressed that intervention was required at senior level to address performance issues within the Trust. She asked for teams and individuals to be monitored against clear performance objectives and that timelines of information recording and provision to be developed.

Mr Higgs commented that the dashboard displayed a majority of greenRAG ratings because of the leadership of the Executive Team. TheBoard had to take responsibility for the performance issues within the organisation.

Quality Governance ReportMs Pugh informed the Board that there had not been a Governance and Quality Committee held in October. A quorate e-mail group had been convened instead to consider three essential reports, in order to ensure external reporting deadlines were achieved for the Quality Report, Risk Register, and Draft Safeguarding Annual Report. Ms Pugh took the Board through the key messages from the Quality Governance report and the following was highlighted:

- There had been 7 serious incidents, which was an increase on last month.

- Incidents of failure to return from leave had increased which was a growing concern, therefore a 6 month deep dive was being undertaken in to this area. With regards to Triangle of Care, the Trust was looking at how it could better equip carers when a service user did not want to return to hospital from leave. Outcomes from this work would be taken to Governance and Quality Committee initially, and then to Board.

- Older Adult and Acute Services had seen a significant increase in disruptive behaviour from patients. The increase in Acute had been down to particular patients and so should improve soon.Older Adults had seen an increase in the challenging behaviour type of patients.

- Ms Pugh highlighted that the category ‘patient accident’ consisted of such things as observed falls and knocks, none of which were serious and none which had resulted in injury.

- With regards to safeguarding, there had been an increase in child alerts, all of which had been managed appropriately.

Mrs Cooper queried the circumstances surrounding the incidents of absconsions of sectioned patients, as there had been 2 quite recently. Ms Pugh explained that the recent incident had been due to tailgating. The matter had been raised with staff and awareness in general had been raised. The patient in question had returned themselves to the ward and no harm had come to them. Ms Pugh explained that the termabsconsion had to be used every time a patient had exited the hospital grounds. Therefore an incident of absconsion would have to be

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recorded even if a patient simply went just outside of the gate.

Workforce Report Ms Ingram explained that the report submitted to the recent Finance and Performance Committee had contained figures for August, instead of September. Ms Ingram explained that this was a reporting error and reporting would be back to normal next month. The figures in the report for Board were for September. Ms Ingram took the Board through the workforce report highlighting the key messages. The following was noted:

- Sickness had decreased by 0.32% to 5.44%. - Another 4 hour strike was due to take place on 24th November

2014 with regards to the national pay dispute which the Trust was not anticipating any service disruption.

- Awareness raising training appeared to be increasing the level of child safeguarding alerts within the Trust.

Considerable discussion was held around the sickness levels within the Trust. The following was noted:

- 75% of sickness absence were long term sickness cases, with the primary cause being stress/anxiety/depression.

- The sickness absence management policy was being fully adhered to.

- A brainstorming session had been held week commencing 27th

October 2014 to come up with creative ideas. Proposals from the meeting were being submitted to MExT on 11th November 2014, and included such things as stress resilience training for staff, and bringing people back to work earlier in a more supportive fashion.

- With regards to action 300.1 from October’s Trust Board meeting, the outline proposal for the review of sickness absence would be circulated to the Board soon, with a headline report regarding the sickness absence review to be presented to January Trust Board.

- Mr Higgs highlighted the high level of bullying and harassment figures within the NHS which had been brought to light in the private session of the Board. Within the NHS it was reported to be 22%, compared to a very minor figure in the private sector. He queried whether there was any context there.

- Dr Gutteridge highlighted the Boorman Report 2009; sickness absence was a challenge for all public sector organisations as the public sector by its nature attracted a more vulnerable workforce, and had government pressures and targets to meet.

- Mr Graham also reminded the Board of the infection control measures in place within the NHS, which the private sector did not have to adhere to. The NHS had a very generous sickness absence scheme, which was not punitive.

- Ms Pugh informed the Board that a considerable portion of staff were off with mental health issues and the Trust had a duty of care to explore all options of rehabilitation with staff. In some cases there was an association between the workplace and ill health.

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- The Chair queried what was being done regarding short term sickness absence. Ms Ingram clarified that about 1 in 4 of cases

- were due to short term sickness absence, with the main reasons being back problems, and cold and flu. There would inevitably be an increase in short term sickness during the winter due to colds.A different approach was needed, and the measures that were being proposed would help address this.

- It was noted that Older Adults had been at approximately 10% sickness in March, but their sickness level had reduced to 5.31%,which was an excellent reduction.

Appraisals were discussed and Ms Ingram advised that she expectedthe figures to drop slightly due to the yearly cycle of appraisals. Work was being undertaken with managers to improve appraisal figures, and to spread the appraisal process over the full year in future, instead of having most of them in the first half of the year as per the current process.

It was clarified that the Occupational Health Service had transferred successfully on 1st November 2014.

Finance ReportMr Axcell took the Board through the finance report and the following was highlighted:

- Month 6 showed a surplus of £536K, which was £178k ahead of plan to achieve the £808k surplus by year end.

- The Trust was currently carrying provisions for any financial risks anticipated at this stage.

- It was hoped that that the benefits of the Mutually Agreed Resignation Scheme would start to be seen in the figures for October. Work was being done with HR as to why the benefits had not been seen already.

- The Capital programme had seen a slight slippage. Schemes had been committed at the Estates and Capital Planning Group.

The Board noted the performance of the Trust as at month 6.

314.2 Board Statements for Monitor and TDA – Month 6

The Board noted the content of the submissions, which set out theBoards statements and declarations regarding the Trust’s performance as at the end of month 6 2014/15. The Board declarations had already been signed off for submission to the TDA on the 31st October as a Chair’s action. The Finance and Performance Committee had also endorsed the returns.

The Board endorsed and ratified the submission as at month 6.

314.3 Governance and Quality Committee Chair’s Report

Dr Gutteridge took the Board through the Governance and Quality Committee Chair’s report. As had already been explained there had

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been no Committee meeting held in October, however a quorate e-mail group had been convened instead. The suggestions regarding the Risk Register had been agreed during the private session of the Board.

It was explained that even if the Committee was not quorate it was important for a meeting still to take place in order to discuss key issues for Trust Board. The Chair advised that it was vital that the Committees undertook their business as without that assurance the Board would need to focus down on levels of detail and in so doing, inhibit the Board’s ability to take the required strategic overview.

Mr Graham highlighted a recent week where there had been Committee meetings during a school half term when many people had leave. It was suggested a review of 2015 Board and Committee schedules was undertaken to avoid key holiday periods.

The Board accepted the report for assurance and endorsed the decisions and recommendations made by the Committee.

Ms Edwards

314.4 Finance and Performance Committee Chair’s Report

Mr Higgs updated the Board on the business of the Finance and Performance Committee.

Mr Higgs drew attention to the Trust’s EBITDA which stood at 5.8%. This was a powerful figure. The Trust had a liquidity of 83 days, and had a £14,885 million cash provision. Tax payer equity stood at £5.2 million.

There were still concerns regarding performance and activity but these were being monitored.

Mr Higgs praised the excellent work the Trust was doing taking on apprentices. The Chair also expressed her support and endorsement regarding the Trust apprenticeship scheme.

The Trust’s cash position was highlighted, with Mr Higgs and Mr Graham both expressing anxiety over the position. Mr Graham stressed the need for good use of public money, and Mr Higgs raised the issue that it made the Trust vulnerable to take over. Dr Hill also commented that the amount of cash being held did not look right when the Trust was pushing for cost improvements.

The Chair reassured the Board that once strategy was in place the Trust would spend money. The Board had already agreed that its focus was growth. The Business Opportunities Team may well present opportunities for spending of cash in the future.


314.5 Audit Committee Chair’s Report

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Mr Matthews briefed the Board on the business transacted within the Audit Committee. A report had been received which detailed the progress of the Winterbourne and Francis recommendations, which had been awarded significant assurance.

The amended Terms of Reference were submitted to the Board for completeness, and it was acknowledged there may be more changes required following work on the Risk Strategy.


314.6 Management Executive Team (MExT) Chair’s Report

Mr Graham informed the Board that the main topic of discussion at MExT meetings had been CIP 2015/16 and 2016/17, details of which would be discussed at the Board Development Session on 17th

December 2014. Other topics of discussion had been tenders, Section 75, and the ombudsman report.

The Board accepted the update for assurance.

314.7 Quality Update Report and Francis Winterbourne Recommendations UpdateMs Pugh updated the Board on the report, which provided a quarterly update on the ongoing implementation of the Quality Improvement Strategy. Quality continued to be embedded in line with the 7 quality improvement priorities. There were no significant concerns to report concerning the 7 areas. The subject would be discussed with the Board in detail during the December Governance and Quality Committee where the QGAF was on the agenda for review.

The Board accepted the report for assurance.

314.8 Safeguarding Annual Report

Ms Pugh took the Board through the annual report on safeguarding. The report had also been submitted to Governance and Quality Committee, and included future priorities.

Dr Hill commended Ms Cooper, the author of the report, for the production of such a good report for such a complex area.

Ms Pugh clarified that the report would be taken to the Safeguarding Board once it had received the Board’s approval.

Mr Higgs queried the activity figures within the report and what this meant for the Trust. Ms Pugh explained that the Trust had a high number of reported alerts compared to other organisations, but this was because its systems were fully embedded. The Trust were happy with the level of alerts reported as it meant it had a health reporting structure.

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The Board approved the Safeguarding Annual Report.

315. LEADERSHIP, CULTURE, AND WORKFORCE

315.1 Medical Directors’ UpdateDr Weaver had no items to bring to the Board’s attention.

315.2 Nurse Director Update

Ms Pugh informed the Board that the Trust had been awarded a gold star award as part of the Triangle of Care membership scheme for the implementation of the Triangle of Care across all inpatient and CRHT Services.

The Chair commended the hard work and effort which had been put in by staff, and particularly Ms Jo Marshall, Triangle of Care Lead. The Chair’s personal thanks should be passed to Ms Marshall for her work on the project.

The Board received the update for information and assurance.

Ms Oum

316.3 Monthly Ward Staffing Report

Ms Pugh took the Board through the report and highlighted the key messages. Ms Pugh drew the Board’s attention to the exception reports for variance on Clent and Holyrood Wards. The variance had been due to staff sickness, and the challenging behaviour of service users. The Board were assured that safe staffing levels were maintained. There had been no reported incidents, and no further actions were required.

The Chair queried whether the report could be used as a more enhanced workforce report. It was also queried by Dr Hill whether the right staffingwas in place to ensure adequate skill mix. Ms Pugh explained that the Trust could only draw on what resources it had and so the fill rate of RMNs would be affected by sickness. A rolling programme of recruitment was in place.

It was agreed that future Ward Staffing Reports would include detail regarding split between planned and actual, substantive and temporary, qualified and unqualified, staff.

The Board noted the data, and were assured of safe staffing levels for September 2014.

Ms Pugh

316.4 New Duty of Candour

Ms Edwards advised the Board on the implications of the new statutory Duty of Candour and recommended actions. For NHS Trusts and Foundation Trusts the Duty of Candour was intended to take effect from October 2014, however there was no exact date available yet.

It was thought that most of the systems and processes that were needed

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to ensure compliance with the new duty were already in place.

Ms Edwards informed the Board that the Department of Health referred to the National Patient Safety Agency’s ‘Being Open’ guidance, which suggested a number of steps that providers should implement.

A meeting had been arranged for the 4th November to consider current policies and processes and to take forward any actions that may be required. Ms Pugh was leading on this.

The National Patient Safety Agency’s suggested steps were talked through, and incident processes mentioned. It was decided that an audit would be undertaken in to serious incident and complaint handling processes to provide assurance on application of duty of candour. The audit outcome and any areas identified for improvement would be reported to Board through the Governance and Quality Committee.

The paper recommended the nomination of a lead executive and non executive responsible for candour. Ms Ingram queried whether anyone should be nominated at all as the whole Board had responsibility for candour.

Dr Gutteridge highlighted that the duty was followed anyway as the Board worked to the Nolan Principles, which included transparency.

The Chair mentioned a presentation by Grant Thornton on the Duty of Candour which she had found very useful. The Chair advised that she would circulate the slides to the Board.

The Chair would give consideration to the need for a Non Executive lead for candour, as the matter had not yet been discussed with the Non Executives.

The Board noted the new Duty of Candour requirements, their implications, and good practice guidance outlined. The Board were happy to make a public commitment to implementing a policy of candour.

Ms Pugh/ Dr Gutteridge

Ms Oum

Ms Oum

317. STRATEGIC DEVELOPMENT AND DIRECTION

317.1 2014/15 Annual Plan and Board Assurance Framework Review –Quarter 2Ms Edwards took the Board through the report which comprised of performance against objectives demonstrating progress made against each of the 14 high level objectives, and assurances on the management of risks related to achieving the 2014/15 objectives (Board Assurance Framework (BAF)).

Of the 14 strategic objectives identified there were 9 with full assurance and 5 with significant assurance.

The Audit Committee had asked to see the BAF on a 6 monthly basis,

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Signature……………………………………………………….. Date…………….

Ms D Oum, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board

and would use it to help set the internal audit plan for the next few years. The Board were happy with this idea.

Mr Matthews highlighted objective 3 ‘support a culture of innovation and new ways of working to enable staff to contribute to all aspects of the QIPP agenda’. Mr Matthews queried whether the level of assurance should be a level 3, or whether it should be lower than this. Ms Edwards clarified that it was the level of assurance against the objectives, rather than the level of risk.

Mr Graham highlighted that the staff survey results were good and the Trust was within the top quartile for them. The Trust was doing quite well with regards to this objective.

The chair queried whether the sources of assurance noted were effectively providing the assurance needed, or was the Trust just carrying out the activity. The Board was aware of the risks but needed toknow the impact of things and be assured that everything was satisfactory. Dr Gutteridge advised that she did not think that the right metrics were in place at present to provide the assurances needed.

Ms Edwards advised that there were a number of assurances within the Risk Register and if the Board were going to look at risk they needed to look at the BAF objectives framework and the Risk Register together. This would be undertaken in the Board Development session on the morning of the 3rd December 2014.

The Board noted the contents of the report and would look at it further during the Board Development Session due to be arranged for the morning of 3rd December 2014.

318. ANY OTHER BUSINESS

No items of other business were raised.

319. DATE AND TIME OF NEXT MEETING

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Board meeting date:3rd December 2014

Agenda Item number: 3 Enclosure: 2

Title Summary of Confidential session of Trust Board held on 5th

November 2014

Accountable Director: Ms Oum, Chair

Author: Mandy Edwards, Interim Company Secretary

CONTEXT AND BACKGROUND FOR REPORTBest practice in corporate governance requires that business considered in private session is reported into the public session as soon as possible. Given the arrangement of the Board meetings, the earliest opportunity is at the public session of the following month.This report outlines the business considered in private at the meeting of the Board held on 5th November 2014.

KEY ISSUES FOR BOARD OF DIRECTORS CONSIDERATION AND DECISION Chair’s UpdateThe Chair provided an update on recent activities as part of her induction which included:

Ms Oum had met with service users, staff and had started to meet with external stakeholders.

Stakeholder discussions had highlighted the importance of being responsive to the requirements of external stakeholders within the local health economy.

The Chief Executive Officer’s (CEO’s) overview The Board received an update on:

NHS England Five Year Forward View – key messages included ensuringdelivery of this year’s and next year’s CIP measures, and that there will be a different NHS financial outlook in five years. FT Re-activation – Monitor had recently licensed 3 Trusts as NHS FTs. TheTrust would not know until mid December whether there will be a Monitor assessment team available to commence its re-assessment in January 2015.Unison Industrial Action - The previous Unison strike, which took place on 13th October, had not impacted on services and was managed very effectively with 33 members of staff taking part. An announcement had been made that further industrial action was planned for 24th November with a potentially wider impact, although this was yet to be confirmed.

CIP PMO and Service Transformation ReportA report was presented which highlighted:

There had been no significant change to the financial position since the previous Board meeting. Three new projects had been signed off by MExT for implementation and there were 4 red risks held at project level.

Update on Clinical and Social Care VisionThe Board were appraised of the feedback received to date from the engagement work undertaken with stakeholders to inform and contribute to the development of the Trust’s Clinical and Social Care Strategic Vision 2015-2020.Trust Wide Risk RegisterTwo further strategic risks had been added to the existing Governance, Quality and Operational risks which are reviewed by the Governance & Quality Committee. The Risk strategy and policy will be updated during December and as part of this there will be a Board development session on risk at the beginning of the month. In addition, risk responsibilities will be made more explicit within the recently updated Committee terms of reference prior to final Board approval in January.Update on Canalside HouseThe Board considered the long term options with regard to the occupation of Canalside House. Nurse Director Update The Board were provided with information regarding:

The Trust’s action plan to minimise any Ebola contamination risks.Potential impact of participation in the wider health economy NHS on call rota.

Medical Directors’ UpdateDr Weaver updated the Board regarding a complaint that had been referred to the NHS Ombudsman. The complaint had been partially upheld by the Ombudsman and the Trust had used this experience as part of its lessons learnt process.Review of the Recommendations from Staff Engagement Review and Independent InvestigationThe general findings from the recent staff engagement work were presented to the Board. It was pleasing to note that 17% of the total Trust workforce had participated in the focus groups. From the findings, the 16 recommendations had been collated into 5 different themes. The Board discussed the findings and it was agreed that a plan would be brought back to the Board with actions prioritised and drawn into clear categories. Service and Business Development PMO ReportProgress updates were provided on all new and existing opportunities, including the business case for an upcoming tender submission.For AssuranceThe Board noted the minutes of the Governance and Quality Committee meeting held on 10th September 2014, the Audit Committee held on 18th September 2014 and the Finance and Performance Committee meeting held on 22nd September 2014. Any Other BusinessNo further business was raised.

RECOMMENDATIONS The Board is invited to note the business transacted in the private session held on 5th

November 2014.

Enc 3

MATTERS ARISING FROM PUBLIC MEETING

Item No.

Date Added Action Responsibility Due

Date Update

187 5th Feb2014

A Board to Board to be organised with the 2 CCG’s to take place within the next 6 months.

Ms Edwards Early 2015

Walsall CCG Board to Board (B2B) complete. AB2B to be scheduled with

Dudley CCG in early 2015.

244.14th

June2014

Integrated DashboardMr Axcell to look into benchmarking of reference costs against estates costs.

Mr Axcell

5th Nov 2014March 2015

To be incorporated as part of CIP planning.

280 3rd Sept 2014

Wider staff engagement work and focus groupoutcomes to be submitted to Board.

Ms Ingram

5th Nov 2014

3rd Dec 2014

On agenda.

286.1 3rd Sept 2014

Report to be submitted to Board on the deep dive being done in to staff well-being and incidents across operations, looking at Occupational Health and Health and Safety.

Ms Pugh7th

January 2015

Report to be presented to the next Health and Safety

Committee, and then submitted to Trust Board in

the New Year.

286.1 3rd Sept 2014

Public health and epidemiology to be looked at to see if sickness is increasing in general, and the increase in Trust levels occurring as a result.

Ms Ingram Nov 2014

To be incorporated in to longer term piece of triangulation work on

sickness (see action 300.1 below)

300.1 1st Oct 2014

Workforce Report

Ms Ingram to liaise with the other Executives about a forensic analysis and triangulation of sickness activity. Ms Ingram to circulate a proposal to the Board for agreement, with the full report to be submitted to Board at a later date.

Ms Ingram/Ms Edwards

Nov 2014

7th

January2015

Two linked pieces of work – longer term

view/triangulation plus short term plan to reduce

sickness. Outline proposal for review of sickness

absence to be circulated to Board. Headline report

regarding sickness absence review to be

presented to January Trust Board.

Enc 3

Item No.


Date Update

300.5 1st Oct 2014

Procurement StrategyMr Axcell to review learning from other organisations regarding the size andstaffing levels of theirProcurement Teams.

The Procurement Strategy to be brought back to the Board in December 2014 for approval.

Mr Axcell

Dr Hill /Mr Axcell

3rd Dec 2014

3rd Dec 2014

Deferred to January 2015.

305 5th Nov 2014

Board Culture Statement

Amend culture statement to include reference to service users and carers, quality culture, and safeguarding culture, and include revised statement on Private andPublic agendas for December Board meetings.

Draft a form of words to include in the statement that references the Trust’s financial obligations, and sustainable financial position.

Ms Edwards

Mr Axcell

3rd Dec 2014

3rd Dec 2014

Action complete.

Action complete.

314.1 5th Nov 2014

Performance Report

Team and individual monitoring against clear performance objectives, and timelines of information recording and provision to be developed.

Mr Axcell 3rd Dec 2014

314.3 5th Nov 2014

Review of 2015 Board and Committee schedules to avoid key holiday periods.

Ms Edwards 3rd Dec 2014

In progress.

315.2 5th Nov 2014

Chair’s personal thanks tobe passed to Ms Marshall for her work on theTriangle of Care Project.

Ms Oum 3rd Dec 2014

Action complete.

316.3 5th Nov 2014

Future Ward Staffing Reports to include detail regarding split between planned and actual, substantive and temporary,

Ms Pugh 3rd Dec 2014

Enc 3

Item No.


Date Update

staff.

316.4 5th Nov 2014

Duty of Candour

Give consideration to Non Executive lead for candour.

Circulate Grant Thornton presentation slides regarding Duty of Candour.

Undertake an audit in to serious incident and complaint handling processes to provide assurance on application of duty of candour. Audit outcome and any areas identified for improvement to be reported to Board through Governance and Quality Committee.

Ms Oum

Ms Oum

Ms Pugh/Dr Gutteridge

7th Jan 2015

3rd Dec 2014

TBC

Under consideration. To be confirmed January 2015

Slides have been requested and will be

distributed once received

Enc 4

REGISTER OF INTERESTS 3rd Dec 2014 CURRENT DIRECTORS

Date of appointment to the Board

Post Declared Interests

Ms Danielle Oum 08.09.14 Chair Non-Executive Director, Walsall Healthcare NHS TrustNon-Executive Director, Optima Community TrustWest Midlands Committee Member, National Housing Federation

Dr Stuart Hill 20.09.10 Non-Executive Director

Lay Member – Solicitors Disciplinary TribunalLay Member – Chartered Institute of Management Accountants Disciplinary CommitteeLay member - National Register of Public Service Interpreters Disciplinary CommitteeIndependent Person – Standards, Wolverhampton City CouncilLay member – RICS/IPA Fixed Charged Receivership Scheme Joint Regulation CommitteeLay Member – Financial Reporting CouncilTribunals PanelLay Member, RCVS Preliminary Investigation Committee

Michael Higgs 01.10.08 Non-Executive Director

Non-Executive Director of Extra Care Trust

David Matthews 20.09.10 Non-Executive Director

Nothing to declare

Dr Robin Gutteridge 01.12.11 Non-Executive Director

Consultant in Health and Wellbeing, Faculty of Education, Health and Wellbeing, University of WolverhamptonChartered Psychologist: Full member Division of Teachers and Researchers Accredited Member of the British Association for Counselling and Psychotherapy (BACP)Member of the College of Sexual and Relationship Therapists (CoSRT)HCPC Registered Counselling Psychologist: Number PYL27928.

Gill Cooper 01.06.13 Non Executive Director

Trustee – Frederick Pearson Fisher CharityServing Justice of the Peace – Dudley Bench

Gary Graham 01.09.08 Chief Executive Nothing to declare

Dr Kate Gingell 01.10.12 Joint Medical Director

Nothing to declare

Marsha Ingram 23.03.12 Director of People and Corporate Development

Nothing to declare

Wendy Pugh 01.10.08 Director of Operations & Nursing

Nothing to declare

Dr Mark Weaver 01.10.12 Joint Medical Director

Nothing to declare

Mark Axcell 28.04.14 Director of Finance and Performance

Trustee – A Child of Mine Charity

Board meeting date:3rd November 2014

Agenda Item number:8

Enclosure: 5

Report Title: Chair’s Comments

Accountable Director: Danielle Oum, Chair

Author (name & title): Mandy Edwards, Interim Company Secretary

Purpose of the report: To advise the Board on recent and forthcoming activities and events undertaken by the Chair and Non-Executives. To note key aspects of stakeholder engagement and areas of strategic relevance.

Action required from the BoardDecision / Approval Gain assurance Discussion Information

What other Trust Committee or Group has considered the key elements of this report?

Committee: None

Date reviewed: N/AKey points or recommendations from Committee:

Strategic Objective(s) to which this paper relates:High quality

servicesInclusive

partnershipsLeadership

cultureResponsible

workforceSupporting strategies

Effective/efficient resources

The CQC domains that this report relates to are:

Please give brief details:

Caring Stakeholder engagement and strategic leadership are important elements of a Chair’s role in ensuring strong governance and a responsive organisation.Responsive

Effective

Well-led

Safe

Title Chair’s Comments

Introduction

This paper forms the Chair’s monthly report to the Board regarding Chair and Board activities undertaken during the previous month, together with a forward look at programmed work.

Summary of key points, issues and risks

During November I have been completing my induction meetings with external stakeholders, and together with board colleagues, focusing in on the Trust’s vision, strategy and staff engagement. In summary, the things I have been involved in and my key learning points are:1. NED and Associate NED recruitment:

As part of the process for appointing a new NED and seeking an Associate NED I have been actively promoting applications for the roles across my networks and drawing attention to the growth potential of the Trust. I have also sought to encourage stakeholder involvement in the selection process, highlighting the Trust as outward facing and pro partnership.

2. IBP UpdateI have taken time to read the entire Integrated Business Plan, offering a fresh eye and input on the initial redraft in readiness for sharing with partners and submission to Monitor as a key part of our FT assessment reactivation.

3. Strategy refreshTogether with the Chief Executive I have been in liaison with Grant Thornton regarding the work they are doing with the Trust to build on and beyond the Board’s existing strengths.

4. Stakeholder engagementThis month I have given particular focus to the Walsall locality and have gained insight into partners’ views that they would welcome greater collaboration and more effective communication, brokering introductions. They would also welcome the potential to explore the concept of a Black Country Health Summit.

5. Growth agendaTogether with the Deputy CEO, I was provided with assurance by the business Development PMO about the principles, model and risks associated with a forthcoming tender. Together with assurances from the lead NED and Director of Finance regarding the financial model, the tender submission was approved under a Chair’s action.

6. Ambassador / NetworkingI attended the national FTN Conference in Liverpool on the 18th & 19th November. Key themes included a proposal by Andy Burnham that Health and Wellbeing Boards become

the commissioners supported by CCGs, with integrated provision of Acute, Mental Health, Community Services and Social Care. Jeremy Hunt announced the launch of MyNHS, a new part of the NHS Choices website where data will be published from across hospitals,GPs and local councils allowing the public to compare services in different parts of the country. Professor Jane Reid presented on Human Factor Science as a driver for safety culture. Simon Stevens spoke about adjustment to emergency tariffs and efficiency savings targets and identification of clinically relevant access standards for mental health for next year, and indicated that as LHEs identify into one of the four healthcare models set out in the 5 year forward view special provisions will be made for regulation. A range of FT providers, local authorities and Monitor showcased examples of collaborative service redesign, including joint strategic and delivery plans across CCGs, FTs, LAs and NHS Trusts.

Networking opportunities with other Mental Health Trust chairs and directors have enabled me to explore best practice approaches to NED and Executive involvement in understanding service delivery and operational reality. All said they incorporate board walk activity, including some unannounced out of hours visits, as well as patient attendance at public board meetings to share their stories.

7. Next MonthOver the next month my plan is to focus on Strategy refresh, FT readiness and NED recruitment.

Recommendation

It is recommended that: the board notes the Chair’s induction activities.

Board action required

The Board is asked to receive this report for information and assurance.


Agenda Item number: 9 Enclosure: 6

Report Title: CEO Strategic Overview and Horizon Scan

Accountable Director: Gary Graham, Chief ExecutiveAuthor (name & title): Mandy Edwards, Interim Company Secretary

Purpose of the report: This report summarises recent publications and information, which are of relevance or interest to the Trust. It sets out the key points in each publication and makes recommendations to the Board of any action the Trust plans to take.

Action required from the Board

Decision / Approval Gain assurance Discussion Information


Committee: N/A

Date reviewed:Key points or recommendations from Committee:


servicesInclusive


cultureResponsible





Caring The report provides information and highlights necessary action to ensure the Trust remains abreast of all relevant strategic developments that may impact all 5 CREWS domains.

Responsive

Effective

Well-led

Safe

Introduction

This report provides a summary of recent information and news of interest and relevance to the Board making recommendations to the Board of any action the Trust has taken or plans to take.


Summary of key areas for action:Recommendation for future Action Responsible

personOne Chance to get it rightImproving people’s experience of care in the last few days and hours of life.

Paper to be prepared and agreed through Trust governance processes.

Director of Operations, Nursing & Estates

Monitor - NHS foundation trusts: financial accounting guidance - updated

Review the updated guidance and apply anything of relevance to the Trust.

Director of Finance, Performance & IM&T

Department of Health - Jeremy Hunt: message to NHS staff on using technology and sharing information

Review the paper and identify any required action.


Department of Health - Ebola: top facts and mythbuster guidance

Consider inclusion in appropriate internal & external communications.


NHS Employees - Workforce Bulletin -New 2015 NHS Pension Scheme regulations - summary for employers

Assess if the summary would be useful to be communicated to Trust staff

Director of People & Corporate Development

NHS Confederation - Mental Health Network Annual Conference

Consider Trust representation at the Conference and agree timescale for Board briefing paper


Care Quality Commission - New fundamental standards published

Review the regulations and highlight implications and actions to the Board

Company Secretary/ Director of Operations, Nursing & Estates

Recommendation

It is recommended that the Board note and discuss the information contained within this report and consider the proposed actions.


The Board is asked to: Agree the recommended actions and nominated leads identified within the report.

Strategic Overview and Horizon Scan ReportOctober 2014

This report summarises recent important publications and information items, setting out the key points of each item and making recommendations to the Board of any action the Trust has taken or plans to take.

Trust Internal NewsRecommendation for future Action

Responsible person

First “In the Loop” newsletterSimon Johnson introduces his role as Staff Engagement Officer. The newsletter encourages people to complete their staff survey and gives results from Quarter 1 & 2 of the staff friends & family test. It also gives feedback on staff focus groups.

For Information

One Chance to get it rightPublished June 2014 by the Leadership Alliance for the Care of Dying People, One Chance to get it right - Improving people’s experience of care in the last few days and hours of life replaces the Liverpool Care Pathway. The TDA are asking all Trusts to look at the implications for their own organisations and provide a response to the TDA. http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/end-of-life-care/care-in-the-last-days-of-life.aspx

Paper to be prepared and agreed through Trust governance processes.


Monitor Website link: https://www.gov.uk/government/organisations/monitor

Recommendation for future Action

Responsible person

NHS foundation trusts: financial accounting guidance - updatedNHS foundation trust finance staff should use this guidance, which is updated regularly, to do their work.

The guidance has been updated and can be found at:https://www.gov.uk/government/publications/nhs-foundation-trusts-financial-accounting-guidance

Review the updated guidance and apply anything of relevance to the Trust.


Monitor awarded foundation trust status to 3 NHS trusts, effective from 1st November 2014Bridgewater Community Healthcare NHS Trust, Derbyshire Community Health Services NHS Trust and Royal United Hospital Bath NHS Trust are the Trusts which have been authorised.This means that there are now 149 NHS foundation trusts in total, over 60% of all trusts in England’s NHS. Bridgewater and Derbyshire are also the first community health to achieve foundation trust status.

The full news story can be found at:https://www.gov.uk/government/news/greater-say-for-patients-as-monitor-authorises-new-foundation-trusts

For Information

NHS foundation trust bulletin October 2014The FT Bulletin has information for foundation trust chairs, chief executives, finance, medical and nursing directors and board secretaries.

The bulletin can be found at:https://www.gov.uk/government/publications/nhs-foundation-trust-bulletin-october-2014

For Information

Department of Health (DoH)Website link: https://www.gov.uk/government/organisations/department-of-health


Responsible person

NHS well prepared for cold winter pressuresThe NHS has plans for winter in place earlier than ever before.NHS leaders, GPs, social services and other health professionals have run one of the widest winter planning exercises the NHS has ever seen.Local medical experts identified pressure points and a range of measures to address them, including:

More action to keep people out of hospital Closer involvement of GPs and social service organisations A public information campaign encouraging people with non-urgent

medical problems to use the full range of NHS services

The full news story can be found at:https://www.gov.uk/government/news/nhs-well-prepared-for-cold-winter-pressures

For information

Jeremy Hunt: message to NHS staff on using technology and sharing informationThe Secretary of State for Health talks about the importance of using technology and information to improve patient care and public health.National health and social care organisations, backed by the government, launched radical new plans to improve health outcomes and the quality of patient care through digital technology and innovation.

The full article can be found at:https://www.gov.uk/government/speeches/jeremy-hunt-message-to-nhs-staff-on-using-technology-and-sharing-information

A paper has also been produced which gives a framework for action that will support frontline staff, patients and citizens to take better advantage of the digital opportunity. This can be found at:https://www.gov.uk/government/publications/personalised-health-and-care-2020

Review the paper and identify any required action.


Ebola: top facts and mythbuster guidanceThe DoH has produced guidance notes which set out the important facts about the Ebola virus disease and dispel some common myths. They are for organisations to use, if they wish, in their communications with their staff and stakeholders.

Consider inclusion in appropriate internal & external communications.


The guidance can be found at:https://www.gov.uk/government/publications/ebola-top-facts-and-mythbusterThe Dementia Challenge is an ambitious programme of work designed to make a real difference to the lives of people with dementia and their families and carers including a website with up to date news regarding Dementia. Main highlights this month included:

Pharmaceutical regulators from 10 countries have met for urgent talks on dementia.Dementia care experts met at the third Global Dementia Legacy event in Japan to discuss innovation and sustainable care.

More information can be found at:http://dementiachallenge.dh.gov.uk

For Information

NHS EnglandWebsite link: http://www.england.nhs.uk


Responsible person

“We must all champion for mental health care”NHS England’s National Clinical Director for Mental Health, Dr Geraldine Strathdee has met with a group of Local Government mental health champions who see the impact of poor mental health first hand.

“The champions are keen to improve the prevention and treatment of psychological illness and to work with NHS commissioners who are similarly committed in their own work and in the programmes they do with councils and Health and Wellbeing boards.”

The full article can be found at:http://www.england.nhs.uk/2014/11/18/mh-champion/

For Information

Diagnosing dementia: “any appropriately skilled clinician can make the diagnosis and brain scanning not always needed”Alistair Burns, National Clinical Director for dementia at NHS England has produced an article which states that “dementia is a clinical syndrome and at one level simply implies brain failure and the diagnosis is a two stage process.” He goes on to quote NICE Dementia Guidelines on brain scanning which states “Imaging may not always be needed in those presenting with moderate to severe dementia, if the diagnosis is already clear.”

The full article can be found at:http://www.england.nhs.uk/2014/10/13/ambassadors/

For Information

NHS England welcomes soaps’ ‘positive’ mental health stories NHS England has welcomed better portrayals of mental health in prime

For Information

time TV storylines after a report showed the subject being covered more authentically and more often.

The full article can be found at:http://www.england.nhs.uk/2014/11/11/soaps-positive-mental-health-stories/

A report ‘Making a drama out of a crisis’ was launched by Time to Change, the anti-stigma campaign run by Mind and Rethink Mental Illness and can be found at:http://www.time-to-change.org.uk/news/tv-drama-and-soaps-are-cleaning-their-act-when-depicting-mental-health

NHS Employers - Workforce BulletinWebsite link: http://www.nhsemployers.org/about-us/our-communications/nhs-workforce-bulletin


Responsible person

New 2015 NHS Pension Scheme regulations - summary for employersNHS Employers have published a summary of the new 2015 NHS Pension Scheme regulatory consultation, for employers.The summary includes further information on:

Membership entitlements Contribution rates Scheme flexibilities Transfers in and out Protection arrangements for existing members.

The full summary can be found at:http://www.nhsemployers.org/your-workforce/pay-and-reward/pensions/nhs-pension-scheme/new-2015-scheme

Assess if the summary would be useful to be communicated to Trust staff


Foundation Trust Network (FTN)Full newsletters can be obtained from [email protected]


Responsible person

Annual Conference 17th & 18th November The FTN’s annual conference and exhibition took place in Liverpool with over 700 attendees.Slides and notes from the sessions will be made available to delegates in the coming week and a conference round up can be found at http://www.foundationtrustnetwork.org/events/ftn-conference-2014/

Next year's event will be held in Birmingham on 10-11 November.

For Information

November Issue 67 – Main highlights:NAO report on NHS financial distress and BCF plans The National Audit Office published two reports into the Better Care Fund planning process and NHS finances. The report Planning for the Better Care Fund, says the Better Care Fund is an innovative idea, but

For Information

the quality of early preparation and planning did not match the scale of the ambition.

The report can be found at:http://www.nao.org.uk/wp-content/uploads/2014/11/Planning-for-the-better-care-fund.pdf

October Issue 66 – Main highlights:CQC publish next group of providers for inspectionThe CQC has announced the next group of acute, community health, mental health and independent providers to be inspected between January and March 2015 as part of the regulator’s new approach.

Mental health Trusts to be inspected are:- Kent and Medway NHS and Social Care Partnership Trust- Sussex Partnership NHS Foundation Trust- Tees, Esk and Wear Valleys NHS Foundation Trust

The full publication can be found at: http://www.cqc.org.uk/content/next-group-providers-be-inspected

For Information

This week next week – 21st November 2014 Main highlights:Monitor state that measures of mental health provision need to change. David Bennett acknowledged that money has tended to flow to physical health and has called for a “significant reallocation of resources” towards mental health.

The publication can be found at: http://bulletins.foundationtrustnetwork.org/t/ViewEmail/t/DB10E4F907715B7F/88051ED9D6D7140EF6A1C87C670A6B9F

For Information

This week next week – 14th November 2014 Main highlights:Concerns that children in mental health crisis are confined in prison for assessment due to lack of capacity.

The publication can be found at: http://bulletins.foundationtrustnetwork.org/t/ViewEmail/t/25748B4412EA719C/84E7D1F31C5C7B839A8E73400EDACAB4

For Information

This week next week –7th November 2014 Main highlights:"Serious and ingrained" problems found in child mental health services. The Health Select Committee has warned.

Increasing numbers of healthcare providers are in financial difficulty. According to the National Audit Office

The publication can be found at:http://bulletins.foundationtrustnetwork.org/t/ViewEmail/t/C976F1E89F78B685/507BD331BE2634C49A8E73400EDACAB4

For Information

Mental Health Foundation Website link: http://www.mentalhealth.org.uk


Responsible person

Report Calls for Better Mental Health Services for Children and Young People: The Mental Health Foundation have welcomed the publication of a House of Commons Health Committee report looking at mental health services for children and young people which criticises the Departments of Health and Education, NHS England, Ofsted and the Care Quality Commission.

Full article and can be found at:http://www.mentalhealth.org.uk/our-news/news-archive/2014/14-11-05-report-children-young-people-mental-health/?view=Standard

The Health Committee report can be found at:http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/342/34202.htm

For Information

Local authorities must invest in public mental healthThe Mental Health Foundation Chief Executive, Jenny Edwards stated that “The revelation obtained by Mind under the Freedom of Information Act showing local authorities’ spending on public mental health is only 1.4% of their public health spending is of great concern”.The full article can be found at:http://www.mentalhealth.org.uk/our-news/news-archive/2014/14-10-28-local-authorities-mental-health/?view=Standard

For Information

NHS Benchmarking NetworkWebsite link: http://www.nhsbenchmarking.nhs.uk/index.php


Responsible person

NHS ConfederationWebsite link: http://www.nhsconfed.org


Responsible person

Booking opens for Mental Health Network Annual Conference &Exhibition 2015, 18th March 2015 at ETC Venues, Central London.Simon Stevens, chief executive of NHS England, is confirmed as a keynote speaker and will be addressing delegates on NHS England’s current and future priorities for mental health services.

Further information can be found at:http://www.nhsconfed.org/news/2014/11/mhn-ace-booking-open

Consider Trust representation at the Conference and agree timescale for Board briefing paper


Care Quality Commission (CQC)Website link: http://www.cqc.org.uk


Responsible person

New fundamental standards publishedThe government has published the fundamental standards regulationswhich replace the previous 16 essential standards. They include two regulations – the duty of candour and the fit and proper person requirement for directors – which will come into force on 27th

November for NHS trusts, Foundation Trusts and some special health authorities that provide care and treatment to people that is regulated by CQC.

The remaining fundamental standards will come into force from April 2015 and are:

care and treatment must be appropriate and reflect service users' needs and preferences.service users must be treated with dignity and respect.care and treatment must only be provided with consent.care and treatment must be provided in a safe way.service users must be protected from abuse and improper treatment.service users' nutritional and hydration needs must be met.all premises and equipment used must be clean, secure, suitable and used properly.complaints must be appropriately investigated and appropriate action taken in response.systems and processes must be established to ensure compliance with the fundamental standards.sufficient numbers of suitably qualified, competent, skilled and experienced staff must be deployed.

More Information can be found at:http://www.cqc.org.uk/content/publishing-new-fundamental-standards

Review the regulations and highlight implications andactions to the Board

Company Secretary/Director of Operations, Nursing & Estates


Agenda Item number:10.1 Enclosure:7

Report Title: Trust Integrated Performance Dashboard Month 7 (October 2014/15)

Accountable Director: Mark Axcell - Director of Finance and Performance

Author (name & title): James Parker – Commissioner Liaison Manager

Purpose of the report:To update the Board on all aspects of Trust performance at month 7 of 2014/15

Quality and SafetyService User ExperienceEfficiencyResourcesMonitor and Trust Development Authority



Committee:

Governance and Quality Committee considered elements from within the Quality and Safety domain, and the Service User Experience domain.Finance and Performance Committee considered elements from the Efficiency, Resource and Quality and Safety Domains

Date reviewed

Finance and Performance Committee – 24th November 2014

Key points or recommendations from Committee:

Strategic Objective(s) to which this paper relates:High quality Inclusive Leadership Responsible Supporting Effective/efficient

services partnerships culture workforce strategies resources

What impact or implications does this report have on any of the following:


Caring The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Responsive The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Effective The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Well-led The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Safe The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Title Trust Integrated Performance Dashboard Month 7 (October)2014/15

Introduction

This paper presents the Trust’s performance at the end of month seven 2014/15 financial year.

The 2014/15 Integrated Dashboard allows comparison and triangulation across Quality and Safety, Service User Experience, Efficiency, and Resources to give a comprehensive picture of the performance of the Trust.

The 2014/15 Integrated Dashboard also includes performance, and exception commentary, by service line, so that the Board is better able to see achievements as well as any adverse performance within the overall aggregate level.


Sickness - Trust Sickness for September 2014 is 4.92%. This is a decrease of 0.26% compared to September 2014.

CPA Formal Review and Copies of Care Plan – Both indicators have seen a dip in performance during month seven and have fallen below the 95% target. The underperformance is being closely monitored by the Trust Contract Activity Review Meeting, with action plans in place to address the underperformance.

The 12 month rolling sickness percentage has increased from 5.39% in September 2014 to 5.40% in October 2014. Long Term Sickness accounts for 74.3% of Sickness in the 12 month rolling period.

The overall finance risk rating for the month remains green with a score of 4.1.

Our overall governance risk rating for the month remains green with a score of 0.

Further detail (if required)

Recommendation

It is recommended that the Board note the performance of the Trust as at month seven anddebate accordingly.


Debate the content of the reports accordingly.

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oth

indi

cato

rs h

ave

seen

a d

ip in

per

form

ance

dur

ing

mon

th se

ven.

The

und

erpe

rfor

man

ce is

bei

ng c

lose

ly

mon

itore

d by

the

Trus

t Con

trac

t Act

ivity

Rev

iew

Mee

ting,

with

act

ion

plan

s in

plac

e to

add

ress

the

unde

rper

form

ance

. Ef

ficie

ncy

Dom

ain

•Ac

tivity

aga

inst

con

trac

t (N

HS A

ctiv

ity)

– As

at

mon

th s

even

the

Tru

st h

as r

epor

ted

186,

356

units

of a

ctiv

ity a

gain

st a

tar

get

of 1

86,1

74 y

ear

to d

ate.

Cer

tain

se

rvic

es h

ave

been

iden

tifie

d fo

r add

ition

al in

vest

men

t, an

d ac

tion

plan

s are

in p

lace

to a

ddre

ss th

e sh

ortf

all.

The

unde

rper

form

ance

is b

eing

clo

sely

mon

itore

d by

th

e Tr

ust F

inan

ce a

nd P

erfo

rman

ce C

omm

ittee

. •

IAPT

Peo

ple

who

hav

e su

cces

sful

ly c

ompl

eted

trea

tmen

t (Du

dley

) – Y

ear t

o da

te D

udle

y re

mai

n be

low

the

targ

et. H

owev

er in

mon

th th

ere

has

been

a s

igni

fican

t im

prov

emen

t, w

ith a

repo

rted

figu

re o

f 52.

5% a

gain

st th

e ta

rget

of 5

0.5%

. The

und

erpe

rfor

man

ce is

driv

en b

y th

e sig

nific

ant p

ress

ures

put

on

the

serv

ice

by lo

ng

term

sick

ness

epi

sode

s.

Reso

urce

s Dom

ain

•Co

st Im

prov

emen

t Pro

gram

me

(CIP

) - T

he T

rust

’s C

IP ta

rget

for t

he y

ear i

s £2,

087k

. The

in y

ear a

chie

vem

ent o

f CIP

is fo

reca

st a

t £1,

799k

whi

ch le

aves

£28

8k to

be

man

aged

cen

tral

ly th

roug

h un

com

mitt

ed re

serv

es. T

he fu

ll ye

ar re

curr

ent e

ffect

of t

hese

sche

mes

is £

2,09

8k, r

epre

sent

ing

a re

curr

ent £

11k

plan

ned

over

-ac

hiev

emen

t. Th

e in

dica

tor i

s rat

ed a

mbe

r as a

refle

ctio

n of

the

wor

k on

-goi

ng to

del

iver

the

full

year

effe

ct o

f the

£2,

087k

pla

n. T

he T

rust

inco

me

has i

mpr

oved

to

a su

rplu

s at M

onth

seve

n du

e to

the

back

date

d ac

tivity

reco

rded

for t

he n

ewly

est

ablis

hed

deto

x be

d pr

ovisi

on a

t Bus

hey

Fiel

ds. I

nves

tigat

ion

into

the

high

vo

lum

e of

act

ivity

reco

rded

is u

nder

way

to a

scer

tain

the

true

fina

ncia

l im

pact

read

y fo

r Mon

th e

ight

.

•Tu

rnov

er –

the

incr

ease

in tu

rnov

er is

due

to th

e M

utua

lly A

gree

d Re

signa

tion

Sche

me

(MAR

S) th

at th

e Tr

ust u

nder

took

this

finan

cial

yea

r.

•Si

ckne

ss -

The

in-m

onth

Tru

st si

ckne

ss a

bsen

ce ra

te fo

r mon

th se

ven

is 4.

92%

, whi

ch is

a d

ecre

ase

of 0

.26%

com

pare

d to

mon

th si

x. T

he 1

2 m

onth

rolli

ng si

ckne

ss

perc

enta

ge h

as in

crea

sed

from

5.3

9% in

mon

th s

ix to

5.4

0% in

mon

th s

even

. Lon

g Te

rm s

ickn

ess

acco

unts

for

73.3

% o

f sic

knes

s in

the

12 m

onth

rol

ling

perio

d.

Whi

lst a

ll sic

knes

s le

vels

and

com

plia

nce

with

the

polic

y co

ntin

ues

to b

e cl

osel

y m

onito

red

by m

anag

ers

acro

ss s

ervi

ce li

nes,

and

sup

port

ed b

y HR

col

leag

ues,

a

wat

chin

g br

ief

is ad

vise

d, g

iven

tha

t th

ere

has

been

an

incr

ease

in lo

ng t

erm

epi

sode

s of

sic

knes

s. R

egul

ar c

ase

revi

ew m

eetin

gs h

ave

been

arr

ange

d w

ith

Occ

upat

iona

l Hea

lth fo

r all

of th

e lo

ng te

rm e

piso

des.

•

Appr

aisa

l Da

ta C

aptu

re h

as d

ecre

ased

to

58%

for

mon

th s

even

and

rem

ains

bel

ow t

he t

hres

hold

. A

targ

eted

app

roac

h ha

s be

en u

sed

to e

nsur

e th

at t

he

impo

rtan

ce o

f sta

ff ap

prai

sals

and

the

capt

ure

of d

ata

is a

prio

rity.

•

Plea

se n

ote

that

the

met

hod

for r

epor

ting

Man

dato

ry T

rain

ing

was

revi

ewed

in m

onth

six

mea

ning

that

no

figur

e w

as re

port

ed in

the

prev

ious

das

hboa

rd w

here

ch

ange

s w

ere

mad

e. T

here

is a

n ac

cura

te f

igur

e fo

r th

e m

onth

sev

en r

etur

n, h

owev

er d

ue t

o th

e ch

ange

in r

epor

ting,

the

re is

no

tren

d an

alys

is. T

his

will

co

mm

ence

from

mon

th e

ight

.

Trus

t Lev

el In

tegr

ated

Das

hboa

rd –

Exc

eptio

n Co

mm

enta

ry

Serv

ice

Line

Sum

mar

y •

Activ

ity a

gain

st c

ontr

act

rem

ains

bel

ow t

he t

arge

t as

at

mon

th s

even

, w

hich

co

rrel

ates

with

the

unde

rper

form

ance

of t

he In

com

e ag

ains

t Pla

n. T

his

is cl

osel

y m

onito

red

by O

pera

tiona

l col

leag

ues

and

the

serv

ices

are

con

fiden

t tha

t thi

s w

ill

impr

ove.

•Th

is se

rvic

e lin

e ha

s un

ders

pent

aga

inst

bud

get b

y £4

7k in

Oct

ober

201

4, d

ue to

a

redu

ctio

n in

War

d st

affin

g sp

end.

It is

exp

ecte

d th

at th

e ex

pend

iture

leve

ls w

ill

incr

ease

bef

ore

year

end

and

the

ser

vice

will

not

con

tinue

to

unde

rspe

nd o

n a

mon

thly

bas

is.

•Si

ckne

ss le

vels

have

incr

ease

d fo

r m

onth

sev

en t

o 8.

54%

fro

m 7

.21%

in m

onth

six

. Thi

s is d

riven

by

high

leve

ls of

long

term

sic

knes

s.

Serv

ice

Line

Sum

mar

y •

CPA

Form

al R

evie

w a

nd C

opie

s of

Car

e Pl

an –

Bot

h in

dica

tors

hav

e se

en a

dip

in

perf

orm

ance

du

ring

mon

th

seve

n.

The

unde

rper

form

ance

is

bein

g cl

osel

y m

onito

red

by t

he T

rust

Con

trac

t Ac

tivity

Rev

iew

Mee

ting,

with

act

ion

plan

s in

pl

ace

to a

ddre

ss th

e un

derp

erfo

rman

ce.

•Ac

tivity

aga

inst

con

trac

t re

mai

ns b

elow

the

tar

get

as a

t m

onth

sev

en,

whi

ch

corr

elat

es w

ith th

e un

derp

erfo

rman

ce o

f the

Inco

me

agai

nst P

lan.

Thi

s is

clos

ely

mon

itore

d by

Ope

ratio

nal c

olle

ague

s an

d th

e se

rvic

es a

re c

onfid

ent t

hat t

his

will

im

prov

e.

•Co

mm

unity

Ser

vice

s ar

e ov

er s

pent

by

£22k

due

to

exte

nded

Age

ncy

usag

e an

d th

e no

n-de

liver

y of

CIP

, w

hich

was

exp

ecte

d to

tak

e ef

fect

fro

m J

uly

14.

The

fore

cast

exp

ects

del

iver

y of

an

agre

ed s

chem

e by

Dec

embe

r, in

clud

ing

redu

ced

tem

pora

ry s

taffi

ng c

ost,

base

d on

the

impl

emen

tatio

n of

the

new

str

uctu

re o

f th

e se

rvic

es.

•Si

ckne

ss le

vels

with

in th

e co

mm

unity

ser

vice

line

hav

e se

en a

n in

crea

se to

6.8

2%

in m

onth

seve

n, th

ere

has b

een

an in

crea

se in

sick

ness

for 7

con

secu

tive

mon

ths.

69

.7%

is d

ue to

long

term

epi

sode

s.

•Co

mpl

aint

s U

phel

d/Pa

rtia

lly U

phel

d is

rate

d as

Am

ber f

or m

onth

sev

en, h

owev

er

it is

only

in re

latio

n to

two

com

plai

nts w

hich

dist

orts

the

perc

enta

ge fi

gure

.

Serv

ice

Line

Sum

mar

y •

Activ

ity a

gain

st c

ontr

act r

emai

ns b

elow

the

targ

et a

s at m

onth

seve

n. T

he H

ead

of

Serv

ice

has p

lans

in p

lace

whi

ch w

ill se

e an

incr

ease

in A

ctiv

ity le

vels.

•Th

is se

rvic

e lin

e ha

s a fu

ll ye

ar C

IP ta

rget

of £

80K

for 2

014/

15 w

hich

has

now

bee

n m

et w

ithin

the

CAM

HS

serv

ice.

Add

ition

al in

vest

men

t w

ill b

e ad

ded

to s

uppo

rt

the

Prim

ary

Care

to s

uppo

rt t

he r

ecen

t Old

er A

dult

Prim

ary

Care

pilo

t sch

eme

in

Dudl

ey.

•Si

ckne

ss l

evel

s ha

ve s

een

a sig

nific

ant

impr

ovem

ent

for

mon

th s

even

with

a

decr

ease

from

6.2

3% in

mon

th si

x to

4.3

9% in

mon

th se

ven.

•Co

mpl

aint

s U

phel

d/Pa

rtia

lly U

phel

d is

rate

d as

Am

ber

for m

onth

sev

en, h

owev

er

it is

only

in re

latio

n to

two

com

plai

nts w

hich

dist

orts

the

perc

enta

ge fi

gure

.

Serv

ice

Line

Sum

mar

y •

CPA

Form

al R

evie

w a

nd C

opie

s of

Car

e Pl

an –

Bot

h in

dica

tors

hav

e se

en a

dip

in

perf

orm

ance

du

ring

mon

th

seve

n.

The

unde

rper

form

ance

is

bein

g cl

osel

y m

onito

red

by t

he T

rust

Con

trac

t Ac

tivity

Rev

iew

Mee

ting,

with

act

ion

plan

s in

pl

ace

to a

ddre

ss th

e un

derp

erfo

rman

ce.

•Th

is se

rvic

e lin

e ha

s re

duce

d its

in m

onth

exp

endi

ture

to £

8k u

nder

spen

d. T

his

is du

e to

redu

ced

tem

pora

ry st

affin

g us

age.

•

Sick

ness

lev

els

with

in O

lder

Adu

lts s

ervi

ce l

ine

have

see

n a

shar

p de

crea

se i

n m

onth

seve

n to

4.0

5% fr

om 5

.31%

in m

onth

six.

Serv

ice

Line

Sum

mar

y •

Reco

very

is u

nder

spen

t for

Apr

il - O

ctob

er 2

014.

Cos

t pre

ssur

es re

mai

n fr

om la

st y

ear w

ithin

EAS

whe

re th

ere

are

2.00

WTE

age

ncy

wor

kers

un

fund

ed to

man

age

asse

ssm

ents

, for

whi

ch a

solu

tion

is be

ing

scop

ed.

The

serv

ice

now

has

a ru

n-ra

te c

onsis

tent

with

bud

get,

due

to v

acan

cies

w

ithin

Wal

sall

SMS

and

addi

tiona

l Crim

inal

Just

ice

grow

th fu

ndin

g.

•Th

e hi

gh a

mou

nt o

f tu

rnov

er r

epor

ted

this

year

is d

riven

by

the

TUPE

tr

ansf

er o

f Dud

ley

Subs

tanc

e M

isuse

em

ploy

ees.

•Si

ckne

ss l

evel

s w

ithin

the

Rec

over

y Se

rvic

e Li

ne h

ave

seen

a s

harp

de

crea

se in

mon

th se

ven

to 4

.45%

from

6.0

6% in

mon

th si

x.

9 9 9

Trus

t Per

form

ance

Rep

ort

Mon

th 7

20

14/1

5

10

10

Part

2 –

Con

trac

tual

and

Qua

lity

KPI

s, m

onth

7

KPI

Targ

etLo

cAp

rM

ayJu

nJu

lyAu

gSe

ptO

ctYT

DRA

G

89Ta

rget

713

2025

3540

4848

Trus

t A

ctua

l7

1628

3843

4961

61

43Ta

rget

46

811

1416

2121

Dud

ley

Actu

al5

913

1720

2327

27

46Ta

rget

48

1214

2124

2727

Wal

sall

Actu

al2

715

2123

2634

34

1. N

ew ca

ses

acce

pted

to E

I -

Cum

ulat

ive

KPI

Targ

etLo

cAp

rM

ayJu

nJu

lyAu

gSe

ptO

ctYT

DAc

tual

RAG

100%

100%

100%

100%

100%

100%

100%

(67/

67)

(76/

76)

(65/

65)

(90/

90)

(70/

70)

(81/

81)

(91/

91)

95%

Dudl

ey10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%

95%

Wal

sall

100%

100%

100%

100%

100%

100%

100%

100%

97%

95%

97%

96%

97%

100%

97%

(89/

92)

(99/

104)

(82/

84)

(102

/106

)(9

2/94

)(1

00/1

00)

(113

/116

)

95%

Dudl

ey

95%

95%

98%

96%

96%

100%

95%

96%

95%

Wal

sall

100%

95%

97%

97%

100%

100%

100%

98%

0.7%

0.0%

0.9%

2.0%

1.7%

2.0%

1.9%

(30/

4510

)(1

/470

1)(4

2/44

47)

(101

/493

7)(7

9/47

09)

(90/

4563

)(9

4/49

83)

<7.5

%Du

dley

0.0%

0.0%

0.6%

2.9%

1.8%

1.8%

3.2%

1.5%

<7.5

%W

alsa

ll1.

5%0.

04%

1.3%

1.0%

1.5%

2.2%

0.4%

1.1%

<64

days

Trus

t

4045

5236

6239

5046

<64

days

Dudl

ey

3937

3937

5232

4039

<64

days

Wal

sall

41

5871

3576

4861

56

92.1

%

92.1

%

92.1

%

92.1

%

92.1

%

2. G

ate-

keep

ing

of

inpa

tient

adm

issio

n *

95%

Trus

t10

0%

3. 7

day

follo

w u

p on

In

patie

nt d

ischa

rge

*95

%Tr

ust

97

%

4. D

ToCs

(All

reas

ons)

<7

.5%

Trus

t1.

3%

95.4

%

95.8

%

95.8

%

95.8

%

92.1

%

5. A

vera

ge le

ngth

of

stay

*

6. U

sers

with

a co

py

of th

eir c

are

plan

s *95

%Tr

ust

96.2

%

95%

Wal

sall

96.2

%

95%

Dudl

ey96

.2%

95%

95%

95%

95.4

%

95.4

%95

.1%

95.1

%

95.4

%

95.4

%

95.4

%

95.1

%

11

11

11

Part

2 –

Con

trac

tual

and

Qua

lity

KPI

s, m

onth

7

KPI

Targ

etLo

cAp

rM

ayJu

nJu

lyAu

gSe

pOc

tYT

DAc

tual

RAG

1187

(100

/mth

)

579

(49/

mth

)

608

(51/

mth

)

0Tr

ust

00

00

00

00

0Du

dley

00

00

00

00

0W

alsall

00

00

00

00

8a. A

ppro

priat

e ad

miss

ions

of U

nder

18

s to

Adul

t War

dNo

targ

etTr

ust

00

11

00

13

98%

100%

97%

100%

100%

100%

98%

99%

98%

97%

95%

93%

96%

93%

94%

94%

98%

100%

96%

100%

100%

100%

98%

99%

99%

96%

94%

89%

97%

94%

95%

95%

100%

100%

100%

100%

100%

100%

100%

100%

97%

98%

97%

95%

95%

92%

93%

94%

100%

Trus

t10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

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Sect

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fican

t in

crea

se in

inci

dent

num

bers

sin

ce th

e pr

evio

us

mon

th.

Com

mun

ity

The

mon

thly

(mea

n) a

vera

ge fo

r inc

iden

ts re

latin

gto

Com

mun

ity S

ervi

ces (

calc

ulat

ed u

sing

data

from

the

last

12

mon

ths)

is

9.58

Com

mun

ity S

ervi

ces r

epor

ted

16 in

cide

nts

durin

gth

e m

onth

and

saw

an

incr

ease

sin

ce th

e pr

evio

us

mon

th.

Due

to th

e lo

w n

umbe

rs re

port

ed th

ere

are

no fu

rthe

r sig

nific

ant t

rend

s or e

xcep

tions

for t

hese

ser

vice

are

as

Reco

very

Early

Inte

rven

tion

Tabl

e 2.

3 To

tal R

ecov

ery,

Ear

ly In

terv

entio

n &

Com

mun

ity in

cide

nts

by C

ause

Gro

up a

nd sh

owin

g a

posit

ion

on th

e pr

evio

us m

onth

s fig

ures

024681012141618

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Com

mun

ity

Com

mun

ity12

Mon

thly

Ave

rage

Mea

n +

2S.D

.M

ean

- 2S.

D.

051015202530354045

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Reco

very

Reco

very

12 M

onth

ly A

vera

ge

Mea

n +

2S.D

.M

ean

- 2S.

D.

02468101214161820

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14

Jul-14

Aug-14

Sep-14

Oct-14

Early

Inte

rven

tion

E.I.

12 M

onth

ly A

vera

ge

Mea

n +

2S.D

.M

ean

- 2S.

D.

Sect

ion

3

Sect

ion

3.1

- Ser

ious

Inci

dent

sG

over

nanc

e Q

ualit

y Re

port

20

14

SI N

umbe

rD

ate

of In

cide

ntSe

rvic

e Li

neSe

rvic

e Ar

eaIn

cide

nt D

escr

iptio

nLe

vel o

f Ris

kLe

vel o

f res

pons

eC

urre

nt s

tatu

s

2014

/320

7701

/10/

2014

Ops

- A

cute

Ser

vice

sP

sych

iatri

c Li

aiso

n Te

am -

Wal

sall

Com

plet

ed S

uici

de -

Liga

ture

Mod

erat

eLe

vel 1

Ful

l Inv

estig

atio

nO

ngoi

ng

2014

/325

4206

/10/

2014

Ops

- A

cute

Ser

vice

sLa

ngda

le W

ard

Sel

f Har

m -

Med

icat

ion

Ove

rdos

eM

oder

ate

Leve

l 1 C

linic

al R

evie

wO

ngoi

ng

2014

/341

6916

/10/

2014

Ops

- A

cute

Ser

vice

sC

RH

T (W

alsa

ll)C

ompl

eted

Sui

cide

- Li

gatu

reLo

wLe

vel 1

Ful

l Inv

estig

atio

nO

ngoi

ng

2014

/343

5519

/10/

2014

Ops

- A

cute

Ser

vice

sA

mbl

esid

eA

ttem

pted

Sui

cide

- Li

gatu

reH

igh

Leve

l 1 F

ull I

nves

tigat

ion

Ong

oing

2014

/344

8720

/10/

2014

Ops

- O

lder

Adu

ltsW

oods

ide

(CM

HTO

P)

Sel

f Har

m -

Med

icat

ion

Ove

rdos

eM

oder

ate

Leve

l 1 C

linic

al R

evie

wO

ngoi

ng

Char

t 3.2

To

tal n

umbe

r of S

erio

us In

cide

nts d

urin

g th

e la

st 1

2 m

onth

s

Tabl

e 3.

1 Li

st o

f Ser

ious

Inci

dent

raise

d du

ring

the

mon

th o

f O

ctob

er 2

014

The

mon

thly

(mea

n) a

vera

ge fo

r ser

ious

inci

dent

s acr

oss t

he T

rust

(cal

cula

ted

usin

g da

ta fr

om th

e la

st 1

2 m

onth

s) is

5.4

•Th

ere

has b

een

a de

crea

se in

the

num

ber o

f ser

ious

inci

dent

s sin

ce th

e pr

evio

us m

onth

and

this

has

seen

the

mon

thly

figu

re fa

ll be

low

the

12 m

onth

ave

rage

•Du

ring

this

mon

th t

here

wer

e 5

serio

us in

cide

nts,

3 o

f the

se a

re b

eing

inve

stig

ated

as F

ull I

nves

tigat

ions

, an

d 2

are

Clin

ical

revi

ews.

•Al

l of t

he In

cide

nts r

elat

e to

Ser

ious

Har

min

g Be

havi

our.

•2

rela

ted

to c

ompl

eted

Sui

cide

s•

1 w

as in

rela

tion

to a

n in

patie

nt A

ttem

pted

Sui

cide

(lig

atur

e)•

2 re

late

d to

Med

icat

ion

over

dose

s

0246810

Serio

us In

cide

nts

Trus

t Ave

rage

Mea

n +

2S.D

.M

ean

- 2S.

D.

58%

26

%

11%

5%

se

rious

Har

min

g Be

havi

our

Acce

ss, A

dmiss

ion,

Tra

nsfe

r Disc

harg

e

Patie

nt A

ccid

ent

Infe

ctio

n Co

ntro

l Inc

iden

t

Char

t 3.1

Su

mm

ary

of th

e Se

rious

Inci

dent

type

s dur

ing

the

last

12

mon

ths

Sect

ion

4 N

atio

nal G

uida

nce:

o o o o

MDA/

2014

/039

07-O

ct-20

14

TELIG

ENTM

impla

ntable

card

iover

ter de

fibrill

ators

(ICD)

and C

OGNI

STM

card

iac re

sync

hron

isatio

n the

rapy

de

vices

(CRT

-D) m

anufa

cture

d by B

oston

Scie

ntific

Ri

sk of

loss

of th

erap

y due

to ra

pid ba

ttery

deple

tion.

Addit

ional

seria

l num

bers

of de

vices

are a

ffecte

d sinc

e the

man

ufactu

rer’s

origi

nal n

otific

ation

in A

ugus

t 201

3

Actio

n Not

Requ

ired

The T

rust

does

not u

se an

y of th

ese d

evice

s, the

refor

e no a

ction

was

requ

ired

CEM/

CMO/

2014

/007

07-O

ct-20

14

Ebola

outbr

eak i

n Wes

t Afric

a Th

is me

ssag

e was

to up

date

Trus

ts on

the c

urre

nt ou

tbrea

k of E

bola

virus

dise

ase (

EVD)

in W

est

Afric

a, an

d to r

emind

you o

f the n

eed t

o rem

ain vi

gilan

t for c

ases

impo

rted t

o the

UK.

Circu

lated

for

Infor

matio

n Th

is ale

rt wa

s circ

ulated

in lin

e with

the

requ

ireme

nts of

the w

ork.

The

Tru

st ha

s alre

ady

unde

rtake

n som

e pre

para

tions

in re

lation

to th

is iss

ue.

MDA/

2014

/040

09-O

ct-20

14

LIFEP

AK®

1000

defib

rillato

r. Ma

nufa

cture

d by P

hysio

-Con

trol. A

ll ser

ial nu

mber

s. Ri

sk of

failu

re to

deliv

er a

shoc

k. Th

is is

due t

o une

xpec

ted sh

ut do

wn of

the d

efibr

illator

caus

ed by

a ba

ttery

with

very

low ch

arge

. Co

nfusin

g ins

tructi

ons f

or us

e mea

n tha

t batt

eries

aren

’t alw

ays r

eplac

ed w

hen t

hey h

ave a

low

or ve

ry low

ch

arge

.

Actio

n Not

Requ

ired

The T

rust

does

not h

ave a

ny of

thes

e de

vices

, the

refor

e no a

ction

was

requ

ired.

EFN/

2014

/41

15-O

ct-20

14

High

Volt

age H

azar

d Aler

t - D

ANGE

ROUS

INCI

DENT

NOT

IFIC

ATIO

N (U

PDAT

E) -

Ferra

nti -

DS2

Tapc

hang

er

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

Gove

rnan

ce Q

ualit

y Re

port

20

14

EL (1

4)A/

15

15-O

ct-20

14

Drug

aler

t clas

s 4, fo

r infor

matio

n, Be

echa

m gr

oup P

LC an

d Bee

chma

m Gr

oup L

imite

d tra

ding a

s Gl

axos

mithk

line U

K, A

moxil

vials

for in

jectio

n 500

mg an

d 1.0g

; aug

menti

n intr

aven

ous 6

00mg

and 1

.2g. a

ve

ry low

incid

ence

of cr

acks

has b

een f

ound

in vi

als us

ed fo

r pac

kagin

g spe

cific

batch

es of

thes

e pro

ducts

.

Actio

n Co

mpl

eted

Du

dley P

harm

acy w

ere n

ot aff

ected

by th

is ale

rt as

they

had p

urch

ased

none

of th

is pr

oduc

t. W

alsall

Man

or P

harm

acy h

ad st

ock o

f this

on th

e re

tail s

ales s

helvi

ng w

ithin

the D

epar

tmen

t. This

ha

s bee

n rem

oved

and t

he st

ock w

ill ha

s bee

n se

nt ba

ck to

the s

uppli

er. D

WMH

wer

e una

ffecte

d EF

N/20

14/42

16

-Oct-

2014

Hi

gh V

oltag

e Haz

ard A

lert -

DAN

GERO

US IN

CIDE

NT N

OTIF

ICAT

ION

(DIN

) - M

erlin

Ger

in - C

E2 -

Circu

it Br

eake

r Du

ring a

n iso

lation

proc

edur

e, to

enab

le tem

pora

ry ge

nera

tion t

o be i

nstal

led, th

e circ

uit br

eake

r was

open

ed

manu

ally a

nd th

e mim

ic sta

tus of

the

circu

it bre

aker

was

obse

rved t

o cha

nge f

rom

ON to

OFF

. How

ever

it wa

s note

d tha

t the p

ower

had n

ot be

en w

ithdr

awn f

or th

e circ

uit (li

ghts/

powe

r still

on).

Follo

wing

this

incide

nt the

Ene

rgy N

etwor

ks A

ssoc

iation

has i

ssue

d a D

ange

rous

Incid

ent N

otific

ation

(DIN

).

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

EFN/

2014

/43

20-O

ct-20

14

High

Volt

age H

azar

d Aler

t - D

ANGE

ROUS

INCI

DENT

NOT

IFIC

ATIO

N (D

IN) -

Lucy

Swi

tchge

ar -

SFRM

U CF

1 - R

ing M

ain U

nit

Follo

wing

an in

vesti

gatio

n into

a re

porte

d abn

orma

l con

dition

with

in an

SF6

gaug

e on a

Lucy

Swi

tchge

ar

Ring

Main

Unit

the E

nerg

y Netw

orks

Ass

ociat

ion ha

s iss

ued a

n upd

ated D

ange

rous

Incid

ent N

otific

ation

(D

IN) in

relat

ion to

the i

ncide

nt.

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

EFN/

2014

/44

21-O

ct-20

14

DANG

EROU

S IN

CIDE

NT N

OTIF

ICAT

ION

(DIN

) - D

ynap

ower

Ene

rgy M

anag

emen

t - P

ower

skid

Inver

ter

Follo

wing

an in

vesti

gatio

n into

the f

ailur

e of a

n inv

erter

in a

batte

ry sto

rage

syste

m the

Ene

rgy N

etwor

ks

Asso

ciatio

n has

issu

ed an

upda

ted D

ange

rous

Incid

ent N

otific

ation

(DIN

) in re

lation

to th

e inc

ident

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

MDA/

2014

/041

21-O

ct-20

14

Baby

therm

infan

t war

mers

and o

pen i

nfant

care

units

for n

ewbo

rns.M

anufa

cture

d by D

raeg

er M

edica

l.Mod

el nu

mber

s: 80

04, 8

010 a

nd 80

00W

B.

Actio

n not

requ

ired

The T

rust

does

not u

se ba

bythe

rm in

fant w

arme

rs,

these

are l

ikely

to be

used

in ne

onata

l de

partm

ents

DH/20

14/00

3 21

-Oct-

2014

Re

mind

er fo

r the

testi

ng of

fire &

smok

e dam

pers

and e

nsur

ing th

e inte

grity

of fi

re st

oppin

g Th

is ale

rt hig

hligh

ts the

need

: To

ensu

re ap

prop

riate

syste

ms ar

e in p

lace w

ithin

orga

nisati

ons t

o ens

ure t

he ro

utine

insp

ectio

n,ma

inten

ance

and t

estin

g of a

ll fire

and s

moke

damp

ers t

akes

plac

e, an

d tha

t safe

mea

ns of

acce

ss is

prov

ided t

o ens

ure t

his w

ork c

an be

unde

rtake

n.To

ensu

re ap

prop

riate

syste

ms ar

e in

place

to en

sure

that

the in

tegrity

of fi

re st

oppin

g can

be co

nfirm

edwi

thin a

n org

anisa

tion's

prem

ises.

Asse

ssing

Re

levan

ce

The T

rusts

Clin

ical G

over

nanc

e Dep

artm

ent is

cu

rrentl

y liai

sing w

ith th

e Tru

sts E

states

De

partm

ent a

nd

EFN/

2014

/45

22-O

ct-20

14

DANG

EROU

S IN

CIDE

NT N

OTIF

ICAT

ION

(DIN

) - M

EM -

R338

FY37

/AP/

D1 –

Isolat

or

Follo

wing

the f

ailur

e of a

3 ph

ase i

solat

or, w

ithin

switc

hgea

r sup

plying

a pu

mp/m

otor,

set th

e Ene

rgy

Netw

orks

Ass

ociat

ion ha

s iss

ued a

Dan

gero

us In

ciden

t Noti

ficati

on (D

IN) in

relat

ion to

the i

ncide

nt.

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

EFN/

2014

/38

(U)

27-O

ct-20

14

Low

Volta

ge H

azar

d Aler

t - D

ANGE

ROUS

INCI

DENT

NOT

IFIC

ATIO

N (D

IN) -

UPD

ATE

- Unk

nown

ma

nufac

turer

- Co

mpou

nd fil

led LV

Link

Box

Fo

llowi

ng an

inve

stiga

tion i

nto th

e fail

ure o

f a co

mpou

nd fil

led LV

link b

ox, w

hich r

esult

ed in

a fire

eman

ating

fro

m a m

anho

le, th

e Ene

rgy N

etwor

ks A

ssoc

iation

has i

ssue

d an u

pdate

d Dan

gero

us In

ciden

t Noti

ficati

on

(DIN

) in re

lation

to th

e inc

ident.

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

EFN/

2014

/46

28-O

ct-20

14

High

Volt

age H

azar

d Aler

t - N

ATIO

NAL E

QUIP

MENT

DEF

ECT

REPO

RT (N

EDeR

) - M

erlin

Ger

in - G

ENIE

- Ci

rcuit B

reak

er

Follo

wing

an in

ciden

t whe

re th

e circ

uit br

eake

r lost

all S

F6 ga

s pre

ssur

e whe

n bein

g ope

rated

into

the ea

rth

posit

ion th

e Ene

rgy N

etwor

ks A

ssoc

iation

have

issu

ed a

Natio

nal E

quipm

ent D

efect

Repo

rt (N

EDeR

) in

relat

ion to

the i

ncide

nt

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

Gove

rnan

ce Q

ualit

y Re

port

20

14

EFN/

2014

/46

28-O

ct-20

14

High

Volt

age H

azar

d Aler

t - N

ATIO

NAL E

QUIP

MENT

DEF

ECT

REPO

RT (N

EDeR

) - M

erlin

Ger

in - G

ENIE

- Ci

rcuit B

reak

er

Follo

wing

an in

ciden

t whe

re th

e circ

uit br

eake

r lost

all S

F6 ga

s pre

ssur

e whe

n bein

g ope

rated

into

the ea

rth

posit

ion th

e Ene

rgy N

etwor

ks A

ssoc

iation

have

issu

ed a

Natio

nal E

quipm

ent D

efect

Repo

rt (N

EDeR

) in

relat

ion to

the i

ncide

nt.

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

EFN/

2014

/47

29-O

ct-20

14

DANG

EROU

S IN

CIDE

NT N

OTIF

ICAT

ION

(DIN

) - 4

way c

ompo

und f

illed L

V Lin

kbox

Fo

llowi

ng an

incid

ent w

hen s

moke

was

repo

rted t

o be e

mana

ting f

rom

a com

poun

d fille

d LV

linkb

ox th

e En

ergy

Netw

orks

Ass

ociat

ion ha

s iss

ued a

Dan

gero

us In

ciden

t Noti

ficati

on (D

IN) in

relat

ion to

the i

ncide

nt.

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

EFN/

2014

/48

30-O

ct-20

14

High

Volt

age H

azar

d Aler

t - N

ATIO

NAL E

QUIP

MENT

DEF

ECT

REPO

RT (N

EDeR

) - F

KI -

Eclip

se -

Circu

it Br

eake

r Du

ring a

plan

ned s

witch

ing op

erati

on di

scha

rge w

as he

ard f

rom

the re

ar of

the p

anel.

It is

susp

ected

that

the

volta

ge tr

ansfo

rmer

conta

cts di

d not

fully

enga

ge. F

ollow

ing th

is inc

ident

the E

nerg

y Netw

orks

Ass

ociat

ion

have

issu

ed a

Natio

nal E

quipm

ent D

efect

Repo

rt (N

EDeR

).

Actio

n not

requ

ired

The T

rusts

autho

rising

offic

er ac

know

ledge

d re

ceipt

of th

e aler

t and

that

no ac

tion w

as re

quire

d by

the T

rust

Gove

rnan

ce Q

ualit

y Re

port

20

14

Sect

ion

Tr

ust S

umm

ary

of a

ll Sa

fegu

ardi

ng a

nd

Vuln

erab

le a

dults

act

ivity

Sect

ion

5 - T

rust

Sum

mar

y of

all

Safe

guar

ding

Act

ivity

G

over

nanc

e Q

ualit

y Re

port

N

ovem

ber 2

014

Referral

Alert Only

Referral

Alert Only

54

23

32

1 1Un

der 1

8 De

ath

Gran

d To

tal

57

45

Case

Typ

eAl

ert o

nly

Refe

rred

To

tal

curr

ent

mon

thAl

ert o

nly

Refe

rred

To

tal

curr

ent

mon

thAl

ert o

nly

Refe

rred

To

tal

curr

ent

mon

thAl

ert o

nly

Refe

rred

To

tal

curr

ent

mon

thAl

ert o

nly

Child

11

36

92

21

Pare

ntal

Men

tal H

ealth

Con

cern

s (Ch

ild)

11

21

11

12

Und

er 1

8 Ad

miss

ion

11

Gra

nd T

otal

31

41

01

47

112

02

1

Tota

l cur

rent

m

onth

1 1

Refe

rred

Wal

sall

Child

Acut

eCo

mm

unity

E.I.

Dudl

ey

Pare

ntal

Men

tal H

ealth

Co

ncer

ns (C

hild

)

Old

er

Und

er 1

8 Ad

miss

ion

Reco

very

21

Gran

d To

tal

14 6 01

Sect

ion

5.1

- Saf

egua

rdin

g Ch

ildre

n ac

tivity

Com

men

tary

Grap

h 5.

1.1

This

grap

h pr

ovid

es in

form

atio

n re

latin

g to

the

last

12

mon

ths a

nd sh

ows a

bre

akdo

wn

of S

afeg

uard

ing

case

s whi

ch a

re ju

st fo

r ale

rt a

nd th

ose

whi

ch h

ave

been

pro

gres

sed

to th

e co

ntin

ue u

nder

Saf

egua

rdin

g

Tabl

e 5.

1.1

This

show

s tha

t the

num

ber o

f Saf

egua

rdin

g ca

ses

brok

en d

own

by c

ase

type

and

show

ing

the

loca

lity

. Thi

s also

show

s inf

orm

atio

n on

whe

ther

the

case

is fo

r ale

rt o

nly

or if

it h

as b

een

refe

rred

for f

urth

er in

vest

igat

ion

to a

noth

er a

genc

y. 5

cas

es h

ave

been

rere

rred

with

in D

udle

y ; 4

with

in W

alsa

ll.

Ther

e ar

e no

not

ed tr

ends

to th

e ch

ild sa

fegu

ardi

ng a

lert

figu

res.

It is

not

ed th

at th

ere

has b

een

a hi

gher

num

ber o

f cas

es th

at h

ave

been

sent

thro

ugh

appr

opria

tely

from

the

loca

l au

thor

ity.

Tabl

e 5.

1.2

This

tabl

e pr

ovid

es in

form

atio

n on

the

trai

ning

com

plia

nce

Tabl

e 5.

1.3

This

show

s inf

orm

atio

n as

in ta

ble

1.2

but s

how

s thi

s inf

orm

atio

n br

oken

dow

n by

Ser

vice

line

•21

cas

es in

tota

l wer

e ra

ised

acro

ss th

e tr

ust d

urin

g O

ctob

er

Tabl

e 5.

1.1

Tota

l num

ber o

f Saf

egua

rdin

g Ch

ildre

n ca

ses

for t

he

curr

ent m

onth

, sho

win

g ca

se ty

pe a

nd b

roke

n do

wn

by lo

calit

y , a

nd

show

ing

curr

ent s

tatu

s

Tabl

e 5.

1.3

This

show

s the

tota

l num

ber o

f Saf

egua

rdin

g Ch

ildre

n c

ases

bro

ken

dow

n by

serv

ice

line,

sho

win

g C

ase

type

and

num

ber o

f inc

iden

ts a

nd st

atus

.

Grap

h 6.

1.1

Tota

l num

ber o

f Vul

nera

ble

Adul

ts in

cide

nts

repo

rted

du

ring

the

Last

12

Mon

ths

Grap

h 5.

1.1

- Tot

al n

umbe

r of S

afeg

uard

ing

Child

ren

inci

dent

s rep

orte

d du

ring

the

last

12

mon

ths

0510152025

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

2013

2014

Child

- Al

ert

Child

- Re

ferr

al

Sect

ion

5 - T

rust

Sum

mar

y of

all

Safe

guar

ding

Act

ivity

Go

vern

ance

Qua

lity

Repo

rt

Nov

embe

r 201

4

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Dudl

ey1

12

42

13

25

01

4DO

L's R

efer

ral

1DO

L's A

ctiv

e1

22

13

DOL'

s Clo

sed

12

42

11

23

Wal

sall

00

01

07

71

10

11

DOL'

s Ref

erra

l1

1DO

L's C

lose

d1

77

11

Gra

nd T

otal

11

25

28

103

60

00

Referral

Alert Only

Referral

Alert Only

Oct

623

2221

MAR

AC42

41

Dom

estic

Abu

se41

31

4Do

mes

tic H

omic

ide

Revi

ew1

1Sa

fegu

ardi

ng A

dult

17

726

2726

Dom

estic

Abu

se17

Gra

nd T

otal

59

Adul

tPa

rent

al M

enta

l Hea

lth C

once

rn (A

dult)

Patie

nt C

onsid

ered

Hig

h Ri

skPo

sitio

n O

f Tru

st (A

dult)

Gra

nd T

otal

17 38

2014

2013

Gra

nd T

otal

926 1 16 19 2

Dudl

eyW

alsa

ll

Gra

nd T

otal

8618572

Sect

ion

5.2

- Vul

nera

ble

Adul

ts a

ctiv

ity

Com

men

tary

Tabl

e 5.

2.1

The

Safe

guar

ding

das

hboa

rd in

corp

orat

es a

pro

cess

of c

aptu

ring

Depr

ivat

ion

Of L

iber

ties (

DOL'

s). F

urth

er tr

aini

ng a

nd d

evel

opm

ent i

s bei

ng

unde

rtak

en a

cros

s all

serv

ice

line.

Tabl

e 5.

2.2

This

show

s tha

t the

num

ber o

f Vul

nera

ble

Adul

ts ca

ses b

roke

n do

wn

by ca

se ty

pe a

nd sh

owin

g th

e lo

calit

y. T

his a

lso sh

ows i

nfor

mat

ion

on

whe

ther

the

case

is fo

r ale

rt o

nly

or if

it h

as b

een

refe

rred

for f

urth

er in

vest

igat

ion

to a

noth

er a

genc

y .

•Th

ere

are

no n

oted

tren

ds to

the

adul

t saf

egua

rdin

g al

ert f

igur

es. I

t is n

oted

that

ther

e ha

s bee

n a

high

er n

umbe

r of c

ases

that

hav

ebe

en se

nt th

roug

h ap

prop

riate

ly fr

om th

e lo

cal a

utho

rity.

Gra

ph 5

.2.1

Th

is gr

aph

prov

ides

info

rmat

ion

rela

ting

to th

e la

st 1

2 m

onth

s and

show

s a b

reak

dow

n of

Vul

nera

ble

Adul

ts ca

ses w

hich

are

just

for a

lert

an

d th

ose

whi

ch h

ave

been

pro

gres

sed

to th

e co

ntin

ue u

nder

Saf

egua

rdin

g.

Tabl

e 5.

2.3

Dom

estic

abu

se ca

ses a

re n

ow b

eing

repo

rted

as s

epar

ate

figur

es to

disp

lay

the

prev

alen

ce w

ithin

the

serv

ice.

Ca

se fi

gure

s are

also

show

n fo

r MAR

AC (m

ulti

agen

cy ri

sk a

sses

smen

t con

fere

nce)

, the

se fi

gure

s dem

onst

rate

how

man

y ca

ses a

re h

eard

at

MAR

AC w

here

the

vict

im, p

erpe

trat

or o

r chi

ldre

n ar

e op

en ca

ses t

o m

enta

l hea

lth.

Tabl

e 5.

2.2

To

tal n

umbe

r of V

ulne

rabl

e Ad

ults

inci

dent

s for

the

curr

ent

mon

th, s

how

ing

case

type

, num

ber o

f inc

iden

ts a

nd st

atus

.

Gra

ph 5

.2.1

Tot

al n

umbe

r of V

ulne

rabl

e Ad

ults

inci

dent

s re

port

ed d

urin

g th

e La

st 1

2 M

onth

s

Tabl

e 5.

2.1

De

priv

atio

n O

f Lib

ertie

s (DO

L's)

Th

is sh

ows t

he to

tal n

umbe

r of a

ctiv

e ca

ses o

f DO

L's,

bro

ken

dow

n by

Loca

lity

01020304050607080

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

2013

2014

Aler

t

Refe

rral

Tabl

e 5.

2.3

To

tal n

umbe

r of c

ases

of D

omes

tic

Abus

e fo

r the

curr

ent m

onth

, the

se

incl

ude

case

s rep

orte

d w

ithin

the

Trus

t an

d Ex

tren

ally

not

ified

by

MAR

AC

(Mul

ti-Ag

ency

Risk

Ass

essm

ent

Conf

eren

ce)

Sect

ion

N

HS S

afet

y Th

erm

omet

er

This

is th

e in

form

atio

n co

llect

ed re

gard

ing

Patie

nt H

arm

. Men

tal H

ealth

Dat

a is

curr

ently

onl

y ga

ther

ed fo

r Old

er P

eopl

e Se

rvic

es. I

t will

be

a sn

ap sh

ot o

f inf

orm

atio

n co

llect

ed o

n on

e da

y ea

ch m

onth

, foc

usin

g on

the

follo

win

g do

mai

ns:

Pres

sure

Ulc

ers(

PU),

Falls

, Urin

ary

Trac

t Inf

ectio

ns(U

TI's)

, Ven

ous t

hrom

boem

bolis

m (V

TE),

Cath

eter

s & h

arm

s.

The

Perf

orm

ance

Dep

artm

ent s

ubm

it th

is da

ta m

onth

ly to

the

NHS

Info

rmat

ion

Cent

re, t

hen

Com

miss

ione

rs w

ill re

view

the

perf

orm

ance

and

pub

lish

this

data

.

OVE

RALL

SU

MM

ARY

OF

DOM

AIN

S –

Oct

ober

201

4 TH

ERM

OM

ETER

SU

RVEY

– O

ctob

er 2

014

TEAM

Pr

essu

re

Ulc

ers

Falls

Ca

thet

ers

UTI

's an

d Ca

thet

er

New

VTE

Ha

rms

Ceda

rs W

ard

0 0

2 0

0 0

Holy

rood

War

d 0

1 0

0 0

1 Li

nden

War

d 0

0 0

0 0

0 M

alve

rn W

ard

0 0

0 0

0 0

CMHT

OP

Wal

sall

0 1

7 1

0 1

CMHT

OP

Dudl

ey

0 0

0 0

0 0

CMHT

OP

Cent

ral

* *

* *

* *

TOTA

L 0

2 9

1 0

2

DOC_

2014

1022

_Saf

ety_

Them

omet

er_O

utco

me_

Repo

rt.p

pt

Out

of t

he 9

2 pa

tient

s on

the

Surv

ey fo

r Oct

ober

201

4 th

e re

cord

ed b

reak

dow

n fo

r eac

h do

mai

n is

as fo

llow

s:

Pres

sure

Ulc

ers:

0

Falls

: 2

(1 H

arm

ful,

1 Lo

w H

arm

) Ca

thet

ers:

9

(6 <

28 D

ays,

2 >

28 D

ays,

1 N

ot K

now

n)

UTI

's an

d Ca

thet

er:

1 (N

ew U

TI)

New

VTE

: 0

Num

ber o

f Pat

ient

Har

ms:

2

Not

e fo

r Nov

embe

r and

Dec

embe

r sub

miss

ions

, num

bers

for H

olyr

ood

and

Mal

vern

are

now

com

bine

d.Fr

om F

ebru

ary

– th

e da

ta fr

om th

e 3

Wal

sall

CMHT

’s w

ere

com

bine

d in

to th

e CM

HTO

P Ce

ntra

l.Fr

om M

ay th

e 3

Wal

sall

CMHT

’s a

re re

cord

ed u

nder

CM

HTO

P W

alsa

ll bu

t for

June

’s s

ubm

issio

n th

e 3

Wal

sall

CMHT

’s w

ere

reco

rded

und

er C

MHT

OP

Cent

ral

Sect

ion

6 -

Saf

ety

Ther

mom

eter

Sect

ion

6 -

Saf

ety

Ther

mom

eter

Go

vern

ance

Qua

lity

Repo

rt

Nov

embe

r 201

4

Sep1

3O

ct13

Nov

13De

c13

Jan1

4Fe

b14

Mar

14Ap

r14

May

14Ju

n14

Jul1

4Au

g14

Sep1

4

Har

m F

ree

95.9

593

.62

96.7

798

.78

94.3

895

.88

96.7

97.1

796

.63

97.8

794

.68

97.9

296

.77

One

Har

m4.

056.

383.

231.

225.

624.

123.

32.

833.

371.

064.

261.

043.

23

Two

Har

ms

00

00

00

00

01.

061.

061.

040

Thre

e Ha

rms

00

00

00

00

00

00

0

Four

Har

ms

00

00

00

00

00

00

0

Patie

nts

7494

9382

8997

9110

689

9494

9693

0%10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Harm

Fre

e: p

atie

nts w

ith H

arm

Fre

e Ca

re

DUDL

EY A

ND

WAL

SALL

MEN

TAL H

EALT

H PA

RTN

ERSH

IP N

HS T

RUST

, All

War

ds, A

ll Se

ttin

gs, A

ll Se

rvic

es, A

ll Ag

es, A

ll Se

xes

Sep1

3O

ct13

Nov

13De

c13

Jan1

4Fe

b14

Mar

14Ap

r14

May

14Ju

n14

Jul1

4Au

g14

Sep1

4

Pres

sure

Ulc

ers

02.

130

1.22

1.12

2.06

2.2

1.89

2.25

1.06

2.13

1.04

3.23

Falls

02.

132.

150

1.12

01.

10

1.12

1.06

3.19

1.04

0

Cath

eter

& U

TI1.

351.

060

03.

372.

060

0.94

01.

061.

061.

040

New

VTE

2.7

1.06

1.08

00

00

00

00

00

Patie

nts

7494

9382

8997

9110

689

9494

9693

0%

0.5%1%

1.5%2%

2.5%3%

3.5%

Type

s of H

arm

: pat

ient

s with

eac

h ty

pe o

f Har

m

DUDL

EY A

ND

WAL

SALL

MEN

TAL H

EALT

H PA

RTN

ERSH

IP N

HS T

RUST

, All

War

ds, A

ll Se

ttin

gs, A

ll Se

rvic

es, A

ll Ag

es, A

ll Se

xes

Sep1

3O

ct13

Nov

13De

c13

Jan1

4Fe

b14

Mar

14Ap

r14

May

14Ju

n14

Jul1

4Au

g14

Sep1

4

Falls

with

Har

m0

2.13

2.15

01.

120

1.1

01.

121.

063.

191.

040

Low

Har

m0

1.06

2.15

00

01.

10

1.12

1.06

2.13

1.04

0

Mod

erat

e H

arm

01.

060

01.

120

00

00

1.06

00

Seve

re H

arm

00

00

00

00

00

00

0

Deat

h0

00

00

00

00

00

00

Patie

nts

7494

9382

8997

9110

689

9494

9693

0%

0.5%1%

1.5%2%

2.5%3%

3.5%

Falls

with

Har

m: p

atie

nts w

ith h

arm

from

a fa

ll DU

DLEY

AN

D W

ALSA

LL M

ENTA

L HEA

LTH

PART

NER

SHIP

NHS

TRU

ST, A

ll W

ards

, All

Sett

ings

, All

Serv

ices

, All

Ages

, All

Sexe

s

NHS

Saf

ety

Ther

mom

eter

"I

t's n

ot ju

st co

untin

g, it

's ca

ring"

The

NHS

Saf

ety

Ther

mom

eter

is a

loca

l im

prov

emen

t too

l for

mea

surin

g, m

onito

ring

and

anal

ysin

g pa

tient

ha

rms a

nd 'h

arm

free

' car

e.

The

follo

win

g fe

w p

ages

incl

ude

data

spec

ifica

lly r

elat

ing

to D

udle

y an

d W

alsa

ll M

enta

l hea

lth .

this

show

s 12

mon

ths w

orth

of d

ata,

pro

vidi

ng in

form

atio

n on

eac

h of

the

Crite

ria r

elat

ing

to th

e Sa

fety

Th

erm

omet

er.

•Fa

lls w

ith H

arm

: pat

ient

s with

har

m fr

om a

fall

•Ty

pes o

f Har

m: p

atie

nts w

ith e

ach

type

of H

arm

•Ha

rm F

ree:

pat

ient

s with

Har

m F

ree

Care

•Pr

essu

re U

lcer

s - N

ew &

Old

: pat

ient

s with

an

old

or n

ew p

ress

ure

ulce

r•

Pres

sure

Ulc

ers -

All:

pat

ient

s with

an

old

or n

ew p

ress

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ulce

r•

Pres

sure

Ulc

ers -

New

: pat

ient

s with

a n

ew p

ress

ure

ulce

r•

New

VTE

s: p

atie

nts w

ith a

new

VTE

•Ca

thet

er &

New

UTI

:•

All V

TEs:

Appe

ndix

1

This

docu

men

t is t

aken

dire

ctly

from

the

NHS

Saf

ety

Ther

mom

eter

web

site

, an

d p

rovi

des

data

for

Dudl

ey a

nd W

alsa

ll M

enta

l Hea

lth ,

offe

ring

a co

mpa

rison

aga

inst

the

natio

nal a

vera

ge

Sect

ion

6 -

Saf

ety

Ther

mom

eter

Go

vern

ance

Qua

lity

Repo

rt

Nov

embe

r 201

4

Sep1

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ct13

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13De

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Patie

nts

7494

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8997

9110

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9494

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0%

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sure

Ulc

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All:

pat

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an

old

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ulce

r DU

DLEY

AN

D W

ALSA

LL M

ENTA

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TNER

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NHS

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ST, A

ll W

ards

, All

Sett

ings

, All

Serv

ices

, All

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, All

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Sep1

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ct13

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13De

c13

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essu

re U

lcer

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ld0

2.13

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Pres

sure

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00

00

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00

00

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Patie

nts

7494

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9110

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0%

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Pres

sure

Ulc

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& O

ld: p

atie

nts w

ith a

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d or

new

pre

ssur

e ul

cer

DUDL

EY A

ND

WAL

SALL

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ds, A

ll Se

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ll Se

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ll Ag

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ll Se

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c13

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May

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g14

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essu

re U

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Pres

sure

Ulc

ers -

New

: pat

ient

s with

a n

ew p

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ure

ulce

r DU

DLEY

AN

D W

ALSA

LL M

ENTA

L HE

ALTH

PAR

TNER

SHIP

NHS

TRU

ST, A

ll W

ards

, All

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ings

, All

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ices

, All

Ages

, All

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s

Sect

ion

6 -

Saf

ety

Ther

mom

eter

Go

vern

ance

Qua

lity

Repo

rt

Nov

embe

r 201

4

Sep1

3O

ct13

Nov

13De

c13

Jan1

4Fe

b14

Mar

14Ap

r14

May

14Ju

n14

Jul1

4Au

g14

Sep1

4

All V

TEs

6.76

2.13

3.23

4.88

2.25

4.12

4.4

1.89

2.25

2.13

2.13

2.08

2.15

Old

DVT

1.35

1.06

1.08

1.22

01.

030

0.94

1.12

1.06

1.06

1.04

2.15

Old

PE

1.35

00

2.44

2.25

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1.06

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0

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All V

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AN

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ENTA

L HE

ALTH

PAR

TNER

SHIP

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TRU

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ll W

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ings

, All

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ices

, All

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, All

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s

Sep1

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s: p

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nts w

ith a

new

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DU

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TNER

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, All

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Cath

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& N

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, All

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, All

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ices

, All

Ages

, All

Sexe

s

It's not just counting ... It's caring

Pressure Ulcers All Pressure Ulcers Falls All Falls

Catheters VTE

Patients with new VTE Harm Free Care Harm free Care 1

Sect

ion

Mor

talit

y Re

port

This

repo

rt p

rovi

des

Qua

rter

ly in

form

atio

n on

the

Mor

talit

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ures

for t

he T

rust

look

ing

at Q

uart

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.

Sect

ion

- Q

uart

erly

Mor

talit

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port

Gov

erna

nce

Qua

lity

Repo

rt

Nov

embe

r 201

4

Case

Typ

eJu

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pTo

tal

Phys

ical

/Nat

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33

713

Susp

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12

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1

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Coro

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PM

/ In

ques

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02

22

22

24

Qtr

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Tabl

e .2

M

orta

lity

figur

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r the

last

Qua

rter

, bro

ken

dow

n by

age

ban

d, a

nd n

atur

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dea

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Tabl

e .1

M

orta

lity

figur

es fo

r Qua

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2, s

how

n by

nat

ure

of d

eath

This

repo

rt lo

oks t

o hi

ghlig

ht le

vels

of m

orta

lity

with

in th

e Tr

ust.

The

figur

es lo

ok a

t the

per

iod

of 0

1/07

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4 -

30/0

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14. T

his i

nfor

mat

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is gr

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d in

to 3

are

as, l

ooki

ng a

t:

•Ph

ysic

al H

elat

h / N

atur

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ause

s•

Susp

ecte

d / A

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l Sui

cide

•

Case

s whi

ch a

re o

utst

andi

ng w

ith th

e Co

rone

r aw

aitin

g Po

st M

orte

m.

Thes

e ar

e al

l cas

es o

f pat

ient

s who

are

kno

wn

to th

e Tr

ust o

r hav

e a

serv

ice

hist

ory

with

the

Trus

t.

• •

Char

t .1

Ta

ken

from

Tab

le

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orta

lity

figur

es fo

r Qua

rter

2, b

roke

n do

wn

by a

ge b

and,

and

nat

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of d

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00.

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/ In

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Phys

ical

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2014

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)(7

46)

0 A

mor

tisat

ion

(244

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0)(2

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(142

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42)

0 N

et O

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plus

2,06

916

218

218

1,15

11,

278

127

PD

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403

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197

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5

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1,79

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010

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040

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060

070

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0

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Run

Rate

201

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Cu

mul

ativ

e Budg

eted

Plan

ned

Run

Rate

Actu

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unRa

te

0

500

1,00

0

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0

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0

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0

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Capi

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Cum

ulat

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ned

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Actu

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pend

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mar

y In

com

e &

Exp

endi

ture

Sta

tem

ent I

nclu

ding

Fun

ctio

nal A

naly

sis

6

Com

men

tary

•Th

e Tr

ust i

s re

porti

ng a

sur

plus

to M

onth

07

of £

612k

, whi

ch is

£19

6k a

head

of p

lan.

•Th

ere

are

risks

aro

und

rela

ting

to n

on N

HS

in

com

e: s

lippa

ge o

n de

tox

beds

, non

re

cove

ry o

f out

of a

reas

SM

S a

ctiv

ity a

nd

unde

r per

form

ance

aga

inst

NC

As.

•Th

ere

cont

inue

s to

be

cost

pre

ssur

es in

co

rpor

ate

area

s in

Est

ates

and

P

erfo

rman

ce a

nd IT

.

•M

AR

s pa

ymen

ts o

f ove

r £80

0k h

ave

been

in

curr

ed a

nd a

re b

eing

man

aged

in th

e po

sitio

n at

pre

sent

.

•A

dditi

onal

exp

endi

ture

may

be

incu

rred

as

serv

ices

take

act

ion

to a

ddre

ss th

e un

der

perfo

rman

ce o

n so

me

activ

ity li

nes.

•Th

e ex

pend

iture

in O

lder

Adu

lts o

n ba

nk

and

agen

cy h

as c

ontin

ued,

alth

ough

this

ha

s be

en m

itiga

ted

by s

ubst

antiv

e st

aff

leav

ing

in M

onth

07

unde

r MA

RS

.

•Th

e fo

reca

st o

uttu

rn is

in li

ne w

ith p

lan.

A

nnua

l Pla

nIn

Mon

thYe

ar to

Dat

eFO

T M

07

2014

/15

Pla

nA

ctua

lV

aria

nce

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nA

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0

NH

S R

even

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ities

59,1

784,

931

4,92

9(3

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34,4

98(2

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7)

Rev

enue

from

LA

s2,

564

214

205

(8)

1,49

61,

480

(116

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To

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om A

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61,7

425,

145

5,13

4(1

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77(1

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C

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Fun

ctio

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C

orpo

rate

Dep

artm

ents

(12,

216)

(1,1

05)

(1,1

94)

(89)

(7,0

79)

(7,2

32)

(153

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01)

Cen

tral R

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ves

(452

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3)(3

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(438

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(121

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Fun

ctio

ns(1

2,66

8)(1

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9)(7

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84)

(322

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Ope

ratio

nal S

ervi

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Tota

l Acu

te &

Old

er A

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(18,

575)

(1,5

43)

(1,4

79)

64(1

0,85

7)(1

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6)47

144

0

Tota

l Com

mun

ity S

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(15,

660)

(1,2

81)

(1,3

15)

(34)

(4,1

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2237

M

edic

al S

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562

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tal E

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812

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415

612

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Trus

t Inc

ome

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tem

ent –

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me

7

Com

men

tary

•Th

e Tr

ust h

as n

egot

iate

d bl

ock

cont

ract

agre

emen

ts w

ith it

s ho

st a

nd n

eigh

bour

ing

CC

Gs,

whi

ch re

duce

s th

e ris

k of

in y

ear

loss

of i

ncom

e, b

ut e

qual

ly th

is li

mits

the

scop

e fo

r ove

r per

form

ance

.

•M

onth

07

has

seen

ano

ther

impr

ovem

ent i

n th

e le

vel o

f act

ivity

, alb

eit i

n th

e bl

ock

cont

ract

s ag

ains

t ind

icat

ive

targ

ets.

•Th

ere

is n

orm

ally

a la

g in

rece

ivin

g da

ta o

n N

CA

act

ivity

, but

this

is e

xpec

ted

to c

atch

up

in th

e co

min

g m

onth

s.

•Th

e in

pat

ient

det

ox s

ervi

ce a

t Bus

hey

Fiel

ds is

now

in o

pera

tion

and

is p

lann

ing

to

oper

ate

fully

for t

he re

mai

nder

of t

he y

ear,

but t

he a

ctiv

ity in

rece

nt m

onth

s ha

s no

t be

en a

t a le

vel t

o de

liver

the

annu

al ta

rget

, an

d m

onth

07

has

seen

a re

duct

ion

in

plan

ned

adm

issi

ons,

alth

ough

ther

e ha

ve

been

unp

lann

ed a

dmis

sion

s re

quiri

ng

deto

x.

•Th

e lo

ss o

f the

SM

S c

ontra

ct m

eans

that

th

ere

will

not

be

inco

me

agai

nst t

he n

on

host

Cou

ncils

, whi

ch re

sults

in a

cos

t pr

essu

re o

f £11

8k.

A

nnua

l Pla

nIn

Mon

thYe

ar to

Dat

eFO

T M

07

2014

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nA

ctua

lV

aria

nce

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nA

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aria

nce

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£'

000

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000

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000

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000

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even

ue F

rom

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S A

ctiv

ities

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ley

CC

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254

0 15

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15,7

780

0 W

alsa

ll C

CG

27,3

782,

282

2,28

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S W

alsa

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0 0

0 0

0 0

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andw

ell &

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t Birm

ingh

am C

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2,07

817

317

30

1,21

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212

0 0

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verh

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on C

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288

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0 16

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(0)

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340

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235

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135

135

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59,1

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cal A

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alsa

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2,11

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181

120

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0 0

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ther

HC

0 0

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1 1

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l Rev

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from

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564

214

205

(8)

1,49

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380

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tal R

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om A

ctiv

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61,7

425,

145

5,22

984

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1735

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(45)

(155

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t Inc

ome

& E

xpen

ditu

re S

tate

men

t- C

orpo

rate

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ctio

ns

8

Com

men

tary

•C

orpo

rate

Est

ates

– T

he d

elay

ed

deliv

ery

of C

IP P

lans

is c

reat

ing

finan

cial

risk

for t

he E

stat

es

budg

ets.

Pro

posa

ls a

re in

pla

ce

for s

avin

gs th

roug

h ex

tern

al

cont

ract

s ac

ross

the

Trus

t but

co

ntin

ue to

slip

furth

er in

to th

e fin

anci

al y

ear.

•Th

ere

is a

risk

of f

urth

er u

nder

sp

end

in th

e C

EO

bud

get i

f the

re

are

no S

T fu

nded

mov

es b

efor

e th

e ye

ar e

nd.

•Th

e re

crui

tmen

t of a

Bus

ines

s In

telli

genc

e P

roje

ct M

anag

er h

as

incr

ease

d th

e IT

& P

erfo

rman

ce

expe

nditu

re fo

r the

yea

r on

a no

n-re

curr

ing

basi

s.

An

nual

Pla

nIn

Mon

thYe

ar to

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eFO

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07

20

14/1

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000

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Cor

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edic

al(1

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71)

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Cor

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(1,8

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(137

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11)

4921

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te F

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00)

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6 (7

25)

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100

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te P

erfo

rman

ce &

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(213

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9)(1

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06)

(126

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Tota

l Cor

pora

te F

unct

ions

(12,

216)

(1,1

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(1,1

94)

(89)

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79)

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Trus

t Inc

ome

& E

xpen

ditu

re S

tate

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t-Ope

ratio

nal S

ervi

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9

Com

men

tary

•Ac

ute

& O

lder

Adu

lt se

rvic

es s

pent

less

than

ex

pect

ed o

n st

affin

g in

mon

th 0

7. I

nclu

ded

with

in

this,

Acu

te w

ard

cost

s wer

e £3

9k b

elow

the

aver

age

since

the

rede

sign

in O

ctob

er 2

013,

whi

lst

OA

war

d st

aff c

osts

wer

e £1

5k b

elow

the

aver

age

since

ext

ra sc

rutin

y w

as in

trod

uced

in S

epte

mbe

r 20

13.

Unc

over

ed v

acan

cies

in C

RHT,

OA

com

mun

ity te

ams a

nd p

sych

olog

y co

ntin

ue to

de

liver

sig

nific

ant v

acan

cy sa

ving

s, a

s exp

ecte

d.

•Th

e O

A or

gani

c w

ards

(in

part

icul

ar, L

inde

n) a

re

expe

cted

to g

ener

ate

the

bulk

of t

he O

A w

ard

over

spen

d th

is ye

ar, w

hen

com

parin

g av

erag

e co

sts o

ver t

he 1

4 m

onth

s Sep

t 13

to O

ct 1

4 to

the

new

‘saf

er st

affin

g’ b

udge

t lev

el.

•

Ther

e is

a ye

ar to

dat

e va

rianc

e fr

om b

udge

t for

m

edic

al se

rvic

es (m

ainl

y re

late

d to

tim

ing

of

trai

ning

exp

endi

ture

, and

slip

page

on

intr

oduc

ing

the

new

dru

g Ar

ipip

razo

le);

the

unco

mm

itted

co

ntin

genc

y fu

nds h

ave

incr

ease

d to

£13

8k fo

r the

ye

ar.

•Co

mm

unity

- Re

crui

tmen

t to

post

s and

rem

oval

of

agen

cy c

osts

is st

ill e

xpec

ted

by D

ecem

ber,

post

m

anag

emen

t of c

hang

e pr

oces

s. An

y fu

rthe

r sli

ppag

e is

likel

y to

resu

lt in

mov

ing

from

bre

ak-

even

out

turn

to a

n ov

er sp

end.

•

CAM

HS R

estr

uctu

re fo

r £80

k CI

P ta

rget

has

bee

n de

liver

ed in

full

for t

he y

ear a

nd E

arly

Inte

rven

tion

serv

ice

line

rem

ains

in fo

reca

st to

und

er sp

end.

•

SMS

have

add

ition

al c

osts

due

to th

e re

plac

emen

t of

staf

f with

tem

pora

ry a

rran

gem

ents

unt

il th

e ou

tcom

e of

the

curr

ent t

ende

r is k

now

n.

An

nual

Pl

anIn

Mon

thYe

ar to

Dat

eFO

T M

07

20

14/1

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anAc

tual

Varia

nce

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alVa

rianc

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£'00

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000

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000

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0£'

000

£'00

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000

Ope

ratio

nal S

ervi

ces

Ac

ute

and

Old

er A

dults

Man

agem

ent a

nd A

dmin

istra

tion

(1,0

44)

(89)

(80)

10(5

98)

(460

)13

821

2Ac

ute

Serv

ices

(8,2

96)

(688

)(6

41)

47(4

,858

)(4

,500

)35

833

6Ac

ute

Esta

tes

(2,6

77)

(223

)(2

24)

(1)

(1,5

62)

(1,5

61)

0 (1

0)O

lder

Adu

lts(6

,558

)(5

43)

(535

)8

(3,8

39)

(3,8

64)

(25)

(98)

Tota

l Acu

te &

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er A

dults

(18,

575)

(1,5

43)

(1,4

79)

64(1

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6)47

144

0

Com

mun

ity S

ervi

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Com

mun

ity E

stat

es(7

56)

(63)

(65)

(2)

(441

)(4

53)

(12)

(20)

Man

agem

ent a

nd A

dmin

istra

tion

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0)(1

6)(6

)(1

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(133

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13C

omm

unity

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vice

s(4

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,483

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2)6

Early

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rven

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96)

(594

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(4,2

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27R

ecov

ery

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ices

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49)

(262

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(1,8

20)

1810

Tota

l Com

mun

ity S

ervi

ces

(15,

660)

(1,2

81)

(1,3

15)

(34)

(4,1

94)

(4,1

72)

(22)

37

Med

ical

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vice

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2,76

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61)

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0

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l Ope

ratin

g Se

rvic

es(4

7,00

4)(3

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383)

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562

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Cap

ital P

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e

10

Com

men

tary

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sm

all a

mou

nt o

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endi

ture

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be

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curre

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resp

ect o

f old

yea

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hem

es £

34k

•Th

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lanc

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endi

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yea

r to

date

rela

tes

in th

e m

ain

to th

e A

gile

W

orki

ng P

ilot (

to in

clud

e W

i-Fi

Pro

visi

on) t

hat w

as ro

lled

out a

t the

be

ginn

ing

of th

is fi

nanc

ial y

ear a

nd

the

seco

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hase

in th

e B

FH

Hea

ting

Con

trols

sch

eme

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num

ber o

f oth

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chem

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re in

th

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oces

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d fo

r ap

prov

al b

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nd/o

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ccru

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have

bee

n m

ade

in M

th7

for w

orks

com

plet

ed a

t the

end

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Oct

ober

that

had

not

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n in

voic

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or G

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din

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syst

em.

11

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men

tary

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s de

taile

d be

low

Mon

itor h

ave

issu

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ew F

inan

cial

met

rics,

but

th

e FR

R w

ill c

ontin

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be

repo

rted

in o

rder

to p

rovi

de a

de

gree

of c

onsi

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cy d

urin

g th

e tra

nsiti

on

•Th

e re

duce

d pl

anne

d su

rplu

s fo

r 20

14/1

5 of

£80

8k m

eans

that

the

plan

ned

FRR

will

redu

ce to

3.7

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e un

ders

pend

ing

in M

onth

07

has

resu

lted

in a

n ac

tual

FR

R o

f 3.

90.

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onito

r hav

e pu

blis

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in 2

013

a ne

w fi

nanc

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sses

smen

t too

l, ca

lled

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tinui

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vice

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etric

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ch in

corp

orat

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o m

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s: C

apita

l Ser

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Cap

acity

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even

ue a

vaila

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for D

ebt

serv

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or C

apita

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vice

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d L

iqui

dity

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h fo

r Liq

uidi

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rela

tive

to tu

rnov

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anci

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m

onth

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give

s an

ove

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4, w

hich

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Fina

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form

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Met

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Key

Dat

a Ite

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4 Fu

ll Ye

ar

C

urre

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ear

to D

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Fo

reca

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uttu

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Ac

coun

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anAc

tual

Varia

nce

Plan

Fore

cast

Varia

nce

(m

c 01

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c 02

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c 03

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c 04

)(m

c 05

)(m

c 06

)(m

c 07

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£000

s£0

00s

£000

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£000

s£0

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£000

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ontin

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of S

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isk

Rat

ings

Liqu

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io (d

ays)

530

4.0

4.0

4.0

0.0

4.0

4.0

0.0

Cap

ital S

ervi

cing

Cap

acity

(tim

es)

540

4.0

4.0

4.0

0.0

4.0

4.0

0.0

Ove

rall

Con

tinui

ty o

f Ser

vice

Ris

k R

atin

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04.

04.

04.

00.

04.

04.

00.

0

Am

ende

d M

onito

r Fin

anci

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Rat

ing

Met

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an

Scor

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Plan

W

eigh

ted

FRR

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an

Act

ual -

Mon

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Scor

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ctua

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onth

7

Wei

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R

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7

EBIT

DA

mar

gin

6.0%

3 0.

756.

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0.75

EBIT

DA,

% a

chie

ved

100.

0%5

0.50

110.

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0.50

Net

Ret

urn

afte

r Fin

anci

ng1.

5%3

0.60

2.3%

4 0.

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argi

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ende

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riter

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5 4

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argi

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chie

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85%

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urn

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anci

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men

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turn

for M

onth

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how

n in

the

tabl

e to

the

left.

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derly

ing

posi

tion

refle

cts

the

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t re

serv

es, a

ppro

xim

atel

y £5

00k

in y

ear,

and

the

fact

that

£50

0k h

as b

een

used

to s

uppo

rt no

n-

recu

rrin

g co

st p

ress

ures

in

201

4/15

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•C

ontin

uity

of S

ervi

ce

scor

es a

re a

t a m

axim

um

of 4

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Key

Met

rics

Cur

rent

Mon

th M

etric

s

Varia

nce

By

Mon

th

R

AG

by

Mon

th

(A) A

ccou

ntab

ility

Fra

mew

ork

Sub

Sign

Plan

Act

ual /

Fo

reca

stVa

rianc

eR

AG

Rat

ing

Jul

Aug

Sep

Jul

Aug

Sep

C

ode

(m

c 01

)(m

c 02

)(m

c 03

)(m

c 04

)(m

c 07

)(m

c 08

)(m

c 09

)(m

c 18

)(m

c 19

)(m

c 20

)

£0

00s

£000

s£0

00s

£0

00s

£000

s£0

00s

NH

S Fi

nanc

ial P

erfo

rman

ce

1a) F

orec

ast O

uttu

rn, C

ompa

red

to P

lan

100

+/-

808

808

0GR

EEN

00

0GR

EEN

GR

EEN

GR

EEN

1b) Y

ear t

o D

ate,

Act

ual c

ompa

red

to P

lan

150

+/-

417

707

290G

REE

N12

216

418

0GR

EEN

GR

EEN

GR

EEN

Fina

ncia

l Effi

cien

cy

2a

) Act

ual E

ffici

ency

recu

rrin

g/no

n-re

curr

ing

com

pare

d to

pl

an -

Year

to d

ate

actu

al c

ompa

red

to p

lan

200

+/-

G

REE

N

GR

EEN

GR

EEN

GR

EEN

- Tot

al E

ffici

enci

es fo

r Yea

r to

Dat

e co

mpa

red

to P

lan

210

+/-

1,46

11,

461

0

01

0

- Rec

urre

nt E

ffici

enci

es fo

r Yea

r to

Dat

e co

mpa

red

to

Plan

215

+/-

1,46

11,

461

0

01

0

2b) A

ctua

l Effi

cien

cy re

curr

ing/

non-

recu

rrin

g co

mpa

red

to

plan

- Fo

reca

st c

ompa

red

to p

lan

220

+/-

G

REE

N

GR

EEN

GR

EEN

GR

EEN

- Tot

al E

ffici

enci

es fo

r For

ecas

t Out

turn

com

pare

d to

Pl

an22

5+/

- 2,

616

2,61

60

0

00

- R

ecur

rent

Effi

cien

cies

for F

orec

ast O

uttu

rn c

ompa

red

to

Plan

230

+/-

2,61

62,

616

0

00

0

Und

erly

ing

Rev

enue

Pos

ition

3) F

orec

ast U

nder

lyin

g su

rplu

s / (

defic

it) c

ompa

red

to

Plan

250

+/-

1,08

81,

088

0GR

EEN

720

720

883G

REE

NG

REE

NG

REE

N

Cas

h an

d C

apita

l

4) F

orec

ast Y

ear E

nd C

harg

e to

Cap

ital R

esou

rce

Lim

it35

0+/

- 0

00G

REE

N0

6868

GR

EEN

GR

EEN

GR

EEN

5) P

erm

anen

t PD

C a

cces

sed

for l

iqui

dity

pur

pose

s40

0+/

-

0

GR

EEN

G

REE

NG

REE

NG

REE

N

Trus

t Ove

rall

RA

G R

atin

g45

5

G

REE

N

GR

EEN

GR

EEN

GR

EEN

(B) C

ontin

uity

of S

ervi

ce R

isk

Rat

ings

Year

to D

ate

Rat

ing

460

+/-

4.00

4.00

0.00

GR

EEN

00

0GR

EEN

GR

EEN

GR

EEN

Fore

cast

Out

turn

Rat

ing

465

+/-

4.00

4.00

0.00

GR

EEN

00

0GR

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GR

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(C) N

umbe

r of u

nres

olve

d Va

lidat

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Erro

rs (L

evel

1

only

)47

0

0

0

00

Cas

h Fl

ow S

tate

men

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13

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men

tary

Cas

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e an

ope

ratin

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rplu

s of

£1,

354k

fo

r the

firs

t sev

en m

onth

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, and

re

ceiv

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ash

of £

888k

in re

spec

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and

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cash

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as re

ceiv

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of in

tere

st, a

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spen

t £77

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n ca

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duci

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yabl

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om th

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nd a

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on

2014

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tal e

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expe

nditu

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cas

h te

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was

less

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ceiv

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reci

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d am

ortis

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on

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as to

in

crea

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h ba

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This

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use

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igur

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com

pare

act

ual c

ash

agai

nst a

s th

e ye

ar p

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assu

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wor

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h Fl

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1,35

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in P

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Pay

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ter P

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t mee

ts th

e 95

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rget

ac

ross

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e of

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four

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cato

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e Tr

ust o

nly

mee

t the

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targ

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for o

ne o

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and

dela

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ause

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quis

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rais

ing

orde

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retro

spec

tivel

y.

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onth

ly re

min

ders

are

now

bei

ng

sent

out

to a

ll A

utho

risin

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outli

ning

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impo

rtanc

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Out

of O

ffice

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ys o

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s at

the

mon

th

end

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figu

re w

as 5

3% a

t the

end

of

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tem

ber.

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age

d 90

day

s or

ol

der a

t the

end

of O

ctob

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his

figur

e w

as 1

5% a

t the

end

of

Sep

tem

ber.

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are

cont

inui

ng d

ispu

tes

with

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cal A

utho

ritie

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d A

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w g

reat

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an 9

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chie

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k.

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nt F

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sact

ed in

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th 0

7 =

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98k.

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rget

is £

2,61

6k, b

ut th

e Tr

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as re

view

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inte

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f £2,

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tary

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dget

s fo

r the

2014

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targ

et h

ave

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olve

d to

the

appr

opria

te b

udge

t are

as.

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ork

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ngoi

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ure

that

the

FYE

of a

ll th

e 20

14/1

5 sc

hem

es is

real

ised

and

del

iver

able

from

1st

Apr

il 20

15.

•W

ork

is o

ngoi

ng to

ens

ure

2015

/16

sche

mes

beg

in to

del

iver

cas

h re

duct

ion

by 1

st A

pril

2015

.

Sta

tem

ent o

f Fin

anci

al P

ositi

on

16

Com

men

tary

Non

Cur

rent

Ass

ets

•D

epre

ciat

ion

and

amor

tisat

ion

exce

ed c

apita

l exp

endi

ture

in

201

4/15

. Thi

s is

to b

e ex

pect

ed a

t the

beg

inni

ng o

f the

fin

anci

al y

ear a

s ca

pita

l sch

emes

get

und

erw

ay.

•P

rogr

ess

agai

nst c

apita

l sch

emes

is re

view

ed e

lsew

here

in

this

repo

rt

Cur

rent

Ass

ets

•R

ecei

vabl

es a

re £

405k

less

than

at 3

1 M

arch

201

4

•C

ash

is £

1,74

7k h

ighe

r tha

n th

e ba

lanc

e at

31

Mar

ch 2

014

•A

n an

alys

is o

f cas

h flo

ws

can

be s

een

else

whe

re in

this

re

port

Cur

rent

Lia

bilit

ies

•P

ayab

les

have

incr

ease

d by

£60

9k

•N

HS

LA P

rovi

sion

s ha

ve in

crea

sed

by £

11k,

pro

visi

ons

in

rela

tion

to m

edic

al p

ay a

rrea

rs a

nd s

taff

of fi

xed

term

co

ntra

cts

have

rem

aine

d co

nsta

nt.

Prov

isio

ns•

This

pro

visi

on is

in re

spec

t of V

AT

over

-rec

over

ed fr

om

HM

RC

. Thi

s ha

s re

duce

d by

£43

0k in

the

year

as

mos

t ou

tsta

ndin

g is

sues

are

now

thou

ght t

o be

reso

lved

.

Tax

Paye

rs’ E

quity

•Th

e C

urre

nt Y

ear I

&E

figu

re re

flect

s th

e su

rplu

s YT

D o

f £6

12k

17

Tr

ust B

oard

M

eetin

g Da

te –

3rd

Dec

embe

r 201

4

Wor

kfor

ce R

epor

t 20

14/1

5 M

onth

7

18

Wor

kfor

ce R

epor

t - C

onte

nts

Page

Key

Mes

sage

s 3

Wor

kfor

ce D

ashb

oard

4

FTE

v W

orkf

orce

Pla

n 5

Turn

over

6

Sick

ness

Abs

ence

7

Appr

aisa

l 8

Man

dato

ry T

rain

ing

9

19

Key

Mes

sage

s

Sick

ness

Abs

ence

– T

rust

sick

ness

for O

ctob

er 2

014

was

4.9

2%, a

dec

reas

e of

0.2

6% fr

om S

epte

mbe

r (5.

18%

). T

his r

educ

tion

is du

e pr

imar

ily to

the

retu

rn to

wor

k of

a n

umbe

r of i

ndiv

idua

ls w

ho h

ad b

een

of o

n lo

ng te

rm si

ck.

Ther

e ha

s bee

n a

corr

espo

ndin

g sig

nific

ant r

educ

tion

in th

e pr

opor

tion

of si

ckne

ss a

ttrib

utab

le to

stre

ss/a

nxie

ty. F

ollo

win

g di

scus

sions

with

colle

ague

s fro

m a

cros

s th

e Tr

ust,

an im

med

iate

term

act

ion

plan

is b

eing

impl

emen

ted

to im

prov

e st

aff h

ealth

and

wel

l-bei

ng, a

nd p

reve

ntin

g st

aff

sickn

ess

whe

re p

ossib

le. T

he fo

cus o

f the

se a

ctio

ns is

to su

ppor

t sta

ff to

impr

ove

thei

r ow

n he

alth

, bet

ter m

anag

e st

ress

and

to

crea

te m

ore

flexi

ble

oppo

rtun

ities

for s

taff

to re

turn

to w

ork

as so

on a

s pos

sible

aft

er a

per

iod

of a

bsen

ce.

Vaca

ncy

Man

agem

ent –

The

vac

ancy

pos

ition

has

incr

ease

d to

213

FTE

Vac

anci

es in

Oct

-14

follo

win

g th

e im

plem

enta

tion

of

MAR

S. O

f whi

ch 5

0 po

sts a

re c

urre

ntly

bei

ng re

crui

ted

to.

To a

ddre

ss th

e ga

p sh

ort t

o m

id te

rm W

orkf

orce

/Rec

ruitm

ent

plan

s hav

e be

en d

evel

oped

by

Head

s of S

ervi

ce.

The

nex

t pha

se o

f thi

s pr

ogra

mm

e of

wor

k is

to co

nver

t the

Ser

vice

leve

l pla

ns

into

pro

-act

ive

and

targ

eted

recr

uitm

ent p

lans

whi

ch w

ill b

e im

plem

ente

d in

Q4

2014

/15.

N

atio

nal P

ay D

ispu

te –

A to

tal o

f 33

staf

f too

k pa

rt in

the

strik

e on

Mon

day

13th

Oct

ober

. Th

e ea

rly si

gns a

re th

at 1

5 m

embe

rs o

f st

aff t

ook

part

in th

e st

rike

actio

n on

Mon

day

24th

Nov

embe

r. A

s agr

eed

by th

e Bo

ard,

pay

for t

he h

ours

lost

was

ded

ucte

d fr

om

Oct

ober

and

this

prin

cipl

e w

ill b

e fo

llow

ed fo

r Nov

embe

r. As

sura

nce

– A

s par

t of t

he 2

014/

15 In

tern

al A

udit

Prog

ram

me,

the

depa

rtm

ent h

as re

cent

ly b

een

the

subj

ect o

f tw

o in

tern

al a

udit

repo

rts –

one

on

payr

oll a

nd o

ne o

n pr

oces

ses

rela

ting

to c

hang

e m

anag

emen

t. Th

e fin

ding

s of b

oth

repo

rts w

ere

that

the

inve

stig

atio

ns fo

und

ther

e to

be

signi

fican

t ass

uran

ce re

latin

g to

the

desig

n an

d op

erat

ion

of in

tern

al co

ntro

ls in

thes

e im

port

ant

area

s. T

he d

epar

tmen

t are

cur

rent

ly fi

nalis

ing

actio

n pl

ans t

o ad

dres

s the

reco

mm

enda

tions

, whi

ch w

ill b

e pr

esen

ted

to th

e Au

dit

Com

mitt

ee a

t its

Dec

embe

r mee

ting.

M

anda

tory

Tra

inin

g –

Com

plia

nce

rem

ains

abo

ve T

rust

targ

et.

Ther

e is

a pr

oact

ive

piec

e of

wor

k ta

rget

ing

to in

crea

se co

mpl

ianc

e in

Info

rmat

ion

Gove

rnan

ce, a

s par

t of t

he IG

tool

kit.

20

Wor

kfor

ce D

ashb

oard

445

Dudl

ey a

nd W

alsa

ll M

enta

l Hea

lth P

artn

ersh

ip N

HS T

rust

Staf

f in

Post

Targ

etCo

rpor

ate

Med

ical

Acut

e Se

rvic

esCo

mm

unity

Se

rvic

esEa

rly

Inte

rven

tion

Olde

r Adu

ltsRe

cove

ry

Serv

ices

Oper

atio

ns

Man

agem

ent

DWM

H (S

ep-

14)

DWM

H (O

ct-

14)

Mon

th o

n M

onth

Tren

dH

eadc

ount

8511

517

497

160

163

7310

710

4710

08Fu

nded

Est

ablis

hmen

t85

.713

4.7

224.

010

6.5

172.

818

3.9

84.1

95.6

1,12

5.4

1,12

5.4

Staf

f in

Post

FTE

(Con

trac

ted)

77.5

106.

116

4.3

88.0

148.

414

3.1

66.2

87.5

945.

791

1.7

No

of V

acan

cies

8.2

28.6

59.7

18.6

24.4

40.8

17.9

8.1

179.

721

3.7

Vaca

ncy

%9.

6%21

.2%

26.7

%17

.4%

14.1

%22

.2%

21.3

%8.

4%16

.0%

19.0

%N

o of

Sta

rter

s (H

eadc

ount

)6

03

00

21

218

14N

o of

Lea

vers

(Hea

dcou

nt)

51

31

14

11

5418

Turn

over

% (1

2 M

onth

s)8-

14%

22.4

9%16

.62%

15.4

7%14

.05%

9.71

%14

.65%

35.4

7%23

.29%

16.2

0%17

.27%

Abse

nce

Targ

etCo

rpor

ate

Med

ical

Acut

e Se

rvic

esCo

mm

unity

Se

rvic

esEa

rly

Inte

rven

tion

Olde

r Adu

ltsRe

cove

ry

Serv

ices

Oper

atio

ns

Man

agem

ent

Trus

t (Pr

evio

us

Mon

th)

Trus

t (Cu

rren

t M

onth

)M

onth

on

Mon

th Tr

end

Sick

ness

% (M

onth

)4.

68%

5.44

%3.

90%

8.54

%6.

82%

4.39

%4.

05%

4.45

%0.

82%

5.18

%4.

92%

Sick

ness

Day

s Lo

st F

TE (M

onth

)12

812

843

718

620

217

992

221,

471

1,39

0N

o of

Sic

knes

s Ep

isod

es (M

onth

)9

2542

2128

2713

816

617

4Lo

ng T

erm

Sic

knes

s %

(Mon

th)

72.4

7%22

.69%

35.0

0%62

.55%

69.9

7%43

.79%

81.9

2%37

.06%

51.6

7%50

.02%

Cost

of S

ickn

ess

(Mon

th)

£10K

£11K

£31K

£15K

£17K

£13K

£7K

£1K

£116

K£1

07K

Mat

erni

ty %

(Mon

th)

1.32

%0.

00%

3.03

%2.

21%

2.02

%2.

52%

3.00

%1.

14%

1.98

%1.

93%

Sick

ness

% (1

2 M

onth

s)4.

68%

4.05

%3.

41%

7.33

%5.

02%

5.57

%7.

77%

5.09

%2.

78%

5.39

%5.

40%

Long

Ter

m S

ickn

ess

% (1

2 M

onth

s)81

.27%

61.4

6%68

.89%

67.5

0%76

.53%

78.6

0%75

.80%

73.6

5%74

.18%

73.3

1%Co

st o

f Sic

knes

s (1

2 M

onth

s)£1

10K

£197

K£3

33K

£137

K£2

63K

£314

K£1

06K

£73K

£1,5

64K

£1,5

51K

Deve

lopm

ent

Targ

etCo

rpor

ate

Med

ical

Acut

e Se

rvic

esCo

mm

unity

Se

rvic

esEa

rly

Inte

rven

tion

Olde

r Adu

ltsRe

cove

ry

Serv

ices

Oper

atio

ns

Man

agem

ent

Trus

t (Pr

evio

us

Mon

th)

Trus

t (Cu

rren

t M

onth

)M

onth

on

Mon

th Tr

end

Appr

iasa

ls C

ompl

eted

4672

8772

121

7938

4061

157

2Ap

prai

sals

Out

stan

ding

4327

9122

4179

3269

419

419

Appr

aisa

l %70

%51

.69%

72.7

3%48

.88%

76.6

0%74

.69%

50.0

0%54

.29%

36.7

0%59

.32%

57.7

2%M

anda

tory

Tra

inin

g85

%

Empl

oyee

Rel

atio

ns

Targ

etCo

rpor

ate

Med

ical

Acut

e Se

rvic

esCo

mm

unity

Se

rvic

esEa

rly

Inte

rven

tion

Olde

r Adu

ltsRe

cove

ry

Serv

ices

Oper

atio

ns

Man

agem

ent

Trus

t (Pr

evio

us

Mon

th)

Trus

t (Cu

rren

t M

onth

)M

onth

on

Mon

th Tr

end

No

of E

R Ca

ses

41

55

Oct

-14

21

FTE

v W

orkf

orce

Pla

n

Staf

f in

Post

FTE

dec

reas

ed b

y 34

FTE

from

946

FTE

in S

ep-1

4 to

912

FTE

in O

ct-1

4 fo

llow

ing

the

impl

emen

tatio

n of

MAR

S.

Trus

t Wid

e Ac

tual

FTE

has

redu

ced

by 7

5 FT

E si

nce

Nov

-201

3.

The

HR T

eam

are

wor

king

in p

artn

ersh

ip w

ith H

eads

of S

ervi

ce to

dev

elop

shor

t to

mid

term

W

orkf

orce

/Rec

ruitm

ent P

lans

to re

crui

t to

vaca

ncie

s.

Nov

-13

Dec-

13Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14Ju

l-14

Aug-

14Se

p-14

Oct

-14

WP

Targ

et11

5111

5111

5111

5111

5111

1311

1311

1311

1311

1311

1311

13Ac

tual

FTE

987

982

976

973

961

957

959

961

960

946

946

912

800

850

900

950

1000

1050

1100

1150

1200

Actu

al FT

E v

Wor

kfor

ce P

lan

22

Turn

over

(12

Mon

ths)

The

12 m

onth

Tur

nove

r inc

reas

ed to

17.

27%

in O

ct-2

014,

an

incr

ease

of j

ust u

nder

8%

from

the

sam

e pe

riod

last

yea

r.

The

reas

ons f

or th

e in

crea

se th

roug

hout

the

year

are

the

impl

emen

tatio

n of

MAR

S in

201

4-15

, in

whi

ch 3

4.89

FTE

left

the

Trus

t. T

urno

ver e

xclu

ding

em

ploy

ees l

eavi

ng th

roug

h M

ARS

is 1

3.52

%.

Addi

tiona

l TUP

E tr

ansf

er o

f Dud

ley

SMS

Serv

ices

in A

pril

2014

incr

ease

d th

e po

sitio

n.

The

turn

over

rate

exc

lude

s Jun

ior D

octo

rs, d

ue to

the

natu

re o

f the

i rot

atio

nal c

ontr

acts

.

Nov

-13

Dec-

13Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14Ju

l-14

Aug-

14Se

p-14

Oct

-14

Low

er T

arge

t8.

00%

8.00

%8.

00%

8.00

%8.

00%

8.00

%8.

00%

8.00

%8.

00%

8.00

%8.

00%

8.00

%Tu

rnov

er %

9.42

%9.

99%

10.1

3%10

.46%

11.3

0%11

.58%

11.3

3%11

.73%

11.9

4%12

.57%

16.2

0%17

.27%

Upp

er T

arge

t14

.00%

14.0

0%14

.00%

14.0

0%14

.00%

14.0

0%14

.00%

14.0

0%14

.00%

14.0

0%14

.00%

14.0

0%

3.00

%5.

00%

7.00

%9.

00%

11.0

0%13

.00%

15.0

0%17

.00%

19.0

0%

DWM

H Tu

rnov

er %

by

Mon

th

23

Sick

ness

ate

L

al L

ev

cute

Man

a

Com

mu

Com

m

rly In

te

Old

er A

ecov

e

pera

tServ

ice

No

of E

piso

des

(Mon

th)

Sick

ness

%

(Mon

th)

Sick

ness

%

(12

Mon

ths)

Corp

orat

e9

5.44

%4.

05%

Med

ical

Dire

ctor

ate

253.

90%

3.41

%Ac

ute

Serv

ices

428.

54%

7.33

%Ac

ute

Man

agem

ent

21.

64%

3.19

%Co

mm

unity

Ser

vice

s21

6.82

%5.

02%

Com

mun

ity M

anag

emen

t0

0.00

%0.

68%

5.57

%O

lder

Adu

lts27

4.05

%7.

77%

Trus

t wid

e si

cken

ss h

as d

ecre

ased

for t

he 2

nd co

nsec

utiv

e m

onth

to to

4.9

2% in

Oct

-14.

12

Mon

th ro

lling

sick

ness

has

in

crea

sed

slig

htly

to 5

.40%

The

posi

tion

has i

mpr

oved

follo

win

g a

num

ber o

f em

ploy

ees

retu

rnin

g fr

om Lo

ng T

erm

Sic

knes

s in

Mon

th.

A w

orki

ng g

roup

has

bee

n se

t up

to fo

cus o

n im

prov

ing

sick

ness

abs

ence

and

staf

f wel

lbei

ng.

Prop

osal

s of n

ew

appr

oach

es h

ave

been

agr

eed

by th

e Ex

ecut

ive

Team

and

will

be

impl

emen

ted

over

the

com

ing

mon

ths.

DWM

H To

tal

174

4.92

%5.

40%

Reco

very

Ser

vice

s13

4.45

%5.

09%

Ops

Man

agem

ent

80.

82%

2.78

%

Early

Inte

rven

tion

284.

39%

Nov

-13

Dec-

13Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14Ju

l-14

Aug-

14Se

p-14

Oct

-14

Targ

et4.

68%

4.68

%4.

68%

4.68

%4.

68%

4.68

%4.

68%

4.68

%4.

68%

4.68

%4.

68%

4.68

%Si

ckne

ss %

5.27

%5.

37%

6.13

%5.

81%

5.30

%5.

84%

4.90

%5.

03%

5.40

%5.

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Board meeting date: 3rd

December 2014Agenda Item number: 10.2 Enclosure: 8

Report Title: Trust Development Authority Self Certification DocumentsMonthly report (Month 7)

Accountable Director: Mark Axcell – Director of Finance, Performance, and IM&T

Author (name & title): James Parker – Commissioner Liaison Manager

Purpose of the report: As part of the NHS Trust Development Authority Accountability Framework for NHS Trust Boards, a self-certification process has been set up. As a provider organisation we are required to provide the NHS Trust Development Authority with two monthly self-certifications in relation to the Foundation Trust application process. The self-certification process consists of two forms as per its introduction in 2013/14:

Monitor Licensing RequirementsTrust Board Statements

Both submissions are included in this enclosure, and have already been reviewed by the Chief Executive Officer and the Trust Chairman to approve submission to the Trust Development Authority.



Committee: Finance and Performance Committee

Date reviewed: 23rd November 2014

Key points or recommendations from Committee:


servicesInclusive


cultureResponsible



What impact or implications does this report have on any of the following:


Caring The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Responsive The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Effective The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Well-led The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Safe The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources

Title Trust Development Authority Self Certification DocumentsMonthly report (Month 7)

Introduction

This paper presents the Trust’s compliance with Monitor Licensing Requirements at the end of month seven, 2014/15 financial year, together with Board statements on compliance with fundamental standards of:

o Clinical qualityo Financeo Governance


Governance Risk Rating (GRR) remains 0 with 0 being the best rating possible.

Monitor Financial Risk Rating (FRR) remains 4 with 5 being the best rating possible. The overall FRR is rating is therefore Green.

The Board is required by the NHS TDA to provide and return the oversight self-certification governance declarations no later than close of play on 30th November 2014.

Late submissions will be over-ridden to a red governance risk rating.

Recommendation

It is recommended that the Board note the performance of the Trust as at month seven, and the fact that these documents have been approved for submission by the Finance and Performance Committee and the Chairperson and Chief Executive.


The Board is asked to ratify the submitted Board statements and Monitor licensing requirements declarations.

NHS TRUST DEVELOPMENT AUTHORITY

OVERSIGHT: Monthly self-certification requirements - Compliance Monitor Monthly Data.

CONTACT INFORMATION:

Enter Your Name:

Enter Your Email Address

Full Telephone Number: Tel Extension:

SELF-CERTIFICATION DETAILS:

Select Your Trust:

Submission Date: Reporting Year:

Select the Month April May June

July August September

October November December

January February March

COMPLIANCE WITH MONITOR LICENCE REQUIREMENTS FOR NHS TRUSTS:

James Parker

[email protected]

01384324527 4527

Dudley And Walsall Mental Health Partnership NHS Trust

31/10/2014 2014/15

1. Condition G4 – Fit and proper persons as Governors and Directors (also applicable to those performing equivalent or similar functions). 2. Condition G5 – Having regard to monitor Guidance. 3. Condition G7 – Registration with the Care Quality Commission. 4. Condition G8 – Patient eligibility and selection criteria.

5. Condition P1 – Recording of information. 6. Condition P2 – Provision of information. 7. Condition P3 – Assurance report on submissions to Monitor. 8. Condition P4 – Compliance with the National Tariff. 9. Condition P5 – Constructive engagement concerning local tariff modifications.

10. Condition C1 – The right of patients to make choices. 11. Condition C2 – Competition oversight.

12. Condition IC1 – Provision of integrated care.

Further guidance can be found in Monitor's response to the statutory consultation on the new NHS provider licence: The new NHS Provider Licence

COMPLIANCE WITH MONITOR LICENCE REQUIREMENTS FOR NHS TRUSTS:

Comment where non-compliant or at risk of non-compliance

1. Condition G4 Fit and proper persons as Governors and Directors.

Timescale for compliance:

2. Condition G5 Having regard to monitor Guidance.


3. Condition G7 Registration with the Care Quality Commission.



4. Condition G8 Patient eligibility and selection criteria.


Yes N/A

30/11/2014

Yes N/A

30/11/2014

Yes N/A

30/11/2014

Yes N/A

30/11/2014


5. Condition P1 Recording of information.


6. Condition P2 Provision of information.


7. Condition P3 Assurance report on submissions to Monitor.


8. Condition P4 Compliance with the National Tariff.



9. Condition P5 Constructive engagement concerning local tariff modifications.


Yes N/A

30/11/2014

Yes N/A

30/11/2014

Yes N/A

30/11/2014

Yes N/A

30/11/2014

Yes N/A

30/11/2014


10. Condition C1 The right of patients to make choices.


11. Condition C2 Competition oversight.


12. Condition IC1 Provision of integrated care.


Yes N/A

30/11/2014

Yes N/A

30/11/2014

Yes N/A

30/11/2014

NHS TRUST DEVELOPMENT AUTHORITY

OVERSIGHT: Monthly self-certification requirements - Board Statements Monthly Data.

CONTACT INFORMATION:

Enter Your Name:

Enter Your Email Address

Full Telephone Number: Tel Extension:

SELF-CERTIFICATION DETAILS:

Select Your Trust:

Submission Date: Reporting Year:

Select the Month April May June

July August September

October November December

January February March

BOARD STATEMENTS:

James Parker

[email protected]

01384324527 4527

Dudley And Walsall Mental Health Partnership NHS Trust

31/10/2014 2014/15

CLINICAL QUALITY FINANCEGOVERNANCE

The NHS TDA’s role is to ensure, on behalf of the Secretary of State, that aspirant FTs are ready to proceed for assessment by Monitor. As such, the processes outlined here replace those previously undertaken by both SHAs and the Department of Health.

In line with the recommendations of the Mid Staffordshire Public Inquiry, the achievement of FT status will only be possible for NHS Trusts that are delivering the key fundamentals of clinical quality, good patient experience, and national and local standards and targets, within the available financial envelope.

BOARD STATEMENTS:

For CLINICAL QUALITY, that

1. The Board is satisfied that, to the best of its knowledge and using its own processes and having had regard to the TDA’s oversight model (supported by Care Quality Commission information, its own information on serious incidents, patterns of complaints, and including any further metrics it chooses to adopt), the trust has, and will keep in place, effective arrangements for the purpose of monitoring and continually improving the quality of healthcare provided to its patients.

1. CLINICAL QUALITY Indicate compliance.


RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A


2. The board is satisfied that plans in place are sufficient to ensure ongoing compliance with the Care Quality Commission’s registration requirements.



RESPONSE:


BOARD STATEMENTS:


3. The board is satisfied that processes and procedures are in place to ensure all medical practitioners providing care on behalf of the trust have met the relevant registration and revalidation requirements.



RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A

Yes

30/11/2014

N/A

For FINANCE, that

4. The board is satisfied that the trust shall at all times remain a going concern, as defined by the most up to date accounting standards in force from time to time.

4. FINANCE Indicate compliance.


RESPONSE:


BOARD STATEMENTS:

For GOVERNANCE, that

�. The board will ensure that the trust remains at all times compliant with the NTDA accountability framework and shows regard to the NHS Constitution at all times.

5. GOVERNANCE Indicate compliance.


RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A

Yes

30/11/2014

N/A


�. All current key risks to compliance with the NTDA�s Accountability Framework have been identified (raised either internally or by external audit and assessment bodies) and addressed � or there are appropriate action plans in place to address the issues in a timely manner.



RESPONSE:


BOARD STATEMENTS:


7. The board has considered all likely future risks to compliance with the NTDA Accountability Framework and has reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance.



RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A

Yes

30/11/2014

N/A


�. The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans are in place to deliver the annual operating plan, including that all audit committee recommendations accepted by the board are implemented satisfactorily.



RESPONSE:


BOARD STATEMENTS:


�. An Annual �overnance Statement is in place, and the trust is compliant with the risk management and assurance framework re�uirements that support the Statement pursuant to the most up to date guidance from �� Treasury �www.hm-treasury.gov.uk�.



RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A

Yes

30/11/2014

N/A


10. The �oard is satisfied that plans in place are sufficient to ensure ongoing compliance with all e�isting targets as set out in the NTDA oversight model� and a commitment to comply with all known targets going forward.



RESPONSE:


BOARD STATEMENTS:


11. The trust has achieved a minimum of �evel 2 performance against the re�uirements of the Information �overnance Toolkit.



RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A

Yes

30/11/2014

N/A


12. The board will ensure that the trust will at all times operate effectively. This includes maintaining its register of interests, ensuring that there are no material conflicts of interest in the board of directors� and that all board positions are filled, or plans are in place to fill any vacancies.



RESPONSE:


BOARD STATEMENTS:


13. The board is satisfied that all e�ecutive and non-e�ecutive directors have the appropriate �ualifications, e�perience and skills to discharge their functions effectively, including setting strategy, monitoring and managing performance and risks, and ensuring management capacity and capability.



RESPONSE:


BOARD STATEMENTS:

Yes

30/11/2014

N/A

Yes

30/11/2014

N/A


14. The board is satisfied that: the management team has the capacity, capability and e�perience necessary to deliver the annual operating plan� and the management structure in place is ade�uate to deliver the annual operating plan.



RESPONSE:


Yes

30/11/2014

N/A

Page 1 of 7

Board meeting date: 03rd December 2014

Agenda Item number:10.3

Enclosure9

Report Title: Governance and Quality Committee Chair Report

Committee: Governance & Quality Committee

Author (name & title): Tom Jinks – Governance ManagerWendy Pugh – Director of Operations and NursingDr Robin Gutteridge – NED and Chair of Governance and Quality Committee

Action required from the Board

Decision / Approval Gain assurance Discussion Information

Key issues and Risks

At the Governance and Quality Committee meeting held on the 12 November 2014, key issues were discussed around the dimensions of Risk. Quality, and Safety, Experience and Effectiveness and Regulation and Compliance. Time was allocated to more detailed consideration of the following:

In relation to Quality and Safety:

The Governance and Quality Committee discussed key issues relating to Quality and Safety including, the monthly Quality Report, The Trust Wide Risk Register .Quarterly Serious Incident and Embedding Lessons Review, Claims Update Report and the Quality Improvement Strategy Refresh . In addition there was also a spotlight session held regarding Overdose related Incidents.

In relation to Experience and Effectiveness:

The Experts by Experience monthly update report, the newly revised Experts by Experience (EBE) Recruitment process, Induction and Work Plan and the Q2 Service Experience Update report was presented reviewed and discussed by the Committee.

In relation to Regulation and Compliance:

The Committee received the latest Trust Performance Report, the Claims Update Report and the half yearly Coronial Update report.

Page 2 of 7

1.0 Quality and Safety

1.1 The Quality Report for October

The report was scrutinised for assurance and the committee discussed the contents of the report.

There were no noted trends or exceptions for Board consideration.

The Quality Report is recommended to the Board for approval

1.2 The Quality and Governance Risk Register

The Quality and Governance Risk Register was considered. No new Quality Risks are recommended to the Board for addition to the register this month.

It was also noted that there the Trust Risk Strategy is currently under review. 1.3 Director of Operations and Nursing Update:

It was reported that the new legislation regarding Duty of Candour is likely to have some impact on the Trust. Whilst the Trust already meets a large proportion of the requirements and operates an open and honest culture, specific timescales and requirements may mean changes to current governance andcomplaints processes may need to occur. It was also reported that members of the Governance Team are attending a National Duty of Candour Training / awareness session in November 15.

1.4 Medical Director & Clinical Director for G&Q Update:

It was reported to the committee that the Clinical Director for Governance and Quality was currently absent from work on long term sickness leave. It was therefore agreed that in relation to the Suicide Prevention Group, work would be covered by the Medical Director with support from the Governance Team, with any other Governance or Quality issues being covered by the most appropriate Clinical Director.

1.5 Quality Improvement Strategy Refresh

The Committee received a copy of the refreshed Quality Improvement Strategy which had been updated and modified. A position statement / assurance had been provided against each of the performance indicators that were contained within the strategy. The Committee formally agreed with the proposed amendments and requested Board consideration for the development of some new outcome based measures for Quality Performance Indicators which would then be included within the revised strategy.

1.6 Quality Improvement Update Report - Q2 2014/15

The Committee received the Q2 Quality Improvement Update report. The report highlighted to the committee that there had been positive progress made against all of the priorities, and that there had been strong engagement and links to the Trust’s Clinical Audit Programme.

Page 3 of 7

It was also reported that a new project group had been established that was specifically focusing on the quality of service users care plans.

1.7 Safeguarding Annual Report

The Chair reported to the committee that following the October virtual G&Q meeting, the Safeguarding Annual Report had been recommended to the Board and subsequently approved and that a Board Development Training Session on Safeguarding is also in the process of being arranged.

A further spotlight session is planned in April 15 that will focus on continuing lessons and the role of supervision.

1.8 Ligature Review

The Committee received and endorsed the Ligature Review report that provided details of the latest annual ligature review that had been conducted across the Trust.

Further assurance was provided on the work that has taken place over the past year in regards toaddressing the identified ligature points and the committee was informed that the Capital Planning Committee have also been fully involved in this process.

The committees was also informed that any change to clinical environments or the occurrence of any near miss or actual incident results in a new ligature assessment being undertaken.

1.9 Serious Incidents and Embedding Lessons Quarterly Report - Q2 2014/15

The Q2 Serious Incidents and Embedding Lessons Quarterly Report was presented to the Committee. The report highlighted the following key points:

There have been a total of 16 new serious incidents which had been formally logged on Unify - this was a small increase on the previous quarterThere had been a total of 9 internal investigations carried out.A summary of the investigations that were closed during Quarter 2 included brief information about each incident, the identified root cause and associated action plansA summary of the Embedding Lessons database for the quarter had shown a reduction in the number of breached / outstanding actions since the last quarter. It was noted that there weresome breaches (over 120 days) specifically around dual diagnosis in the Recovery Service Linebut assurance was given that appropriate mitigation plans are in place to address this

The committee requested that further consideration is given as to the classification of incidents and as to the appropriateness of assigning 120 days for the completion of longer term complex actions.

Page 4 of 7

2.0 Experience and Effectiveness 2.1 The monthly report from the Experts by Experience was accepted.

2.2 Experts by Experience Recruitment, Induction and Work Plan

The committee was updated about the Experts by Experience (EBE) Recruitment process. Anewly revised draft work plan and reporting structure was considered and discussed. The intention is to ensure the EBE’s work better informs both strategic planning and quality. In principle the committee supported the recommendations and proposals, but it was agreed the EBE’s need more time to review, comment on and contribute to the proposals. It was therefore decided to defer the item for further discussion at the next G&Q meeting

2.3 The Quarterly Service Experience Update report (Q2)

The report was presented to the committee and was discussed and agreed..

3.0 Regulation and Compliance

3.1 The Performance Report was received for information and assurance. No particular trends were noted

3.2 Claims Report

A claims update and summary report was presented to the committee – the following key points were noted:

There have been 8 new claims received (6 employers liability (EL) and 2 public liability (PL))5 claims have been closed or settled (3 EL - 2 successfully defended and 1 withdrawn, 1 CNST - successfully defended, 1 PL - admitted)15 claims are currently still open (9 EL, 4CNST, 2 PL)It was noted that Employer liability claims appear to be increasingFaulty barriers at Bushey Fields Hospital continue to pose a risk

The committee noted the contents of the report and the Chair requested an update on the barrier situation at Bushey Fields Hospital is raised at the next Health and Safety Committee.

4.0 Spotlight Session – Overdose Incidents

A deep-dive report that had been undertaken to investigate a recent reported overdose incidents was presented to the committee.

The report highlighted the following key findings to the committee, which were then discussed in detail:

Acute services are the main contributor for reporting serious self-harming behaviour incidentsOverdose incidents contribute for approximately 1/3 of the Trust self-harming behaviour incidents Overdose incidents follow a similar reporting trend as that shown for total harming behaviour

Page 5 of 7

Overdose incidents can be classified as serious self-harm or attempted suicide on the incident report and there were far lower numbers of attempted suicide recorded. However it is very dependent on how staff are recording the incident.There are more incidents reported in Walsall than Dudley and are mainly from CHRT and Ambleside ward.An analysis was undertaken of people who frequently feature in reports of overdose to investigate how many might be using this as an unhelpful coping strategy . There were, however, no specific trends identified.Twenty serious overdose case incidents were reviewed which showed far more female service users overdosing and they tended were between the ages of 30/40 which reflects females patients with personality disorders on Ambleside ward.Patients with Personality Disorder and Personality/Bi-polar featured highly in the analysis of serious incident overdose cases by diagnosis. The percentage of overdose serious incident cases where alcohol drug and dual diagnosis were linked was 30%.75% of service users were involved in overdose serious incidentsCRHT and Ambleside were reported as being the main the main reporters of overdose serious incidents.A large majority of service users reviewed in this analysis were seen on the day of the incident or within a 3 day period. This implied that high risk patients were being seen frequently at the time or were inpatients.Most of the overdoses involved “over the counter medication” or mixed overdoses.Poor medication compliance was documented in some investigation reports as a being a reason for relapseSeveral concerns were raised around medication supply/access. This included access to medications and restriction of medications on inpatient areas.The overall reporting culture of the services areas has been reviewed to ensure that there is consistency across all service lines - lower reporting numbers are recorded from the community service area

The committee held an in depth discussions into the above points and the following actions were requested / agreed:

A review of risk assessments to be included in the planned section 17 leave audit Further discussions to be undertaken with Heads of Service regarding dual diagnosis service users and the reporting of overdose incidentsContinued / ongoing monitoring of overdose incidents.

Following the discussions, the Committee endorsed the encouragement of a positive reporting culture’

5.0 Committee Business, Reporting and Planning

5.1 The Chair informed the committee that if future G&Q meetings were deemed non-quorate, the meeting would still take place, but decisions would need to be formulated as recommendations andreferred to Board for decision

Page 6 of 7

5.2 There were no matters of concern in the Exception reports which were received from the following Sub-groups:

Infection Prevention Control Committee

Medicines Management Group

Policy and Procedures Group - After lengthy discussion about the process currently in place to agree new and revised policies and procedures, the Committee concluded that it is assured about the robustness of consultation and process occurring at the Policies and Procedures Group. However, it is not fully assured that all policies and procedures are adequately reviewed by appropriately knowledgeable staff for relevance and fitness for purpose. The Committee also resolved to seek clarification about the boundaries of delegated authority from the Board .

Key action points and work in progress

Safeguarding – The Committee has requested a further spotlight session on safeguarding to take place in April 15 that will focus on embedding lessons and the role of supervision

Quality Improvement Strategy Refresh- The Committee formally agreed with the proposed amendments and requested Board consideration for the development of some new outcome based measures for Quality Performance Indicators which would then be included within the revised strategy.

Serious Incidents and Embedding Lessons Quarterly Report Q2 2014/15 - The committee requested that further consideration is given as to the classification of incidents and as to the appropriateness of assigning 120 days for the completion of longer term complex actions.

Claims Update Report – The committee requested that the issue of the failed car par barrier at Bushey Fields Hospital is discussed by Health and Safety Committee.

Overdose Deep Dive Report - A review of risk assessments is to be included in the planned section 17 leave audit . In addition there are to be further discussions undertaken with Heads of Service regarding “dual diagnosis” service users and the reporting of overdose incidents.

The Suicide Prevention Strategy - The strategy was accepted this month and is referred to the Board for approval

.

Page 7 of 7

Interfaces with other Committees

The business that was discussed by the committee interfaces with the following Committees / Groups:

Audit CommitteeFinance and Performance CommitteeMExTCARM/ CQRClinical Audit and Effectiveness CommitteeEmbedding Lessons Group Regulation and Risk Working GroupSafeguarding Strategic GroupSuicide Prevention Group Equality and Diversity Steering GroupR&D CommitteeHealth & Safety CommitteeInfection Prevention Control CommitteeMedicines Management Committee Mental Health Forum Policy & Procedures GroupResuscitation Committee

Recommendations and requests for direction

The Board is asked to:

Accept this report for assurance about the exercise of delegated authority by the Governance and Quality Committee

Endorse the decisions and recommendations made by the Governance and Quality Committee.

In particular, the Board is asked to:

Approve the Quality Report for September 2014 (period ending 31st October 2014)

Agree the proposed management of the Quality risks detailed on the Trust Wide Risk Register as recommended by the Governance and Quality Committee.

Give consideration for the development of new outcome based measures for Quality Performance Indicators.

The Suicide Prevention Strategy was accepted this month by G&Q and is therefore referred to the Board for approval

Page 1 of 2

Board meeting date: 3rd December2014

Agenda Item number: 10.4 Enclosure: 10

Report Title: Finance and Performance Committee Chair Report

Committee: Finance and Performance Committee (F&P)

Author (name & title): Mike Higgs – NED and F&P Chair


Key issues & risks

The Finance and Performance committee met on 24th November 2014 and considered the Finance, Performance information and HR position for November.

The committee reviewed the following items of business

Performance

The trust is currently green rated across 14 out of 15 KPIs . The committee reviewed in detail the performance against copies of care plans which had dipped below 95% for the first time this year. The committee received an update from the Associate Director of Operations on actions being taken to improve performance. This included frequent reviews at a team and individual level of performance and progress. The committee will keep a watching brief on this during December through weekly updates to ensure that performance returns to 95%

The committee reviewed the position on activity. As part of the scrutiny of activity – teams where underperformance on activity had been an issue had been asked to present revised trajectories to improve activity. These were reviewed and all teams had hit their trajectories for October. The trajectories for November were discussed. Early indications at the mid month suggest that teams are on plan to deliver November forecasts.

This had resulted in an improved position on activity which in September was 97% of contract activity to 98% with activity over perfoming by 1% in month.

The committee reviewed the position on EAS in relation to waiting times – a more detailed piece of work on capacity, demand and waiting times is being completed for EAS and the committee will receive this in December

Page 2 of 2

FinanceThe committee received an update on the financial position for the Trust . The trust remains ahead of plan for the year. Discussion took place regarding the forecast outturn for the Trust. The committee also received an update on outstanding SMS payments. Progress had been made in chasing payment and the committee supported the view of the Deputy Director of Finance that we continue to progress these outstanding payments.

Workforce Report

Sickness had reduced for October and progress continued to be made in reviewing cases of sickness. The committee reviewed the vacancy levels across the Trust. Workforce plans are currently being developed at a service line level which when complete will need to ensure we are actively recruiting to vacancies where appropriate. It was agreed that vacancy levels would continue to be reviewed closely by the committee

PBR Update. The PBR lead presented an update on progress towards PBR. Unclustered activity remains an issue for the Trust. Discussion took place around immediate actions to clear backlog and longer term actions to ensure that clustering processes are embedded in the Trust. It was agreed that the Director of Finance, Performance and IM&T would take executive lead in addressing PBR issues

Terms of ReferenceThe terms of reference were agreed by the committee


The business that was discussed by the committee interfaces with the following Committees/Groups:

MEXTAudit CommitteeGovernance & Quality CommitteeCARMCQR


The Trust Board are asked to :-

Accept this report for assurance about the exercise of delegated authority by the Finance and Performance Committee

Endorse the decisions and recommendations made by the Finance and Performance Committee.

Page 1 of 3

Board meeting date: 3rd December 2014

Agenda Item number: 10.5 Enclosure: 11

Report Title: MHA Scrutiny Committee Chair Report

Committee: Mental Health Act Scrutiny Committee

Author (name & title): Dr Stuart Hill – Chair of MHA Scrutiny Committee


Key issues and risks

The Mental Health Act Scrutiny Committee (MHA SC) met on the 11th November 2014. The meeting had unfortunately been postponed from 4th September due to diary pressures, however the Associate Lay Manager (ALM) meeting did take place on 11th September.

1.0 MHPG Meeting Update

It was confirmed that the meetings have been found to be very informative by the Police and other external parties. The Section 136 policy is to be extended to include the use of street triage. The funding elements were discussed, as it was not open 24 hours a day and service was not commissioned.

The new 136 suite at Dorothy Pattison Hospital would be ready in about a week after it had been made fit for purpose : the existing suite will continue to be used in the meanwhile.

2.0 CQC Compliance

The meeting heard that an action plan is in place to implement all CQC complaints under the ‘should, could and must’ categories. The long term actions in relation to CAMHS and Older Adult provision are being progressed. The quick wins have been implemented first and the emphasis has now shifted to seeking assurances that the Trust has attained compliance against actions. This second phase is being led by Ms Pugh as Chair of the steering group. It was confirmed that MExT and G&Q Committee were monitoring progress against the action plan.

The biggest concern is the implementation of the estates plan for Holyrood, with work starting next week. Ms Pugh assured the Committee that there would be no gaps in the process and the use of CREWS and CQC workbooks could be used to engage involvement of ownership.

The Committee will continue to seek assurance and monitor the progress of CQC actions on a

Page 2 of 3

high level.

3.0 Updated Policies

Ms Bibi had circulated the draft S.18 MHA 1983 – Absent Without Leave and S 132 – Informing Patients of their Rights Under the MHA 1983, for discussion by the Committee before she went on maternity leave. The documents were presented as part of the consultation process.Committee members were asked to send comment to Mr Jinks by 25 November 2014. In addition Mr Omar was asked to discuss the draft policies with Mrs Williams and send any comments to Mr Jinks.

4.0 OASIS Records

It was not clear what progress had been made, and so the item was deferred to the next meeting. It was noted however different Oasis datasets were provided by the two localities, causing a delay in implementation. The opportunity will be taken to explore the position from the MHA administrators’ perspective before the next meeting. An outline project plan was requested so this important matter can be taken forward and progress monitored.

5.0 Associate Lay Manager Update

A number of useful points had been raised at the ALM Meeting on 11th September 2014 and as good governance it was decided the minutes of these meetings should be circulated to MHA SC members.

Issues raised included:

Car parking on the Bushey Fields site.Differences in admin procedures between Dudley and Walsall, in particular the diarying and scheduling of extension and renewal hearings. Concerns that inappropriate placements could create a ‘revolving door’ where service users continually returned to the Trust for treatment.

More generally:

CRB checks were completed for the new ALMs and most had observed their first hearings.100% of ALM appraisals have been conducted.It was confirmed that ALMs have to complete mandatory training, so they were Section11 compliant. Specific MHA training was provided by an external supplier.The MHA Admin Manager was monitoring the number of hearings to ensure the Chair and attendance rota was spread fairly across all ALMs. Decisions need to be noted explicitly in paperwork.

6.0 Trends, Triangulation of Data, AMHP Report and Findings from a Deep Dive into an Increase in AMHP Assessments of Over 60s.

The ‘deep dive’ into the increase in MH assessments in the over 60’s had revealed showed no specific reasons and the action was closed.

Page 3 of 3

The meeting deferred detailed examination of the MHA SC dashboard; more recent data will be available at the next meeting on 4th December. In particular there will be a new section relating to DoLs. In the longer term the compilation of the stats will be automated through OASIS.

The meeting asked Mr Omar to add 3 questions to AMHP assessment proforma:

Do you think that the referral was appropriate or not?If not, what alternatives could be explored?What else could be done before referral was requested?

The responses will be collated for discussion at future MHA meetings

7.0 IMHA Service

The Committee received a report on the survey of inpatients in September 2014 asking for opinions on the IMHA service. The results showed that although there was an improvement in Dudley, the service was poor in Walsall. The contract monitoring report will be circulated and the results will be discussed at the next Committee Meeting.

8.0 Terms of Reference, Committee Effectiveness, Attendance and MHA/MCA Training

These matters were discussed briefly and deferred to the next meeting on 4th December 2014.

9.0 Monitoring of Risk

The Committee discussed concerns about the availability of AMHPs to conduct assessments and the pressure on care co-ordinator staffing. It was not clear whether the risk had been captured on any risk register. Mr Jinks was asked to check the position on this specific item and also to inform the Committee of any other risks associated on any subject within the MHA Scrutiny Committee’s agenda.


The business that was discussed by the committee interfaces with the following Committees/Groups:

MEXTGovernance & Quality Committee Clinical Audit and Effectiveness CommitteeEquality and Diversity Steering GroupSafeguarding Strategic Group


The Board is asked to accept this report for assurance.

1

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em

otiv

atio

nto

join

inw

ithac

tiviti

es.

•E

very

one

has

diffe

rent

inte

rest

san

dab

ilitie

s –

activ

ities

shou

ldbe

tailo

red

tosu

itth

ein

divi

dual

. •

Nee

dac

tiviti

esth

atdo

not t

ake

a lo

tofc

once

ntra

tion.

•

Itap

pear

sth

atm

ore

activ

ities

are

bein

gpr

ovid

edin

Wal

sall

than

inD

udle

y. If

the

war

dha

san

Act

ivity

Coo

rdin

ator

ther

ear

em

ore

activ

ities

taki

ngpl

ace.

•

Pat

ient

ssu

gges

ted

itw

ould

be a

goo

did

eato

have

mor

ebo

ards

orpo

ster

set

c. to

adve

rtise

and

prom

ote

activ

ities

Out

com

es

Feed

back

shar

edw

ithTh

erap

eutic

Aud

itC

omm

ittee

RIS

– R

ecov

ery

Inte

rven

tion

Serv

ice

EB

Es

have

atte

nded

the

first

gro

up s

essi

on w

ith R

IS (a

nxie

ty m

anag

emen

t in

Wal

sall

and

min

dful

ness

in D

udle

y ) t

o fin

d w

ays

of c

aptu

ring

feed

back

from

pat

ient

s an

d ca

rers

to e

nsur

e th

at g

roup

s ar

e fu

lly s

uppo

rting

the

nee

ds o

f tho

se w

ho

parti

cipa

te. I

nitia

l fin

ding

s fro

m th

e pr

e-in

terv

entio

n qu

estio

nnai

re s

how

that

pat

ient

s ac

cess

ing

the

cour

se w

ere

conc

erne

d ab

out h

ow lo

ng th

ey h

ad to

wai

t to

acc

ess

the

cour

se, a

nd la

ck o

f und

erst

andi

ng a

bout

Min

dful

ness

as

no in

form

atio

n w

as

prov

ided

bef

ore

com

men

cing

the

Min

dful

ness

cou

rse.

In W

alsa

ll, s

ervi

ce u

sers

wer

e ha

ppy

with

the

leng

th o

f tim

e to

acc

ess

the

cour

se a

nd th

e m

ajor

ity re

ceiv

ed in

form

atio

n le

afle

ts p

rior t

o st

artin

g th

e gr

oup

ther

apy

sess

ion

and

all f

elt t

hat t

he

serv

ice

will

hel

p th

em b

ette

r und

erst

and

and

addr

ess

thei

r diff

icul

ties.

Pos

t-int

erve

ntio

nqu

estio

nnai

reto

beco

mpl

eted

atth

een

dof

the

cour

se.

13

Prog

ress

aga

inst

SE

Stra

tegy

Serv

ice

Expe

rienc

e Do

mai

ns

Stra

tegi

c O

bjec

tives

20

14/1

5

Prog

ress

RA

G

Ratin

g

Tell

us a

bout

yo

ur

expe

rienc

e

1. Im

prov

e sy

stem

s,

tech

nolo

gies

and

op

portu

nitie

s fo

r ser

vice

us

ers

and

care

rs to

giv

e fe

edba

ck a

t all

stag

es o

f th

eir r

ecov

ery

jour

ney

2. E

ffici

ent a

nd e

ffect

ive

syst

ems

are

in p

lace

for

mon

itorin

g an

d ac

ting

on th

e ex

perie

nce

of u

nder

-re

pres

ente

d gr

oups

• In

trodu

ce a

sta

ndar

d P

RE

MS

su

rvey

link

ed to

CR

EW

S a

cros

s al

l tea

ms

Cor

e su

rvey

que

stio

nnai

re d

rafte

d, to

be

circ

ulat

ed to

HO

S fo

r ra

tific

atio

n.

• Dep

loy

the

IPA

Ds

Issu

es ra

ised

with

IT d

ue to

diff

icul

ties

with

Wifi

acce

ss.

• Im

plem

ent c

onsi

sten

t int

egra

ted

arra

ngem

ents

for i

ndep

ende

nce

in

com

plex

inve

stig

atio

ns

Inde

pend

ent m

atrix

now

in p

lace

, circ

ulat

ed to

all

HoS

/Med

ical

D

irect

ors

and

item

put

in T

eam

Brie

f for

wid

er c

ircul

atio

n.

• Est

ablis

h a

yout

h en

gage

men

t pl

anFo

llow

ing

cons

ulta

tion,

You

ng M

inds

hav

e ag

reed

to fa

cilit

ate

the

deve

lopm

ent o

f the

You

th E

ngag

emen

t Pla

n, in

clud

ing

met

hods

of

eng

agem

ent a

nd d

eliv

erin

g th

e Yo

uth

Foru

m –

to c

omm

ence

in

Janu

ary

2015

.

• Ens

ure

SE

D le

afle

ts a

re

acce

ssib

le a

t all

site

s an

d th

at

trans

late

d ve

rsio

ns a

re a

vaila

ble

Aud

it in

pro

gres

s. T

rans

late

d ve

rsio

ns a

re a

vaila

ble

on re

ques

t. C

ostin

g be

ing

obta

ined

for l

eafle

ts fo

r the

5 m

ost w

idel

y us

ed

lang

uage

s.

Mak

ing

sens

e of

info

rmat

ion

3. T

here

is a

n in

tegr

ated

and

ef

fect

ive

syst

em fo

r re

ceiv

ing,

act

ing

and

repo

rting

on

serv

ice

expe

rienc

e fe

edba

ck

incl

udin

g tri

angu

latio

n an

d cr

oss

refe

renc

ing

Intro

duce

enh

ance

d co

mpl

aint

s re

ports

to B

oard

Com

plet

ed –

pro

duce

d a

mor

e de

taile

d re

port

whi

ch in

clud

es

info

rmat

ion

abou

t the

them

e an

d na

ture

of e

ach

com

plai

nt,

actio

ns,

prog

ress

to d

ate

and

a pr

ogre

ss R

AG

ratin

g.

Impl

emen

t mon

thly

tria

ngul

atio

n re

ports

for

SI,

com

plai

nts

and

Saf

egua

rdin

g

Term

s of

Ref

eren

ce c

urre

ntly

und

er re

view

and

to in

clud

e qu

arte

rly re

porti

ng a

s op

pose

d to

mon

thly

.

Upl

oad

anec

dota

l fee

dbac

k (fr

om

EB

Es

etc.

) ont

o S

afeg

uard

to

supp

ort m

ore

auto

mat

ed re

porti

ng.

Con

cern

s ra

ised

by

EB

Es

that

are

not

reso

lved

dire

ctly

are

bei

ng

logg

ed o

n S

afeg

uard

and

han

dled

in li

ne w

ith o

ur p

olic

y. E

BE

in

telli

genc

e to

be

inpu

t on

to S

afeg

uard

and

to tr

iang

ulat

e fin

ding

s w

ith o

ther

ser

vice

exp

erie

nce

data

.

14

Put

ting

actio

ns in

pl

ace

4. A

sim

ple,

inte

grat

ed a

ppro

ach

is in

pl

ace

to a

gree

app

ropr

iate

act

ions

an

d en

sure

cle

ar a

ccou

ntab

ility

for

deliv

ery

Set

up

auto

mat

ic a

ctio

n al

erts

via

sa

fegu

ard

No

prog

ress

to d

ate

Has

the

actio

n m

ade

a di

ffere

nce?

5. T

here

is a

n ef

fect

ive

syst

em fo

r en

surin

g th

at le

sson

s fro

m fe

edba

ck

are

lear

ned

and

embe

dded

6. C

omm

unic

atin

g fe

edba

ck to

all

key

stak

ehol

ders

is re

gula

r, co

nsis

tent

an

d cl

ear

7. T

he T

rust

lear

ns fr

om e

xter

nal

inte

llige

nce,

ben

chm

arki

ng a

nd b

est

prac

tice

• Im

plem

ent a

n in

tegr

ated

em

bedd

ing

less

ons

proc

ess

with

th

e G

over

nanc

e te

am th

at id

entif

ies

outc

omes

as

a re

sult

of a

ctio

n fro

m fe

edba

ck

Liai

sed

with

Gov

erna

nce

to d

iscu

ss th

e em

bedd

ing

less

ons

proc

ess

and

a m

onth

ly u

pdat

e w

ill b

e pr

esen

ted

at th

e S

ervi

ce S

tand

ards

mee

tings

to o

btai

n an

upd

ate

on a

ctio

ns ta

ken/

less

ons

lear

ned.

• Int

rodu

ce th

e “M

akin

g a

Diff

eren

ce” S

taff

Aw

ard

‘Rec

ogni

se’ c

ards

are

now

bei

ng ro

lled

out t

o st

aff.

• Dev

elop

a “Y

our E

xper

ienc

e M

atte

rs” b

log

or b

ulle

tin to

sha

re

best

pra

ctic

e w

ith s

taff

No

prog

ress

to d

ate

15

Futu

re S

ervi

ce E

xper

ienc

e Ac

tiviti

es

Rec

over

y In

terv

entio

n Se

rvic

es P

ost I

nter

vent

ion

Surv

eyE

BE

s w

ill a

lso

be

atte

ndin

g th

e la

st g

roup

ses

sion

s to

com

plet

e a

‘pos

t-int

erve

ntio

n’ q

uest

ionn

aire

to e

valu

ate

the

impa

ct o

f int

erve

ntio

ns a

nd to

hig

hlig

ht a

ny s

ervi

ce im

prov

emen

ts. F

ull r

esul

ts to

be

incl

uded

in Q

3 S

ervi

ce E

xper

ienc

e R

epor

t.

My

Car

e Pa

cks

Eva

luat

ion

and

feed

back

on

the

new

car

e pa

cks.

EB

Es

to p

rovi

de a

con

tem

pora

ry re

view

from

ser

vice

use

rs a

nd

mon

itor e

ffect

iven

ess

of c

are

plan

s.

Voic

eabi

lity

EB

Es

will

be

goin

g on

to th

e w

ards

to ta

lk to

ser

vice

use

rs a

bout

the

IMH

A ro

le d

ue to

the

low

upt

ake

of th

e ad

voca

cy

serv

ice

by s

ervi

ce u

sers

and

to ra

ise

awar

enes

s of

the

serv

ice.

Res

truc

ture

of W

reki

n W

ard

EB

Es

to p

rovi

de a

ser

vice

use

r and

car

er p

ersp

ectiv

e to

the

new

stru

ctur

e an

d ar

e su

ppor

ting

the

deve

lopm

ent o

f an

info

rmat

ion

fold

er c

onta

inin

g co

ntac

t inf

orm

atio

n ab

out g

roup

s an

d su

ppor

t ava

ilabl

e fo

llow

ing

disc

harg

e.

APP

END

IX A

Page

1of

18

Rec

ord

of fo

rmal

com

plai

nts

rece

ived

asfr

om 0

1/04

/201

4to

30/

09/1

4

Acut

e Se

rvic

es

Case

No

Date

Re

ceiv

ed

Depa

rtm

ent

Cate

gory

De

tails

Of C

ompl

aint

Cu

rren

t pro

gres

s / a

ctio

ns

RAG

5283

25

/09/

2014

Ki

nver

War

d Cl

inic

al S

taff

- Lac

k O

f Co

nfid

ence

in a

bilit

y Ha

ve a

bsol

utel

y no

con

fiden

ce in

any

of t

he te

am

at B

ushe

y Fi

elds

Hos

pita

l due

to th

e w

ay h

is da

ught

er w

as tr

eate

d w

hilst

in th

eir c

are.

Ong

oing

/ aw

aitin

g co

nsen

t (B

efor

e be

com

ing

a fo

rmal

com

plai

nt, t

he p

atie

nt

was

tran

sfer

red

to D

PH d

ue to

the

conc

erns

in

itial

ly ra

ised

on 1

1/08

/14)

5377

25

/09/

2014

CR

HT (W

alsa

ll)

Trea

tmen

t - F

aile

d To

Pr

ovid

e/ p

oor

No

resp

onse

to c

all m

ade

to C

risis

Team

. O

n-go

ing

/ und

er i

nves

tigat

ion

5355

16

/09/

2014

Cl

ent W

ard

Med

icat

ion

- Disp

utin

g M

edic

atio

n ne

eds r

evie

win

g fo

r son

and

alth

ough

Dr

agr

eed

to c

hang

e it

ther

e ha

s bee

n no

co

mm

unic

atio

n to

the

war

d ab

out t

his a

nd it

is

not d

ocum

ente

d in

his

note

s cor

rect

ly.

Clos

ed d

ue to

no

resp

onse

Co

nsen

t not

rece

ived

5351

15

/09/

2014

Am

bles

ide

War

d Pa

tient

s Pro

pert

y - M

issin

g Co

ncer

ned

that

her

dau

ghte

r's p

erso

nal i

tem

s ha

ve g

one

miss

ing.

Dau

ghte

r has

also

bee

n at

tack

ed b

y an

othe

r pat

ient

.

On-

goin

g / u

nder

inv

estig

atio

n

Cont

acte

d w

ard

on re

ceip

t of c

ompl

aint

in o

rder

to

see

of it

ems c

ould

be

foun

d.

5340

08

/09/

2014

CR

HT (W

alsa

ll)

Inad

equa

te S

uppo

rt

Rece

nt c

onta

ct w

ith C

RHT

was

not

hel

pful

for

daug

hter

at a

ll.

Clos

ed d

ue to

no

resp

onse

Co

nsen

t nev

er re

ceiv

ed

5341

05

/09/

2014

Ad

min

Ser

vice

s (D

PH)

Attit

ude

Of -

Rec

eptio

nist

Pa

tient

unh

appy

with

rece

ptio

nist

at D

PH.

Part

ially

Uph

eld

/ aw

aitin

g sig

n of

f Li

ne m

anag

er to

disc

uss i

ssue

s rel

atin

g to

cu

stom

er se

rvic

e sk

ills w

ith re

cept

ion

staf

f. Re

cept

ion

staf

f str

uggl

e to

hea

r req

uest

s whe

n ba

ckgr

ound

noi

se in

rece

ptio

n. M

anag

er to

co

ntac

t est

ates

re v

oice

box

es in

cen

tral

re

cept

ion.

5325

01

/09/

2014

Ki

nver

War

d At

titud

e O

f - P

sych

iatr

ist

Whe

n in

rest

rain

t at B

ushe

y Fi

elds

the

Doct

or

was

rude

and

nas

ty to

pat

ient

. Cl

osed

/ Sa

fegu

ardi

ng in

vest

igat

ion

APP

END

IX A

Page

2of

18

5318

28

/08/

2014

O

ut P

atie

nts

(DPH

) At

titud

e O

f - P

sych

iatr

ist

Extr

emel

y un

happ

y w

ith th

e sh

oddy

way

he

was

tr

eate

d by

Doc

tor i

n a

rece

nt a

ppoi

ntm

ent.

Und

ergo

ing

inve

stig

atio

n - 3

on-

goin

g co

mpl

aint

s ab

out t

he sa

me

Cons

ulta

nt.

5287

14

/08/

2014

Ki

nver

War

d Tr

eatm

ent -

Fai

led

To

Prov

ide/

poo

r Da

ught

er a

dmitt

ed to

Bus

hey

Fiel

ds o

n Su

nday

ev

enin

g, n

o se

rvic

es o

r act

ion

take

n to

dat

e du

e to

bei

ng a

Wal

sall

patie

nt.

Clos

ed D

ue T

o N

o Re

spon

se

Agre

emen

t sum

mar

y an

d co

nsen

t not

rece

ived

.

5286

13

/08/

2014

O

ut P

atie

nts

(DPH

) M

edic

atio

n - D

elay

In

Rece

ivin

g Ha

s not

rece

ived

any

hel

p fr

om h

er c

onsu

ltant

w

hilst

seei

ng th

em fo

r sev

eral

yea

rs, a

dded

on

Mun

chau

sen

synd

rom

e to

reco

rds w

hich

is n

ot

true

. Lef

t with

no

med

icat

ion

or su

ppor

t.

Not

Uph

eld

/ aw

aitin

g sig

n of

f N

o ac

tion

requ

ired.

5284

07

/08/

2014

O

ut P

atie

nts

(DPH

) Tr

eatm

ent -

Fai

led

To

Prov

ide/

poo

r So

n no

t rec

eive

d an

y su

ppor

t fro

m M

enta

l Hea

lth

serv

ices

at a

ll.

Imm

edia

te st

eps t

aken

by

the

med

ical

team

who

m

et w

ith c

ompl

aina

nt o

utsid

e of

the

com

plai

nts

proc

ess.

Pa

rtia

lly U

phel

d / a

wai

ting

sign

off

Refe

rral

s to

CRS

to b

e di

scus

sed

in a

lloca

tion

mee

ting

and

a re

cord

kep

t on

Oas

is of

who

was

pr

esen

t at t

he m

eetin

g, th

e pl

an a

gree

d an

d al

loca

tion

of ta

sks f

or fo

llow

up.

Co

pies

of a

ll le

tter

s per

tain

ing

to p

atie

nts

asse

ssm

ents

are

to b

e se

nt to

mot

her.

The

Trus

t nee

ds to

pro

vide

cla

rific

atio

n of

the

inte

rfac

e be

twee

n N

atio

nal /

Regi

onal

Dea

f M

enta

l Hea

lth S

ervi

ces a

nd L

ocal

Sec

onda

ry

Men

tal H

ealth

Ser

vice

s acr

oss a

ll sp

ecia

lties

.

5269

05

/08/

2014

CR

HT (D

udle

y)

Com

mun

icat

ions

- Fa

ilure

W

ith p

atie

nt

Crisi

s tea

m n

ever

cal

led

him

bac

k w

hen

he

need

ed th

eir h

elp.

W

ithdr

awn

/ clo

sed

Com

plai

nant

info

rmed

that

an

inte

rnal

in

vest

igat

ion

had

been

car

ried

out a

nd th

is m

embe

r of s

taff

is m

ovin

g to

a d

iffer

ent t

eam

.

5244

28

/07/

2014

La

ngda

le W

ard

Arra

ngem

ents

- Ad

miss

ion

Adm

issio

n to

DPH

was

stre

ssfu

l to

fam

ily a

nd

son;

ther

e w

as a

lack

of s

uppo

rt a

nd

com

mun

icat

ion.

Clos

ed D

ue T

o N

o Re

spon

se

Sum

mar

y ag

reem

ent a

nd c

onse

nt n

ot re

ceiv

ed.

APP

END

IX A

Page

3of

18

5216

08

/07/

2014

CR

HT (D

udle

y)

Attit

ude

Of -

Nur

sing

Staf

f U

nhap

py w

ith th

e at

titud

e sh

e re

ceiv

ed fr

om th

e Cr

isis w

orke

r who

was

car

ing

for h

er si

ster

. Pa

rtia

lly U

phel

d / c

lose

d Di

scus

s iss

ues w

ith st

aff i

n PD

R.

5219

07

/07/

2014

Cl

ent W

ard

Conc

ern

For W

ellb

eing

Ra

ising

con

cern

s abo

ut th

e ca

re a

nd la

ck o

f pr

oced

ures

on

Clen

t War

d Bu

shy

Fiel

ds H

ospi

tal.

Part

ially

Uph

eld

/ clo

sed

Com

mun

icat

ion

issue

s - T

he T

rust

and

the

war

d ar

e lo

okin

g in

to h

ow th

e tr

iang

le o

f car

e ca

n fu

rthe

r be

inco

rpor

ated

in o

rder

to in

volv

e ca

rers

fu

rthe

r in

the

deliv

ery

of c

are.

Tria

ngle

of c

are

lead

s hav

e be

en id

entif

ied

for t

he w

ard.

Cle

nt a

re

wor

king

tow

ards

arr

angi

ng re

gula

r mon

thly

dro

p in

sess

ions

, and

the

Trus

t is l

ooki

ng to

intr

oduc

e ca

rer a

war

enes

s tra

inin

g.

Lack

of p

urpo

sefu

l the

rape

utic

act

iviti

es -

To

disc

uss w

ith a

cute

lead

if C

lent

war

d w

ill b

e ad

vert

ising

for O

ccup

atio

nal T

hera

pist

and

ac

tivity

wor

ker.

The

outc

ome

of th

e co

mpl

aint

to b

e fe

d ba

ck to

th

e te

am d

urin

g st

aff m

eetin

g.

5203

01

/07/

2014

CR

HT (W

alsa

ll)

Conf

iden

tialit

y - B

reac

h Te

am h

ave

spok

en to

fath

er-in

-law

inst

ead

of

patie

nt o

r par

tner

as r

eque

sted

, the

refo

re

brea

chin

g co

nfid

entia

lity.

Sin

ce th

is co

nver

satio

n th

e te

am h

ave

stop

ped

visit

ing

him

at h

ome

and

have

ask

ed h

im to

go

to D

PH in

stea

d.

Not

Uph

eld

/ clo

sed

No

actio

n to

be

take

n.

5153

09

/06/

2014

O

ut P

atie

nts

(DPH

) Tr

eatm

ent -

Fai

led

To

Prov

ide/

poor

Da

ught

er h

as g

one

miss

ing.

Lac

k of

supp

ort f

rom

Co

nsul

tant

and

team

thro

ugho

ut h

er c

are.

Pa

rtia

lly U

phel

d / c

lose

d Pa

tient

foun

d de

ceas

ed

At w

eekl

y m

ulti-

disc

iplin

ary

mee

tings

a li

st o

f all

the

patie

nts w

ho a

re jo

intly

man

aged

by

CC a

nd

Psyc

hiat

rist w

ho d

o no

t att

end

thei

r allo

cate

d O

P ap

poin

tmen

t will

be

iden

tifie

d an

d ro

bust

risk

pl

an d

evel

oped

and

act

ivat

ed to

supp

ort t

he

indi

vidu

als.

Co

ntac

t fro

m p

lace

men

t pro

vide

rs in

dica

ting

any

APP

END

IX A

Page

4of

18

adve

rse

chan

ge to

the

patie

nt w

ill b

e fo

llow

ed u

p w

ith a

face

to fa

ce v

isit w

ith th

e pa

tient

and

pr

ovid

er to

ens

ure

effe

ctiv

e ris

k m

anag

emen

t.

5136

02

/06/

2014

CR

HT (W

alsa

ll)

Com

mun

icat

ions

- Fa

ilure

W

ith P

atie

nt

Conc

erne

d th

at n

o ac

tion

was

take

n fr

om C

RHT

as p

rom

ised.

Pa

rtia

lly U

phel

d St

aff t

o w

rite

all c

onta

cts o

n th

e sy

stem

and

ap

poin

tmen

ts in

thei

r dia

ry.

5134

29

/05/

2014

Cl

ent W

ard

Oth

er

Not

hap

py th

at h

er d

augh

ter c

anno

t visi

t her

hu

sban

d (p

atie

nt) o

n th

e w

ard.

Cl

osed

Due

To

No

Resp

onse

Co

nsen

t not

rece

ived

5109

12

/05/

2014

CR

HT (W

alsa

ll)

Inad

equa

te S

uppo

rt

No

supp

ort o

ver b

ank

holid

ay fr

om C

RHT.

Pa

rtia

lly U

phel

d / c

lose

d St

aff r

emin

ded

to e

nsur

e al

l rec

ords

(inc

ludi

ng

OAS

IS) a

re u

pdat

ed.

5104

09

/05/

2014

Ps

ychi

atric

Li

aiso

n Te

am -

Wal

sall

Clin

ical

- As

sess

men

t Fa

ther

is c

once

rned

abo

ut so

n as

he

was

as

sess

ed in

A&

E an

d no

t dee

med

app

ropr

iate

for

serv

ices

, yet

hou

rs a

fter

he

was

arr

este

d fo

r ho

ldin

g so

meo

ne a

t kni

fe p

oint

.

Not

Uph

eld

/ clo

sed

Whe

re th

e se

rvic

e us

er is

kno

wn

to C

RS, l

iaiso

n w

ith C

RS a

nd C

RHT

need

s to

be d

ocum

ente

d w

ith

an a

gree

d pl

an a

s to

who

will

con

duct

the

follo

w-

up a

nd in

wha

t tim

e-fr

ame.

The

pla

n sh

ould

be

shar

ed w

ith th

e se

rvic

e us

er a

nd a

ny re

lativ

e in

volv

ed in

the

disc

harg

e pl

an so

as t

o av

oid

misu

nder

stan

ding

or c

onfu

sion.

5046

10

/04/

2014

Am

bles

ide

War

d At

titud

e O

f - P

sych

iatr

ist

Son

is un

happ

y ab

out t

he a

ttitu

de o

f the

Dr i

n re

latio

n to

his

mom

's fin

ance

s.

Clos

ed D

ue T

o N

o Re

spon

se

Cons

ent n

ot re

ceiv

ed.

APP

END

IX A

Page

5of

18

Com

mun

ity S

ervi

ces

Case

No

Date

Rec

eive

d De

part

men

t Ca

tego

ry

Deta

ils O

f Com

plai

nt

Curr

ent p

rogr

ess /

act

ions

RA

G

5350

10

/09/

2014

CR

S N

orth

(Dud

ley

- PO

P)

Attit

ude

Of -

Psy

chol

ogist

U

nhap

py w

ith p

sych

olog

ist’s

att

itude

. U

phel

d / a

wai

ting

sign

off

To a

rran

ge a

n al

tern

ativ

e th

erap

ist.

53

01

18/0

8/20

14

CRS

Nor

th (W

alsa

ll - M

oss)

Ca

re P

lan

- Cha

nges

W

ould

like

to h

ave

his c

are

plan

tr

ansf

erre

d fr

om D

orot

hy P

attis

on to

Du

dley

.

On-

goin

g / u

nder

inve

stig

atio

n

52

32

18/0

7/20

14

CRS

Nor

th (W

alsa

ll - M

oss)

Ap

poin

tmen

ts -

Canc

elle

d Ca

re C

o-or

dina

tor n

ot v

ery

help

ful.

Wai

ting

time

for a

ppoi

ntm

ents

wer

e no

t as

pro

mise

d. T

here

was

no

cont

inui

ty o

f ca

re w

hilst

an

inpa

tient

.

Part

ially

Uph

eld

/ clo

sed

Ca

re C

o-or

dina

tor m

ade

an u

rgen

t re

ferr

al fo

r a p

sych

olog

ical

ass

essm

ent.

52

31

16/0

7/20

14

CRS

Sout

h (W

alsa

ll)

Conc

ern

For W

ellb

eing

Fe

els t

here

cou

ld b

e m

ore

done

for h

er

mot

her a

s the

re is

no

impr

ovem

ent.

Daug

hter

is n

ot h

appy

with

the

way

thin

gs

are

goin

g w

ith m

othe

r's c

are.

Clos

ed d

ue to

no

resp

onse

Co

nsen

t not

pro

vide

d. C

once

rns r

elay

ed

to M

edic

al D

irect

or.

51

52

09/0

6/20

14

CRS

Nor

th (W

alsa

ll - M

oss)

Di

agno

sis -

Que

stio

n Q

uest

ions

dia

gnos

is.

Part

ially

Uph

eld

/ clo

sed

Chan

ge o

f Doc

tor a

nd c

are

coor

dina

tor.

Cons

ulta

nt to

mon

itor a

nd o

vers

ee c

are

arra

ngem

ents

.

APP

END

IX A

Page

6of

18

5133

27

/05/

2014

CR

S N

orth

(Wal

sall

- Mos

s)

Refe

rral

Pro

cess

- G

ener

al

Ther

e is

signi

fican

t miss

-com

mun

icat

ion

betw

een

the

psyc

hiat

ric re

ferr

al se

rvic

e an

d CB

T as

the

refe

rral

has

not

bee

n se

nt.

Part

ially

Uph

eld

/ clo

sed

Refe

rral

pro

cess

es a

nd lo

ggin

g al

read

y re

view

ed.

This

spec

ific

refe

rral

alre

ady

rem

ade

and

acce

pted

. Ca

re C

o-or

dina

tor t

o up

date

pat

ient

on

a re

gula

r bas

is to

ens

ure

cons

tant

co

mm

unic

atio

n.

51

14

19/0

5/20

14

CRS

Nor

th (D

udle

y - P

OP)

Co

mm

unic

atio

ns -

Failu

re W

ith

Patie

nt n

ever

rece

ived

lett

ers t

o in

form

hi

m o

f the

app

oint

men

ts h

e ha

d an

d no

w

he is

hav

ing

to w

ait a

gain

.

Part

ially

Uph

eld

/ clo

sed

En

sure

all

com

mun

icat

ion

rega

rdin

g ap

poin

tmen

ts w

ith se

rvic

e us

ers b

e do

cum

ente

d on

Oas

is.

51

45

19/0

5/20

14

CRS

Sout

h (W

alsa

ll)

Conf

iden

tialit

y - B

reac

h Co

nfid

entia

lity

brea

ched

due

to re

cord

s be

ing

sent

to th

e GP

. Pa

rtia

lly U

phel

d / a

wai

ting

sign

off

Upd

ate

OAS

IS sy

stem

s asa

p to

ens

ure

patie

nt's

GP d

etai

ls ar

e no

w a

ccur

ate.

He

ads o

f Ser

vice

and

Clin

ical

Dire

ctor

s to

ensu

re th

at th

e In

form

atio

n G

over

nanc

e po

licy

is re

-circ

ulat

ed v

ia te

am b

rief,

Wed

nesd

ay w

ire a

nd te

am m

eetin

gs.

51

12

16/0

5/20

14

CRS

Nor

th (W

alsa

ll - M

oss)

Pr

ivac

y/Di

gnity

- Cu

ltura

l Sen

sitiv

ity

Feel

s pic

ked

on d

ue to

cul

ture

and

faith

an

d th

at u

nnec

essa

ry q

uest

ions

wer

e as

ked

by P

sych

iatr

ist. C

PN h

as n

ot

prov

ided

the

supp

ort n

eede

d. P

atie

nt

feel

s he

shou

ld b

e gi

ven

mor

e no

tice

of

appo

intm

ents

.

On-

goin

g / u

nder

inve

stig

atio

n

51

03

12/0

5/20

14

CRS

Nor

th (W

alsa

ll - M

oss)

Ap

poin

tmen

ts -

Tim

e To

Rec

eive

Da

ught

er is

self-

harm

ing

and

need

s an

appo

intm

ent u

rgen

tly; s

he h

as b

een

wai

ting

too

long

.

Part

ially

Uph

eld

/ clo

sed

Appo

intm

ent m

ade

with

Psy

chol

ogist

. CP

N w

ill c

ontin

ue to

supp

ort o

n a

wee

kly

basis

. Pat

ient

aw

are

of C

risis

cont

act

deta

ils.

50

53

23/0

4/20

14

CRS

Nor

th (D

udle

y - P

OP)

At

titud

e O

f - N

ursin

g St

aff

Unh

appy

with

CPN

. Pa

rtia

lly U

phel

d / c

lose

d Ch

ange

d CC

APP

END

IX A

Page

7of

18

5068

23

/04/

2014

CR

S So

uth

(Wal

sall)

At

titud

e O

f - S

ocia

l Wor

ker

Patie

nt h

as n

ot re

ceiv

ed a

ny

com

mun

icat

ion

with

new

CC,

she

has

mad

e no

effo

rt to

mak

e co

ntac

t or a

tten

d th

e CP

A fo

r pat

ient

.

Part

ially

Uph

eld

/ clo

sed

Lack

of c

omm

unic

atio

n fr

om C

are

Coor

dina

tor/

CRS

- All

cont

acts

to b

e re

spon

ded

to in

the

abse

nce

of C

are

Coor

dina

tors

if th

ey a

re o

n sic

k le

ave

by

duty

wor

ker.

Real

loca

te th

e in

itial

CC

50

41

07/0

4/20

14

CRS

Sout

h (W

alsa

ll)

Attit

ude

Of -

Soc

ial W

orke

r Fe

els u

nsup

port

ed b

y So

cial

Wor

ker.

Clos

ed D

ue T

o N

o Re

spon

se.

Patie

nt n

ot c

onfir

med

det

ails.

Early

Inte

rven

tion

Serv

ices

Ca

se N

o Da

te R

ecei

ved

Depa

rtm

ent

Cate

gory

De

tails

Of C

ompl

aint

Cu

rren

t pro

gres

s / a

ctio

ns

RA G

5352

15

/09/

2014

CA

MHS

Dud

ley

(Elm

s)

Trea

tmen

t - F

aile

d To

Pr

ovid

e/

Diss

atisf

actio

n w

ith th

e se

rvic

e an

d tr

eatm

ent r

ecei

ved

over

la

st 6

yea

rs.

On-

goin

g / u

nder

goin

g in

vest

igat

ion

52

93

18/0

8/20

14

CAM

HS W

alsa

ll (C

anal

side)

Ac

cess

To

Serv

ices

- Pr

oble

ms

Unh

appy

abo

ut th

e la

ck o

f co

mm

unic

atio

n fr

om C

AMHS

Pa

rtia

lly U

phel

d / c

lose

d Pa

tient

refe

reed

to P

aedi

atric

Occ

upat

iona

l The

rapy

. Di

scus

sions

with

team

rega

rdin

g pa

thw

ays t

o tr

y to

redu

ce

med

ic w

aitin

g tim

es.

APP

END

IX A

Page

8of

18

5294

14

/08/

2014

Ea

rly In

terv

entio

n In

Ps

ycho

sis

Attit

ude

Of -

Ps

ychi

atris

t W

ishes

to c

ompl

ain

abou

t the

ca

re a

nd tr

eatm

ent s

he h

as

rece

ived

from

bot

h in

patie

nt

serv

ices

and

psy

chia

tric

team

af

ter l

eavi

ng h

ospi

tal.

Not

Uph

eld

/ aw

aitin

g sig

n of

f W

ill d

iscus

s with

staf

f in

both

team

s the

impo

rtan

ce o

f bod

y la

ngua

ge a

nd th

e po

tent

ial c

once

rns w

hen

aski

ng p

atie

nts t

o le

ave

the

cons

ulta

tion

room

and

how

this

may

be p

erce

ived

.

52

61

06/0

8/20

14

CAM

HS W

alsa

ll (C

anal

side)

Ap

poin

tmen

ts -

Tim

e To

Rec

eive

Ca

nnot

und

erst

and

why

CAM

HS

are

not m

akin

g he

r son

a

prio

rity

whe

n hi

s nee

ds a

re

urge

nt.

Clos

ed D

ue T

o N

o Re

spon

se

Cons

ent n

ot re

ceiv

ed

51

73

04/0

7/20

14

Enha

nced

Prim

ary

Care

(Wal

sall

Attit

ude

Of -

Nur

sing

Staf

f Da

ught

er e

xper

ienc

ed d

istre

ss

at in

itial

app

oint

men

t with

a

Prim

ary

Care

Nur

se.

Not

Uph

eld

/ clo

sed

6

x 1

hour

sess

ions

on

Com

pass

iona

te M

indf

ulne

ss to

be

mad

e av

aila

ble

to st

aff m

embe

r com

plai

ned

agai

nst.

Peer

Obs

erva

tion

sess

ions

cur

rent

ly u

tilise

d fo

r Ban

d 6

nurs

es

to b

e ut

ilise

d fo

r Ban

d 7

nurs

es.

51

58

16/0

6/20

14

CAM

HS W

alsa

ll (C

anal

side)

Ap

poin

tmen

ts -

Tim

e To

Rec

eive

W

hilst

on

the

wai

ting

list t

o be

se

en b

y CA

MHS

the

crite

ria

chan

ged

so h

er d

augh

ter h

ad to

be

refe

rred

aga

in.

Not

Uph

eld

/ clo

sed

Ap

poin

tmen

t mad

e w

ith te

am.

51

63

12/0

6/20

14

CAM

HS W

alsa

ll (C

anal

side)

Ar

rang

emen

ts -

Adm

issio

n CA

MHS

hav

e st

oppe

d ru

nnin

g a

cour

se w

hilst

pat

ient

was

on

the

wai

ting

list.

Clos

ed /

Refe

rred

to T

he M

anor

and

requ

este

d GP

refe

rral

to

CAM

HS.

51

43

05/0

6/20

14

Enha

nced

Prim

ary

Care

(Wal

sall

Attit

ude

Of -

Nur

sing

Staf

f U

nhap

py w

ith P

rimar

y Ca

re M

H N

urse

as t

here

was

a c

onfli

ct o

f in

tere

st b

etw

een

her s

eein

g hi

m a

nd h

is ex

-par

tner

.

Part

ially

Uph

eld

To re

min

d GP

surg

erie

s of p

roto

col a

roun

d se

eing

pa

rtne

rs/f

amily

mem

bers

. Thi

s to

be d

iscus

sed

in P

MH&

TTs

busin

ess m

eetin

g an

d re

info

rced

in m

anag

emen

t sup

ervi

sion.

N

urse

to re

ceiv

e co

mpa

ssio

nate

min

dful

ness

trai

ning

in h

ouse

vi

a Cl

inic

al P

sych

olog

ist.

51

38

02/0

6/20

14

Enha

nced

Prim

ary

Care

(Wal

sall

Attit

ude

Of -

Nur

sing

Staf

f He

lp w

as n

eede

d bu

t gat

eway

w

orke

r ref

used

any

ass

istan

ce.

Part

ially

Uph

eld

/ clo

sed

For t

he te

am le

arni

ng d

isabi

lity

cham

pion

to a

tten

d fu

rthe

r tr

aini

ng o

n As

perg

ers a

nd c

asca

de th

is to

all

staf

f via

SDM

. Fo

r sta

ff m

embe

r to

revi

ve 1

day

s tra

inin

g on

com

pass

iona

te

APP

END

IX A

Page

9of

18

min

dful

ness

from

Clin

ical

Psy

chol

ogist

in th

e te

am.

For a

ll ne

w st

arte

rs in

c te

mpo

rary

staf

f in

bot

h EA

S an

d PM

H&TT

S to

be

awar

e of

the

refe

rral

/acc

ess c

riter

ia.

5119

20

/05/

2014

CA

MHS

Dud

ley

(Elm

s)

Appo

intm

ents

- Ca

ncel

led

Appo

intm

ent d

ue o

n 23

/5 b

ut

has b

een

canc

elle

d as

Doc

tor i

s of

f sic

k, n

o on

e in

form

ed th

e fa

mily

abo

ut th

is un

til th

ey

calle

d th

e te

am to

ask

a

ques

tion.

Part

ially

Uph

eld

/ clo

sed

All p

atie

nts d

ue to

be

seen

by

a cl

inic

ian

that

is k

now

n to

be

off

wor

k du

e to

long

term

illn

ess a

re to

be

cont

acte

d w

ithin

two

days

of a

bsen

ce to

eith

er re

arra

nge

the

appo

intm

ent o

r re

allo

cate

the

clin

icia

n.

A no

te h

as b

een

appl

ied

to th

e m

edic

al n

otes

for p

atie

nt th

at if

CA

MHS

are

con

tact

ed b

y fa

ther

then

a re

turn

cal

l mus

t be

mad

e to

him

. If

he is

una

vaila

ble

then

a m

essa

ge w

ill b

e le

ft.

If fa

ther

doe

s not

retu

rn th

e ca

ll w

ithin

24

hour

s the

n a

tele

phon

e ca

ll w

ill b

e m

ade

to m

othe

r.

5108

09

/05/

2014

En

hanc

ed P

rimar

y Ca

re (D

udle

y)

Attit

ude

Of -

Nur

sing

Staf

f Pr

imar

y Ca

re N

urse

was

rude

, ab

rupt

and

her

com

mun

icat

ion

was

poo

r. He

r bod

y la

ngua

ge

expr

esse

d a

bad

attit

ude.

Not

Uph

eld

Apol

ogy

give

n an

d an

othe

r wor

ker a

lloca

ted.

51

10

08/0

5/20

14

CAM

HS D

udle

y (E

lms)

Re

ferr

al P

roce

ss -

Gene

ral

CAM

HS is

not

fit f

or th

e pu

rpos

e it

is m

eant

for a

nd th

e la

ck o

f ser

vice

pro

vide

d to

my

son

is a

disg

race

.

Uph

eld

/ clo

sed

Appe

ars t

hat a

n er

ror i

n re

latio

n to

CAM

HS a

ccep

tanc

e cr

iteria

re

sulte

d in

the

failu

re to

acc

ept t

he m

ost r

ecen

t ref

erra

l.

50

52

21/0

4/20

14

Enha

nced

Prim

ary

Care

(Wal

sall

Attit

ude

Of -

Nur

sing

Staf

f Th

e nu

rse

at re

cent

ap

poin

tmen

t was

com

plet

ely

unpr

ofes

siona

l, an

d th

e pa

tient

ca

me

out t

he m

eetin

g fe

elin

g ev

en m

ore

frag

ile th

an w

hen

she

first

ent

ered

.

Clos

ed D

ue T

o N

o Re

spon

se

Patie

nt n

ever

con

firm

ed d

etai

ls.

Old

er A

dult

Serv

ices

Ca

se N

o Da

te R

ecei

ved

Depa

rtm

ent

Cate

gory

De

tails

Of C

ompl

aint

Cu

rren

t pro

gres

s / a

ctio

ns

RAG

53

45

05/0

9/20

14

Mal

vern

War

d Ap

poin

tmen

ts -

Canc

elle

d Da

ught

er n

ot h

appy

that

her

fath

er h

as n

ot

rece

ived

ECT

ther

apy

sess

ion,

as r

ecen

t ap

poin

tmen

t did

not

go

ahea

d.

On-

goin

g / u

nder

inve

stig

atio

n

APP

END

IX A

Page

10

of 1

8

5174

19

/06/

2014

W

oods

ide

(CM

HTO

P)

Com

mun

icat

ions

- Fa

ilure

With

CP

N h

as b

een

off s

ick,

pat

ient

not

kep

t in

form

ed a

nd n

o on

e el

se h

as b

een

allo

cate

d to

this

patie

nt.

Part

ially

Uph

eld

/ aw

aitin

g sig

n of

f Co

ntin

genc

ies f

or st

aff s

ickn

ess a

nd a

bsen

ce

furt

her D

uty

Wor

ker C

onta

ct [s

afe

and

wel

l] an

d/or

, bas

ed u

pon

Clin

ical

Nee

d, a

Hom

e [r

espo

nse]

visi

t arr

ange

d.

51

11

16/0

5/20

14

Holy

rood

Pr

ivac

y/Di

gnity

- Pe

rson

al S

pa

Unl

ocke

d do

ors t

o be

droo

ms o

n Ho

lyro

od

war

d ar

e un

acce

ptab

le.

Not

Uph

eld

/ clo

sed

Be

tter

sign

s to

be p

lace

d ar

ound

war

ds.

50

80

28/0

4/20

14

Woo

dsid

e (C

MHT

OP)

Pl

acem

ent

Son

wan

ts m

om p

lace

d in

a h

ome

rath

er th

an

rece

ivin

g su

ppor

t fro

m p

artn

er a

t hom

e.

Part

ially

Uph

eld

/ clo

sed

Cont

inue

mon

itorin

g an

d re

view

of

Care

Pl

an a

nd B

est I

nter

ests

of p

atie

nt b

y O

ACM

HT

incl

udin

g lia

ison

with

all

agen

cies

in

volv

ed [p

artic

ular

ly H

ome

Care

].

5051

22

/04/

2014

O

ut P

atie

nts (

HLC)

Di

agno

sis -

Que

stio

n Th

e Co

mm

unity

Psy

chia

trist

refu

sed

to a

ccep

t a

hosp

ital d

iagn

osis

of v

ascu

lar d

emen

tia.

Not

Uph

eld

/ clo

sed

Advi

sed

it w

as D

r's c

linic

al o

pini

on fo

r va

scul

ar d

emen

tia d

iagn

osis

base

d on

the

evid

ence

pro

vide

d du

ring

the

asse

ssm

ent.

50

39

15/0

4/20

14

Ceda

rs W

ard

Med

icat

ion

- Del

ay In

Rec

eivi

ng

Patie

nt fe

els s

he h

as b

een

negl

ecte

d du

ring

her c

are.

N

ot U

phel

d, c

lose

d He

lp w

as o

ffere

d to

pat

ient

; she

refu

sed

to

enga

ge w

ith se

rvic

es.

Resp

onse

hel

d w

ith S

ED a

s NFA

for p

atie

nt.

50

38

07/0

4/20

14

CMHT

OP

Wes

t Co

ncer

n Fo

r Wel

lbei

ng

Unh

appy

abo

ut th

e tr

eatm

ent r

ecei

ved

by th

e Tr

ust a

nd p

lace

men

t whe

re h

usba

nd is

re

sidin

g.

With

draw

n. M

P in

volv

emen

t Ac

tivel

y lo

okin

g fo

r pla

cem

ent.

Revi

ew a

ppoi

ntm

ent b

roug

ht fo

rwar

d.

Reco

very

Ser

vice

s Ca

se N

o Da

te

Rece

ived

De

part

men

t Ca

tego

ry

Deta

ils O

f Com

plai

nt

Curr

ent p

rogr

ess /

act

ions

RA

G

APP

END

IX A

Page

11

of 1

8

5387

26

/09/

2014

Su

bsta

nce

Misu

se S

ervi

ce

(KH)

At

titud

e O

f - N

ursin

g St

aff

Com

plai

nant

not

hap

py w

ith th

e at

titud

e of

alc

ohol

team

nur

se.

Clos

ed d

ue to

no

resp

onse

.

51

79

24/0

6/20

14

EAS

(Wal

sall)

At

titud

e O

f - P

sych

iatr

ist

Attit

ude

of D

r at o

ut-p

atie

nt

appo

intm

ent w

as d

read

ful,

appe

ared

to

be

not i

nter

este

d an

d ha

rdly

sp

oke

to th

e pa

tient

dire

ct.

Und

ergo

ing

inve

stig

atio

n - 3

on-

goin

g co

mpl

aint

s ab

out t

he sa

me

Cons

ulta

nt.

51

29

29/0

5/20

14

EAS

(Wal

sall)

At

titud

e O

f - P

sych

iatr

ist

Dr's

man

ner w

as h

arsh

and

rude

and

an

ove

rall

disg

race

. U

phel

d / r

espo

nse

rece

ived

but

on

hold

as 3

on-

goin

g co

mpl

aint

s abo

ut th

e sa

me

Cons

ulta

nt.

51

13

16/0

5/20

14

EAS

(Dud

ley)

Sa

ndrin

gham

Cl

inic

al -

Asse

ssm

ent

Unh

appy

with

clin

ical

ass

essm

ent

and

havi

ng to

wai

t a w

eek

for a

n ap

poin

tmen

t at E

AS.

Not

Uph

eld

/ clo

sed

N

otes

indi

cate

she

was

seen

with

in 2

4 ho

urs b

y EA

S.

Dr to

writ

e to

GP

rega

rdin

g m

edic

atio

n.

50

90

29/0

4/20

14

Subs

tanc

e M

isuse

Ser

vice

(R

C)

Appo

intm

ents

- Ti

me

To

Rece

ive

Patie

nt h

as b

een

wai

ting

a lo

ng ti

me

for a

n ap

poin

tmen

t for

SM

S in

Du

dley

.

Part

ially

Uph

eld

/ clo

sed

Typi

ng o

f let

ters

for E

AS a

sses

smen

ts sh

ould

not

be

dela

yed

furt

her t

han

2 w

eeks

aft

er a

sses

smen

t has

ta

ken

plac

e.

Alte

rnat

ive

way

s of c

onta

ctin

g pa

tient

s (fo

r ins

tanc

e te

leph

one)

shou

ld b

e in

pla

ce w

hen

appo

intm

ents

ar

e m

ade

at su

ch sh

ort n

otic

e.

Urg

ent r

efer

rals

shou

ld b

e se

nt b

y fa

x/ te

leph

one

or

inte

rnal

em

ails

and

conf

irmat

ion

shou

ld b

e so

ught

. Cl

ear r

efer

ral p

athw

ays s

houl

d be

est

ablis

hed

betw

een

DWM

HT

and

CRI-A

H S

MS

serv

ices

to a

void

un

nece

ssar

y de

lays

in th

e pr

ovisi

on o

f ser

vice

s for

pa

tient

s with

subs

tanc

e m

isuse

pro

blem

s and

dua

l di

agno

sis, a

s thi

s can

cle

arly

lead

to u

ndue

pre

ssur

es

on E

AS se

rvic

es a

s a re

sult

of re

-ref

erra

ls.

50

40

07/0

4/20

14

Gras

mer

e Re

habi

litat

ion

War

d Vi

olen

ce -

Pt O

n Pt

Th

reat

enin

g be

havi

our

Feel

s sin

gled

out

by

a st

aff m

embe

r an

d bu

llied

and

har

asse

d.

With

draw

n Ex

plai

ned

the

lock

ed d

oor p

olic

y an

d hi

s inf

orm

al

stat

us, a

nd p

atie

nt u

nder

stan

ds a

nd is

satis

fied

with

th

is, w

ithdr

ew c

ompl

aint

aft

er d

iscus

sing

conc

erns

w

ith w

ard

man

ager

.

APP

END

IX A

Page

12

of 1

8

5028

03

/04/

2014

EA

S (D

udle

y)

Sand

ringh

am

Refe

rral

Pro

cess

- Ge

nera

l Th

inks

EAS

hav

e be

en d

elay

ed a

ctin

g on

a re

ferr

al fr

om th

e GP

. N

ot U

phel

d / c

lose

d.

Patie

nt w

as a

sses

sed

2 da

ys p

rior t

o hi

s adm

issio

n an

d w

as fe

lt to

be

men

tally

wel

l at t

he ti

me

of th

e as

sess

men

t. Pr

ior t

o th

is as

sess

men

t his

wife

was

of

fere

d th

e op

port

unity

to b

ring

her h

usba

nd to

A&

E fo

r a c

risis

asse

ssm

ent w

hich

she

decl

ined

.

5027

02

/04/

2014

Gr

asm

ere

Reha

bilit

atio

n W

ard

Viol

ence

- Pt

On

Pt

Thre

aten

ing

beha

viou

r An

othe

r pat

ient

on

the

war

d is

bein

g ve

rbal

ly a

busiv

e.

Uph

eld

/ clo

sed.

Pa

tient

is c

urre

ntly

inap

prop

riate

ly p

lace

d on

Gr

asm

ere

give

n th

e pr

oble

ms t

hat s

he p

oses

. Pa

tient

to b

e re

mov

ed fr

om G

rasm

ere

War

d to

a

mor

e su

itabl

e an

d se

cure

env

ironm

ent

com

men

sura

te w

ith h

er b

ehav

iour

s and

nee

ds. T

his

is bo

th fo

r her

ow

n pr

otec

tion

and

the

prot

ectio

n of

ot

hers

. Co

nsid

erat

ion

shou

ld b

e gi

ven

to p

laci

ng c

ompl

aina

nt

on le

vel 3

obs

erva

tions

whi

lst o

ther

pat

ient

is st

ill o

n Gr

asm

ere.

APPENDIX B

Page 13 of 18

Governance and Quality Committee:

Meeting date:

Agenda Item number: Enclosure:

Report Title: Experts by Experience Recruitment, Induction and Work Plan

Accountable Director: Marsha Ingram, Director of People and Corporate DevelopmentAuthor (name & title): Mary Bytheway, Strategic Planning Manager

Purpose of the report: To update the Committee on the progress we have made in enhancing the scope and function of our Experts by Experience. To seek approval for a new approach to EBE activity reporting.

Action required from the CommitteeDecision / Approval Gain assurance Discussion Information


Committee: none


Is referral to Trust Board required? Yes

If yes, for what purpose? The same recommendation will be made to Board with regard to EBE activity reporting.


servicesInclusive

partnerships Leadership

culture Responsible workforce

Supporting strategies




Caring EBEs reach out to service users across the Trust and in the community, providing a valuable channel for service users and carers to share their views with us

Responsive Feedback is timely and appropriate, actions are taken to address issuesEffective EBE work plan is aligned to services and supports staff with service improvement

inputWell-led Provides information to Board and its committees in order to support effective action

and decision making about service experience feedbackSafe Triangulation of themes with other factors supports safe service delivery and issue

resolution

APPENDIX B

Page 14 of 18

Title Experts by Experience Recruitment, Induction and Work Plan

IntroductionIn November last year, the Trust agreed to recruit to the existing EBE vacancies in order to have a greater focus on service user engagement and feedback. Our current EBEs were getting involved in more detailed work and were in high demand from staff! During the selection process it became apparent that we had some very capable candidates and it was agreed that we would extend the team from the existing 8 to 12. This report provides the Committee with an update on the recruitment process, induction and work plans of the new team. A number of recommendations are made that will improve clarity of their role and support our focus on embedding lessons. The recommended changes will allow our EBEs to demonstrate to the Trust how their feedback has been used to improve services and it will also help them to triangulate their findings with other factors. Summary of key points, issues and risksThe following key points are highlighted in the report appended:

1. EBEs are a rich source of service feedback and are in high demand, hence the decision to recruit more

2. It can be difficult to resolve or escalate concerns raised by EBEs so we have proposed some changes to help this

3. It is often difficult to see how the Trust has responded to feedback so we are making this more explicit in the reporting structure

4. Whilst anecdotal feedback is valuable, we want our EBEs to get more involved in detailed and measurable work and we have developed a work plan that supports this

Further detail (if required)The full report is appended. RecommendationThe recommendations to the Committee are:

1. Change the EBE reporting from monthly to quarterly in line with the Quarterly Service Experience Report

2. Concerns raised by EBEs and that are not resolved directly, to be logged onto Safeguard and handled in line with our policy

3. Quarterly EBE report to focus on providing an update on the agreed work plan / projects

4. Senior EBEs continue to attend GQC every month to provide a “service user perspective” on appropriate agenda items

Action requiredThe Committee is asked to receive the report for information and assurance and to approve the above recommendations.

APPENDIX B

Page 15 of 18

Title Experts by Experience Recruitment, Induction and Work Plan

Introduction In November last year, the Trust agreed to recruit to the existing EBE vacancies in order to have a greater focus on service user engagement and feedback. Our current EBEs were getting involved in more detailed work and were in high demand from staff! During the selection process it became apparent that we had some very capable candidates and it was agreed that we would extend the team from the existing 8 to 12.At the same time, in order to introduce our new EBEs more effectively, it was agreed that we would appoint two “senior EBEs”. This role would be: introducing new EBES to staff, helping them to get out and about and involved in projects and to signpost. As an interim measure we asked Agnes Wallwork and Lynne Jankowska to undertake this supervisory role.

The EBE Role The role of an ‘Expert by Experience’ is to use their experiences of mental health services, as a service user or a carer of someone with mental health problems, to inform and influence the delivery, planning and quality of services within the Trust. The EBEs also represent the interests and views of local service users and carers in Dudley and Walsall, with the overall aim of improving the experiences of people who use our services. EBEs work across the Trust, having regular contact with directors, senior managers, staff, service users and their carers. EBEs are recruited in accordance with our Volunteer Policy. They work for 12 hours per month and are paid for this and their travel expenses. The two Senior EBEs work for 20 hours per month to allow time for their involvement in GQC. They are involved in many activities across the Trust, the main ones are described below:

Participate and contribute to service transformation and service improvement activities

Participate in and advise on the development of policies and procedures, strategies and delivery plans

Seek service users’ and carers’ views on service experience through informal visits, service experience surveys, drop in sessions and focus groups

Support the development of good quality patient information

Attend and participate in formal meetings, such as Governance and Quality Committee, Research and Development Committee to provide a “service user perspective” on Trust activities

Participate in the recruitment and selection of Trust staff and the induction process

Develop links with local service user and carer community and voluntary groups to build relationships and help extend involvement with the Trust

Participate actively with community and FT membership involvement and engagement activities and events

APPENDIX B

Page 16 of 18

Recruitment Update All 12 EBE posts have been filled. We currently have two potential vacancies due to the resignation of Debbie Bills and the failure to engage one of our new recruits. The team has recently completed their final induction and have had the opportunity to meet with the Chief Executive and Chair.

Meet our EBEs Next month we will be holding ‘Meet the EBEs’ events across our sites for staff and service users to drop in, a member of SED will also be attending. An ‘Introduction to our new EBEs’ article will go into the Trust’s membership magazine, ‘One-in-4’, to promote the new EBEs. Staff have been provided with an update through Wednesday Wire and Team Brief about the EBE role, how they can support service users and carers and their involvement in Trust activities.The EBE leaflet will be updated, highlighting each area of specialist interest our EBEs have and these will be distributed across sites.

Lynne Jankowska (SENIOR EBE DUDLEY)

Lynne is an experienced service user who likes listening to service users and helping them find additional support. She enjoys report writing, discussing findings and liaising with Heads of Service. Lynne is actively involved with the G&Q Committee, Approved Mental Health Practitioner Panel, the personalization agenda and the new structure of Wrekin Ward. She has also provided a service user perspective to care planning, the development of crisis cards and the Trust’s new Wellmind app.

Razia Chaudhry(DUDLEY)

Razia is an experienced carer who has been challenging stigma and discrimination surrounding mental illness within the Asian Community for many years. Razia has years of professional and personal experience working with and supporting individuals who have suffered from poor mental health. Razia’s particular interests are in promoting mental health and enabling communities.

Debbie Bills(DUDLEY)

As a former carer and current service user, Debbie enjoys talking to service users and carers and reassuring them that their views count. Debbie’s particular interests are in promoting carers rights, the Triangle of Care initiative and supporting young people. Debbie engages with many carers groups and organisations that provide support to service users.

Emma Salt (DUDLEY)

Emma has been accessing services since she was 13. Her special interests are CAMHs and young people’s services. She has worked for Rethink Mental Illness for a number of years sharing her story with schools, colleges and organisations throughout the country.

APPENDIX B

Page 17 of 18

Kristina Horley(DUDLEY)

Kristina has accessed Primary Care services and is also a carer for her friend who is Bi-polar. Her special interests are working with children and young people and she has a passion for challenging stigma and discrimination surrounding mental health.

Najma Tariq(DUDLEY)

Najma is an experienced carer who has been involved with Trust services for a number of years, through caring for family members who have mental health conditions. She would like to share her experiences to help others within the Asian community where mental illness is still a taboo subject.

Agnes Wallwork (SENIOR EBE WALSALL)

Agnes is an experienced service user who enjoys listening to service users and carers and feeding back any issues or concerns through relevant committees to help improve people’s experiences. She is actively involved in the G&Q Committee, Research and Development Committee and in the implementation of the Triangle of Care programme. She is currently supporting the development of the Rehab Pathway model and evaluating Older Adults services.

David Clarke(WALSALL)

David has been a carer for his partner, who has been an inpatient in both Bushey Fields Hospital and Dorothy Pattison Hospital, for many years. He has been in contact with many areas of mental health services over the years, including the Crisis Resolution and Home Treatment Team and the Assertive Outreach service. His special interests are improving access to support and information for carers.

Beckie Millington (WALSALL)

Beckie is currently a service user with the Walsall SMS service and has been a carer for someone with mental health issues. She is passionate about looking at Mental Health and substance misuse.

Andrew Simpson(WALSALL)

Andrew is currently a service user accessing Trust services. He is a volunteer for Walsall SUE and a Healthwatch Assembly Member. His areas of special interest are helping service users and carers who do not have the confidence to speak up for themselves.

Pat Nye (WALSALL)

Pat has been a service user for a number of years. She is the Chairperson for Walsall Service Users Empowerment and is dedicated to listening and empowering service users. As an EBE she is actively involved in the proposed Rehabilitation Pathway and has participated in the Community Services Transformation workshop and Older Adult Workshops to discuss and engage in the model development. She is passionate about educating people about mental illness.

Vacant Post (WALSALL) This post will be advertised in Q4 2014/15

APPENDIX B

Page 18 of 18

Work Plan The EBE team will be aligned to special areas of interest, with each EBE bringing different skills and experience to the role. This includes working with young people, experience of primary care services and substance misuse services, caring for someone with a mental illness and supporting service users and carers. Each one has considerable knowledge and experience of using our services. Our EBEs will be getting involved in a number of projects to provide a service user and carer perspective. For example, the current work plan comprises:

Using EBE Feedback to Improve Services In the course of their work EBEs do come across areas of concern. In the main these are raised and resolved there and then with the responsible team manager. If a concern is shared with an EBE by individual service user or carer, they are signposted to SED in line with our Complaints Policy. Specific EBE concerns have to date been reported via our QPRs where managers have the chance to address the issues raised and suggest any necessary corrective action. These are then reported via the Quarterly Service Experience Report that comes to GQC. There are occasions, where due to timing, some concerns do get reported but have not been resolved or actioned. To improve this process, we are proposing that any unresolved concerns raised by our EBEs are fed directly into Safeguard and handled in line with our policy.

.

Project / Activity1. Evaluation and feedback on the new ‘My Care Packs’ – to provide service user/carer views and monitor the effectiveness of care

plans

2. Engaging with service users accessing the Recovery Intervention Service

3. Raising awareness of the Independent Mental Health Advocacy Service

4. Supporting the implementation of the Triangle of Care programme 5. To conduct a survey with patients on acute wards to support the Therapeutic Audit

6. Involving EBEs in the new structure of Wrekin Ward – to promote recovery and reduce the number of re-admissions

7. Rehab Pathway development – to provide a service user carer perspective to the proposed new model, to support the development of the new pathway and provide an input on how services may be shaped in the future

8. Engaging with Older Adults Service line – working with service users and carers to capture feedback about the service and service improvements

9. Wrekin Ward information pack to support recovery following discharge

Page 1 of 13


Agenda Item number: 11.3

Enclosure: 13

Report Title: Enhancing Quality through Safer Staffing Levels- Six Month Update - Review of Inpatient Nurse

Staffing - Monthly Exception Report October 2014 data

Accountable Director: Wendy Pugh – Director of Operations, Nursing & EstatesAuthor (name & title): Wendy Pugh – Director of Operations, Nursing & Estates

Rosie Musson – Head of Nursing Quality and Innovation

Purpose of the report:

This report aims to provide the Trust Board with:

1. Summary of National Quality Board (NQB) Expectations and actions taken by Trust

2. 6 monthly update in line with the commitment requested by the NQB

3. Monthly summary report of planned and actual staffing which has been submitted to NHS Choices as part of a national staffing return for October 2014



Committee:



servicesInclusive


cultureResponsible



Page 2 of 13



Caring Ensuring staffing levels support compassionate careResponsive Ensuring staffing levels are responsive to meeting patient

needEffective Ensuring staffing levels meet patients’ needs and support

recoveryWell-led Ensuring rostering is well led and staffing levels are changed

to meet need.Safe Ensuring staffing levels are adequate to deliver safe care

Page 3 of 13

Title Enhancing Quality through Safer Staffing Levels- Six Month Update -Review of Inpatient Nurse Staffing - Monthly Exception Report

Introduction

This paper forms

The six monthly review/update of nurse staffing in line with the commitment requested by theNational Quality Board (NQB) (2013) document, Nurse Staff Guide ‘How to ensure the right people, with the right skills are in the right place at the right time!’ the recommendations from which were subsequently aggregated and released as Hard Truths, 2014.

Contained in the Contained in this report are

1. Summary of NQB Expectations and actions taken by Trust

2. 6 monthly update in line with the commitment requested by the NQB

3. Monthly summary report of planned and actual staffing which has been submitted to NHS Choices as part of a national staffing return for October 2014


1. The Trust continues to comply and improve processes to meet the NQB requirements

2. Following the staffing review which was presented to the Trust Board in June 2014, the Trust has implemented the recommendations made by the Board in relation to the minimum requirement of 2 qualified staff members per shift 24/7

3. The establishment for inpatient acute services will remain the same and will be reviewed again following the publication of the National Framework

4. Staffing levels relating to inpatient older adults wards are being reviewed as part of the older adults review.

5. At the Chief Nursing Officer Conference Nov 25th a national framework will be launched supporting Trusts in assessing and determining inpatient staffing levels.

6. The Trust is engaged in a Health Education West Midlands project that aims to help Mental Health Trusts embed the framework and also is commencing a work stream to develop a community staff tool. This will be a multi-disciplinary tool. Projected completion date April 2015

7. The Trust has now received the monthly staff fill report in line with NQB for 6 months. Exception reporting and triangulation with incident data has taken place which the trust Board has received.

Page 4 of 13

Further work is required to enhance the report through greater triangulation with workforce metrics e.g. use of bank and agency

The Trusts escalation framework can be utilsed by staff to report concerns relating to staffing levels. The Trusts quality report contains a category specific to staffing levels which is informed by the incident reporting system.

Options for e-rostering are currently explored to further support effective rostering to best meet patient need.

Further detail (if required)

BackgroundThis report serves as the six monthly review/update of nursing staffing for the Board in line with the requirements set out by the National Quality Board (NQB). The NQB laid out its expectations of Provider and Commissioning organisations to publish nursing and midwifery staffing in their guidance called “How to ensure the right people, with the right skills are in the right place at the right time”. The guidance followed recommendations from the Francis report and other high profile national reviews such as those by Prof Sir Brice Keogh, the Cavendish Review and Don Berwick’s review into patient safety in England.

1. Summary of NQB Expectations and actions taken by Trust

The NQB set out 10 expectations, 9 of which are relevant to Provider organisations and broadly cover the following areas: Accountability and responsibility of Boards, Evidence based decision making, Supporting and fostering professional environment, Openness and transparency, Planning future requirements Role of Commissioning

Below is a summary of the expectations and the actions that have been taken by the Trust:

EXPECTATION 1 - Boards take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability.

This requires Boards to ensure that there are robust systems and processes for receiving assurance about adequacy of staffing capacity and capability to deliver high quality care and that this monitored on an on-going basis through reports to the Board in order to have a deeper understanding on the impact on quality and clinical outcomes. In practice, this requires Boards to request and receive papers on establishments reviews carried out at least six monthly, with consideration and discussions at a public Board meeting. Further exception reports to the Board are expected to also be published on a monthly basis and uploaded onto NHS Choices.

Trust UpdateAn inpatient nursing staffing review was included in a report presented to Trust Board in June 2014. This is the second report the Trust Board has received and meets the requirement of the 6 monthlyreview/update on inpatient nursing. Further work is ongoing to review staffing levels through the visioning of future provision of older adult services. Acute service staffing was reviewed as part of

Page 5 of 13

service transformation as previously reported to the Trust Board. This has not altered since the last report and will be reviewed following the publication in November 2015 of a national framework to help mental health Trusts assess their staffing levels.

The Trust Board has also received monthly exception reports on the information uploaded to NHS choices regarding staff fill rates for inpatients. Further work is in progress relating to this report to ensure effective triangulation with workforce metrics.

EXPECTATION 2 - Processes are in place to enable staffing establishments to be met on a shift-to-shift basis.

This involves daily review of the actual staff available on a shift by shift basis versus the planned levels, and ensuring that solutions are sought to address the shortfalls. This review should occur between nursing leaders responsible for inpatient care. Included in this is the effective use of the e-rostering systems and the development and implementation of escalation policies and plans to help staff with decision making during times of increased pressure and demand.

Trust UpdateThe Ward Manager or the Nurse in Charge of a shift is responsible for the review of staffing levels in response to unplanned absence and unexpected demand as a result of increased activity and level of dependency. This process is overseen by Heads of Service and on call manger as required.The wards currently use a paper based rostering system. This is being reviewed and options are being scoped to discuss moving towards e-rostering which would enable greater scrutiny of effective usage of roster. Escalation processes are in place through management structures to help meet unplanned demands and decision making.The Trusts escalation process is in place for staff to raise concerns about staffing levels including the Trusts incident reporting system which is utilsed by staff to report staffing concerns.

EXPECTATION 3 - Evidence-based tools are used to inform nursing, midwifery and care staffing capacity and capability. (Currently there are no evidence based staffing tools that have been validated for use in establishing staffing levels on mental health wards).

In June 2014 the Board received a report detailing the outcome of an inpatient staffing review. An evidence based tool (Keith Hurst Tool) had been used alongside local intelligence and need. It was felt very important to use local intelligence and identified need as the tools related to assessing safer staffing as yet are limited in validity. This was further augmented by Professional scrutiny led by the Executive Nurse and the Head of Nursing in consideration of known risks and identified mitigating actions. This approach is in line with the findings of a National project specific to mental health which concluded early on that: • There is a lack of research evidence to inform Safer Staffing in inpatients and in community settings for mental health

• Existing tools had significant limitations in their reliability and usability

• A key issue for Safer Staffing was the ability to measure need, on a daily basis and over time

Page 6 of 13

At the Chief Nursing Office Conference in November 2014 an output from the national project will be published framework to support inpatient wards to determine safe staffing levels. This will be utilsed by the Trust upon publication. It is not anticipated this framework will provide expected figures more a framework to assist decision making.

To take forward safer staffing in the region, Health Education West Midlands is now leading a project to embedding the inpatient framework and also to develop a ‘community safer staffing tool’ by April 2015. The Trust is engaged in this project.

EXPECTATION 4 - Clinical and managerial leaders foster a culture of professionalism and responsiveness where staff feels able to raise concerns.

Post Francis Inquiry, staff have become more aware of the need to highlight staff shortages by reporting this as an incident through the risk management processes. Safer staffing is an incident category in the Trust monthly Quality Report, which is reported pan Trust and service line. The monthly report is received by service line quality groups, the Governance and Quality Committee, Commissioner Quality Review Meetings and at Trust Board. Immediate concerns are addressed through management accountability structures.

Governance process in the Trust also support the triangulation of incident reporting with the monthly staffing report received by Board for assurance on exceptions. Teams are also aware of the Trust escalation processes including whistleblowing.

It has also been evident through the monthly collection of staff fill data (where service report fill rates over 100%) that ward managers/nurse in charge are empowered to take action where there are local gaps to meet unplanned need.

EXPECTATION 5 - A multi-professional approach is taken when setting nursing, midwifery and care staffing establishments.

This requires close working relationships and ownership of responsibilities for key elements of staffing establishments for staff at different levels of the organisation from direct care staff to Board members.

The Trust has taken a multi professional approach to understanding and setting required staffing levels.Transformation programmes are all subject to a business case which goes to the Management Executive Meeting, Trust Board and cascaded through service lines and to direct care staff. Transformation has ongoing updates and each project has a quality impact assessment which is signed off by the Director of Operations and Joint Medical Directors.

Intensive work is underway across all service lines to agree and implement 5 year workforce plans, which will involve the development of new ways of working and innovative roles. This has included targeted training for managers in workforce planning and on-going sessions led by the Directors of Operations and Nursing until each service line is completed and signed off. This process has promoted a bottom up approach led by the Heads of Service.

Page 7 of 13

EXPECTATION 6 - Nurses, midwives and care staff has sufficient time to fulfill responsibilities that are additional to their direct caring duties.

This includes ensuring that there is sufficient time to undertake continuous professional development to fulfill mentorship and supervisory roles. It requires establishment uplifts that reflect realistic expectations on meeting training and development, planned and unplanned leave.

Ward managers are supernumerary. This enables them to undertake supervisory roles and to cover shortfalls in emergency situations. The team budgets reflect 24% headroom factored in response to annual leave plans, bank holidays, training and sickness.

EXPECTATION 7 - Boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review.

This is similar as outlines in Expectation 1. The Board already receives a workforce report containing a number of workforce metrics as part of the integrated performance dash board. Data providesinformation broken into service lines.

Additionally, commencing from June 2014, the Board has received exception monthly reports on planned and actual staff fill rates. All inpatient nursing staffing data collated within the month is published on NHS Choices, two weeks after uploading on the Unify system.

EXPECTATION 8 - NHS providers clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service on each shift.

The Trust has implemented a standardised approach to displaying this information across all inpatient services. Details of the Nurse in Charge, names and roles of staff on duty and the planned versus actual number of staff is published on a shift by shift basis. Further work is being undertaken to enable wards to be able to display this information electronically on the information screens. The Trust will be completing and audit of compliance.

EXPECTATION 9 - Providers of NHS services take an active role in securing staff in line with their workforce requirements.

Included in this are workforce plans to ensure sufficient supply of nurses to meet patients demand, to have strategies for managing recruitment and retention and being represented at Local Education and Training Board.

Intensive work is underway across all service lines to agree and implement 5 year workforce plans, which will involve the development of new ways of working and innovative roles.

There have been several effective recruitment drives for Qualified Nurses which has included greater use of media for advertising and a central approach to Band 5 recruitment which has promoted values based recruitment. The program is led by the director of Nursing. The purpose of this new recruitment program was to ensure that there was a standardised process applied throughout the whole recruitment process and that efficiencies were made from the point of advertising, shortlisting, interviewing and checking documents post appointment. This was achieved through central declaration of all vacancies; setting in advance shortlisting panels with membership from all service areas and application of the

Page 8 of 13

same standards to shortlisting. This is a rolling program and further sessions are scheduled on an on-going basis.

There are currently 378 Registered Nurses in the Trust and 123 unqualified nurses. Therefore the combined nursing workforce equates to 50.75% of the total Trust Workforce (based on ESR data received on 4 November 2014) Over the next 12 months there are a number of developments which are being planned and some have already commenced delivery including. Initiatives are important for developing the existing workforce to deliver the Trusts Clinical and Social Care Vision. Some of the initiatives include:

Nurse Portfolio of Development Opportunities to be published by the end of December 2014. This will include up to 25 different development offerings to include internal and external courses which will all be free for nurses to book onto following an appraisal and agreement with their Line Manager. It will also be used as a resource pack containing current nursing information including the revised Code of Professional Conduct for Nurses

Band 6 Acute Nurse Development Programme- already commenced. One day per month over 6 months to work on a Personal Change Action and work with their peers to engage in a Spotlight on Nursing initiative which will be presented to the Director of Nursing at the end of the course.

Experienced Band 5 Nurse Development Programme- one day per month for 6 months

Community Band5-6 Nurse Development Programme- to be underpinned by assessment against a competency framework and support of a Mentor in Practice

Band 6 Nurse Development Programme for Older Adults- currently being planned

On going Health care Assistant Programme

COMMISSIONERS:

EXPECTATION 10 - Commissioners actively seek assurance that the right people, with the right skills, are in the right place at the right time within the providers with whom they contract.

This may of course require further discussion and negotiations about the staffing capacity to meet the demands and conditions set out in the contracts.

Page 9 of 13

2. Six monthly update in line with the commitment requested by the National Quality Board (NQB)

This section of the report provides the Board with an update on staffing establishment on inpatient wards. Since the last full review in June 2014, the Trust ensured recommendations have been implemented and has monitored staffing level through the Trusts performance monitoring and governance reporting processes.

In June 2014 an inpatient staffing review was presented to the Trust Board which made a series of recommendations to the Trust Board. The Trust Board accepted the recommendation that on Older Adults and Acute inpatient wards that there should be a minimum of 2 qualified staff per shift. This recommendation has been implemented and is monitored by the Ward managers and Heads of Service.

The Director of Operations and Nursing and Head of Nursing and Quality have reviewed the current establishment. In both instances no recommendations are made to change the current establishment in this report. A description of the current position and rationale for no current changes for both acute inpatient services and older adults is detailed as follows -

Update on Acute Inpatient service staffing establishmentDuring the last 6 months the staffing establishment for inpatient acute wards has remained the same. This is based on the fact that the establishment was reviewed as part of service transformation in 2013and again reviewed as part of the June 2014 review demonstrated that this was acceptable. It is proposed this remains the same at present. No immediate risks regarding set establishment has been identified through the Trusts escalation process. However in light of the National Framework for staffing levels being launched in November nursing establishment will be reviewed in accordance with the framework over the next six months. This will be informed by the detailed workforce plans which are being finalised.

Older Adult ServiceThe nurse staffing establishment for Older Adults is currently under reviews part the older adults service redesign and visioning. Therefore no recommendations are made at the time of the report to alter staffing establishment.

Following the recommendation relating to the minimum of two qualified nurses per shift, the budgets for older adults have been rebased. Older Adults has also participated in the successful recruitment drives.

.

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e Tr

ust h

as o

neex

cept

ion

to re

port

to th

e Tr

ust B

oard

.

Exce

ptio

nsR

atio

nale

Impa

ctR

emed

ial A

ctio

nsH

olyr

ood

War

d –

Bus

hey

Fiel

ds H

ospi

tal

87.6

%D

ay –

Ave

rage

fill

rate

–

Reg

iste

red

Nur

sing

(low

rang

e)

Aver

age

fill r

ate

for r

egis

tere

d nu

rse

diffe

red

from

plan

ned

staf

fing

durin

g O

ctob

er

follo

win

g re

ason

s:

Annu

al le

ave/

sick

leav

e of

re

gist

ered

nur

ses

Addi

tiona

l car

e st

aff

requ

ired

to m

eet s

ervi

ce

need

s (1

11.2

%)

Safe

sta

ffing

leve

ls m

aint

aine

d,

no re

porte

d in

cide

nts

No

actio

n re

quire

d

Page

12

of 1

3

Tren

d An

alys

is a

vera

ge fi

ll ra

te(2

014/

15)

The

follo

win

g ta

ble

show

s a

2014

/15

mon

th tr

end

of th

e to

tal a

vera

ge fi

llra

tes

plan

ned

vers

es a

ctua

l for

the

Trus

t. It

show

s th

e im

prov

emen

t in

the

data

qua

lity

and

sign

ifica

nt u

nder

stan

ding

of t

he c

aptu

ring

plan

ned

hour

s of

wor

king

.

Page 13 of 13

Recommendation

The Trust Board receives this report for assurance and discussionnote the Trusts current position against the NQB recommendationsnote the current position relating to inpatient establishment

continue to receive monthly planned and actual fill rates (further work is required for greater triangulation with workforce metrics) and continue to receive exception reportsnote that the Trust is engaging in a regional project, this will open safer staffing discussions to community teamsnote further work will be undertaken to utilize the framework delivered through the national project pending publication.


To receive the report for assurance and discussion.