eput.nhs.uk · 2017-06-19 · Board of Directors Part 1 Meeting 28 September 2016 FINAL SEPT Meeting of the Board of Directors held in Public at 10.30am on Wednesday 28 September

Board of Directors Part 1 Meeting 28 September 2016 FINAL

SEPT

Meeting of the Board of Directors held in Public at 10.30am on

Wednesday 28 September 2016

Lecture Theatre, Hawthorn Centre, Rochford Hospital, Union Lane,

Rochford SS4 1RB

Our Vision

“Providing services that are in tune with you”

PART ONE – MEETING HELD IN PUBLIC AGENDA

1 APOLOGIES FOR ABSENCE CL (verbal)

2 DECLARATIONS OF INTEREST LC (verbal)

PRESENTATION: CARE COORDINATION MODEL

By Carolyn Hanna and Kevin McKenny

3 MINUTES OF THE LAST MEETING HELD ON 27 JULY 2016 (attached)

4 ACTION LOG (attached)

5 QUALITY AND OPERATIONAL PERFORMANCE

(a) Finance & Performance Committee Assurance Report SM/MM (attached)

(b) Quality Report AB (attached)

(c) Safer Staffing Report AB (attached)

6 ASSURANCE, RISK AND SYSTEMS OF INTERNAL CONTROL

(a) Board Assurance Framework NL (attached)

(b)

Sub-Committees

(i) Quality Committee

(ii) Investment & Planning Committee

(iii) Audit Committee

LC

LC

JW

(attached)

(attached)

(attached)

7 STRATEGIC INITIATIVES

(a) SEPT/NEP Merger:

(i) General Update

NL

(attached)

(b) National and Local System Updates: STPs, West Essex ACO and Essex Mental Health Strategy Update

SM (verbal)

(c) Five Year Forward View NL (attached)

8 REGULATION AND COMPLIANCE

(a) Board Governance Update NL (attached)

(b) SIRO Annual Report 2015/16 MM (attached)

(c) Annual Planning 2016/17 NL (attached)

Board of Directors Part 1 Meeting 28 September 2016 FINAL

(d) CQC Inspection Action Plan Update SM (attached)

(e) Statement of Compliance for Revalidation (Doctors) MK (attached)

(f) Junior Doctors Strike MK (attached)

9 OTHER REPORTS

(a) Use of Corporate Seal SM (verbal)

(b) Correspondence circulated to Board members since the last meeting

LC (verbal)

(c) New Risks identified that require adding to the Risk Register or any items that need removing

All (verbal)

10 ANY OTHER BUSINESS

11 DATE AND TIME OF NEXT BOARD OF DIRECTORS MEETING

Wednesday 26 October 2016 at The Lodge, Runwell Chase, Wickford, Essex, SS11 7XX

12 ‘QUESTION THE DIRECTORS‘ SESSION

There will be a 15 minute session for members of the public to ask questions of the Board of Directors.

13 RESOLUTION

To exclude members of the Public and Press

Lorraine Cabel Chair

SEPT: Board of Directors Meeting Part 1 Minutes 27 July 2016

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In the Chair, Board of Directors Meeting Page 1 of 15

SEPT MINUTES OF PUBLIC BOARD OF DIRECTORS

PART 1 held on Wednesday 27 July 2016

at The Lodge, Runwell Chase, Wickford SS11 7XX

Members present: Lorraine Cabel (Chair) Chair Sally Morris (CEO) Chief Executive Andy Brogan (AB) Executive Director Mental Health & Executive Nurse Randolph Charles (RC) Non-Executive Director Alison Davis (AD) Non-Executive Director Nigel Leonard (NL) Executive Director Corporate Governance Mark Madden (CFO) Executive Chief Finance Director Malcolm McCann (MMc) Executive Director Community Health Services & Partnerships Mary-Ann Munford (MAM) Non-Executive Director In attendance: Ro y Birch (RBi) Public Governor JoyDas (JD) Appointed Governor Max Forrest (MF) Associate Director Communications Colin Harris (CH) Public Governor Cathy Lilley (CL) Trust Secretary [Minute Taker] Kresh Ramanah (KR) Public Governor Kim Shaw (KS) Head of Infection Prevention & Control Julie Thornton (JT) Clinical Lead Tony Wright (TW) Public Governor The Chair welcomed members of the public, staff and Governors to the meeting and reminded members of the Trust’s vision: providing services in tune with you.

151/16 APOLOGIES FOR ABSENCE

Apologies for absence were received from: Steve Cotter (SCo) Non-Executive Director Steve Currell (SCu) Non-Executive Director Dr Milind Karale (MK) Executive Medical Director Janet Wood (JW) Vice-Chair/Non-Executive Director CL confirmed that the meeting was quorate.

152/16 DECLARATIONS OF INTEREST

RC advised that his daughter is a commissioner for immunisation at NHS England.

153/16 PRESENTATION: FLU IMMUNISATION

The Board received a presentation from Kim Shaw, Head of Infection Prevention & Control, and Julie Thornton, Clinical Lead on the staff flu immunisation programme.


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There is a recurring pressure on the NHS because of flu during every winter and the importance of immunisation for frontline clinical staff was highlighted as vaccination protects and reduces the risk of spreading flu to patients, service users, colleagues and family members particularly as 30-50% of infected staff are asymptomatic but infectious. The flu immunisation programme is a staff health and wellbeing CQUIN and the target is to achieve an uptake of flu vaccinations by frontline clinical staff of 45% in Essex mental health and community services and 75% in West Essex community services (the equivalent of 1,326 frontline staff members) with a value of £366,266. On behalf of the Board, the Chair thanked TS and RW for an interesting and informative presentation.

154/16 MINUTES OF THE MEETING HELD ON 29 JUNE 2016

Subject to the following amendment, the minutes were agreed to be a correct record:

Safer Staffing page 6 4th para to include: AD asked if this support was in addition to site managers’ usual duties and whether providing this support wold have an impact on their other duties. AB confirmed that this was part of the expectations of the role.

155/16 ACTION LOG AND MATTERS ARISING

The Board noted the action due in July was covered by an agenda item. Referring to minute 150/16 Governor/Public Query Tracker, NL confirmed that he had briefed Roy Birch on the risk rating system within the Trust’s Board Assurance Framework.

156/16 FINANCE & PERFORMANCE COMMITTEE ASSURANCE REPORT

On behalf of Janet Wood, Chair of the Committee, AD provided assurance that a full and robust debate and scrutiny had taken place at the meeting held on 21 July 2016 on all performance issues and that mitigating actions and monitoring processes had been requested where appropriate Performance The CEO stated that the Committee reviews and monitors the financial, operational and organisational performance of the Trust, and assurance was provided to the Non-Executive Directors (NEDs) that action was being taken to mitigate risks where necessary. The CEO advised that the Committee received an updated action plan for the HSE Notice of Contravention/Investigation and pointed out that no further communication had been received from the HSE. She confirmed that the Quality Committee is monitoring the issue.


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The Board noted there had been a significant improvement with the production of community mental health service data following the discontinuation of the information system. There had been an improving position on month 2 with data supporting all but three KPIs required to meet Trust reporting requirements now available. The Board noted that assurance had been provided that action is continuing to ensure that all contractual and regulatory data requirements are met but that SE commissioners have raised a contract performance notice as a result of the Trust’s failure to provide a small proportion of contractual data. In addition, the Trust has not been able to provide local authority partners with mental health partnership reports since April 2016. The CEO also drew the Board’s attention to the seven hotspots originally reported for June 2016 two of which related to a NHSI indicator. However, she was pleased to confirm that following validation, the % of CPA reviews within 12 months was 95% as opposed to the 92.1% reported at the Committee meeting. As the target was 95% this was no longer a hotspot. Other hotspots included:

SI investigations: there was one MH report submitted over the 72 hour target out of four incidents reported during June. Changes to internal sign-off processes have been introduced to prevent future delays that are anticipated to result in 100% target achievement

Out of area placements and bed occupancy: during June 7 patients were transferred OOA compared to 12 in May and 8 in April. There had continued to be pressure on adult acute bed availability and occupancy as reported previously. However, assurance was provided that all patients have now been repatriated or discharged

PbR cluster data: the Trust had breached three PbR targets in June; assurance was provided that action is being taken to return to previous levels of performance and compliance

% of outpatients not seen for 12 month: the data to support this new KPI indicated a deterioration in performance; however, there were concerns regarding current data quality. Assurance was provided that action continues to be taken to validate data and address the underlying issues preventing target achievement

Early intervention in psychosis access target: the CCG has not made additional funding available to meet the target from 1 April 2016. The Trust is working with the CCGs to agree the funding required

Prone restraints: a reduction in prone restraints has been identified as a quality account priority. For June there were 27 prone restraints which is above the monthly average for 2015/16 of 22.1 and if this trend continues, the forecast outturn is 324 compared to 266 last year. The Restrictive Practice Group has been asked to review its action plan and determine if any further actions can be taken.

The CEO advised there were three emerging risks: vacancy rate % unfilled posts; patient safety related incidents reporting rate; and agency cap breaches. Following a question by RC regarding the use of restrictive practices, AB provided assurance that the Trust applies the principles of ‘no force first’ and the individual’s care plan would include clear instructions on how situations should be deescalated. The majority of prone restraints are in relation to administering medication and he


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advised that the Trust is reviewing practices, recognising the importance of the patients’ dignity. The Quality Committee reviews and monitors all restraints in detail. MAM shared concerns regarding the continuing cost pressures on the Trust and the impact this could have on the quality of services provided, and asked how this was taken forward with commissioners. The CEO recognised the system-wide challenges and provided assurance that robust discussions are held with commissioners both on an ongoing basis and during the contracting round. Finance The Board was reminded that as agreed at the Board meeting in June, a revised plan has been submitted that results in the Trust having a £257k surplus for the year; this includes the Sustainability and Transformation Funds (STF) as part of the new control total. The CFO reported that the Trust’s financial position at month 3 June 2016 was a surplus of £2,635 which was £196k above current revised plan. He highlighted the hotspots and emerging risks which included Cost Improvement Programme (CIPs) where the target efficiency requirement is £12.7m of which £2.3m is being met from CQUIN leaving a delegated target of £10.436m of which £737k is yet to be identified; and Operational Services (Mental Health) where there was an underlying cost pressure. Now that the Quality Impact Assessments (QIAs) are being shared with Clinical Commissioning Groups (CCGs), it is anticipated that concerns may be raised by commissioners regarding the identified savings. The net capital programme is lower than plan by £356k mainly due to timing differences in capital expenditure on certain backlog maintenance and IT projects. Assurance was provided that the progress of these projects and corresponding capital expenditure as monitored. The CFO advised that the total expenditure as at monthy 3 on agency staff was £2,264k against a target of £3,000k resulting in a favourable variance of £736k. He highlighted, however, a potential risk associated with agency staff expenditure as a result of acquiring the Whipps Cross UCC contract that has required temporary staff to deliver the service as a result of the rapid contract mobilisation required. The Board was pleased to note that the Trust’s financial sustainability risk rating remained at 4 which demonstrated the strong financial health of the Trust as opposed to the planned risk rating of 3. The CFO commented that NHS Improvement was currently consulting on its proposed approach to overseeing and supporting NHS Trusts and Foundation Trust through a Single Oversight Framework. The framework will replace parts of Monitor’s Risk assessment Framework specifically the way in which NHSI will monitor, rate and intervene in respect of finance, quality and operational performance; in addition, new organisational health metrics will be monitored by NHSI ad there wold also be changes to the quality metrics. The CEO pointed out that the Finance & Performance Committee had considered the impact of the framework on how the Trust’s finances and performance are monitored, and agreed that the changes should be incorporated in to the Trust’s performance framework, if not already included. There is some


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concern regarding the approach to and thresholds for incorporating variation to control totals and this will be fed back to NHSI as part of the consultation process. The Board acknowledged the progress achieved against the Trust’s corporate objectives and that in order to streamline reporting, there would be changes to the monitoring arrangements for 2016/17. In addition the Board noted and supported the revisions to two corporate objectives relating to vacancy rate and sickness rate reduction. The Chair noted that the Essex Success Regime has a system-wide deficit of £190m that would, in her view, inevitably be distributed amongst commissioners and providers to reverse. She asked if the process for identifying allocations was known. The CFO replied stating that information about this had not yet been released; however, it was recognised that there was a requirement for the system to be in balance by 2021. The Board:

1 Noted the performance and finance report and confirmed acceptance of assurance provided

2 Supported the changes to the following two corporate objectives:

To achieve a vacancy rate of 10% to support safer staffing and manage talent effectively

The Trust aspires to achieving a sickness rate reduction of 4.3% but recognises for monitoring purposes the threshold for monitoring this hotspot is 4.7% in line with benchmarking data.

157/16 QUALITY REPORT

AB presented the report which focused on aspects of care relating to three key categories: safety, experience and improvement, and highlighted that there was a further small increase to 98.89% of patients did not experience any of the four harms covering pressure ulcers, falls, blood clots and urine infections for those patients who have a urinary catheter in place. He pointed out that of the 1,989 patients surveyed, 22 patients were identified as having one of the four harms with 18 patients within community services and four patients within mental health services. The Board was pleased the Trust consistently continue to achieve a high rate against the national ambition of 95%. AB highlighted that there had been no avoidable pressure ulcers or avoidable/ unavoidable falls to date; however, this was to be expected at the beginning of the year. AB provided an update following the conclusion of the evaluation of suicide prevention training packages for deployment across all mental health services. He anticipated that a training package that can be deployed in bite-size sessions would be adopted and that a train the trainer course which be supported. The Board received and discussed the report, and confirmed acceptance of assurance provided.


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158/16 SAFER STAFFING REPORT

AB introduced the Safer Staffing report for nursing, midwifery and care staff that contained details and a summary of planned and actual staffing on a shift-by-shift basis as part of the Hard Truths commitment. He highlighted that the majority of wards in LD, Secure Services and Community Health Services were above 95%. As reported in previous months, a recruitment campaign was ongoing and being monitored through a number of workstreams. AB advised that Trust continued to advertise vacancies via professional publications (including the Irish Nursing Times) and social media, and by attending recruitment fayres. AB reported on Clifton Lodge that remained a hotspot and advised that Basildon MHU had been reduced to a potential emerging risk along with Rawreth and Heath Close. He assured the Board that there were no concerns with regards to the safety and quality of care on the wards and that mitigating actions were in place. The Board noted that whilst recruitment was being undertaken, site managers on wards were being utilised to provide support alongside ward managers and matrons to ensure wards remained safe. AB pointed out that a comparison with some other Trusts’ dashboards had been undertaken and was pleased to advise that there were very few Trusts that could demonstrate the same level of fill rate. RC asked if the ‘good news’ in relation to the Trust’s dashboard is promoted externally. AB confirmed that the Trust’s positive fill rate position is widely shared with external stakeholders. LC also pointed out that the information is publicly available as is nationally reported. In response to a question by MAM, AB confirmed that it was possible to compare fill rates with other mental health Trusts. AD noted that the fill rate figures and sickness rates for Robin Pinto were particularly high and queried if there was a direct correlation with the high vacancy rate. AB advised there were various reasons for the rates; in particular the challenges with recruitment due to the isolation of the Unit. He confirmed that this was monitored and provided assurance that the ward is run efficiently and that appropriate support is provided. The Board:

1 Received and discussed the report 2 Approved the report.

159/16 NON-MEDICAL EDUCATION AND TRAINING UPDATE

The Board received an update report from AB on the main initiatives in non-medical education and training initiatives that have taken place within the Trust over the past six months including:

the multi-professional Deanery quality performance review

Physical health care training

Leadership programmes


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Care certificate implementation

Band 1-4 progression routes

Quality improvement performance framework

Health visitor call to action

Mandatory training The Board noted in particular that the Workforce Partnerships had not yet declared the budget for 2016/7 although a small interim payment had been made to Trusts of 10% of the 2015/16 allocation. However, this payment would not cover many study leave requests. In addition, the overspend on last year was covered by money from the student tariff (NMET) but the level of payment for this year has not yet been advised. The CEO advised that the issues were caused by incorrect allocation and that this had been escalated. The Board received and noted the report.

160/16 BOARD ASSURANCE FRAMEWORK (BAF)

NL presented the Board Assurance (BAF) report and reminded the Board that the BAF was a living document which was subject to changes, which provided a comprehensive method for the effective management of the potential risks that may prevent achievement of the key aims agreed by the Board. NL pointed out that there had been no changes to the risk ratings in the BAF since the last report to the Board in June and no new risks had been recommended for inclusion on the Corporate Risk Register (CRR). He advised that the outstanding risk assessment that had the potential to escalate to the CRR - no handover protocol for Drug and Alcohol patients on discharge from wards is in place affecting patient care – had been assessed. As the risk score was below the threshold for escalation to the CRR, it would be included and monitored on the mental health operational risk register. Referring to paragraph 1.4 of the report, AD asked for greater clarity regarding the issue raised in relation to whether the identified actions would robustly mitigate the risks going forward. NL provided assurance that there were appropriate mitigations in place but that some action plans were more detailed than others. The Board reviewed the BAF and:

1 Approved the BAF at July 2016 2 Did not identify any updates or changes required to the BAF 3 Noted the review and approval of BAF action plans 4 Noted the approval of the updated Risk Management and Assurance

Framework, particularly the revised monitoring and reporting arrangements associated with the BAF.


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161/16 SUB-COMMITTEES

(i) Quality Committee The Chair presented the report of the meeting held on 14 July 2016 and provided assurance that robust discussions were held on a number of issues some of which had already been covered by the Board as separate agenda items including the Quality and Safer Staffing reports. The Chair also extended an invitation to Directors who were not members of the Committee to attend a future meeting as an observer. In addition, minutes were available on request. The Chair highlighted:

a case study covering a patient within community health services from which a critical incident review was undertaken following complications with the patient’s health care. The investigation highlighted a number of lessons and the Committee was pleased to note that processes are now in place to prevent a repeat of this incident

the detailed report on reducing the incidence of omitted doses of medicines. The Committee was pleased to note that there has been a significant reduction since 2014 in both community and mental health services and that this is the fourth audit that has been completed over a five year period and that on each occasion there has been an improvement with 99% of doses being admitted correctly

the continued progress with the CQC action plan. The Committee agreed realignment of actions and timescale for the reorganisation of psychology provision particularly as it was felt that these are longer-term actions to improve the quality of service overall rather than to simply address the CQC concerns

the CQC action plan audit was taking place and the final action plan would be presented to the Board at its September meeting

CQC have completed two MHA inspections and the MHA Office has continued to undertake MHA audits; no escalation of issues had been required

the update on the Quality Strategy, the Quality Academy and Quality Champions

the comprehensive update on the transformations and innovations within Essex Children, Young People & Families services that have or are expected to result in quality improvements with two Quality Champions being appointed through the Quality Academy

the positive validation of the Committee from both members and non-members following the Committee’s effectiveness review

the Health, Safety & Security Annual Report 2015/16; the HR & Workforce Framework; and the People Experience Framework were approved

no risks had been identified for escalation to the Board. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action identified. (ii) Investment & Planning Committee The Chair advised that the Committee had met on 20 July 2016 and that a full written report would be provided at the September Board meeting. She provided assurance


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that robust discussions were held on a number of issues and that no risks were identified. The Board received and noted the verbal update. (iii) Charitable Funds Committee On behalf of RC, NL presented the report of the meeting held on 6 July 2016 and provided assurance that robust discussions were held on a number of issues including:

Approval from both SEPT and ELFT to work towards a transfer date of April 2017 for funds to transfer out of the SEPT charity

The SEPT general bidding process for 2016/17 would be rolled out over the coming weeks with bids to be returned by the end of September 2016

Outcome of the Committee efficacy review was considered. The Board noted that the Committee had agreed to continue to fund the annual contribution to the NHS Retirement Fellowship for the current financial year from Charitable Funds. The CEO advised that a review of staff usage of this organisation would be undertaken, the outcome would be taken into consideration when considering future funding. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action identified.

162/16 SEPT/NEP MERGER PROPOSALS UPDATE

The Board received a detailed update report from NL on the progress of the SEPT/NEP merger proposals. He pointed out that the report was similar to that presented in June as the NEP Board had not met in June and therefore received this paper at its meeting on 20 July. It was therefore being presented to the SEPT Board in the same format to ensure that each public meeting of both Boards receive the same information. NL reminded the Board of the preferred name of the new organisation – Essex Partnership University NHS Foundation Trust with the alternative names of Anglia Health Partnership University NHS FT or Eastern Health Partnership University NHS FT – and that staff and stakeholders of both organisations were being consulted. NL also provided an update on the progress with the due diligence process; the information gathering phase has been completed and work on analysing the data had commenced. A comprehensive report on the risks and opportunities of the merger across all work streams will be considered by the Board in its part 2 meeting. Further due diligence will be undertaken after both Boards have considered the initial report and outlined any further lines of enquiry to be pursued. NL provided a verbal update following the Merger Project Board meeting on 25 July. Discussions at the meeting included further consideration of the due diligence; agreement to increase frequency of meetings; further meetings with commissioners who are leading on the Essex mental health commissioning strategy as the importance of aligning with this was recognised; updates from workstreams.


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The Board noted the increased momentum in the communications and engagement plan with both the CEO and NL attended the NEP Board meeting on the 20th; in addition a regular blog would be published for staff and a monthly written briefing would be sent to Governors. MAM asked if commissioners were aligning the mental health strategy for Essex with the STP process. NL advised that there had been an extension for the STP plans that no longer aligns with the publication of the strategy; the Merger Project Board was keeping an oversight of this. The Board received and noted the progress report.

163/16 BOARD GOVERNANCE UPDATE

NL introduced an update on a range of governance and procedural issues. NL highlighted NHSI has published a consultation on its proposed approach to overseeing and supporting NHS FTs and Trusts that replaces Monitor’s Risk Assessment Framework and the TDA’s Accountability Framework. The new framework offers potential to align regulation with the CQC and to support a movement of sector-led improvement. EOSC will manage the response on behalf of the Trust. NL also pointed out that a report by NHS England Implementing the Five-Year Forward View for Mental Health – is intended as a blueprint for the changes that NHS staff, organisations and other parts of the system can make to improve mental health. The implementation plan gives a clear indication to the public and people who use services what they can expect from the NHS and when, as well as setting out by financial year what money is due to be made available. The Board was pleased to note that the Trust has been invited to present our work on Freedom to Speak Up at the NHSE’s conference in August. The Board received and noted the report.

164/16 Q1 NHS IMPROVEMENT COMPLIANCE REPORT

Referring to the performance and finance updates reported under agenda item 5(a), NL presented the Q4 NHSI compliance report relating to the Trust’s financial position, governance and performance for the Board’s review and approval. The Board was pleased to note that the predicted NHSI financial sustainability rating for Q1 is 4 and that there are no matters requiring exception reporting to NHSI that have not already been reported. NL, however, highlighted that the Trust has not achieved all of the NHSI KPIs as at the end of Q1 in relation to the achievement of Early Intervention Access (EIP) targets. He reminded the Board that as previously reported these targets could not be achieved unless adequate funding was provided.


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AD queried the impact of making the statement of ‘non-compliance’ and if the commissioners were aware of the Trust’s intentions. The CFO advised that it is not a requirement for commissioners to be aware of the declarations the Trust intends to submit and there has been no formal confirmation; however, the commissioners are aware of the position as are involved in the additional funding discussions. AD asked if NHSI would take further action. NL replied that nationally there is a significant number of provider organisations that are in a similar position with eight Trusts who have already not been able to meet the 50% target. The Board:

1 Received and noted the report 2 Approved the submission of the following statements to NHSI:

The Board anticipates that the Trust will continue to maintain a financial sustainability risk rating of at least 3 over the next twelve months

The Board anticipates that the Trust’s capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return

The Board confirms that there are no matters arising in the quarter requiring an exception report to NHSI (per table 3 of the RAF) which have not already been reported

The Board does NOT confirm the following statement in the light of the risk identified in respect of achieving EIP access targets without additional funding: The Board is satisfied that plans in place are sufficient to ensure ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forwards.

165/16 SOCIAL AND HEALTH CARE INTEGRATION

The Board received an update report from NL on the recent publication Stepping up to the place: the key to successful health and care integration that provides further guidance on how to successfully move towards integration across health and social care. NL advised that the Association of Directors of Adult Social Services, Local Government Association, NHS Clinical Commissioners and NHS Confederation (the Group) have stated in the report that the imperative to integrate, innovate and transform has never been greater/ The Group recognises, however, that integration is not an answer in itself or a panacea for the system’s financial challenges. Its primary purpose is to shift the focus of health and care services to improving public health, and meeting the holistic needs of individuals, of drawing together all services across a ‘place’ for greatest benefit, and of investing in services which maximise wellbeing throughout life. The Group is developing a self-assessment toolkit for local system leaders to provide a framework from which to assess and challenge their current capacity to lead system


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transformation and to identify what actions need to be taken. NL reported that there were three key areas identified for consideration by organisations going through an integration process, namely sustained effort and commitment by the leadership, financial investment and clear accountability through good governance systems and processes. AD queried if there was any reference to pooling budgets. NL advised that the report covers this by referring to individual systems to make their own decisions. The Board received and noted the report.

166/16 BOARD OF DIRECTORS SELF-ASSESSMENT 2016

The Chair presented the report detailing the outcome of the Board of Directors’ self-assessment review for 2016. She was pleased to advise that the responses indicated a very positive view of the effectiveness of the Board and there were no questions where respondents felt that the Board did not meet expectations. An action plan has been developed based on the feedback and the Board was pleased to note that there were three areas where no actions were identified and several where actions were already being taken forward. The Board was also pleased that there were already a number of examples of good practice and positive feedback provided in the self-assessment. A progress report on the action plan will be presented at the January 2017 Board meeting. The Board received and discussed the report. Action:

1 Update on progress with action plan to be presented at January 2017 Board meeting (LC).

167/16 ESTABLISHMENT REVIEW

AB presented an update report on the work undertaken as part of the nursing establishment review of all the inpatient areas in line with the expectations within the Safer Staffing guidance. AB pointed out that, as advised under agenda item 8(a) Board Governance update, the National Quality Board (NQB) has published further guidance Supporting NHS providers to deliver the right staff, with the right skills, in the right place, at the right time: safe sustainable and productive staffing. This resource has been designed to support Board with making local staffing decisions to achieve the best possible care for patients within the available staffing resource. It emphasises the need to apply the principles contained within previous guidance to both nursing and midwifery staff and the broader multi-professional team. The updated NQB expectations state that the Board should ensure there is an annual strategic staffing review with evidence that this is developed using a triangulated approach that takes account of all healthcare professional groups and is in line with financial plans.


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The Board was reminded that establishment reviews have been undertaken over the past three years on a six-monthly basis comprising data collection, use of evidence-based tools, and triangulation of results of the tools by use of professional judgement. The reviews have also included benchmarking ward areas across the Trust and scrutiny of Unify data submitted on a monthly basis to the national database to identify planned and actual staffing per shift. AB highlighted that there are no nationally recommended tools to be used within mental health, learning disability or community health services. However this is currently being reviewed nationally and the Trust is taking forward work on dependency tools within inpatient areas with Keith Hurst. The Board discussed the detailed report on the establishment review for Mental Health, Secure Services, Learning Disabilities and Community Health Services, and approved the recommendation that no changes were required. The Board also noted the recommendations that there would be further monitoring of specific wards including Clifton, Rawreth, Lagoon and Alpine, and that establishments had been updated for Hadleigh and Beech (St Margaret’s) following an increase in commissioning intentions. The Board:

1 Discussed and reviewed the report 2 Approved the recommendation that no changes were required as detailed

in the report.

168/16 USE OF CORPORATE SEAL

The Board noted that the seal had not been used since the last meeting.

169/16 CORRESPONDENCE TO THE BOARD SINCE THE LAST MEETING

The Board noted that there had not been any correspondence to the Board since the last meeting

170/16 NEW RISKS IDENTIFIED THAT REQUIRE ADDING TO THE TRUST RISK REGISTER OR REMOVED FROM THE REGISTER

The Board noted there were no new risks identified.

171/16 ANY OTHER BUSINESS

None.

172/16 DATE AND TIME OF NEXT MEETING

The next meeting will take place on place on Wednesday 28 September 2016 at 10:30 at the Hawthorn Centre, Rochford Hospital, Union Lane, Rochford SS4 1RB.


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173/16 RESOLUTION TO EXCLUDE MEMBERS OF THE PUBLIC & PRESS

In accordance with provision 14.20.2 of the Constitution and paragraph 18E of Schedule 7 of the NHS Act 2006, the Board of Directors resolves to exclude members of the public from Part 2 of this meeting having regard to commercial sensitivity and/or confidentiality and/or personal information and/or legal professional privilege in relation to the business to be discussed. The Board noted and agreed the resolution.

174/16 STAFF RECOGNITION SCHEME

The Chair and CEO were delighted to present certificates to:

Individual ‘In Tune’ Awards - Mark Holland, Community Matron, Halsey Treatment Centre Biggleswade - Carly Greening, Administration, Kempston Clinic - Sandra Malisauskeine, Facilities, Thurrock Hospital

Team ‘In Tune Awards’ - Facilities Team, Thurrock Hospital

o Ben Davies, Facilities Supervisor o Alicja Kazmiercaz, Facilities Assistant o Danial Wellend, Porter o Steve Wood, Porter

- Poplar Ward, Rochford Hospital o Dean Glackin-Fuller o Kelly Mann, Clinical Psychologist o Louise Summers, Clinical Unit Manager o Helaina Troy, Staff Nurse o Joshua Westbury, Consultant – Child & Adolescent

- Thurrock Catering, Thurrock Hospital o Christine Wooldridge

- The Care Home Practitioner Team, West Essex o Sheila Holland, Manager o Lea Dodd, Care Home Practitioner o Julie Malone, Care Home Practitioner o Abi Tilbury, Care Home Practitioner

175/16 MEMBERS OF THE PUBLIC/STAFF/GOVERNORS QUESTIONS

Questions from member of the Public, Staff and Governors are detailed in Appendix 1. The meeting closed at 12:45.


Signed ………………………………………………. Date …………………...............


Appendix 1: Governors/Public Query Tracker (Item 175/16)

Governor /Member of Public

Query Assurance provided by the Trust Actions

RB Commented on the potential impact of the Essex Success Regime on the Trust and services

CEO confirmed that the ESR would be looking at sustainability of services as well as a key focus on resolving the financial challenges across the areas covered by the regime.

-

RB Referring to the shortfall on CPD budgets, asked if this would have an impact on revalidation

CEO confirmed that CPD is part of revalidation. However, the Trust was working with the Workforce Partnerships to address the incorrect allocation of budgets.

-

KR Asked what consideration is being given to holding back posts for staff who could be at risk as a result of the merger

AB replied that the usual HR procedures would be applied for staff who were at risk due to organisation change. There could be some vacancies but one of the challenges would be the geographical placements. However, the Trust had been involved in previous mergers/acquisitions and would use previous experience to manage organisational change effectively.

-

RB Queried the impact of the removal of bursaries for student nurses particularly on the number of future applications

CEO and AB commented that it would be difficult to predict the impact recognising that the demographics of mental health student nurses was different to acute;

-

Agenda Item 4 Board of Directors Part 1 Meeting

28 September 2016

Board of Directors Meeting Part 1 28 September 2016 Page 1 of 1

SEPT Board of Directors Meeting: Action Log (following Part 1 meeting held on 27 July 2016)

Lead Initials Lead Initials Lead Initials

Andy Brogan AB Alison Davis AD Sally Morris SM

Lorraine Cabel LC Milind Karale MK Mary-Ann Munford MAM

Randolph Charles RC Nigel Leonard NL Janet Wood JW

Steve Cotter SCt Malcolm McCann MMc

Steve Currell SCl Mark Madden MM Cathy Lilley CL

Minutes

Ref

Action Owner Dead-line

Outcome Status

Comp/Open

RAG rating

June 135/16

Safer Staffing Report: establish reasons for the decrease in sickness absence rates during the month in Meadowview

AB Aug 16 Open

June 142/16

Board Governance Update: Board Committee effectiveness review update to be presented at Sept meeting

NL Sept 16 Included on Sept BoD agenda Open

June 013/16

Children, Young People & Families Strategy 2016-19: progress update to be presented at Nov meeting

MMc/ TS

Nov 16 Open

July

166/16

Board of Directors Self-Assessment 2016: Update on progress with action plan to be presented at Jan Board

NL Jan 17 Open

June 142/16

Board Governance Update: Social and Health Care Integration Report to be presented at July meeting

NL July 16 Included on July Board meeting agenda Comp

Requires immediate attention /overdue for action

New action or required next meeting

Action Completed

Future Actions

Page 1 of 3

Agenda Item No: 5a

SUMMARY REPORT BOARD OF DIRECTORS MEETING PART 1

28 September 2016

Report title: Assurance Report from the Finance & Performance Committee

Lead: Janet Wood Non Executive Director

Report Author(s): Faye Swanson Director of Compliance & Assurance

Report discussed previously at: Finance & Performance Committee – 22.09.2016

Level of Assurance:

Level 1

Level 2

Level 3

Purpose of the Report

This report is provided by the Chair of the Finance and Performance Committee to provide assurance to the Board of Directors that the performance (operational and financial) of the Trust as at Month 5 – August 2016 was subject to appropriate and robust scrutiny. For noting, as there was no Board of Directors meeting in August 2016, Board members received the minutes from the FPC meeting dated 25 August 2016 to provide assurance on Month 4 – July 2016 performance (operational and Financial).

Approval

Discussion

Information

Recommendations / Action Required

Based on the information provided the Board of Directors is asked to:

Confirm acceptance of the assurance provided

Request any further action / assurance

Summary of Key Issues

The committee considered:

Quality and Performance as at Month 5 – August 2016

Financial performance as at Month 5 – August 2016

Executive Operational Sub Committee Part One Minutes relating to meetings that took place in August 2016

Policy approvals

The new Single Oversight Framework issued by NHI Improvement

An assurance report from the Workforce Transformation Group The committee approved:

Mobile Phone Policy

Policy for Policies

Extension of policies due to expire between September 2016 and March 2017 until June 2017

Relationship to Trust Strategic Priorities

SP 1: Quality Services

SP 2: Quality Leadership & Workforce

SP 3: Sustainability of Service Provision

SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness

Page 2 of 3

Relationship to the Board Assurance Framework

Are any existing risks in the Board Assurance Framework affected?

Yes

If yes, insert relevant risk

Learning from Serious Incidents – BAF#13060607 Compliance with CQC standards – BAF#14033001 Vacancy Fill Rates – BAF#15042101 30% Slippage CIP – BAF#15042103 Delivery of the transformation programme – BAF#15042105

Do you recommend a new entry to the Board Assurance Framework is made as a result of this report?

No

Corporate Impact Assessment OR Board Statements: Assurance(s) against:

Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan & Objectives

Data Quality Issues Involvement of Service Users/ Healthwatch N/A

Communication and Consultation with stakeholders required N/A

Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £

X

Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity

Equality Impact Assessment (EIA) Completed?

No If yes, EIA Score N/A

Acronyms / Terms used in the report

FPC Finance & Performance Committee

HSCIC Health and Social Care Information Centre

NICE National Institute for Health and Care Excellence

EPR Electronic Patient Records

HSE Health & Safety Executive

HSSC Health, Safety and Security Committee

CEO Chief Executive Officer

NEDs Non Executive Directors

NHS National Health Service

CCGs Clinical Commissioning Groups

RCA Route Cause Analysis

MH Mental Health

EOSC Executive Operational Sub Committee

OOA Out of Area

KPI Key Performance Indicators

PICU Psychiatric Intensive Care Unit

ECR Electronic Patient Records

NHSI National Services for Health Improvement (formerly Monitor)

CPA Care Pathway Assessment

PbR Payment by Results

CQUIN Commissioning for Quality and Innovation

WTE Whole Time Equivalent

CFO Chief Finance Officer

CHS Community Health Services

CPR Castle Point and Rochford

EIP Early Intervention in Psychosis Programme

FRT First Response Team

ALOS Average Length of Stay

Page 3 of 3

MH OP Mental Health Older People

IAPT Improving Access to Psychological Therapies

YTD Year to Date

CIP Cost Improvement Programme

STF Sustainability and Transformation Funding

Supporting Documents &/or Further Reading

None

Lead

Janet Wood, Non Executive Director

Assurance Report From Finance and Performance Committee

1

Agenda Item 5a Board of Directors Meeting

28 September 2016

SEPT

ASSURANCE REPORT FROM THE FINANCE AND PERFORMANCE COMMITTEE (Part 1)

PURPOSE OF REPORT

This report is provided by the Chair of the Finance and Performance Committee to provide assurance to Board members that the performance (operational and financial) and governance arrangements of the Trust as at Month 5, August 2016 were subject to appropriate and robust scrutiny.

ASSURANCE REPORT

The committee met on 22 September 2016 and considered the performance and governance arrangements of the Trust as at Month 5 – August 2016. The Finance and Performance Committee (FPC) is constituted as a standing committee of the Board of Directors. The Board of Directors has delegated responsibility to this committee for the oversight and monitoring of the Trust’s financial, operational and organisational performance in accordance with the relevant legislation, national guidance, Monitor’s Code of Governance and current best practice. The committee is required to ensure that risks associated with the performance and governance arrangements of the Trust are brought to the attention of the Board of Directors and/ or to provide assurance that these are being managed appropriately by the Executive Directors. The committee will be responsible for ensuring the Executive Directors of the Trust are held to account for the reported performance and any actions to address issues/ risks that may be identified by its members.

1.0 Actions arising from previous meetings

1.1 Action Log

An action log is in place and this was reviewed. There were no actions due for completion in August 2016.

2.0 Quality and Performance

The CEO presented the Quality and Performance report for Month 5 - August 2016. The performance of the Trust was discussed and assurance was sought by the Non-Executive Director members from the CEO and Executive Directors that action was being taken to mitigate risks where necessary. NEDs also took the opportunity to understand the context for reported performance and the systems and processes in place to support service delivery and implementation of action. A summary of discussions and key actions agreed (as appropriate) is set out below. It was noted that three new indicators had been incorporated into the Quality & Performance report:

Falls

Safety Thermometer

Safer Staffing ( measures )


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The committee was advised that (as previously reported) the Trust continues to experience some issues with producing community mental health service data as a result of discontinuation of the CarePlus information system and with producing inpatient mental health service data as a result of the switch off of IPM. The position reported was slightly better than reported in August but issues are not fully resolved and progress is slowing. The committee was reminded that despite most data being provided to support the MH KPI contractual requirements the SE CCGs have raised two contract performance notices. A remedial action plan has been agreed and weekly SitReps commenced to the CCG on 19 August 2016. The Trust has advised that it aims to fully meet contractual requirements for September in October 2016. Failure to achieve this could result in contract penalties. There is a risk that the Trust will not meet its reporting requirements in full but every effort is being made to mitigate this risk. Assurance was provided that the EOSC has discussed the impact of the ongoing issues on patient care and operational management of services affected. No significant risks were identified.

2.1 Serious Incidents

Mental Health The committee was advised that during August 2016 there were 8 Serious Incidents reported in Mental Health Services:

5 Unexpected Deaths

1 Falls/ Fractures

1 Serious Self Harm

1 AWOL (Secure Services) Year to date there have been 27 serious incidents which is similar to the number experienced in the year April to August 2015 (26). So far this year there have been 14 unexpected deaths, giving a forecast for unexpected deaths of 33 which if the current trend continues will result in more unexpected deaths compared to 2015/16 (29). It was noted that 3 of the unexpected deaths reported in August related to patients in contact with the “Therapy For You” service. Assurance was sought that trends associated with this service provision were reviewed and included in thematic review outcomes presented to the Quality Committee. A discussion took place in respect of action the Trust has taken in response to the findings of the review of deaths at the Southern Health NHS Trust. It was confirmed that a Mortality Review Group has been established (reporting to the Quality Committee), a review and gap analysis of the findings undertaken and a workplan developed to strengthen the mortality review systems in place. Community Health Services August has seen a slight reduction in the number of grade 3 / 4 pressure ulcers from 31 in July to 27. In the ytd there have been 185 grade 3 and 4 pressure ulcers reported. There were no avoidable pressure ulcers reported in August (with just 1 reported in the year to date). Currently there are 27 RCA’s in progress. The forecast outturn for 16/17 if trends continue suggests that there will be less grade 3 and 4 pressure ulcers (444) reported this year compared to 15/16 (453). Analysis shows that South Essex CHS has a significant reduction year to date with a current forecast of 199. The 2015/16 outturn was 278. West Essex and Bedfordshire CHS are showing a slight increase. No other serious incidents were reported within community services (1 ytd).


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2.2 Hotspots

The CEO advised the committee that 8 hotspots were identified by the EOSC for bringing to the attention of the FPC as a result of reviewing performance relating to August 2016 against agreed targets, one of which relates to an NHSI indicator.

2.2.1 Indicator: New Early Intervention in Psychosis Access Target (previous hot spot)

During August 67% (10 out of 15) of new EIS referrals received were allocated to a care coordinator and started treatment within 14 days, compared to the NHSI target of 50%. As in previous reporting periods since April 2016, it was noted that this performance excludes over 35’s and treatment is not NICE compliant. From October (as a result of introduction of the new NHSI Single Oversight Framework) the Trust will be required to report progress with the access target based on meeting the full compliance requirement. Failure to meet the target in two consecutive months will result in NHSI intervention. The Trust has not been funded to deliver the new access target. Considerable work has been undertaken with local CCGs in an effort to agree additional funding to meet the new target requirements. The CEO advised that as the Trust could be exposed to potential risk as a result of failing to deliver the target it will need to consider potential mitigation if the CCGs do not provide any additional funding. It was agreed that an option appraisal should be developed as soon as possible.

2.2.2 Indicator: AWOL (Detained - return after midnight) and AWOL (Detained - return same day) – previous hot spot

An increase in AWOLs has been reported month on month and this trend has continued in August. 18 abscond incidents were reported during August 2016. All AWOLS reported in August resulted in low or no harm. 1 AWOL met CQC reporting criteria in August: a patient failed to return from Section 17 leave from Alpine Ward, Brockfield House. Assurance was provided that the Associate Director of Inpatient Services is currently conducting a full review of all incidents reported. A preliminary report had been completed identifying the trends and factors identified so far and remedial action is being taken forward as a result. The final report will be presented to the Quality Committee.

2.2.3 Indicator: Restraints (previous hot spot)

The CEO advise that the Trust is currently exceeding the (internal) benchmark number of restraints (based on the number of incidents reported in previous years), however it was noted that the national benchmarking rate is 3.66 restraints per 10 beds (National Benchmarking Club Nov – Jan 2016) and the Trust remains below this rate at 3.43 per 10 beds. Number of Restraints The Trust reported 163 restraints in August (667 ytd). This provides a forecast of 1600 if trends continue which is significantly above the target of 1206 (14/15 outturn). Prone Restraints A reduction in prone restraints has been identified as a quality (account) priority. In August there were 31 prone restraints which is an increase of 11 from last month. Year to date there have been 132 prone restraints and the 2016/17 forecast if trends continue will be 317 prone restraints. This represents a significant increase on the number last year (266).


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Assurance was provided that the Sign Up To Safety Restrictive Practice Workstream is being re-invigorated having undertaken a great deal of action but not necessarily delivering the reduction that was anticipated.

2.2.4 Indicator: Average Length of Stay of Discharges and Current Inpatients MH OP (previous hot spot)

The committee was advised that the average LOS on discharge (exc con care) remains above the benchmark of 76 days (121 days August, 118 days ytd). The average LOS of current patients increased in August from 140 days in July to 185 days.

By applying the % beddays lost to DTOCs (Functional 17.2%, Organic Assessment 20.1% ) it can be calculated that the average LOS of current inpatients without DTOCs would be 151 days. DTOCs are therefore a contributory factor in long LOS, rather than the defining factor.

2.2.5 Indicator: % Bed Occupancy (previous hot spot)

The committee was advised that in August bed occupancy continues to be a hot spot with high occupancy in acute wards, PICU, LD and Intermediate care which has potential impact on the quality of care provided. There continues to be low occupancy in older people organic assessment, older people dementia and continuing care which is impacting on contracted activity targets.

2.2.6 Indicator: PBR Cluster Data (previous hot spot)

The CEO advised that in August the Trust continued to breach 3 clustering targets as follows:

Indicator Target August July June

% users assigned to a cluster 95% 77% 78% 80%

% initial clusters adhering to the ‘red rules’

70% 65% 57% 63%

% within Cluster Review Periods 90% 57% 61% 65%

The committee noted that performance this month has continued to deteriorate and this was identified as a potential risk as contracts for 17/18 are likely to be based on patient clustering as well as outcomes.. Internal management monitoring information has not been available for community services following the system change and assurance was provided that capacity has been identified from 1 October to support intensive data validation aimed at increasing cluster compliance.

2.2.7 Indicator : Sickness Absence (mental health and specialised services) (previous emerging risk)

The committee noted that overall the Trustwide sickness rate for August is 4.4%. This is just above the stretch target agreed as a Trust corporate objective of 4.3%. However mental health services have an absence rate of 5.9% (5.6% ytd) and specialised services 6.9% (6.8% ytd). Both services have been above the agreed (and benchmark) target of 4.8% all year. Assurance was provided that appropriate management information is routinely available to identify sickness patterns and trends of individual staff and that this is being used to manage absence.

2.2.8 CQC Compliance Intelligence/ Quality dashboard performance

The CEO advised that the EOSC has identified Hadleigh Ward as a potential hotspot for further investigation and discussion as a result of considering on-going intelligence gathering, incident and performance trends and feedback from quality and compliance visits undertaken by SE CCGs and the internal compliance team. A data pack is to be prepared as a basis for the discussion and further


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action agreed as necessary. Assurance was provided that the matron has been temporarily based on the ward to lead the necessary management action required to address concerns raised.

2.3 Update on Previous Hot Spots

The committee noted improvement associated with hotspots reported in August (July activity):

Indicator: % CPA Reviews within 12 months Target achieved

Indicator: SI Investigations: No reports submitted outside targets (MH only)

Downgraded - The CCG issued a contract performance notice for this target. There were no breaches for August 2016. The RAP has been achieved. Therefore, this has been downgraded from a hotspot.

Indicator: How Did We Do? Surveys This indicator has been downgraded as a hot spot as the food rating score for August 2016 is 8.1 the highest score year to date.

Indicator: Vacancy Rate % unfilled posts Downgraded to emerging risk

Indicator: % Staff Supervision Downgraded to emerging risk

2.4 Emerging Risks

2.4.1 Indicator: Patient Safety Related Incidents: Reporting Rates (previous Emerging Risk)

For August 2016 there has been a continued reduction in incident reporting rates bringing the trust below the NRLS reporting benchmark of 38.6 MHS incidents per 1000 bed days and 146 CHS incidents per 1000 bed days. Incident reporting rates are monitored via CQC intelligence reporting and the Transparency Index.

Target Aug

Mental Health

38.6 17.2 South Essex MH: 19.7 incidents per 1000 bed days (175 incidents) (down from 21.2 reported for July)

Specialist Services: 11.7 (47 incidents) ( down from 21.2 reported for July )

CHS 146 65.2 August rates have seen some improvements, they are listed below:

WECHS : 28.6 incidents per 1000 bed days (57 incidents )

SEECHS 118.6 ( 79 incidents ) West Essex Commissioners have requested an investigation into the lower number of incidents and higher levels of severity. This has been completed and some under reporting has been identified.

The Executive Operational Committee agreed to downgrade this risk (accepted by finance and performance committee) until the Mobius link with DATIX, which is currently in its testing environment, is released.

2.4.2 Indicator: DNA Rate Community Health Services

This is rated amber due to August performance in Children’s services showing an increase in DNA’s:

Target Aug YTD

Trustwide 5.6% (Child 14/15 OT )

7.6% 6.2%

BCHS 8.2% 6.4%

SEECHS 7.0% 6.0%

WECHS 7.0% 6.2%


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A question has been raised by commissioners seeking assurance that the Trust takes into account school holiday periods when booking clinics.

2.4.3 Indicator : National Staff FFT scores

The Staff Friends and Family test results for Q1 16/17 have been released. Only 8 responses were received from SEPT employees, compared to an average number of 614 responses across all organisations. Only two organisations provided fewer responses than SEPT. So far in Q2 the Trust has provided 162 responses. The Executive Director of Corporate Governance was requested to discuss increasing communications to staff with the Head of Communications.

2.4.4 Indicator: Vacancy Rate % unfilled posts (previous hot spot)

The trust rate has decreased to 10.9% ( 455 WTE vacancies ) from 11.2% ( 468 WTE vacancies ) last month. The number of staff in post has increased by 11 WTE and the number of funded posts has dropped by 2 WTE. The vacancy rate for registered nurses has increased from 13.6%( 198 WTE vacancies ) last month to 14.0% ( 201 WTE vacancies ) at the end of August:

20.8 WTE BCHS

24.9 WTE SECHS

47.1 WTE WECHS

83.9 WTE South Essex Mental Health

21.1 WTE Specialist Services The Director of Mental Health and Deputy Director of Finance advised that in October, 12 hour shifts are to be introduced. It is anticipated that following restructuring of establishments to reflect this change, there will be a reduction of circa 40 vacancies in the south Essex MH service. YTD there have been 273 starters and 193 leavers. There were 52 new starters during this period and 49 leavers. A breakdown of the reasons for leaving the trust was provided to the EOSC. For the third month in succession, retirement is the main cause for leaving.

2.4.5 Indicator: Staff Training

The committee was advised that a contract performance notice regarding compliance with safeguarding training has been issued by SE Essex commissioners. Concerns have also been noted by West Essex commissioners. It was noted that CCG concern partly relates to contractual targets being higher than the Trust target (e.g 95% SEMH and CHS and 100% BCHS), but also that the Trust is not achieving (in all cases) the target that it has set internally.

Training Course

CHS MHS Specialist SEPT

Safeguarding Adults Level 3

84% 70% 66% 81%

Safeguarding Children Level 3

89% 87% 83% 89%

Safeguarding Children Levels 4/5/6

100% - - 100%

Safeguarding Level 1

94% 93% 97% 94%

Safeguarding Level 2

93% 93% 97% 93%


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In addition, whilst overall training compliance is above the Trust target of 90% (91.1% in August) it was identified that nine divisions are less than 90% compliant with training requirements.

2.4.6 Indicator: % Staff Supervision

The Trust did not achieve the 90% target for supervision in August, achieving 87.6% (Exc Bank) There are efforts in place to increase the supervision compliance of Bank staff as previously reported and August has seen a slight increase to 11.1% (this has risen from the previous two months (June 5.6%, July 7.2%)).

2.4.7 Indicator: % Staff Appraised

The Trust is below the 90% target for appraisal, achieving 88.7% in August which is a slight reduction from July 2016 (89.4%). Trends across divisions in compliance with workforce targets were noted.

2.5 Contract Exceptions Summary

The committee was assured by Executive Directors that other performance issues, as identified in the contract monitoring reports presented to the EOSC were being handled as part of day to day management of the service and that escalation was not required to the FPC.

2.6 Quality and Safety Information

Performance in respect of all the remaining key quality and safety measures was presented to the committee. No further action was requested in respect of reported performance.

3.0 Finance

The committee received a report on financial performance presented by the Chief Finance Officer. He confirmed that the content of the report had previously been considered by the EOSC which had provided an opportunity for more of the Trust’s senior leaders to be involved in the discussion of the organisations performance. The financial performance of the Trust was discussed and assurance was sought by the NED members from the CEO and Executive Directors that action was being taken to mitigate risks where necessary. NEDs also took the opportunity to understand the context for reported performance.

3.1 Overview

The CFO presented a summary of performance for Month 5 - August 2016 to the committee as follows:

Annual Plan 2016/17

Forecast Outturn

YTD Position

Plan Actual

Operating (Surplus)/Deficit £000

(£257k) (£257k) (£2,989k) (£3,259k)

Capital Expenditure £5,011k £5,011k £2,109k £611k

Cash Balance £41,068k £41,068k £43,204k £50,590k

FSRR Rating 3 3 3 4

The Trust’s Continuing Operating position at month 5 is a surplus of £3,259k, which is £270k above the current revised plan.


8

The CFO advised the committee that the Trust has been identified by NHSI as one of the top performing Trusts financially as a result of being ahead of its financial plan. The CFO advised that he has made it clear to NHSI that this position is not likely to be sustained as there are a number of reasons why the actual position is better than forecast at this time and the Trust intends that the final position will be in line with the original plan agreed.

3.2. Hotspots and Emerging Risks

The committee was advised of and discussed seven items: 1. Cost Improvement Plan (CIPs) – target efficiency requirement is £12.7m, of which £2.3m is

being met from CQUIN. This leaves a delegated target of £10.436m to divisions and departments, of which £0.5m is yet to be identified and £1.6m of the identified CIPs remain to be actioned.

Assurance was sought by NEDS in respect of the certainty of CQUIN income. The CFO confirmed that based on the progress made with CQUIN improvement schemes and feedback to date he was satisfied that the Trust would be able to allocate the funding identified as planned. Concern was raised by NEDS that £1.6m of CIPs remain to be actioned. Assurance was provided by the CFO that this does not mean CIPs have not been identified. Some CIPs are not planned to be implemented until later in the year. Until they are commenced, funding cannot be removed from delegated budgets. The committee noted that it had received assurance that plans to address the shortfall in identified CIPs in community health services should have been confirmed by now but noted that a shortfall in the CHS CIP plan remained. The CEO confirmed that the CHS division is currently underspending and this mitigates the risk non recurrently associated with the CIP shortfall. . The Executive Director of CHS has been asked to develop recurrent plans for delivering the CIP.

2. Adverse variance on year to date income of £150k due to two factors, namely:

Contract delays with the theatre space for Podiatry / Podiatric surgery in BCHS has

impacted on activity levels, resulting in under-performance on income c£90k.

Underachievement in relation to non–contractual activity (NCA) income. 3. Operational Services (Mental Health) - adverse variance of £0.535m. The financial position

for the service continues to deteriorate for a number of reasons:

The additional funding for IAPT ended in month 4. A Business case has been put to commissioners for continued funding and is awaiting approval.

The impact of black alert pressures in Basildon & Southend hospitals on Mountnessing Court and Clifton & Rawreth wards.

Year-to-date deficit on CIP plan - £438k

Out of Area placement (ECR) beds not funded - £322k, additional beds on the recently opened Thorpe Ward is expected to alleviate Out of Area placement cost pressures in the future. The current adverse variance has to be borne by the division but the deficit is not expected to increase. The impact reported in month 4 was £297k based on estimates but actual invoice in month 5 increased the impact to £322k.

Increased staffing cover, due to change in operational policy, and consequent pay pressure in the Assessment Unit relating to a facility for people who are detained by the Police under Section 136 of the MH Act.


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Underachievement on NCA income in the Assessment Unit, and

High agency and bank staff usage in RAID.

The above is partly offset by vacancies in the Community and Psychology teams. 4. The payroll staff list return is very low at 58% against a target of 90%. Payroll staff lists are

sent out to budget holders on a monthly basis for checking, and must be reviewed, signed and returned to management accounts. The checking and return of staff lists is an important control that provides assurance that we are paying staff correctly.

NEDs explored whether the issues identified were the responsibility of the payroll provider. It was confirmed that this was not the case.

5. Emerging risks, yet to be quantified –anecdotal information has identified potential financial performance risks concerning the Essex Sexual Health contract in relation to redundancy costs and increased activity and costs associated with SH24 (the online testing app). It was confirmed that a detailed report will be presented to EOC, by the operational lead Director, in the coming weeks.

6. The non-clinical SLA with Princess Alexandra Hospital is budgeted at £585k but the

proposed SLA (not yet agreed) is stated at £834k, resulting in a potential adverse impact of £249k in a full year. £104k of this has been incorporated into month 5 position. In addition, the SLA with the Bedford Hospital Trust was £775k but the proposed SLA (not yet agreed) is £872k, resulting in a potential adverse impact of £97k in a full year. £41k of this adverse impact has been included in month 5 position. The total potential adverse impact of these revised SLAs is £346k. The negotiation process is still on-going, the Clinical Director and the Contracts Team are working to establish the revised SLA charges.

7. Other potential risks noted and scoped includes the impact of the new contract for Junior

Doctors, weather and climate change impact on service delivery (particularly during winter months). The CFO advised that an assessment of the cost impact of the new junior doctor contract is currently being undertaken. In addition NHS Property Services occupancy has been agreed but the financial figures are yet to be agreed. The impact of these risks will be quantified and factored into future financial reports.

3.3 Financial Sustainability Risk Rating

The CFO advised that as at the end of month 5, the Trust has achieved a financial sustainability risk rating of 4, versus the planned risk rating of 3. This result demonstrates the Trust is in strong financial health.

3.4 Capital Plan

The CFO advised that at the end of month 5, the capital plan had assumed a total spend of £2,109k against which only £611k has been incurred. Of the total underspend of £1,498k, there is £321k relating to schemes which are in progress but for which expenditure is being incurred slightly later than planned. This includes the Basildon MHU electrical works and the roll out of electronic safer staffing.

The remaining £1,177k relates to allocations against which schemes have not yet been presented to or approved by the CPPG. This includes the roll-out of e-prescribing, lighting upgrades at Thurrock & Rochford Hospitals and Rochford CCTV.


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3.5 Working Capital

The CFO advised that the cash is more than plan this month mainly due to the net impact of receivables and payables being more than anticipated. This is mainly as a result of settlement of some SLA debtor invoices received earlier than anticipated and delays in the payment of some creditor invoices currently under dispute, such as NHS Property Services invoices, Princess Alexandra Hospital Drugs invoices and North & East London CSU SLA ICT Services invoices. The Finance Department, with the respective budget holders, is working with the creditor organisations to resolve these disputes and process the relevant invoices accordingly. The Trust holds provisional debtor balances of £12,266k at the end of month 5. As at the end of month 5, the Trust is recording provisional total creditors in the Statement of Financial Position of £33,006k.

4.0 Sub-Committee Reports

4.1 Executive Operational Sub-Committee

The committee considered three sets of Part 1 minutes of the Executive Operational Sub Committee:

16 August 2016

23 August 2016

30 August 2016 The quality of service provided by NHS Property Services was discussed and identified as a matter of local and national concern.

5.0 Approval of Policies

The committee approved the following policies:

Mobile Phone Policy

Policy for the development, review, monitoring and control of approved documents (policy for policies)

The committee approved extension of policies due to expire between September 2016 and March 2017 until June 2017 to facilitate a focus on harmonisation of critical policies in advance of the proposed merger with NEP.

6.0 Review of Workplan & Schedule of Business

The Chair presented the outcome of a mid year review of the committees workplan. It was confirmed that the committee had received the majority of planned reports required to meet its ToR in line with the workplan timescales. Changes were agreed to the workplan to reflect the needs of the committee. The schedule of business for the committee was reviewed. It was agreed that routine assurance reports from the Workforce Transformation Group should be added, but the committee did not require 6 monthly detailed reports. It was agreed that exception reports would be requested if specific issues were identified.


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7.0 New NHSI Single Oversight Framework

The CFO and Director of Compliance and Assurance advised the committee on the content of and risks associated with the new regulatory regime to be introduced by NHSI with effect from October 2016. It was confirmed that a detailed baseline assessment of the Trust’s performance against the new thresholds and implications of this was being undertaken and this will be presented to the committee next month. This has been recommended as a potential risk to be included in the BAF in the meantime.

8.0 Workforce Assurance Report

The committee received a report from the Chair of the Workforce Transformation Group that provided assurance on the activities being overseen by the committee and issues associated with these to be brought to the attention of the FPC. No risks were identified for escalation to the committee.

9.0 Future Quality Reporting Proposal

The committee discussed and welcomed changes to future quality reporting systems that had been agreed by the Quality Committee. The committee welcomed elimination of duplication and the introduction of a new format for reporting performance to the Board of Directors.

10.0 Summary

The committee members were assured by the information provided and the actions that are being taken. No further hotspots, risks, actions or matters for escalation were identified.

RECOMMENDATION & ACTION REQUIRED

The Board of Directors is recommended to:

Confirm acceptance of the assurance provided

Request any further action / assurance Report prepared by: Faye Swanson. Director of Compliance & Assurance On behalf of: Janet Wood Non Executive Director / Chair of the Finance and Performance Committee

Page 1 of 2

Agenda Item No: 5b

SUMMARY REPORT BOARD OF DIRECTORS MEETING PART 1

28 September 2016

Report title: Quality Report – Proposal for Future Lead: Andy Brogan

Executive Director of Mental Health and Executive Nurse

Report Author(s): Faye Swanson Director of Compliance & Assurance Sarah Browne Deputy Director of Nursing

Report discussed previously at: Quality Committee – 15.09.2016

Level of Assurance:

Level 1

Level 2

Level 3


To present an overview of proposals for the future reporting of quality related metrics as recommended by the Quality Committee.

Approval

Discussion

Information


The Board of Directors is asked to:

1. Discuss and approve the proposed future reporting arrangements recommended by the Quality Committee set out in this report.

2. Provide any feedback on/ideas for future reporting arrangements to be incorporated into action to be taken.


The Board (and sub-committtee) efficacy review identified duplication in respect of quality related data presented to the Quality Committee, Finance & Performance Committee and the Board of Directors. The review also identified that the current Quality Report content to the Quality Committee and Board of Directors does not fully meet the needs of the intended audience; temporary reduction of the frequency of Quality Committee meetings (to bi-monthly) requires a review of quality reporting requirements in order to ensure good governance arrangements are in place going forward and existing arrangements are potentially causing reworking of similar data that is impacting on capacity and potentially accuracy/consistency of data being presented /used for assurance and decision making. A review of the existing quality (data) reporting processes was therefore undertaken and the proposals for the future presented, discussed and agreed in principle by the Quality Committee when it met on 15th September 2016. The presentation slides attached set out the existing arrangements in place; the issues associated with these and on slide 6 a summary of the proposed future quality data reporting arrangements to the Quality Committee, Finance and Performance Committee and the Board of Directors as

Page 2 of 2

recommended by the Quality Committee. On slide 8 a timetable for implementation is set out which highlights action required to transition from the existing arrangements to those recommended (by end of November 2016). The proposal, welcomed by the Quality Committee included development of an alternative, more visual way of presenting key data to the Board of Directors (example provided is that currently in place at Salford Royal NHSFT). This was also discussed and agreed in principle by the Finance & Performance Committee when it met on 22 September 2016. Discussion on the format and content of the proposed Board of Directors scorecard is now underway and this will be extended to include key financial information and significant risks.








No


N/A


No



Data Quality Issues X

Involvement of Service Users/ Healthwatch N/A



X

Governance Implications

Impact on Patient Safety /Quality

Impact on Equality & Diversity X


No If yes, EIA Score N/A


None


None

Lead

Andy Brogan Executive Director of Mental Health and Executive Nurse

Faye Swanson

Director of Compliance

and Assurance

Future Summary

Quality Reporting

Arrangements

September 2016

Sarah Browne

Deputy Director of

Nursing

1

Purpose Board Efficacy Review identified potential duplication / overlap

in respect of quality related data presented to the Quality

Committee, Finance & Performance Committee and the Board

of Directors

Existing Quality Report presented to Quality Committee and

Board of Directors doesn’t fully meet perceived needs

The reduction in frequency of Quality Committee requires

refreshed view of what the committee needs in terms of data

on a bi-monthly basis

Consider and agree future summary quality reporting

arrangements to the Quality Committee, Finance &

Performance Committee and Board of Directors

2

Current State: Quality Committee

Quality Report • Monthly

• Previous months data

• Contains (those in red already in

quarterly performance report)

• Safety thermometer

• Sign up to Safety (narrative update)

• Early detection of deteriorating patients

(narrative update)

• Pressure ulcers grade 1-4

• Falls

• SIs and SI investigations

• Restraints

• Omitted doses of medication

• FFT

• Learning lessons

• Separate safer staffing report

Issues • Duplication of (similar but

not the same) content in

F&P report

• Produced too early?

Inconsistent with position

reported in F&P report

• Introduces re-working of

same data

• Lack of clarity of purpose of

report

• Bi-monthly meetings in

future will mean that same

report presented to Board

has not had previous

discussion

3

Current State: Finance &Performance Cttee

Quality & Perf Report • Monthly

• Previous months data

• Contains 40 plus indicators

that monitor quality (directly or

indirectly)

• Reports progress against

quality account priorities

(numbers and narrative) which

are aligned to SUTS priorities

• Previous month, trend YTD

and comparisons with

previous year and benchmarks

where available

Issues

• Content seen as

performance against targets

not monitoring of quality

• Duplication of (similar but

not the same) content in

Quality report

• Inconsistent with position

reported in Quality Report

• Potential for overlap or

gaps in ensuring follow up

of quality related issues

• Safer staffing reported to

ET and Board but not in

Q&P report

4

Current State: Board of Directors

• Monthly (except Aug/

Dec)

• Quality Report

presented

• Assurance Report from

Quality Committee

• Assurance Report from

F&P Committee

• Separate Safer staffing

report

Issues

• Lack of clarity of purpose /and

of content of Quality Report

• Assurance Reports from Q and

F&P Committees are very

different

• Board do not receive a

summary of quality &

performance

• F&P assurance report

summarises performance in a

narrative style which isn’t easy

• Separate quarterly Public

Quality Dashboard on website

5

Proposal: Summary Quality Monitoring Fin & Performance • Monthly

• Data relating to

previous month (plus)

• Focus on

achievement of

“ambition” (target)

• Incorporate items not

currently duplicated

• Falls

• Safety

thermometer

• PUs grade 1-2

• Incorporate safer

staffing

• Clear identification /

allocation of

responsibility for

follow up

Quality Committee • Bi-monthly

• Receive new Quality

Report (extract of Q&P

report containing proxy

measures of quality)

• Committee to determine

content

• Focus on trends over

time not just the previous

month

• Narrative (detailed)

reports on Quality

Priorities / SUTS

provided at agreed

frequency as before

• Safer staffing trends

incorporated into QR

• Learning lessons:

presented as existing to

Learning Oversight

Group

Board Of Directors • Monthly

• New summary BOD

scorecard

• Quality only? Could

incorporate Finance

and BAF

• Safer staffing

incorporated into

scorecard

• Publish this to replace

public dashboard

• Assurance reports

from QC and FPC

can be harmonised

and FPC report re-

focussed

6

7

Proposal: Timetable September

• QC to receive (and

agree) proposal for

the future

• Begin process of

merging existing QR

into Q&P Report (at

least consistent!) for

ET and FPC

• Start process of

agreeing the

“ambitions”/ proxy

measures of quality

that QC and BOD

receive

• Do not produce QR

for QC & BOD

• Existing assurance

reports from QC and

FPC to BOD as

before

October

• No QC meeting

• Q&P Report to ET

and FPC contains

agreed additional

quality measures

• Finalise future QC

report content

• Attempt new BOD

scorecard

• Reduce / reformat

FPC assurance report

to BOD (dependant

on scorecard

availability)

• Do not publish public

dashboard (q2)

November

• Q&P Report to ET

and FPC contains

agreed additional

quality measures

• QC to receive new

Quality Report

(extract of Q&P report

containing proxy

measures of quality)

• Data will be as at

September 2016 for

trend discussion

• BOD scorecard in

place

• Assurance reports

from QC and FPC

harmonised

8

1

Agenda Item No: 5c

SUMMARY REPORT

BOARD OF DIRECTORS PART I

28th September 2016

Report title: Safer Staffing Report

Executive Lead: Andy Brogan, Executive Director Mental Health, Executive Nurse

Report Author(s): Sarah Browne, Deputy Director of Nursing

Report discussed previously at:

Quality Committee and Executive Team

Level of Assurance:

Level 1

2

3


To provide the Board of Directors with the monthly safer staffing report.

Approval

Discussion

Information


1. Note the contents of this report 2. Identify any further work required to be taken forward.


The key issues:

Monthly shift by shift information required as part of the delivery of the Hard Truths commitments

Active recruitment is ongoing

Twice daily teleconference call in continue covering South Essex Mental Health Services

Hot spots and emerging risks for fill rates are outlined but no safety concerns have been identified








No


Do you recommend a new entry to the

No

2

Board Assurance Framework is made as a result of this report?



Data Quality Issues

Involvement of Service Users/ Healthwatch

Communication and Consultation with stakeholders required

Service Impact/Health Improvement Gains

Financial Implications Capital £ Revenue £ Non Recurrent £



Impact on Equality & Diversity


No


SI Serious Incident

NHS National Health Service

Beds Bedfordshire

SEECHS South East Essex Community Health Services

WECHS West Essex Community Health Services

CMHT Community Mental Health Team

MH Mental Health

COD Cause of Death

RCA Root Cause Analysis


NA

Executive Lead

Andy Brogan Executive Director Mental Health, Executive Nurse

Monthly Shift By Shift Staffing Report

3

Agenda Item 5c

Board of Directors 28th September 2016

SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

MONTHLY SHIFT BY SHIFT STAFFING REPORT

1.0 PURPOSE OF REPORT

The purpose of this report is to provide the Board of Directors with the monthly shift by shift information required to be presented as part of the delivery of the Hard Truths commitments associated with publishing staffing data regarding nursing, midwifery and care staff.

2.0 OVERVIEW

A monthly report to Board containing details and summary of planned and actual staffing on a shift-by-shift basis is part of the Hard Truths commitments. As discussed in previous reports, the information returned to the central collection captures the identified staffing required for each shift in relation to the number of patients on the ward and the dependency of the patients, allowing flexing of the staffing required. This information continues to be reviewed on a weekly basis via teleconference call with lead nurses and senior managers to identify any hotspots from the previous week, any mitigations and actions taken to ensure safe staffing as well as discuss any concerns for the following week. Twice daily teleconference calls continue for South Essex Mental Health Inpatient areas led by senior managers (Director or Associate Director of Mental Health) with matrons of the wards to review each ward. The purpose of this call is to identify staffing on the wards, reviewing use of agency and bank staff as well as the dependency of the ward to enable identification of any areas of concern and to move staff if required to support wards. The call also looks forward to shifts to ensure appropriate night cover and weekend cover with a clear process for escalation if required. A SitRep is circulated to the Chief Executive and senior staff identified above. The following section details the dashboard covering each ward reported via Unify alongside agreed quality indicators. This information is reported through the safer staffing database on the intranet covering all ward areas across the trust to enable review by managers as live reporting as well as detail further information covering, bank and agency usage as well as the level of observations required. Further information is also available within the intranet section to record if bank staff are permanent staff and whether bank and agency staff are known to the wards. The report considers the fill rate on the revised staffing levels following the board reviews. As discussed over the past months Essex Mental Health Services have been showing a lower than expected fill rate within some of the wards although this has improved from earlier in the year. The report also details the percentage of bank and agency staff known to the ward areas, detailing that the staff are generally known to the units. Committee members can be reassured that through the twice daily teleconference calls and monitoring of incidents there have been no safety concerns identified on these wards, and the site manager and matrons have supported wards when required to cover, whilst active recruitment is underway


4

The Trust continues to advertise vacancies actively including Nursing Times, Irish Nursing Times, NHS Jobs, along with social media sites such as Facebook and Twitter. We plan to continue to attend recruitment fairs as well as continue to take forward the active recruitment campaign. A number of further workstreams are also in place to review staffing including reducing agency staffing as well as monitoring and review of vacancies. The individual report and dashboard now identifies hot spots and emerging risks as discussed at October’s Quality Committee with assurance given regarding safety throughout the report. The following two pages contain the dashboards for both August and July to allow comparison of data. As has been previously reported, some of the data relating to % Bank and Agency staff used and known are still showing as greater than 100%. Further work is being undertaken with the safer staffing database to reduce this issue going forward.


5

3.0 DASHBOARD

Day Night

WARD NAME Location

NO OF

BEDS

OPEN

Occupancy

Rate

(excluding

leave days)

STAFF

(WTE

Contract-

ed)

Vacancy

Rate

FILL

RATE

Register

ed

FILL

RATE

Unreg

FILL

RATE

Register

ed

FILL

RATE

Unreg

%

Appraised

in previous

12 months

% Bank

Use

% Bank

Staff Used

Permanent

or Known

% Agency

Use

% Agency

Used

Known

FALLS

Moderate &

Severe

PRESSUR

E

ULCERS

HCAIsSickness

Rate

Long Term

Sickness

Rate

TARGET: >90% >90% >90% >90%

Basildon MHAU Basildon 20 94.8% 20.8 24.2% 90.2% 96.9% 98.4% 97.0% 79% 43.10% 97.3% 10.30% 78.0% 0 0 10.1% 6.8%

Beech (Rochford) Rochford 24 101.9% 22.3 12.4% 94.5% 97.3% 88.7% 106.0% 92% 48.50% 95.3% 1.50% 25.5% 0 0 10.5% 4.4%

Cedar Ward Essex Rochford 24 80.5% 19.9 17.2% 94.5% 95.8% 96.8% 97.5% 91% 34.50% 92.4% 7.00% 81.0% 0 0 10.0% 0.0%

Clifton Lodge Westcliff 35 81.4% 32.4 8.8% 89.7% 101.5% 82.3% 109.2% 93% 39.30% 100.1% 2.10% 86.4% 0 0 2.2% 0.0%

Gloucester Basildon 25 94.2% 18.2 20.0% 91.5% 93.9% 95.7% 100.0% 100% 32.80% 91.0% 1.90% 62.8% 0 0 2.0% 0.0%

Grangewater Basildon 28 94.0% 16.9 30.3% 98.4% 94.7% 96.9% 100.0% 77% 38.00% 94.3% 14.30% 90.5% 0 0 13.7% 8.0%

Hadleigh Unit Basildon 10 90.3% 20.2 26.4% 98.4% 98.7% 83.9% 99.4% 93% 54.70% 98.5% 7.20% 86.0% 0 0 24.9% 18.9%

Maple Rochford 24 84.1% 21.2 19.3% 91.1% 97.6% 74.2% 119.3% 93% 46.60% 101.2% 5.30% 71.6% 0 0 15.6% 8.5%

Mayfield Rochford 24 26.7% 21.5 12.7% 96.6% 102.0% 100.0% 100.0% 90% 26.50% 100.5% 0.60% 8.3% 0 0 4.5% 0.0%

Meadowview Thurrock 24 79.2% 21.6 7.0% 98.4% 99.1% 91.9% 103.1% 57% 30.90% 94.1% 0.80% 36.8% 0 0 15.2% 9.4%

Mountnessing Ct Mountnessing 22 108.8% 24.5 11.9% 94.8% 99.6% 93.5% 105.6% 95% 37.70% 96.2% 0.60% 56.3% 0 0 8.8% 4.2%

Rawreth Court Rayleigh 35 71.2% 31.8 8.0% 90.0% 97.2% 96.8% 99.4% 86% 33.90% 105.6% 2.90% 70.7% 0 0 9.2% 6.9%

Thorpe Basildon 20 96.1% 2.0 88.4% 99.2% 99.5% 96.7% 101.2% 90% 58.00% 96.4% 39.50% 92.0% 0.0%

Poplar Adolescent Unit Rochford 12 86.3% 25.7 10.1% 94.2% 96.8% 100.0% 99.4% 92% 41.90% 95.5% 2.20% 63.1% 0 0 0.6% 0.0%

Alpine Brockfield 13 95.5% 16.6 20.4% 99.2% 101.4% 100.0% 100.0% 71% 37.80% 99.9% 0.20% 0.0% 0 0 0.2% 0.0%

Aurora Brockfield 12 85.8% 12.9 6.9% 101.6% 98.4% 100.0% 100.0% 82% 29.60% 98.4% 0.1% 0.0% 0 0 10.2% 7.9%

Causeway Brockfield 16 88.9% 20.7 14.3% 90.4% 99.5% 100.0% 98.9% 93% 31.70% 99.0% 2.10% 91.5% 0 0 6.7% 5.0%

Dune Brockfield 15 100.0% 17.7 5.5% 92.7% 101.4% 100.0% 100.0% 94% 23.80% 98.8% 0.20% 0.0% 0 0 2.5% 0.0%

Forest Brockfield 15 83.9% 16.7 -0.5% 96.9% 102.6% 100.0% 100.0% 100% 24.90% 99.5% 0.1% 0.0% 0 0 10.8% 10.4%

Fuji Brockfield 12 90.6% 24.4 20.4% 93.0% 102.4% 80.6% 103.7% 78% 34.50% 100.4% 0.70% 77.8% 0 0 10.3% 5.2%

Lagoon Brockfield 15 92.9% 21.0 5.4% 96.0% 103.8% 96.7% 100.0% 81% 54.10% 101.3% 0.1% 100.0% 0 0 8.4% 5.1%

Robin Pinto Unit Luton 14 95.6% 14.4 28.9% 98.4% 100.5% 100.0% 100.0% 70% 29.10% 101.2% 28.60% 97.4% 0 0 11.2% 9.6%

Woodlea Clinic Bedford 8 100.0% 18.6 12.4% 109.8% 94.4% 103.2% 98.4% 94% 30.30% 106.0% 10.20% 95.0% 0 0 24.1% 16.5%

Heath Close Billericay 11 73.6% 24.8 14.2% 98.6% 91.4% 100.0% 100.0% 95% 44.4% 82.9% 1.7% 28.8% 0 0 8.9% 7.1%

Cumberlege IC Rayleigh 22 98% 23.6 18.3% 99.2% 95.3% 100.0% 96.5% 86% 24.90% 18.00% 3.70% 11.5% 0 0 7.9% 4.1%

Avocet Saffron Walden 19 87% 27.3 -0.9% 98.4% 95.8% 96.8% 100.0% 93% 0.50% 27.30% 8.20% 10.5% 0 0 7.6% 6.4%

Beech Epping 12 91% 18.4 40.6% 99.5% 100.0% 98.4% 100.0% 90% 0.10% 100.00% 5.10% 32.4% 0 0 5.9% 3.9%

Plane Epping 22 90% 27.6 10.8% 100.0% 100.0% 100.0% 100.0% 97% 0.20% 40.00% 3.40% 22.4% 0 0 1.6% 0.0%

Poplar Epping 22 94% 29.0 6.3% 100.0% 100.0% 100.0% 100.0% 92% 0.40% 11.10% 7.00% 32.4% 0 0 4.2% 0.0%

The Archer Unit Bedford 20 70% 36.4 -8.3% 100.0% 98.0% 96.8% 103.2% 91% 3.30% 35.80% 4.80% 20.5% 0 0 1.5% 0.0%

575 649.1 13.9% 96.1% 98.3% 94.5% 101.4% 88.0% 31.9% 95.4% 5.0% 70.8% 7.9% 4.6%TRUST INPATIENT TOTAL

August

ESSEX MENTAL HEALTH INPATIENT SERVICES

CAMHS SERVICES

FORENSIC SERVICES

LEARNING DISABILITY SERVICES

COMMUNITY HEALTH SERVICES


6

Day Night

WARD NAME Location

NO OF

BEDS

OPEN

Occupancy

Rate

(excluding

leave days)

STAFF (WTE

Contract-ed)

Vacancy

Rate

FILL

RATE

Register

ed

FILL

RATE

Unreg

FILL

RATE

Regist

ered

FILL

RATE

Unreg

% Appraised

in previous 12

months

% Bank

Use

% Bank Staff

Used

Permanent or

Known

% Agency

Use

% Agency

Used Known

FALLS

Moderate &

Severe

PRESS

URE

ULCER

S

HCAIsSickness

Rate

Long Term

Sickness

Rate

TARGET: >90% >90% >90% >90%

Basildon MHAU Basildon 20 20.8 24.2% 90.2% 98.4% 95.2% 100.9% 83% 44.60% 100.0% 13.60% 81.0% 0 0 17.0% 9.6%

Beech (Rochford) Rochford 24 22.3 12.4% 100.7% 96.0% 95.2% 98.8% 100% 50.90% 96.6% 0.90% 16.7% 0 0 5.9% 4.5%

Cedar Ward Essex Rochford 24 19.9 17.2% 92.8% 100.5% 98.4% 94.8% 93% 30.30% 89.4% 6.60% 74.2% 0 0 2.3% 0.3%

Clifton Lodge Westcliff 35 32.4 8.8% 91.9% 99.8% 83.9% 103.3% 100% 42.80% 99.2% 3.20% 89.7% 0 0 1.0% 0.0%

Gloucester Basildon 25 18.2 20.0% 98.0% 98.5% 100.0% 100.9% 100% 39.10% 85.1% 1.60% 62.5% 0 0 1.2% 0.0%

Grangewater Basildon 28 16.9 30.3% 97.6% 100.0% 100.0% 100.0% 93% 26.50% 92.2% 19.20% 97.6% 0 0 11.2% 10.6%

Hadleigh Unit Basildon 15 20.2 26.4% 96.0% 99.5% 91.4% 99.4% 93% 54.00% 100.0% 6.50% 108.5% 0 0 18.5% 14.4%

Maple Rochford 24 21.2 19.3% 94.2% 96.6% 93.6% 101.6% 93% 44.90% 100.0% 5.60% 69.4% 0 0 7.6% 5.0%

Mayfield Rochford 24 21.5 12.7% 95.7% 101.5% 100.0% 100.0% 100% 18.50% 100.0% 2.30% 0.0% 0 0 3.2% 1.8%

Meadowview Thurrock 24 21.6 7.0% 99.2% 99.1% 100.0% 100.0% 70% 21.50% 92.0% 2.40% 27.3% 0 0 15.3% 5.8%

Mountnessing Ct Mountnessing 22 24.5 11.9% 93.9% 98.9% 96.8% 98.9% 90% 36.00% 97.9% 0.40% 150.0% 0 0 6.6% 4.1%

Rawreth Court Rayleigh 35 31.8 8.0% 92.7% 97.5% 96.8% 97.3% 86% 25.20% 100.0% 5.30% 75.6% 0 0 10.1% 4.9%

Thorpe Basildon 20 2.0 88.4% 98.3% 98.9% 100.0% 100.0% 100% 60.20% 100.0% 40.40% 92.3% 0 0 0.0% 0.0%

Poplar Adolescent Unit Rochford 12 25.7 10.1% 95.8% 95.7% 100.0% 97.8% 88% 36.10% 100.0% 2.10% 0.0% 0 0 0.8% 0.0%

Alpine Brockfield 13 16.6 20.4% 99.2% 101.5% 96.8% 100.0% 93% 36.60% 99.3% 0.00% - 0 0 2.7% 0.0%

Aurora Brockfield 12 12.9 6.9% 101.5% 100.0% 100.0% 100.0% 100% 29.70% 86.8% 0.0% - 0 0 11.5% 8.7%

Causeway Brockfield 16 20.7 14.3% 86.2% 101.0% 100.0% 98.9% 93% 33.40% 98.6% 0.70% 66.7% 0 0 13.0% 9.5%

Dune Brockfield 15 17.7 5.5% 95.2% 99.2% 100.0% 100.0% 100% 22.90% 98.7% 0.00% - 0 0 0.4% 0.0%

Forest Brockfield 15 16.7 -0.5% 92.7% 112.4% 100.0% 100.0% 94% 26.80% 100.0% 0.0% - 0 0 13.1% 12.3%

Fuji Brockfield 12 24.4 20.4% 96.0% 102.0% 90.3% 99.2% 78% 32.80% 98.4% 0.70% 0.0% 0 0 6.2% 3.9%

Lagoon Brockfield 15 21.0 5.4% 98.4% 104.2% 98.4% 100.8% 93% 51.90% 100.0% 0.0% - 0 0 5.4% 5.3%

Robin Pinto Unit Luton 16 14.4 28.9% 100.0% 100.0% 100.0% 100.0% 70% 36.20% 100.0% 23.90% 93.8% 0 0 23.6% 14.2%

Woodlea Clinic Bedford 8 18.6 12.4% 105.0% 100.0% 100.0% 100.0% 94% 31.10% 100.0% 15.30% 95.1% 0 0 10.9% 8.9%

Heath Close Billericay 8 24.8 1.0% 100.0% 92.4% 100.0% 98.6% 95% 38.4% 74.0% 2.8% 35.3% 0 0 1.6% 1.6%

Cumberlege IC Rayleigh 22 23.6 18.3% 96.0% 100.0% 100.0% 104.6% 95% 25.90% 21.00% 1.70% 25.0% 0 0 2.2% 0.0%

Avocet Saffron Walden 19 27.3 -0.9% 101.6% 97.4% 101.7% 96.9% 93% 0.90% 0.00% 10.70% 12.8% 0 0 8.9% 8.5%

Beech Epping 10 18.4 40.6% 99.5% 99.5% 100.0% 100.0% 90% 0.00% - 2.60% 36.8% 0 0 10.1% 5.2%

Plane Epping 22 27.6 10.8% 100.0% 100.0% 100.0% 100.0% 97% 0.00% - 1.00% 60.0% 0 0 3.4% 1.6%

Poplar Epping 22 29.0 6.3% 100.0% 99.6% 100.0% 100.0% 84% 0.00% - 3.00% 80.0% 0 0 6.0% 3.8%

The Archer Unit Bedford 20 36.4 -8.3% 100.0% 96.8% 98.4% 100.0% 100% 3.70% 44.40% 5.30% 19.2% 0 0 1.7% 0.0%

TRUST INPATIENT

TOTAL577 649.1 86.5% 99.0% 97.7% 99.8% 31.1% 96.5% 5.6% 76.7%

July

ESSEX MENTAL HEALTH INPATIENT SERVICES

CAMHS SERVICES

FORENSIC SERVICES

LEARNING DISABILITY SERVICES

COMMUNITY HEALTH SERVICES


7

4.0 HOTSPOTS

The dashboard above shows that the majority of wards in Learning Disability, Secure Services and Community Health Services are above 95%. As discussed in previous months, a recruitment campaign is continuous and being monitored through a number of workstreams. Since last Board two safer staffing submissions have been completed. In July, one ward was identified as a hot spot (Clifton Lodge) and one ward as a potential emerging risk (Causeway). One ward has remained as a hotspot during August:

Clifton Lodge (second registered which is covered by unregistered staff) Three further wards have been identified as a hotspot during August:-

Hadleigh

Maple

Fuji These were for registered staff on night shifts. None of these wards are stand alone and are on sites where site managers are also available to support the wards during the night as required. One ward has been identified as potential emerging risk during August:-

Beech (Rochford) During this time on the wards whilst recruitment is ongoing, site managers are being utilised to support wards alongside the ward managers and matrons to ensure the wards are safe as discussed through the monitoring at the twice daily teleconference calls and SitRep. This information is also being triangulated with the Quality Dashboard and CQC compliance information. Within all the other wards highlighted as hotspots, there have been no significant concerns in regards to the safety and quality of care on the ward when reviewing clinical incidents and safeguarding reports.

5.0 RECOMMENDATIONS

It is recommended that the Board of Directors:

1. Note the contents of this report 2. Identify any further work required to be taken forward.

6.0 ACTION REQUIRED


1. Approve report Report prepared by Sarah Browne Deputy Director of Nursing

On behalf of

Andy Brogan Executive Director of Mental Health and Executive Nurse

1

Agenda Item No: 6a

SUMMARY REPORT BOARD OF DIRECTORS MEETING PART ONE 28 September 2016

Report title: Board Assurance Framework 2016-17

Executive Lead: Nigel Leonard Executive Director of Corporate Governance

Report Author(s): Joanne Sims Head of Assurance

Report discussed previously at: Executive Operational Sub Committee – 20.09.2016

Level of Assurance: Different levels of assurance apply to each risk on the 2016-17 Board Assurance Framework (BAF). Internal Audit provided “full assurance” in respect of the Assurance Framework and Risk Management arrangements in March 2016.

Level 1

2

3


This report presents the Board of Directors with the Board Assurance Framework for 2016/17 (appendix 1) as at September 2016 for discussion, update and approval. Following the re-introduction of the impact rating process for Corporate Objectives 2016-17 a summary is provided at appendix 2 for approval.

Approval

Discussion

Information



1. To review and approve the Board Assurance Framework at September 2016 as detailed at appendix 1

2. Identify updates and changes required including further mitigating actions, controls

and enhanced monitoring arrangements as appropriate 3. To note the review and approval of BAF action plans by the EOSC on the 20

September 2016 4. To agree the removal of the following two risks:-

If learning from incidents is not embedded quality and patient safety may not be maintained or improved. The Francis Report and more recently the Southern Health report have re-emphasised the risk to patient safety if learning from SI's is not implemented.

If care is not clearly documented detailing person centred care in line with risk and needs assessments this may impact on the identification of individual clinical need and a high quality of outcome may not be achieved.

5. Reduce the risk rating to 4 x 3 =12 for the following 2 risks:-

If record keeping standards are not in line with Trust policy quality of care may be

2

compromised

Reduced level of contingency will not be able to mitigate risk of CIP shortfall.

6. Agree the escalation of the following new risk to the BAF:-

There is a potential risk that the introduction of the new NHS I Single Oversight Framework results in increased intervention by regulators as a result of the Trust failing to meet new thresholds for financial and quality performance required to achieve maximum autonomy under the new monitoring regime. (Impact 5 x likelihood 3 = 15)

7. Note the re-introduction of the impact rating process for corporate objectives and

agree ratings for 2016-17 as recommended by the Executive Operational Sub Committee.


As agreed (and set out in the revised Risk Management Framework) this report contains the full BAF which will only be presented quarterly going forward. A summary of risks will be provided in the intervening months.

Action plans to support 7 of the current risks detailed on the BAF 2016/17 were received by the EOSC on the 20 September 16 for review, challenge and approval.

The EOSC received the Corporate Risk Register on the 20 September 2016.

The EOSC escalated one new risk to the CRR:-

If the reasons for increase in AWOL incidents experienced in July and August is not fully understood and action taken, there may be harm caused to patients and the reputation of the Trust.

Risk scoring 4 (impact) x 3 (likelihood) = 12








Yes


All risks identified on the BAF


No

3



Data Quality Issues









No If yes, EIA Score



CRR Corporate risk register

BAF Board Assurance Framework

EOSC Executive Operational Subcommittee

CQC Care Quality Commission


Appendix 1 Board Assurance Framework 2016-17 as at the 21 September 2016 Appendix 2 Impact ratings for the 2016-17 Corporate Objectives

Executive Lead

Nigel Leonard Executive Director of Corporate Governance

1

Agenda item 6a Board of Directors

28 September 2016

SEPT

BOARD ASSURANCE FRAMEWORK REPORT 2016-17 AT SEPTEMBER 2016

PURPOSE OF THE REPORT

This report presents the Board of Directors with the Board Assurance Framework for 2016/17 (Appendix 1) as at 21 September 2016 for discussion, update and approval. Following the re-introduction of the impact rating process for Corporate Objectives 2016-17 (to strengthen the links between the BAF and those objectives with the highest impact if not achieved) a summary of proposed impact ratings is provided at appendix 2 for approval.

SEPTEMBER 2016 UPDATE

1. Board Assurance Framework 2016/17

1.1 The Board Assurance Framework (BAF) provides a comprehensive method for the

effective management of the potential risks that may prevent achievement of the key aims agreed by the Board of Directors.

1.2 The BAF 2016/17 was last reviewed and approved by the Board of Directors on the 27

July 2016 and the Executive Operational Sub Committee (EOSC) on the 21 September 2016.

1.3 The EOSC, Executive Directors and Service leads have reviewed the risks detailed in

the 2016/17 BAF as at the 21 September 2016 and updates are set out in Table 1 below:

Table 1 – BAF 2016/17 Overview at the 16 September 2016

No. Real Risk Exec

Lead Overview Update Risk scoring status

Aim 1 Safe Care

R1 If learning from incidents is not embedded quality and patient safety may not be maintained or improved. The Francis Report and more recently the Southern Health report have re-emphasised the risk to patient safety if learning from SI's are not implemented.

MMc, AB

Reviewed by the Deputy Director of Nursing and Executive Director of Mental Health and Executive Nurse (26/8/16). There has been a reduction in avoidable pressure ulcers and falls. Independent reviews of unexpected deaths has been undertaken together with recent NHS England review of SI reporting.

Current risk scoring 4 x 3 = 12 Recommendation is made to reduce the risk rating to 4 x 2 =8 and remove from the BAF. The risk will remain on the Clinical Governance and Quality Directorate risk register for continued monitoring.

R12 The findings and recommendations identified in the review of patient deaths in the care of southern health could identify gaps in the trusts processes for reviewing mortality which will require significant action.

AB Reviewed by the Deputy Director of Nursing and Executive Director of Mental Health and Executive Nurse (26/8/16).Supporting action plan continues to be implemented.

Current risk scoring 4 x 3 = 12 Risk scoring remains unchanged

2

No. Real Risk Exec Lead

Overview Update Risk scoring status

R2 If care is not clearly documented detailing person centred care in line with risk and needs assessments this may impact on the identification of individual clinical need and a high quality of outcome may not be achieved.

AB , MMc

Reviewed by the Deputy Director of Nursing and Executive Director of Mental Health and Executive Nurse (26/8/16). Personalised care planning does not appear as a major issue following reviews. Action to continuously improve care planning is on-going and links closely with record keeping. Actions will be transferred to the action plan associated with the following risk: “If record keeping standards are not in line with Trust policy quality of care may be compromised.”

Current risk scoring 4 x 3 =12 Recommendation is made to close this risk.

R3 If services fall short of the standards required to remain compliant with the Health and Social Care Act there is the potential for CQC enforcement action or in extreme cases closure of services.

NL Reviewed by the Director of Compliance and Assurance (16/9/16). BAF Action plan updated. The EOSC and Quality Committee have considered and agreed the position to be reported to the CQC at the end of September and the Board will consider the recommendation when it meets September 16. The position reported confirms broad satisfaction that action has been taken to address CQC recommendations and that in all but one area there is sufficient assurance that the action can be closed. Ongoing actions and compliance processes continue to be taken to maintain CQC compliance.

Current risk scoring 4 x 3 =12 Risk scoring remains unchanged Review risk scoring following meeting with the CQC 21.10.2016

R4 If record keeping standards are not in line with Trust policy quality of care may be compromised.

MMc, AB

Reviewed by the Deputy Director of Nursing and Executive Director of Mental Health and Executive Nurse (26/8/16).This risk will be further reviewed after the implementation of Mobius upgrades.

Current risk scoring 4 x 4 = 16 Recommendation is made to reduce the risk scoring to 4 x 3 = 12

Aim 5 Right Staff, Right Skills, Right Place

R5 If there is a high reliance on Bank and Agency staff as a result of vacancies and sickness this will impact on the quality and continuity of SEPT services

NL Reviewed by the Deputy Director of Human Resources (14/9/16) and Executive Director of Corporate Governance (16/9/16). Action plan continues to be implemented but there is a need to review the monitoring mechanism in place in order to focus action on the right issue.

Current risk scoring 4 x 4 =16 Risk scoring remains unchanged

3



Aim 7 Financially Sound

R6 If there is a high reliance on agency staffing as a result of vacancies and sickness this will result in the Trust breaching the agency cap set by Monitor.

NL Reviewed by the Deputy Director of Human Resources (14/9/16) and Executive Director of Corporate Governance (16/9/16). Agency SLA review has taken place and all contract arrangements for clinical workers (Except mental health medical) have been moved across to the new CPP Agency Framework where the rates are cheaper (with some exceptions where rates are cheaper on LPP framework Additional agencies added including Healthcare Solutions, Mayfair and Hallam. Agencies used for community medical workers have also been written to and requested to book through new framework agreement. Review of agency work being booked under the new framework is underway to ensure all allied health professional agency workers are being booked correctly under the new framework and price cap rates are applied. A review of all administration agency usage is to take place over the next two months with a view to reducing costs.

Current risk rating 4 x 3 = 12 The EOSC considered this risk and it was agreed that the rating remains unchanged at this stage and will be re-considered following the introduction of NHS I Single Oversight Framework as the threshold for intervention as a result of variation from planned agency expenditure is less sensitive than anticipated.

Aim 8 Clear Strategy for Securing Our Success

R7 As a result of a number of risks relating to regulatory approval and delivery of a comprehensive and compelling business case there is a risk that the merger will not be completed by April 2017, or at all, resulting in the benefits identified in the merger proposal (clinical and patient benefits, commissioner benefits and financial benefits) not being delivered.

NL Reviewed by the Executive Director of Corporate Governance (16/9/16). Business case on target to be completed by November 16. Merger approval process has now been clarified.

Current risk scoring 4 x 3 =12 Risk scoring remains unchanged this month however will require review next month to take into account potential new risk for merged organisation as a result of changes in commissioning intentions due September / October 2016.

4



Priority 4 – Innovation and transformation

R8 40% slippage on a £10.5 million CIP anticipated.

MM Reviewed by the Executive Chief Finance Officer (21.09.2016). Currently showing circa £10.6m of schemes actioned through the budget and £0.5m to be identified.

Current risk rating 5 x 3 = 15 Risk scoring remains unchanged

R9 Reduced level of contingency will not be able to mitigate risk of CIP shortfall.

MM Reviewed by the Executive Chief Finance Officer (21.09.2016).

Current risk rating 4 x 4 =16 Recommendation is made to reduce the rating to 4 x 3 = 12

R11 That the significant pressure to achieve a number of transformational programmes creates significant management and resource pressure that impacts on the delivery of the key objectives of the organisation 2016/17.

MM Reviewed by the Director of Contracting & Business Development (16/09/2016). Detailed project and/or mobilisation plans are in place for all live 2016/17 Transformation projects and regular project team meetings are in place to monitor progress, assign new actions and discuss issues, risks and mitigation.

Current risk rating 5 x 4 = 20 Risk scoring remains unchanged

The BAF is attached in full at appendix 1.

2. Corporate Risk Register (CRR)

The EOSC last received the CRR on the 20 September 2016 and one new risk was escalated to the CRR as follows;

If the reasons for the increase in AWOL incidents experienced in July and August is not fully understood and action taken there may be harm caused to patients and the reputation of the Trust. Risk scoring 4 (impact) x 3 (likelihood) = 12

A critical review is underway of all July and August AWOL incidents by the Associate Director of Adult Inpatient Services to identify potential trends and causes. Assurance that a preliminary report has been developed and action is being taken to address findings was provided to the FPC on 22 September 2016 and a full report will be presented to the Quality Committee.

3. Impact Rating the Corporate Objectives

As a result of feedback from the EOSC and Finance and Performance Committee the Risk Management and Assurance Framework was updated and the impact rating of corporate objectives re-introduced to provide clarity on those risks to be escalated to the BAF and CRR. Any Corporate objective that scores 10 or above in the impact rating assessment process results in the objective rating of HIGH (Orange) and objectives scoring over 20 are considered to be EXTREME (Red). These objectives will be entered on the Board Assurance Framework and associated high / extreme risks monitored by the Board of Directors.

5

Any objective scoring 9 or below in the impact rating assessment process results in an overall risk rating of MEDIUM (Yellow) and objectives scoring below 4 results in an overall impact rating of LOW (Green). These objectives will be quality assured and monitored by the EOSC using the Corporate Risk Register for those risks quantified as high or extreme. All other risks will be detailed within directorate risk registers. Work has been undertaken to impact rate the Corporate Objectives for 2016-2017. Meetings have taken place between the Head of Assurance, Executive Director leads and directors and a summary is provided at appendix 2. The EOSC reviewed the impact ratings for each corporate objective and makes recommendation for approval to the Board of Directors. Following final approval of the impact ratings by the Board of Directors work will be undertaken to (re)allocate all existing risks to the BAF or Corporate Risk Register appropriately.

4. Directorate Risk Registers

Work will be undertaken to review all directorate risk registers against the corporate aims and directorate objectives for 2016-17 together with moderate and low risks identified within the 16-17 Operational Plan.

5. Hotspots from the Performance & Quality Report

The Finance and Performance Committee considered the hotspots identified within the August 2016 Quality and Performance Report on the 25 September 2016. The committee identified potential risk associated with continued deterioration of clustering mental health patients. A risk assessment is to be undertaken and the risk allocated to the appropriate risk register. The Finance and Performance Committee also discussed in detail the introduction of the NHSI Single Oversight Framework and noted a number of significant changes to financial and performance monitoring and reporting. This includes changes from quarterly to monthly reporting and the potential for regulatory intervention if KPIs are not achieved for 2 consecutive months. Recommendation is made to escalate the following risk to the BAF:-

There is a potential risk that the introduction of the new NHS I Single Oversight Framework results in increased intervention by regulators as a result of the Trust failing to meet new thresholds for financial and quality performance required to achieve maximum autonomy under the new monitoring regime. 5 (impact) x 3 (likelihood) = 15

6. Recommendations


1. To review and approve the Board Assurance Framework at September 2016 as detailed at appendix 1

2. Identify updates and changes required including further mitigating actions, controls and

enhanced monitoring arrangements as appropriate

3. To note the review and approval of BAF action plans by the EOSC on the 20 September 2016

6

4. To agree the removal of the following two risks:-

If learning from incidents is not embedded quality and patient safety may not be maintained or improved. The Francis Report and more recently the Southern Health report have re-emphasised the risk to patient safety if learning from SI's are not implemented.

If care is not clearly documented detailing person centred care in line with risk and needs assessments this may impact on the identification of individual clinical need and a high quality of outcome may not be achieved.

5. Reduce the risk rating to 4 x 3 =12 for the following two risks:-

If record keeping standards are not in line with Trust policy quality of care may be compromised

Reduced level of contingency will not be able to mitigate risk of CIP shortfall.

6. Agree the escalation of the following new risk to the BAF:-

There is a potential risk that the introduction of the new NHS I Single Oversight Framework results in increased intervention by regulators as a result of the Trust failing to meet new thresholds for financial and quality performance required to achieve maximum autonomy under the new monitoring regime.

7. Note the re-introduction of the impact rating process for corporate objectives and agree

ratings for 2016-17 as recommended by the Executive Operational Sub Committee and set out in Appendix 2.

Prepared by: Joanne Sims Head of Assurance On behalf of: Nigel Leonard Executive Director of Corporate Governance

Appendix 1 - Agenda Item 6a - Board of Directors - 28 September 2016

Links to -

I L RR I L RR Q1 Q2 Q3 Q4 I L RR

Actions remain

open on the BAF

Action plan.

Gap in

Control

Assurance Gap in

Assurance

Date

reviewed

Direction of risk Post

Mitigation

target risk

scoring

Potential Risk Is the level of

risk

acceptable post

mitigation ?

Mitigating actions Target

Comp

Date

SEPT Board Assurance Framework 2016-17 At September 16

Assumption

Strategic Priority 1: Quality Services

The NHS is the only healthcare system in the world with a definition of quality enshrined in legislation. An organisation delivering high quality care will be offering care that is clinically effective, safe and delivering as positive experience as possible for patients. We believe that SEPT is

such an organisation; our main driver is to improve the health of the communities that we serve. We are realistic that less funding may mean that some of our high standards may have to be re-defined to be affordable but we are absolutely certain that we will not compromise safety as a

result.

Aim 1 : Safe care

1. To fully implement the action plan put in place as a result of the Southern Health Care learning. Including the definition of avoidable death, the establishment of an avoidable death group, development metrics to report on avoidable deaths and targeted action to reduce deaths.

Lead Director Corporate Governance Statement, CQC Quality and Safety

Standards, Annual Governance Statement . Operational Plan

Risk

Category

Lead Directorate

Objective/

High Level

Actions/

Source

ControlInitial

Risk

Rating

Current

Risk Score

↓ Adverse Incident

Reporting Policy and

Procedure in place

including SI and new

process for critical

incidents.

SI reporting and learning

reports presented to

relevant Groups and

Committees in accordance

with clinical governance

processes. Assurance

report presented to Board,

Quality Governance

Committee & Clinical

Governance.

Standardised reporting

template in place to

capture learnings from

RCA, this will be reviewed

on an ongoing basis.

Internal and External

Reviews including Essex

MHS Sis and external

review by the Centre for

Suicide Prevention

Clinical staff involved in

investigations and receive

RCA training.

SMT report in place

covering action plans and

sign off by SMT of

completion of plans,

trends and themes.

Database in place

capturing

recommendations from

each SI.

Quality Strategy, Quality

Academy and Sign up to

Safety.

Learning from SIs

currently on Intranet,

process for regular

communications sent

Patient

Safety

Reputation

Compliance

Andy

Brogan /

Malcolm

McCann

↔24 SI reporting and

learning reports

presented to

relevant Groups

and Committees

in line with

clinical

governance

processes.

Quality report

presented to

Board, Quality

Committee &

Clinical

Governance

Committee.

Review of

Suicides

(including

benchmarking

information

undertaken and

action plans

developed.

Evidence of

implementation

of SI learning

held in SI office

provided by

Ops.Following

the completion

of 3 independent

reviews no

common themes

have been

identified.

Analysis of SI’s

from April

onwards

undertaken by

the Medical

Director looking

at clinical care.

4Carried forward

from the BAF

15-16

REF-

BAF13060607

Learning from SI's will continue to

inform Patient Safety Work streams

and Quality Improvement Programme.

SI Team & Consultant Nurse to run

regular audits to ensure learning

embedded following completion of

action plan.

Trends & Themes reviewed by Risk

Team / Clinical Gov and included within

Datix and trends & Themes to be

reported through Clinical Governance

Committee. Review undertaken of

Southern Health Report , actions

identified to strengthen monitoring

arrangements. All SI actions now

captured and monitored on DATIX.

Annual review of serious incidents

The Trust will

ensure learning

from serious

incidents is

embedded and

facilitates

improvements in

quality and safety

4 Sep-16Jul-15 4 2 8 No gaps

currently

identified.

8

Executive Director Mental Health, Executive Nurse Impact of not achieving the Corporate Objective 4 (consequence) x 3 (likelihood) =

12 impact rating

Recommendation

s made to reduce

the risk scoring

due to reduced

avoidable

pressure ulcers

and falls.

Independent

reviews of the

unexpected

deaths. Recent

NHS England

review of SI

reporting. This

risk will be

regulary reviewed

and monitored.

If learning from

incidents is not

embedded quality

and patient safety

may not be

maintained or

improved. The

Francis report and

more recently the

Southern Health

report has re-

emphasised the

risk to patient safety

if learning from SI's

are not

implemented.

16

September 16 1



System in place for

reviewing mortality

rates and identify

significant trends

and concerns for

immediate action

The findings and

recommendations

identified in the

review of patient

deaths in the care

of southern health

could identify gaps

in the trusts

processes for

reviewing mortality

which will require

significant action.

Safety

Compliance

Reputation

Andy

Brogan

4 3 12 4 3 12 ↔ ↔ To fully implement the action plan put

in place as a result of the Southern

Health Care learning.

Including the definition of avoidable

death, the establishment Mortality

Review Group and Deceased Patients

Review Group ,development metrics to

report on avoidable deaths and

targeted action to reduce deaths.

Mar-17 4 2 8 TOR Mortality Review

Group established and

taking forward associated

work plan

Workplan not

fully implemented

at this stage and

data metrics not

developed

Reporting to

Quality

Committee

Workplan not

fully

implemented at

this stage and

data metrics

not developed

Sep-16

Links to -


Care planning and

delivery of care will

be personalised

and centred

around the patient

If care is not clearly

documented

detailing person

centred care in line

with risk and needs

assessments this

may impact on the

identification of

individual clinical

need and a high

quality of outcome

may not be

achieved

Patient

Safety

Compliance

Andy

Brogan /

Malcolm

McCann

4 3 12 4 3 12 ↔ ↓ Electronic Records Project Board

established and implementing action

plan. Review of community

documentation used and launch of

revised documentation. Move from

ECPA to Mobius. Ongoing roll out of

trending forms. Develop regular

reporting on compliance to key

committees. Care planning training to

be undertaken through a coaching

approach delivered by practice

development. Ongoing monitoring

through internal CQC inspections and

practice development.

Mar-16 4 1 4 Issues with

personalised care

planning are not

currently

appearing as a

major issue

following reviews,

however work still

in progress and

links with record

keeping.

Recommendation

is made by the

Executive

Director of Mental

Health and

Executive Nurse

that risk is

removed and the

risk associated

with record

keeping will by

reviewed 3/12/16

after

implementation of

new Mobius

upgrades etc.

Care planning process

and procedures and

Training. Effectiveness

monitored by SMTs.

Compliance checks for

monitoring quality

including CQC internal

checks. Audit programme

in place. All inpatient units

undertake an audit of

records monthly to review

care planning and record

keeping. Standards

identified to commence

baseline audits. Audit tool

reviewed. Spot checks

undertaken by ward

managers as part of

supervision. Areas of

Learning from SI taken

forward and SI audits post

completion of action plans

undertaken to ensure

learning embedded.

Electronic Records Board

task and finish group.

Complaints reviewed and

monitored in relation to

personalised care and

Areas

outstanding on

the associate

Joint Learning

from CQC

inspection to be

fully implemented

and Electronic

Project Board

action plan.

Reporting to CG

Committee and

SMTs.

Care planning

advisory group.

Electronic

Records Project

Board. Quality

Committee

approved CQC

action plans

January 2016.

Areas

outstanding on

the associate

BAF risk action

plan . Learning

from CQC

inspection to

fully

implemented

Sep-16

ControlPost

Mitigation

target risk

scoring

Gap in

Control

Assurance Gap in

Assurance

Date

reviewed

Is the level of

risk

acceptable post

mitigation ?

Raised by the

Quality

Committee

January 16 .

Linked to

corporate

objective 16/17.

Escalated from

the CRR June

16.

CRR16011401

Current

Risk Score

Direction of risk Mitigating actions Target

Comp

Date

Directorate

Objective/

High Level

Actions/

Source

Assumption Potential Risk Risk

Category

Lead Initial

Risk

Rating

Corporate Governance Statement, CQC Quality and Safety

Standards, Annual Governance Statement . Operational Plan

Carried forward

from the BAF

15-16

REF-

BAF13062001

Gap in

Control

Initial

Risk

Rating

Lead Directorate

Objective/

High Level

Actions/

Source


Category

Is the level of

risk

acceptable post

mitigation ?

Post

Mitigation

target risk

scoring

Assurance Gap in

Assurance

Date

reviewed

Current

Risk Score


Comp

Date

Executive Director of Corporate Governance 4 (consequence) x 3 (likelihood) =

12 impact rating

Impact of not achieving the Corporate Objective

Direction of risk Control

Lead Director

Aim 1 : Safe care

3. Fully implement the CQC Inspection actions identified

September 16 2



The trust will

remain compliant

with the CQC

standards in all

services at all

times

If services fall short

of the standards

required to remain

compliant with the

Health and Social

Care Act there is

the potential for

CQC enforcement

action or in extreme

cases closure of

services.

Safety

Compliance

Reputation

Nigel

Leonard

4 3 12 4 3 12 ↔ ↔ Participation in all CQC consultations.

Development of local portfolios for all

wards / teams and uploaded to the

intranet.

Exec task and finish group in place

Individual Core Service Action Plans

developed and actioned. Audit

commenced of completed actions.

BAF Action plan revised May 16 new

actions identified. Internal CQC

Inspection programme has

commenced, areas identified for

improvement to be identified and

actioned by operational services. Next

steps plan being developed

Mar-16 4 2 8 The risk of non

compliance with

CQC Standards

cannot be

eliminated and

this rating reflects

this position.

CQC Comprehensive

inspection facilitated.

Outcome action plan

developed and submitted

to the CQC. Task and

finish groups established

and concluded to take

learning and

recommendations forward.

Executive task and finish

group established to take

forward outstanding

actions. Core services

action plans developed,

implemented and

monitored. Compliance

team intelligence

monitoring. Compliance

team compliance checking

programme. MHA spot

checking programme.

MHA intelligence system.

Reporting to

Quality committee, MHA

and Safeguarding

Standing Committee,

MHA hospital managers

undertake reviews of

section reviews.

Areas identified

for action

following CQC

MHA visits.

Final Report

received from

CQC providing

positive

assurance - trust

overall rating

GOOD. Full

review of CQC

actions and

audit of

implementation

completed -

August 2016.

Quality

Committee

(15.09.2016)

has

recommended

closure of all the

CQC

recommendation

s expect ONE.

Audit outcomes

identify some

gaps in

assurance.

Levels

generally

acceptable to

EOSC but

actions to

monitor going

forward

established.

Sep-16

Date

reviewed

Current

Risk Score

Direction of risk Directorate

Objective/

High Level

Actions/

Source


Category

Lead Initial

Risk

Rating


Comp

Date

Post

Mitigation

target risk

Is the level of

risk

acceptable post

mitigation ?

Control Gap in

Control

Gap in

Assurance

Identified from

the Operational

plan 16-17 and

carried forward

from the BAF

15-16

REF -

BAF14033001

Assurance

September 16 3



123 Care planning advisory

group in place reporting to

Clinical Governance

Group.

Records management

policy and procedures /

Staff should be operating

under professional

standards.

Record keeping identified

as a learning stream

following CQC Inspection

and will be monitored by

Care Planning Advisory

Group

Internal CQC spot checks.

Quality of Records / CPA

BAF action plan.

Areas of learning from SI

investigations taken

forward.

Clinical Audits reported

through Clinical

Governance routes and

SMTs

Recommendation

made by the

Executive

Director of Mental

Health and

Executive Nurse

to reduce the risk

scoring to 4 x 3

=12

Assurance

Areas

outstanding on

the associate

Joint BAF risk

action plan 1

area complete, 4

areas in

progress. Audit

tool to be

reassessed

Sep-16Trends

identified from

SI analysis.

CQC

Inspection

Basildon MHU -

Moderate

concern. CQC

MH Act visits

and recent and

internal

compliance

visits identified

gap in

assurance.

Gap in

Control

ControlPotential Risk Risk

Category


Comp

Date

Identified from

the Operational

plan 16-17 and

carried forward

from the 15-16

BAF

REF -

BAF14033003

Records are

maintained in line

with Trust Policy

and procedure

Lead Assumption

↓

Directorate

Objective/

High Level

Actions/

Source

Initial

Risk

Rating

Current

Risk Score

Is the level of

risk

acceptable post

mitigation ?

Gap in

Assurance

12 ↔Andy

Brogan /

Malcolm

McCann

Internal Audits

scopes to

request focus on

records where

possible. Care

Planning

Advisory Group

oversee

monitoring. CQC

actions and

timescales

approved by the

Quality

Committee.

Electronic

Records Group

Post

Mitigation

target risk

scoring

Date

reviewed

Spot checks undertaken by ward

managers as part of supervision

Continued drive to deliver

improvements through supervision and

staff bulletin.

Learning from CQC Inspection being

actioned and implemented. Record

keeping identified as a learning stream.

Audit tool developed however following

feedback from operational services tool

to be reassessed as too lengthy.

Further work is required to review the

tool and remove duplication and to

identify where information can be

pulled from other sources.

Mar-16 4If record keeping

standards are not in

line with Trust

policy quality of

care may be

compromised;

3 12 4 3Safety

Compliance

4

September 16 4


Links to -


Substantive posts

are recruited too

If there is a high

reliance on Bank

and Agency staff as

a result of

vacancies and

sickness this will

impact on the

quality and

continuity of SEPT

services

Safety

Compliance

Reputation

Nigel

Leonard

4 3 12 4 4 16 ↔ ↔ Full revision of vacancies and

recruitment drive within all Operational

areas, which includes national

advertising, attendance at University

Recruitment Fairs, open-ended

adverts. Sickness workshops/OLM and

absence advisor in place to consider

means of reducing sickness rates.

Meetings arranged to discuss and

identify on-going recruitment initiatives

and ways to attract staff to the Trust .

HR resource identified to concentrate

on hard to fill vacancies and actions

being taken forward include recruitment

and induction mandatory workshops,

candidate packs, feedback

questionnaires for new starters. Report

to be presented to ET in May 2016

proposing recruitment advertising

initiatives and incentives for

consideration.

New Bank system implement on 1st

April 2016 which integrates with

healthroster. Weekly Monitoring

process in place for all agency price

cap and framework breaches. Monthly

report going to performance from June

2016. Service Level Agreements with

the specified approved agencies are in

July 2015

and On-

going

4 2 8 Sickness reports to Board,

ET & Directorate SMTs.

OLM training for

managers.

Sickness Absence Polices

and procedures review

Bradford factor reduced to

100 at May 2016.

Recruitment and retention

Policies and Procedures

reviewed. Analysis

undertaken of staff

anticipated to retire and

proactive recruitment to

take place against

identified numbers. The

trust has increased the

number of support workers

on the bank by 50+

workers. Recruitment and

operational services

attend all local university

recruitment fair . Absence

Advisors in post to support

Line Managers in

addressing absences

across the Trust

new bank system

implemented and Full

Hotspots

identified in Safer

Staffing Reports.

Recruitment

initiatives

continue as per

the BAF Risk

action plan.

Actions

completed for

15/16. New

actions identified

to address risk

for 16/17.

Sickness and

Bank & Agency

levels reports

presented to

relevant Groups

and Committees

in accordance

with HR

processes.

Assurance

report presented

to Board, ET &

Quality group.

Trust has been

successful in

filling a majority

of its Nursing

vacancies as per

the BAF action

plan Decrease

in sickness rates

as at May 2016.

Monitoring of

vacancy rates

has shown a

decrease at May

2016. Decrease

in Framework

and price cap

Hotspots

identified in

Safer Staffing

Reports.

Recruitment

initiatives

continue as per

the BAF Risk

action plan.

Some key

posts remain

challenging to

recruit too.

West Essex

NHSP contract

ahs not been

reviewed.

None of the

agencies in

use are agreed

framework

agencies and

within price

cap. Work

commenced in

May 2016 to

move all

agencies over

to compliance.

Sep-16

Executive Director of Clinical Governance and Quality

Assurance

Impact of not achieving Corporate Objective 4 (consequence) x 3 (likelihood) =

12 impact rating

Directorate

Objective/

High Level

Actions/

Source

Assumption Lead Gap in

Assurance

Post

Mitigation

target risk

scoring

Initial

Risk

Rating

Current

Risk Score

Direction of risk Mitigating actions Is the level of

risk

acceptable post

mitigation ?

Date

reviewed

Target

Comp

Date

Identified from

the Operational

Plan 16-17 and

carried forward

from the BAF15-

16

REF -

BAF15042102

Strategic Priority 2: Quality Leadership and Workforce

We will only be able to achieve our strategic vision if we have the best staff and an organisational culture that supports staff in delivering the best quality services. Excellent leadership at all levels, clinically and managerially is key to delivering the other three strategic priorities. It’s not

just about the numbers of staff and the competencies they have; we want our staff to have shared values and belief systems that engender trust from our patients and their carers.

Aim 5 : Right staff, Right skills, Right Place

12. To achieve a reduction in turnover rates to 8.4% to support safer staffing and manage talent effectively

15. The Trust aspires to achieving a sickness rate reduction of 4.3% but recognises for monitoring purposes the threshold for monitoring this hotspot is 4.7% in line with benchmark data.


Standards, Annual Governance Statement , Monitors Risk

Assessment Framework

Control Gap in

Control

Risk

Category

Potential Risk

September 16 5


Links to -


Category

Lead Mitigating actions Target

Comp

Date

Control Gap in

Control

Assurance Gap in

Assurance

Date

reviewed


Breach of Monitors

agency cap

If there is a high

reliance on agency

staffing as a result

of vacancies and

sickness this will

result in the Trust

breaching the

agency cap set by

Monitor.

Compliance

Reputation

Nigel

Leonard

4 3 12 4 3 12 ↔ ↔ Framework agreements in place and

reviewed on a regular basis to ensure

compliance. Agency breaches have

decreased as at May 2016,

Recruitment and Retention programme

and Sickness Absence management

programme in place. To ensure further

compliance especially on NHS

Professionals contract in West Essex

since May 2016 further 6 Agencies

have been added to Trust approved

framework. Discussion ongoing with 2

other agencies. Weekly reporting in

place for Agency Framework Breaches

and Agency Price Cap Breaches which

are raised with ET on a monthly basis,

any areas with high levels of price cap

breaches are being supported and

looking at ways of reducing agency

costs. September 2016 Review of all

administrative agency usage across the

trust with an attempt to reduce.

Framework agreements

and weekly monitoring of

breaches to NHSI and

monthly reporting to

Board. Option paper on

the provision of bank and

agency workers in West

Essex to be presented by

end of August 2016. As at

September 2016 there has

been a considerable

reduction in framework

breaches over the last 4

weeks due to movement

of clinical agency workers

over to the new CPP

framework. Framework

breaches have seen a

decrease from around 60

to average of 30 breaches

per week. Have also seen

a decrease in number of

shifts reporting price cap

breaches this has dropped

to under 100 per week as

at end July. expecting to

see further improvement

in August when new

Framework comes into

Staff may not be

available through

approved

agencies. For

specialist or

difficult to fill

positions

agencies may not

be able to supply

workers within

price caps. From

September 2016

may see an

increase in

agency usage

among within

corporate areas

due to non

replacement of

staff because of

pending merger

Monitoring of

SLAs and

breaches in

framework and

price cap

Agencies may

not adhere to

framework

agreements

Sep-16

Impact of not achieving the Corporate Objective 4 (consequence) x 3 (likelihood) =

12 impact rating

Executive Director of Corporate Governance

Directorate

Objective/

High Level

Actions/

Source

Post

Mitigation

target risk

scoring

Direction of risk Is the level of

risk

acceptable post

mitigation ?

Current

Risk Score


Standards, Quality Governance Framework , Annual

Governance Statement

Strategic Priority 3: Sustainability of Service Provision

We want SEPT to be a provider of health and social care services going forward and therefore ensuring that we remain viable is a key priority. However, we recognise that sustainability of strong health and social care economies is as important and therefore our strategy will be

developed and delivered in partnership with our CCG and local authority colleagues and will prioritise the benefits to patients not organisations.

Aim 7 : Financially sound

16. To achieve a reduction in agency spend of £1.5m and achieve the Monitor price cap of 6%

Initial Risk

Rating

Identified from

the Operational

Plan 16-17

REF -

BAF27041601

September 16 6


Links to -


8 Given the

complexity and

scale of this

transaction a

target rating of 8

is acceptable.

Due to the

number the of

mitigating actions

August 16

displayed only.

Full action plan in

place and

available on

request.

Patient

Safety

Reputation

Compliance

Nigel

Leonard

5 i. Regulatory risk: 11.08.16 due

diligence process interim report to Trust

Boards in July 16 - further lines of

enquiry and outstanding issues to be

resolved in final report for September

16. PwC quality assurance report will

be updated providing assurance of

robust and adequate process

undertaken; first draft of FBC presented

to Merger Project Board ready for

Investment Committee and Board

consideration.

ii. Stakeholder risk: joint discussions

with staff side representatives occured

in August to map a way forward for

merger transaction; further

communication with local authority

Overview & Scrutiny Committees tkane

place offering information;

commissioner representative on

Merger Project Board and within clinical

work streams; stakeholder reference

group (service users and support)

being put in place

iii. Project plan for merger: 11.08.16

refreshed draft Post Transaction Plans

submitted from each work stream and

being quality assured by Project

Management Office; work commenced

on defining the Long Term Finance

Model and initial organisational

development plan. Weaknesses in

plan being addressed with each work

stream as appropriate so that

September Merger Project Board

receives good first draft of PTIP and

early indications of LTFM.

Comprehensive update of risk register

following due diligence work

undertaken and each risk being

addressed in PTIP. Additional

resource for clinical work stream and

PMO identified.

Overall risk rating remains high until

there is solid progress in the three core

parts of the FBC: post transaction plan;

long term financial model;

organisational development plan.

4 (consequence) x 3 (likelihood) =

12 impact rating

Executive Director of Corporate Governance Impact of not achieving the Corporate Objective

No gaps

currently

identified but

the challenge

of securing

unequivocal

commissioner

support

accurately

reflected in all

commissioning

plans across

Essex is not to

be under

estimated even

allowing for

greater

commissioner

engagament

and

involvement in

the merger

transaction;

this in part

reflects the

context for

commissioning

organisations

and national

NHS planning

initiatives such

as STPs

adding

complexity to

the transaction.

Sep-162↔30 January

2016 Board

Meeting

BAF16032401.

Identified in the

Operational

Pan 16-17. Risk

reviewed and

carried forward

to 16-17 BAF.

The merger

proposal is

approved by the

CMA and Monitor

as regulatory

bodies, has

necessary

stakeholder

support and is

approved by a

majority vote of

both Council of

Governors

As a result of a

number of risks

relating to

regulatory approval

and delivery of a

comprehensive and

compelling

business case there

is a risk that the

merger will not be

completed by April

2017, or at all,

resulting in the

benefits identified in

the merger

proposal (clinical

and patient

benefits,

commissioner

benefits and

financial benefits)

not being delivered.

Project plan monitored by

Merger Project Board;

regular reports to

Executive Management

Teams, Investment

Committee, Board of

Directors and Council of

Governors; FBC has to be

signed off by independent

external opinion and by

Medical Directors

regarding benefits plan,

financial status and clinical

quality; external regulatory

oversight of the whole

transaction is the single

biggest control - NHSI will

assess the FBC and give

the transaction a risk

rating and this will inform

the vote of the Governors;

newly merged

organisation will be

authorised and licenced by

NHSI and the Care Quality

Commission as all other

NHS Foundation Trusts

are.

Internal audit revieiwed

the project in August 2016

to report to Audit

Committee. Business case

in place to deliver for

November 16. Approval

process has also now

been clarified

PwC review of

PMO identified

lack of capacity

and this staring to

be addressed in

PMO and Clinical

Work Stream;

some other areas

e.g. Contracts

and Governance

remain tight on

capacity - further

support can now

be offered from

the Merger PMO

but ability to

manage

'business as

usual' and

merger

transaction

remains a gap in

control that is

closely managed.

44 20 4 3 12 ↔

Date

reviewed

Monitoring

through Merger

Project Board,

Exec Teams,

Board and

Governor

meetings.

Additional

scrutiny

provided by

Investment

Committee that

receives an

update on

project progress

at each meeting;

additional

meetings

scheduled

where needed.

Internal audit

scrutinised the

project in August

2016 for

reporting to

Audit Committee

External support

from PwC

commenced

08.06.16

External

independent

reviews as part

of the FBC.

Engagement

with HOSC,

healthwatch and

other key

stakeholders

gives additional

assurance.

Full EIA to be

undertaken as

part of the FBC

process.

Monitor risk

rating for the

transaction.

Mar-17

Mitigating actions Gap in

Control

AssuranceTarget

Comp

Date

Control

Aim 8 Clear Strategy for Securing Our Success

18. To implement the merger with North Essex Partnership University NHS Foundation Trust

Lead Director

Gap in

Assurance


Standards, Annual Governance Statement, Monitors Risk

Assessment Framework


Category

Lead Is the level of

risk

acceptable post

mitigation ?

Directorate

Objective/

High Level

Actions/

Source

Initial

Risk

Rating

Current

Risk Score

Direction of risk Post

Mitigation

target risk

scoring

September 16 7


Links to -


The Trust CIP

programme of

identified schemes

is delivered in full.

40% slippage on a

£10.5 million CIP

programme

anticipated.

Finance Mark

Madden

5 4 20 5 3 15 ↓ ↔ CIP plans produced. Currently showing

circa £10.6m of schemes actioned

through the budget and £0.5m to be

identified. QIAs reviewed and none

rejected internally.

Mar-17 4 2 8 Reviewed by the

Chief Financial

Officer

recommendation

made to reduce

risk scoring from

5 x 4 =20 to 5 x 3

= 15 approved by

the Board of

Directors May 16

Financial Plan and

monitoring arrangements.

CIP programme and

plans. PMO .

Financial Plan

does not identify

schemes for full

value of CIP,

residual gaps still

exist, subject to

further review.

Significant push

back from some

commissioners to

proposed

schemes.

Reporting to ET

and Finance

and

Performance

Committee.

Hotspots

reported to

Board.

Transformation

Steering Group.

QIAs for 100%

of target not yet

approved and

detailed

implementation

plans still not in

place for all

schemes.

Significant

push back from

some

commissioners

to proposed

Sep-16

Contingency /

Reserves sufficient

to meet shortfall on

CIP plans

Reduce level of

contingency will not

be able to mitigate

risk of CIP shortfall.

Reduced reserves

of 3.5m gap

Finance Mark

Madden

4 4 16 4 3 12 ↔ ↓ Continually reviewed for unavoidable

cost pressures. Potential to review

each quarter with updates and

recommendations/revisions if required.

Mar-17 4 3 12 Reviewed by the

Chief Financial

Officer

recommendation

made to reduce

risk scoring from

4x4=16 to 4x3=12

Financial Plan and

monitoring arrangements.

Unknown cost

pressures and

implications of

CIP shortfalls

Reporting to ET

and Finance

and

Performance

Committee.

Hotspots

reported to

Board.

None identified Sep-16


Standards, Monitors Risk Assessment Framework , Annual


Post

Mitigation

target risk

scoring

Is the level of

risk

acceptable post

mitigation ?

Control Gap in

Assurance

Date

reviewed

Lead Gap in

Control

AssuranceDirection of risk Mitigating actions Target

Comp

Date

19. Successful completion of our CIP programmes including the transformational programme to achieve circa £10.4m delegated efficiency requirement.

Initial

Risk

Rating

Impact of not achieivng the Corporate Objective

Current

Risk Score

4 (consequence) x 3 (likelihood) =

12 impact rating

Identified from

Operational

Plan 16-17

REF -

BAF16040802

Lead Director Chief Finance Officer

Identified from

Operational

Plan 16-17

REF -

BAF16040801

Strategic Priority 4: Innovative and Transformational Approach to Efficiency and Effectiveness

Directorate

Objective/

High Level

Actions/

Source


Category

September 16 8


Links to -


Management

capacity

That the significant

pressure to achieve

a number of

transformational

programmes

creates significant

management and

resource pressure

that impacts on the

delivery of the key

objectives of the

organisation

2016/17

Safety

Finance

Reputation

Compliance

Mark

Madden

and all

Executive

Directors

5 4 20 5 4 20 ↔ ↔ Detailed project and/or mobilisation

plans are in place for all live 2016/17

Transformation projects and regular

project team meetings are in place to

monitor progress, assign new actions

and discuss issues, risks and

mitigation.

Mar-16 5 2 10 PMO and BAF action plan.

PMO lead for each

scheme. Reporting to

Transformation steering

group. Projects have an

associated Quality Impact

Assessment (QIA) which

is scrutinised as part of an

approvals process, and

which includes details of

any likely impact on

quality, together with risk

mitigation.

The ensuing BAF action

plan is in place and is

reviewed / updated

monthly.

All QIAs have not

generated budget

virement

approval to

remove budgets

Quarterly

reporting to

Finance and

Performance

Report.

Transitional

Steering Group

monitoring.

All plans not

been actioned

at this stage

and gaps has

still not been

closed

Sep-16

Chief Finance Officer Impact of not achieving the Corporate Objective 4 (consequence) x 3 (likelihood) =

12 impact rating

Gap in

Assurance

Post

Mitigation

target risk

scoring

Current

Risk Score

ControlRisk

Category

Lead Initial

Risk

Rating

Reassessed for

15-16

REF-

BAF15042105

Lead Director

Is the level of

risk

acceptable post

mitigation ?

Directorate

Objective/

High Level

Actions/

Source

Assumption Potential Risk AssuranceGap in

Control


Comp

Date

Date

reviewed

20. Achieve forecast savings through the Deliver of the 6 transformational programmes:


Standards, Monitors Risk Assessment Framework , Annual


RISK RATING

Impact

Lik

elih

oo

d

1 2 3 4 5

1 Low 1

Low 2

Low 3

Medium 4

Medium 5

2 Low 2

Medium 4

Medium 6

Medium 8

High 10

3 Low 3

Medium 6

Medium 9

High 12

High 15

4 Medium 4

Medium 8

High 12

High 16

Extreme 20

5 Medium 5

High 10

High 15

Extreme 20

Extreme 25

September 16 9

Appendix 2 – Agenda Item 6a – Board of Directors Meeting – 28 September 2016

Corporate Objectives 2016-17 Draft Impact Ratings

Corporate Objective Director lead

Impact Rating

1. To fully implement the action plan put in place as a result of the South Health Care learning. Including the definition of avoidable death, the establishment of an avoidable death group, develop metrics to report on avoidable deaths and targeted action to reduce deaths.

AB 4 x 3 = 12

2. Achieve the sign up to safety milestones for 2016/17 AB 3 x 2 = 6

3. Fully implement the CQC inspections actions identified NL 4 x 3 = 12

4. Full implementation of the Quality Academy AB 3 x 2 = 6

5. Implementation of the workforce development quality priority AB 3 x 2 = 6

6. To achieve parity of esteem implement 25% of the standards in the Trust’s physical health guideline MK 3 x 2 = 6

7. Review the Trust’s complaints process to ensure compliance with the Trust policy and procedure is 100%. NL 3 x 2 = 6

8. Implement 24/7 services to 25% of the population to ensure; - Patients needing urgent or emergency hospital care will receive the same quality of assessment, diagnosis, treatment and review on any day of the week.

MK (MMc/AB)

3 x 3 =9

9. Mental Health Access Standards; More than 50 percent of people experiencing a first experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks referral; - 75 percent of people with common mental health conditions referred to the improved access to psychologist therapies (IAPT) programme will be treated within

six weeks of referral, with 95 percent treated within 18 weeks.

- Continue to meet a dementia diagnosis rate of at least two thirds of the estimated number of people with dementia.

AB (MK)

4 x 3 =12

10. Deliver actions set out in local plans to transform care for people with learning disabilities , including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy.

AB 3 x 3 = 9

11. To improve out of hospital care through building greater depth of capability in collaboration with commissioners and service users through the implementation and achievement of KPIs in respect of avoidable admissions, reduce discharges, improve length of stay and better value for the public purse.

MMc 4 x 2 = 8

12. To achieve a vacancy rate of 10% to support safer staffing and manage talent effectively. NL 4 x 3 = 12

13. Fully implement the Freedom to Speak Up Guardian and reporting procedures Trust wide NL 3 x 2 = 6

14. To reach an agreement with the CCGs regarding mental health services component fitting into categories of either specialist or locality and ensuring staff levels are appropriate in each area.

MMc 4 x 3 = 12

15. The Trust aspires to achieving a sickness rate reduction of 4.3% but recognises for monitoring purposes the threshold for monitoring this hotspot is 4.7% in line with benchmark data.

NL 4 x 3 = 12

16. To achieve a reduction in agency spend of £1.5m and achieve the Monitor price cap of 6% NL 4 x 3 =12

17. To improve efficiency and productivity in line with the Lord Carter review. MM 3 x 3 = 9

18. To implement the merger with North Essex Partnership University NHS Foundation Trust NL 4 x 3 = 12

19. Successful completion of our CIP programmes including the transformational programme to achieve circa £10.4m delegated efficiency requirements. MM 4 x 3 = 12

20. Achieve forecast savings through the Deliver of the 6 transformational programmes: 1. Corporate restructure 2. Dementia/Challenging Behaviour Pathway 3. Estates Rationalisation 4. Workforce Redesign 5. Inpatient Redesign 6. Income Generation

MM (ALL EXECS)

4 x 3 = 12

21. Essex Success Regime: Support the implementation of the STP to: ‐ improve inequalities in access to treatment in mental health

‐ greater integration between mental health and physical care in the community

‐ transformation: including quality, access, finance, sustainability, workforce and leadership, technology and research.

SM 4 x 2 = 8

22. West Essex: Support the implementation of the STP to: ‐ improve inequalities in access to treatment in mental health

‐ greater integration between mental health and physical care in the community.

‐ transformation: including quality, access, finance, sustainability, workforce and leadership, technology and research.

MMc 4 x 2 = 8

23. Bedfordshire: Support the implementation of the STP to: ‐ improve inequalities in access to treatment in mental health

‐ Greater integration between mental health and physical care in the community

‐ transformation: including quality, access, finance, sustainability, workforce and leadership,,technology and research.

MMc 4 x 2 = 8

Any Corporate objective that scores 10 or above in the impact rating assessment process results in the objective rating of HIGH (Orange) and objectives scoring over 20 are considered to be

EXTREME (Red). These objectives will be entered on the Board Assurance Framework and associated rated high / extreme risks monitored by the Board of Directors.

Any objective scoring 9 or below in the impact rating assessment process results in an overall risk rating of MEDIUM (Yellow) and objectives scoring below 4 results in an overall impact rating of

LOW (Green). These objectives will be quality assured and monitored by the EOSC using the Corporate Risk Register for those risks quantified as high or extreme. All other risks will be detailed

within directorate risk registers.

1. Assess impact of an achievement of objective on Trust 2. Assess the likelihood of the objective not being realised.

Level Detail description examples

1 Rare – may occur only in exceptional circumstances (up to 20%)

2 Unlikely – could occur at some time (21% to 40%)

3 Possible – might occur at some time (41% to 60%)

4 Likely - will probably occur in most circumstances (61% to 80%)

5 Almost certain – is expected to occur in most circumstances (81% to 100%)

3. Determine the overall Impact Rating of the objective by multiplying the

potential impact with the likelihood of occurrence.

Impact

1 2 3 4 5

1 L o w

L o w Low Medium Medium

2 L o w

Medium Medium Medium High

Lik

elih

oo

d

3 Low

Medium Medium High High

4 Medium

Medium High High Extr eme

5 Medium

High High Extr eme Extr eme

Level Detail description example

1 Negligible - no service disruption; no workforce shortages or implications, no

obvious harm to patients or staff; low financial loss (up to £200,000)

2 Low – temporary service disruption with minimal operational impact; some

workforce shortages with minimal impact on service delivery minimal harm to

patients or staff; increased level of care 1-7 days; adverse publicity unlikely;

financial loss £200,001 - £500,000

3 Moderate – temporary service disruption with operational impact, workforce

shortages which marginally impact on service volume; medical intervention

required; local adverse publicity possible; financial loss £500,001 - £2,500,000

4 Severe – temporary significant service disruption; workforce shortages with

significant impact on service volume; suicide/incident rates which significantly

exceed national average: increased level of care over 15 days; national adverse

publicity; financial loss £2,500,001 - £6,500,000

5 Extreme – total service failure; high profile death, permanent illness or disability

due to significant clinical failure; significant multiple injuries; extended service

closure; protracted national adverse publicity; financial loss over £6,500,001

SEPT

1

Agenda Item No: 6(b)(i)

SUMMARY REPORT

BOARD OF DIRECTORS MEETING PART 1

28 September 2016

Report title: Board of Directors Quality Committee Assurance Report Non-Executive Lead: Lorraine Cabel, Chair of the Trust, Chair of the Quality Committee

Executive Lead: Andy Brogan, Executive Nurse & Executive Director Mental Health

Report Author(s): Cathy Lilley, Trust Secretary

Report discussed previously at: Quality Committee meeting held on 15 September 2016

Level of Assurance:

Level 1

2

3


To provide assurance to the Board that the Quality Committee is discharging its terms of reference and delegated responsibilities effectively, and that the risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively.

Approval

Discussion

Information


1 To note the contents of the report 2 To confirm acceptance of assurance given in respect of risks and actions identified 3 To request further action/information as required 4 To note that the issue in relation to safer staffing at Clifton Lodge will remain a risk on the

Corporate Risk Register.


At its meeting on 15 September 2016, the Quality Committee:

Reviewed the Safer Staffing Report

Received a detailed presentation on the Quality Priority – Falls, noting the reduction since the introduction of measures

Received and agreed the proposals for future quality reporting arrangements

Approved the final position report in relation to the CQC Comprehensive Inspection Action Plans

Noted the operational service transformation and innovations within South East Essex including Care Coordination Service, End of Life – the case for change, and Neighbourhood Team development

Received an update report on ‘openness’ including Duty of Candour and Freedom to Speak Up

Was updated on the National Nursing Framework

Received a briefing on the updated NQB Guidance – ‘Safe, sustainable and productive staffing’

Approved the Medicines Management Annual Report 2015/16

Approved the Annual Senior Information Risk officer (SIRO) Report 2015/16

Approved five policies and procedures

Received assurance report from seven sub-committees

Received a referral from the Finance & Performance Committee concerning the increase in AWOLs






SEPT

2


Are any existing risks in the BAF affected? Yes

If yes, insert relevant risk Following risks already included on the BAF: 1 Learning from SIs embedded and facilitates

improvements in quality and safety 2 Trust will remain compliant with CQC standards in

all services at all times 3 Substantive posts are recruited to 4 Breach of Monitor’s agency cap 5 Management capacity

Do you recommend a new entry to the BAF is made as a result of this report?

No



Data Quality Issues Involvement of Service Users/ Healthwatch

Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains


Governance Implications Impact on Patient Safety /Quality


Equality Impact Assessment (EIA) Completed? No If yes, EIA Score

Acronyms / Terms used in the Report

CQC Care Quality Commission SI Serious Incident

ET Executive Team CCG Clinical Commissioning Group

BAF Board Assurance Framework SUTS Sign Up To Safety

F2SU Freedom to Speak Up HSE Health & Safety Executive

IG Information Governance LOSC Learning Oversight Sub-Committee

BCHS Bedford Community Health Services SIRO Senior Information Risk Officer

CHPPD Care Hours Per Patient Day CPR Castlepoint & Rocfhord


Main report

Non-Executive Lead

Lorraine Cabel, Chair of the Trust & Chair of the Quality Committee

SEPT Board of Directors

Board of Directors Part 1 28 September 2016 Page 1 of 5

Agenda Item 6(b)(i) Board of Directors Meeting Part 1

28 September 2016

BOARD OF DIRECTORS QUALITY COMMITTEE ASSURANCE REPORT

1 Purpose of Report

This report is provided to the Board of Directors by the Chair of the Board of Directors Quality Committee. As an integral part of the Trust’s agreed assurance system, the report is designed to provide assurance to the Board that:

risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively. This is an integral part of the Trust’s agreed assurance system

the Committee is discharging its terms of reference and delegated responsibilities effectively.

2 Executive Summary

2.1 Minutes of meetings held on 14 July 2016 These were approved on 15 September 2016 and are available in full to Board members via the Chair’s Office or on the intranet. 2.2 Summary of discussions and issues identified as well as assurances provided at the meeting held on 15 September 2016: 2.2.1 Quality Report: The Committee received a presentation on future summary

quality reporting arrangements. Members were reminded that the Board efficacy review had identified potential duplication/overlap in respect of quality related data presented to the Quality Committee, Finance & Performance Committee and the Board of Directors. In addition, the Quality Report presented to both the Quality Committee and the Board does not fully meet perceived needs. The reduction in the frequency of Quality Committee also required a refreshed view of what the Committee needs in terms of data on a bi-monthly basis.

The proposed Quality & Performance Report for the Finance & Performance Committee would include data relating to the previous month and would focus on the achievement of ‘ambition’ (target). It would also incorporate items not currently repoeted, i.e. falls, safety thermometer, pressure ulcers grades 1-2 as well as safer staffing. There would be clear identification/allocation of responsibility for follow up. The proposed Quality Report for the Quality Committee would include an extract from the Quality & Performance Report that would contain proxy measures of quality. There were also be a focus on trends over time including safer staffing trends, as well as detailed narrative reports on quality priorities/ Sign Up to Safety learning lessons. The proposed Scorecard for the Board would replace the current public dashboard and would include safer staffing and quality, as well as finance and potentially the BAF. The assurance reports from the Quality and Finance & Performance Committees would be harmonised and re-focused.



The development and introduction of the new reporting format will take place over a two month period with the aim of presenting the new reports to the Quality and Finance & Performance Committees and the new Scorecard to the Board at their respective meetings in November. During the development period the current Quality Report would not be produced for the Quality Committee and the Board.

The Committee supported the new reporting format for recommendation for adoption by the Board of Directors and agreed that it was a more focused, accessible and transparent approach.

2.2.2 Quality Priority – Falls: A detailed report was presented on the work being

undertaken to reduce the number of falls and the degree of harm from falls across the Trust’s older people’s inpatient and rehabilitation units which was being undertaken in line with the Trust’s Quality Strategy and as part of the Sign Up to Safety campaign. The Committee noted the actions taken to date including an audit that had demonstrated some areas of good practice as well as areas for improvement; the introduction of a training package based on the national Fallsafe Project as well as face to face training; and the establishment of a multi-disciplinary Falls Group which is responsible for strategic falls prevention and the scrutiny of falls data and the identification of themes to ensure learning is disseminated to teams. The Committee noted, however, that national benchmarking data was not currently available. The Committee was pleased to note that since the introduction of measures to raise awareness of falls and falls prevention, there has been a reduction in falls, harm from falls and the number of people who fall on more than one occasion.

2.2.3 Safer Staffing Report: The report highlighted that the majority of wards in Learning Disability, Secure Services and Community Health Services were above 95%. However, Clifton Lodge remained a hotspot from the previous month and Hadleigh, Maple and Fuji have been identified as hotspots with Causeway and Beech at Rochford as emerging risks. The Committee discussed the actions being taken to address the hotspots.

Assurance was provided that whilst recruitment is being undertaken, site managers on wards are being utilised to support wards alongside ward managers and matrons to ensure the wards are safe; there were no significant concerns with regards to the safety and quality of care on the wards when reviewing clinical incidents and safeguarding reports. The Committee discussed the ways in which this information is triangulated with other reports to correlate trends and noted that the Compliance Team gathers intelligence on a regular basis, producing monthly analysis for ET’s review.

2.2.4 CQC Exception & Assurance Report: A detailed summary progress report in

response to the recommendations made by the CQC following its inspection of services carried out in June/July 2015 was presented. The Committee noted the compliance process that had been followed in order to provide sufficient assurance of the final position and that there had been learning from the inspection. This process consisted of two assurance ‘tests’ carried out on each recommendation: Test 1 ‘have the actions been completed as reported?’ and Test 2 ‘is there evidence that the action taken has engendered



change/improvement?’. In respect of Test 1, ET is satisfied that action was taken as agreed in respect of all recommendations except five; in respect of Test 2, there was just one recommendation where no assurance was available. The Committee approved the recommendations in the report and action plan, noting that for the seven areas where full assurance had not been provided that action taken had resulted in change/improvement, that ongoing action and appropriate monitoring arrangements would be established. Sustainability KPI/monitoring arrangements would also be implemented to minimise the risk of issues identified by CQC in 2015 being identified again in any future inspection.

2.2.5 South East Essex Integrated Services: The Committee received an update on

the operational service transformation and innovations within services in South East Essex including the Neighbourhood Team development; Care Coordination Service in CPR CCG; and the End of Life – the case for change. The Committee noted that both CPR and Southend CCGs have commenced a journey to deliver integrated care and with a key theme in prevention, placing greater emphasis on system-wide approaches that wrap services around the needs of individuals and not the organisation.

2.2.6 Openness Report: The Committee noted that with regards to the Duty of Candour requirement, there continued to be good progress on a number of areas of work to support staff in encouraging and open and transparent culture. Assurance was provided that all serious incidents have followed Duty of Candour requirements and it was noted that going forward these requirements will also be applied to critical incidents which are currently monitored through the weekly Moderate Harm meeting.

The Committee was pleased with the excellent progress of the Freedom to Speak Up (F2SU) initiative that an intranet page for staff had been launched and that there was ongoing training for the Principal and Local Guardians. In addition, the Trust’s Principal Guardian has attended national events to talk to others about our experience and is also linking with the National F2SU Team. To date there have been a small number of concerns raised and resolved which have been managed by locally. The Committee requested that the Board committee reporting lines for this initiative is clarified.

2.2.7 National Nursing Framework: An overview of the newly published National

Nursing Framework and the Trust’s action plan against the 10 commitments was provided.

The new framework covers all nursing, midwifery and care professionals in all settings and is aimed to be used to ensure that staff achieve the best quality of experience for patients and people, the best health and wellbeing outcomes for the populations, and to use finite resources wisely to obtain the best value for every £ spent. It is closely aligned to the Five-Year Forward View and the ‘Triple Aim’ in seeking to develop new ways of working that are person-focused and provide seamless care across the boundary that has traditionally separated health and social care. The framework also sets out 10 aspirational commitments alongside the 6Cs.

2.2.8 Updated NQB Guidance – ‘Safe, sustainable and productive staffing’: The

new guidance sets out updated expectations to help NHS provider Boards to



make local decisions that will deliver high quality care within the available staffing resources. The updates are aligned to the findings within the Carter Report. NHS Improvement is also coordinating work to develop safe staffing improvement resources.

The report sets out the expectations of having safe, effective, caring responsive and well-led care with having the right staff, with the right skills in the right place and time. The report also sets out expectations for measurement and improvement covering patient outcomes, people productivity and financial sustainability (this will include a monthly Board review of workforce metrics, indicators of quality and outcomes and measures of productivity); reporting, investigating and acting on incidents; patient, carer and staff feedback; from May 2016 all acute Trusts report monthly on care hours per patient day (CHPPD); and the development of local quality dashboard for safe sustainable staffing. The Committee noted that the Board would still be responsible for staffing requirements but would need to consider this in line with the efficiency review as well as taking professional judgement into account.

2.2.9 Annual Reports: The following reports were approved:

Medicines Management Annual Report 2015/16

Annual Senior Information Risk Officer (SIRO) Report 2015/16. 2.2.10 Policies: The Committee approved the following policies and procedures:

Corporate Health & Safety Policy and Procedures

Fire Safety Policy and Procedure (RM02)

Clinical Coding Policy and Procedure (CLP/PG73)

Registration Authority Policy and Guidance (CP29)

Access to Records Procedure (CPG9d)

The Committee noted that with effect from September all policies and procedures review dates would be extended in light of the merger; however, reviews would be undertaken if there were any regulatory or legislative changes that would affect the Trust’s policies.

2.2.11 Sub-Committees: Assurance reports were received from the following:

Clinical Governance & Quality Sub-Committee: There were no significant issues raised or hotspots identified at the recent meetings. However, discussions took place in recognition of the increase in both deaths and restraint figures. Assurance was provided that ongoing monitoring was in place: there was ongoing work within the relevant workstreams as well as weekly reporting of SIs to ET. In addition, an independent review of unexpected deaths was currently being undertaken.

Health, Safety & Security Sub-Committee: There had been an increase in the number of hotspots since the last report including the safe use of curtain hooks, increase in abscond, fire doors at Ampthill BCHS, window restrictors, restrictive practice audit/recording and property policy review. Assurance was provided that mitigating actions were in place to address the hotspots and that there were no overdue high or medium risk actions on the action log.

Executive Physical Health Sub-Committee: There were no significant issues raised at the recent meetings.



Learning Oversight Sub-Committee: There were no significant issues raised at the recent meetings. The Committee suggested that future reports could include a case study to demonstrate the work being undertaken by the LOSC.

Mortality Review Sub-Committee: There was one risk identified that is included on the BAF in relation to implementing the recommendations from the Mazaars report on Southern Healthcare. Assurance was provided that an action plan was being implemented to take forward the actions. The Committee’s terms of reference were approved.

Patient & Carer Sub-Committee: There were no significant issues raised at the recent meetings. The Committee noted that further consideration was being given to the remit of this Committee.

Information Governance Sub-Committee: There were no significant issues raised at the recent meetings. The Committee noted the progress with the IG Toolkit and the ongoing discussions in relation to the actions required for the merger.

2.3 Risks/hotspots

The Committee noted that the HSE Notice of Contravention was already included on the Corporate Risk Register

The Committee received a referral from the Finance & Performance Committee regarding its concerns with the Increase in AWOL. A critical incident investigation report would be presented at a future meeting of the Quality Committee.

3 Action Required


1 Note the contents of this report 2 Confirm acceptance of assurance given in respect of risks and action identified 3 Request further action/information as required.

Report prepared by Cathy Lilley, Trust Secretary On behalf of:

Lorraine Cabel Chair of the Trust and Chair of the Quality Committee 28 September 2016

Investment and Planning Committee

Brd Rpts/Secs SEPT 1

Agenda Item No: 6b (ii)

SUMMARY REPORT


28 September 2016

Report title: Investment & Planning Committee

Executive Lead: Lorraine Cabel

Report Author(s):


Level of Assurance: 1

Purpose of the Report This report is provided to the Board of Directors by the Chairman of the Investment and Planning Committee. It is designed to provide assurance to the Board of Directors that risks that may affect the achievement of the organisations objectives are being managed effectively.

Approval

Discussion

Information


1. Note the summary of the meeting held on 20 July 2016 and the 6 September 2016. 2. Confirm acceptance of assurance given in respect of risk and the action identified 3. Request further action/information as required.

Summary of Key Issues The key issues: Meeting of the 20 July 2016

Review of Successful/Unsuccessful Tenders

Services Disaggregation/Mobilisation Update

Sustainable Development and Carbon Management Assurance Report

Due Diligence Findings Effectiveness Review Update Sustainable Transformational Plan Operational Plan Revised Workplan

Meeting of the 6 September 2016

Review of Successful/Unsuccessful Tenders

Capital Project Programme Board Assurance Report

Estates Strategy

Effectiveness Review Update

Risks to Raise










Yes

If yes, insert relevant risk BAF 16032401 Merger


No



Data Quality Issues N/A



Service Impact/Health Improvement Gains N/A




Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed?

Yes / No If yes, EIA Score


NHSI EOSC

NHS Improvement (formerly Monitor) Executive Operational Sub-Committee


Executive Lead

Lorraine Cabel, Chair



Agenda Item No: 6b (ii)

Board of Directors Meeting: 28.9.16


INVESTMENT AND PLANNING COMMITTEE

PURPOSE OF REPORT

This report is provided to the Board of Directors by the Chairman of the Investment and Planning Committee. It is designed to provide assurance to the Board of Directors that risks that may affect the achievement of the organisations objectives are being managed effectively.

EXECUTIVE SUMMARY

Investment & Planning Committee Meeting 20 July 2016 and 6 September 2016 Meeting of the 20 July 2016 The Investment and Planning Committee met on the 20 July 2016 and approved the minutes of the meeting held on the 18 May 2016. These are available to Board members on request. At the meeting held on 20 July 2016 the following matters were discussed:

1. Review of successful/unsuccessful tenders – Tenders in Progress There are 13 tenders in progress.

Unsuccessful Tenders The Trust was unsuccessful in the following tenders:

Diabetes Services – However, Trust has been approached to trail a 2 year diabetes service.

Community Dental Essex

Successful Tenders

The Trust was awarded the tender for Whipps Cross.

2. Services Disaggregation/Mobilisation Update – Essex Sexual Health – The new service was launched on the 1 April 2016. Whipps Cross – The service went ‘live’ on the 19 July. The Trust was successful in negotiating an extended contract of 15 months from 9 months to allow the Trust to operate effectively and safely.



3. Sustainable Development and Carbon Management Assurance Report The Sustainable Development and Carbon Management Assurance report was presented to the Investment and Planning Committee. The report highlighted the following:

Terms of Reference – The terms of reference are to be reviewed in September 2016.

Group will recommend opportunities and highlight risks arising from Sustainable Development.

An updated Strategy will be developed in line with changing recommendations from the Sustainable Development Unit and legislation with an intermediate Holding Document pending the decision to merge with North Essex

Change of funding from annual budget to case by case funding through an agreed and prioritised investment programme.

4. SEPT/NEP Merger

Proposed New Name At the Board of Directors meeting held in June the Board approved the recommendation of the Merger Project Board that staff and stakeholders of both organisations should be consulted on the name of the new organisation adopting Essex Partnership University NHS FT as the preferred option. It was noted that a paper is also being presented to the NEP Board on the 20 July with regard to the proposed name of the new organisation. Due Diligence PwC have been asked to undertake a review of the due diligence process to provide additional assurance to Trust Boards that all reasonable steps have been taken to identify risk to the transaction. It was noted that PwC will be producing a full assurance report for the Merger Project Board to be held on the 25 July.

The Due Diligence Findings were discussed in Part II of the Investment Committee. Full Business Case

The Full Business Case is in the process of being prepared and audit and support is being requested.

5. Effectiveness Review Update

There has been good progress being made with the actions relating to the terms of reference that are being taken forward by the Working Group which was established to review the thematic action plan. There are no overdue actions and those due by September are expected to be delivered on time and an update report will be provided at the Investment & Planning Committee.

6. Sustainable Transformational Plan

The above report was discussed and noted.

7. Annual Planning Timetable 2017/18 The Committee approved the timetable for 2017/18 Annual Planning Cycle.

8. Revised Workplan 2016/17 The workplan has been revised to include the following:

Governors will be invited to consider the first draft FBC in September 2016 and the final FBC in November 2016.

The annual review of the IM&T Strategy has been moved from July 2016 to December 2016.



At the meeting held on 6 September 2016 the following matters were discussed: The Investment and Planning Committee met on the 6 September 2016 and approved the minutes of the meeting held on the 20 July 2016. These are available to Board members on request. At the meeting held on 6 September 2016 the following matters were discussed:

1. Review of successful/unsuccessful tenders –

Tenders in Progress There are 14 tenders in progress.

Unsuccessful Tenders The Trust was unsuccessful in the following tenders:

Interim Community Forensic Services. A meeting is to be held with commissioners to receive feedback.

2. Capital Project Programme Board Assurance Report

The above report was presented to the Investment and Planning Committee and highlighted the following:

Terms of Reference – The revised Terms of Reference acknowledged that there is a requirement for clinical representation at the meeting, and asked that Andy Brogan, Executive Director of Mental Health and Executive Nurses, allocates an appropriate senior level speciality nurse to attend. All amendments were noted and agreed.

Capital Bids Options Appraisal Form – The revised form was approved.

Maple Ward Garden and Cedar Ward Garden – Bids were approved.

Maple Ward Environment – Awaiting further breakdown of costs before bid is approved.

3. Estates Strategy

Due to the potential merger an Essex wide Estates Strategy is to be prepared.

4. Effectiveness Review Update A paper is to be presented to the Finance and Performance Scrutiny Committee and

the Board of Directors meeting in September.

5. Risks to Raise

It was noted that the timetable for theFull Business Case is to be raised as a risk and

would be discussed further under Part II.

Management of Risk This committee is not responsible for managing any of the Trusts’ significant risks (as identified in the Board Assurance Framework). New Risks The Timetable and resource for the proposed merger was identified as a risk. This has been added to the Full Business Case and the Merger Risk Register.



ACTION REQUIRED

The Board of Directors are asked to:

1. Note the summary of the meeting held 20 July and the 6 September 2016.

2. Confirm acceptance of assurance given in respect of risk and the action identified.

3. Request further action/information as required. Lorraine Cabel Chair of Investment and Planning Committee

Assurance Report – Audit Committee


Agenda Item No:6b (iii)

SUMMARY REPORT

BOARD OF DIRECTORS MEETING

PART 1

28 September 2016

Report title: Board of Directors Audit Committee Assurance Report

Executive Lead: Janet Wood, Chair

Report Author(s): Carol Riley, Audit Committee Secretary


Assurance reports provided to the Board following Audit Committee meetings.



To provide assurance to the Board that the duties of the Audit Committee, which include Governance, Risk Management and Internal Control, have been appropriately complied with.

Approval

Discussion

Information


1. To note the contents of the report 2. To confirm acceptance of assurance given in respect of risks and actions identified 3. To request further action/information as required.


The key issues discussed at the meeting held on the 14 September 2016.

Internal Audit Progress Report

Fraud Awareness Survey

LCFS Standard Self Review Tool

Letter to Governors for year ended 31 March 2016

Health Sector Audit Committee Briefing

Annual Review of Audit Services

Extension of SFIs, SOs and Scheme of Delegations

Waiver of Standing Orders

2016/17 Costing Assurance Audit

Finance Procedures

Audit Committee Chairs Activity

Audit Committee Chair’s Annual Report










No



No



Data Quality Issues





N/A





No If yes, EIA Score No



ECFO Executive Chief Finance Officer


Executive Lead

Janet Wood Audit Committee Chair



Agenda Item: 6b (iii) Board of Directors

Meeting: 28.9.16

SEPT

ASSURANCE REPORT FROM THE AUDIT COMMITTEE CHAIR PART ONE


This report is provided by the Chair of the Audit Committee, a sub-committee of the Board of Directors to provide assurance to Board members that the duties of the Audit Committee which include Governance, Risk Management and Internal Control have been appropriately complied with.

2.0 EXECUTIVE SUMMARY

Audit Committee meeting 14 September 2016 The Audit Committee met on the 14 September 2016 and approved the minutes of the meeting held on 24 May 2016. These minutes are available to Board members on request. At the meeting held on 14 September 2016 the following matters were discussed:

1. Internal Audit and LCFS

Internal Audit Progress Report: 2015/16 audit work is now complete. For 2016/17 3 final audit reports have been completed, one draft report and eight audits are in progress. LCFS: Members received an update on LCFS work. It was noted that since the last meeting held in May 2016 there has been one referral made and one re-referral. Fraud Awareness Survey - 77 responses have been received overall. LCFS Standard Self Review Tool – The Trust’s overall rating is ‘Green’ which is good.



2.Report from Ernst & Young (External Auditors)

Letter to Governors for the year ended 31 March 2016 External Audit presented the above report which is due to be presented to the Council of Governors at their meeting to be held on the 5 October. Health Sector Audit Committee Briefing External Audit presented the above report and requested the Committee consider the following:

Impact of the UK’s decision to leave the EU

Do we have procedures in place to appoint an external auditor

Off payroll working

Annual self assessment

Views on the 2017/18 National Payment Tariff

3. Annual Review of Audit Services The Trust continues to receive a good level of service from both our internal auditors, Mazars and our external auditors, Ernst and Young.

4. Extension of SFIs, SOs and Scheme of Delegations

The Committee approved the above to remain in use for the remaining six months of the financial year and the review date to be extended to April 2017.

5. Waiver of Standing Orders: The Committee noted that the standing orders for competitive quotations were waived on two occasions to the value of £26,924. There were no waivers of standing orders in relation to competitive tenders.

6. 2016/17 Costing Assurance Audit A report was presented with regard to the 2016/17 costing assurance audit and the implications for the Trust. It was noted that there would be an audit of costing arrangements, for selected Trusts, during 2016/17 and that this would be conducted by Ernst & Young (E&Y). The report highlighted the following:

The reference costs submission audit should not find any significant issues. Any recommendations should be easy to accommodate.

The implementation of PLICS is effectively on hold until after the merger. The merger gives us the opportunity to review the whole costing function (guidance, requirements and resources) to produce a system that will deliver to NHS Improvements outcomes.

It was agreed that the 2016/17 Costing Assurance Audit would be a standing item on the agenda until the outcome of the process is known.



7. Finance Procedures The following finance procedures were approved: - Patient/Client Property and Money Procedure - Fraud, Theft and Corruption

8. Audit Committee Chairs Activity:

The Audit Committee Chair reported that no issues had been raised with the internal and external auditors.

9. Audit Committee Chair’s Annual Report The above report is attached as appendix 1.

3.0 MANAGEMENT OF RISK

The Audit Committee is not responsible for managing any of the Trust’s significant risks (as identified in the Board Assurance Framework).

4.0 NEW RISKS

There are no new risks that the Audit Committee has identified that require adding to the Trusts’ Assurance Framework, nor bringing to the attention of the Board of Directors.

5.0 ACTION REQUIRED

The Board of Directors are asked to:

1. Note the summary of the meeting held on 14 September 2016

2. Confirm acceptance of assurance given in respect of risk

3. Request further action/information as required.

Janet Wood Non Executive Director Chair of Audit Committee



Appendix 1


AUDIT COMMITTEE CHAIR’S REPORT FOR THE ACCOUNTING PERIOD APRIL 2015 TO END MARCH 2016

PURPOSE OF REPORT

This report provides the Board of Directors with a review of the progress undertaken in dealing with Audit Committee matters covering the 2015/16 financial year.

The Audit Committee is comprised of four Non Executive Directors, with myself as Chair.

INTRODUCTION

Apart from the Committee’s regular work which is identified in a later section, there were six areas which required exceptional input from the Committee. They were:

The accounting arrangements on the disaggregation of Bedford and Luton mental health services from SEPT

Internal Audit and LCFS tender

Extension of external audit contract

Committee efficacy review

Merger with NEP Bedford and Luton Procurement Process – Due Diligence On 1st April 2015 mental health services in Bedford and Luton transferred from SEPT to ELFT. The external auditors carried out some early work in 2015/16 to assure the Audit Committee on the accounting treatment of the disaggregation, this included complex accounting transactions in respect of estates transfer and the exit arrangements from the Local Government Pension Scheme.

Internal Audit and Local Counter Fraud Services Tender The committee market tested internal audit and counter fraud services in 2015/16. A one year contract (with the possibility to extend for a further year) was awarded to Mazars for both services. A one year contract was deemed appropriate in light of the impending merger with NEP.



Extension of External Audit contract

The committee considered the ongoing arrangements in respect of external audit. SEPTs current external auditors, Ernst and Young, were in their 5th year on contract in 2015/16. The Trusts Standing Financial Instructions state ‘the NHSFT will undertake a market testing exercise for the appointment of the external auditor at least once every five years’. In light of this, the Audit Committee sought the Board of Directors approval in March 2016 to waive standing financial instructions in this respect. This was on the basis that the 2016/17 financial year could be the last year prior to merger and the Trust could potentially lose the benefits around continuity of external audit provider if a market testing exercise was undertaken. The 2016/17 financial year will be a challenging year in terms of additional risks and advice required for the merger, and the knowledge base which the current provider holds on the Trust would mean any advice sought would be based on a firm understanding of the Trust. The Board agreed to waive standing orders. The Governors will be asked to approve the extension of the current contract with Ernst and Young for the financial year 2016/17 at the Council meeting on 13th September 2016. Committee efficacy review During 2015/16 the effectiveness of all the Boards standing committees was reviewed. Positive feedback was received in relation to the effectiveness of the Audit Committee. There were no recommendation for change/improvement. Merger with NEP During 2015/16 SEPT have entered into a merger process with NEP, with a view to merging on 1st April 2017. The audit committee will play an important role in ensuring that the process and procedures undertaken in respect of the merger follow appropriate governance and best practice. The Committee received its first update in relation to the merger at its May 2016 meeting, covering arrangements for procurement of advisors, arrangement for due diligence and merger project board budget. The committee will receive ongoing updates throughout the process. The committee will continue to seek assurance from both internal and external auditors that the approach to merger is appropriate. Regular Work and Other Issues In common with previous years the remaining work of the Audit Committee can be summarised as follows:

consideration and agreement of the Trust’s external and internal audit plans

reviews of internal and external audit reports

consideration of the Trust’s financial accounts before presentation to the Trust Board

receiving the Annual Governance statement from the Chief Executive

twice yearly review of risk management and assurance arrangements

consideration of the Trust’s charitable fund accounts for presentation to the Board

consideration of the annual audit letter issued by the Trust’s external auditors



monitoring of recommendations from both internal audit and external audit reports

review of the Standing Financial Instructions and related documents

reviewing bad debt write offs and waivers to standing orders and standing financial instructions

the receipt and debate of regular assurance reports

receipt and debate of counter fraud reports from the counter fraud specialist

receipt and debate of local security management services reports

Clinical Governance reports presented to the Committee appropriate Directors

Approval of financial policies and procedures

regular review of the Audit Committee’s terms of reference

regular report on the Audit Committee Chair’s activities

Review the use of management consultants and legal advisors The Audit Committee Chair continues to meet with the Trust’s Accounting Officer on a regularly to discuss any issues arising from Audit Committee meetings. The Audit Committee Chair also meets with the appropriate Directors to review matters associated with assurance in relation to patient safety and quality. The Audit Committee Chair also meets regularly with both sets of Auditors for private discussions.

ACTION REQUIRED

The Audit Committee is asked to approve the contents of this report. Janet Wood Chair of the Audit Committee

Agenda Item No: 7a(i)

SUMMARY REPORT


28 September 2016

Report title: Merger between North Essex Partnership University NHSFT and South Essex Partnership University NHSFT: progress report

Executive Lead: Nigel Leonard, Executive Director Corporate Governance

Report Author(s): Tom Wilson, Interim Project Manager

Report discussed previously at: Merger Project Board

Level of Assurance:

Level 1

2 3


This paper updates the Board on the work to pursue a merger between North Essex Partnership University NHS Foundation Trust (NEP) and South Essex Partnership University NHS Foundation Trust (SEPT).

Approval Discussion Information


The Board is asked to: ‐ note the general update on the merger plan ‐ confirm the name of the merged organisation as Essex Partnership University NHS

Foundation Trust


Update This paper provides a brief update on the progress of the merger project covering due diligence, the development of the Full Business Case and engagement with stakeholders. Proposed Name of New Organisation Following engagement with staff and stakeholders the Board is asked to confirm its recommendation that the new organisation is named Essex University Partnership NHS Foundation Trust.


SP 1: Quality Services SP 2: Quality Leadership & Workforce SP 3: Sustainability of Service Provision SP 4: Innovative & Transformational Approach to Efficiency and Effectiveness



Yes

If yes, insert relevant risk BAF 16032401


No the existing BAF entry has been updated to reflect the current situation.



Data Quality Issues Involvement of Service Users/Healthwatch Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains Financial Implications Capital £ Revenue £ Non Recurrent £

TBC

Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed?


A formal Equality Impact Assessment (EIA) will be commenced in May.

TBC


LTFM Long Term Financial Model

NHSI NHS Improvement (formerly Monitor)

OD Organisational Development

PMO Programme Management Office

PTIP Post Transaction Implementation Plan


Executive Lead

Nigel Leonard Executive Director Corporate Governance, SEPT

Board Report September 2016 Page 1 of 2

Agenda item 7a(i) Board of Directors Meeting: Part 1

28th September 2016

MERGER BETWEEN NORTH ESSEX PARTNERSHIP UNVERSITY NHS FOUNDATION TRUST & SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

1 PURPOSE OF REPORT This paper provides an update on the progress of the merger between North Essex Partnership University NHS Foundation Trust (NEP) and South Essex Partnership University NHS Foundation Trust (SEPT). 2 EXECUTIVE SUMMARY Update Due Diligence Since the last public update of the merger in July 2016 the formal due diligence process has been completed and submitted by the Merger Project Board to Trust Boards and Council of Governors for consideration. PricewaterhouseCoopers (PwC) have been engaged to support the merger work and were asked to undertake a quality assurance review of the due diligence process that was undertaken by in-house teams and their report was also submitted.

Overall the recommendation from the Merger Project Board and accepted by both Trust Boards was that no risks had been identified from the due diligence process that changed the underlying rationale for merger or should impact on the timetable. Further work to answer some outstanding queries noted from the July reports has now been completed and the formal due diligence phase has now been closed. All risks noted as part of the due diligence exercise have been added to the merger risk register and will be addressed as part of the Full Business Case (FBC).

Full Business Case Work has commenced on the drafting of the FBC and the initial chapter structure and outline contents has been circulated for comment to the Merger Project Board. Prior to being submitted to the November 2016 Trust Board for approval, as a significant transaction the FBC will be scrutinised at SEPT’s Investment Committee, that will include relevant Governors from the Council of Governor’s Strategic Transactions Group, and will be considered at NEP’s Strategic Transactions Committee, that is a committee of the Council of Governors.

Further discussions with NHS Improvement (NHSI) have been held to clarify the timetable and process for the merger following submission of the FBC. Broadly speaking, NHSI’s teams will assess the FBC and supporting documentation through a series of site visits in December and January before a “Board to Board” meeting is held in February followed by NHSI giving the transaction a risk rating. The revised FBC will then come to the Trust Board for approval again before the transaction is approved by a vote of the Council of Governors.

Interim Board The process for the formal appointment of an Interim Board to manage the merger from the point of FBC to appointment of a substantive Board in September 2017 is underway and on schedule. The Interim Board will be appointed by the beginning of November.

Proposed name of the new organisation Significant engagement has taken place on the proposed new organisation’s name following the Trust Board’s recommendations in July.

Staff, Governors, members and the Proposed Merger Stakeholder Reference Group were offered three options:

Essex Partnership University NHS Foundation Trust (preferred by the Trust Boards) Anglia Health Partnership University NHS Foundation Trust Eastern Health Partnership University NHS Foundation Trust

Board Report September 2016 Page 2 of 2

There was considerable feedback from Bedfordshire-based staff that none of the options referenced Bedfordshire. Several people suggested that either the Anglia or Eastern options would better reflect the geographical spread of the proposed new organisation.

There was also some support for a new option, suggested by a staff member, of South East Partnership University NHS Foundation Trust. This was felt to be a more accurate geographical reference and to be “future-proofed” against potential expansion of the proposed new Trust.

A few comments suggested including “health”, “mental health” and “social care” within the name.

Nonetheless the overwhelmingly popular option with all stakeholders asked was Essex Partnership University NHS Foundation Trust and the Board is recommended to confirm this as the new name of the proposed new Trust.

Communications & Engagement Vision and Values Engagement with staff, Governors, members, services users, carers and the public on the proposed new visions and values recommended by the Board is ongoing, with the online survey deadline being extended to 3rd October 2016. Stakeholder Reference Group The first meeting of this group was held at the end of August. It was well attended and stakeholders seemed engaged and keen to be involved in merger proposals going forward. It was agreed that, in particular, members would be engaged on draft plans for clinical developments and on production of a Plain English summary version of the Full Business Case. A schedule of bi-monthly meetings is in production and members are self-selecting to the positions of chair and vice-chair of the group. Health Overview and Scrutiny Committees (HOSC) and Healthwatches Detailed progress reports were provided to Essex HOSC and Thurrock HOSC in advance of discussion of the merger at both HOSC meetings earlier this month.

Additionally, Southend HOSC has requested attendance at a meeting to update members on merger proposals in early October.

This engagement is in response to the update letters sent to all HOSCs from CEOs in July/ August 2016 as part of the comms and engagement plan.

An outcome of attendance at the HOSC meetings to date has resulted in communications and engagement of local Healthwatches to be added to the plan. 3 ACTION REQUIRED The Board is asked to: - note the general update on the merger plan - confirm the new name of the merged organisation as Essex Partnership University NHS

Foundation Trust 4 RECOMMENDATIONS The Board is asked to: - note the update. - confirm the new name of the merged organisation as Essex Partnership University NHS

Foundation Trust.

Report prepared by Tom Wilson Interim Project Manager

On behalf of

Nigel Leonard Executive Director Corporate Governance

Agenda Item No: 7c

SUMMARY REPORT

Trust Board of Directors

28 September 2016

Report title: Implementing the Five Year Forward View for Mental Health

Executive Lead: Nigel Leonard, Executive Director of Corporate Governance

Report Author(s): Gill Brice, Associate Director of Planning


Executive Team

Level of Assurance:

Level 1

2

3


To update the Trust Board of Directors on the recent publication, Implementing the Five Year Forward View for Mental Health.

Approval

Discussion

Information


To note the content of the report and the implications it has on the Operational Plan 2017/18.


Implementing the Five Year Forward View for Mental Health outlines the timeframes and funding to deliver the programmes of work which will transform mental health services. It provides detail on implications for workforce and how data and payments will be used to drive and monitor the change. The document sets out objectives to be achieved by 2020/21 in the following areas:

Children and Young People’s Mental Health

Perinatal mental health

Adult mental health: common mental health problems

Adult mental health: community, acute and crisis care

Adult mental health: secure care pathway

Health and Justice

Suicide Prevention

Sustaining transformation: Testing new approaches

Sustaining transformation: A healthy NHS workforce

Sustaining transformation: Infrastructure and hardwiring








No.


Do you recommend a new entry to No.

the Board Assurance Framework is made as a result of this report?



Data Quality Issues


Communication and Consultation with stakeholders required N/a


Financial Implications N/a

Governance Implications N/a

Impact on Patient Safety /Quality N/a

Impact on Equality & Diversity N/a


No If yes, EIA Score N/a


CYP Children and Young People

STP Sustainability and transformational plan


https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf

Executive Lead


https://www.england.nhs.uk/wp-content/uploads/2016/07/fyfv-mh.pdf

Agenda Item 7c Trust Board of Directors

28 September 2016

SEPT

IMPLEMENTING THE FIVE YEAR FORWARD VIEW FOR MENTAL HEALTH

1.0 PURPOSE OF THE REPORT

To update the Trust Board of Directors on the recent publication Implementing the Five Year Forward View for Mental Health from NHS England.


Introduction Implementing the Five Year Forward View for Mental Health outlines the timeframes and funding to deliver the programmes of work which will transform mental health services. It provides detail on implications for workforce and how data and payments will be used to drive and monitor the change. The plan is set out over 12 chapters. The first chapter frames the implementation against the backdrop of current and previous funding allocated in the context of the Five Year Forward View for Mental Health. Although the ambitions for NHS mental health care extend beyond 2020/21, the objectives discussed are the priorities for the next five years. The plan emphasises that trajectories and assumptions should be treated as indicative to support localities in developing their own implementation and delivery plans. An Annex to the plan also provides a tool for sustainability and transformational plan (STP) footprints to calculate their own pro-rata element of any national figures used. Children and Young People’s (CYP) The plan sets a number of objectives to be achieved by 2020/21 including the following:

70,000 additional CYP each year will receive treatment with at least 35 per

cent of those with diagnosable mental health conditions accessing NHS

community-based treatment.

95 per cent of children in need receive treatment for eating disorders between 1-4 weeks.

in-patient stays for children and young people will only take place

where clinically appropriate. The document outlines that the use of specialist in-patient beds for CYP should reduce drastically over the next five years due to investment in community-based services. The plan details that localities must ensure they are working with the existing Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT) programme to ensure a highly skilled workforce. NHS England state that the majority of new funding over the period is included in CCG baselines to support delivery of Local Transformation Plans and wider improvements in CYP

services. Additional funding for in-patient services will support temporary additional capacity whilst community services are developed and the commissioning model shifts towards localities. Perinatal The plan sets out that by 2020/21 more pregnant women or women who have given birth in the last 12 months will receive specialist perinatal mental health community or in-patient treatment. The expansion in provision of services will require the development of specialist evidence based community teams and in-patient mother and baby units. Workforce development will be supported by the creation of a competence framework by Health Education England (HEE) to ensure the correct skill mix in the workforce, by October 2017. NHS England state that by 2020/21, all teams should be sufficiently staffed to meet the recommended levels. The document details that the profile of funding will increase over the period, in phases, to allow for the development of new and improved services, including workforce requirements. Localities, including sustainability and transformation plans (STPs) are able to bid for a perinatal community development fund in the autumn of 2016/17 and NHS England will develop a plan for improving perinatal mental health data over the coming years. Common Adult mental Health Problems

The plan sets out that by 2020/21 at least 25 per cent of people (or 1.5 million) with common mental health conditions will have access to psychological therapies. The majority of new psychological therapy services will be integrated with physical healthcare, and co located with primary and community care. NHS England detail that funding to support the growth in these services will be held centrally until 2018/19, when it will then be added to CCG baselines. In 2016/17 and 2017/18 targeted areas will be chosen to help develop the evidence base for services at scale. Adult mental health community, acute and crisis care

The plan sets out the following objectives to be achieved by 2020/21:

adult community mental health services will provide timely access to evidence- based, person-centred care, which is focused on recovery and integrated with primary and social care and other sectors.

crisis resolution and home treatment teams should be delivering best practice CORE standards and inappropriate out of area treatments (OATs) should be eliminated. NHS England is working with stakeholders to create a national definition of OATs, so that localities can correctly monitor levels by March 2017.

The document outlines that an extra £15 million will be made available through a bidding process in 2016/17 and 2017/18 to improve health-based places of safety, and transformation funding for mental health liaison will be made available from 2017/18. Mental health liaison is expected to become self-sufficient within 12 months.

Further detail on proposed delivery models for physical health checks for people with severe mental illness will be published by December 2016.

Adult mental health: secure care pathway The plan sets out that by 2020/21 NHS England will lead a comprehensive programme of work to increase access to high quality care that prevents avoidable admissions and supports recovery for people, as close to home as possible. NHS England detail that they will invest £94 million centrally from 2017/18 to 2020/21 in community-based services to help reduce admissions, with the allocation of this money decided through a bidding process.

Health and Justice The plan sets out the following objectives to be achieved by 2020/21:

there will be improvement in mental health care pathways across the secure

settings access to liaison and diversion (L&D) services will be increased to reach 100

per cent of the population, whilst continuing to ensure close alignment with police custody healthcare services.

The document details that to deliver the planned expansion there may need to be a 45 per cent increase in the relevant workforce. NHS England has stated that they will be working with HEE in order to achieve this.

The funding to achieve this objective will be held centrally, and work is underway to evaluate the savings that increased L&D services will achieve for the justice system. Suicide Prevention The plan sets out that by 2020/21 the number of people taking their own lives will be reduced by 10 per cent nationally compared to 2016/17 levels.

NHS England recognise that this objective is a complex public health challenge and will require multi-agency work. By 2017 CCGs will fully contribute to the development and delivery of local multi-agency suicide prevention plans together with local partners. Funding will be held centrally, and transferred to CCGs in 2018/19, with more detail on the allocations released in 2017/18. Sustaining transformation: Testing new approaches The plan sets out that by 2020/21 the amount of people sent far from home to receive treatment will reduce resulting in savings and increase recovery rates.

In 2016/17 a programme will start which gives clinicians and managers responsibility for both the budget and the provision of secondary and tertiary care. Six sites have been selected for a 12 month pilot. These areas will be pump-primed with £1.8million in 2016/17. Subsequent funding will be made available subject to evaluation of the first year of the programme. Sustaining transformation: A healthy NHS workforce The plan sets out that by 2020/21 there will be a focus of the health and wellbeing of the workforce to improve satisfaction, productivity and retention.

In March 2016 NHS England introduced a £450 million financial incentive focused on improving staff health and wellbeing across the NHS. Mental health support for staff working in the NHS is a key part of this scheme. Providers can access part of this money by developing a plan to support staff, implementing mental health initiatives and ensure uptake and locally agreed access metrics are met.

Sustaining transformation: Infrastructure and hardwiring

The plan sets out the activity necessary to align the frameworks and infrastructure, including governance, accountability and transparent reporting across five areas: 1. workforce planning 2. data and transparency 3. payment, outcomes and other system levers 4. innovation and technology 5. governance and accountability

NHS England’s Support Offer The document details NHS England’s leadership system level support and outlines the work underway across a range of areas. The document states that NHS England will work with arms-length boards to develop evidence based treatment pathways and the supporting infrastructure. Planning will span referral to recovery with common activities, including expert reference groups, RTT standards, types of intervention and outcomes, specification of dataset changes required for monitoring, gap analysis, workforce strategy development, implementation guidance and the design of levers, incentives and payment models. NICE will also provide support.

Implications for SEPT

SEPT continues to be actively involved in the three system wide STPs being developed in each health economy, and is working with our Commissioners in relation to their integrated models for health.

In addition the Trust has worked as part of an Essex wide bid for the community perinatal investment monies outlined in the Implementing the Five Year Forward View for Mental Health document. This is an area which SEPT already has experience in.

The Trust continues to pursue the merger with North Essex Partnership University NHS foundation Trust (NEP). As part of that work the Trusts have set up a number of working groups looking at the clinical benefits. This includes focusing on the areas of priority for the commissioners, and considering new pathways and models of care which allow the new organisation to achieve the objectives set out in Implementing the Five Year Forward View for Mental Health. The commissioners have advised that their new mental health strategy due to be published later this year is based on the Five Year Forward View for Mental Health and this will inform the commissioning intentions accordingly.

3.0 RECOMMENDATION

The Trust Board of Directors is asked to consider the content of this report and the implications it has for the Operational Plan 2017/18 and the system wide STPs.

4.0 ACTION REQUIRED:

The Trust Board of Directors is asked to consider and note this report. Report prepared by Gill Brice, Associate Director of Planning On behalf of:

Nigel Leonard, Executive Director of Corporate Governance

1

Agenda Item No: 8(a)

SUMMARY REPORT


29 September 2016

Report title: Board of Directors Governance Update Executive Lead: Nigel Leonard, Executive Director Corporate Governance

Report Author(s): Cathy Lilley, Trust Secretary


Level of Assurance:

Level 1

2

3


The purpose of this report is provide an update on a range of governance and procedural issues that require the Board’s attention.

Approval

Discussion

Information


1 To note the contents of the report 2 Agree that a full update report on the actions identified following the Board of Directors

Standing Committees annual effectiveness review be presented at the October Board meeting

3 To request any further information or action.


The Board of Directors Governance Update report includes a number updates to be brought to the Board’s attention including:

Single Oversight Framework has been published setting out the approach to how NHSI will oversee FTs and Trusts to help determine the level of support needed to deliver high quality, sustainable healthcare services with the aim of helping providers attain and maintain CQC ratings of ‘good’ or ‘outstanding’. There are five themes – quality of care, finance and use of resources, operational performance, strategic change, and leadership and improvement capability, and providers will be placed in one of four segments that will help determine the level of support required.

National Code on Conflicts of Interest: A consultation has been launched on proposals to strengthen the management of conflicts of interest to clamp down on inappropriate behaviour to ensure that the NHS is one of the leading healthcare organisations in the world in tracking these issues.

Culture and Leadership: NHSI and the King’s Fund have published tools and supporting guidance to help with diagnosing current culture and targeting the right areas for collective leadership. In addition, NHSI is developing a strategy for supporting whole Board development that reflects the Well-led framework and the Healthcare Leadership Model.

Care Models, MCPs, STPs: A Q&A document has been published by NHSI on the new care models; NHSE has produced a new framework outlining how place-based partnerships can replicate the work of the MCP vanguards when establishing their own programmes. NHSE has also published a support guide involving and engaging with local people in the development of STPs.

Financial: NHSI has produced a financial ‘reset’ describing new financial special measures for Trusts; NHSE and NHSI have also published policy proposals on the national tariff for the next two years; and the Healthcare Education and Training tariff has now been published.

Board of Directors Committees’ Effectiveness Review: Good progress continues to

2

be made with the implementation of the action plan. However, it is proposed that a full update is now provided at the October Board meeting; this will not take account of the findings/good practice from the PwC well-led review of NEP as originally planned as there has been a delay with publishing and sharing the report.

Legal & Policy Update Report is available on request from the Trust Secretary.







Are any existing risks in the Board Assurance Framework affected? No

If yes, insert relevant risk n/a


No




Communication and Consultation with stakeholders required Service Impact/Health Improvement Gains


N/A


Impact on Equality & Diversity Equality Impact Assessment (EIA) Completed? No If yes, EIA Score

Acronyms / Terms used in the Report

CQC Care Quality Commission NHSE NHS England

TDA Trust Development Authority FT Foundation Trusts

SOF Single Oversight Framework NHSI NHS Improvement

MCP Multispeciality Community Provider PwC Pricewaterhouse Coopers

STPs Sustainability & Transformation Plans


Main report Legal & Policy Updates

Non-Executive Lead

Nigel Leonard Executive Director Corporate Governance



Agenda Item 8(a) Board of Directors Meeting Part 1

28 September 2016

BOARD OF DIRECTORS GOVERNANCE UPDATE

1 Purpose of Report

The purpose of this report is to provide an update on a range of governance and procedural issues that require the Board’s attention.

2 Executive Summary

2.1 Proposed Single Oversight Framework As reported in July, NHS Improvement (NHSI) has now published its new Single Oversight Framework (SOF) that sets out how the approach to overseeing NHS FTs and NHS Trusts to help determine the level of support they need to deliver high quality, sustainable healthcare services. It aims to help providers attain and maintain CQC ratings of ‘good’ or ‘outstanding’; it does not give a performance assessment in its own right. The SOF will help NHSI identify providers’ potential support needs across five themes:

Theme Overview of oversight measures

1 Quality of care

NHSI will use CQC’s most recent assessments of whether a provider’s care is safe, effective, caring and responsive

In-year information where available

Delivery of the four priority standards for 7-day hospital services

2 Finance and use of resources

Focus on a provider’s financial efficiency and progress in meeting its control total

Use of resources approach is being co-developed with CQC

3 Operational performance

NHS constitutional standards and other national standards

4 Strategic change How well providers are delivering the strategic changes set out in the Five Year Forward View with a particular focus on STPs, new care models and devolution (where relevant)

5 Leadership and improvement capability (well-led)

Building on their well-led framework, CQC and NHSI will develop a shared system view of what good governance and leadership looks like, including ability to learn and improve

Providers will be placed in one of four segments that will help determine the level of support required: maximum autonomy, targeted supported, mandated support, and special measures. NHSI will be meeting with the Trust following their completion of a shadow segmentation on how we would have performed under the framework over



the last two months. The whole sector’s shadow segmentation will be circulated in early October. The SOF marks a significant shift from the previous regulatory and accountability frameworks operated by Monitor and the Trust Development Authority (TDA). It offers potential to align regulation with the CQC and introduces a greater emphasis on improvement and support. The SOF will be operational from 1 October; however, it is expected that the shift in approach will be gradual and NHSI will need to remain cognisant of the different statutory bases of FTs and Trusts, and to ensure due separation between its own functions, i.e. regulatory intervention and support. 2.2 National Code on Conflicts of Interest NHS England (NHSE) has launched a major consultation on proposals to strengthen the management of conflicts of interest, clamp down on inappropriate behaviour and ensure that the NHS is one of the leading healthcare organisations in the world in tackling these issues. All NHS organisations will be required to run a register that lists potential conflicts of interest held by staff such as hospitality received, involvement in sponsored events and private business interests. This will include the requirement for doctors to reveal the amount of money they earn from private work. There is a six-week consultation period which provides an opportunity for all interested parties to make their voices heard about these proposals which cover gifts, hospitality, employment, sponsorship and other interests. In March this year, NHSE set up a group to look into developing a stronger approach to managing conflicts of interest, both real and perceived. Their proposals include:

Setting out what is and is not acceptable in relation to individual types of interest such as the need to seek prior approval from the employing NHS organisation for any outside employment

The processes by which interests should be identified and conflicts of interest managed appropriately, for example ensuring all senior staff complete an annual declaration of interest

Information which NHS organisations must publish in relation to the interests of their staff

Ensuring that staff and others understand what constitutes both interests and conflicts of interest as well as the circumstances in which they can occur

The processes which organisations should have in place to ensure they appropriately manage any breaches of conflicts of interest policy.

Guidance from the centre will be issued following the consultation to support with ensuring effective implementation of the plans. A review on the implications to the Trust and how the requirements will be implemented will be undertaken once the guidance is issued, and an update will be provided to the Board.



2.3 Creating a Culture and Leadership Programme NHSI and The King’s Fund have published tools and supporting guidance to help Trusts diagnose their current culture and target the right areas for collective leadership strategy. These tools form the first phase of a two-year programme that is aimed at developing cultures that enable and sustain continuously improving, high quality care. 2.4 Effective Leadership NHSI is developing a strategy for supporting whole Board development that reflects NHSI’s Well-led framework and NHS Leadership Academy’s Healthcare Leadership Model. NHSI is currently offering support with making Non-Executive Director appointments including:

access to a talent database of people across the country who are interested in non-executive roles

publishing details of vacancies on both NHSI’s and Cabinet Office’s websites

support to improve the diversity of Boards, including help to achieve the goal of 50/50 gender balance on all NHS Boards by 2020.

2.5 STPs: Engaging Local People: local plans for local people – communicating change NHSE has produced a guide for local areas to use to support them in involving and engaging with local people in the development of Sustainability & Transformation Plans (STPs). Aimed at STP communications leads and footprint leaders, the guidance clarifies the level of patient and public participation expected and highlights that this needs to be done effectively to avoid a risk of legal challenges and delays. The guidance also highlights the potential positive benefits of involving people, communities and stakeholders in developing STPs, suggesting that it leads to better quality plans and a range of insights.

2.6 Multispeciality Community Provider Framework A new framework from NHSE outlines how place-based partnerships can replicate the successful work of the 14 multispeciality community provider (MCP) vanguards when establishing their own programmes. The MCP vanguards will move specialist care out of hospitals and into the community, removing the divides between primary, community, mental health, social care and acute services to provide efficient, joined-up and preventative care. 2.7 Oversight of New Care Models: Questions Answered As reported at previous Board meetings, the new care models programme is delivering a key element of the NHS Five year forward view and NHSI is working to support innovative change. NHSI is working with national partners and a number of vanguards to identify potential issues and develop and test solutions for providers. NHSI has published a new document that aims to tackle questions it has received on its oversight and outlines what other guidance and support it can give. The document covers issues such as integration and competition, transition to a new care model, oversight of new care models, alignment of oversight among arm’s length bodies, and governance issues. The document will be periodically updated to address any issues and questions that may continue to emerge.



2.8 Strengthening Financial Performance and Accountability in 2016/17 A financial ‘reset’ describing new financial special measures for Trusts has been published by NHSI. The rest restates the criteria for accessing sustainability funding in 2016/17 and also restates a series of ‘practical’ measures designed to help cut the provider deficit in 2016/17. 2.9 Two-Year Tariff Proposals NHSE and NHSI have published policy proposals for the 2017/18 and 2018/19 national tariff which would see national prices set until 2019/20 – which is a break away from the traditional one-year planning cycle. The proposals which include changes to local payment rules for mental health, which are currently being consulted on, could help stabilise NHS planning during a difficult period of transformation. 2.10 Healthcare Education and Training Tariff As reported at the July Board meeting, the awaited Healthcare Education and Training tariff has been published and sets out the national tariffs for healthcare education and training placements in the academic year 2016 to 2017, how the tariffs will be implemented, and in what circumstances the national tariffs may be varied and how to do this. 2.11 Board of Directors Committees’ Effectiveness Review At its meeting in April 2017, the Board received an update report on the findings of its standing committees’ effectiveness following a comprehensive review that had taken account of the individual standing committees’ reviews, the findings of a supplementary questionnaire completed by Board members for committees where they were not a member and the independent committee governance structure reviews undertaken in June 2015 and more recently 2016. The Board is reminded that the reviews indicated that there is an extremely positive view that the committees are operating in line with their terms of reference and demonstrate assurance, challenge, scrutiny and monitoring in respect of supporting the effective working of the Board. As reported at the June meeting, good progress has been made with the implementation of the action plan that had been developed to take forward the recommendations to enhance the Board committee structure effectiveness. The Board agreed that a full report would be provided at its September meeting as this would provide the opportunity to take account of any learning and/or good practice identified following the merger governance due diligence review, and in particular the independent well-led review on North Essex Partnership University NHS FT (NEP) undertaken by Pricewaterhouse Coopers. The Board is aware, however, that this report has not been finalised and therefore not shared with the Trust. It is therefore recommended that a full update report is presented at the October Board meeting that will not take into account the findings/good practice from the well-led report. 2.12 Legal & Policy Update This report is continued to be produced weekly and discussed at the Executive Operational Sub-Committee (EOSC). Copies are available on request from the Trust Secretary.



3 Action Required


1 Note the contents of this report 2 Agree that a full update report on the actions identified following the Board of

Directors Standing Committees’ effectiveness review is presented at the October meeting

3 Identify any further action. Report prepared by Cathy Lilley, Trust Secretary On behalf of:

Nigel Leonard Executive Director Corporate Governance 28 September 2016

1

Agenda Item No: 8b

SUMMARY REPORT

BOARD OF DIRECTORS

PART I

Report title: Senior information Risk Officer (SIRO) Annual Report (2014/2015)

Executive Lead: Mark Madden

Report Author(s): Alice Williams, Information Governance Manager

Report discussed previously at: Information Governance Steering Committee



To present the Annual SIRO report on the activity and achievements of the Information Governance Agenda 2015/16 and to provide assurance / progress on developments

Approval

Discussion

Information

Recommendations / Action Required To discuss and note the comments of the report.


The purpose of this report is to document organisational compliance with legislative and regulatory requirements relating to the handling of information, including compliance with the Data Protection Act 1998, Freedom of Information 2000, compliance with the Information Governance (IG) Toolkit and provide assurance of ongoing improvement to managing risks to information.








None



N/A


Impact on CQC Regulation Standards, Commissioning Contracts, Trust Annual Plan &

2

Objectives





Governance Implications Impact on Patient Safety /Quality Impact on Equality & Diversity


Yes / No If yes, EIA Score N/A


SIRO Senior Information risk Officer

IT&T Information technology & Telecommunications

IG Information Governance

HSCIC Health & Social Care Information Centre

OLM On line Mandatory

PIA Privacy Impact Assessment

ICO Information Commissioners Office


Executive Lead

Mark Madden Executive Chief Finance & Resources Director Senior Information Risk Officer (SIRO)

3

Agenda Item: 8b

Board of Directors Meeting: 28.9.16


FINANCE AND RESOURCING DIRECTORATE

ANNUAL SENIOR INFORMATION RISK OFFICER (SIRO) REPORT


The purpose of this report is to document organisational compliance with legislative and regulatory requirements relating to the handling of information, including compliance with the Data Protection Act 1998, Freedom of Information 2000, compliance with the Information Governance (IG) Toolkit and provide assurance of ongoing improvement to managing risks to information. The report will detail any Serious Untoward Incidents within the previous twelve months, relating to any losses of personal data or breaches of confidentiality. The report will outline the direction of information governance work during 2015/16 and how it aligns with the strategic business goals of having “quality services”, a “quality workforce” and “innovative and transformational approach to efficiency and effectiveness”. This report will also highlight some of the IG work streams taking place during 2016/17.

2.0 INFORMATION GOVERNANCE BACKGROUND

All Trusts are mandated to meet the requirements set out in the IG Toolkit. A minimum of level 2 compliance was needed to be reached by the 31st March 2016, so that the Trust is Information Governance compliant. The Trust submitted the Toolkit on the 31st March 2016 and met the level 2 requirement.

3.0 INFORMATION GOVERNANCE ASSURANCE FRAMEWORK 2016/17

The Trust needed to carry out a baseline assessment against the 45 Information Governance requirements in July 2016. The Trust submitted the baseline assessment on 31st July 2016. Actions will now be identified to ensure evidence collected to support each requirement is reviewed and up to date. The compliance for each requirement will need to be submitted in October 2016. This will require existing evidences to be reviewed and amended/updated as necessary. Following the submission in October 2016, further actions will be identified and where possible scores will be increased or gaps identified. The Trust will submit its IG Toolkit return, for general publication, before the end of March 2017.

4

4.0 ACCOUNTABILITY

The Trust has the following governance structure in place to support the Information Governance agenda;

Reporting structure:

IG Framework Supporting Job Roles Senior Information Risk Officer (SIRO) Caldicott Guardian Director of ITT Deputy Director of ITT Associate Director of System Implementation & Data Quality Associate Director of Systems Development Assistant Director of IT Strategy & Technical Projects Associate Director of IT Service Delivery Head of Records Management Head of Legal Services FOI, DPA & Litigation Lead Information Governance Manager Records Manager Information Governance Administrators Associate Director of Business Analysis

5.0 STATUS OF ORGANISATIONAL COMPLIANCE 2015/16

The version 13 IG Toolkit online submissions are;

Baseline 31st July 2015 Status: Complete

Performance Update 31st October 2015 Status: Complete

Final 31st March 2016 Status: Complete The Trust is compliant with level 2 for each of the 45 requirements.

6.0 POLICIES

The Quality Committee approved the Information Governance Framework and policies (with their associated procedures), in March 2016, to reach the required compliance of the IG Toolkit;

Information Governance Framework

Information Governance & Security Policy plus associated procedures

Records Management Policy plus associated procedures

5

Information Risk Policy and procedure

Data Protection Act 1998 and Confidentiality Policy plus associated procedures

Information Sharing & Consent Policy plus associated procedures

Data Quality Policy and procedure

Freedom of Information Policy and procedure

Paper and Electronic Corporate Records Policy plus associated procedures

Adverse Incident Policy (inc. Serious Incidents) plus associated procedures

This list is not exhaustive.

7.0 SERIOUS INCIDENT REQUIRING INVESTIGATION (SIRI)

From June 2013, IG related incidents scoring a level 2 against the criteria of the SIRI tool, developed by the Health & Social Care Information Centre (now known as NHS Digital) and supported by the Information Commissioners Office (ICO), must be reported using the SIRI tool via the IG Toolkit website. The details of the incident should be reported to NHS Digital, the CCG and ICO once the incident is submitted. There have been no Information Governance reportable SIRIs during 2015/16.

8.0 INFORMATION GOVERNANCE INCIDENTS

Regular Information Governance incidents and near-misses are reported through Datix as per the Trust’s internal reporting process. Incident investigations are carried out on all incidents reported through Datix. Each incident will be tested against the criteria of the SIRI tool to assess whether the incident meets a level 0, level 1 or level 2. Following the outcome of the incident level the appropriate action is taken and processes changed if appropriate. All staff involved in an incident will undertake additional training, if appropriate, using the national Information Governance Training Tool (IGTT). Incident reports are provided to the Learning Oversight Sub-Committee to provide an update on how many incidents have taken place, what action has been taken and whether there are any significant risks identified. Staff are encouraged to report incidents across the Trust and awareness campaign has been undertaken by the IG Team to ensure that incidents are recorded on Datix. From April 2015 to March 2016, the IG team investigated and closed 299 incidents on Datix.

9.0 RISK MANAGEMENT & ASSURANCE

The SIRO is responsible for the development and implementation of the organisations’ Information Risk procedure. Data Flow Mapping has been undertaken and will remain an ongoing process to ensure flows are reviewed and additional flows added, where appropriate. Information asset registers have been established and maintained by the appropriate departments, such as, IT&T, Records Management and Information Governance etc. The Associate Director of System Development is currently working on a project, with an external organisation, to develop a centralised system to capture all the information assets. As per the Information Risk Policy, the Information Asset Owners and Information Asset Administrators have been identified as senior individuals (Deputy, Associate, and Assistant Directors) whose role will be to understand and address risks to the identified information assets they ‘own’ and to provide assurances to the SIRO (Via the Information Governance Team) on the security and use of those assets through the process of implementation of

6

information governance / security guidance. The SIRO will update the Quality Committee if any risks to the assets are identified. The SIRO has completed the following training;

Information Risk Management (completed using the IGTT)

Introduction to Information Governance (completed using the IGTT)

Patient Confidentiality (completed using the IGTT)

The Caldicott Guardian in the NHS and Social Care (completed using the IGTT)

SIRO training course (completed with Dilys Jones) The Caldicott Guardian has completed the following training;

Caldicott Guardian Training MasterClass (completed with an external organisation) The Trust currently has the following potential “hot” spots;

Post being sent to the wrong address – this may be as a result of record keeping or staff not validating the recipient details before posting the information

Information asset register – currently lists of assets are kept and maintained by different departments. A central database of the assets will be put in place to improve the consistency and timeliness of any risk identification as per the recommendation of the external audit team.

The following actions have been taken in regard to the identified “hot” spots;

Post –

Communication articles have been published to advise staff to check the addresses details, validate information and check only the relevant and appropriate information is sent to the recipient.

The Information Governance Manager advised the Lessons Learnt Group attendees about the appropriate process for sending post and asked them to feedback to their teams.

Policy and training regarding the accessing of friends, family or your own records have also been tightened. Articles have been published to raise awareness.

The Information Governance Manager attended senior management meetings to raise awareness.

Guidance is available to staff via the Information Governance section on the intranet.

Training has been attended by the Legal, Records and Information Governance teams for the implementation of the GDPR.

Information Asset Register –

The Information Governance Manager is working closely with the Associate Director of System Implementation and the supplier to implement a centralised database which will meet the requirements of the IG Toolkit.

Training will begin for the implementation of the IAMS system in September 2016.

10.0 FREEDOM OF INFORMATION REQUESTS

All Freedom of Information requests made to the Trust are managed by the Legal Team in the Governance Directorate. A summary of Freedom of Information requests is reported to the Information Governance Steering Sub-Committee as regular performance updates.

7

11.0 SUBJECT ACCESS & ACCESS TO RECORDS REQUESTS

All Subject Access Requests are managed by the Legal Team and Access to Records requests made to the Trust are managed by the Records Management Team. A summary of requests is reported to the Information Governance Steering Sub-Committee as regular performance updates.

12.0 WORK PROGRAMMES AND DOCUMENTATION FOR THE TRUST

The IG Toolkit has 45 requirements covering the following areas, broken down in to levels (0 – 3) and each level broken down to varying numbers of components to achieve and demonstrate compliance;

Information Governance Management

Confidentiality and Data Protection Assurance

Information Security Assurance

Clinical Information Assurance

Secondary Use Assurance

Corporate Information Assurance In summary, the Version 13 IG Toolkit requirements have led to the following work being carried out and completed (April 2015 – March 2016);

Numerous staff communication articles being published

IG policies and procedures being reviewed and approved

Staff completing their mandatory OLM training

IG spot checks conducted and any risk fed back to department managers

Data flow mapping reviewed and updated

Information Asset Register project initiated

Fair Processing Notices reviewed and put in place (for staff/patients/contractors)

SIRO in post and trained

Caldicott Guardian in post and trained

IG reports produced for Quality Committee

Annual IG report produced for Board

Privacy Impact Assessments completed and reviewed

Information Sharing Agreements completed and reviewed

Internal processes reviewed to ensure they meet legal, national and local guidance as a result of the changes to the Health & Social Care Act 2012.

13.0 STAFF AWARENESS

The following subjects have been covered as regular staff communications to support level 1 of the IG Toolkit (April 2015 – March 2016);

Disposing of confidential waste

Ensuring meeting rooms are cleared of paperwork following meetings

Appropriate use of systems and networks

How to send confidential information in emails

Validating recipient details before posting information

Validating recipient details before sending an email

When to complete a Privacy Impact Assessment

Validating printer details before printing confidential information

Safe use of mobile devices

IG policies and procedures approved by the Executive Team (ET)

Advising staff of the importance of completing the Data Flow Mapping Tool

Reporting of Information Governance incidents via Datix

8

Premise closures – importance of ensuring all data is removed from a building when vacating

CONCLUSION

The last year has seen the Information Governance Team, consisting of 4.5 staff members (including the Information Governance Manager), worked really hard to raise the profile of Information Governance within the Trust. There is increased awareness amongst staff of their information governance responsibilities, as well as the risks and consequences of failure to comply with processes and requirements. There has been an increase of advice sought from the IG Manager for new projects. The IG manager also presented at the new Junior Doctors intake for Information Governance training. The plan for the future will be to maintain a minimum of level 2 against the requirements of the IG Toolkit (version 14).

ACTION REQUIRED:

The Information Governance Steering Group is asked to:

1. Note the contents of this report.

2. Approve the continued commitment to support the compliance arrangements to attain a level 2 IG Toolkit requirements during 2016/17

Report prepared by Alice Williams, Information Governance Manager. On behalf of Mark Madden Executive Chief Finance Officer/Senior Information Risk Officer (SIRO)

SEPT

Agenda Item No: 8c

SUMMARY REPORT

BOARD OF DIRECTORS MEETING

PART 1

28 September 2016

Report title: Annual Planning Timetable 2017/18

Executive Lead: Nigel Leonard, Executive Director of Corporate Governance

Report Author(s): Gill Brice, Associate Director of Planning

Report discussed previously at: N/a

Level of Assurance:

Level 1

2

3


To update the Trust Board of Directors on the planning guidance published from NHS England and NHS Improvement (NHSI).

Approval

Discussion

Information


To note the content of the report and the implications it has on SEPT’s Operational Plan 2017/18.


NHS England and NHS Improvement (NHI) published planning guidance for 2017/18 and 2018/19 on 22 September 2016. The document details how the NHS operational planning and contracting processes will now change to support Sustainability and Transformation Plans (STPs) and the ‘financial reset’. It reaffirms national priorities and sets out the financial and business rules for both 2017/18 and 2018/19. To support the STP process and embed the ‘financial reset’, the document details that the annual NHS planning and contracting round will now be streamlined significantly. The aim being to provide greater certainty and stability; simplify processes and ensure they are more joined up; cut transaction costs; and support partnership and transformation. The 2017-19 operational planning and contracting round will be built out from STPs. Two-year contracts will reflect two-year activity, workforce and performance assumptions that are agreed and affordable within each local STP. NHS England and NHSI state that operational plans for 2017/18 will need to demonstrate:

• how they will be delivering the nine ‘must-dos’; • how they support delivery of the local STP, including clear and credible milestones

and deliverables; • how they intend to reconcile finance with activity and workforce to deliver their

agreed contribution to the relevant system control total; • robust, stretching and deliverable activity plans which are directly derived from their

STP, reflective of the impact that the STP’s well-implemented transformation and efficiency schemes will have on trend growth rates, agreed by commissioners and

SEPT

providers and consistent with achieving the relevant performance trajectories within available local budgets;

• how local independent sector capacity is factored into capacity planning and local providers engaged throughout;

• the planned contribution to savings; • how risks have been jointly identified and mitigated through an agreed

contingency plan the impact of new care models, including where appropriate how contracts with secondary care providers will be adjusted to take account of the introduction of new commissioning arrangements for multispecialty community providers (MCPs) or primary and acute care systems (PACS) during 2017-19.








No.



No.



Data Quality Issues


Communication and Consultation with stakeholders required N/a


Financial Implications N/a

Governance Implications N/a

Impact on Patient Safety /Quality N/a

Impact on Equality & Diversity N/a


No If yes, EIA Score N/a


STP Sustainability and Transformational Plan

NHSI NHS Improvement


https://www.england.nhs.uk/wp-content/uploads/2016/09/NHS-operational-planning-guidance-201617-201819.pdf

Executive Lead




SEPT

SEPT

ANNUAL PLANNING TIMETABLE 2017/18


The purpose of this report is to provide the Trust Board of Directors with information regarding the annual planning process for 2017/18.


National Planning Guidance NHS England and NHS Improvement (NHI) published planning guidance for 2017/18 and 2018/19 on 22 September 2016. The document details how the NHS operational planning and contracting processes will now change to support Sustainability and Transformation Plans (STPs) and the ‘financial reset’. It reaffirms national priorities and sets out the financial and business rules for both 2017/18 and 2018/19. The document outlines that STPs are more than just plans, they represent a different way of working, with partnership behaviours becoming the new norm as good organisations cannot implement the Five Year Forward View and deliver the required productivity savings and care redesign in silos. This means improving and investing in preventative, primary and community based care. NHS England outline that the solutions will not come solely from within the NHS, but from patients and communities, and wider partnerships including local government, and the third sector; and effective public engagement will be essential to their success. To support the STP process and embed the ‘financial reset’, the document details that the annual NHS planning and contracting round will now be streamlined significantly. The aim being to provide greater certainty and stability; simplify processes and ensure they are more joined up; cut transaction costs; and support partnership and transformation. The document sets out that the 2017-19 operational planning and contracting round will be built out from STPs. Two-year contracts will reflect two-year activity, workforce and performance assumptions that are agreed and affordable within each local STP. NHS England are issuing a two-year tariff for consultation and two-year CQUIN and CCG quality premium schemes. They are engaging with the sector on the indicators and measurements for these CQUINs. For the first time, a single NHS England and NHSI oversight process will provide a unified interface with local organisations to ensure effective alignment of CCG and provider plans. They set out that as requested by NHS leaders, the timetable is now being brought forward to provide certainty earlier – with a target deadline of all 2017-19 contracts signed by 23 December 2016. NHS England and NHSI state that to ensure organisational boundaries and perverse financial incentives do not get in the way of transformation, from April 2017 each STP (or

SEPT

agreed population/geographical area) will have a financial control total that is also the summation of the individual organisational control totals. All organisations will be held accountable for delivering both their individual control total and the overall system control total. It will be possible to flex individual organisational control totals within that system control total, by application and with the agreement of NHSI. Core baseline STP metrics will be published in November 2016. The nine must dos for the NHS in 2016/17 remain unchanged:

1. STPs 2. Finance 3. Primary Care 4. Urgent and emergency care 5. Referral to treatment times and elective care 6. Cancer 7. Mental Health 8. Learning disabilities 9. Improving quality in organisations

NHS England and NHSI state that operational plans for 2017/18 will need to demonstrate:

• how they will be delivering the nine ‘must-dos’;

• how they support delivery of the local STP, including clear and credible milestones and deliverables;

• how they intend to reconcile finance with activity and workforce to deliver their agreed contribution to the relevant system control total;

• robust, stretching and deliverable activity plans which are directly derived from their STP, reflective of the impact that the STP’s well-implemented transformation and efficiency schemes will have on trend growth rates, agreed by commissioners and providers and consistent with achieving the relevant performance trajectories within available local budgets;

• how local independent sector capacity is factored into capacity planning and local providers engaged throughout;

• the planned contribution to savings;

• how risks have been jointly identified and mitigated through an agreed contingency plan the impact of new care models, including where appropriate how contracts with secondary care providers will be adjusted to take account of the introduction of new commissioning arrangements for multispecialty community providers (MCPs) or primary and acute care systems (PACS) during 2017-19.

CCG and provider plans will need to be agreed by NHS England and NHSI, with a clear expectation that they must be fully aligned in local contracts. It requires a genuine commitment for local leaders to run a shared, open-book process to deliver performance

SEPT

and improvement within the growing, but fixed, funding envelope available to that local area. NHS England and NHSI state that this approach has been seen in the development of STPs and it is their expectation to see it carried forward into operational plans. Implications for SEPT SEPT is actively involved in 3 STPs currently and is working with commissioners and other providers on these plans for submission in October 2016. SEPT continue to actively pursue a merger with North Essex University NHS foundation Trust (NEP) and are currently writing to the Full Business Case (FBC) for submission to NHSI in November 2016. It is envisaged that the FBC will be the basis of the operational plan for both organisations. As part of the preparation for the FBC work with Price Waterhouse Cooper (PwC) regarding the cultures of both organisations has been undertaken. This included a Board to Board meeting in August 2016 where the proposed strategic objectives for the organisations were agreed as follows:

• Continuously improve patient safety, experience and outcomes, and reduce clinical variations

• Attract, develop, enable and retain high performing and diverse individuals and teams

• Achieve top 25% performance for national operational, financial and productivity measures

• Influence and enable service improvement plans with system partners, including commissioners and service users

As it customary in both NEP and SEPT planning events involving a wide range of staff and stakeholders have been organised for December 2016, in recognition that the planning cycle has changed for a submission date for December 2016. These events will be joint with NEP and will provide staff and stakeholders to explore areas cited in the FBC including the clinical model and estates rationalisation. As with previous years these events will also provide the opportunity to focus on delivering the requirements arising from contract negotiations. In summary, the Trust is well placed to meet the requirements of this year’s planning process. A draft timetable is attached under appendix 1. The Board will note that the NHSI timeline will require the October Trust Board meeting to delegate authority to the Chief Executive, Executive Director of Corporate Governance and Executive Chief Finance Officer to make any final adjustments to the draft operational plan and the final operational plan in November’s Board prior to submission.

3.0 RECOMMENDATION

The Trust Board of Directors is asked to consider and discuss the content of this report.

SEPT

4.0 ACTION REQUIRED:

The Trust Board of Directors is asked to consider and discuss the content of this report. Report prepared by Gill Brice Associate Director of Planning On behalf of:


SEPT

Appendix One Planning Timetable

Event

Date

Provider control totals and STF allocations published

30 September 2016

Full STP submissions to NHSI

21 October 2016

Draft Operational Plan to (Board Part 2)

26 October 2016

Board Development Session

9 November 2016

Draft Operational Plan to NHSI

24 November 2016

Board Approval of the Operational Plan

30 November 2016

Draft Operational Plan to the Council of Governors

1 December 2016

Trust wide / Stakeholder Events

Friday 2 December 2016 – for Mental Health Services Wednesday 7 December 2016 – for Community Services

Review Strategic plan options and operational plan with Council of Governors Project Team

TBC December 2016

National deadline for signing of contracts

23 December 2016

Submission of final 2017/18 to 2018/19 Operational Plans.

23 December 2016

1

Agenda Item No: 8d

SUMMARY REPORT

BOARD OF DIRECTORS MEETING PART ONE

28th September 2016

Report title: CQC ACTION PLAN Executive Lead: Sally Morris

Chief Executive

Report Author(s): Faye Swanson, Director of Compliance and Assurance Chris Jennings, Compliance Officer

Report discussed previously at: Quality Committee



This report provides the Trust Board of Directors with a summary of progress made by the Trust in response to the recommendations made by the CQC following its inspection of services carried out in June/ July 2015. The report presents the position agreed and recommended by the Executive Team and Quality Committee to be reported to the CQC as at September 2016.

Approval

Discussion

Information


The Board of Directors is asked to: 1. Note the contents of this report 2. Agree the recommended position to be reported to the CQC


The accompanying report details the process undertaken to provide assurance in relation to the closure of the CQC Action Plan developed as a result of the CQC Comprehensive Inspection completed in June / July 2015. The report confirms the position in relation to progress with the action plan as recommended by the Executive Team and the Quality Committee. There is sufficient assurance available to recommend closure of all but ONE CQC recommendation taking into account the action taken and the assurance available on the difference it has made. Follow up action to address the recommendation not delivered; to strengthen assurance in respect of a range of activities and to sustain compliance has been identified.








Yes: BAF 16-17 and REF - BAF14033001

If yes, insert relevant risk If services fall short of the standards there is the potential for CQC enforcement action or in extreme cases closure of services

Do you recommend a new entry to the No

2

Board Assurance Framework is made as a result of this report?



Data Quality Issues Nil



Service Impact/Health Improvement Gains Nil


Nil


Impact on Equality & Diversity Nil


No If yes, EIA Score


CQC Care Quality Commission

NEP North Essex Partnership University NHS Foundation Trust

MHA Mental Health Act

MCA Mental Capacity Act


Accompanying Report

Executive Lead

Sally Morris Chief Executive

1

Agenda Item 8d Board of Directors Meeting

28 September 2016

SEPT

CQC Action Plan

1.0 Purpose

This report provides the Board of Directors with a summary of progress made by the Trust in response to the recommendations made by the CQC following its inspection of services completed in June / July 2015. The report presents the position agreed by the Executive Team and Quality Committee to be reported to the CQC as at September 2016.

2.0 Background

The CQC undertook a Comprehensive Inspection of all Trust Services in June / July 2015 to review compliance against the Fundamental Standards and Key Lines of Enquiry (KLOE’s). As a result of the inspection, informal feedback was gathered and a number of key areas of improvement were identified. Rather than await the publication of a formal report, the Trust established a series of task and finish groups to begin addressing the issues identified so that immediate improvement could be made where possible. The feedback reports published by the CQC in November 2015 confirmed the Trust had received an overall rating of “Good” but the CQC did identify 4 “Must Do” and a number of “Should Do” recommendations for the Trust to take forward. Following the receipt of the final feedback reports (November 2015) the Trust developed a detailed action plan aimed at addressing the recommendations made by the CQC and to bring about real improvement within Trust services. The action plan was approved in January 2016, shared with the CQC and Monitor (now NHS Improvement) with the intention that the actions would be completed by the end of September 2016. In order to achieve this, actions were assigned to individuals and the task and finish groups were refreshed based on the final report content and changes were made to ensure the right groups took the actions forward. In total 8 groups were established around the following improvement themes:

Seclusion and Restrictive Practice

Estates and Risk Management

Medication

Record Keeping

Workforce

Patient Experience and Clinical Governance

Mental Health Act (MHA) and Mental Capacity Act (MCA)

Electronic Records (developed into the Electronic Records Project Board) Each group was led by an Executive Director and had representation from operational and support services to ensure all aspects of the recommendations would be addressed. Progress with the overall action plan was overseen by an Executive Task and Finish Group which met fortnightly to ensure progress reported was monitored and any concerns could be escalated appropriately. The Quality Committee received an exception based assurance report throughout the year within which overall progress was reported and slippage identified where necessary.

2

The CQC did not identify any recommendations in respect of the “Well Led” domain. Actions to continually strengthen the Trust’s “Well Led” related activities were identified as a result of an internal self-assessment and incorporated into the Governance Development Plan 2016/17 which is being monitored by the Finance & Performance Committee. By April 2016, the majority of actions allocated to the various Task & Finish groups had been completed and it was agreed by the Quality Committee that the groups should be ended and the remaining actions were transferred to the Executive Task and Finish Group. The CQC has been provided with progress reports against the action plan on two occasions since January 2016 and updates on progress have been provided to NHS Improvement in April and July 2016 as part of the routine quarterly compliance reports.

3.0 Assurance Process

The Trust recognised that simply reporting progress with the agreed actions may not have provided sufficient assurance that there had been learning from the inspection. It was agreed therefore that a robust compliance process would be implemented in order to provide the Executive Team, Quality Committee and ultimately the Board of Directors with the necessary assurance in respect of the position reported in September 2016. The compliance process implemented consisted of two separate assurance “tests” carried out on each recommendation.

Test 1 Have the actions been completed as reported? This was undertaken as a desktop audit to check the actions reported as being completed had in fact been completed. The audit involved checking every action identified and collating evidence of the action reported.

Test 2 Is there evidence that the action taken has engendered change / improvement? A comprehensive programme of audit was undertaken by the Compliance Team to determine whether the recommendations made by the CQC had been addressed and if any improvement had been made as a result. The audits included data gathering, speaking with patients and staff, reviewing patient notes, undertaking observations and reviewing the environment.

The Compliance Team collated and analysed the results of both tests and presented these to the Executive Task & Finish Group. Further discussions were held collectively and individually with Executive Directors in order to agree the final position to be reported and recommended to the Quality Committee.

4.0 Outcome

Full details of the recommendations made by the CQC, the actions agreed, the assurance identified and the recommended position agreed by the Executive Team as at 9 September 2016 was presented to the Quality Committee on the 15th September 2016. In respect of Test 1- did the Trust take the action that it agreed to take?: The Executive Team was satisfied that action was taken as agreed in respect of all recommendations except five. There were two specific actions (closure of the learning disability (LD) eligibility assessment waiting list as the service is not commissioned and implementation of a “significant events” screen within the electronic patient records (EPR)) which formed part of a range of actions to respond to the five recommendations (two relating to LD psychology services, one relating to clinical risk assessment and two relating to electronic patient records).

3

The Executive Team was satisfied that the issues identified in respect of long waiting times and lack of prioritisation of long waiting patients in the LD psychology service had been addressed without the closure of the waiting list (although this will be pursued). The Executive Team acknowledged that the “significant events” screen had been incorporated into version 2 of Mobius currently being rolled out, but that there had not been sufficient agreement on the content for it to be made available for use. A task and finish group met on 23 September 2016 and has now agreed the significant event screen content but has agreed to delay implementation until the end of December 2016 to coincide with implementation of revised ECPA documentation. The Quality Committee accepted the recommendations made by the Executive Team and has recommended that the Board of Directors accept the position reported. In respect of Test 2 – is there sufficient assurance that the action taken has resulted in change/ improvement? The assurance process identified that in respect of just one recommendation there was no assurance available. This relates to training provided in respect of verification of death. The Test 1 process identified some confusion in respect of Trust policy which impacted on the development and delivery of an appropriate training package. The Executive Team was however assured that the training package is now in place and will be delivered within the next 4 weeks. In respect of the majority of recommendations the Executive Team was satisfied that there was sufficient assurance that action taken has resulted in change/ improvement. However a conservative approach was taken to reporting assurance levels found and in some cases this has identified that there is not full assurance that changes / improvement has been achieved (yet). The Quality Committee accepted recommendations made by the Executive Team and has recommended that the Board of Directors accept the position reported. Overall Position: The Executive Team reflected on the outcome of both Test 1 and Test 2 in order to agree the recommended position overall for each CQC recommendation as at September 2016. The Executive Team concluded that there is sufficient assurance available to recommend closure of all but ONE CQC recommendation taking into account the action taken and the assurance available on the difference it has made. The recommendation required the Trust to “ensure that all relevant patients have easy access to psychological therapies”. The recommendation related mainly to inpatient mental health services. The Executive Team was satisfied that some action has been taken but was not satisfied that this has led to change or improvement. The Director of Mental Health has been requested to develop a new action plan and take forward action to improve the current provision. The Quality Committee accepted the overall position reported in respect of the CQC Action Plan and has recommended that the Board of Directors report this to the CQC.

5.0 Next Steps

In drawing its conclusions and making the recommendations contained in this report, the Executive Team and Quality Committee were clear that this is not the end of following up and implementing the CQC recommendations. Where there was not full assurance that action taken has resulted in change/ improvement (yet), on-going action and appropriate monitoring arrangements will be established in respect of:

Electronic Records System (Mobius)

Quality / Choice of Food

Seclusion

Restraint

Care planning

4

Mental Health Act implementation

Restrictive practices Sustainability KPI/ monitoring arrangements will also be implemented to minimise the risk of issues identified by the CQC in 2015 being identified again in any future inspection. The arrangements detailed above will be incorporated into the pre and post-transaction implementation plan (PTIP) that is currently being developed to ensure that the new organisation; created as a result of the proposed merger of SEPT and NEP; maintains compliance with the CQC Fundamental Standards. The CQC has requested confirmation of the final position reported to the Board of Directors as at the end of September 2016. The action plan and progress made as at 23 September 2016 has been shared with the CQC Inspection Manager. A meeting has been arranged to take place 21st October 2016 with the CQC to discuss the progress reported and the implications associated with this.

7.0 Action Required


1. Consider and discuss the content of this report 2. Agree the recommended final position to be reported to the CQC.

Report prepared by: Faye Swanson Director of Compliance and Assurance On behalf of Sally Morris Chief Executive

1

Agenda Item No: 8e

SUMMARY REPORT

Board of Directors PART 1

28 September 2016

Report title: Statement of Compliance for Revalidation

Executive Lead: Dr Milind Karale

Report Author(s): Dr Milind Karale


Level of Assurance:


To provide the Trust Board/Designated Body with the information on the implementation of revalidation within the Trust for 2015/16 appraisal year so that an annual statement of compliance can be signed and provided to the higher level Responsible Officer at NHS England.

Approval

Discussion

Information


To note the content of the above report and approve the compliance statement. The Designated Body (SEPT) through its Chairman or Chief Executive to submit the compliance statement to the Higher Responsible Officer at NHS England.


The Board of the South Essex Partnership NHS Foundation Trust as a designated body has a responsibility to ensure that it is compliant with the Medical Professional (Responsible Officers) Regulation 2010 (as amended in 2013) Act. The report is expected in the format stipulated by NHS England and includes details about the quality assurance, clinical governance, Trust’s performance on revalidation, actions plans to strengthen the revalidation process, audits on concerns of doctors’ practice and audits on the appraisals input and output. As of 31st March 2016 there were 86 doctors with a prescribed connection to SEPT. Of the 86 doctors, 79 had an annual appraisal (91.9%). 59 doctors had a completed appraisal as per ‘Category 1A’1 during the appraisal year (1st April 2015 to 31st March 2016) and 20 were defined as completed appraisals meeting ’Category 1B’2 requirements. 5 appraisals were defined as ‘Approved incomplete or missed appraisals’3 and 2 were defined as ‘unapproved incomplete or missed appraisals’4. Out of the 5 ‘Approved incomplete or missed appraisals’ 2 were new starters with SEPT and as they started after April 2015 they were not due an appraisal by 31st March 2016, 2 were on sabbatical for the majority of the appraisal year and 1 was Long Term Sick leave. Both of the 2 ‘Unapproved incomplete or missed appraisals’ have now been completed. The way in which these figures have been calculated is different from last year due to changes in definitions, thus making it difficult to make direct comparisons with the last year’s figures. As against the defined completed appraisal rate of 94.6% for the 2014/15 year, the defined completed appraisal rate for 2015/16 is 91.9%, showing a slight decrease of 2.7%. This decrease is directly attributable to the change in the definition of a ‘completed 1B’ appraisal. However, when comparing our completed appraisal rate for 2015/16 nationally, our rate is higher than our peers. As mentioned our completed appraisal rate for 2015/16 was 91.9%. This is higher than both other organisations in the same sector which achieved 89.8% and compared to organisations from all sectors which

2

achieved 88.1%. During this period, concerns were raised about the conduct of 4 doctors. No practice was restricted and none underwent formal remediation during this period. The report details the action plan to improve the appraisal rates in the category 1A1.


Quality Services

Quality Leadership and Workforce

Sustainability of Service Provision

Innovative and Transformative approach to efficiency and effectiveness



No



No



Data Quality Issues NA

Involvement of Service Users/Healthwatch NA

Communication and Consultation with stakeholders required NA


No new financial

implications


Impact on Equality & Diversity X


If yes, EIA Score

NA



Executive Lead

Dr Milind Karale Responsible Officer ( Revalidation)

1

A Framework of Quality

Assurance for Responsible

Officers and Revalidation

Annex D - Annual Board Report Template

2

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Directorate

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Nursing Trans. & Corp. Ops. Commissioning Strategy

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Publications Gateway Reference: 03551

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Document Name

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Publication Date

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Additional Circulation

List

Description

Cross Reference

Action Required

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Guidance

[email protected]

http://www.england.nhs.uk/revalidation/

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A template board report for use by designated bodies to monitor their

organisation’s progress in implementing the Responsible Officer

Regulations.

From June 2015

Gary Cooper, Project Manager Quality and Assurance, Professional

Standards Team

16 June 2015

All Responsible Officers in England

Foundation Trust CEs , NHS Trust Board Chairs, Medical Appraisal

Leads, CEs of Designated Bodies in England, NHS England Regional

Directors, NHS England Directors of Commissioning Operations, All NHS

England Employees, Directors of HR, NHS Trust CEs

The Medical Profession (Responsible Officers) Regulations, 2010 (as

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Regulations 2012

A Framework of Quality Assurance for Responsible Officers and

Revalidation, Annex D - Annual Board Report Template, version 4 April

2014.

Designated Bodies to receive annual board reports on the

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A Framework of Quality Assurance for Responsible Officers and

Revalidation, Annex D - Annual Board Report Template

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the intranet is the controlled copy. Any printed copies of this document are not controlled. As a

controlled document, this document should not be saved onto local or network drives but should

always be accessed from the intranet. NB: The National Health Service Commissioning Board was

established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the

National Health Service Commissioning Board has used the name NHS England for operational

purposes.

3

Contents

Contents 3

1. Executive Summary 4

2. Purpose of the Paper 5

3. Background 6

4. Governance Arrangements 6

5. Medical Appraisal 8

6. Revalidation Recommendations 10

7. Recruitment and engagement background checks 10

8. Monitoring Performance 10

9. Responding to Concerns and Remediation 11

10. Risks and Issues 11

11. Board Reflections 11

12. Corrective Actions, Improvement Plan and Next Steps 12

13. Recommendations 13

Annual Report Template Appendix A –

Audit of all missed or incomplete appraisals 14

Annual Report Template Appendix B –

Quality assurance of appraisal inputs and outputs 16

Annual Report Template Appendix C –

Audit of concerns about a doctor’s practice 17

Annual Report Template Appendix D –

Audit of revalidation recommendations 18

Annual Report Template Appendix E –

Audit of recruitment and engagement background checks 20

4

Annex D – Annual Board Report Template

Executive summary

As of 31st March 2016 there were 86 doctors with a prescribed connection to SEPT. Of the 86 doctors, 79 had an annual appraisal (91.9%). 59 doctors had a completed appraisal as per ‘Category 1A’1 during the appraisal year (1st April 2015 to 31st March 2016) and 20 were defined as completed appraisals meeting ’Category 1B’2

requirements. 5 appraisals were defined as ‘Approved incomplete or missed appraisals’3 and 2 were defined as ‘unapproved incomplete or missed appraisals’4 . Out of the 5 ‘Approved incomplete or missed appraisals’ 2 were new starters with SEPT and as they started after April 2015 they were not due an appraisal by 31st March 2016, 2 were on sabbatical for the majority of the appraisal year and 1 was on Long Term Sick leave. The 2 ‘Unapproved incomplete or missed appraisals’ have now been completed. Please see Annex A for the audit of Missed and Incomplete appraisals.

The way in which these figures have been calculated is different from last year due to changes in definitions, thus making it difficult to make direct comparisons with the last year’s figures. As against the defined completed appraisal rate of 94.6% for the 2014/15 year, the defined completed appraisal rate for 2015/16 is 91.9%, showing a slight decrease of 2.7%. This decrease is directly attributable to the change in the definition of a ‘completed 1B’ appraisal. However, when comparing our completed appraisal rate for 2015/16 nationally, our rate is higher than our peers. As mentioned our completed appraisal rate for 2015/16 was 91.9%. This is higher than both other organisations in the same sector which achieved 89.8% and compared to organisations from all sectors which achieved 88.1%. There are areas in which SEPT is trying to improve. The following actions are being taken to reduce the number of completed Category 1B appraisals2, approved incomplete or missed appraisals3 and unapproved incomplete or missed appraisals4.

Continue to ensure that all doctors on our prescribed connection list are fully engaged with the appraisal and revalidation process to minimise the missed/delayed appraisals.

Encourage the doctors to contact the Appraisal and Revalidation Team to alert them about any potential delays in the process and the need for assistance.

Continue with a consistent and robust process to deal with delay without a valid reason.

5

Further training and guidance to all doctors regarding the requirements and definitions of completed appraisals.

Over the 2015/16 appraisal year the RO made 32 positive revalidation

recommendations and 4 deferral requests (34 recommendations made in total). No

non-engagement notifications were made. Out of the 34 recommendations made, all

were made on time.

______________________

1 A Category 1a completed annual medical appraisal is one where the appraisal meeting has taken

place in the three months preceding the agreed appraisal due date*, the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting, and the entire process occurred between 1 April and 31 March. 2 A Category 1b completed annual medical appraisal is one in which the appraisal meeting took place

in the appraisal year between 1 April and 31 March, and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor, but one or more of the following apply:

- the appraisal did not take place in the window of three months preceding the appraisal due date; - the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor between 1 April and 28 April of the following appraisal year; - - the outputs of appraisal have been agreed and signed-off by the appraiser and the

doctor more than 28 days after the appraisal meeting. 3

An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. 4

An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of either a Category 1a or 1b completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal.

Purpose of the Paper

The purpose of revalidation is to assure patients, public and employers that licensed doctors are up to date and fit to practice on a continual/regular basis. Licensed Doctors demonstrate this by maintaining a portfolio of supporting information which is drawn from their practice (including complaints, Serious Incidents, clinical governance) and including this information in their annual appraisals which are based on the GMC’s core guidance for doctors, Good Medical Practice. This report forms part of The Framework of Quality Assurance (FQA) which was launched by NHS England in April 2014. The purpose of this report is to provide the Trust Board/Designated Body with information on the implementation of revalidation within the Trust for the 2015/16 appraisal year so that an annual statement of compliance can be signed and provided to the higher level responsible officer.

6

Background

Medical Revalidation was launched in 2012 to strengthen the way that doctors are regulated, with the aim of improving the quality of care provided to patients, improving patient safety and increasing public trust and confidence in the medical profession. Provider organisations have a statutory duty to support their Responsible Officers in discharging their duties under the Responsible Officer Regulations Act5 and it is expected that Trust Boards will oversee compliance by:

monitoring the frequency and quality of medical appraisals in their organisations;

checking there are effective systems in place for monitoring the conduct and performance of their doctors;

confirming that feedback from patients is sought periodically so that their views can inform the appraisal and revalidation process for their doctors; and

Ensuring that appropriate pre-employment background checks (including pre-engagement for Locums) are carried out to ensure that medical practitioners have qualifications and experience appropriate to the work performed.

_________________

5 The medical profession (Responsible Officers) Regulations, 2010 as amended in 2013’ and ‘The General Medical Council

(Licence to Practice and Revalidation) Regulations Order of Council 2012’

Governance Arrangements

The appraisal and revalidation structure within SEPT which makes up the Appraisal and Revalidation Team is as follows:

Responsible Officer

Director of Medical Appraisal and Revalidation

Appraisal and Revalidation Support Manager

Appraisal and Revalidation Administrator

7

The Responsible Officers key responsibilities are to ensure compliance with the Responsible Officer Regulations, to maintain a list of doctors for whom they are responsible, to ensure that effective systems and processes for doctors’ appraisal are in place, to ensure doctors’ performance and conduct is monitored, to ensure appropriate action is taken to remedy identified areas of weakness in doctors’ performance and to ensure that the necessary employment checks are carried out.

The key responsibilities of the Director of Medical Appraisal & Revalidation, Appraisal & Revalidation Support Manager and the Appraisal & Revalidation Administrator are to support and assist the Responsible Officer in undertaking this role.

Progress on appraisal rates and revalidation readiness is monitored by the Appraisal and Revalidation Support Manager and reports are sent to the Responsible Officer and Director of Medical Appraisal and Revalidation on a monthly basis. The Responsible Officer can also access the completed appraisals at any time for monitoring and quality assurance purposes.

There is a process in place for ensuring that we maintain an accurate list of prescribed connections. A report is sent from the Workforce Department containing information on medical new starters and leavers each month to the Appraisal and Revalidation Support Manager. Medical HR and if appropriate, the clinicians concerned are then contacted for verification of this information. The additions and removals to the list are then made as necessary.

Policy and Guidance

All new national guidance and amendments to existing documentation is read, shared with the necessary people and implemented where possible. SEPT’s Medical Appraisal and Development policy and procedure has been updated this year to ensure compliance with national guidance .

8

Medical Appraisal

Appraisal and Revalidation Performance Data

The activity levels of appraisal outputs per individual departments can be summarised as follows:

Mental Health Essex

Mental Health Bedfordshire and Luton

Care of the Elderly, West Essex

Community Paediatrics Bedfordshire and Luton

Other Total

Number of doctors

61 4 6 8 7 86

Number of completed 1A appraisals

45 3 4 3 4 59

Number of completed 1B appraisals

12 1 1 4 2 20

Number of Approved Incomplete/Missed appraisals

4 0 1 0 0 5

Number of Unapproved Incomplete/Missed appraisals

0 0 0 1 1 2

Number of doctors who were not due an appraisal by 31st March 2016

1 0 1 0 0 2

Please see Appendix A ‘Audit of all missed or incomplete appraisals audit’ for information and reasons for all missed and incomplete appraisals. Appraisers As of 31st March 2016 SEPT has 17 formally trained and approved medical appraisers spread throughout the Trust, 1 of which was newly appointed and trained in 2015/16 year. This currently equates to each appraiser completing 5 to 6 appraisals per appraisal year which is within the guidelines. Further new medical appraiser training will be organised as and when required. There is on-going support for the medical appraisers by way of updates and the Appraisal and Revalidation Team are available to deal with their queries as and when they arise. We have sent some of the current appraisers on external appraiser training this year as required. Further appraiser refresher training will be organised for 2016/17 year.

9

Quality Assurance

There are quality assurance processes in place which cover the appraisal portfolio, the individual appraisers and the organisation.

The appraisal portfolios are reviewed by the Appraisal and Revalidation Support Manager upon completion to ensure that they are completed as per the required guidance. If any issues arise out of this process then they are sent to the Director of Medical Appraisal and Revalidation and Responsible Officer so that any necessary action can be taken. This may include providing advice and guidance to improve quality of the input and output of appraisal or re-opening the appraisal so that amendments can be made.

In addition the Director of Medical Appraisal and Revalidation and Responsible Officer scrutinises the appraisal outcomes of all the doctors who are due for revalidation to ensure that they meet the GMC criteria for the Responsible Officer to make a recommendation.

An audit on the completed appraisals is carried out on an annual basis. The results of this audit can be seen in Appendix B ‘Quality assurance audit of appraisal inputs and outputs’.

The individual appraisers include their appraiser role within their own annual appraisal for discussion and reflection. Each appraisee is expected to complete an anonymised feedback of their experience which is summated annually and provided to individual appraisers for their reflection. With the number of feedback increasing over the years we will be able to calibrate and analyse to further improve the quality.

The organisation is quality assured by the close monitoring of timelines on the appraisal process and by the review and analysis of feedback from the electronic system.

Individual doctors are required to include in their portfolio any necessary information on complaints and/or significant events that they have been named in for each appraisal year so that lessons learnt and reflections can be drawn upon.

Reviews of lessons learned from any complaints and significant events are undertaken by the Clinical Risk Department and are incorporated into regular updates and teaching sessions within the Trust.

Access, security and confidentiality

Generally access to each doctor’s portfolio is restricted to the individual doctor with each user having their own username and password. The exception to this is the Responsible Officer, Director of Medical Appraisal and Revalidation, Administrators and Appraisers. The appraisers have access to the individual’s portfolios of the doctor they are appraising once the doctor has submitted the appraisal for review. The electronic system reminds the doctors that patient identifiable data should not be included within the appraisal portfolio and the doctor has to electronically sign a declaration that no such data has been included. The appraiser also checks when reviewing the appraisal portfolio that no patient identifiable data has been included. There have been no information management breaches with regards to the appraisal and revalidation process to date.

10

Clinical Governance

Corporate data is used and provided to the doctor to include in their annual appraisal. Such data includes information on complaints, significant events, audits and attendance at internal weekly teaching sessions. This information/data is obtained by the individual doctor from the relevant department a couple of months prior to the appraisal. The doctors include their updated job plan, mandatory training record and declare any probity issues and issues relating to suspensions and investigations that they may be involved in.

Revalidation Recommendations

During the 2015/16 appraisal year 32 positive revalidation recommendations were made, all of which were made on time. 4 deferral requests were also made for valid and justifiable reasons and no non- engagement notifications were made. Please see Appendix C ‘Audit of revalidation recommendations’ for a further breakdown.

Recruitment and engagement background checks

There are systems in place to ensure that we are compliant with the Responsible Officer regulations with regards to recruitment and employment checks. Medical HR carries out the necessary pre-employment checks prior to any medical staff joining the Trust and for locum agency doctors. There are also some post-employment checks that are carried out by the Appraisal and Revalidation Team which include name of last Responsible Officer, revalidation due date, copies of previous appraisals, appraisal due date and the MPIT Form. There is an annual audit which takes place at the end of each appraisal year to verify that the necessary checks are being carried out and to ensure compliance. The results of this audit can be seen in Appendix E ‘Audit of recruitment and engagement background checks’.

Monitoring Performance

Monitoring the performance of all doctors working within the Trust is carried out regularly in a variety of ways. Some examples include monitoring adherence to Trust policies and procedures, recording data on complaints, significant events and service provision, compliance with mandatory training and revalidation requirements and feedback from trainees. There is also a Trust policy and procedure on Maintaining High Professional Standards – Conduct and Capability for Medical and Dental Staff which outlines the process to be followed when concerns arise.

11

Responding to Concerns and Remediation

There are Trust policies and procedures relating to responding to concerns and remediation entitled ‘Maintaining High Professional Standards – Conduct and Capability for Medical and Dental Staff policy and procedure’ and ‘Remediation policy and procedure’. These policies and procedures outline the process for addressing and handling concerns within a supportive framework. The ‘Audit of concerns about a doctors’ practice which contains the types and numbers of concerns and remediation programmes that arose in the appraisal year can be seen in Appendix D.

Risk and Issues

In the 2015-16 appraisal year there has been a slight (2.8%) decrease in the completed appraisal figures when compared to 2014-15 results. This decrease is directly attributable to the decline in the number of doctors on our prescribed connection list and the change in the definition of a ‘completed 1B’ appraisal. Measures are being taken to reduce the delays of appraisals in the future. However, the completed appraisal rate is still above NHS Englands 90% threshold and we are continuing to achieve good engagement from the medical workforce with the appraisal and revalidation process.

Board Reflections

2015-16 was a satisfactory year in relation to SEPT complying with the Annual Appraisal and Revalidation of doctors. All revalidation recommendations made by the Responsible Officer were positive and there were very few deferral requests. There were no ‘non-engagers’ during this year. There are some areas to be improved upon regarding appraisal rates, namely improving the completed 1A appraisal rate by reducing the completed 1B, approved missed and incomplete appraisals. This is being monitored by the Responsible Officer through an action plan. The Board will need to continue its support for annual appraisal and revalidation process in order to maintain and improve upon current processes, and to ensure compliance with the Responsible Officer Regulations Act.

12

Corrective Actions, Improvement Plan and Next Steps

The Appraisal and Revalidation Teams actions and next steps are summarised in the below action plan. Action Plan for the Appraisal and Revalidation Team:

Action How Date for completion

Continue to reduce the number of completed 1B appraisals and approved incomplete or missed appraisals.

Continue to inform clinicians to contact the Appraisal and Revalidation Team if there is to be a delay to their appraisal being completed along with the reasons so that allowances/extensions can be made where appropriate.

Continue to ensure that all doctors on our prescribed connection list are fully engaged with the appraisal and revalidation process to minimise the missed/delayed appraisal

Continue to make the process more robust so that those who are not completing their appraisals on time without valid/justifiable reasons are dealt with appropriately and consistently i.e. non-engagement, formal process, and disciplinary proceedings.

Further training and guidance to all doctors regarding the requirements and definitions of completed appraisals.

31/03/2017

Calibrate and analyse the feedback from the appraisal system so that learning points can be identified and included in an update session for the appraisers

Extract and analyse the feedback for the appraisal system

Identify learning points and areas of strength with a view to improving processes further and include this in communications and update sessions

31/12/2016

Appraiser refresher training Contact the necessary trainers to organise a date and arrange finance

Collate information to be included

Communicate date

31/03/2017

13

Appraisee training Organise a date and location

Collate information to be included

Communicate date

31/03/2017

Case Manager Training Identify those to undergo training

Arrange finance

Arrange training date and location with trainers and communicate

31/03/2017

Ensure no late revalidation recommendations are made

Make sure SEPT prescribed connection list is up to date at all times and that we are aware of when all revalidation dates are due

Meet regularly to review and discuss those due for revalidation so that timely recommendations can be made or deferred as appropriate

Make our recruitment and pre-employment checks more robust

31/03/2017

Recommendations

1. To approve the attached ‘statement of compliance’, based on the findings of the

report, which confirms that the organisation, as a designated body, is compliant

with the Responsible Officer regulations.

2. To approve the submission of the report along with the annual audit and statement of compliance to the higher level Responsible Officer.

14

Annual Report Template Appendix A Audit of all missed or incomplete appraisals audit

Totals

Number of doctors on GMC Connect as of 31 March 2016

86

Number of doctors who were not due for an appraisal by 31 March 2016 (new starters after April 2015)

2

Number of Completed 1A appraisals for 2015-16 59

Number of Completed 1B Appraisals for 2015-16 20 (these are where the appraisal meetings have been held within the appraisal year but one of the following applied:

the appraisal did not take place in the window of three months preceding the appraisal due date;

the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor between 1 April and 28 April of the following appraisal year;

the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor more than 28 days after the appraisal meeting)

Approved Incomplete/Missed Appraisals for 2015-16

5 (2 were new starters who were not due an appraisal by 31st March 2016, 2 were on sabbatical for the majority of the appraisal year and 1 was LTS).

Unapproved Incomplete/Missed Appraisals for 2015-16

2 (Both were completed outside the appraisal year and have now been completed)

Doctor factors (total) 25

Maternity leave during the majority of the ‘appraisal due window’ 0

Sickness absence during the majority of the ‘appraisal due window’ 1

Prolonged leave during the majority of the ‘appraisal due window’ 2

Suspension during the majority of the ‘appraisal due window’ 0

New starter within 3 month of appraisal due date 0

New starter more than 3 months from appraisal due date 0

15

Postponed due to incomplete portfolio/insufficient supporting

information

0

Appraisal outputs not signed off by doctor within 28 days 3

Lack of time of doctor 0

Lack of engagement of doctor 0

Other doctor factors 19

(describe)

No appraisal completed in 2015/16 appraisal year

No appraisal prior to joining SEPT

Missed appraisal with previous organisation

Appraisal meeting took place after appraisal due date (new

‘Completed 1B’ definition)

2

2

1

14

Appraiser factors 2

Unplanned absence of appraiser 0

Appraisal outputs not signed off by appraiser within 28 days 2

Lack of time of appraiser 0

Other appraiser factors (describe) 0

Organisational factors 0

Administration or management factors 0

Failure of electronic information systems 0

Insufficient numbers of trained appraisers 0

Other organisational factors (describe) 0

16

Annual Report Template Appendix B Quality assurance audit of appraisal inputs and outputs

Total number of appraisals completed 118

Number of

appraisal

portfolios

sampled (to

demonstrate

adequate

sample size)

Number of the

sampled

appraisal

portfolios

deemed to be

acceptable

against

standards

Appraisal inputs 26 26

Scope of work: Has a full scope of practice been

described?

26 26

Continuing Professional Development (CPD): Is CPD

compliant with GMC requirements?

26 231

Quality improvement activity: Is quality improvement

activity compliant with GMC requirements?

26 241

Patient feedback exercise: Has a patient feedback

exercise been completed?

26 13

Colleague feedback exercise: Has a colleague feedback

exercise been completed?

26 12

Review of complaints: Have all complaints been included? 26 262

Review of significant events/clinical incidents/SUIs: Have

all significant events/clinical incidents/SUIs been

included?

26 262

Is there sufficient supporting information from all the

doctor’s roles and places of work?

26 21

Is the portfolio sufficiently complete for the stage of the

revalidation cycle (year 1 to year 4)?

For example

Has a patient and colleague feedback exercise

been completed by year 3?

Is the portfolio complete after the appraisal which

precedes the revalidation recommendation (year

5)?

Have all types of supporting information been

included?

26 21

Appraisal Outputs

Appraisal Summary 26 23

Appraiser Statements 26 26

Personal Development Plan (PDP) 26 25 1 We are taking measures to improve individual doctors’ reflective notes within their CPD and Quality

Improvement Activities. This is ongoing. 2 Based on evidence submitted within appraisal portfolio

17

Annual Report Template Appendix C Audit of revalidation recommendations

.

Revalidation recommendations between 1 April 2015 to 31 March 2016

Recommendations completed on time (within the GMC recommendation

window) 36

Late recommendations (completed, but after the GMC recommendation

window closed)

0

Missed recommendations (not completed) 0

TOTAL 36

Primary reason for all late/missed recommendations

For any late or missed recommendations only one primary reason must be

identified

No responsible officer in post 0

New starter/new prescribed connection established within 2 weeks

of revalidation due date

0

New starter/new prescribed connection established more than 2

weeks from revalidation due date

0

Unaware the doctor had a prescribed connection 0

Unaware of the doctor’s revalidation due date 0

Administrative error 0

Responsible officer error 0

Inadequate resources or support for the responsible officer

role

0

Other 0

Describe other

TOTAL [sum of (late) + (missed)] 0

18

Annual Report Template Appendix D Audit of concerns about a doctor’s practice

Concerns about a doctor’s practice High

level1

Medium

level1 Low

level1 Total

Number of doctors with concerns about their

practice in the last 12 months

Explanatory note: Enter the total number of

doctors with concerns in the last 12 months. It is

recognised that there may be several types of

concern but please record the primary concern

0

0

4

4

Capability concerns (as the primary category) in

the last 12 months

0 0 0

0

Conduct concerns (as the primary category) in

the last 12 months

0

0

4

4

Health concerns (as the primary category) in the

last 12 months

0 0 0 0

Remediation/Reskilling/Retraining/Rehabilitation

Numbers of doctors with whom the designated body has a prescribed connection

as at 31 March 2016 who have undergone formal remediation between 1 April

2015 and 31 March 2016

Formal remediation is a planned and managed programme of interventions or a

single intervention e.g. coaching, retraining which is implemented as a

consequence of a concern about a doctor’s practice

A doctor should be included here if they were undergoing remediation at any point

during the year

0

Consultants (permanent employed staff including honorary contract holders, NHS

and other government /public body staff)

0

Staff grade, associate specialist, specialty doctor (permanent employed staff

including hospital practitioners, clinical assistants who do not have a prescribed

connection elsewhere, NHS and other government /public body staff)

0

General practitioner (for NHS England area teams only; doctors on a medical

performers list, Armed Forces)

0

Trainee: doctor on national postgraduate training scheme (for local education and

training boards only; doctors on national training programmes)

0

Doctors with practising privileges (this is usually for independent healthcare

providers, however practising privileges may also rarely be awarded by NHS

organisations. All doctors with practising privileges who have a prescribed

connection should be included in this section, irrespective of their grade)

0

1 http://www.england.nhs.uk/revalidation/wp-

content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

http://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

http://www.england.nhs.uk/revalidation/wp-content/uploads/sites/10/2014/03/rst_gauging_concern_level_2013.pdf

19

Temporary or short-term contract holders (temporary employed staff including

locums who are directly employed, trust doctors, locums for service, clinical

research fellows, trainees not on national training schemes, doctors with fixed-

term employment contracts, etc) All Designated Bodiess

0

Other (including all responsible officers, and doctors registered with a locum

agency, members of faculties/professional bodies, some management/leadership

roles, research, civil service, other employed or contracted doctors, doctors in

wholly independent practice, etc) All Designated Bodiess

0

TOTALS 0

Other Actions/Interventions

Local Actions: 0

Number of doctors who were suspended/excluded from practice between 1 April

and 31 March:

Explanatory note: All suspensions which have been commenced or completed

between 1 April and 31 March should be included

0

Duration of suspension:

Explanatory note: All suspensions which have been commenced or completed

between 1 April and 31 March should be included

Less than 1 week

1 week to 1 month

1 – 3 months

3 - 6 months

6 - 12 months

0

0

0

0

0

Number of doctors who have had local restrictions placed on their practice in the

last 12 months?

0

GMC Actions:

Number of doctors who:

Were referred by the designated body to the GMC between 1 April and 31

March

0

Underwent or are currently undergoing GMC Fitness to Practice

procedures between 1 April and 31 March

0

Had conditions placed on their practice by the GMC or undertakings

agreed with the GMC between 1 April and 31 March

0

Had their registration/licence suspended by the GMC between 1 April and

31 March

0

Were erased from the GMC register between 1 April and 31 March 0

National Clinical Assessment Service actions: 0

Number of doctors about whom the National Clinical Advisory Service (NCAS) has

been contacted between 1 April and 31 March for advice or for assessment

0

Number of NCAS assessments performed 0

20

Annual Report Template Appendix E

Audit of recruitment and engagement background checks

For how many of these doctors was the following information available within 1 month of the doctor’s starting date (numbers)

Tota

l

Identity

check

(Com

ple

ted)

Past G

MC

issues (

Identified

) C

urr

ent G

MC

conditio

ns o

r

undert

akin

gs

Ongoin

g

GM

C/N

CA

S

Investig

ation

(Identified)

DB

S

2 r

ecent

refe

rences

1

Nam

e o

f la

st

responsib

le

offic

er

Refe

rence fro

m

last re

spo

nsib

le

offic

er2

Lang

uag

e

com

pete

ncy

3

Local co

nd

itio

ns

or

und

ert

akin

gs

Qualif

icatio

n

check

4

Revalid

atio

n d

ue

date

2

Appra

isal du

e

date

2

Appra

isal

outp

uts

2

Unre

solv

ed

perf

orm

ance

concern

s

Permanent employed

doctors

5 5 0 0 0 5 5 5 2 5 0 5 5 5 5 0

Temporary employed

doctors

13 13 0 0 0 13 13 10 10 13 0 13 12 13 8 0

Number of new doctors (including all new prescribed connections) who have commenced in last 12 months (including where appropriate locum doctors)

Permanent employed doctors 5

Temporary employed doctors 13

Locums brought in to the designated body through a locum agency 48

Locums brought in to the designated body through ‘Staff Bank’ arrangements 0

Doctors on Performers Lists 1

Other

Explanatory note: This includes independent contractors, doctors with practising privileges, etc. For membership organisations this

includes new members, for locum agencies this includes doctors who have registered with the agency, etc

0

TOTAL 67

21

Locums brought in to the

designated body through

a locum agency

48 48 0 0 0 48 48 48 0 48 0 48

0 0 0 0

Locums brought in to the

designated body through

‘Staff Bank’ arrangements

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Doctors on Performers

Lists

1 1 0 0 0 1 1 1 1 1 0 1 1 1 1 0

Other

(independent contractors,

practising privileges,

members, registrants,

etc)

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Total (these cells will sum

automatically)

67 67 0 0 0 67 67 64 13 67 0 67 18 19 14 0

1 Some of the temporary and permanent doctors are known to the Trust and are moving posts internally i.e. a trainee moving to an NHS locum post. Therefore it is not

necessary to obtain recent references in these circumstances 2

Not applicable for locum agency staff 3

Based on applications, Interviews and references for non-agency doctors and references and assurances from Agency Locum doctors. Some of the temporary doctors are

not formally assessed but are considered competent due to knowledge of them to the Trust (internal movements). 4

By checking the GMC register for substantive consultants confirming entry in the Specialist Register. Non substantive posts, either by GMC register, CV or copies of

certificates.

22

For Providers – use of locum doctors:

Explanatory note: Number of locum sessions used (days) as a proportion of total medical establishment (days)

NB: this section may change as a result of the SCL Project

The total WTE headcount is included to show the proportion of the posts in each specialty that are covered by locum doctors

Locum use by Service:

Total establishment in

specialty (current

approved WTE

headcount)

Consultant:

Overall number

of locum days

used

SAS doctors:

Overall

number of

locum days

used

Trainees (all

grades): Overall

number of locum

days used

Total Overall

number of locum

days used

Mental Health Essex (71.25) 18525 days (1124) 6.06%

(1460) 7.88% (0) 0% (2584) 13.94%

Mental Health Bedford &L Luton (4.00) 1040 days

(13) 1.25% (0) 0% (0) 0% (13) 1.25%

West Essex (6.40) 1664 days (0) 0% (285) 17.12% (442) 26.56% (727) 43.68%

Community Paediatrics Bedford (8.23) 2139.8 days

(145) 6.77% (0) 0% (0) 0% (145) 6.77%

Other (0.33) 85.8 days (0) 0% (0) 0% (0) 0% (0) 0%

Total in designated body (This includes all

doctors not just those with a prescribed

connection)

(90.21) 23454.6 days (1282) 5.46% (1745) 7.43% (442) 1.88% (3469) 14.79%

5 x 52 = 260 days work a year not taking into account any leave

The same figures were not being routinely collected for 2014/15 year so no comparisons can be made

23

Number of individual locum attachments by

duration of attachment (each contract is a

separate ‘attachment’ even if the same doctor

fills more than one contract)

Total

Pre-

employment

checks

completed

(number)

Induction or

orientation

completed

(number)5

Exit reports

completed (number)5

Concerns reported

to agency or

responsible officer

(number)

2 days or less 0 0 0 0 0

3 days to one week 0 0 0 0 0

1 week to 1 month 70 70 * * 0

1-3 months 3 3 3 * 0

3-6 months 0 0 0 0 0

6-12 months 0 0 0 0 0

More than 12 months 0 0 0 0 0

Total 73 73 3 0 0

5 Numbers only include the inductions and Exit reports returned (they do not reflect the number sent to consultants to complete)

Note – The information within this appendix was not readily available and was obtained from looking retrospectively at the data. Going forward a process

will be drawn up so that the required information is available.

OFFICIAL

A Framework of Quality Assurance for Responsible Officers and Revalidation

Annex E - Statement of Compliance

OFFICIAL

2

Statement of Compliance Version number: 2.0 First published: 4 April 2014 Updated: 22 June 2015 Prepared by: Gary Cooper, Project Manager for Quality Assurance, NHS England Classification: OFFICIAL

Publications Gateway Reference: 03432

NB: The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the NHS Commissioning Board has used the name NHS England for operational purposes.

OFFICIAL

3

Designated Body Statement of Compliance

The board of South Essex Partnership University NHS Foundation Trust can confirm that

an AOA has been submitted,

the organisation is compliant with The Medical Profession (Responsible Officers) Regulations 2010 (as amended in 2013)

and can confirm that:

1. A licensed medical practitioner with appropriate training and suitable capacity has been nominated or appointed as a responsible officer;

Yes

2. An accurate record of all licensed medical practitioners with a prescribed connection to the designated body is maintained;

Comments: Yes

3. There are sufficient numbers of trained appraisers to carry out annual medical appraisals for all licensed medical practitioners;

Comments: Yes

4. Medical appraisers participate in ongoing performance review and training / development activities, to include peer review and calibration of professional judgements (Quality Assurance of Medical Appraisers1 or equivalent);

Comments: Yes

5. All licensed medical practitioners2 either have an annual appraisal in keeping with GMC requirements (MAG or equivalent) or, where this does not occur, there is full understanding of the reasons why and suitable action taken;

Comments: Yes

6. There are effective systems in place for monitoring the conduct and performance of all licensed medical practitioners1 (which includes, but is not limited to, monitoring: in-house training, clinical outcomes data, significant events, complaints, and feedback from patients and colleagues) and ensuring that information about these matters is provided for doctors to include at their appraisal;

Comments: Yes

7. There is a process established for responding to concerns about any licensed medical practitioners1 fitness to practise;

Comments: Yes

1 http://www.england.nhs.uk/revalidation/ro/app-syst/

2 Doctors with a prescribed connection to the designated body on the date of reporting.

http://www.england.nhs.uk/revalidation/ro/app-syst/

OFFICIAL

4

8. There is a process for obtaining and sharing information of note about any licensed medical practitioner’s fitness to practise between this organisation’s responsible officer and other responsible officers (or persons with appropriate governance responsibility) in other places where the licensed medical practitioner works;3

Comments: Yes

9. The appropriate pre-employment background checks (including pre-engagement for locums) are carried out to ensure that all licenced medical practitioners4 have qualifications and experience appropriate to the work performed;

Comments: Yes

10. A development plan is in place that ensures continual improvement and addresses any identified weaknesses or gaps in compliance.

Comments: Yes

Signed on behalf of the designated body

[(Chief executive or chairman]

Official name of designated body: _ _ _ _ _ _ _ _ _ _ _

Name: _ _ _ _ _ _ _ _ _ _ _ Signed: _ _ _ _ _ _ _ _ _ _

Role: _ _ _ _ _ _ _ _ _ _ _

Date: _ _ _ _ _ _ _ _ _ _

3 The Medical Profession (Responsible Officers) Regulations 2011, regulation 11:

http://www.legislation.gov.uk/ukdsi/2010/9780111500286/contents

1

Agenda Item No: 8f

SUMMARY REPORT


28 September 2016

Report title: Industrial Action- October 2016 Executive/Non-Executive Lead: Dr Milind Karale , Executive Medical Director

Report Author(s): Freya Francis, HR Business Partner


Level of Assurance:

Level 1

2

3

Purpose of the Report To advise and assure the Trust Board of Directors on the contingency plans for the forthcoming period of industrial action affecting junior doctors.

Approval X

Discussion

Information

Recommendations / Action Required To approve the contingency plans in place for the forthcoming industrial action.


The key changes:

Details of the forthcoming industrial action including future strike action.

Details of the contingency plans in place to mitigate where possible the strike action.

Details of the pre planning to understand the impact of the industrial action.


SP 1: Quality Services X

SP 2: Quality Leadership & Workforce X

SP 3: Sustainability of Service Provision X








2

Data Quality Issues












Appendix 1-The reporting requirements and timeframes for the periods of industrial action. Appendix 2 -The assurance template to be submitted on 26 September 2016

Executive Lead

Milind Karale Medical Director

Board of Directors

Page 1 of 2

Agenda Item: 8f Board of Directors Meeting Part 1

28 September 2016

SEPT

INDUSTRIAL ACTION –OCTOBER 2016

1 Purpose of Report

This report seeks to advise and assure the Trust board on the contingency plans for the forthcoming industrial strike action scheduled for October 2016.

2 Executive Summary

In August 2016 the British Medical Association (BMA) Council confirmed it’s for

industrial action from the BMA Junior Doctors Committee. A planned industrial action

is due to take place in the form of a full withdrawal of labour for five days (emergency

cover will not be provided), between the hours of 8am and 5pm during the following

periods:

5, 6 and 7 October (weekend covered) and then 10 - 11 October

14 - 18 November

5 - 9 December.

The senior medical team has met to agree a contingency plan to manage the impact

of the industrial action. The clinical directors will ensure that alternative arrangements

are made to cover the junior doctor clinics in their line management. The training

programme and the non-clinical meetings for doctors for the duration of industrial

action have be cancelled to ensure that they are able to cover as many clinical

duties as possible. Pre booked annual leave for senior medical staff will be adjusted

where possible to support with service delivery during this period. Plans are,

therefore in place to ensure that a safe service will be provided during the period of

the industrial action.

Communications has been prepared to be issued week commencing 26 September

2016 to all junior medical staff to gather information in respect of their intentions

during this period which is vital to assist the Trust with its service planning. Whilst

there is no objection to asking staff in advance whether or not they intend to strike,

they are not obliged to answer, or may change their mind at the last minute of their

intentions.

Arrangements have been put in place to deduct pay for those that do not attend work

on the planned strike days.

NHS England requests that assurance returns are completed and will require Trust Board sign off prior to submission back to NHS England, in order to ensure Board

Board of Directors

Page 2 of 2

members are fully assured on the plans being taken by Trusts to ensure patient safety during the action, and the ability of their organisation to recover from the impact of the industrial action. Appendix 1 highlights the reporting requirements and timeframes in respect of the industrial action. Appendix 2 is the assurance template to be submitted on 26 September 2016.

3 Action Required


1. Note and agree the contents of this report and plans in place for the forthcoming industrial action.

Report prepared by: Freya Francis, HR Business Partner On behalf of: Dr Milind Karale, Executive Medical Director

30 September 2015

Appendix 1

Assurance

Dates of industrial action Unify2 opens Unify2 closes

Weds 5 to Fri 7 and Mon 10 to 11 October

1000hrs Mon 19 September 1500hrs Mon 26 September

Mon 14 to Fri 18 November 1000hrs Mon 31 October 1500hrs Fri 4 November

Mon 5 to Fri 9 December 100hrs Mon 21 November 1500hrs Fri 25 November

Collection of situation reporting on days of action

Dates of industrial action AM Unify2 collection PM Unify2 collection Weds 5 to Fri 7 October 0800hrs to 1030hrs daily to

report the staffing position as at 0900hrs

1630hrs to 1830hrs return to normal report

Sat 8 and Sun 9 October (Acute, Ambulance & NHS 111 only)

0800hrs to 1030hrs daily to report continued impact of industrial action

No evening collection

Mon 10 to 11 October 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs


Mon 14 to Fri 18 November 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs


Mon 5 to Fri 9 December 0800hrs to 1030hrs daily to report the staffing position as at 0900hrs


RWN SOUTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

NB: Only enter numbers (ie not text) into the cells below or your upload will not process.

New (first) outpatient

(excluding 2ww)

cancellations

New (first) 2ww

outpatient cancellations

Review (subsequent)

outpatient

cancellations

0 29 September 2016 0 0 0

0 30 September 2016 0 0 0

0 01 October 2016 0 0 0

0 02 October 2016 0 0 0

0 03 October 2016 0 0 0

0 04 October 2016 0 0 0

0 05 October 2016 0 0 0

0 06 October 2016 0 0 0

0 07 October 2016 0 0 0

0 08 October 2016 0 0 0

0 09 October 2016 0 0 0

0 10 October 2016 0 0 0

0 11 October 2016 0 0 0

0 12 October 2016 0 0 0

0 13 October 2016 0 0 0

0 14 October 2016 0 0 0

0

1 Yes If NO please specify

0


0


0

13 D) 96-100%

0


0

17 Yes

Please specify nature of

event and mitigation or

reason not checked

#REF!

Please confirm you have checked for any events that may have an impact on your organisation during the period of

industrial action (such as primary care training) and that appropriate mitigation has been undertaken

Are you assured you can provide appropriate mental health crisis intervention teams for the duration of the industrial

action?

Provide the number of outpatient appointments that you expect to cancel as a result of industrial action (NB cancellations should be

submitted against the date the procedure/appointment was due to take place, not the day it was cancelled) to be split into New (excluding

2ww), New 2ww and Review

Unify2 Upload Template

Junior doctors strike - October Action (IAAT3)

Organisation:

Period:#REF!

25th November 2015

Assurance for 5th-11th October

Please confirm that you are assured you can maintain business critical services for the duration of the industrial action

What is the (percentage) bed occupancy you expect to achieve immediately prior to the commencement of the period of

industrial action?

Are you assured that you will be able to establish a major incident response, in line with your Incident Response Plan,

during the period of industrial action

Do you expect to achieve a bed occupancy percentage lower than your normal occupancy prior to the commencement of

industrial action?

0


0


0


0


0


0


0


0


###

Name Andy Brogan #REF!

0Role Deputy CEO

0Email [email protected]

0Telephone 1268739683

0Name Sally Morris

0Role Chief Executive

0Email [email protected]

0Telephone 1268739677

0Name Dr Milind Karale

0Role Medical Director

Email [email protected]

Telephone 1268739689

NameSam Hepplewhite

Role Chief Operating Officer North East Essex

Email sam.hepplewhite.nhs.net

Telephone 1206918746

Please confirm you have a plan to manage the weekend period, including surges in activity, ability to safely discharge and

releasing capacity

28Please provide details of the Medical Director who supports this

submission

Please confirm that you have engaged with the consultant body and they will cover shifts that are likely to be affected by

the industrial action

Please confirm that arrangements will be in place for executive oversight, command and control and escalation during the

period of industrial action

26

27Please provide details of the Chief Executive, who has reviewed

and authorised this submission

Please provide details of the Accountable Emergency Officer,

who has reviewed and authorised this submission

Please confirm that your assurance for industrial action to manage and mitigate clinical risks has been agreed with your

Board

Please confirm that actions have been taken in partnership and agreed with CCGs, the appropriate A&E Delivery Board(s)

and other partner organisations to maximise community support to acute trusts, including the purchase of additional bed

capacity to help the trust enter the period of industrial action with a positive bed balance and additional primary care

capacity

Please confirm that you have agreed local arrangements for the immediate return to work of all appropriate staff in the

event a major incident is declared

Please confirm you have a plan for the recovery to business as usual following the period of industrial action (including

elective activity)

Please confirm that you have in place appropriate arrangements for informing patients, carers, relatives and staff

regarding the impacts of industrial action and for handling media enquiries, including spokespeople

29Please provide details of the CCG Chief Officer who has agreed

your industrial action plan