Trust Board Meeting Agenda Board...Agenda Trust Board Part 1, 27 January 2020 Page 1 of 2 Timing Number Item Enclosure Item Presenter Action of the Board Public and Patient Focus 9.00

Agenda Trust Board Part 1, 27 January 2020 Page 1 of 2

Timing Number Item Enclosure Item Presenter

Action of the Board

Public and Patient Focus 9.00

15 mins 20/1722 Open Forum

Opportunity for the public to ask questions of the Board

Verbal Public Respond to questions

9:15 30 mins

20/1723 Patient Story This month’s patient story will tell the journey of one of our service users who received end of life care, and why the development of an easy read advanced care plan is so important to enable the patient voice to be heard and personalised end of life care to be achieved.

Verbal Gail Briers Discuss and note

9:45 20 mins

20/1724 Safety Walkabout Feedback • 0-19 Service, Prince Street Clinic,

Knowsley visited on 6 December 2019

• Child and Adolescent Mental Health Service, Wigan visited on 13 December 2019

• Think Well-being Team, Alexandra Park, St Helens visited on 17 January 2020

• Assessment and Home Treatment Team, Harry Blackman House, St Helens visited on 24 January 2020

Verbal Mike Tate Stephen McAndrew Jonathan Berry Innes Arnold

Note

Assurance (reports from) 10:05 1 min

20/1725 Apologies for absence

Verbal Helen Bellairs Receive apologies

10:06 1 min

20/1726 Declarations of Interest Verbal Helen Bellairs Identify and avoid conflicts of interest

10:07 2 mins

20/1727 Minutes of the Board Meeting held on 27 November 2019

Helen Bellairs Confirm as accurate and approve

10:09 1 min

20/1728 Matters arising and action points Helen Bellairs Note progress

10:10 5 mins

20/1729 Chairman’s Report Helen Bellairs Note

10:15 5 mins

20/1730 Chief Executive’s Business Report Simon Barber Note

10:20 15 mins

20/1731 Report from Executive Leadership Group Meetings held on 12 December 2019 and 9 January 2020.

Simon Barber Receive assurances and note decisions made

10:35 10 mins

20/1732 Report from Audit Committee Meeting held on 11 December 2019

Alison Tumilty Receive assurances and note decisions

Trust Board Meeting Agenda Meeting held in public 27 January 2020

Room 3 Hollins Park House Winwick, WA2 8WA

Agenda Trust Board Part 1, 27 January 2020 Page 2 of 2

Timing Number Item Enclosure Item Presenter

Action of the Board

made 10:45

10 mins 20/1733 Report from Quality Committee

Meeting held on 11 December 2019

Jonathan Berry

Receive assurances and note decisions made

10:55 10 mins

20/1734 Digital Transformation Group Quarterly Update

Simon Barber Discuss and receive assurances

11:05 10 mins Break

11:15 10 mins

20/1735 Finance Report – Month Nine

John McLuckie

Discuss and receive assurances

Governance (approvals and decisions required of the Board) No Reports

Performance and Quality 11.25

45 mins 20/1736

Quality and Performance Report

John McLuckie

Discuss and note

Safety and Risk 12:10

15 mins 20/1737 Serious Incident Report

Gail Briers Discuss and note

12:25 10 mins

20/1738 Learning from Deaths Quarterly Report

Sandeep Ranote

Discuss and receive assurances

12:35 30 mins Lunch

13:05 15 mins

20/1739 Board Assurance Framework

Gail Briers Discuss and note

Strategy and Future Focused 13:20

15 mins 20/1740 Strategy Update – High Level

Objectives 2019/20 Quarterly Update

Tracy Hill Information and discussion

13:35 45 mins

20/1741 Focus On.. Patient Access and Patient Journey Workstreams

Presentation

John Heritage Discuss and note

14:20 Close

Date of next meeting: Monday 24 February 2020 at 9.00am at Lecture Room 3, Hollins Park House, Winwick, WA2 8WA

Exclusion of the Public: The Chairman will propose a Part 2 meeting on the basis: “That publicity would be prejudiced to the public interest by reason of the confidential nature of the business to be transacted, and that the public be excluded”

We will always do our very best to make the right decisions for the health and well-being of our patients and staff.

Agenda Item No NWBH (20/1727)

20/1727 Approved Minutes Trust Board Meeting 27 November 2019 Page 1 of 14

MEETING OF THE TRUST BOARD Part One

Approved Minutes of a meeting held on 27 November 2019 in Lecture Room 3, Education Centre, Hollins Park, Winwick, Warrington, WA2 8WA

Commencing at 9.00am

Present: Mrs H Bellairs Chairman Mr S Barber Chief Executive Ms G Briers Chief Nurse and Deputy Chief Executive Mrs T Hill Director of Strategy and Organisational Effectiveness

Professor S Ranote Medical Director Mr J Heritage Chief Operating Officer

Mr J McLuckie Chief Finance Officer Ms A Tumilty Non-Executive Director

Dr J Berry Non-Executive Director Mr I Arnold Non-Executive Director

Apologies: Ms T Kalloo Non-Executive Director Mr M Tate Non-Executive Director

Mr S McAndrew Non-Executive Director In Attendance: Mrs J Hughes Company Secretary Ms J Sayer Corporate Governance Coordinator Ms T Jones Head of Communications Ms J Hiley Clinical Director Operations and Integration Ms J McDonnell Deputy Director Nursing and Governance Mr C Pearson Governor for St Helens Constituency Mr J O’Flaherty Staff Governor, Nursing

Mr V Foulds Governor for Sefton Constituency Ms L Prescott Chief Pharmacist Ms J Neve Nurse Consultant

Item 19/1704: Ms K Ryder Health Team Manager, St Helens Community Nursing

Ms S Ryan Operations Manager, St Helens Community Nursing



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19/1703 Open Forum Mrs H Bellairs, Chairman opened the public meeting and welcomed the public. Questions were invited from the Governors and Public. Mr J O’Flaherty, Staff Governor, thanked everyone on behalf of the nursing staff for their involvement to make the Care Quality Commission inspection a positive experience. Thank you particularly to Wendy Caton, Interim Compliance Manager and Suzanne Hand, Compliance Officer. Mr C Pearson, Governor for St Helens Constituency, commented that the Governor Focus Group discussion was relaxed, dynamic and progressive. Mrs Bellairs shared feedback from the Care Quality Commission that they were very impressed, and the governors were an engaged group.

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19/1704 Patient Story Ms G Briers, Chief Nurse and Deputy Chief Executive, introduced this month’s Patient Story. This month’s Patient Story focuses on the Contact Cares Service that provides a broad range of services that focus on integrated activity. It is managed by St Helens Integrated People’s Services. The presentation included a video; Kath’s Story, she describes her experience of the care provided by the team. Members of the Team were present to explain how the integrated service helped service user Kath. Contact Cares is a shared service following the ethos of St Helens Cares, bringing together a wide range of public service organisations united by one goal to improve people’s lives in St Helens and improve the place as a whole. Our Trust staff work alongside staff from local partner organisations to provide a truly integrated health and social care service through a single front door and single access point. The service is split into three levels: initial contact and assessment; face-to-face assessment; and provision. Service user Kath’s story demonstrates the positive impact the integrated approach has on someone’s life. Kath had a fall and ended up in hospital. Contact Cares supported her to regain her independence and return home with ongoing support in place to meet



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her needs. The team is collating data which demonstrates the difference Contact Cares is making in terms of reducing hospital admissions and reducing costs across health and care services in St Helens. John McLuckie commented: “This is a great example of where people and services are actively working together as a place.” Mrs Bellairs thanked Ms Ryder and Ms Ryan for attending the Board and sharing the story.

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19/1705 Safety Walkabout Feedback Mrs Bellairs introduced the Safety Walkabout feedback: Intensive Support Team, Willis House, Knowsley – visited 1 November 2019 by Simon Barber Mr Barber, Chief Executive explained that the team provides intensive support for Learning Disabilities and has been in place for approximately 12 months, it is locally and nationally funded under the transforming care agenda for Learning Disabilities and focussed on reducing Learning Disability beds through facilitating Learning Disability care outside of hospital. The service is psychology led and consists of a small multi-disciplinary team. The pilot phase is ending and has been recommissioned for a further term in St Helens and Knowsley. There are no issues. Risk and safety is understood and training compliance is good. The short-term funding of the service means some staff are given fixed-term contracts which impacts on staff turnover and consistency of staff, due to a lack of job security. There are measurables that demonstrate the service is achieving outcomes and improving quality of life; for this reason will be recommissioned. Mr Barber commented that he would like to see staff offered permanent contracts by the Trust; the service is good and risk of being decommissioned minimal. The addition of a Forensic Clinical Psychologist is being looked at to further enhance the team. Ms A Tumilty, Non-Executive Director asked how the proven benefits of the service are shared nationally. Mr Barber responded that this is communicated through the Regional Transforming Care Board and shared as a ‘case study’ across the country. Mersey Care NHS Foundation Trust and Cheshire and Wirral Partnership NHS Foundation Trust are also vehicles to share information.



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Improving Access to Psychological Therapies, St John’s Unit, Halton – visited 8 November 2019 by Gail Briers Ms Briers, Chief Nurse and Deputy Chief Executive commented that she met with the Manager and Psychology Lead, the Well-being Practitioners and a Well-being Practitioner in training, and also saw the front desk in action Morale is good and the Manager is well thought of by the other staff. There were no training or other issues noted, however, recruitment and retention of staff is a pressure; there is a fast-track progression route for Well-being Practitioners making retention a challenge; jobs are out to advert. To address gaps due to unfilled posts slippage on vacancies is being used for an external staffing agency to support the situation to maintain triage. Difficulties are also noted occasionally in sourcing appropriate accommodation to deliver the service; rooms within GP surgeries for example. Learning Disability Community Team, Warrington – visited 15 November 2019 by John Heritage Mr Heritage, Chief Operating Officer explained that the team is situated at Hollins Park; this is the most multi-disciplinary of the Trust Learning Disability teams. He met the new Manager and the Deputy Manager during the visit. Staff talked about a change of culture taking place over the last 12 months and that it “has been great”, with staff saying they felt supported. There is an issue with forms on RiO being suitable for Learning Disability is to be addressed. Overall the visit was really positive with nothing of concern to report. Mrs Bellairs commented that she was pleased to hear the feedback about the positive and embraced change in culture. Mr Pearson referred to the visit to Willis House and added that Mr Barber’s comments about offering staff permanent employment demonstrated care of others and he thanked him. The Board noted the feedback received.

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19/1706 Apologies for absence As above



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19/1707 Declarations of Interest There were no declarations of interest in agenda items.

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19/1708 Minutes of the Board Meeting held on 28 October 2019 The minutes of Part One formal Board Meeting held on 28 October 2019 were accepted as a true and accurate record of the meeting with the following amendments: Paragraph 21; wording change to ‘the team gave an example of how learning is fed back; an example of this was provided and how it prompted a change in practice’. Paragraph 61; wording changed to ‘to indicate that the papers received by the Committee provide facts but that the Committee contain fact but want further focus on providing assurance. Paragraph 68; include ‘new’. Paragraph 85; Sentence removed, also include ‘under delegated limits’. Paragraph 91; include ‘at May 2020 Board’. Paragraph 94; replace substantive with substantially.

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19/1709 Matters arising and action points All items with a due date of 27 November were included as agenda items

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19/1710 Chairman’s Report Mrs Bellairs introduced the Chairman’s report. The report provides an update on the Chairman’s activities since the last meeting held on 28 October 2019. It also includes areas covered in Part Two of the Trust Board Meeting. Professor S Ranote, Medical Director thanked Mrs Bellairs for her involvement in the mock Patient Safety Panels at the Clinicians Quality and Safety Conference. The Board noted the content of the report.

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19/1711 Chief Executive’s Business Report Mr Barber introduced the Chief Executive’s report to provide a résumé of key issues of Trust business and items that impact on the Trust and its services; he highlighted the following areas: Mr Barber thanked those involved with the on-boarding of the Improving Access to Psychological Therapies Service in St Helens into the Trust. Mr Barber informed the Board that Alan Yates has been appointed as



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the new Chair of Cheshire and Merseyside Health and Social Care Partnership. And Also John Rouse is moving on from Greater Manchester Health and Social Care Partnership. Mr Rouse has worked with both Mr Barber and Professor Ranote and has been good for Greater Manchester. The Board wished him well. Well-being Enterprises and North West Boroughs Healthcare are recognized as another great partnership. Having put themselves forward for a Health Service Journal Award they are congratulated for being highly commended in the category of Community or Primary Care Service Redesign for the North/Midlands/East Region. The Board noted the content of the report.

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19/1712 Report from Executive Leadership Group Meeting held on 7 November 2019 Mr Barber introduced the report to provide the Trust Board with a summary of activity from the meeting of the Executive Leadership Group held on 7 November 2019, and to provide assurance of decisions aligned to the Terms of Reference. Updates were received from the Operations Group and Workforce Strategy Group that were escalated to the Executive Leadership Group. The Board: • Reviewed the update provided by the Executive Leadership

Group for the meeting held on 7 November 2019 • Received assurance that the Executive Leadership Group is

fulfilling its purpose and Terms of Reference.

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19/1713 Report from Quality Committee Meeting held on 13 November 2019 Dr Berry introduced the report to provide the Board with a summary of activity from the meeting of the Quality Committee held on 13 November 2019, and to provide assurance of decisions aligned to the Terms of Reference. The Care Quality Commission Inspection has progressed since the 13 November update which reported core service inspections had taken place. There was a St Helens Borough update which covered Pressure Ulcer care. Quality matters including safety provision and supervision were also discussed. All matters are progressing well and giving assurance. Further work with partners is required and on-going; however, overall activity is very impressive.



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Good progress has been made against quarter two quality priorities. A fine was received from the Guardian of Safe Working Hours for a breach of the 72 hour maximum limit in seven days; the Quality Committee is assured of the overall processes. The fine of goes into our own funds to contribute to training. The new way the Quality Committee conducts its business is working well to gain assurances. Ms Tumilty, with regard to pressure ulcer care package, asked if we moving towards delivering the recommendations of our internal auditors. Dr Berry responded that all process type objectives are completed or in hand. Ms Briers added that metrics are in development to provide qualitative outcomes; significant progress towards this has been made. The Board reviewed the update provided by the Quality Committee for the meeting held on 13 November 2019, confirmed agreement for the ‘ask’ of the Board for all activity undertaken and received assurance that the Quality Committee is fulfilling its purpose and Terms of Reference.

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19/1714 Finance Report - Month Seven Mr J McLuckie, Chief Finance Officer introduced the report to inform the Board of the month seven, October, financial performance and performance against the Single Oversight Framework. The report presents a current assessment of the financial position to inform the Board of a range of indicative outcomes for the full year outturn position. The following areas were highlighted from the report: Adverse variance to budget in the year to date is £190k in month seven. However we are still on track to deliver control totals and therefore achieve quarter three Public Sustainability Funding. There is an £851k capital underspend to date; the position is affected by the timing of spend; the majority of Estates funds have been committed. The cash balance is £3.7m higher than the planned balance, however, this was expected; contributing factors are in the report. Single Operating Framework out of area placements are higher than the trajectory with actions being taken. Use of agency provision breached the cap; this is being closely monitored. The risk to our forecast is reduced due to Her Majesty’s Revenue and



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Customs accepting our calculation for the VAT reclaim in relation to the Atherleigh Park scheme; the Trust is looking to expedite the refund. Ms Tumilty commented that the report provided good detail on key areas and thanked Mr McLuckie for his pursuance of the VAT reclaim. The Board noted the Knowsley Centre for Independent Living overspend. Mr McLuckie confirmed he will be speaking to the Clinical Commissioning Group to influence a proactive approach for next year. The Board discussed the paper and: • Received the month seven financial performance and

performance against the Single Oversight Framework • Noted updates and progress on planning assumptions and

risks • Agreed the current assessment of the Trust’s financial position

and the resulting range of outcomes presented for the year.

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19/1715 Bi-Annual Safer Staffing Report Ms Briers introduced the report which covers the period 1 April 2019 to 30 September 2019, to provide the Trust Board with the progress and compliance against national requirements for safer staffing and to provide an update in relation to the Trust’s safer staffing initiatives. Ms Briers provided an update; ward establishment reviews has been done in order for work on investment in inpatient staffing, with some nursing staff, assistant nursing staff and peer support workers and an increase in the psychological model. This is not just for safer staffing but for safer staffing to deliver on a new model of care being introduced, with the addition of a Senior Psychologist and new and an additional Band 6 post on inpatient wards. The next phase is around Occupational Therapy. Mrs T Hill, Director of Strategy and Organisational Effectiveness, commented that the report was really good and that she was appreciative of the amount of work to bring together in the report. Dr Berry commented that the report details progress and asked when the new work streams will start to deliver. Ms Briers responded that the recruitment of peer support workers is taking place now, the model for psychology has been agreed in principle and least restrictive work has been agreed. Ms Bellairs asked if the new Band 6 posts had been budgeted for in 2019-20; this was confirmed. Ms Tumilty asked if the extra cost of the new model would be offset by savings from bank and agency. Ms Briers explained that a



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considerable amount would offset the new investment but that the safety aspect is central; to make night and weekend staffing more robust and agreeing how much of the Band 6 time is spent supporting management and how much time is clinical and part of the roster, to create greater efficiency. It is a really well thought out plan. Professor Ranote commented that inpatient wards have become places of safety. The work with regard to vacancies on inpatient wards should done collaboratively to look at the care mode in terms of how clinical expertise is utilised in conjunction with how it works within the multidisciplinary team. Ms Bellairs noted that the new model of care would improve opportunities for career progression on wards and improve retention on wards; currently staff move into community posts for progression. The Board: • Discussed the report and confirmed that they were assured

around safer staffing levels. • Approved the report for publishing on the Trust website, and

for sharing with commissioners. • The Board agreed the next update would be received in April

2020.

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19/1716 Healthcare Worker Flu Vaccinations 2019-20 Mr Heritage introduced the Healthcare Worker Flu Vaccinations 2019-20 report which fulfils the requirement for the self-assessment to be included in the Trust Board papers before the end of December 2019. The Board discussed the rate of administration of the vaccine, its impact on staff attendance and the information and promotion aimed at staff on the benefits of having the vaccine, however, it remains a personal choice to have the vaccine. Ms Briers explained that ideally the take-up of the vaccine should be within the first few months of the flu campaign but that the period of time the vaccine is made available is extended to February 2020 because, in the event of an outbreak, more people may request it later. The Board discussed the report and: • Received assurance that the 2019-20 flu campaign is

progressing in accordance with the plan. • Agreed that the Trust can discharge the duty to publish the

Trust approach to the flu vaccination programme for front line staff in Board papers by December 2019.



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19/1717 Summary Capital Business Case Mr Barber introduced the report to present the Summary Capital Business Cases for the Nurse Call/Attack System for Knowsley Resource and Recovery Centre and the redecoration of ward areas within Knowsley Resource and Recovery Centre. Delegated authority was used to replace anti-barricade lock sets as a result of a serious incident; a limited number of inpatient wards needed locks and keys replacing and also to replace a bladder scanner. Ms Tumilty was really pleased with the cases for capital expenditure which had both been mentioned at her latest walkabout in Knowsley. It was established that the redecoration did not include interview rooms, however, Mr Barber confirmed that a painter is being recruited for planned maintenance and the redecoration of the interview rooms can be planned as an early job. The Board considered and approved the capital expenditure for the Nurse Call/Attack system at Knowsley Resource and Recovery Centre at a cost of £138,645 and the redecoration scheme at a cost of £131,000. The Board noted the use of delegated authority by the Chief Executive and Chief Finance Officer.

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19/1718 Quality and Performance Report Mr McLuckie introduced the Quality and Performance Board Report to end of October 2019; it is designed to allow the Trust Board to monitor their defined Key Performance Indicators at a Trust-wide Level. Safe The cumulative reduction in suspected suicides continues to show as a red rating; although a half percent reduction has been achieved. The Board acknowledged the reduction in restraints and seclusions. Ms Briers explained that this is attributable to the new and different way we manage people who are acutely unwell; reducing the use of restraint and using alternatives. Effective Improving Access to Psychological Therapies target is being met. The percentage of adult mental health inpatient occupancy has seen a seven month increase in admission. Re-admissions within 30 days of discharge has also risen; these are areas which are being looked into with any patterns tracked and monitored. ‘Did not attend’ rates are under target with the introduction of text



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message reminders which are working well. Responsive Mr Heritage highlighted that Improving Access to Psychological Therapies issues would be likely to exist for a number of months due to the way data is calculated. Vacancies that we cannot recruit to are ongoing and alternative staffing solutions are being sought. Well Led Professor Ranote provided an overview of the new job planning indictor showing as 79 percent. Currently 90 percent of our new job plans have been agreed and signed off. At the end of the month 84 out of 86 doctors will be fit to work with two remaining in mediation and none on sick leave. Objectives are clearer and aligned to service need and Trust high level objectives. Team job planning has been undertaken with shared objectives as well as individual objectives. Feedback from consultants has been positive; they feel supported corporately. Mrs Bellairs noted a keenness to have job plans signed off; a positive indicator of new culture being established. Mr McLuckie identified a move in the right direction with regard to training and an increase in medicines management training. Caring Later Life and Memory Service and Mixed Sex Accommodation performance against targets is good. Friends and Family Test progress is on track. Ms Tumilty referenced three Ombudsman complaints that have been upheld and asked if this is an expected rate and if there are lessons to be learned? Ms Briers verified that numbers of complaints that get referred to the Ombudsman are low and in terms of lessons learned complaints form part of a suite of learning or might be specific to individuals and not for wider sharing but for consideration. There is no particular trend. Other Items – Inpatient Staffing Establishment Review Mr Heritage informed the Board that the inpatient Staffing Establishment Review report should have referenced that the review forms part of wider reviews. The Board noted the content of the Quality and Performance Report.

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19/1719 Serious Incident Report Ms Briers introduced the report to inform the Board of serious incident reviews commissioned in October 2019, recent and planned Coroners



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Inquests and all deaths reported in October 2019. Six serious incidents were reported through the Strategic Executive Information System during October. A chart in the report allows comparison of performance across the quartiles. The report provides assurance and gives a reminder of the function of the weekly Patient Safety Panel and detail around local Patient Safety Panels which are now established. A request from the last Board meeting was for more information about lessons learned. Additional areas including reviews and reflections delivered to teams by Matrons, Heads of Quality and Assistant Clinical Directors, feature in the report. Peer reviews provide an opportunity for learning across the organisation. Care collaboratives are referenced ensuring pan-borough learning. Patient Safety Alerts and events are described in the report. Professor Ranote noted the high number of incidents resulted from drug and alcohol toxicity, particularly in Wigan. Ms Briers noted that this was a feature of the thematic review and that alcohol featured in a number of areas but was more noticeable in Wigan where there are the most inquests. Mrs Bellairs commented that the suicide prevention training notes drug and alcohol as being factors to suicide in more cases than mental health. Professor Ranote reflected that the issue needs to be ‘system owned’ and for a wider approach with Public Health etc. The Board discussed the paper and received the latest position regarding serious incidents, deaths reported and inquests and noted that the Quality Committee is undertaking their delegated activity for the scrutiny and oversight of serious complex incidents, complaints and claims. The Board received assurance that serious incidents are being managed effectively by the Trust.

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19/1720 Board Assurance Framework Ms Briers introduced the Board Assurance Framework to acknowledge that the Board has delegated the authority to the Audit Committee to seek assurance on the Trust’s risk management process and to acknowledge that the Board Assurance Framework contains all risks rated 15 or above and the risks mapped across from the Trust Risk and Opportunities Universe 2019/20 which may impact on the delivery of the Trust strategy. Ms Bellairs commented positively that the paper feels to be a more ‘live’ document than previously; there are no out-of-date review dates and the format is working.



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Mrs Bellairs asked about progress with the strategic objective/high strategic risk area relating to staff health and well-being due to operational pressures with a rating status as green. Mrs Hill commented that the plan which came out of a workshop held in August was due to be completed by December with regard to mental health specifically. The Board discussed the paper and: • Noted the current position with regards to progress and

actions taken to mitigate the risks contained within the Board Assurance Framework.

• Noted that the Audit Committee is now reviewing and managing the systems and processes to effectively identify and manage risks.

• Noted that the Audit Committee activity is reported separately. • Noted the progress of the strategic risks on the 2019/20 Board

Assurance Framework. • Noted the alignment of risk to the 2019/22 Trust Strategy.

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19/1721 Strategy Update – Estates Strategy Mr Heritage introduced the report and provided a presentation summarising delivery against the 2018/19 Estates Strategy, outlining achievements for 2019/20 and key objectives for 2020/21. The presentation covered four estates priorities: Priority one, Ensuring we have appropriate locations and buildings for services is about enabling and delivering change across the organisation. Projects around capital spend are included. The official opening of Yew Trees Huyton Core Rehabilitation Unit took place on Friday; a TV personality opened the unit. Positive feedback has been received from the event. Priority two is around the delivery of the estates functionality itself. The Trust Board receives updates within the Chief Executives Report. Priority three, ensuring work with partners concerns our role in place with strategic estates groups at different levels of maturity; it is a challenge to get traction with how we want to work in place and co-locate some of our accommodation. The pace of delivery is expected to improve as place develops and we hope to co-locate some of our partners. Priority four is to ensure statutory compliance; boiler servicing, asbestos management, electrical safety, legionella etc. A monthly estates function report demonstrates compliance. We continue to meet NHS cleanliness standards.



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A workshop with estates colleagues will look at priorities and estates utilisation and capital estates plan for 2021 to be developed. We will be looking at a trust-wide catering solution; the current contract is coming to an end, however, has been extended to allow time for decisions to be made with partners for future catering solutions. Mr Arnold asked about confidence in statutory compliance where we have a formal agreement with partners and Mr Heritage noted that in terms of leased properties we have to hold the person holding the lease accountable for being compliant. Mr Arnold asked about informal agreements in place and where we co-locate as opposed to formal lease. Mr McLuckie mentioned use of space in other establishments. Action: Mr Heritage to confirm the responsibilities around compliance in informal agreements for use of accommodation. Ms Bellairs added that the amount of premises/sessions needed to be determined; is it a number of rooms solely utilised or a number of rooms used on a sessional basis i.e. an afternoon once a week? The Board received assurance of progress towards delivering the Trust Estates Strategy 2018/2021 with specific reference to progress during 2018/19.

Chief Operating Officer

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Date of next meeting: Monday 27 January 2020 at 9.00am at Lecture Room 3 Education Centre Hollins Park Winwick Warrington WA2 8WA Exclusion of the Public: The Chairman would propose a Part 2 meeting on the basis “That publicity would be prejudiced to the public interest by reason of the confidential nature of the business to be transacted, and that the public be excluded”.

Signed………………………………………………………….. Date:………………………… Chairman

Agenda Item No NWBH 20/1728

Page 1 of 5 20/1728 Matters Arising Matrix (Part 1)

TRUST BOARD MATTERS ARISING – Board Meeting 27 January 2020

FOLLOW-UP ACTIONS MATRIX – Part One DATE: 27 November 2019

Date / Agenda Reference

Item/subject: Decision taken

and/or Action required:

Format:

Responsible Person:

Deadline:

Outcome:

25 March 2019 19/1581

Benefits Realisation

Report – Information

Management Platform

The Board thanked Mr McLuckie for the report which provided the right amount of detail and requested that a further update be provided twelve months after the clinical elements had been implemented, expected in October or November.

Benefits Realisation Report – Information

Management Platform JM

November 2020

27 November 2019 19/1721

Strategy Update – Estates Strategy

Mr Arnold asked about informal agreements in place and where we co-locate as opposed to formal lease. Mr McLuckie mentioned use of space in other establishments.

Mr Heritage to confirm the responsibilities around compliance in informal agreements for use of accommodation.

Report JH March 2020



DELEGATED ACTIONS MATRIX - Part One DATE: 27 November 2019

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Format:

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29 October 2018 18/1511

Focus on… Care Quality Commission

Well Led Inspection

DELEGATED TO THE QUALITY COMMITTEE The Board discussed the current various reporting mechanisms through the Quality Committee and it was established that the Quality Committee will oversee the action plan and provide a detailed report and assurances to the Board via the delegated action updates. 26 November 2018 Update Agenda item 18/1520 The Quality Committee was notified that actions have been circulated to the borough leadership teams, with a further update to the Quality Committee in December where it will be determined if future reporting will be directly to the Trust Board. 28 January 2018 Update Agenda Item 19/1536 The Care Quality Commission Action Plan is now compete; all specific actions have been taken or are near completion. The plan has now been populated with other external assurances the Trust has received, such as Mental Health Act Commission Visits, which have been very good. 25 February 2019 Update Agenda Item 19/1556 Feedback regarding the Kingsley Mental Health Act visit and positive feedback following the Rydal visit provides good evidence and assurance. The action plan is still on track, however further stakeholder involvement is needed. A review of the risk ratings will be undertaken to ensure that they are correct. A further update will be brought to the March Trust Board.

Quality Committee Update

T Kalloo

Monthly – until

completion

Next update due

January 2020

Agenda Item 20/1733



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25 March 2019 Update Agenda Item 19/1572 The Quality Committee noted the progress on the must do actions, the Attention Deficit Hyperactivity Disorder requires a NICE compliant pathway; which is being progressed with Commissioners. There is a risk in relation to assessment response times, which we are working to manage; this requires partnership working with primary care and other partners. 29 April 2019 Update Agenda Item 19/1593 The Quality Committee received an update and details of the monthly Care Quality Commission engagement meeting, which monitors the actions of the ‘must do’ actions from the Well Led report. Actions are now in place for the ‘should do’ actions. Discussions have taken place and continue regarding the sustainability of the Attention Deficit Hyperactivity Disorder model. 28 May 2019 Update Agenda Item 19/1614 The Board received an update via the new Quality Committee Report. The Quality Committee received a further update, there are no areas of concern or of exception to report to the Board, and monthly updates will continue. 24 June 2019 Update Agenda Item 19/1634 The Board received an update via the Quality Committee Report. The Care Quality Commission Action Plan received a further update; all must do actions are complete where possible, however further conversations are on-going regarding funding. 29 July 2019 Update Agenda Item 19/1652 The Board received an update via the Quality Committee Report. The Care Quality Commission



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Deadline:

Outcome:

Action plan received a further update; the Committee await assurance that outcomes from the two targeted peer reviews will provide the anticipated change. 30 September 2019 Update Agenda Item 19/1675 The Board received an update via the Quality Committee Report. At the August meeting a further update was provided, the Committee noted that delivery of some actions is beyond our control, however continue to work with Commissioners and engage in CQC relationship meetings. At the September meeting, the updated confirmed that the 2019 inspection had commented and preparation was on-going, the Must do action plan update was provided the further recommendation provided were accepted by the Quality Committee. 28 October 2019 Update Agenda Item 19/1694 The Board received an update via the Quality Committee Report for the October meeting. CQC ‘must do’ actions indicate an improvement in psychology but it is not at the required position yet. The 24 hour crisis team will make a big difference to patients. Self-assessment for District Nurses has moved from outstanding to good due to lack of understanding of the team. 27 November 2019 Update Agenda Item 17/1713 The Clinical Quality Commission Inspection has progressed since the 13 November Quality Committee update which reported core service inspections had taken place. The Well led inspection has now also taken place.



TRUST BOARD MATTERS ARISING - FOLLOW-UP MATRIX – ARCHIVE (6 months) PART ONE



Format:

Responsible Person:

Deadline:

Outcome:

28 January 2019 19/1544

Freedom to Speak Up

Report

The Board asked in relation to bully and harassment if the Guardian asks if the formal route has already been used, and if the reporting includes cases that have been referred back to the formal process, if these instances are within the numbers shown. Mrs Hill agreed to look at the processes and data with the Guardian to establish the position relating to harassment and bullying reported to the Guardian.

Freedom to Speak Up Report

TH

July 2019

Completed Agenda

Item 19/1659

24 June 2019 19/1639

Board Assurance Framework

The Board discussed and asked for clarity for the Red Amber and Green ratings shown on the Board Assurance Framework for both the rating of adequacy of controls and the rating against action plan. The Board requested that descriptions are added to the key.

Board Assurance Framework

GB September

2019

Completed Agenda

Item 19/1679

DELEGATED ACTIONS – PART ONE – ARCHIVE (6 months)

Date



Format:

Responsible Person:

Deadline:

Outcome:

No items archived within last 6 months

Agenda Item No

NWBH 20/1729

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20/1729 Chairman’s Report

DATE OF MEETING 27 January 2020

Item

No

.

20/1

729

TITLE OF REPORT Chairman’s Report

PRESENTED BY Helen Bellairs, Chairman

AUTHOR(S) Helen Bellairs, Chairman

REPORT PURPOSE

Information Assurance X Approval/ Decision

To provide a summary of Part Two of the Board meeting held on 27 November 2019. To provide an update of activities undertaken by the Chairman and Non-Executive Directors and any actions taken on behalf of the Board since its last meeting. To provide a summary of business carried out by the Governors.

ALIGNMENT TO THE TRUST’S STRATEGIC OBJECTIVES (X) We will deliver quality, safe and efficient services with

a highly skilled and motivated workforce X

We will engage with our communities and staff to deliver services differently

X

We will deliver whole person care through targeted

growth

We will play an active role in place-based care systems to

maintain a whole person care focus X

We will retain our values and culture X

We will grow and develop the Trust at scale, being seen

as an equal partner in any system-wide collaboration

SUBJECT MATTER/CONTENT CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS

Committee / Group Date

Audit Committee

Quality Committee

Remuneration Committee

Executive Leadership Group Sub Group Name (if applicable):

Other Group Name: Trust Board Private Meeting 27 November 2019

This content has not been considered elsewhere

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) No

Risk Reference Strategic Objective Description (as per BAF)

RECOMMENDATIONS (what is the ‘ask’ of the Board)

The Trust Board is asked to: Note the Report

Trust Board Meeting Meeting held in public

Agenda Item No

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Report to Trust Board 27 January 2020

Chairman’s Report

1. UPDATE FROM PART TWO OF THE BOARD MEETING HELD ON 27 NOVEMBER 2019 Endorsement of System or Locality Five Year Strategic Plans Mr S Barber, Chief Executive, introduced a report that provided the Board with assurance regarding the involvement of the Trust in the creation of external strategic plans and to seek the Board’s support for those plans. The report included a précis of each of the seven plans which we are connected with. Each full plan had been circulated previously. The Wigan plan was discussed at our November meeting. In general the Board recognised the themes and similarities in the plans and was interested in how best practice could be established and how that would be shared. The monitoring of delivery of the plans would be within each organisation for its own part but via the Health and Wellbeing Boards to ensure the whole picture was seen. The Strategic Transformation Partnerships will also have a view about progress and through them NHS Improvement/England. Focus On: Care Quality Commission Well Led Inspection This month we focussed on our Care Quality Commission Inspection. Ms G Briers, Chief Nurse and Deputy Chief Executive, provided a verbal update and presentation on the Care Quality Commission inspection which took place in the last quarter and culminated in the Well Led Inspection which took place on the 25 and 26 November 2019. She confirmed that the Core Services inspected were:-

• Forensic inpatient secure wards • Mental health crisis services and health based places of safety • Specialist community mental health services for children and young people • Wards for older people with mental health problems • Wards for people with learning disabilities Ms Briers also confirmed that since the Core Service inspections were completed the Trust has developed an action plan. The plan had been scrutinised by the Quality, Safety, Safeguarding and Governance Group and delivery will be overseen by the Board's Quality Committee. Ms Briers confirmed that the action plan was submitted to the Care Quality Commission Lead Inspector along with evidence of progress so far.

Agenda Item No

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The Chief Executive, Chief Nurse and Deputy Chief Executive and Chairman received verbal feedback on the Well-led element of the Inspection. This was largely very positive with areas for improvement highlighted. We are still awaiting the report however the Board was informed that a brief written summary of each of the Care Quality Commission Core inspections, including the Well Led element, had been received and areas of good practice and areas for improvement had been highlighted. Areas for improvement have been included into the action plan. The Trust has also provided additional evidence where there was a need for further clarification. Serious Incident Update Ms Briers provided a verbal update for a serious incident which cannot be shared publically at this time as it would breach the confidentiality of a patient. The detailed monitoring of Serious Incidents is carried out by the Quality Committee. This section of Part Two allows the Chief Nurse to update the whole Board on particular incidents. Prospect Partnership Update and the Development of NHS-led Provider Collaboratives The Trust is a member of one of these partnerships/collaboratives and Mr J Heritage, Chief Operating Officer, introduced a report to provide the Board with an update of progress of the Prospect Partnership (low and medium secure mental health services) and the future development of the NHS-led Provider Care Collaboratives for low and medium secure mental health. The Partnership is led by Mersey Care NHS Foundation Trust, in partnership with North West Boroughs, Cheshire and Wirral Partnership NHS Foundation Trust and two independent sector providers, Elysium Healthcare and Cygnet Healthcare. The partnership benefits from collaborative working and development of common pathways; we lead on a number of those areas including the female pathway. Earlier this year we bid for a Forensic Outreach Team to support people in the community across the collaborative area. NHS England/Improvement have identified three new areas for the Collaborative approach; Tier 4 Child and Adolescent Mental Health Services, Adult Low and Medium Secure Services and Eating Disorder Services. The current Prospect Partnership is to be on a fast track to become a Provider Collaborative and the Board will be provided with the risk sharing agreement in due course. Greater Manchester Mental Health NHS Foundation Trust is becoming the lead for the Collaborative Care Model in Greater Manchester which brings a challenge to the Trust as Cheshire and Mersey and Greater Manchester may develop different care models.

Agenda Item No

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The Board discussed the involvement of the Trust and the influence that NHS Specialist Commissioning would have on the developments and difficulties in getting to the solution for all three areas of focus. There was concern raised about how the NHS Led Provider Care Collaboratives balance with Place based arrangements, as they work on a bigger footprint. Future Strategic Direction of the Trust Mrs Hill provided an update of actions since the last Board Meeting. Notification had been received from the NHS England/ Improvement Regional Management Team that they are supportive of the Trust and Mersey Care NHS Foundation Trust progressing to stage one of the transaction process. Communication confirming this position has been shared with all staff, Governors, Commissioners and wider stakeholders. Governance arrangements supporting the programme of work have been drafted and were in the process of being agreed and the Transaction Board will commence meetings in January 2020. The potential impact of this process was debated as the Board do not want any unintended adverse consequences affecting staff or patients and service users.

2. MEETINGS AND ACTIVITIES UNDERTAKEN BY THE CHAIRMAN

In addition to the formal Board meeting each month I carry out a range of routine activities. One of the highlights was our annual ‘Our Stars’ Awards where I had the opportunity to join the shortlisted staff and their colleagues at the event on the 28 November 2019. It is a fantastic evening celebrating the fantastic work that staff are doing across the organisation. I also had the opportunity on the 29 November 2019 to spend a half day with staff at the frontline of safeguarding children in our care. The session highlighted the issues surrounding ‘County Lines’ abuse of children and young and vulnerable people. It was an excellent thought provoking session that was very positively received by everyone who attended. On the 3 December 2019, I took part in an assessment for Aspiring Executive Directors. The session was arranged by the Northern Talent Board and focussed on potential Human Resources and Organisational Development Directors. I have volunteered to continue be part of the programme. On 9 December 2019, following a request from Governors, the Governors training session comprised an adapted version of the Suicide Awareness Training which staff

Agenda Item No

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have been undertaking. We used the programme collectively with time for each governor to reflect and record their responses to the programme. 11 December 2019 saw the annual Carol Concert in Hollins Park. This is attended by patients and staff and I represented the Board along with Colin Pearson who represented the Governors. The table below shows the other meetings I have attended and activities I have undertaken not reported elsewhere.

Meeting/activity Date

NHS Providers National meeting of Chairs and Chief Executives

5 December 2019

Trust Board Development Day 10 December 2019

Warrington Service User/carer Forum 13 December 2019

Prospective Governor Event 17 December 2019

Warrington Together Chairs Meeting 17 December 2019

NHS Improvement/England Chairs and Chief Executives’ Meeting

18 December 2019

External Assessor on Non-Executive Director interviews

9 January 2020

Quality Accounts Stakeholder Event 15 January 2020

Governors’ Team Charter Working Group 15 January 2020

Non-Executive Directors’ meeting 17 January 2020

Governors’ Young Governors Working Group 22 January 2020

Patient Safety Walkabout 24 January 2020

I have also continue to have regular 1-1 meetings with the Chief Executive and three way meetings with the Company Secretary. I also continue to meet the Chair of Mersey Care NHS Foundation Trust on a 1-1 basis. Actions taken on behalf of the Board There have been no actions taken by me on behalf of the Board.

3. SUMMARY OF THE BUSINESS CONDUCTED BY THE COUNCIL OF GOVERNORS There is no business to report this month, the next Council of Governors meeting will be held on 29 January 2020 and the business conducted will be reported to the February Board meeting.

4. ACTIVITIES CARRIED OUT BY THE NON-EXECUTIVE DIRECTORS

At the end of each quarter, I report the activities of the Non-Executive Directors these are set out in the table below.

Agenda Item No

NWBH 20/1729

Page 6 of 8


Non-Executive Director

Activity Dates/Notes

Jonathan Berry

Board Meetings

28 October 2019 25 November 2019

Quality Committee 9 October 2019 13 November 2019 11 December 2019

Non-Executive Director Meeting 13 November 2019

‘Our Stars’ Awards 28 November 2019

Trust Board Development Days 10 December 2019

Activities related to SID role Chairman’s Personal Development Review Council of Governors Meeting 6 November 2019 Re appointment of Chairman to 2nd Term

Reading and Internet Research On-going activity

Mandatory Training On-going activity



Tricia Kalloo

Quality Committee 9 October 2019 13 November 2019

Audit Committee 9 October 2019






Alison Tumilty

Board Meetings 28 October 2019 25 November 2019

Audit Committee 9 October 2019 11 December 2019

Freedom to Speak Up Meeting 23 October 2019


Audit Committee Effectiveness Review

20 November 2019






Mike Tate Board Meetings 28 October 2019 25 November 2019

Agenda Item No

NWBH 20/1729

Page 7 of 8







Audit Committee Effectiveness

Review

20 November 2019

Patient Safety Walkabout 4 October 2019 6 December 2019


NHS Finance Learning Sets 12 December 2019

Mental Health Act Lead Meeting 12 December 2019





Stephen McAndrew

Board Meetings 28 October 2019



Making Families Count 7 October 2019

Service User and Carer Forum 16 October 2019


Review

20 November 2019



Patient Safety Walkabout 13 December 2019



Innes Arnold

Board Meetings 28 October 2019 25 November 2019



Coaching Conversations Programme

6 November 2019 4 December 2019 8 January 2020

MIAA Working in Collaboration seminar

8 November 2019


Agenda Item No

NWBH 20/1729

Page 8 of 8




NHS Providers NED Induction Training

14 November 2019 15 November 2019


Review

20 November 2019



Mental Health Act Lead Meeting 12 December 2019



5. RECOMMENDATION

The Board is asked to note the report. Helen Bellairs Chairman

Page 1 of 4

Page 1 of 4 20/1730 Chief Executive’s Business Report


Item

No

.

19/1

730

TITLE OF REPORT Chief Executive’s Business Report

PRESENTED BY Simon Barber, Chief Executive

AUTHOR(S) Simon Barber, Chief Executive

REPORT PURPOSE

Information X Assurance Approval/ Decision

To provide a résumé of key issues of Trust business and items that impact on the Trust and its services.

ALIGNMENT TO THE TRUST’S STRATEGIC OBJECTIVES (x) We will deliver quality, safe and efficient services with



X


growth X

We will plan an active role in place-based care systems to





CONTENT / SUBJECT MATTER CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS


Audit Committee

Quality Committee


Executive Leadership Group – sub-groups that report in and assurance provided for:

Other Group Name:

This content has not been considered elsewhere (x) x




The Trust Board is asked to note the contents of the report.




Chief Executive’s Business Report

1. PENSIONS TAX IMPLICATIONS ON THE NHS – A SOLUTION FOR 19/2020

On 6 December 2019 Julian Kelly, Chief Financial Officer, NHS England and NHS Improvement, wrote to all Chief Executives and Chairs of Trusts asking them to send a letter to, “all consultants and other clinical staff who have the potential to be impacted by annual allowance pensions tax during 2019/20 and meet the eligibility criteria set out in the NHS England FAQs”. Setting out “a binding contractual commitment between the employer and clinician to provide an additional salary supplement in retirement to compensate for any reduction in pension from a 2019/20 annual allowance charge”. The letter from Julian confirmed that, “local employers will incur no net extra costs as a result of this policy, which will be funded nationally as and when additional payments to employees are due.” I can confirm that all letters were sent and a separate communication was sent to all staff to ensure that anyone who felt they might be eligible but had been missed off the distribution list had the opportunity to notify People Services and request a letter. This latter step was felt to be necessary as, “the legal status of this letter is that it will constitute a formal variation to your contractual terms of employment”.

2. WINTER PRESSURE FUNDING

The Trust has been successful in securing additional winter pressure funding from NHS England and NHS Improvement to support the delivery of services over the winter period. This funding will be used to support a range of services over the winter period including providing funding for staffing capacity within the urgent care pathways across mental health and community services, additional clinical capacity within our mental health bed management team to support improved bed flow and usage. The funding will also provide some short-term additional capacity within our People Services team for occupational health service support. The additional funding will also enable the Trust to increase bed capacity by two beds for female patients requiring inpatient admission across the Borough of Wigan. More detail about the funding is contained in the Commercial Report which is contained within the Board pack this month.

3. QUALITY ASSURANCE AND IMPROVEMENT FRAMEWORK – SPECIALISED

COMMISSIONING 2018-2021 The Quality Surveillance Team, formerly National Peer Review Programme, led an Integrated Quality Assurance Programme for the NHS and is part of the National Specialised Commissioning Directorates, Quality Assurance and Improvement Framework.


The Quality Surveillance Team has in place four regional teams that align and engage with specialised commissioning hubs in the four NHS England regions; North, Midlands and East, London and South. The Quality Surveillance Team regional teams will be involved in the surveillance and review visits of all specialised and cancer services.

The role of the Quality Surveillance Team is to improve the quality and outcomes of clinical services by delivering a sustainable and embedded quality assurance framework for all cancer services and specialised commissioned services within NHS England.

We are required to enter data regarding Chesterton and Marlowe Low Secure Units. We are confirmed as “Routine Surveillance” for the last review period, so we will continue our quarterly contract meetings with NHSE as per usual business.

4. MEDICINES OPTIMISATION PROGRAMME – HFMA VALUE & INNOVATION

AWARD This year’s HFMA awards took place on the 5 December 2019 and Cheshire and Merseyside Health and Care Partnership, in partnership with Mersey Internal Audit Agency, took the award for its Medicines Optimisation Programme. The programme is based on integration, with a steering group drawn from providers, finance, commissioners, community pharmacy and primary care. All elements of medicines optimisation have been brought together under a single framework across the system, while all projects are owned by a chief pharmacist or head of medicines management. This ensures delivery at place level, with benefits delivered consistently and at pace across the region. The benefits realisation process is continually evolving to capture and evidence clinical outcomes and patient experience.

The Trust’s Chief Pharmacist, Lorraine Prescott and her team are actively contributing to the programme. I would like to recognise the work and involvement of Lorraine and the Medicines Management Team. The programme estimates full-year savings of around £8m from six projects, including a focus on wet age-related macular degeneration; making better use of patients’ own medication; and anticoagulation medicines. Whilst these specific projects and savings do not directly impact the Trust a planned Clozapine Optimisation Project is expected to deliver significant clinical, safety and associated financial benefits to the Trust.

5. EUROPEAN UNION EXIT

Following the vote at the second reading of the Withdrawal Agreement Bill on 20 December 2019, the Government has stepped down preparations for a no-deal exit from the European Union. The Department of Health and Social Care has informed NHS England and NHS Improvement that for the health and care system this means that no-deal preparations should cease. As a result, staff


working on no-deal preparations are being redeployed. It is key that we maintain the important learning and organisational memory gained from all the work to date, and as a result we have been asked to retain a key point of contact in case we need to stand up an operational response in late 2020 and to support embedding agreed legacy items. I would like to take the opportunity to thank all those individuals who have supported the processes that we have adhered to in support of the planning for what was a potential no deal European Union exit.

6. RECOMMENDATION

The Trust Board is asked to note the contents of the report.

Simon Barber Chief Executive


Page 1 of 27

20/1731 Report from Executive Leadership Group Meeting held on 12 December 2019 and 9 January 2020


Item

No

.

20/1

731

TITLE OF REPORT Report from Executive Leadership Group Meetings held on 12 December 2019 and 9 January 2020

PRESENTED BY Simon Barber, Chief Executive

AUTHOR(S) Simon Barber, Chief Executive

REPORT PURPOSE


To provide the Trust Board with summary of activity from the meetings of the Executive Leadership Group held on 12 December 2019 and 9 January 2020, and to provide assurance of decisions aligned to the Terms of Reference.




X


growth X


maintain a whole person care focus






Audit Committee

Quality Committee


Executive Leadership Group – sub-groups that report in and assurance provided for:

EU Exit Steering Group

Operations Group

Workforce Strategy Group

Clinical Leadership Group

JCNC

Quality, Safety, Safeguarding & Governance Group

Digital Transformation Group

Transformation & Efficiency Strategy Group

12 December 2019 And 9 January 2020

Other Group Name:

This content has not been considered elsewhere




The Trust Board is asked to: Review the update provided by the Executive Leadership Group for the meetings held on 12 December 2019 and 9 January 2020, and receive assurance that the Executive Leadership Group is fulfilling its purpose and Terms of Reference.




Page 2 of 27


Report to Trust Board

27 January 2020

Report from Executive Leadership Group held on 12 December 2019 and 9 January 2020

1. PURPOSE AND AUTHORITY

The Executive Leadership Group is established and constituted to provide the Trust Board with an update on the activities of and the decisions taken by the operational groups that report to it. Appendix one details those groups. 2. ACTIVITY OF THE EXECUTIVE LEADERSHIP GROUP AT THE MEETINGS HELD ON 12 DECEMBER 2019 AND 9 JANUARY

2020

The Activity of the Executive Leadership Group is set out against the specific terms of reference, detailing the items discussed, assurances received, decisions made and the ‘ask’ of the Board against each item.


Page 3 of 27


2.1 Governance The group will carry out the following functions:

The group shall review and approve the terms of reference for all groups that report to it on an annual basis and shall, where appropriate review and agree those groups’ work plans.

The group shall have regard to the strategic objectives of the Trust when reviewing the work plans of the groups

What was discussed Assurance Received / Issues noted

Decisions made Ask of the Board

The revised Terms of Reference for Quality, Safety, Safeguarding and Governance Group were approved this month

The Executive Leadership Group was assured that the changes were appropriate

None To be assured that the process to approve changes to Terms of reference has been appropriately followed.

The governance structure in Appendix one was reviewed to see if any new Groups need to be reflected.

The governance structure doesn't include the Patient Access and Patient Journey Groups.

To revise the governance structure in Appendix one to include the Patient Access and Patient Journey Groups.

To be assured that governance structure in Appendix one is a dynamic picture and will be revised as and when appropriate.


Page 4 of 27


2.2 Management & Assurance The Executive Leadership Group shall manage effectively the groups that report to it.

The Executive Leadership Group shall request and review reports from the groups that report to it in order to gain assurances that the business of each group is being conducted effectively.

A report from the Operations Group on 3 December 2019 was received and discussed.



Management & Assurance:

Key highlights from the Trust Board and performance packs were discussed.

The Executive Leadership Group is assured that the Operations Group continues to be sighted on Trust Board key areas of focus.

None To be assured that key areas of interest are being discussed.

Contracting:- A detailed discussion took place about the key points raised from regular contract meetings across the Trust and the need to ensure a consistent link between Business Development and the Contracting functions with regards to confirmation of income for any new business cases.

The Executive Leadership Group was assured that a process is being developed to escalate any areas of concern or required actions from contract meetings that take place.

None

To be assured that there is a process being developed for noting contract concerns and actions.


Page 5 of 27




Groups that report into the Operations Group Patient Access Group: The Operations Group received assurance that all boroughs are utilising the new patient access dashboard and that we are slowly heading towards the target of 92 percent.

The Executive Leadership Group can be assured that the patient access work is progressing and noted that we should be able to report to Exec Performance by January 2020 and to the Board by April 2020.

None The Board can be assured that the patient access work which the board has previously heard about is progressing.

Patient Journey Group: The Operations Group reported that the re-constituted Group had met and that the key priorities and a work plan had been agreed. The Terms of Reference were also agreed including membership. A Project Lead for the Community Nursing work stream would be identified and be reported at the next meeting.

The Executive Leadership Group was assured that progress continues to be made in relation to this work.

None

The Board can be assured that the patient journey work which the board has previously heard about is progressing.


Page 6 of 27




Information Assurance Group The Group reported on the on-going challenges to ensure that the correct information is captured in relation to out of area placements on the clinical system. This will be an indicator that will be tested as part of the Quality Account process for 2019/2020. The Deputy Director of Finance and Contracting and Assistant Director of Operations - Corporate are meeting on 3

December to review the current standard operating procedure and ensure it is robust and agree the guidance to be re-issued to clinical teams and managers.

The Executive Leadership Group was assured that a detailed work plan was in place with key priorities identified for the Information Assurance Group.

None

To be assured that further work on internal reconciliation of process checks will be carried out in January to ensure that full data capture in relation to out of area placements is taking place.

Focus on Session: The Group heard that work is taking place to design a new-look Operational Performance Report by the 1 April 2020. The report will bring together a range of information and data including presenting at a Trust level service data based on CQC core service domains.

The Executive Leadership Group noted the progress being made and will receive future updates.

The Chief Operating Officer will discuss the approach with the Chief Nurse/Deputy Chief Executive to ensure that the appropriate Quality and Safety data is included.

To be assured that the Performance Cycle is being continually improved.


Page 7 of 27


A report from the Operations Group on 7 January 2020 was received and discussed.



Updates from groups that report into Operations Group were received: Patient Access: All services now have correct waiting times assigned and all targets set.

The Executive Leadership Group was assured that good progress is being made with the Patient Access work-stream and the setting and monitoring of agreed targets for services.

None

To be assured that the Trust Transformation project Patient Access has ongoing Executive oversight and support.

Patient Journey: a) Progress is being made towards

mobilising the Cheshire and Merseyside Crisis Resolution Home Treatment service and recruitment is progressing.

b) Progress is also being made to mobilise the Wigan Crisis Resolution Home Treatment and wider assessment team changes.

c) Progress is being made towards implementing the recommendations of the Community Nursing review.

The Executive Leadership Group was assured that good progress is being made in line with agreed timeframes.

None

To be assured that the Trust Transformation project Patient Journey and the key projects within it has ongoing Executive oversight and support.


Page 8 of 27




Trust Operational priorities and deep dive sessions The Operations Group had received a presentation on the NHS Benchmarking data focusing on inpatient and community mental health services for 2018/2019. The report shows where the Trust appeared to be a positive or negative outlier compared to the national position to local Mental Health Trusts. It was also agreed that the CAMHS Benchmarking Data would be presented as the Deep Dive session in February.

The Executive Leadership Group raised a point of concern that historically some KPIs when investigated showed differences in what was being recorded.

The Chief Operating Officer should consider using the COO group to gain agreement on a standardised approach to data recording for some indicators

To be assured that benchmarking data will be used to support discussions within the Patient Access and Patient Journey Transformation programmes.

Business Development The Head of External Projects continues to provide an update to the Operations Group on the commercial pipeline and on-going business development opportunities and recent successes.

The Executive Leadership Group is assured of the connectivity between business development and operations.

To be assured that the Trust continues to have a well performing business development function.


Page 9 of 27


A report from the Workforce Strategy Group held on the 22 November 2019 was received and discussed



Strategy Pillar - Fit for the Future As previously reported Professional groups are progressing with the Workforce Strategies for: Medical, Medicines Management, AHP and Psychology. A range of amendments were discussed within the group and a consistent template developed. There will be a final document for approval in January.

There is limited assurance on the completion and timeline for professional group workforce strategies. Further work is required with the involvement of Professional and Exec leads. Assurance needs to be provided that the Strategies will be fit for purpose and meet our ongoing requirements for risks.

To bring the strategies for review.

To be assured that our key professional groups will work together to develop consistent Workforce Strategies.

Strategy Pillar – Talent & Succession The group reported a risk to the commitment that we will have 1percent of our workforce in a peer support role by the end of March 2020 as quoted in the People Strategy. An update on the current onboarding position was provided.

The Executive Leadership Group was not assured that this commitment would be met.

The Executive Leadership Group requested further information on plans to supplement Occupational Health capacity to provide appointments for new starters.

To be assured that risk to progress has been escalated and is being tracked against this objective.


Page 10 of 27




Strategy Pillar – Great Development A discussion took place on the allocation of spend for upskilling monies. We have received £100K and allocated £95K. Agreements on the areas of upskilling money spend includes: - Suicide prevention train the trainers (8) - Positive Behavioral Support training train

the trainers (4) - Diabetes training - Coaching for Safety Culture - Unconscious Bias training - Inclusivity and Civility training - Talent Management / Leadership

Programme - Breastfeeding awareness training - Perinatal Mental Health - Tai Chi for Falls and Arthritis (5 x

instructor course, plus 2 x updates) - Voice of the Child

The Executive Leadership Group was assured that the monies are being allocated based on risks and key objective areas.

None

To note and be assured of the decisions made.


Page 11 of 27




Strategy Pillar – Engagement & Wellbeing The Group was informed of the need to have a procedure for recording flexible working requests. The Trust does not currently record applications or the current uptake of flexible working arrangements. Engagement to commence with Partnership forum regarding the rationale and benefits for staff of recording current position for flexible working. The Trust is currently piloting a flexible working approach for ward based staff on Austen Ward and the findings will be presented to Workforce Strategy in February 2020.

The Executive Leadership Group was assured that actions are being taken to manage the process and engagement is taking place.

None

To be assured that that this gap is being actively addressed.

Strategy Pillar – Engagement & Wellbeing Equality, Diversity and Inclusion Following the last CQC inspection new lead roles have been appointed for EDI within People Services (Sue Hunt and Rachel Cowley). Action plans are being developed and opportunities to expand on EDI networks are progressing.

The Executive Leadership Group to receive a further update at the next meeting

None To be assured that questions raised by CQC about staff networks are being addressed by the Workforce Group.


Page 12 of 27




Workforce Risks Workforce risks were discussed in particular the supply of internal talent in key leadership roles. The intention is next year to use some of the upskilling monies to continue the successful Empowering Leaders Programme. We will then be able to code all of our leaders and identify when someone is ready to step up.

The Executive Leadership Group was assured that the risks are being actively managed and updated in a timely manner.

None

The Board can be assured that risks are being regularly reviewed.

A report from the Workforce Strategy Group held on the 13 December 2019 was received and discussed



Strategy Pillar - Fit for the Future A workforce planning toolkit is currently being developed and implemented within the Borough teams, supported by the HR Business Partners. This will support bottom up skills analysis and plans.

The Executive Leadership Group was assured of this approach.

None

To be assured of a service led skills based approach to workforce planning and transformation.


Page 13 of 27




Strategy Pillar – Talent & Succession Career Pathway for people of working age:

The Group was advised of progress against the Trust KPI’s as set in the 2019/20 priorities and in the Trust’s People Plan as follows: - increase our formal work experience

base line by 10 percent from 80 placements across the trust to 88 by 31

March 2020.

- support at least ten 16-24 year olds to undertake structured traineeship opportunities by 31 March 2020.

- support at least five people between 19-24 years of age to undertake structured Supported Internship Programmes by 31

March 2020.

Convert 20 percent of those undertaking Work Based Learning Placements to employment in the Trust.

The Executive Leadership Group was assured that we are on target to achieve or exceed the KPI’s with exception for supported internships (long term work experience for people with special educational needs and disabilities) but note that this in an internal target.

None

To note and be assured of decisions made.


Page 14 of 27




Strategy Pillar – Engagement & Wellbeing A discussion took place regarding the most appropriate forum for the receipt of information regarding the Freedom to Speak Up themes and if it should be reported through the Workforce Strategy Group to ensure lessons learnt are rolled out effectively.

The Executive Leadership Group felt that the Workforce Strategy Group was not the right place for operational information to be shared.

It was agreed that Freedom to Speak Up themes should be reported to the Partnership Forum. Freedom To Speak Up will now also report directly to Board.

To be assured that Freedom to Speak up themes will be more appropriately discussed at the Partnership Forum, allowing conversation with staff side colleagues as well as operations.

Strategy Pillar – Engagement & Wellbeing

Equality, Diversity and Inclusion:

A paper was presented that recommended a new governance structure for Equality and Inclusion.

The existing employee network will remain to share learning and themes across different protected characteristics. A proposal was discussed to establish specific networks for: - Four new inclusion networks to be

launched, ideally with Executive sponsors for each (BAME, LGBT+, Women’s and Disability)

- A workforce led E&I working for all equality and inclusion objectives affecting staff.

The Executive Leadership Group was assured but wanted a review of the agreed actions and timelines. The Executive Leadership Group felt that the Workforce Strategy Group was not the right place for the networks to report.

It was agreed that there should be a staged and phased approach for the network groups to ensure we provide the right support and exposure. It was agreed to launch the BAME group first and identify an Exec sponsor to champion the group. It was decided that the ongoing reporting should feed into the Operational Group or the Partnership Forum.

To be assured that staff networks are being launched with Executive sponsorship.


Page 15 of 27




Workforce Risks The group was assured that the risks are being actively managed and updated in a timely manner.

The Executive Leadership Group was assured that the risks are being monitored and managed.

None

To be assured of the continuation of monitoring and updating of risks in a timely manner.

A report from the Clinical Leadership Group held on the 11 November 2019 was received and discussed

What was discussed Assurance Received/ Issues noted

Decisions Made Ask of the Board

Terms of Reference: A discussion took place regarding the membership of CLG and it was supported that the Director of Nursing and Quality would become deputy chair. It was also supported that ACDs from all the Boroughs would be included in the membership to provide greater clinical challenge, scrutiny and peer review. It was also agreed that CLG would move back monthly as there is a gap for NICE guidance being approved.

The Executive Leadership Group was assured that the effectiveness of CLG is being continuously improved.

The revised Terms of Reference will be presented to the Executive Leadership Group in February 2020.

To be assured that the effectiveness of CLG is being continuously improved.


Page 16 of 27




Quality Assurance: A piece of work has been completed to improve the signing off of Quality Impact Assessment and a decision was made that the plans should now go through the Transformational Delivery Group before CLG to receive scrutiny of plan first. A number of models were presented and approved: - Urgent Care Patient Flow – Adults - Learning Disability Standardised Staffing

Review - Leadership Review - Back Office Review - Putting Patient Access First There were also a number of schemes that were deferred as there was no representation at the meeting: - Quality Assurance - Informatics - Halton Medic - Community Medical Effective Discharge LD Inpatient Bed Review

The Executive Leadership Group was assured of the effective use of the quality impact assessment process. There was concerns about lack of representation preventing progress

The Medical Director to raise this with the Director of Nursing and Quality.

To be assured of the effective use of the quality impact assessment process.

Clinical Scrutiny: The NICE tracker was presented for consideration and discussion.

The Executive Leadership Group is assured that issues re NICE compliance will be escalated and mitigated by the NICE Lead.

None To be assured that issues re NICE compliance will be escalated and mitigated.


Page 17 of 27




Clinical Scrutiny - Patient Access – Standard Operating Procedure: A presentation was delivered on the new Standard Operating Procedure. A recommendation was made regarding the ‘did not attend’ and the ‘opt in’ process. The procedure was approved once this change is made.

The Executive Leadership Group was assured that procedures are appropriately reviewed prior to approval.

None

To be assured that procedures are appropriately reviewed prior to approval

Joint Consultation & Negotiating Committee – Meeting held on 23 December 2019 was received and discussed



Assurance: Papers for JCNC sub committees were approved.

Assurance on subcommittee structure.

None

To be assured that the reporting hierarchy is working appropriately.

Negotiation: Workforce Development The Deputy Director of HR & OD updated the group on the proposals to develop workforce strategies for the different professions. It was stated that these would be reviewed by the Workforce Strategy Group

Assurance that staff side is sighted on the development of these strategies

None

To be assured that Trade Union partners have been briefed on the creation of these strategies


Page 18 of 27




Trust Business Development The Chief Executive noted the St Helens IAPT service had transferred in to the Trust from Lancashire Care with no issues noted.

Assurance that staff side is sighted on this development.

None

To be assured that Trade Union partners have been briefed.

Organisational Changes The Chief Executive updated the Group on progress with the transaction and the next steps which included the publication in the New Year of the FAQ’s and the first Transaction Board.

Assurance that we are living up to our commitment of open communication with staff side colleagues.

None

To be assured that Trade Union partners have been briefed.

Business Plan The Director of Strategy & Organisational Effectiveness briefed the Group on the work being done by the Directors and Deputies Group and the Leadership Group to reduce the number of additional “projects” or objectives across the organisation and to create a strategy that describes benefits to patients and staff that outlast the organisation.

Assurance that staff side is briefed on the change in approach that will be evident in our refreshed strategy.

None

To be assured that staff side were supportive of the approach


Page 19 of 27


A report from the Quality, Safety, Safeguarding and Governance Group (QSSGG) held on the 10 December was received and

discussed



Caring

It was noted that the quarter two Patient Experience report was received and approved. From this quarter a total of 78 complaints were received, 37 were closed. Out of the 37 complaints 21 were upheld partially or fully. A recommendation was made to rename the making families matter work-stream to “Kinsider”.

The Executive Leadership Group is assured of the actions being taken to monitor complaints.

The Executive Leadership Group approved the name change to “Kinsider” and to consider this as one of the quality priorities for 2020-21.

To be assured that actions are being taken to monitor complaints.

Responsive

It was noted that the Community Mental Health Survey 2019 results had been received, which comprised 29 questions grouped into 11 categories. The Trust scored “about the same” for all 11 categories. The results were shared with borough leadership teams in November to identify opportunities for improvement.

The Executive Leadership group was assured that the Trust is responding appropriately to the survey.

None To be assured that the outcomes of the survey has led to that actions being identified for opportunities to improve.


Page 20 of 27




It was noted that the Complaints Improvement Plan had been approved for quarter three. The improvement plan comprises nine objectives with an overall total of 34 action areas; 32 are on track for completion, two are mainly on track with minor issues with mitigating activities in place. These areas relate to testing the new process for identifying a lead investigator and the subsequent full roll out of this model following testing. This work links closely with the “Kinsider” (formerly making families matters) initiative. The audit of complaints by MIAA auditors is near completion and the group will receive and review the actions following its receipt.

The Executive Leadership Group was assured that actions are being taken to improve the quality of complaints.

To receive a further paper for the phase two action plan at a later meeting and the results of the MIAA audit.

To be assured of progress with the actions and to note he decision to develop a phase two plan action plan to provide additional assurance on the quality of complaints.

Safe

The outcomes of the scoping exercise of Rapid tranquilisation incidents within Wigan borough to identify progress made following the POMH audit 2018 action plan were noted. Whilst some improvements were noted in 12 of the 13 areas compared with the 2018 audit there is further work required. In one area there was a reduction in compliance for reviewing a care plan following post-rapid tranquilisation administration.

The Executive Leadership group was assured that this exercise is being effectively managed.

There is a need for a re-audit to be undertaken once local actions have been completed; and a recommendation made for this audit to be Trust-wide.

To be assured that local actions are identified to address areas of concern. To note decision made.


Page 21 of 27




Updates from the health collaborative included:

VTE audit: The group reviewed the results of the Wigan borough VTE audit and noted concern that the report does not reflect the context of no instances of VTE having been reported.

Diabetes: the review of service level agreements with specialist services and review of equipment is underway. 480 Diabetes training places have been identified, commencing early 2020.

Sepsis – NEWS2 is operational however community services are unable to record in RiO. Mitigations are in place for community services to record paper records whilst scoping for electronic recording of e-observations takes place.

The Executive Leadership group was assured that action are being taken to address concerns.

None To be assured that actions are being taken to address areas of concern.

Least Restrictive Practice Care Collaborative: A CPA collaborative has been established with an agreed work-plan. A positive behaviour support training package is being finalised and funding sourced to support delivery of this. The observation policy has been reviewed and plans are being finalised to ensure effective cascade and training for staff. The group recommended this training is mandatory and a record is required in ESR

The Executive Leadership group was assured of the actions being taken.

None

To be assured that progress is being made with the delivery of this area that has been discussed previously at Board.


Page 22 of 27




to confirm completion and levels of compliance.

The first Safeguarding Exception report was discussed and it was noted that exceptions were raised regarding capacity and demand for the Knowsley and St Helens multi-agency safeguarding hubs (MASH) and the Trust’s limited resource to provide adequate staffing and resources. This risk will be added the Trust risk register. The national changes for adult safeguarding training were noted; there is a need for the Trust to develop options for implementation and delivery against this. The QSSGG to receive a paper scoping requirements and options for delivery of the new training requirements for 2020-21.

The Executive Leadership Group was assured of the proposed actions to be taken and agreed to provide the appropriate support.

The Executive Lead for Knowsley to support a conversation with the CCG regarding capacity. Decision approved to add to the risk register.

To be assured that the appropriate actions are being taken.

The update report for the Security arrangements for the Trust, with the recommendation for the removal of the NED responsibility, in line with national recommendations was discussed.

The Executive Group was assured of the actions being taken to review future requirements.

The Executive Group agreed to the recommend to the Chairman the removal of the NED responsibility as this is no longer a statutory requirement.

To be assured that the necessary actions are being taken to review the Trust requirements.


Page 23 of 27




Patient safety improvement plan phase two was discussed. It was noted that the recruitment to a Suicide Prevention Lead is underway and that a job description is being finalised. Actions are on track for completion.

The Executive Group was assured that the plan is on track for delivery, but questioned the length of time taken over the job description and recruitment of the Lead.

None To be assured that the plan is on track for delivery.

Effective

A Care Programme Approach (CPA collaborative has been established with an agreed work-plan. The work-plan is focussed on the new national guidance which has been published. A Post discharge 72 hour follow up procedure has been developed and has been approved to support this work. The principles of CPA need to be embedded into the relevant transformation projects across the Trust to ensure this is fully embedded into practice as a standardised approach.

The Executive Group was assured that the plan is on track for delivery.

None To be assured that the work-plan is on track for completion.


Page 24 of 27




The Trust has received written feedback from the CQC for each of the five core service inspections and has developed actions to address areas for improvement. Work is ongoing to identify mitigating actions to bring these areas on track for delivery.

The Executive Leadership Group was assured that the action plan is being managed and that it will be reviewed once the inspection reports are received.

None To receive assurance that the action plan is in place with regular monitoring on progress by the QSSGG.

The outline options for quality priorities for 2020-21 had been agreed by QSSGG, these include: Kinsider, Management supervision, Coaching for Safety and Positive Behaviour Support within inpatient services. Leads had been identified to attend the stakeholder event in January 2020.

The Executive Leadership Group were assured that a timetable has been developed to deliver the Quality Accounts for 2019-2020.

None To receive assurance that a timetable has been developed to deliver the Quality Accounts for 2019-20.


Page 25 of 27


A report from the Transformation & Efficiency Strategy Group – Meeting held on 4 December 2019 was received and discussed



Themes/Schemes for 20/21 It was noted that worked up schemes were yet to be completed for the themes previously identified. A discussion took place around the requirement for additional schemes and the work of the Delivery Group to suggest additional/replacement schemes.

The Executive Leadership Group expressed concern that the process was slipping behind schedule and supported the approach being taken by the Group and requested a clear update of the amounts identified as potential savings by theme at the next meeting.

To receive a more detailed update at the next meeting.

To be assured that action is being taken by the Executive Leadership Team and the Transformation & Efficiency Strategy Group in relation to the identification of 2020/21 savings plans.

A report from the Transformation & Efficiency Strategy Group – Meeting held on 7 January 2020 was received and discussed



Planning for 20/21 Trust schemes A number of schemes are progressing but documentation required to evidence decision making and financial savings is still required

Noted the schemes identified to date and the remaining gap to achieve 1.6 percent efficiencies.

All outstanding documentation to be completed for the next Transformation meeting. To reiterate the requirement to identify 1.6 percent efficiencies.

To be assured that progress is being made to support the requirement for 1.6 percent efficiencies


Page 26 of 27


3. RECOMMENDATIONS The Trust Board is asked to: Review the update provided by the Executive Leadership Group for the meeting held on 12 December 2019 and 9 January 2020 and receive assurance that the Executive Leadership Group is fulfilling its purpose and Terms of Reference. Simon Barber Chief Executive


Page 27 of 27


APPENDIX ONE

Agenda Item 20/1732

Page 1 of 14

20/1732 Report from the Audit Committee 11 December 2019


Item

N

o.

20/1

732

TITLE OF REPORT Report from Audit Committee Meeting held on 11 December 2019 PRESENTED BY Alison Tumilty, Non-Executive Director/ Audit Committee Chair AUTHOR(S) Alison Tumilty, Non-Executive Director/ Audit Committee Chair

REPORT PURPOSE


To provide the Trust Board with summary of activity from the meeting of the Audit Committee held on 11 December 2019, and to provide assurance of decisions aligned to the Terms of Reference.

ALIGNMENT TO THE TRUST’S STRATEGIC OBJECTIVES (x) We will deliver quality, safe and efficient services with a highly skilled and motivated workforce X We will engage with our communities and staff to deliver

services differently X We will deliver whole person care through targeted growth We will play an active role in place-based care systems to

maintain a whole person care focus We will retain our values and culture We will grow and develop the Trust at scale, being seen


SUBJECT MATTER/CONTENT CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS Committee / Group Date Audit Committee 11 December 2019 Quality Committee Remuneration Committee Executive Leadership Group Sub Group Name (if applicable):

Other Group Name: This content has not been considered elsewhere (x)

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) Y Risk Reference Strategic Objective Description (as per BAF)

ALL ALL The Risk and Assurance Report including the Board Assurance Framework is reviewed at each meeting of the Audit Committee.


The Trust Board is asked to: • Review the update provided by the Audit Committee for the meeting held on

11 December 2019, and confirm agreement for the ‘ask’ of the Board for all activity undertaken and the requirement for all future Audit Committee reports to provide the appropriate level of assurance.

• Receive assurance that the Audit Committee is fulfilling its purpose and Terms of Reference.


Agenda Item 20/1732

Page 2 of 14



Report from Audit Committee Meeting held on 11 December 2019

1. PURPOSE AND AUTHORITY The Audit Committee is established and constituted to provide the Trust Board with an independent and objective view of assurance from its internal control systems, to direct and gain assurance from the work of internal audit and external audit and gain assurance for compliance with relevant laws and guidance. The committee shall also provide assurance to the Trust Board that appropriate structures, systems and processes are embedded in the organisation to manage patient safety and clinical risk. 2. ACTIVITY OF THE AUDIT COMMITTEE AT THE MEETING HELD ON 11 DECEMBER 2019

The Activity of the Audit Committee is set out against the specific Terms of Reference, detailing the items discussed, assurances received, decisions made and the ‘ask’ of the Board.

Agenda Item 20/1732

Page 3 of 14


2.1 Governance, Risk Management and Internal Control The Committee will gain assurance from the review of accuracy of: • all risk and control related disclosure statements, together with any accompanying Head of Internal Audit Opinion, External

Audit Opinion or other appropriate independent assurances, prior to endorsement by the Board; n/a

• the underlying assurance processes (including the function of committees) that indicate the degree of achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements. This will include a regular ‘deep dive’ into the control and mitigation action relating to strategic or significant operational risks recorded in the risk register within the Risk Assurance Framework;

See below

• the Trust’s Annual Clinical Audit Programme and ensure that outcomes result in service improvement; n/a

• the policies for ensuring compliance with relevant regulatory, legal and Code of Conduct requirements, performing an oversight role in relation to registers where interests, hospitality and partnerships are recorded;

n/a

• the policies and procedures for all work related to fraud and corruption as set out in the NHS Counter Fraud Authority Standards for Providers and as required by the NHS Counter Fraud Authority and the revised NHS Contract.

n/a

What was discussed Assurance Received Decisions made by the Committee Ask of the Board

19/123 Risk and Assurance Report The following points were discussed: • Risk appetite – It was felt that the Trust had not

recently formally considered its appetite for risk. • Assurance map – The NHS Audit Committee

Handbook suggests that it is good practice to build an assurance map that identifies the sources of assurance available which also assesses how well they meet the Trust’s needs.

• Risk ownership – Is risk ownership at the right level? Currently the risk register identifies ownership at various levels.

• Workforce risks – It was noted that three new clinical

It was recognised that there had been vast improvements in the format and content of the report and that there is an effective risk framework operating across the Trust. However, future reports need to highlight specifically what and how assurance is being provided.

Recommendation that the Board review and determine the Trust’s risk appetite for 2020/21. Ms J McDonnell, Deputy Director of Nursing and Governance, to:

• Complete the assurance map for consideration by the committee.

• Review and assess the appropriateness of the levels of risk ownership identified in the risk register

To note and consider. To confirm when risk appetite would be considered next. To consider a BAF risk in relation to the transaction.

Agenda Item 20/1732

Page 4 of 14



risks had been identified due to issues with workforce recruitment and retention. Should this be considered as an organisation wide risk?

and make a recommendation to the committee for consideration. Also, what is the process for managing risk?

2.2 Internal Audit The committee shall ensure that there is an effective Internal Audit function established by management that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will be achieved by: • consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and

dismissal; n/a

• review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation as identified in the Assurance Framework;

See below

• consideration of the major findings of Internal Audit work (and management’s response), and ensure co-ordination between the Internal and External Auditors to optimise audit resources;

See below

• ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation; See below • Annual review of the effectiveness of Internal Audit. n/a What was discussed Assurance Received Decisions made by the

Committee Ask of the Board

19/130 Internal Audit Progress Report Report received from Mersey Internal Audit Agency. The following points were discussed: • Whilst the sickness absence report had not yet been

completed, an early warning was flagged to the committee.

The Trust’s cost improvement programme process received substantial assurance. The committee were assured that the internal

Mersey Internal Audit Agency to share the completed sickness absence report at the February committee meeting. The appropriate representative from People Services to be invited to attend.

To note.

Agenda Item 20/1732

Page 5 of 14


What was discussed Assurance Received Decisions made by the Committee

Ask of the Board

• Early engagement of committee members in next year’s Internal audit plan.

audit plan was on track. Mersey Internal Audit Agency to share a first draft of their 2020/21 internal audit plan at the February committee meeting for input by Audit Committee

19/131 Internal Audit Follow Up Report Mersey Internal Audit Agency presented their report with regard to the follow up on the implementation of agreed action plans.

A high level of assurance was received.

To note.

19/132 Internal Audit Report – Cost Improvement Programme Review Mersey Internal Audit Agency presented their report to the committee. The overall objective of the review was to ensure that the Cost Improvement Programme has been set robustly, is subject to robust challenge prior to agreement and tracked to ensure delivery can be achieved and systems are in place to flag non delivery and seek support where required.

A substantial level of assurance was received.

To note.

19/133 Terms of Reference for Internal Audits: Assurance Framework and Conflicts of Interest Assurance Framework – It was recognised that for the most part the objectives of the review were standard. However, the committee felt that objective four Assessment of the controls (including gaps) and actual

The committee were assured that the terms of reference for the Assurance Framework and Conflicts of

Mersey Internal Audit Agency agreed to refine the wording of objective four.

To note.

Agenda Item 20/1732

Page 6 of 14



Ask of the Board

assurances identified in the Assurance Framework was not as clear as it could be. Conflicts of Interest – The terms of reference for the review were discussed and it was agreed that this was a standard review and therefore there was little room to alter the scope of the review.

Interest reviews were robust.

The committee were happy to accept the terms of reference as presented.

To note.

2.3 External Audit The committee shall ensure that there is an effective Internal Audit function established by management that meets mandatory Public Sector Internal Audit Standards and provides appropriate independent assurance to the Audit Committee, Chief Executive and Board. This will be achieved by: • consideration of the appointment and performance of the External Auditor as far as the rules governing the appointment

permit; n/a

• discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of the audit as set out in their annual plan, and ensure co-ordination, as appropriate, with other External Auditors in the local health economy;

n/a

• discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee;

See below

• Review all External Audit reports, including agreement of the annual audit letter before submission to the Board and any work carried out outside of the annual audit plan, together with the appropriateness of management responses.

See below


Ask of the Board

19/118 External Auditor Fees Board Part 2 discussion.

Agenda Item 20/1732

Page 7 of 14



Ask of the Board

19/134 External Audit Progress Report and Sector Update As above with regard to the risk to the completion of the audit in a timely manner. The auditor raised a potential risk to the completion of the Quality Accounts due to changes in Trust personnel and staff capacity within the governance team. Ms J McDonnell, Deputy Director of Nursing and Governance, responded that appropriate cover arrangements had been agreed for this piece of work.

Ms J McDonnell, Deputy Director of Nursing and Governance, assured the committee that appropriate mitigation plans were in place.

As above To monitor the situation.

As above. To note.

2.4 Counter Fraud The committee shall gain assurance from the work of the Counter Fraud Service to ensure it is compliant with the NHS Counter Fraud Authority Standards for Providers. The committee shall gain assurance from the reviews and investigations undertaken by the Local Counter Fraud Specialist and consider the implications and management responses to their work. This will be achieved by: • consideration of the provision of the Counter Fraud Service, the cost of the service and any questions of resignation and

dismissal; See below

• review and approval of the Counter Fraud strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the needs of the organisation;

See below

• consideration of the major findings of Counter Fraud work (and management’s responses); See below • ensuring that the Counter Fraud function is adequately resourced and has appropriate standing within the organisation; See below • annual review of the effectiveness of Counter Fraud. n/a

Agenda Item 20/1732

Page 8 of 14



Ask of the Board

19/135 Anti-Fraud Progress Report Mersey Internal Audit Agency presented their report.

The committee were assured that the plan was on track.

To note.

19/136 Standards for Providers Action Plan Mersey Internal Audit Agency presented the updated action plan. The committee were pleased to note the agreed actions to turn many of the ambers to greens. The committee were pleased with the approach taken by Mersey Internal Audit Agency and progress being made.

The committee were assured that the action plan was on track.

To note.

2.5 Policy and Business Continuity The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. The Audit Committee shall also be responsible for: • Ratification of Trust policies and procedures via the Authorised Policy Approval Committee (APAC) Report. See below • Receive assurances on business continuity. See below What was discussed Assurance Received Decisions made by the


19/124 Ratification of Trust Policies and Procedures The committee noted the significant progress with regard to

The committee were

The policies and procedures

To note.

Agenda Item 20/1732

Page 9 of 14



the reduction of policies and procedures overdue.

assured with the progress made.

presented were ratified. The committee asked for future reports to specifically highlight what and how assurance is being provided to the committee.

19/126 NHS Core Standards for Emergency Preparedness, Resilience and Response Assurance for 2019-20 The committee questioned whether the major incident desktop exercise scheduled for the final quarter would include other organisations and where the learning from this exercise would go. Could we strengthen the exercise by benchmarking with other organisations?

The committee were assured that a deep dive audit had taken place.

The learning from the exercise is to go back to Audit Committee. Mersey Internal Audit Agency to look at benchmarking.

To note.

2.6 Quality Committee The Audit Committee will receive: • An Annual Report from the Quality Committee to provide assurance on clinical audit activity, health & safety and the

effectiveness of the Quality Committee. n/a

• Also, as appropriate and by exception, the Quality Committee may refer matters relevant to internal control as requested. The Audit Committee may ask the Quality Committee to look further into areas of internal control relating to quality.

See below

• 19/121 Exception reporting from Quality Committee Chair

Agenda Item 20/1732

Page 10 of 14


2.7 Management, Reporting Mechanisms and Review The Audit Committee shall: • Request and review reports and gain assurances from directors and managers on the overall arrangements for integrated

governance, risk management and internal control. See below

• The Chair of the Committee shall draw to the attention of the Board via an update to each Trust Board Meeting key items of business from the Committee Meeting.

n/a

• The Committee will specifically report to the Board annually on its work in support of the Annual Governance Statement specifically commenting on the fitness for purpose of the Assurance Framework, the completeness and degree of embedded approach to risk management in the organisation, the integration of governance arrangements and the appropriateness of the self-assessment against the CQC Fundamental Standards for Quality and Safety.

n/a

• The Terms of Reference for the Audit Committee will be reviewed annually. n/a What was discussed Assurance Received Decisions made by the


19/122 Audit Committee Effectiveness Review The committee reviewed and discussed the actions from Appendix A of the report.

The committee were assured that a robust review had been undertaken.

Point 5 – Third party assurance. The Chief Finance Officer and Assistant Director of Finance to scope and make a recommendation to the Audit Committee. Point 8 – The committee agenda covers data quality, performance targets and financial control. Data quality, performance targets and financial control to be added into the scope of internal audit reviews where appropriate. Add

To note.

Agenda Item 20/1732

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Ask of the Board

a review of the SOF into the audit plan (specific measures each year). Point 10 – Management fully briefs the committee on key risks and gaps in control. Better use of the Risk and Assurance Report to flag risks with control weaknesses. Identify thematic issues and what this is telling us. How gaps in control are managed. Management to provide explicit assurance in the Risk and Assurance Report. Point 11 – Other committees input. Update from the Quality Committee to be provided at each Audit Committee meeting. Joint meeting of the Quality Committee and Audit Committee chairs to be arranged. Point 21 – Reflection time. The attendees agreed to include reflection time at the end of each meeting.

Agenda Item 20/1732

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Ask of the Board

Point 23 – The Board challenges and understands the reporting from the committee. Potential topic for a Trust Board Development Day. Point 27 – Reports from other committees. As per point 11 above. Point 34 – Committee’s role and responsibilities in relation to Annual Reporting. The Audit Committee Chair and the Chief Finance Officer to meet with the Chief Executive and Trust Chair to clarify.

19/127 Health and Safety Update (quarter 2) Update received from Ms J McDonnell, Deputy Director of Nursing and Governance.

The verbal update provided assurance.

Future reports to specifically highlight what and how assurance is being provided to the committee.

To note.

Agenda Item 20/1732

Page 13 of 14


2.8 Delegated Authority The Audit Committee will receive: • The committee shall have delegated authority from the Board to raise issues with Executive Management that the

committee considers to require management intervention and/or investigation where an audit is not deemed to be the most appropriate action.

n/a

2.9 Annual Reporting The Audit Committee shall review the Annual Report and Financial Statements before submission to the Board, focusing particularly on: • the wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the

committee; n/a

• ratification of and compliance with financial and accounting policies and practices; n/a • unadjusted miss-statements in the financial statements; n/a • major judgemental areas; n/a • significant adjustments resulting from the audit. n/a • seeking assurance that the systems for financial reporting to the Board, including those of budgetary control are subject to

review as to completeness and accuracy of the information provided to the Board (including the review of schedules of losses and compensation making recommendations to the Board as required and review of the schedules of debtor balances over six months old)

See below


Ask of the Board

19/128 Aged Debt, Salary Overpayments and Losses Highlight Report and Salary Overpayments Register Report received.

Assurance received via enhanced reporting.

The proposed debt write-offs were approved. Section to be included in the next report on how we manage instances like the Fairhaven situation.

To note.

Agenda Item 20/1732

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Ask of the Board

19/129 Approval of Charitable Funds Annual Report and Accounts • Annual Accounts 2018/19 • Trustees Annual Report 2018/19 • Draft Auditors’ Independent Examiner’s Report

The Charitable Funds Annual Report and Accounts and Auditor’s Report were presented.

Clean audit opinion.

Recommended for full Trustees approval at the January 2020 Trust Board meeting.

To approve.

Other comments None 3. RECOMMENDATIONS The Trust Board is asked to: Review the update provided by the Audit Committee for the meeting held on 11 December 2019, and confirm agreement for the ‘ask’ of the Board for all activity undertaken and the requirement for all future Audit Committee reports to provide the appropriate level of assurance. Receive assurance that the Audit Committee is fulfilling its purpose and Terms of Reference. Alison Tumilty Non-Executive Director

Agenda Item 20/1733

Page 1 of 12


Item

No

.

20/1

733

TITLE OF REPORT Report from Quality Committee Meeting held on 11 December 2019

PRESENTED BY Jonathan Berry, Non-Executive Director

AUTHOR(S) Jonathan Berry, Non-Executive Director

REPORT PURPOSE


To provide the Trust Board with summary of activity from the meeting of the Quality Committee held on 11 December 2019, and to provide assurance of decisions aligned to the Terms of Reference.




X


growth








Audit Committee

Quality Committee 11 December 2019



Other Group Name:

This content has not been considered elsewhere (x)

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) N



The Trust Board is asked to: Review the update provided by the Quality Committee for the meeting held on 11 December 2019, and confirm agreement for the ‘ask’ of the Board for all activity undertaken. Receive assurance that the Quality Committee is fulfilling its purpose and Terms of Reference.


20/1733 Report from the Quality Committee 11 December 2019

Agenda Item 20/1733

Page 2 of 12



27 January 2020

Report from Quality Committee Meeting held on 11 December 2019 1. PURPOSE AND AUTHORITY The purpose of the Quality Committee is to provide leadership and assurance to the Trust Board on the effectiveness of Trust arrangements for quality, safety and risk ensuring there is a consistent approach throughout the Trust, specifically in the areas of: The Quality Committee is authorised by the Trust Board to investigate any activity within its Terms of Reference. The Quality Committee is authorised by Trust Board to obtain outside legal or other independent professional advice and to secure the attendance of non-Board members, including non- Trust staff, with relevant experience and expertise if it considers this necessary. 2. ACTIVITY OF THE QUALITY COMMITTEE AT THE MEETING HELD ON 11 DECEMBER 2019

The Activity of the Quality Committee is set out against the specific Terms of Reference, detailing the items discussed, assurances received, decisions made and the ‘ask’ of the Board.

Agenda Item 20/1733

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2.1 ACTIVITY The Committee ensures that there is good quality governance in place around the quality of care within the Trust through the following eight principles: 1) Ensuring that the fundamental standards of quality and safety (as determined by CQC’s registration requirements) are at a min imum being met by every service that the organisation delivers 2) Ensuring that the organisation is striving for continuous quality improvement and outcomes in every service 3) Ensuring that every member of staff that has contact with patients, or whose actions directly impact on patient care, is motivated and

enabled to deliver effective, safe and person‐centred care 4) Ensuring required standards are achieved

5) Investigating and taking action on sub‐standard performance 6) Planning and driving continuous improvement

7) Identifying, sharing and ensuring delivery of best‐practice 8) Identifying and managing risks to quality of care To achieve its purpose the Committee agenda is divided into six sections enabling quality to be considered, with a focus every meeting on an element of each area, based on a rolling programme. Each of the six areas will have the eight principles above applied to them when being considered by the committee in order to provide assurance to the Trust Board on their delivery.

Agenda Item 20/1733

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Trust Board Delegated Actions The Quality Committee will provide updates on progress against delegated tasks from the Board:

Care Quality Commission Current Position and Compliance Update

Delegated by the Trust Board on 29 October 2018, agenda item 18/1511: The Board discussed the current various reporting mechanisms through the Quality Committee and it was established that the Quality Committee will oversee the action plan and provide a detailed report to the Board via the delegated action updates monthly until completion.


Decisions made by the Committee

Ask of the Board

19/101 Care Quality Commission Current Position and Compliance Update The Committee were provided with an update in respect of the following: • The current position with regards to the Care Quality Commission inspection of the Trust for 2019/2020 • Early actions identified as a result of initial feedback from core services inspections • External Inspections and Quality Assurance Visits • Details of the Trust’s internal framework for governance and oversight of compliance with the engagement meetings with Care Quality Commission • Care Quality Commission Insight Dashboard update

• The 2019 inspection has now concluded following completion of the well-led element of the inspection on 25 and 26 November 2019. • Initial action plan has been developed in response to the initial feedback from core services inspections. • Development of a new refreshed inspection preparation schedule for 2020/21. Feedback following the CQC Well Led Inspection has been very positive. CQC felt a positive

The Committee noted the contents of the report. The Committee is assured that work is in progress; and was pleased with the verbal CQC feedback received so far.

To note the assurance received.

Agenda Item 20/1733

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Ask of the Board

• Improvement and refresh of the Trust internal framework for future CQC Inspections

and inclusive culture in the Trust, and also seen a clear view of how governance works in the Trust. The Draft report will soon be available for fact checking; the final reports are scheduled to be received in February 2020. Assurance was given around the Trust CQC Internal Dashboard and any improvements following the recent visit will be actioned. This will include a refresh of Trust and Executive leads following recent changes to roles and responsibilities. The full action plan will be circulated once the CQC reports have been received.

Agenda Item 20/1733

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Borough/Cross Organisational Assurance The Committee will receive a borough/cross organisational update on a rolling programme that gives assurances that all the elements within the agreed agenda are being delivered in all services in the Trust. This enables the Committee to receive assurance and challenge the leadership teams on their implementation of quality improvements.

See below

Quality Strategy The Committee approve and direct the quality strategy, and will then receive assurance on the delivery and effectiveness of the strategy throughout the year.

See below

Care Group Collaboratives There are six care group collaboratives (and their sub-groups) within the Trust that the Committee will be responsible for assuring the Trust Board on their effectiveness and delivery of quality improvements.

See below



Ask of the Board

19/102 Borough: Sefton The Committee received; an update on implementation of the Trust Quality Strategy; and assurance regarding management of quality and safety issues and risks by providing:

An overview of services delivered in Sefton, contracting arrangements and key issues affecting the Borough.

A focus on Quality Strategy implementation in Borough.

An overview of strengths, challenges, current issues and risks affecting Sefton Borough.

Assurance on how risks are being managed and how lessons learned are shared trust-wide.

Quality Strategy Pillar: Value Added Care Care Group Collaborative: Children’s Services and CAMHS

The Committee received an overview of the health needs in the borough; identifying a significant range of health needs. Borough is working to embed the Trust’s Quality Strategy. Good safety culture explained. Team very clear on risks and challenges. Ten Pieces of work being carried out across the Trust, in particular with regard to upskilling staff, and looking

The Committee was assured by the presentation given. The Committee was assured by the presentation given.

To note the update. To note the update.

Agenda Item 20/1733

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Ask of the Board

The presentation provided the Quality Committee with an update on progress and assurance of actions contained in pillar five – ‘Value Added Care’ An overview of the Children’s collaborative for 0-19 services and CAMHS was given.

at pressure ulcer issues. Also carrying out a number of root cause analysis. CAMHS collaborative exists with updated aims and objectives.

The Committee was assured by the presentation given.

To note the update.

Quality Governance The Committee will receive a rolling report relating to Patient Safety, Effectiveness, and Patient Experience. This will contain plans for the previous quarter in delivering quality improvements for each area, assurance regarding the work of the previous quarter, and plans for the following quarter. The detailed work will be carried out within Trust groups however the Committee will receive assurance regarding the quality and safety improvements in these areas, coordinated by the Integrated Governance Team.

See below



Ask of the Board

19/100 Thematic Analysis of Serious Incidents in Wigan Mrs S Preedy, Assistant Clinical Director for Wigan provided a presentation to update the Quality Committee on serious incident reporting in the Wigan borough with a specific focus on suspected suicides reported in 2019 and the plans to increase patient safety.

Number of risks -Leadership/clinical capacity -Clinical skills/expertise -Regulation 28 outcomes What are we doing New ways of working; team moving to Christopher Home Building in Wrightington, Wigan and Leigh NHS Foundation Trust; the formation of the 24/7 Crisis Resolution Home

The Committee received partial assurance by the work in process and expect to receive an update in May 2020.

To note the progress.

Agenda Item 20/1733

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Ask of the Board

Treatment Service; thematic review of suicides; Trust Wide review of Mental Health Team Standard Operating Procedures, with an aim to be in place by January 2020; extensive engagement with assessment teams; daily MDT meetings.

19/103 Pressure Ulcer Care Package Internal Audit Update Verbal update given on the moves to implement recommendations found in the internal audit report.

Agreed trial of new equipment to identify pressure ulcers in place. Have identified measures currently used and required, baseline data being collated; new reporting to the Board will take place in April 2020. Knowsley Quality Programme looking at this again; working with St Helens and Knowsley Teaching Hospitals to look at this particular problem.

To note progress taking place and that this is heading in the right direction.

Agenda Item 20/1733

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Ask of the Board

19/104 Integrated Governance ‘Safety’ Report The quarterly Integrated Governance Safety Report detailed activity in the previous quarter and identifies anticipated activity in the next quarter in order to assure the Committee that there is good governance in place to manage patient safety across the organisation in line with CQC key lines of enquiry.

Highlights included CQC Key lines of enquiry; Patient Safety Improvement Plan; NHS Patient Safety Strategy; embedding learning to improve practice. Any risks from the above were appropriately identified. Very detailed patient safety improvement plan contained in appendix one of the report and discussed in detail

Received the report and were assured that good governance is in place.

To note the update.

Statutorily required reporting The Committee will be delegated areas of quality and safety to review and provide further assurances to the Trust Board as required by the Trust Board.

See below



Ask of the Board

19/105 Freedom to Speak Up Guardian Report The report updated the Quality Committee on:

Introduction and update to Freedom to Speak Up.

Activity data for the reporting period of quarter two of 2019, discussing themes and trends in comparison with the same period of quarter two in 2018.

Points to note related to cases in quarter two 2019. Updated local and national information regarding

The report provided the Committee with information regarding staff groups and boroughs speaking up and information relating to both local and national information regarding Freedom to Speak Up. Activity shows the profile of

The Committee were assured by the content of the report.

To note the update.

Agenda Item 20/1733

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Ask of the Board

Freedom to Speak Up

Information relating to the Guidance for Boards Paper published in quarter two.

Confidential Case Study

role is working; in 22 months 214 cases show staff trust the system and we are listening to staff. A confidential report on a case study was provided and discussed which shows how well the system is working.

Patient Safety In line with Trust policy and procedure, the Committee will receive a Patient Safety Report every meeting, detailing serious incidents, deaths, inquests, coroner’s activity, claims and legal activity taking place within the Trust to ensure there is Board level understanding and challenge around that activity.

See below



Ask of the Board

19/106 Patient Safety Report (confidential)

The report provides information and detail to the Committee of the serious incidents reported to the Strategic Executive Information System (StEIS) in October 2019; information and detail on the management of incidents in line with the NHS Serious Incident Framework (2015); and detail in relation to high profile serious incidents, complaints and inquests.

Six incidents were reported through StEIS in October 2019.

Four of the reportable incidents are being managed by Concise Review.

One is being managed as a 72 Hour Review.

One is being managed as a Comprehensive Review.

There was one high profile inquest heard in October 2019 (previously

The Committee was assured by the report.

To note the update.

Agenda Item 20/1733

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Ask of the Board

reported).

One high profile inquest has been heard in November 2019.

One high profile inquest has been listed to be heard in December 2019.

2.2 Audit Committee Delegated Actions The Quality Committee will provide updates on progress against delegated tasks from the Audit Committee:

The Committee will receive delegated actions from the Audit Committee where quality assurance is required by the Trust Board.



Ask of the Board

n/a n/a n/a n/a

2.3 Business conducted, not included on Terms of Reference

Exception reporting from internal meetings.



Ask of the Board

n/a

Other areas to note: The Committee noted how successful the use of Skype had been; allowing Ms McDonnell to take part whilst in another part of the country.

Agenda Item 20/1733

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3. RECOMMENDATIONS The Trust Board is asked to: Review the update provided by the Quality Committee for the meeting held on 11 December 2019, and confirm agreement for the ‘ask’ of the Board for all activity undertaken. Receive assurance that the Quality Committee is fulfilling its purpose and Terms of Reference. Jonathan Berry Non-Executive Director

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20/1734 Digital Transformation Group – Quarterly Update


Item

N

o.

20/1

734

TITLE OF REPORT Digital Transformation Group – Quarterly Update PRESENTED BY Simon Barber, Chief Executive Officer AUTHOR(S) Asim Patel, Chief Information Officer

REPORT PURPOSE

Information X Assurance X Approval/ Decision

To provide an update on the key digital developments and projects aligned to the global digital exemplar fast follower programme

ALIGNMENT TO THE TRUST’S STRATEGIC OBJECTIVES We will deliver quality, safe and efficient services with a highly skilled and motivated workforce X We will engage with our communities and staff to deliver

services differently X We will deliver whole person care through targeted growth X We will play an active role in place-based care systems to

maintain a whole person care focus X We will retain our values and culture We will grow and develop the Trust at scale, being seen


SUBJECT MATTER / CONTENT CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS Committee / Group Date Audit Committee Quality Committee Remuneration Committee Executive Leadership Group Sub Group Name (if applicable): Digital Transformation Group

16 December 2019 20 January 2020

Other Group Name: This has not been considered elsewhere (x)

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) Yes / No Risk Reference Strategic Objective Description (as per BAF) 2510

We will play an active role in place-based care systems to maintain a whole person care focus

There is a risk of being unable to provide safe and effective care due to a lack of interoperability and integration of digital systems and services across clinical boundaries leading to a detrimental impact on patient care, clinical safety and the Trust’s reputation.


The Trust Board is asked to note the quarterly update on the global digital exemplar fast follower programme



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Digital Transformation Group – Quarterly Update

1. INTRODUCTION The paper provides an update to the Trust Board on developments and progress made relating to the global digital exemplar fast follower programme overseen by the digital transformation group. The Trust’s Digital Transformation Group meets on a monthly basis and is chaired by the Chief Information Officer and attended by the Chief Clinical Information Officer, Chief Nurse, Director of Operations and Integration, Deputy Director of Finance and representatives from the Informatics team 2. GLOBAL DIGITAL EXEMPLAR AND FAST FOLLOWER PROGRAMME

The global digital exemplar and fast follower funding agreement was formally submitted to NHS Digital in July 2018 and the Trust received confirmation of approval in September 2018. The programme has the following vision: Through digital maturity of our systems and our workforce, we will improve access and outcomes for people with mental and physical health conditions, supporting them to take more control over their recovery and live life well. The vision will be delivered through five working differently programmes:

1. Being paper free at the point of care 2. Creating an efficient and agile workforce 3. Crossing boundaries through interoperability and shared records 4. Digital channels (engagement, choice and access) 5. Being driven by intelligence

The following section provides an update on the working differently programmes that are part of the global digital exemplar and fast follower funding agreement.


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3. GLOBAL DIGITAL EXEMPLAR FAST FOLLOWER PROGRAMME

UPDATE On 7 November the Trust held its final external assurance meeting with colleagues from NHS Digital. The session was opened by the Trust’s Chief Information Officer and there were presentations from a number of clinicians and operational colleagues who described the benefits that their services have realised through the implementation of specific digital schemes. Feedback on the day from NHS Digital was very positive. Formal reporting followed and in early January NHS Digital confirmed that the final tranche of capital programme funds can be drawn-down from the centre. 3.1 Working differently series one: being paper free at the point of care

This working differently series will deliver an integrated patient administration system and a comprehensive electronic clinical care record that can be accessed from anywhere at any time and allows for the capture of data at the point of care. The schemes in this programme will deliver the foundations to reduce variation of practice across services and enable service re-design. Updates for three of the active schemes are provided below; Electronic Prescribing and Medicines Administration, RiO optimisation and text messaging. • Electronic prescribing and medicines administration In the last quarter the main focus for the electronic prescribing and medicines administration team has been on training and preparation for deployments. Tennyson and Byron wards went live in October 2019 but the deployment was then paused to allow for the technical integration between Rio and the electronic prescribing and medicines administration system to be built and tested. This systems integration allows a flow of demographic details between the main patient record and the electronic prescribing and medicines administration system; it auto populates patient information on admission, discharge, and transfer, meaning the need to manually duplicate the information is removed. Due to the higher volume of patients on other wards (compared to cohorts one and two who are already live) this functionality is required for the rollout to progress, but it was not possible to complete the interfacing earlier because of a dependency on the new version of Rio. The project group have therefore continued to adjust the deployment timetable in line with the availability of the systems integration component. Current planning aims to complete the rollout by the end of March 2020, as per original intentions, but the schedule will remain under the regular review of the project group.


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Table 1 – Electronic Prescribing and Medicines Administration deployment timetable Cohort Go-Live

Cohort 1 - Marlowe and Chesterton Wards (Warrington) Complete – August 2019

Cohort 2 - Tennyson and Byron Wards (Warrington) Complete –October 2019

Deploy admission, discharge, transfer integration January 2020

Cohort 3 - Sheridan, Austen and Kingsley Wards (Warrington) January 2020

Cohort 4 - Iris and Taylor Wards (St. Helens) February 2020

Cohort 5 - Weaver and Bridge Wards (Halton) February 2020

Cohort 6 - Knowsley Resource and Recovery Centre (Knowsley) March 2020

Cohort 7 - Westleigh and Sovereign (Wigan) March 2020

Cohort 8 - Golbourne and Priestners (Wigan) March 2020

1600 drug lines have now been configured in the electronic prescribing and medicines administration system and the clinical reference group continues to prepare practice and procedural guidance related to the use of the system. Planning has also begun for a new pharmacy stock control system to be implemented in quarter one in the new financial year. • RiO Optimisation The informatics team maintains close working with the trust’s care collaborative leads, ensuring process improvement and Rio development time is focussed on the areas that add the most value to improving quality. In attendance at care collaborative team meeting, the informatics clinical change leads were tasked with developing a work plan for year, delivering Rio optimisation In the last quarter, Rio optimisation for mental health has focussed on the redesign of adult mental health services in Wigan. The informatics team has been working closely with operational colleagues to support development of the new standard operating procedures for the Wigan Urgent Response and Service Delivery Footprint teams. This has included development of new standardised clinical assessment and referral forms, aimed to improve the triage process, service response time and the overall care pathway. The new operating processes and forms will be going live to coincide with the go-live of the Urgent Treatment Centre at the end of January.


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In addition, support has been given to the mobilisation of the Wigan Crisis Resolution Home Treatment team, which is also scheduled for go-live at the same time as the Urgent Treatment Centre. The informatics team has contributed to the task and finish group for the improvement in data capture for section 136 clients. The group has been led by the Assistant Director of Operations for Warrington, and has identified the requirement for a new section 136 form to be developed in Rio. This form will support the standardisation of practice for section 136, easing the process of data capture and improving the quality of reporting. Rio optimisation within the community physical health services continues to progress. A significant amount of work has been conducted as part of the phased podiatry service redesign, which in now in the closing stages. It has been identified previously that the number of clinical assessment forms for district nursing teams is excessive. Feedback from clinicians has highlighted confusion about which forms should be completed when, especially when forms appear to need to capture the same information. This is a historic issue that pre-dates Rio. In the last quarter, the review of all forms has been completed, led by the care collaborative lead for physical health. This has resulted in the design of some new client focussed assessments, which aim to capture clinical information more easily and efficiently, reduce duplication and simplify the process for clinicians. The forms are currently undergoing testing from district nursing staff and are expected to be released for use imminently. The team continues to support a high number of service mobilisations, developing RiO in readiness for the go-lives of intensive support, mental health link, autism spectrum condition and parent and infant mental health teams. In addition, the team has been working to support service mobilisation of the Wigan and Mid-Mersey Crisis Resolution Home Treatment teams, assisting with the design of the services processes and ensuring RiO functionality is well embedded with standard operating procedures. The informatics team has also overseen deployment of the Rio upgrade at the end of October. The upgrade has introduced a number of enhancements to RiO, particularly around system navigation, bug fixes and new functionality. In addition, the Rio system was moved to a new server infrastructure in order to improve system performance and enable greater system resiliency. The Rio upgrade has received positive feedback from staff. “Since the Rio system was upgraded in October, I find Rio much easier to use and navigate. Being able to save frequently visited parts of the system saves times, and progress notes are more accessible. My team have fed back that Rio feels nicer to use, the layout is more clear and easier to understand. On the whole, much better!”

Avril Butler, Team Manager, Children’s Community Nursing Service


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Finally, project start-up for the development and implementation of the Rio eObservations module is underway. In November, an initial session was held to define project scope and identify key priorities. Focus will be given to the implementation of NEWS2 (national early warning score) and pre and post leave for the inpatient wards, and rollout of NEWS2 across the district nursing teams. This project will be run in conjunction with Mersey Care.

• Text Message Appointment Reminders

The rollout of text message appointment reminders was purposely halted at the beginning of October in order to focus on preparations for the Rio system and infrastructure upgrade as part of standard change control procedures. Unfortunately, the restart of the rollout project was hindered by the issues experienced from the Rio upgrade, where one of the areas of functionality impacted was the production and delivery of text messages. Upon resolving the issues, the team prioritised enablement of text messaging for the Perinatal team and has established the scope of the work required to enable text message appointment reminders for musculoskeletal physiotherapy. Despite the issues experienced in the last quarter, there has been a rising number of text message appointment reminders sent to patients. Between October and December, the text message reminder service for all teams has generated approximately 60,000 messages, averaging 20,000 messages a month and 926 messages per day. Since the introduction of text messaging, a reduction in did not attend rates has been identified within community services. Upon completion of the rollout to musculoskeletal physiotherapy, the reminder service will be targeted to the remaining mental health services for completion before April.

3.2 Working differently series two: creating an efficient and agile workforce

This working differently series will enable a more efficient and dynamic clinical and clerical workforce that will maximise the use of digital solutions to become more agile that will be manifested by the better utilisation of our estate. There will also be noticeable reduction in letter production turnaround times and physical paper transfers. Updates for four of the active schemes are provided below; Electronic Clinical Correspondence, Fax Removal Project, Skype for Business, IT Kit Replacement Programme and the Digital Staff Platform.

• Electronic clinical correspondence The electronic clinical correspondence solution allows GP practices to receive electronic copies of documents directly into their clinical information systems, previously sent by fax or post. This not only saves significant time and cost associated with paper-based correspondence, it also enables near-real time delivery of documentation.


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The solution to produce and send electronic discharges is now in place in all wards and can be used to send any other GP related correspondence. In the last quarter, 56,024 items (over 3,000 more than last quarter) of correspondence have been sent to GP practices and focus is now being given to further deploy the solution within community teams. • SKYPE for Business

As reported previously, 16 video conferencing devices have been installed to work with Skype for Business located across the Trust. In addition to this Skype for Business solution has been rolled out to all computers across the Trust. To support the take up and confidence in using this technology the Chief Information Officer will be allocating some additional resource to support the boroughs in the training and adoption of the technology with a new project manager commencing in January who will be dedicated to embedding and promoting Skype for Business and other agile solutions. An additional 3 video conference screens will be installed in Wigan in by the end of January to support the Urgent Treatment Centre and Crisis Team. There are also requests being considered for additional equipment in Halton to aid multidisciplinary team meetings across the borough of Halton.

• Windows 10 Upgrade Programme and Kit Replacement

The informatics team has continued to support the St Helens and Knowsley Health Informatics Service with the preparations for the deployment of the Windows 10 operating system. Windows 10 will provide a modernised platform with improved features and functionality to support future technology and digital solutions. In the last quarter, testing of the new Windows 10 computer build has concluded and focus is now being turned to the deployment across the trust in line with end of support deadlines for Windows 7. The trust has committed £1m of capital investment for IT equipment replacement programme, which will focus on replacing computers that do not have the required specification to operate Windows 10. Leadership teams for each borough and corporate services have been supplied with a briefing, outlining the arrangements for Windows 10 deployment and requesting their support with communications to their staff. In addition, lists have been provided summarising the IT equipment currently used within their area, along with an indication of whether the equipment meets specification or requires replacement, and what it will be replaced with. The deployment of new equipment and Windows 10 will also include the provision of training materials for staff to gain familiarity with their new devices and operating system.


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• Digital Staff Platform

The Trust continues to explore how digital technology can be used to improve staff experience at work. As part of this work, the Communications Team, working with colleagues in People Services and Informatics, has explored options to develop a new staff platform which will, over time, allow our workforce to: • Feel connected and engaged at work, no matter where they are based or

what their role is • Find the information they need quickly and easily • Access all the digital tools and systems they need to do their job through

one platform • Access many systems at any time without being on the Trust network, and

on all supported devices, including personal devices and mobile phones • Complete simple transactions on the go, at their convenience • Receive alerts to help them keep up to date with the latest Trust

information • Interact, share and collaborate with other staff online • Feedback about their experiences at work

During the last quarter, the procurement activities were finalised and a project manager is now in place who is working closely with the Trust’s communication team. The supplier has produced a first draft design of the staff platform which has been received positively by the Head of Communications and the wider project team.

3.3 Working differently series three: crossing boundaries through interoperability and shared records

This working differently series will enable clinicians to seamlessly view relevant records from other providers in the health and social care economy. The update below covers developments with the St. Helens Care Record and the strategic regional information sharing platform referred to as e-Xchange.

• St Helens Shared Care Record

In the last quarter, the St Helens Shared Care Record continues to be used by Rio users across the Trust. The system is accessed via a link in RiO, and with a single click of a button, staff are able to directly access a given clients record. Between October and December, the St Helens Shared Care Record has been accessed 2236 times by 199 Trust staff and feedback received so far has been very positive, particularly as it makes it possible for health and social care professionals to see relevant clinical information to aid decision making.


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The St Helens Shared Care Record now also includes discharge summaries from St Helens and Knowsley NHS Foundation Trust. The Trust is currently considering the amount of data it is sharing with the St Helens Shared Care Record. At present, the trust is mainly sharing demographic and limited clinical data, but will be reviewing the data items in the coming months.

• Wigan Share to Care Record

The informatics team is also involved with the delivery of the Wigan Share to Care record. The Wigan Share to Care record uses the same technology as the St Helens Shared Care Record, but will be populated with patients registered with a Wigan GP. Testing of the Wigan Share to Care record has been completed and a go-live date is currently being planned. • E-Xchange – Cheshire and Merseyside Shared Record platform

Over the last 12 months e-Xchange has been developing into the strategic information sharing platform for the Cheshire and Merseyside region. The objective of this programme is to have seamless integration with health and social care information systems across the region with access governed by information sharing frameworks and role based access. In the last quarter the Trust informatics team have continued to work closely with the regional programme to connect the Trust to the e-Xchange infrastructure and environment in readiness for a deployment. In parallel the team have enhanced the operating procedures and other process requirements that should underpin the Trust’s go-live. A full paper with recommendations is being prepared for the digital transformation group scheduled in February 2020. The Trust’s Chief Clinical Information Officer will work with his counterparts in the other Mental Health Trusts in the region to formulate an approach for Mental Health data sharing with e-Xchange.

3.4 Working differently series four: digital channels (engagement, choice and access)

This working differently series focuses on connecting our service users and patients with clinicians using digital technologies as well as providing tools to support self-care and maintaining independence. An update on development with the patient held record is provided below which is a key component of this programme.


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• Video Consultation

In the last quarter the informatics team selected a supplier to develop and pilot a video consultation solution. The solution has been demonstrated at various forums including the digital transformation group and has been received very positively by clinicians. This project will be run in conjunction with Mersey Care and the Improving Access to Psychology (IAPT) service has been selected as the pilot service across both Trusts. The initial meeting with the service and digital team has been held and the project manager will start in late January. The first task is to design the processes and the virtual clinic environment which has commenced. A number of benefits have been identified as part of this project including improved patient access and choice.

• Patient held record

As reported previously the Trust’s global digital exemplar partner, Mersey Care delivered a minimum viable technical product in the last quarter of 2018/19 and this has more recently been enhanced based on service user and clinician feedback. At its core the application provides service users with access to the mental health and community record care plans and crisis plan exported from the RiO clinical information system. In addition, service users can use the patient held record application to enter and track goals and to keep a diary. The application also has a feature called ‘circle of care’ which is used to give access of the record to carers and family members. In the final quarter of 2019/20, the informatics team will work with the Clinical Digital Leadership Group and others to adapt the Mersey Care app for North West Boroughs patients and pilot it locally. In addition to this work the Trust’s Chief Information Officer is the lead and senior responsible officer for the digital empowerment work stream across the Cheshire and Merseyside region where the key deliverable is a regional patient held record. In the last quarter through the leadership of the Trust’s Chief Information Officer the scope of the first phase of the regional patient held record has been agreed with stakeholders in Cheshire and Merseyside. The first phase will provide the population of Cheshire and Merseyside digital access to their appointment letters across providers, access to their primary care record and the ability to complete pre and post appointment questionnaires. The solution is being developed in conjunction with a number of suppliers and engagement with three pilot Trusts continues that include Warrington and Halton Hospitals NHS Foundation Trust, St. Helens and Knowsley Hospital NHS Trust and the Clatterbridge Cancer Centre.


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3.5 Working differently series five: being driven by intelligence

This working differently series will deliver a new data warehouse making use of the latest infrastructure and business intelligence tools to provide insights. All relevant information both clinical and corporate will be made available at the point of need to support decision making. Automation of information reporting, continued development of the Trust’s information management platform and management and supervision tool (MaST) are the current active schemes in this programme.

• Automation of information reporting/information management

The clinical solution phase of the information management platform was initiated at the end of April 2018 and was delivered and signed off by the Trust on 21 June 2019. The data warehouse now houses all of the Trust’s risk, human resources, finance and clinical data. The corporate reports that have been released are being routinely used by staff trust wide and operational management use the reporting functionality on a daily basis. It is now embedded into the performance cycle to use real time data to support performance conversations. The development of the Trust quality and performance report is in progress, and the team is working closely with the relevant teams to ensure that this meets the needs from both content and functionality/usability perspective. In the last quarter, as well as deploying additional filters to allow alternative views on the report data, the team have also deployed two more reports. The first is a Trust level dashboard to showcase clinical research performance data, and the second is an additional training compliance report.

• Management and Supervision Tool (MaST)

The Management and Supervision Tool (MaST) is an electronic dashboard that provides critical information to practitioners and managers to better understand their service, supporting clinical decision making. The solution takes information directly from RiO and reflects it back in an easy to understand dashboard which can then be used to understand which patients are in crisis, which patients require an increased level of care and which patients are ready for a less resource intensive care pathway. The system is being piloted with the St Helens and Warrington Recovery teams. Several demonstrations and engagement sessions have taken place with team managers and training sessions took place in December. More training is being scheduled for late January and teams are also being helped to get the most from the system by the clinical change manager who led the adoption and embedding in Mersey Care.


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4. CHILDREN AND YOUNG PEOPLE MENTAL HEALTH DIGITAL TRANSFORMATION During the last quarter the Trust submitted a bid as part of the “Children & Young People’s Mental Health Digital Transformation Funding” expression of interest process. The bids were considered by a panel that comprised of clinical and digital experts and we were pleased to learn that the panel saw value in our proposal and awarded funding of £250,000 to adapt our existing support for children and young people waiting for treatment or follow-up appointments in our eating disorders service. The digital components of the bid included online therapy and supportive information, a two-way communication portal to improve contact with health professionals and connection with people with lived experience. This funding will also be accompanied by central support from NHSX. The Trusts Chief Information Officer and Medical Director are in the process of mobilising the project team. 4. RECOMMENDATIONS The Trust Board is asked to note the quarterly update on the global digital exemplar fast follower programme. Simon Barber Chief Executive

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20/1735 Finance Report Month Nine


Item

N

o.

20/1

735

TITLE OF REPORT Finance Report – Month Nine PRESENTED BY John McLuckie, Chief Finance Officer AUTHOR(S) Sarah Waterworth, Deputy Director of Finance

REPORT PURPOSE


This report is to inform the Board of the month nine financial performance and performance against the NHS Oversight Framework. The report presents a current assessment of the financial position to inform the Board of a range of indicative outcomes for the full year outturn position.

ALIGNMENT TO THE TRUST’S STRATEGIC OBJECTIVES (x) We will deliver quality, safe and efficient services with a highly skilled and motivated workforce X We will engage with our communities and staff to deliver

services differently

We will deliver whole person care through targeted growth We will plan an active role in place-based care systems to


We will retain our values and culture We will grow and develop the Trust at scale, being seen as an equal partner in any system-wide collaboration

SUBJECT MATTER / CONTENT CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS Committee / Group Date Audit Committee Quality Committee Remuneration Committee Executive Leadership Group Sub Group Name (if applicable):

Other Group Name: This content has not been considered elsewhere X

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) Y Risk Reference Strategic Objective Description (as per BAF)

2514 We will deliver quality, safe and efficient services with a highly skilled and motivated workforce.

There is a risk that the Trust may not deliver its planned efficiencies as part of its transformation and improvement plan and consequently may not meet its Control total, leading to the loss of provider sustainability funding and reputational damage.


The Trust Board is asked to: • Receive the month nine financial performance and performance against the

NHS Single Oversight Framework • Note any updates on the full year forecast position and any known or

emerging risks and assumptions • Be assured by the current assessment of the Trust’s financial position and the

resulting range of outcomes presented for the year.



Page 2 of 11


Report to Trust Board – Public Meeting 27 January 2020

Finance Report– Month Nine

1. INCOME AND EXPENDITURE The month nine performance against budget is shown in table 1 below. Table 1 – Income and Expenditure Performance against Budget

The in-month deficit of £72k is a favourable variance to budget of £125k and results in a favourable variance in the year to date of £58k. The Trust has therefore achieved its Provider Sustainability Funding (PSF) for quarter three. The full year position reflects the position agreed by the Board at month five, which is a breakeven position for the year. This includes £1.724m of Provider Sustainability Funding of which £604k relates to performance in Quarter four. Year to date position There is a favourable variance of £3.4m in the year to date on income. This includes an adverse variance due to planned mental health investment standard income which has not been received to date, however this is more than offset by a large number of contract variations, recharges and other receipts that have been agreed post budget setting. Total pay expenditure in the year to date is £237k more than budget in the period. Within this expenditure variance there is a favourable variance in relation to the planned costs associated with the mental health investment standard. This expenditure has not been utilised as planned as commissioners have not invested to the planned levels. However this variance is being fully offset by increased costs associated with the contract variations and recharges. An element of contribution is being made on a number of these items.


Page 3 of 11


A number of operational pressures have emerged in the period to date. Within the inpatient setting, bank costs remain high due to increased levels of special observations being utilised in a number of areas to manage risks. There is a pressure across the inpatient setting of £523k in the year to date. The new inpatient model of care will be implemented in the coming months and reflects a revised approach to the management of acuity and risk. It also provides a consistent baseline against which to monitor and manage expenditure. A deep dive into the staffing of the later life and memory wards has started to highlight some inconsistent practice which will continue to be scrutinised, and where applicable addressed. There are also staffing pressures on a number of other areas including the assessment teams and district nursing teams. These are areas of particular focus for the organisation through the patient journey and patient access projects. Temporary staffing costs in the year to date total £9.570m. The year to date spend on agency is £3.334m at month nine which has led to a 1 percent breach of the Trust agency cap of £3.285m, set by NHS Improvement and reported in the Oversight Framework. The main area of concern continues to be medical, with agency costs being £971k in the year to date. Recruitment issues continue to result in locum cover being required which is resulting in a significant financial pressure and in addition there are some localised pressures requiring both qualified nursing (£1.126m) and allied health professional (£660k) agency resource . Agency requests and usage continue to be monitored closely by operational management. Non pay expenditure exceeds budget by £3.343m however much of this is offset by additional income. There is a £350k pressure in the year to date in relation to the use of out of area beds. However, in month usage and therefore spend was nil. There is also an expenditure pressure of £219k within the Knowsley Centre for Independent Living. There is a favourable variance of £214k on capital financing in the year to date as a result of reduced depreciation charges following an asset revaluation exercise. Forecast position Many of the trends seen in the year to date position continue through to the forecast outturn position reported. The contribution from contract variations and new business increases further in the remainder of the year as a number of additional schemes come on line. Additionally the forecast includes a £1.5m non recurrent value in relation to the Atherleigh Park VAT reclaim. Her Majesty's Revenue and Customs have accepted our calculations of the amount due. The Trust has shared these with the external contractor, who have now submitted the claim. In December, the Trust was notified that it was successful in a number of bids for winter monies. An element of contribution has been made on this income and as much of the spend is already contained within our forecast position, this, as well as some slippage on other new business, has positively impacted the outturn position.


Page 4 of 11


As such the external support assumption, required in order for the Trust to meet its control total has reduced by £500k to £1.0m. The Chief Finance Officers from both organisations are meeting to finalise support arrangements by the end of January. 2. COST IMPROVEMENT PROGRAMME (CIP) Table 2 below shows the year to date Cost Improvement Programme delivery against budget as at month nine. Table 2 – Cost Improvement Programme delivery against budget

The annual Cost Improvement Programme totals £5.651m. As at month nine, £2.218m of savings have been delivered year to date against a target of £2.198m resulting in a favourable variance of £20k. A number of schemes have under-delivered in the year to date however, this has been mitigated by additional non recurrent over achievement from the Leadership review savings. We continue to ensure that recurrent plans to deliver all 2019/20 schemes are in place for 2020/21. The forecast position reports a £1k favourable variance against the plan for the year. The forecast includes the £1.5m non recurrent value in relation to the Atherleigh Park VAT reclaim. This, in addition to contribution from business development have

Schemes

Budget Actual VarianceAnnual Budget

Full Year Forecast Variance

£’000s £’000s £’000s £’000s £’000s £’000sSchemes expected to deliver to planCommunity Medical 53 53 (0) 70 70 -AHP Pathway Review 60 79 19 103 103 0IAPT Review 145 146 1 194 194 0Income generation 68 68 0 91 91 -Leadership Review 271 403 132 362 538 176Leadership and Medical Admin review 63 22 (41) 88 35 (53)LD Review 104 141 37 156 201 45Specific Service Skill Mix Review 65 43 (22) 87 65 (22)CAMHS scheme phase 2 79 60 (19) 105 79 (26)0-19 review 132 132 0 176 176 0Patient Transport 23 22 (1) 30 29 (1)Non Pay - Operations 289 290 1 386 386 -Operational management 90 85 (5) 120 120 0Informatics 264 264 0 352 352 (0)Back Office 381 389 8 520 525 5Total schemes expected to deliver to plan 2,087 2,198 111 2,840 2,966 126

Delays against milestone plans - actions requiredUrgent care Patient Flow - Adults 45 - (45) 60 - (60)Putting patient access First 66 20 (46) 100 35 (65)Total delays against milestone plans - actions required 111 20 (91) 160 35 (125)

High risk - Plan in developmentJoint Working and Collaboration - - - 2,651 1,000 (1,651)Total high risk - plan in development - - - 2,651 1,000 (1,651)

Non recurrent mitigationAtherleigh VAT 1,500 1,500New business contribution - - - - 151 151Total mitigating schemes - - - - 1,651 1,651

Total performance against planned schemes 2,198 2,218 20 5,651 5,652 1


Page 5 of 11


been classed as non-recurrent scheme which have reduced the amount required from collaboration to £1m. 3. CAPITAL Cumulative capital expenditure against plan at month nine and forecast outturn is shown in table 3 below.

Table 3 – Capital expenditure against plan

As at the end of December, total capital expenditure amounted to £2,223k. Excluding the externally funded element of the LED Lighting scheme, total capital expenditure to the end of December was £2,155k. This represents a £904k variance from plan.

Scheme

Annual Plan

2019/20Plan Actual Variance Forecast

Outturn

£'000 £'000 £'000 £'000 £'000

INFORMATICS SCHEMES Information Management Platform 253 253 76 177 85 IT Kit 500 500 404 96 500TOTAL INFORMATICS SCHEMES 753 753 480 273 585GDE SCHEMES Total GDE Resource 2,000 1,300 1,300 EPMA 108 (108) 159 GDE Fast Follower Team 498 (498) 498 IT Kit Replacement Programme 500 (500) 500 RiO Integration - Connexes 277 New Staff Intranet 83TOTAL GDE SCHEMES 2,000 1,300 1,106 194 1,517ESTATES SCHEMES Replacement Locksets 72 72 58 14 58 Yew Trees 246 246 281 (35) 281 Backlog 250 198 133 65 137 Estates Contingency Resource for Other Schemes 645 449 449 LED Lighting 10 Ward Redecoration - Trustwide 7 (7) 142 Flooring - Trustwide 4 (4) 73 Additional Net2 Controller Access Pads & Fobs 9 (9) 9 Wheelchair Access - Thomas House 8 (8) 8 Nurse Call System - Knowsley R&R 139 Rdecoration - Knowsley R&R 6 (6) 131 Anti-Barricade Devices 3 (3) 59 Rydal - Dementia Friendly Environment 35 Bladder Scanners 21 (21) 21 Contingency Balance (for future schemes) 10 Fees 55 41 39 2 55TOTAL ESTATES SCHEMES 1,268 1,006 569 437 1,168OTHER SCHEMES GM Corporate Systems Investment (£100k c/f to 2020/21)GRAND TOTAL 4,021 3,059 2,155 904 3,270MEMORANDUM (schemes excluded from annual plan but funded externally) LED Lighting 68 (68) 132GRAND TOTAL (including memorandum items) 4,021 3,059 2,223 836 3,402

Year to Date


Page 6 of 11


Other than a small contingency balance of £10k, all estates schemes have now been approved. Work on these schemes is progressing and all schemes are expected to complete by 31 March 2020. With regard to Informatics schemes, the Information Management Platform scheme is projected to underspend by £168k by financial year end. Slippage on Global Digital Exemplar (GDE) schemes is projected to be £483k. It has also now been confirmed that the Greater Manchester Corporate Systems Investment of £100k will not be required this year. Including this scheme, the total slippage against this year’s capital programme is £751k. This will need to be carried forward to 2020/21. External funding of £132k for the LED Lighting scheme was only confirmed in the latter part of 2019 and explains why it was not included in the original plan that was approved by the Trust Board. 4. CASH Table 4 below shows the cash position of the Trust for the year to date and the forecast for the year end. Table 4 – Cash Flow Forecast

The Trust’s closing cash balance as at 31 December 2019 was £2m higher than the planned balance. This is predominantly due to the following factors:

• Improvement in financial performance at 2018/19 year end £920k (excluding additional provider sustainability funding).

• Additional provider sustainability funding notified towards the end of April £1.052m.

• Slippage on the capital programme £836k.

Plan Actual Variance ForecastOutturn

£000 £000 £000 £000Opening Cash 6,133 7,957 1,824 7,957Surplus/(Defecit) (2,501) (2,440) 61 0Non Cash - Depreciation 1,672 1,458 (214) 1,936PDC Drawdown 1,000 1,000 0 1,632Loan Drawdown 1,619 0 (1,619) 0Repayment of Loan Principal (1,238) (1,238) 0 (1,622)Capital Expenditure (3,059) (2,223) 836 (3,402)Movement in Working Balances (2,302) (1,152) 1,150 (5,147)Movement in Inventories 176 162 (14) 162Closing Balance 1,500 3,524 2,024 1,516

Year to Date


Page 7 of 11


• Favourable movement in working balances (net of loan facility no longer required).

The cash flow forecast results in the Trust’s cash balance reducing to £1.5m at year end assuming no further significant movements in working capital. This has increased from the last reported position due to the projected slippage against the Global Digital Exemplar (GDE) capital schemes and the carry forward of the Greater Manchester Corporate Systems Investment to 2020/21. Based on this revised position, the Trust will not require borrowing this year. However, cash will still need to be monitored and managed carefully. HMRC have confirmed acceptance of our VAT zero-rating claim for Atherleigh Park. Whilst we are doing what we can to facilitate payment in this financial year, at this stage we have taken a prudent approach and not included this in our forecast outturn cash balance. We have also assumed that the external support that is included within our income and expenditure forecast will not improve the cash position. 5. ASSESSMENT OF 2019/20 FINANCIAL POSITION At month five, the Board agreed a forecast position noting an assessment of the level of risk contained within that forecast position. As the year has progressed a number of the risks outlined at month five have been reconsidered. As at month 9, the additional income required in the forecast against the Knowsley Centre for Independent Living has reduced to £200k. This is due to a winter pressures funding receipt of £50k. The forecast position at month 9 no longer assumes the savings forecast on District Nursing at month five. This is due to the timing of the actions from the ongoing review. The £100k that was projected, has been mitigated by other savings across Knowsley in the revised forecast position. The Later Life wards have achieved the savings that were forecast to month nine. A slightly increased spend is forecast in the revised position on Rydal ward and the risk is considered to be minimal. The Patient Access Cost Improvement Programme is delivering to forecast and the risk assessed as minimal to year end. We revised the lower estimate for the VAT refund at month 7 when we were notified that the claim and our calculations had been accepted. This risk remains at £100k as the exact amounts due have not be confirmed. As detailed above, the external support assumption in the current forecast to enable the Trust to meet its control total has reduced by £500k to £1.0m at month nine due to increased contribution from winter monies and other slippage on new business.


Page 8 of 11


A full valuation of the Trust’s estate is due this financial year. This may have a positive or negative impact on the Trust’s position. Any impact to the financial position this financial year counting towards the control total would be any adjustment to Public Dividend Capital. However, this is unlikely to be material. Based on the above assessment, the risks present at month nine have resulted in a down side scenario as shown in table 5 below. It is compared to the month five and month seven position. Table 5 – Downside scenario

As the forecast position assumes a level of external support, any upside gains from improved financial performance would result in a reduction in the support required therefore no upside scenario is presented. In the opinion of the Chief Finance Officer the level of risk is less than that presented within the approved forecast and the downside deficit has reduced by £1.163m since month five.

6. SINGLE OVERSIGHT FRAMEWORK

The Single Oversight Framework is included as Appendix 1. Operational Performance Operational Performance metrics have achieved target in month nine. The Out of Area bed usage has reduced to 0 in month 9. The metrics included in the Data Quality Maturity Index score have increased from six to 36 in 2019/20. The scores are confirmed when published by NHS Digital – this is three months in arrears. The latest published score is September with the Trust achieving a score of 96.04 percent exceeding the 95 percent target. The improvement in the Data Quality Maturity Index score is a Commissioning for Quality and Innovation measure for 2019/20 effective from July. Work is ongoing across the business intelligence teams and operational management to ensure that achievement of the target of 95 percent is maintained. Quality of Care At month nine Care Programme Approach (CPA) follow up - proportion of discharges from hospital followed up within seven days has achieved the target of 95 percent.

Downside Scenario £'000s £'000s £'000sMonth 5 Month 7 Month 9

Forecast - break even - - -External Support not agreed (1,478) (1,478) (1,000)Q4 PSF/FRF (604) (604) (604)CIL Risk (250) (250) (200)District Nursing actions do not deliver forecast savings (100) (100) -LLAMs actions do not deliver forecast savings (100) (100) -CIP Risk (PPAF) (35) (35) -VAT refund - lower estimate (500) (100) (100)

Downside Surplus/(Deficit) (3,067) (2,567) (1,904)


Page 9 of 11


Finance and use of resources The agency cap score has deteriorated to a two in month as the cap has been breached by 1 percent in the year to date. Despite this, at month nine the overall finance risk score remains in line with plan at three. 7. RECOMMENDATIONS

The Trust Board is asked to: • Receive the month nine financial performance and performance against the NHS

Single Oversight Framework • Note any updates on the full year forecast position and any known or emerging

risks and assumptions • Be assured by the current assessment of the Trusts financial position and the

resulting range of outcomes presented for the year. John McLuckie Chief Finance Officer


Page 10 of 11


Appendix 1 Single Oversight Framework – Operational Performance

Single Oversight Framework – Quality of Care

Operational Performance Metrics2018/19

Indicator Target Reporting Frequency Q4 Q1 Q2 Q3 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

95% Monthly 98.55% (F) 99.07% (F) 99% (F) 96.98% (F) 99% (F) 98.4% (F) 98.7% (F) 98.7% (F) 98.9% (F) 98.9% (F) 98.8% (F) 98.7% (F) 99.2% (F) 99.1% (F) 99.1% (F) 97.8% (F) 98% (F)

53% Quarterly 81.48% (F) 77.97% (F) 83.58% (F) 77.36% (F) 72.73% (F) 87.5% (F) 70.59% (F) 85.71% (F) 75% (F) 75% (F) 71.43% (F) 78.26% (F) 95.24% (F) 76.19% (F) 76.19% (F) 80% (F) 66.67% (F)

95% Monthly 92.3% (A) 92.2% (A) 93.8% (A) 94.7% (A) 95.8% (F) 96.04% (F) Currently reported 3 months behind

50% Quarterly 51.61% (F) 51.57% (F) 48.26% (A) 51.62% (F) 51.44% (F) 50.22% (F) 52.93% (F) 52.93% (F) 52.93% (F) 52.93% (F) 52.93% (F) 52.93% (F) 52.93% (F) 52.93% (F) 52.93% (F) 51.54% (F) 51.7% (F)

within 6 weeks 75% Quarterly 99.11% (F) 98.77% (F) 97.87% (F) 92.55% (F) 98.82% (F) 99.27% (F) 99.5% (F) 99.5% (F) 99.5% (F) 99.5% (F) 99.5% (F) 99.5% (F) 99.5% (F) 99.5% (F) 99.5% (F) 93.28% (F) 91.26% (F)

within 18 weeks 95% Quarterly 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F) 100% (F)

Inappropriate out of area placements for adult metal health services ** Progress in line with agreed trajectory 68 Monthly 38 88 288 288 0 (F) 0 (F) 0 (F) 0 (F) 46 (F) 9 (F) 28 (F) 20 (F) 120 (A) 151 (A) 150 (A) 116 (A) 0 (F)

Operational P

erformance

Overall Combined DQMI score

Total number of bed days patients have spent out of area

Waiting time to begin treatment (from IAPT minimum data set)

A&E maximum waiting time of 4 hours from arrival to admission/transfer/discharge

People with a first episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral (UNIFY2 and MHSDS)

proportion of people completing treatment who move to recovery (from IAPT minimum dataset)

Improving Access to Psychological Therapies (IAPT)/talking therapies

Data Quality maturity Index - MH SDS Quarterly score in DQMI (36 data items)*

Indicator Reporting Frequency Q4 Q1 Q2 Q3 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

3 Month Trend Arrow

Comment

CQC Community Survey AnnualAnnual

Quarterly 80% 84%Quarterly 98% 99% 99% 96% 98% 99% 99% 97% 99% 100% 98% 99% 100% 99% 99% 95% 95%Quarterly 91% 94% 92% 94% 95% 90% 91% 92% 96% 92% 93% 96% 97% 83% 95% 93% 94%Monthly 0 0 0 0 0 0 0 0 0 0 0 0 0Monthly 0 0 0 0 0 0 0 0 0 0 0 0 0Monthly 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Monthly 65 65 67 64 62 65 61 69 73 74 79 81

NHSi Data one

month behind

Count of reported incidents (no harm, low harm, moderate harm, severe harm, death)/Estimated total person bed days for rolling six months shown as rate per 1000 bed days

Monthly 98.27% (F) 95.05% (F) 95.7% (F) 96.42% (F) 98.08% (F) 97.94% (F) 98.63% (F) 98.32% (F) 93.75% (A) 96.65% (F) 94.32% (A) 94.09% (A) 95.91% (F) 97.53% (F) 95.77% (F) 93.79% (A) 98.16% (F)

% clients in settled accommodation Monthly 78% 79% 79% 78% 77% 81% 81% 81% 81% 81% 81% 78% 78%% clients in employment Monthly 10% 10% 10% 10% 10% 10% 9% 9% 9% 9% 9% 9% 9% ↔

Care programme approach (CPA) follow up - proportion of discharges from hospital followed up within 7 days - MHMDS

Quality of Care (safe, effective, caring, responsive)

CQC inpatient/mental health and community survey

2018/19

10 October 2018

The Trust has been rated 'Good' overall following the recent Well-Led and core services inspectionsRatings for the domains of Safe, Effective, Caring and Well-Led have remained as 'Good'. The Rating for Responsive as 'Requires Improvement'

One core service is rated as 'Requires Improvement'One core service is rated as 'Inadequate'All other core services are rated as ‘Good’

Occurrence of any Never Event (https://improvement.nhs.uk/resources/never-events-data/)

Caring

Staff Friends and Family Test % recommended - careCommunity scores from Friends and Family Test - % positiveMental health scores from Friends and Family Test - % positive

Safe

NHS England/NHS Improvement Patient Safety Alerts outstanding Admissions to adult facilities of patients who are under 16 years old

Potential under-reporting of patient safety incidents (https://improvement.nhs.uk/resources/monthly-data-patient-safety-incident-reports/) *

Effective


Page 11 of 11


Appendix 1 continued – Single Oversight Framework – Finance and use of resources

Indicator Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19

Capital Servicing Capacity (Metric) - Target (Times) 1.21 1.31 1.25 1.33 2.25 0.36 0.16 0.01 0.08 0.15 0.23 0.24 0.28 ↑Capital Servicing Capacity (Metric) - Actual (Times) 1.21 1.00 0.89 0.77 2.72 0.45 0.21 0.05 0.06 0.09 0.07 0.16 0.43Capital Servicing Capacity (Rating) - Target 4 3 3 3 4 4 4 4 4 4 4 4 4 ↔Capital Servicing Capacity (Rating) - Actual 4 4 4 4 4 4 4 4 4 4 4 4 4 ↔

Liquidity (Metric) - Target (Days) -10.5 -9.7 -10.7 -9.2 -14.2 -16.0 -16.5 -17.5 -19.2 -19.9 -20.6 -21.1 -21.8 ↓Liquidity (Metric) - Actual (Days) -7.6 -8.7 -9.9 -11.7 -10.7 -12.3 -12.2 -12.8 -13.6 -14.0 -15.2 -14.0 -15.8Liquidity (Rating) - Target 3 3 3 3 4 4 4 4 4 4 4 4 4 ↔Liquidity (Rating) - Actual 3 3 3 3 3 3 3 3 3 3 4 3 4

I&E Margin (Metric) - Target (%) 0.4% 0.4% 0.5% 0.6% -5.1% -3.3% -2.7% -2.4% -2.2% -2.1% -1.9% -1.9% -1.8%I&E Margin (Rating) - Actual (%) 0.4% -0.2% -0.3% -0.6% -5.6% -3.4% -2.7% -2.3% -2.1% -2.1% -2.1% -1.9% -1.7%I&E Margin (Rating) - Target 2 2 2 2 4 4 4 4 4 4 4 4 4 ↔I&E Margin (Rating) - Actual 2 3 3 3 4 4 4 4 4 4 4 4 4 ↔

* Thi

Distance From Financial Plan (Metric) - Target (%) 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% ↔

Distance From Financial Plan (Metric) - Actual (%) 0.00% -0.60% -0.80% -1.20% -0.53% -0.10% 0.00% 0.10% 0.10% 0.00% -0.20% 0.00% 10.00%Distance From Financial Plan (Rating) - Target 1 1 1 1 1 1 1 1 1 1 1 1 1 ↔Distance From Financial Plan (Rating) - Actual 1 2 2 3 2 2 1 1 1 1 2 1 1

Agency Spend - Distance from cap (%) 20.73% 20.13% 17.14% 16.36% 18.00% 15% 12% 8% -1% 3% -1% 1% 2%Agency Spend - Distance from cap (Rating) - Target 1 1 1 1 1 1 1 1 1 1 1 1 1 ↔Agency Spend - Distance from cap (Rating) - Actual 1 1 1 1 1 1 1 1 2 1 2 2 2

Overall Rating - Target 3 2 2 2 3 3 3 3 3 3 3 3 3 ↔Overall Rating - Actual 3 3 3 3 3 3 3 3 3 3 3 3 3 ↔

3 Month Trend Arrow

Finance Score

Page 1 of 1

19/1736 Quality and Performance Report


Item

No

.

19/1

736

TITLE OF REPORT Quality and Performance Report

PRESENTED BY John McLuckie, Chief Finance Officer

AUTHOR(S) John McLuckie, Chief Finance Officer

REPORT PURPOSE


The Quality and Performance Board Report is designed to allow the Trust Board to monitor their defined Key Performance Indicators at a Trust-wide Level. These Key Performance Indicators include national measures and locally-agreed priorities. For each applicable measure a target has been set based on either the national target, or a locally agreed target, which will drive the required standard of performance. If performance is below the required standard, an improvement trajectory will be set and performance will be monitored against this trajectory on a month by month basis.

Whilst a small number of indicators are service specific, this report focuses on key performance indicators at a trust wide, mental health and community level.

This report utilises Statistical Process Control techniques where applicable; used to understand variation in a process and highlight areas that would benefit from further investigation.




X


growth X





as an equal partner in any system-wide collaboration X

SUBJECT MATTER / CONTENT CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS


Audit Committee

Quality Committee



Other Group Name: Executive performance Meeting 16 January 2020





The Trust Board is asked to:

Note and discuss the content of the Quality and Performance Report


December 2019 Quality and Performance Board Report

Context

The Quality and Performance Board Report is designed to allow the Trust Board to monitor their defined Key Performance Indicators at a Trust-wide Level. These Key Performance Indicators include national measures and locally-agreed priorities. For each applicable measure a target has been set based on either the national target, or a locally agreed target, which will drive the required standard of performance. If performance is below the required standard, an improvement trajectory will be set and performance will be monitored against this trajectory on a month by month basis.

Each measure falls within one of the following five domains which correlate to those used by the Care Quality Commission. They are as follows:

The detail behind these measures and a significant number of others are scrutinised by the Operational Performance Group and the Executive Performance Group on a monthly basis.

Whilst a small number of indicators are service specific, this report focuses on Key Performance Indicators at a Trust wide, Mental Health and Community level.

This report utilises Statistical Process Control (SPC) techniques where applicable. Statistical Process Control techniques can be used to understand variation in a process and highlight areas that would benefit from further investigation.

Safe Effective Responsive Well led Caring

Regulatory & External view

Outstanding Good Requires Improvement Inadequate

CQC - Good(Link to CQC report)

NHS Improvement - Segment 1

KeyCurrent Month / (Last Month) Use of Statistical Process Control Charts

G Green - Achieving Target

R

A

Gr

Summary DashboardDecember 2019

Grey - No defined target/target being developed*

SPC rules are used to identify unusual patterns in the data which are unlikely to have occurred due to chance. Special cause variation is the term used when a rule is triggered. The four most common rules are:

A single data point outside the process limitsTwo of three data points close to a process limitShift of points above/below mean lineRun of data points in ascending/descending order

Red - Not achieving target and outside the process control limits

Amber - Not achieving target and within the process control limits

1 2 3 4

Outstanding

Outstanding

The service is performing exceptionally well.Good

GoodThe service is performing well and meeting our expectations.

Requires improvement

Requires improvementThe service is not performing as well as it should and we have told the service how it must improve.

InadequateInadequateThe service is performing badly and we've taken action against the person or organisation that runs it.

Segment Description

1 Providers with maximum autonomy: no potential support needs identified. Lowest level of oversight; segmentation decisions taken quarterly in the absence of any significant deterioration in performance.

2Providers offered targeted support: there are concerns in relation to one or more of the themes. We've identified targeted support that the provider can access to address these concerns, but which they are not obliged to take up. For some providers in segment 2, more evidence may need to be gathered to identify appropriate support.

3Providers receiving mandated support for significant concerns: there is actual or suspected breach of licence, and a Regional Support Group has agreed to seek formal undertakings from the provider or the Provider Regulation Committee has agreed to impose regulatory requirements.

4 Providers in special measures: there is actual or suspected breach of licence with very serious and/or complex issues. The Provider Regulation Committee has agreed it meets the criteria to go into special measures.

Gr 6

R 0A 1

G 7(7)

(1)(2)

(4)

GrRAG

Gr 3

R 0

A 5

G 9

(3)

(1)

(2)

(11)

GrRAG

Gr 10R 1

A 1

G 4

(10)(1)

(1)

(4)

GrRAG

Gr 3

R 3A 0

G 4

(2)

(5)

(1)

(4) GrRAG

Gr 6

R 0

A 1

G 2

(6)(1)

(2)

GrRAG

(0)

Safe Effective

Responsive Well led

Caring

Page 2 of 29

https://www.cqc.org.uk/news/releases/north-west-boroughs-healthcare-nhs-foundation-trust-rated-good-cqc

Indicator Executive Lead Units National (N) or Local (L) Target

Improvement Trajectory set Timescale Target Current Month

TargetCurrent Month

Actual R A G SPC Applicable

Percentage of staff incidents that result in moderate or above harm GB Percentage L - Mar-20 1.0% 1.0% 0.5% ✔ Y

Percentage of patient incidents that result in moderate or above harm GB Percentage L Y Mar-20 9.0% 9.5% 8.5% ✔ Y

Cumulative reduction in suspected suicides GB Percentage L Y Mar-20 10.0% 10.0% 16.9% ✔

Clinical supervision - percentage of clinical staff who have at least one supervision in the quarter GB Percentage L Y Mar-20 80.0% 60.0% 60.0% ✔

Pressure ulcers that have occurred as a result of lapse in care GBX

Pressure ulcers that have deteriorated in our care GBX

Number of restraints at level 3 or above GB Number L Y Mar-20 149 157 165 ✔ Y

Number of seclusions GB Number L Y Mar-20 30 32 22 ✔ Y

Percentage of inpatient falls that result in harm GB Percentage L Y Mar-20 34.2% 34.7% 33.3% ✔ Y

Bed days in adult facilities of patients who are under 18 years old JH Days L - Apr-19 0 0 0 ✔





Mental Health

Community

December 2019

Trust wide

Level

Safe Domain scorecard

Page 3 of 29

Safe Indicator progress sheet December 2019

R A G R A G

✔ ✔

Improvement Trajectory Set Y N Improvement Trajectory Set Y N

✔ ✔

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

19/20 Target/Trajectory 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 1.0% 19/20 Target/Trajectory 9.9% 9.9% 9.9% 9.9% 9.9% 9.9% 9.8% 9.7% 9.5% 9.3% 9.2% 9.0%

Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and TimescalesNot required Not required

Current performance is better than the planned target and does not trigger a process control rule. The Trust takes seriously any incident that results in harm to staff.

Current performance is better than the planned improvement trajectory and does not trigger a process control rule. The Trust takes seriously any incident that results in harm to patients.

Percentage of staff incidents that result in moderate or above harm

Percentage of patient incidents that result in moderate or above harm

Issue Issue

Page 4 of 29

Safe

R A G R A G

✔ ✔

Reported Quarterly from June


✔ ✔


19/20 Target/Trajectory 19/20 Target/Trajectory 20.0% 40.0% 60.0% 80.0%

Issue Issue

Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and Timescales

December 2019

Trustwide - Reduction in suspected suicides Trustwide - Clinical supervision - percentage of clinical staff who have at least one supervision in the quarter

10% reduction vs 2018/19 by March 20

Suicide prevention E-Learning training is mandatory across the Trust. Since the introduction July 2019 over 93% of staff have completed the training. All boroughs have over 91% of their staff having completed their Suicide Prevention E-LearningWe continue to be part of our local authorities multi agency suicide prevention meetings

A Trust Suicide Prevention Lead role has been approved by the Executive Leadership Group following a business case. A job description has been produced and it is expected the successful candidate will start in quarter one 2020/21.

The National Confidential Inquiry into Suicide and Self Harm have amended the 10 Safer Care standards from the previous self-assessment. The Trust completed a previous self-assessment and are using that baseline as part of a working group with NHS England and neighbouring mental health trusts in Cheshire and Merseyside to reassess ourselves against the amended standards and to develop an improvement plan against those areas that we believe as a collective are not being met and also look at areas where individual organisations are performing well so it can be shared across Cheshire and Merseyside.

Current performance is better than target. Current performance is in line with the target.

A Trust-wide focus has continued throughout the quarter in line with the clinical supervision steering group action plan resulting in the achievement of the 60% target. This focus will continue through the next quarter and will see the majority of the clinical supervision training delivered by a John Moores University lecturer.

Indicator progress sheet

Page 5 of 29

Safe December 2019

R A G R A G

✔ ✔


✔ ✔


19/20 Target/Trajectory 165 165 165 165 165 165 162 160 157 155 152 149 19/20 Target/Trajectory 33 33 33 33 33 33 32 32 32 31 31 30

Issue Issue



The increase in restraints is within standard variation, however this is being closely monitored by the least restrictive practise group and more analysis to understand if any particular areas of focus is required. The Positive Behaviour Support training is scheduled to commence with the train the trainer offer in January and will be systematically rolled out across our inpatient units during the next financial year. It is only anticipated that consistent significant impact will be achieved once the training is rolled out across all in-patient units and up to that point the standard variation in incidents is likely to continue.

Not required

Current performance is worse than the planned improvement trajectory but is not triggering a process control rule. There are no current Trust-wide issues to report.

Current performance is better than the planned improvement trajectory and is not triggering a process control rule. There are no current Trust-wide issues to report.

Mental Health - Number of restraints at level 3 or above Mental Health - Number of seclusions

Page 6 of 29

Safe

R A G R A G

✔ ✔


✔ ✔


19/20 Target/Trajectory 36.0% 35.8% 35.7% 35.5% 35.3% 35.2% 35.0% 34.9% 34.7% 34.5% 34.4% 34.2% 19/20 Target/Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

I Issue Issue


December 2019

Current performance is better than the planned improvement trajectory. There are no current Trust-wide issues to report.

There were no bed days in adult facilities for patients who are under 18 years old

Not required Not required


Bed days in adult facilities of patients who are under 18 years oldPercentage of inpatient falls that result in harm

Page 7 of 29

Indicator Executive Lead Units

National (N) or Local (L)

Target

Improvement Trajectory set Timescale Target Current

Month TargetCurrent

Month Actual R A G SPC Applicable

Did not attend rate JH Percentage L Y Mar-20 10.5% 11.0% 11.1% ✔ Y

Percentage of appointments cancelled by the Trust JH Percentage X X X X X X X



Improving Access to Psychological Therapies - Proportion of people completing treatment who move to recovery JH Percentage N - Apr-19 50.0% 50.0% 51.7% ✔ Y

The number of people who have entered (i.e. received) psychological therapies during the reporting period JH Number N - Apr-19 1,068 1,068 993 ✔ Y

Care programme approach follow up - proportion of discharges from hospital followed up within 72 hours JH Percentage N - Apr-19 80.0% 80.0% 89.1% ✔ Y

Percentage of readmissions within 30 days of discharge JH Percentage L Y Mar-20 9.0% 11.0% 12.4% ✔ Y

Percentage Inpatient Occupancy

Adult Mental Health JH Percentage L Y Apr-19 85.0% 90.0% 93.3% ✔ Y

Later life and memory services JH Percentage L Y Apr-19 85.0% 90.0% 83.7% ✔ Y

Secure services JH Percentage L - Apr-19 85.0% 85.0% 75.7% ✔ Y

Percentage of delayed transfers of care JH Percentage L Y Feb-20 6.0% 6.5% 4.1% ✔ Y

Patients requiring acute care who received a gatekeeping assessment by a crisis resolution and home treatment team in line with best practice standards JH Percentage N - Apr-19 95.0% 95.0% 97.8% ✔ Y

Percentage of open patients on Care programme approach having a Health of the Nation Outcome Score assessment in the past 12 months JH Percentage L - Apr-19 90.0% 90.0% 90.1% ✔ Y



Percentage of new birth visits completed within 14 days of birth JH Percentage N Y Mar-20 90.0% 85.0% 85.0% ✔ Y

Trust wide

Effective December 2019

Level

Domain scorecard

Mental Health

Community

Page 8 of 29

December 2019

R A G R A G R A G

✔ ✔ ✔

Improvement Trajectory Set Y N Improvement Trajectory Set Y N Improvement Trajectory Set Y N

✔ ✔ ✔

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

19/20 Target/Trajectory 11.5% 11.5% 11.5% 11.5% 11.5% 11.5% 11.3% 11.2% 11.0% 10.8% 10.7% 10.5% 19/20 Target/Trajectory 14.5% 14.5% 14.5% 14.5% 14.5% 14.5% 14.3% 14.2% 14.0% 13.8% 13.7% 13.5% 19/20 Target/Trajectory 9.5% 9.5% 9.5% 9.5% 9.5% 9.5% 9.4% 9.3% 9.3% 9.2% 9.1% 9.0%

s Issue Issue Issue

Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and Timescales

Trust-wide Did Not Attend rate

Effective

Adult, Children's and Adolescents Mental Health services and Learning Disability services have seen an increase in the percentage of patients who did not attend their appointments in December. Whilst the overall number of patients that did not attend decreased (7669 patients in December compared to 9055 in November) the percentage of patients increased due to lower overall activity.

Current performance is worse than the planned improvement trajectory but does not trigger a process control rule.

Despite a rise in the percentage of patients who have not attended in Mental health services the overall Trust percentage has remained the same as November at 11.1%.


As stated in August with the introduction of text messenger reminder services, community health services continue to see a reduction in patients who do not attend their appointment.

During January to April, text messenger reminder services will be rolled out to our podiatry and muscular skeletal services. This will result in approximately 125,000 additional patient contacts receiving a text reminder, it is anticipated this will result in a further reduction in the number of patients who do not attend.

Current performance is better than the planned improvement trajectory and is showing a special cause - improvement with the latest eleven points below the mean.

Community - Did Not Attend rate

Current performance is worse than the planned improvement trajectory but does not trigger a process control rule.

Mental Health - Did Not Attend rate

Page 9 of 29

December 2019

R A G R A G

✔ ✔


✔ ✔


19/20 Target/Trajectory 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 19/20 Target/Trajectory 1068 1068 1068 1068 1068 1068 1068 1068 1068 1068 1068 1068

Issue Issue


IAPT - Proportion of people completing treatment who move to recovery (from IAPT minimum dataset)

The number of people who have entered (i.e. received) psychological therapies during the reporting period

Not Required

Current performance is better than the planned target and does not trigger a process control rule. There are no current Trust-wide issues to report.

Effective

Current performance is worse than the planned target but does not trigger a process control rule.

Traditionally there is a reduction in the number of people entering services in December due to the Christmas period (998 patients compared to the target of 1068). However there has been a year on year increase (998 patients in 2019, compared to 896 patients in 2018).

The Trust achieved its overall quarter three target with 3290 patients entering service compared to a target of 3204. It is expected that the Trust will continue to achieve its overall prevalence target for the remained of the year as each borough has action plans to address their previous capacity shortfalls.


Page 10 of 29

December 2019C

R A G R A G R A G

✔ ✔ ✔


✔ ✔ ✔



Issue Issue Issue


Effective

Care programme approach (CPA) follow up - proportion of discharges from hospital followed up within 72 hours Percentage of readmissions within 30 days of discharge Mental Health - Percentage of delayed transfers of care


Current performance is worse than the planned improvement trajectory. However does not trigger a process control rule. There are no current Trust-wide issues to report.

Current performance is better than the planned improvement trajectory and does not trigger a process control rule. There are no current Trust-wide issues to report.

Not RequiredNot Required

Current performance is better than the planned target and does not trigger a process control rule. There are no current Trust-wide issues to report.

Not Required

Page 11 of 29

December 2019

R A G R A G

✔ ✔


✔ ✔



Issue Issue

Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and TimescalesNot required Not required

Effective

Mental Health - Percentage of open patients on Care programme approach having a Health of the Nation Outcome Score assessment in the past 12 months

Mental Health - Patients requiring acute care who received a gatekeeping assessment by a crisis resolution and home treatment team in line with best practice standards

Current performance is better than target and does not trigger a process control rule. There are no current Trust-wide issues to report.



Page 12 of 29

December 2019

R A G R A G R A G

✔ ✔ ✔


✔ ✔ ✔


19/20 Target/Trajectory 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 93.3% 91.7% 90.0% 88.3% 86.7% 85.0% 1 19/20 Target/Trajectory 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 93.3% 91.7% 90.0% 88.3% 86.7% 85.0% 19/20 Target/Trajectory 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0% 85.0%

IsIssue Issue


Issue

Effective

Percentage Inpatient Occupancy - Adult Mental Health Percentage Inpatient Occupancy - Later life and memory services

Mental Health - Percentage Inpatient Occupancy - Secure services


Not required Not required


Current performance is better than target and is below the lower process control limit as a low point.Current performance is worse than the planned improvement trajectory. A special cause - concern has flagged from April - November, however it is not triggering a process control rule in month.

There was an improvement in bed occupancy rates during December. The number of patients admitted tends to reduce in December. In 2019 there was a 13% reduction in patients admitted in December compared to the yearly average. Discharges remained broadly the same month on month. This resulted an overall reduction in the bed occupancy rate.

New procedures continue to be implemented regarding both patient flow and the day to day management of inpatient admissions. During December the patient flow managers successfully trailed new procedures in relation to their involvement into the day to day management of bed flow and admission avoidance. It is expected that this pilot will be developed and embedded during January and February.

In addition revised expectations of borough leadership teams and what is expected of them during times of escalation continued to be in place during December and it is assumed that this had an impact on improving patient flow.

Page 13 of 29

December 2019

R A G

✔

Improvement Trajectory Set Y N

✔

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

19/20 Target/Trajectory 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 81.7% 83.3% 85.0% 86.7% 88.3% 90.0%

IsIssue

Comments / Performance Improvement Actions and Timescales

Current performance is better than the planned improvement trajectory and is not triggering a process control rule.

Not required.

Effective

Community - Percentage of new birth visits completed within 14 days of birth


Page 14 of 29

Indicator Executive Lead UnitsNational (N) or Local (L)

Target

Improvement Trajectory set Timescale Target

Current Month Target

Current Month Actual

R A G SPC Applicable

% of our services where anticipated wait times are set and communicated to patients JH Percentage L X

Percentage of patients seen in month that waited longer than the set wait time for that service JH Percentage L X

Percentage of patients that are currently waiting longer than the set wait time for that service JH Percentage L X




People with a first episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral JH Percentage N - Apr-19 53.0% 53.0% 66.7% ✔ Y

Waiting time to begin treatment (from IAPT minimum data set) within 6 weeks JH Percentage L - Apr-19 95.0% 95.0% 91.3% ✔ Y

Number of routine Children and Young Person's Eating Disorder Services care pathways completed within 4 weeks JH Percentage N Y Apr-19 95.0% 92.0% 100.0% ✔ Y

Number of urgent Children and Young Person's Eating Disorder Services care pathways completed within 1 week JH Percentage N - Apr-19 95.0% 95.0% 66.6% ✔ Y

Improving access to Children's and Young People's Mental Health Services. JH Number N X

Out of area placements JH Number L - Apr-19 19 19 0 ✔ Y




Walk in Centre maximum waiting time of 4 hours from arrival to admission/transfer/discharge JH Percentage N - Apr-19 95.0% 95.0% 96.6% ✔ Y

December 2019Responsive

Community

Trust

Mental Health

Level

Domain scorecard

Page 15 of 29

Responsive December 2019

R A G R A G R A G

✔ ✔ ✔


✔ ✔ ✔Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

19/20 Target/Trajectory 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 53.0% 19/20 Target/Trajectory 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 19/20 Target/Trajectory 19 19 19 19 19 19 19 19 19 19 19 19

IsIssue Issue Issue


Mental Health - Out of area placementsMental Health - Waiting time to begin treatment (from IAPT minimum data set) within 6 weeks

Mental Health - People with a first episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral (UNIFY2 and MHSDS)


Not required Knowsley and Wigan boroughs are both achieving 100% compliance. However the Halton team saw a slight improvement from 47% in November to 48% December. As reported at the Trust Board by the Chief Operating Officer in November we anticipate being below the Trust target of 95% until into the new financial year due to the on-going challenges the Halton service is experiencing

In Halton, as a result of the challenges with the team, in total 39 of the 76 patients seen were outside of target with the mean waiting time being 41 days (42 Days in November). The longest wait for a patient to enter treatment was 72 days (105 days in November).

Halton boroughs attendance rate has improved from 87% in November to 95% in December. In addition the vacancy rate has improved from 13.1% in November to 9.3% in December with one new member of staff commencing in early January and the remaining two clinical posts will be interviewed for again in January.

As stated last month the borough leadership team have now appointed an external provider to support the triage function of the assessment process, enabling Trust practitioners to focus on the treatment phase of the patient journey. It is expected that the external provider will commence in the New Year and see up to 50 patients in January and 120 in February.

As of the middle of January there are currently 98 patients waiting over 6 weeks. It is anticipated with the increase capacity provided by the external provider and the improvement in the absence rate and recruitment of the new staff the backlog of patients will be cleared by the end of March.

The borough leadership team continue to work closely with colleagues in the clinical commissioning group on providing assurance on the action plan and its effectiveness.

Current performance is better than target and is not triggering a process control rule. There are no current Trust-wide issues to report.

Current performance is worse than local stretch target of 95%, at 91.3% but above the 75% national target. In month performance is below the lower process control limit and is a low point.


Not required

Page 16 of 29

Responsive December 2019

R A G R A G R A G

✔ ✔ ✔

Improvement Trajectory Set Y N Y N Improvement Trajectory Set Y N

✔ ✔ ✔



Issue Issue Issue



Current performance is worse than target but is within the process control limits. Current performance is better than target but is below the lower process control limit and is at a low point. Performance reduced from 97.5% in November to 96.6% in December.

On investigation, patients not seen within the target related to patient choice. Staff attendance continued to be an issue during December (92%) along with a number of vacancies in one of our walk in centres. Three new staff are awaiting their start dates and one post is currently at the advert stage.

A workshop for borough leadership teams has been arranged for the first week in February to understand the reasons for the increasing wait times experienced at the walk in centres and to put in action plans to reduce these. This workshop will be led by the Director of Operations.

Current performance is better than the planned improvement trajectory. Standardised administration processes have been implemented in Wigan and are being monitored at the weekly patient access meeting. There are no current Trust-wide issues to report.

Not Required

Walk in Centre maximum waiting time of 4 hours from arrival to admission/transfer/discharge

Number of urgent Children and Young Person's Eating Disorder Services care pathways completed within 1 week

Number of routine Children and Young Person's Eating Disorder Services care pathways completed within 4 weeks

Page 17 of 29


National (N) or Local (L)

Target





Staff Attendance JH Percentage L Sep-20 95.0% 94.3% 92.3% ✔ Y

Voluntary staff turnover JH Percentage L Apr-19 11.0% 11.0% 12.3% ✔ Y

Performance Development Review Compliance JH Percentage L Jun-19 90.0% 90.0% 85.4% ✔

Consultant and SAS doctor job plan completion SR Percentage L Jun-19 90.0% 90.0% 95.0% ✔

Percentage of disciplinaries that have been completed in time JH Percentage L L L L L L X L L L

Percentage of open disciplinaries that are on track to be completed in time JH Percentage L L L L L L X L L L

Statutory Training Compliance JH Percentage L Apr-19 90.0% 90.0% 90.7% ✔ Y

Core Training Compliance JH Percentage L Apr-19 90.0% 90.0% 95.8% ✔ Y

Specialist Training Compliance JH Percentage L Apr-19 90.0% 90.0% 93.2% ✔ Y

Staff Friends and Family Test % recommended - care JH Percentage L 43891 0.8

Trust

December 2019Well-led

Level

Domain scorecard

Reported Quarterly - Q3 data available from staff survey in March

Page 18 of 29

December 2019Well-led

R A G R A G

✔ ✔


✔ ✔



Issue Issue



Current performance is worse than the planned improvement trajectory and is a low point below the lower control limit.

Current performance is worse than target and is above the process limit as a high point.

Given the deteriorating position of attendance, a focussed performance session was undertaken in December. At month end the sickness position was just under 8%. A number of actions were agreed, which were also discussed at the Executive Performance Meeting and have/are being put in place with data being collected to manage performance around:o All Return to work interviews to be consistently entered onto the electronic record systemo Staff to be referred to occupational health as per the Trust promoting attendance policy;o Operational colleagues to populate details of all staff on a ‘stage’ in line with the Promoting Attendance policy, to improve local performance of attendance;o To support wider actions, an Assistant Director is leading a group of Occupational Health, Operations, People Services and Communications to develop a communications campaign to help support an improvement in attendance. An initial meeting being led by the Assistant Director of Halton / Specialist, is to be held in January to determine the content and the timescales.

People Services will align Human Resource advisors to boroughs from February and support these staff being borough based on a more regularly basis to support local managers. As the policy is deemed not to be as effective as it could be, a revised policy is being developed to be consulted on and agreed by the end of February.

The Trust was successful in securing winter pressure monies, to support the engagement of an agency nurse and to provide weekend clinics to support improved access times. Occupational Health capacity remains a concern, with up to five weeks from referral to consultation; given recruitment challenges for clinical roles.

Voluntary turnover has increased this month to 12.3%. Further analysis shows that there has been an increase in the turnover rate of registered nurses which has increased from 10.4% to 13%. The largest rise was within our St Helens borough where further analysis shows a doubling of the turnover rate for registered nurses when comparing December 2019 to December 2018. The Business Partner for St Helens has been tasked to investigate this. The primary area of concern is within our community nursing.

People Services will be drafting an action plan to be monitored by the workforce strategy Group which will define key actions to be taken in 2020 to help address the rising leaver rates.

Trustwide - Voluntary TurnoverTrustwide - Staff Attendance

Page 19 of 29

December 2019

R A G R A G

✔ ✔


✔ ✔


19/20 Target/Trajectory 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 19/20 Target/Trajectory 90% 90% 90% 90% 90% 90%

Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and TimescalesOverall compliance of 85% which is below the Trust target of 90% Five of the six boroughs are over 85% compliance rate. Data continues to be shared with Business Partners on a monthly basis for discussion in the boroughs to target those teams who are not yet compliant, and data that drills down to individual level is also available on the Information Management Platform. Teams who remain outside of compliance will be raised to the Director of Operations.

Not required.

Trustwide - Performance Development Review Compliance

Trustwide - Consultant and SAS doctor job plan completion

Well-led

Issue Issue


Current performance is worse than the planned target. Current performance is better than the planned target.

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

Apr-

19

May

-19

Jun-

19

Jul-1

9

Aug-

19

Sep-

19

Oct

-19

Nov

-19

Dec-

19

Jan-

20

Feb-

20

Mar

-20

Target Actual

Page 20 of 29

Well-led December 2019S

R A G R A G R A G

✔ ✔ ✔


✔ ✔ ✔


19/20 Target/Trajectory 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 19/20 Target/Trajectory 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Issue





Not required. Not required.Not required

IssueIssue

Trustwide - Statutory Training Compliance Trustwide - Core Training Compliance Trustwide - Specialist Training Compliance


Page 21 of 29

Well-led

R A G


✔


19/20 Target/Trajectory 75% 75% 75% 75%

IsIssue


Quarter 3 data is taken from the annual staff survey and will be available in March.

Not required.

Indicator progress sheet December 2019

Trustwide - Staff Friends and Family Test % recommended - care

Page 22 of 29

Caring


National (N) or Local (L) Target





Complaints completed within allocated timeframe GB Percentage x

Number of ombudsman complaints upheld GB Number L - Apr-19 n/a n/a 0 X

Number of compliments GB Number L - Apr-19 n/a n/a 203 X

Mental health scores from Friends and Family Test - % positive GB Percentage N - Apr-19 92.0% 92.0% 94.0% ✔ Y

Breaches of same-sex accommodation (Unjustified) JH Number N - Apr-19 0.0% 0.0% 0.0% ✔

Care hours per patient day vs Budgeted Care Hours per Patient day JHX

Community scores from Friends and Family Test - % positive GB Percentage N - Apr-19 95.0% 95.0% 94.7% ✔ Y

End of Life Care - Recording of preferred place of death JH Percentage X X X X X X X

End of Life Care - % Died in their recorded Preferred Place of Death JH Percentage X X X X X X X

December 2019Domain scorecard

Level

Community

Mental Health

Trust

Page 23 of 29

Caring

R A G R A G

✔ ✔


✔ ✔


19/20 Target/Trajectory 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 19/20 Target/Trajectory 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

IsIssue Issue

Comments / Performance Improvement Actions and Timescales Comments / Performance Improvement Actions and TimescalesNot required The increase in negative responses accompanied by a positive comment continued in December.

Managers have been asked to remind staff that the scoring system used is 1 'highly likely to recommend' and 5 ' highly likely to not recommend'.

Indicator progress sheet December 2019

Mental health scores from Friends and Family Test - % positive

Community - Scores from Friends and Family Test - % positive

Current performance is better than target. There are no current issues to report. Current performance is worse than the target but is not triggering a process control rule.

Page 24 of 29

Caring

R A G R A G

Co


✔ ✔


19/20 Target/Trajectory 19/20 Target/Trajectory

Issue Issue


December 2019

A target has not been set for the number of compliments, and therefore the measure has not been classified as red, amber, or green. Current performance is within the process limits. There are no Trust-wide issues to report

Not required


Number of compliments Number of ombudsman complaints upheld

A target has not been set for the number of complaints, and therefore the measure has not been classified as red, amber, or green. There are no Trust-wide issues to report

Not required

Page 25 of 29

Caring December 2019

R G

✔


✔


19/20 Target/Trajectory 0 0 0 0 0 0 0 0 0 0 0 0

Issue



Unjustified breaches of same-sex accommodation

There are currently no breaches of same sex accommodation.

Not required

Page 26 of 29

Other items ... ...to draw to the Board's attention December 2020

Speech & Language Therapy

Background

The Trust employs (277 whole time equivalents) a range of Allied Health Professionals across mental health, learning disability and community services, which include the clinical disciplines of: Occupational Therapists, Physiotherapists, Dietitians, Podiatrists, Orthotists and Speech and Language Therapists who form key parts of a number of multi-disciplinary inpatient and community teams. The majority of Allied Health Professionals employed across the Trust are within community (physical health) services.

Within the Allied Health Professional staff grouping, one of the clinical disciplines that is the most challenging for the Trust to recruit and retain are Speech and Language Therapists. These therapists use their specialist skills to assess, diagnose and develop care plans for children and adults with speech (pronunciation or stammering), language (understanding, sentence formation and grammar), communication (social interaction) or eating and drinking difficulties (also known as Dysphagia).

The challenge the Trust is experiencing is similarly experienced by other providers due to the relatively small qualified workforce. There are on average 60 places per year available across the whole of the North West region on undergraduate speech and language therapy programmes. Although there is a speech and language therapy apprentice standard, no universities in the North West are currently offering the programme. Acute trusts and large community providers are the most attractive destinations for those who qualify or are seeking professional progression.

Page 27 of 29

The Current position

The Trust has a funded establishment of 30.47 whole-time equivalent posts across a range of grades in mental health, learning disability and community services.

The Trust has a specific challenge with recruitment and importantly retention of Speech and Language Therapists with turnover for this discipline for 2018 and 2019 being 32% and 39% respectively. This is significantly higher than the 21% turnover for Allied Health Professionals for the same period.

Over 50% of those leaving the Trust have been in post less than two years, with 30% leaving after just twelve months. Themes identified for leaving the Trust include: little opportunity to progress within the profession with a small number of Speech and Language Therapists employed across the Trust; lack of opportunity to develop sub-specialities within the clinical discipline due to the small numbers of clinicians employed and availability of specialist leadership.

The Trust currently has a vacancy rate of 47% across both Paediatric and Adult Speech and Language Therapists, the majority of which are within Paediatric Speech and Language Therapy services.

As a result of the recruitment and retention challenge for Speech and Language Therapists adversely impacts on the Trusts ability to deliver on contracted activity with waiting times increasing for assessment and ongoing treatment within Speech and Language services. Where this is the case, the Trust is working with the appropriate clinical commissioning group on appropriate recovery plans and the challenge is reflected on the Trust Risk Register.

Page 28 of 29

Action we are taking and plans for the future

In order to address the recruitment and retention challenges that the Trust is experiencing a number of actions are being taken forward to support the positon in the short and longer term. A Trust-wide Allied Health Professional Strategy is being developed by the Trust Allied Health Professional lead. This will be completed by Spring of 2020.

The actions that are being taken forward include:

- Focussed recruitment and retention sessions for the wider Allied Health Professional workforce and specifically for Speech and Language Therapists;

- A dedicated focus on understanding the reasons why Speech Language Therapists are either leaving the organisation or we are finding it difficult to recruit with action plans developed to

- As part of a wider Allied Health Professional review, the role and function of Speech and Language therapists will be considered and skill mix required in teams going forward.

As the Trust continues to address challenges with recruitment and retention, agency staff are used where possible although the availability of locum practitioners is challenging due to small numbers practising across Cheshire and Merseyside and the wider North West.

Longer-term actions are in place which it is anticipated will positively impact on the positon, including engagement with the Allied Health Professionals Network to influence university curriculum offers and training place availability across Cheshire and Merseyside and the North West as well as encouraging higher education institutions to offer speech and language therapist apprentice posts. The Trusts anticipated longer-term strategic alignment with Mersey Care NHS Foundation Trust will also provide significant opportunity to improve recruitment and retention of practitioners with a much enhanced speech and language therapy workforce across the two organisations and increased opportunities to develop sub-specialties and increased leadership opportunities.

Page 29 of 29

Page 1 of 11

20/1737 Serious Incident Report


Item

N

o.

20/1

737

TITLE OF REPORT Serious Incident Report PRESENTED BY Gail Briers, Chief Nurse & Deputy Chief Executive AUTHOR(S) Nicola Jones, Head of Patient Safety

REPORT PURPOSE


To inform the Trust Board of: • Serious Incident reviews that have been commissioned in November and

December 2019. • Information on recent and planned Coroners Inquests. • All deaths reported in November and December 2019.

ALIGNMENT TO THE TRUST’S STRATEGIC OBJECTIVES (X) We will deliver quality, safe and efficient services with a highly skilled and motivated workforce X We will engage with our communities and staff to deliver


We will deliver whole person care through targeted growth We will plan an active role in place-based care systems to


We will retain our values and culture We will grow and develop the Trust at scale, being seen as an equal partner in any system-wide collaboration

SUBJECT MATTER/CONTENT CONSIDERED AT THE FOLLOWING COMMITTEES / GROUPS Committee / Group Date Audit Committee Quality Committee 13 November 2019

11 December 2019 Remuneration Committee Executive Leadership Group Sub Group Name (if applicable):

Other Group Name: This report has not been considered elsewhere (x)

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) No Risk Reference Strategic Objective Description (as per BAF) No No Not applicable


The Trust Board is asked to: • Discuss the paper and receive the latest position regarding serious incidents,

deaths reported and inquests. • Note that the Quality Committee is undertaking their delegated activity for the

scrutiny and oversight of serious complex incidents, complaints and claims. • Receive assurance that serious incidents are being managed effectively in the

organisation.


Page 2 of 11



27 January 2020

Serious Incident Report

1. INTRODUCTION / EXECUTIVE SUMMARY This paper has been developed to provide the Board with information on the Strategic Executive Information System (StEIS) reportable activity during November and December 2019. It also details coronial activity for the same period along with full inquest listings for the month of January 2020. The Board are requested to note recent activity on Serious Incident reviews and the assurance processes in place. 2. BACKGROUND

This paper is produced as a standing agenda item for the attention of the Board. 3. NEW INCIDENTS COMMISSIONED FOR REVIEW In November and December 2019 a total of 25 serious incidents were reported through the Strategic Executive Information System; 13 incidents were reported in November and 12 incidents in December. 72 hour reviews were commissioned for all of the incidents reported. All the Serious Incident reports due for submission during November and December 2019 were submitted within the agreed timeframe. Further details of serious incidents and relevant updates are provided to the Trust’s Quality Committee. The graph below shows the number of incidents reported to StEIS in the last 12 months:

0

5

10

15

20

25

30

35

Jan2019

Feb2019

Mar2019

Apr2019

May2019

Jun2019

Jul2019

Aug2019

Sep2019

Oct2019

Nov2019

Dec2019

Data

Mean

UCL

LCL

Page 3 of 11


Twenty-five serious incidents were reported to StEIS during November and December 2019. Thirty-seven 72 hour reviews were received by the Corporate Patient Safety Panel in November and December 2019; of the 37 reviews, 16 were received in November 2019 and 21 in December 2019. 3.1. Strategic Executive Information System Reportable Reviews

Strategic Executive Information System reportable incidents can include:

• Sudden, unexpected death of a community patient in receipt of services or who has been involved with our services within the last six months

• Inpatient suicides • Unexpected death of an inpatient • Suspected suicides of community patients • Serious safeguarding allegations • A never event • Absconds from secure units • Serious self-harm • Any other incident where there is significant learning potential

4. ASSURANCE PROCESSES IN PLACE FOR SERIOUS INCIDENT REVIEWS High level information is provided to the Trust Board at each of its meetings which allows the Trust Board to gain assurance that Serious Incidents are being managed effectively. There is a weekly Corporate Patient Safety Panel which is chaired by the Clinical Director of Operations and Integration and attended by the Chief Nurse & Deputy Chief Executive, Associate Medical Director for Quality and Safety, Pharmacy Safety Lead, Professional Lead for Psychology and the Assistant Clinical Directors for each borough. The role of the panel is to review all 72 hour reviews following a suspected Serious Incident and where necessary, commission further investigations. The panel also reviews and approves serious incident investigations on completion prior to submission to the commissioners. Local Patient Safety Panel meetings take place weekly in each Borough. The role of these panels is to review all local 72 hour reviews and advise on next steps and post review learning. The local patient safety panels also review after action reviews and investigations to ensure local delivery of outcome focused actions. The local Patient Safety Panels report to the Trust Patient Safety Panel for final agreement of investigation level for serious incident 72 hour reviews and for any concerns or delays with delivery of lessons learned locally. Work is ongoing to strengthen areas of positive practice within local patient safety panels in response to minor improvement opportunities identified within an audit report completed by KPMG. A task group has been established to develop a resource toolkit to support consistent qualitative outcomes across all local patient safety panels. This work is incorporated within phase two of the Patient Safety Improvement Plan which remains a dynamic plan aligned to the NHS National Safety Strategy published July 2019.

Page 4 of 11


In December 2019 it was minuted by the Quality Forum that the Trust had been removed from enhanced surveillance for the Serious Incident Framework. 5. LESSONS LEARNED To support the NHS England Serious Incident Framework (March 2015) and to implement learning from serious incident investigations, inquests and other sources of learning such as themes from complaints, the Trust has a Lessons Learned Forum, which is supported by Lessons Learned events taking place across each Borough. Actions to promote lessons learned across the organisation include: • Local learning via After Action Reflection and sessions delivered by Matrons,

Heads of Quality and Assistant Clinical Directors. • Communications via theme of the week, patient safety alerts and lessons learned

events. • Peer Reviews. • Implementation of Local Patient Safety Panels. • Local processes are supported through the Corporate Patient Safety Panel which

will ensure effective delivery. • Ensuring pan borough learning is facilitated and ensuring delivery through

appropriate collaborative groups, with central support and monitoring of effectiveness.

• Thematic Reviews of Serious Incidents.

The Trust Quality, Safety, Safeguarding and Governance Group and Corporate Patient Safety Panel are considering options for streamlining lessons learned across the Trust. It is expected that a new style visual report will be implemented by the end of Quarter four 2019/20. Since the last report to the Trust Board the following have been issued: Communication Brief Description Patient Safety Alerts: Alerts requiring immediate and on-going actions generated from learning following a serious incident. Audience: Issued to all inpatient managers

Two patient safety alerts were issued between November and December 2019. 1. Door stops. An estates and Facilities alert was

distributed warning of the hazards door stops can present to patients. Received on 5 November 2019.

2. Arrow Intraosseous Needles. Needles are not to be used if the safety cap is not attached. Received on 19 December 2019.

Peer Reviews: Internal self-assessment against CQC Key Lines of Enquiry: Safe, Effective, Caring, Responsive and Well led.

There has been one peer review held in December 2019. This took place on Kingsley Ward within the Warrington Borough.

Page 5 of 11


Communication Brief Description Briefing Note: Email communication sent to all staff members

A communications brief was circulated to all staff members via email 23 December 2019 regarding Automated External Defibrillator (AED). The briefing included guidance on the safe use of Automated External Defibrillators during a cardiac arrest situation.

Communication Brief Description Lessons Learned Event for Clinical Staff: Case studies from incidents are discussed for reflection and learning. Open invitation to clinical staff.

One Lessons Learned event was scheduled to take place in November 2019 in Warrington. No Lessons Learned events took place in December 2019.

The Trust Quality Safety Safeguarding and Governance Group and Quality Committee continue to the monitor the effectiveness of the Trusts newly adopted outcome based action plan template. The use of a digital platform to enable the efficient management of a system wide approach is yet to be realised. Work to understand the preferred informatics structure to support this work is ongoing. 6. INQUEST UPDATE There were 15 inquests heard in November and December 2019. Six inquests were heard in November and nine were heard in December 2019. November: Ref/ID: 19/875 Inquest details: Cardiotoxicity, effect of cocaine use, therapeutic use of

antipsychotic and anxiety drugs. Borough: Halton and Specialist Services Inquest date: 13/11/2019 Investigation type: 72 Hour Review Summary: No members of staff were called to give evidence in person at

the hearing. The Coroner gave a narrative conclusion, that the death was drug related. No criticism was made with regards the care that had been provided by the Trust.

Ref/ID: 19/867 Inquest details: The cause of death was not disclosed. Borough: Wigan, Bolton and Greater Manchester Inquest date: Not applicable. Investigation type: None. Summary: No members of staff were called to give evidence.

Page 6 of 11


The service user had not been in the care of the Trust for more than 12 months prior to their death. A statement was provided to the coroner of the care provided. The inquest was discontinued due to a natural cause being established. No criticism was made in relation to the care that had been provided.

Ref/ID: 19/873 Inquest details: Multiple Injuries Borough: Wigan, Bolton and Greater Manchester Inquest date: 15/11/2019 Investigation type: Concise Review Summary: One member of staff was called to give evidence in person at

the hearing. The coroner concluded that the death was due to suicide and raised a number of concerns around the care provided due to demand and capacity on Trust services. The Coroner issued the Trust a Regulation 28 letter. The trust provided a response to the Coroner 10 January 2020.

Ref/ID: 19/870 Inquest details: Hanging Borough: Wigan, Bolton and Greater Manchester Inquest date: 15/11/2019 Investigation type: Comprehensive Review Summary: Two members of staff were called to give evidence in person at

the hearing. The coroner concluded the inquest with a narrative verdict, detailing the injuries sustained were consistent with hanging. It was however noted that the deceased’s intentions remained unclear. There were no concerns raised regarding the care provided by the Trust.

Ref/ID: 19/894 Inquest details: Morphine toxicity, chronic obstructive pulmonary disease Borough: St Helens Inquest date: 19/11/2019 Investigation type: 72 Hour review Summary: No members of staff were called to give evidence in person at

the hearing. The coroner concluded that the death was drug related and raised no concerns about the care that had been provided by the Trust.

Page 7 of 11


Ref/ID: 17/703 Inquest details: Hypoxic brain injury, cardio-respiratory arrest Borough: Halton and Specialist Services Inquest date: 19/11/2019 - 22/11/2019 Investigation type: Concise Summary: Seven members of staff were called to attend the hearing to

provide their evidence in person. The inquest was heard by a jury who returned a conclusion of misadventure which was contributed to by neglect. Non-compliance with prescribed observation levels was cited as a causative factor. A Regulation 28 letter was not issued at the time however the coroner invited the deceased’s family to make submissions in this regard. These were received on 20/12/2019, to which the Trust is required respond by 31/01/2020. This matter is currently ongoing.

December: Ref/ID: 19/899 Inquest details: Bronchopneumonia, resolving subdural haemorrhage Borough: Wigan, Bolton and Greater Manchester Inquest date: 02/12/2019 Investigation type: None Summary: No staff were called to the hearing to give evidence in person.

The coroner gave a narrative conclusion that the death was accidental from an unknown trauma. No concerns were raised about the care provided.

Ref/ID: 19/879 Inquest details: Hanging Borough: Wigan, Bolton and Greater Manchester Inquest date: 03/12/2019 Investigation type: Suicide Summary: Two staff were called to the hearing to give evidence in person.

The coroner concluded that the death was due to suicide and raised no concerns were raised about the care provided.

Ref/ID: 19/878 Inquest details: Combined drug and alcohol toxicity. Borough: Wigan, Bolton and Greater Manchester Inquest date: 09/12/2019 Investigation type: 72 Hour Review Summary: No staff were called to the hearing to give evidence in person.

Page 8 of 11


The coroner returned a narrative conclusion, that the death was drug and alcohol related and raised no concerns about the care provided.

Ref/ID: 19/822 Inquest details: Multiple Injuries Borough: Wigan, Bolton and Greater Manchester Inquest date: 16/12/2019 Investigation type: 72 Hour Review Summary: No members of staff were called to attend the hearing to give

evidence in person. The coroner concluded that the death had been due to suicide and raised no concerns about the care provided.

Ref/ID: 19/856 Inquest details: Drug Toxicity. Borough: Warrington Inquest date: 16/12/2019 Investigation type: Concise Review Summary: Two staff were called to give evidence in person at the inquest

hearing. The coroner concluded that the death was drug related and raised no concerns about the care provided.

Ref/ID: 19/868 Inquest details: Traumatic Head Injury Borough: Halton and Specialist Services Inquest date: 16/12/2019 Investigation type: Concise Review Summary: No staff were called to give evidence in person at the inquest

hearing. The coroner concluded that the death was due to suicide and raised no concerns about the care provided by the Trust.

Ref/ID: 19/920 Inquest details: Hanging Borough: Wigan, Bolton and Greater Manchester Inquest date: 18/12/2019 Investigation type: 72 Hour Review Summary: One member of staff was called to give evidence in person at

the inquest hearing. The coroner concluded that the death was due to suicide and raised no concerns about the care provided by the Trust.

Page 9 of 11


Ref/ID: 19/832 Inquest details: Excessive use of Topiramate Borough: Warrington Inquest date: 19/12/2019 Investigation type: Concise Review Summary: No staff were called to give evidence in person at the hearing.

The coroner gave a narrative conclusion, that the death was a prescribed drug related death and raised no concerns about the care provided.

Ref/ID: 19/869 Inquest details: Hanging Borough: Warrington Inquest date: 19/12/2019 Investigation type: 72 Hour Review Summary: One staff member was called to give evidence in person at the

hearing. The coroner concluded that the death was due to suicide and raised no concerns about the care that had been provided.

Nine inquests have been listed to be concluded in January 2020, as below. Borough January 2020

Halton and Specialist Services 2

Knowsley 0

St Helens 1

Warrington 0

Wigan, Bolton and Greater Manchester 6

Sefton 0

Total 9

Page 10 of 11


7. LEARNING FROM DEATHS The table below identifies the deaths reported during November and December 2019, to show the level of investigation undertaken. 150 deaths were reported through Datix during November and December 2019. Total Investigation Type Datix

review 72 hour review

Concise Investigation

Comprehensive Investigation

Structured judgement review

Nov 84 63 13 8 0 0 Dec 66 54 11 1 0 0

The definitions for expected and unexpected deaths are: Unexpected death: Any unexpected or unintended event which has caused

the death of a person.

• 16 of the 150 deaths were unexpected deaths. Expected death: Where a death has occurred which was an expected or

inevitable consequence of the patient’s medical condition or healthcare.

• 134 of the 150 deaths were an inevitable consequence of the patient’s medical condition.

All of the Trust reported incidents of unexpected death received a 72 hour review. The table below shows the number of deaths reported in the last twelve months and the level of investigation undertaken. Month Total Investigation Type Datix

review only

72 hour review

Concise Investigation

Comprehensive Investigation

Structured judgement review

Jan 62 37 18 3 4 0 Feb 57 38 9 10 0 0 Mar 48 34 10 2 2 0 Apr 65 54 8 3 0 0 May 63 46 9 6 2 0 June 50 30 13 5 2 0 Jul 74 57 11 5 1 0 Aug 57 37 19 1 0 0 Sep 58 44 11 3 0 0 Oct 54 41 11 1 1 0 Nov 84 63 13 8 0 0 Dec 66 54 11 1 0 0

Page 11 of 11


8. SUMMARY

• Twenty-five Serious Incidents were reported through the StEIS system in

November and December 2019. • Thirteen incidents were reported in November 2019. • Twelve incidents were reported in December 2019. • 72 hour reviews were commissioned for all of the serious incidents reported. • Fifteen inquests were heard in November and December 2019. • Six inquests were heard in November 2019. • Nine inquests were heard in December 2019. • Nine inquests are listed to be heard in January 2020. • One hundred and fifty deaths were reported during November and December

2019. • One hundred and thirty-four deaths were expected deaths/inevitable

consequence of a medical condition. • Sixteen deaths were unexpected. • Thirteen deaths reported during November and December 2019 were identified to

meet the StEIS reporting criteria as a serious incident. 9. RECOMMENDATIONS • Discuss the paper and receive the latest position regarding serious incidents,

deaths reported and inquests. • Note that the Quality Committee is undertaking their delegated activity for the

scrutiny and oversight of serious complex incidents, complaints and claims. • Receive assurance that serious incidents are being managed effectively in the

organisation.

Gail Briers Chief Nurse and Deputy Chief Executive

Page 1 of 17

20/1738 Learning from Deaths


Item

No

.

20/1

738

TITLE OF REPORT Learning from Deaths Quarterly Report

PRESENTED BY Sandeep Ranote, Medical Director

AUTHOR(S) Justina Mawson, Trust Governance Manager Nicola Jones, Head of Patient Safety

REPORT PURPOSE


X

To inform the Trust Board of the learning identified from the deaths which occurred in quarter 3 2019/20. To provide assurance to the Trust Board that NWBH is reporting data on deaths in line with the process outlined in the national guidance and implementing recommendations from the learning to make improvements in care.





growth



We will retain our values and culture





Audit Committee

Quality Committee


Executive Leadership Group Sub Group Name (if applicable): <add name of sub group here if applicable>

Other Group Name: Learning from Death Group 17 January 2020





The Trust Board is asked to: Note the paper and receive the latest position with regard to learning from deaths.


Page 2 of 17 Page 2 of 17



Learning from Deaths

1. BACKGROUND In December 2015, the Secretary of State for Health commissioned the Care Quality Commission (CQC) to carry out a review of how acute, community and mental health trusts across the country investigate and learn from deaths to find out whether opportunities for preventing deaths have been missed and to identify any improvements needed. In December 2016 CQC published ‘Learning, Candour and Accountability’ detailing concerns about the way NHS trusts investigate and learn from the deaths of people in their care and the extent to which families and carers are involved in the investigation process. In March 2017 the National Guidance on Learning from Deaths was issued by the National Quality Board. The Guidance builds upon findings from a review of 14 hospitals with the highest mortality rates and the CQC report; Learning, Candour and Accountability: A review of the way NHS trusts review and investigate the deaths of patients in England. The Guidance makes recommendations aiming to initiate a standardised approach to learning from deaths. In June and October 2017 the Trust Board received papers outlining our response to the Guidance on Learning from Deaths that had been issued by the National Quality Board in March 2017. In July 2018 the National Quality Board published specific guidance for NHS trusts on working with families and carers. In March 2019 CQC published reviews from an inspector’s observations from the first year of assessing how well Trusts’ are implementing national guidance introduced to support improved investigations and better family engagement when patients die. We, as a Trust, are aligning and developing our processes to the national guidance and learning from the first year. The Trust Board agreed to receive regular reporting of learning from deaths as set out in the National Quality Board Guidance and that this information would be added to the Trust Serious Incident Report. Subsequent Trust Board Serious Incident Report papers have included the numerical data on deaths, level of review or investigation and early indication of themes.



2. PURPOSE The Trust has set-up a Learning from Deaths Group which is chaired by the Medical Director and meets quarterly. The aim of the group is to ensure thorough consideration of learning and Candour following service users’ deaths. The purpose of this paper is to provide assurance to the Trust Board that service user deaths are being appropriately reported and investigated to ensure lessons are being learned through open and transparent processes. This quarterly report reflects the Trusts journey of continued compliance with the national guidance for Learning from Deaths. 3. LEARNING FROM DEATHS DASHBOARD

The Trusts Learning from Deaths Dashboard displays the Trust’s overall mortality rates and further information on types of investigation which have been commissioned in response to reported incidents of death. This portion of the report describes the data utilised for each table in the dashboard: Table one shows the total number of deaths reported in Datix in line with the main national categories of expected and unexpected deaths. Unexpected deaths are broken down further in line with the national sub-categories as follows:

suicide – either proven or suspected

victim of homicide

death cause under review This data is used to inform further learning (see lessons learned). (See Appendix 1 – Glossary of Terms for definitions of deaths) The highest investigation level of report is shown in table two on the dashboard and provides a list of the types of investigations which the Trust has commissioned for a death in line with the NHS Serious Incident Framework (2015). The number next to each type of investigation shows how many of the deaths reported on Datix have concluded at this level of investigation (see appendix one for definitions of investigation type). Tables four, five, six, seven and eight on the dashboard show the overall assessment of care rating for unexpected deaths, as recorded in each 72 hour review (see appendix 1 for standard of care definitions). Where care is graded as Category C or D further analysis is done within the Patient Safety process to extract key learning points which are described later in the paper under Lessons Learned.



Table nine on the dashboard features the total number of deaths which have occurred for patients who were open to and in receipt of services across the organisation with the exception of the Sefton Borough. This information is taken from the National Spine which is collated on a weekly basis and mapped against the RiO system. Table 10 on the dashboard shows the total amount of deaths reported on Datix by Borough, quarter and year. Deaths are reportable to Datix when there is a recognised potential for further learning and improvement in care in line with our Patient Safety process.



Highest investigation level for all deaths (expected and unexpected)

Expected Q3 Q4 Q1 Q2 Q3

Datix 115 114 127 140 150

2018/2019 267 90 357 Local/72 hour review 45 40 34 36 41

3 131 50 181 Concise 9 14 13 12 11

4 136 40 176 Comprehensive 9 7 4 1 1

2019/20 456 115 571 After action review 2 1 0 0 0

1 131 47 178 Structured Judgement Review 1 0 0 0 0

2 142 47 189 Limted review 0 0 0 0 0

3 183 21 204 LeDer 0 0 0 0 1

Table 1 - in Datix Safeguarding Individual Mgt Review 0 0 0 0 0

HR Review 0 0 0 0 0

Table 2

Table 3

TotalQuarter Unexpected

Learning from Deaths Dashboard - 2019/20

Summary of total number of deaths and total number of cases reviewed

Total number of Deaths recorded in Datix

2018/2019 2019/2020

0

20

40

60

80

100

120

140

160

180

200

2018/2019 Q3 2018/2019 Q4 2019/2020 Q1 2019/2020 Q2 2019/2020 Q3

Total number of Deaths recorded in Datix by Quarter

Expected

Unexpected



Assessment of Care - Unexpected Deaths

Q3 2018-19 Q4 2018-19 Q1 2019-20 Q2 2019-20

Grade Oct Nov Dec TOTAL Grade Jan Feb Mar TOTAL Grade Apr May Jun TOTAL Grade Jul Aug Sep TOTAL

A 4 3 5 12 A 1 4 4 9 A 3 7 6 16 A 5 8 2 15

B 2 7 7 16 B 3 4 4 11 B 1 4 4 9 B 5 5 4 14

C 0 4 3 7 C 3 3 4 10 C 1 6 3 10 C 4 1 2 7

D 0 0 1 1 D 0 0 1 1 D 0 0 0 0 D 0 0 0 0

No grade 5 5 4 14 No grade 4 3 2 9 No grade 0 0 0 0 No grade 0 0 0 0

TOTAL 11 19 20 50 TOTAL 11 14 15 40 TOTAL 5 17 13 35 TOTAL 14 14 8 36

Table 4 Table 5 Table 6 Table 7

Q3 2019-20

Grade Oct Nov Dec TOTAL

A 2 2 0 4

B 2 5 1 8

C 0 3 2 5

D 0 0 0 0

No grade 0 0 0 0

TOTAL 4 10 3 17

Table 8


Summary of total number of deaths and overall assessment of care



Total number of Deaths recorded in RIO by borough Total number of Deaths recorded in Datix

Halton Knowsley

Specialist

Services St Helens Warrington Wigan Total Halton Knowsley Sefton

Specialist

Services St Helens Warrington Wigan Total

2018/2019 91 527 0 480 137 110 1345 2018/2019 15 99 10 13 37 98 85 357

Q3 43 235 0 234 68 45 625 Q3 6 47 8 7 20 46 47 181

Q4 48 292 0 246 69 65 720 Q4 9 52 2 6 17 52 38 176

2019/2020 116 633 0 484 175 144 1552 2019/2020 37 125 24 1 50 179 155 571

Q1 39 179 0 158 59 46 481 Q1 16 38 7 0 13 51 53 178

Q2 26 210 0 158 59 53 506 Q2 16 40 8 1 15 57 52 189

Q3 51 244 0 168 57 45 565 Q3 5 47 9 0 22 71 50 204

Table 9 Table 10

Quarter

2018/2019 Q3

2018/2019 Q4

2019/2020 Q1

2019/2020 Q2

2019/2020 Q3

Table 11

Summary of total number of deaths and total number of cases reviewed


0

10

20

30

40

50

60

70

80

2018/2019 Q3 2018/2019 Q4 2019/2020 Q1 2019/2020 Q2 2019/2020 Q3

Total number of Deaths recorded in Datix

Halton

Knowsley

Sefton

Specialist Services

St Helens

Warrington

Wigan



4. STRUCTURED JUDGEMENT REVIEW

The Trust has yet to receive feedback from the Royal College of Psychiatrists with regard to the outcomes of the pilot contributed to in 2018. In the interim the Trust continues to utilise its own internal investigation process to support Learning from Deaths. A formal update from the Royal College of Psychiatrists will now be requested in writing. The trust will also seek to align our own future practice in the use of structured judgement reviews with the trusts within our regional collaborative. 5. LESSONS LEARNED Q3 2019/20

Within quarter 3 2019/20 six deaths occurred where the expected care was graded as requiring significant improvement (category C) or simply not good enough (category D). The main points of consideration and learning taken from these incidents were the following;

Lack of documentation in response to crisis contacts within Mental Health Assessment Team’s.

Gaps in the coordination of care for service users with complex needs including missed opportunity for medication review and missed opportunities for onward referrals including psychological and occupational therapy.

Missed opportunity to follow up on failed attendance/DNA within the Recovery Team.

For each death where gaps or lapses in care were identified, a further level of investigation has been commissioned. Concise investigations are anticipated to provide recommendations and outcome focused actions for improvements. Action plans are tracked locally by each borough. Where themes have been identified individual pieces of work were commissioned by the appropriate group or work stream to support further learning and action planning. In order to support improvement in line with the themes identified in quarter 3, the following actions are being taken:

A Mental Health Crisis Team will become operational within the Wigan Borough from February 2020. This service will provide a 24 hour crisis response service and is anticipated to alleviate capacity pressure from the core Mental Health Assessment Team Function.

A review of CPA continues in line with the Mental Health Care Collaborative as part of the Trust Quality strategy.

The Trust Suicide Thematic Review was ratified in June 2019 and has outlined several areas for improvement. Findings from the review have been incorporated into the Trust’s suicide prevention work plan. The work plan continues to be monitored by the Trust’s suicide prevention group with oversight via the Trust Quality Safety Safeguarding and Governance Group Meeting.



Where patients had received an excellent standard of care (category A) positive practice was identified in the following areas:

Consistent interventions delivered in line with NICE guidance for schizophrenia.

Support via the Nurse Consultant for dual diagnosis due to challenges in engagement with substance misuse services.

Timely and collaborative working with Cheshire police in response to concerns associated with service user welfare.

Evidence of collaborative engagement with service users and families to offer informed choice around service provision.

The Learning from Deaths group will ensure that the areas of positive practice are shared with the central Patient Safety Panel to support further learning from deaths and improved care. The Trust continues to be connected to the national Learning Disabilities Mortality Review Programme. When received, an update and further details from the national programme will be included in future reports. The trust now has a new identified Learning Disability Mortality Review representative that will formally attend all Learning from Deaths groups and link into the appropriate external forums locally, regionally and nationally. In the absence of national programme updates, there has been progress at local level which is detailed in the external development section of this report. 6. THEMATIC ANALYSIS OF DEATHS REPORTED IN Q3 2019/20

Thematic analysis has been carried out on the 204 deaths reported in Q3 2019/20 in line with the implementation of the Learning from Deaths Policy and Procedure. Over the reporting period, there were 183 expected deaths reported in Datix, of these deaths:

Thirty seven expected deaths were subject to a 72 hour review.

Of the 37 expected deaths reviewed 36 (97%) of those subject to a 72 hour review received an overall assessment of care rated as A or B; one death (3%) of those subject to a 72 hour review received an overall assessment of care rated as C indicating significant room for improvement.

The remaining 146 expected deaths were subject to a Datix investigation; as such the overall assessment of care is not rated as part of this process.

Over the reporting period, there were 21 unexpected deaths reported in Datix, of these deaths:

Seventeen unexpected deaths were subject to a 72 hour review.



Of the 17 unexpected deaths reviewed 12 (71%) of those subject to a 72 hour review received an overall assessment of care rated as A or B; five deaths (29%) of those subject to a 72 hour review received an overall assessment of care rated as C indicating significant room for improvement.

The remaining four unexpected deaths were subject to a Datix only investigation; as such the overall assessment of care is not rated as part of this process. It is to be noted that the unexpected deaths subject to a Datix only investigation relate to interface cases between partner providers; these incidents occurred outside of the care of the Trust.

Page 11 of 17 Page 11 of

17


Learning Points Recommendation from Learning from Deaths

Group Desired Outcome

Learning from Inquests. Management of inpatient observations

Recommendation to Patient Safety panel to support the development and implementation of an observation training package. It is anticipated that future plans to introduce the electronic recording of

observations will allow for improved monitoring and audit of compliance.

Observations will be recorded timely and accurately. Observations will be driven by the service users risk assessment and care plan. The record of observation will qualitatively assist future decisions with regards to the service user’s care and treatment.

Learning from Inquests. Urgent response Safety Huddles

Recommendation to Patient safety Panel to support a daily safety huddle across urgent response and Mental Health Assessment Teams

Where necessary resources will be distributed across the urgent response function to ensure staffing levels are safely equitable to the demand.

Crisis Response The Learning from deaths group support the go live of the new crisis response home treatment within the Wigan Borough.

Service users will have access to a 24 hour crisis response service delivered in partnership with key stakeholders across the local footprint.

CPA/Management of Complex care needs The learning from deaths group continues to support the ongoing project work in relation to complex care needs. This work continues to be monitored through the Patient Journey Group.

Complex care needs will be managed in line with the principles of the Care Programme Approach Framework.

Closer working with NWBH Adult Safeguarding Team

Recommendation to the Central Patient Safety Panel to support closer working and training workshops between community Assessment Teams and Adult Safeguarding

Staff will be upskilled when identifying service users who require Adult Safeguarding input or involvement with community partners such as the MASH (Multi Agency Safeguarding Hub) Team or referral into MARAC (Multi Agency Risk Assessment Conference) for complex case discussion.

Substance misuse Recommendation to the Central Patient Safety Panel to support closer working relationships with the addiction services Change Grow Live. This will be achieved through the development of a ratified sharing agreement to promote information sharing and closer working.

This will enable the sharing of information between NWBH and CGL, promoting closer working and support formulation of long term care.

Military Veterans Recommendation to the Central Patient Safety Panel to promote guidance and communication around priority referrals incorporating military veterans

This piece of work focuses on improving knowledge of front line staff to ensure military veterans are recognised when they engage with mental health services



7. FURTHER DEVELOPMENTS Internal Developments: Family Engagement A review of the first year of the NHS Trust’s implementing the national guidance” was published by the Care Quality Commission in March 2019. One of the key focus areas for development was the involvement of families and carers. To support the involvement of families and carers, North West Boroughs Healthcare commissioned ‘Making Families Count’, which is an independent not-for–profit community interest training company. Three one day Making Families Count training sessions where delivered throughout September and October 2019. The benefits of delivering this training are that we will have early and more effective engagement with families who experience complex and traumatic bereavement. Staff will have a deeper knowledge of the impact of serious incidents on families and an improved understanding of what families want from investigations. The Trust has established an outcome based action plan steering group named ‘KIN-NECT’. Through this steering group four work streams have been launched:

1. Provide high quality standardised meaningful engagement with families 2. Develop a framework for the delivery of a high quality family liaison 3. Engaging a Trust workforce in meaningful engagement with families 4. Improving the application and experience of Duty of Candour.

The work is led by the Director of Nursing and Governance and will be further monitored by the Trusts Quality Committee. Governance process In line with the overall serious incident process and the new model of local patient safety panels reporting to a central patient safety panel, the governance team are working together to ensure that the learning from deaths from local patient safety panels is accurately captured and reported through to the central patient safety panel and the learning form deaths quarterly group and that data is triangulated to strengthen our recommendations for further learning and quality improvement. External Developments North West Boroughs continues to work alongside Greater Manchester Mental Health Trust and Pennine Care to form wider partnership learning via the Greater Manchester Mortality Review Group. The Trust has recently become an active partner within a multiagency Leder panel led by Warrington and Halton Clinical Commissioning Groups.



The Clinical Commissioning Groups have secured funding through NHS England for an eight month project to support the completion of multiagency Leder reviews. The Trust has identified two clinical representatives to contribute to the review process and subsequently share any system wide learning across the Trust. The first panel is scheduled to take place January 2020. Comparing and taking learning from other organisations Learning from deaths demonstrates that NWBH is developing good practice which aligns with case studies published but there are also some points of learning that other organisations have in place which we can consider adopting.

Good practice cited in other areas NWBH currently have in place

To have clear processes in place for how families are initially contacted, how they are given condolences and support, and how they are involved in investigations

Clear pathways of contact – further work in progress via Making Families Count

Support to be offered at multiple points over the course of any review or investigation.

Families and carers are contacted and given an explanation of what had happened and, where appropriate, an apology

Availability of specialist resource and training to be developed within a central Patient Safety Team

Family liaison officer works with families where there has been a serious incident or unexpected death

Families and carers to contribute to deciding the scope of the incident investigation

Engagement with families is individualised and person-centred, and families are invited to contribute to the investigation’s terms of reference and outline any specific questions they want answered about their relative’s care and treatment

A pathway to include timescales, e.g. make contact within three days or up to a maximum of five days.

Family liaison officer meets with the family at the end of the investigation process to explain the outcome of the investigation

Good practice cited in other areas NWBH currently have in place

Offer leaflets, bereavement signposting, and provide pastoral care within the trust. Include Chaplaincy in a pathway

All unexpected deaths subject to 72 hour review

Family liaison officer will support the family for as long as they need them up until the inquest, then work towards closure ensuring any additional needs are met.

For consideration for future development

A personalised letter to be sent from an Executive Director at the end of the investigation to the family, thanking for their contribution, ensuring learning has taken place, offering condolences offering recognition and acknowledgement of the incident.

For consideration for future development



The Associate Medical Director and Head of Patient Safety have engaged with neighboring Trust Mersey Care in attempts to share learning and positive practice. A meeting is being scheduled to take place within the next quarter. Key areas of focus will be the use of the structured judgement tool, the triage process behind this along with a review of how we regionally categorise all deaths within mental health and community services which align with national expectations but also allow quality improvement through our learning process and more meaningful data capture, categorisation and definition which we seek to standardise across the region. Audit North West Boroughs Healthcare participated in a Learning from Deaths audit carried out by our auditors, Mersey Internal Audit Agency (MIAA), to ensure we continue our learning and support our quality improvement. The Trust received feedback which reflected significant assurance. 8. SUMMARY

The Trust has continued to develop the internal framework and governance process from the National Quality Board in relation to Learning from Deaths including the bespoke data dashboard that will continue to be reviewed and improved where required. The Trust has in place a number of meetings where deaths are reviewed including, local and central Patient Safety Panels, Learning from Deaths Group, and the Quality Committee, a sub-committee of Trust Board. Reporting to the Board about the number of deaths and level of investigation occurs monthly in the serious incident report, in addition to the quarterly learning form deaths board report. The Quality Strategy outlines some key areas of action within the following pillars:

Quality assurance – assessing delivery and taking action to constantly improve

Focus on Preventing Harm - reducing variation and ensuring best practice

The Trust has reported a total of 204 deaths on Datix throughout Q3 2019/20 with a total of 54 requiring a further level of investigation. Each death reported on the Datix system is reviewed and those that go on to a 72 hour local review follow the standardised peer review process at local patient safety panel ensuring that the appropriate level of further investigation is commenced if appropriate. The overall number of deaths reported has increased during Q3 2019/20 in comparison to Q3 2018/19.



9. RECOMMENDATIONS The Trust Board is asked to:

To note the paper and receive the latest position regarding learning from deaths.

Sandeep Ranote Medical Director



APPENDIX 1 - GLOSSARY OF TERMS Expected and Unexpected Deaths: Expected death - where a death has occurred which was an expected or inevitable consequence of the patients medical condition or health care. Unexpected death - any unexpected or unintended event, which has led to the death of a person who was receiving care within services. This includes the National categories of; suicide either proven or suspected, victim of homicide and death cause under review. Death cause under review – this would apply to any deaths for which we are awaiting a Coroners’ outcome but there could also be cases where the cause of death is not known to NWBH at the time of it being reported. In these instances, the death will be categorised as ‘death cause under review’ but would later be re-categorised as appropriate. Types of Investigation: Comprehensive Investigation - commissioned when the incident is identified as significantly complex in nature or multi providers are involved in the care delivery to the patient. This requires a multidisciplinary approach with specialist investigators to complete the investigation. Concise Investigation - commissioned when the incident is identified as less complex in nature and can be managed by individuals or small teams to complete. 72 Hour Review - a rapid review document completed within 72 hours of the incident occurring outlining any immediate areas for concern, a suggestion on whether a further investigation is required and the overall standard of care for the patient. Action Review - used as a method of delivering learning shortly after the incident has occurred with a large amount of people i.e. a whole team. This is used more frequently where there have been incidents where the learning and root causes have been identified at the 72 hour review stage. Limited Review – used when a further investigation has been commissioned however due to limitations given to the Trust (in this case by the Police) only aspects of an investigation could be achieved. Safeguarding Individual Management Review - applied to incidents where there has been a child death and safeguarding concerns were outlined during the patients care. These are also completed to support a wider context of learning from a multi-agency approach.



HR Review - completed for incidents where there is or potential for conduct issues which require scrutiny from a HR perspective. Structured Judgement Review - an approved methodology used to review strengths and weakness in the provision of care where incidents of death have been reported. The object is to provide information in relation to learning from positive practice as well as identifying gaps and problems in the delivery of care. Independent Review - where the Trust or its Clinical Commissioning Groups commission an independent review lead externally from the organisation to complete a serious incident review. Standard of care:

A - A good standard of care achieved – A standard of care you would accept for yourself

B - Some room for improvement – The care was satisfactory but some aspects could have been better – no serious lapses

C - Significant room for improvement – Care was less than satisfactory, but no serious lapses in care and treatment

D - Simply not good enough – Care not acceptable, serious mistakes were made and the care/treatment was poor

Agenda Item No

NWBH 19/1639

Page 1 of 6



Item

No

.

20/1

739

TITLE OF REPORT Board Assurance Framework

PRESENTED BY Gail Briers, Chief Nurse and Deputy Chief Executive

AUTHOR(S) Gail Briers, Chief Nurse and Deputy Chief Executive

REPORT PURPOSE


To present the Board Assurance Framework.

To acknowledge that the Trust Board has delegated the authority to the Audit Committee to seek assurance on the Trust’s risk management process.

To acknowledge that the Board Assurance Framework contains all risks rated 15 or above and the risks mapped across from the Trust Risk and Opportunities Universe 2019/20 which may impact on the delivery of the Trust strategy.




X


growth X








Audit Committee

Quality Committee



Other Group Name:

This content has not been considered elsewhere (x) X

This report relates to all risks on the Board Assurance Framework. ALL

RECOMMENDATIONS

The Trust Board is asked to;

Discuss and note the content of the Board Assurance Framework.

Note the current position with regards to progress and actions taken to mitigate the risks contained within the Board Assurance Framework as we enter Quarter four 2019/20.

Note the role of the Audit Committee in fulfilling its delegated responsibility for ensuring effective identification and management of Trust wide risks and associated mitigation.

To be assured that the Board Assurance Framework for 2019/20 will deliver an effective internal system of control as laid out in the Trust’s Annual Governance Statement.


Page 2 of 6



Board Assurance Report

1. BACKGROUND The Board Assurance Report provides a high level summary and assurance that there is an effective risk management system in place. The Board Assurance Framework demonstrates the Trust’s compliance with its governance arrangements and is the key declaration of an effective system of internal control through the Trust’s Annual Governance Statement. All risks detailed are populated on the risk register but only those meeting the threshold of 15 and above with fair or limited controls feature on the Board Assurance Framework (Appendix one). In addition the Risk and Opportunities Universe 2019/20 has been mapped against the Trust strategic themes and Board assurance risks completed. The Board Assurance Framework will continue to be presented at alternate meetings of the Trust Board. 2. GOVERNANCE FRAMEWORK Monitoring of the Board Assurance Framework takes place through the organisation’s governance framework which also provides assurance that robust risk management processes function at each level of the Trust. The Audit Committee provides assurance to the Trust Board that appropriate structures, systems and processes are embedded in the organisation to manage patient safety and clinical risk. The Audit Committee receives a bi-monthly Risk and Assurance Report. An identified risk owner is invited to the Committee to participate in a challenge session and discuss the risk. 3. THE BOARD ASSURANCE FRAMEWORK 2019/20 The Trust Board Assurance Framework captures risks in respect of achieving each pillar of the Trust strategy; focussing on risks to the delivery of the six strategic themes. The Trust strategy sets out the direction and priorities for the Trust over the next three years. The six strategic priorities are;

We will deliver quality, safe and effective services with a highly skilled and motivated workforce.

We will deliver whole person care through targeted growth.

We will retain our values and culture.

We will engage with our communities and staff to deliver services differently.

We will plan an active role in place-based care systems to maintain a whole person care focus and high clinical standards.

We will grow and develop the Trust at scale, being seen as an equal partner in any system-wide collaboration.

Page 3 of 6


Risks associated with the Trust Strategy 2019-22 and Trust Objectives 2019/20 have been developed and approved. The risks to the Trust strategy are representative of the high strategic risk areas as outlined within the Risk and Opportunities Universe 2019/20 (appendix two). The Risk and Opportunities Universe 2019/20 is representative of all risks which have derived internally within the Trust in addition to risks sourced from external influences. Risks are inclusive of those which are considered to be stable and known and those that are emerging and new; the position of the risk on the Risk and Opportunities Universe 2019/20 axis is indicative of this and can be seen within appendix two. The table below is representative of the alignment between identified high strategic risk areas and risks requiring annual focus with the Trusts six strategic themes.

Page 4 of 6


4.1 High Strategic Risk Matrix;

Hig

h s

trate

gic

ris

k m

atr

ix

Str

ate

gic

Th

em

e

1.

We w

ill

deli

ver

qu

ality

safe

an

d e

ffic

ien

t s

erv

ice

s w

ith

a h

igh

ly s

kille

d a

nd

mo

tivate

d w

ork

fo

rce

2.

We

will d

eliv

er

wh

ole

pers

on

care

th

rou

gh

targ

ete

d g

row

th

3.

We

will re

tain

ou

r v

alu

es

an

d o

ur

cu

ltu

re

4.

We w

ill

en

gag

e w

ith

ou

r

co

mm

un

itie

s a

nd

sta

ff t

o

delive

r s

erv

ice

s d

iffe

ren

tly

5.

We w

ill

pla

y a

n a

cti

ve r

ole

in p

lace b

ased

ca

re

syste

ms t

o m

ain

tain

wh

ole

pers

on

fo

cu

ssin

g o

n h

igh

clin

ica

l sta

nd

ard

s

6.

We w

ill

gro

w a

nd

de

velo

p

the T

rust

at

scale

bein

g

seen

as a

n e

qu

al p

art

ner

in

an

y s

yste

m w

ide

co

llab

ora

tio

n.

High Strategic Risk Area

Changes to commissioning arrangements

X X X X X

Availability of work force X X X X X

Growing demand outstripping capacity within available funding linked to long term plan.

X X

Quality Governance Arrangements (including serious incidents, complaints, risk management )

X X

Transformation and Improvement plans.

X X

Staff Health and Wellbeing

X X

Inconsistent delivery across Boroughs

X X X

Attraction and retention of staff to the Trust

X X

Workforce planning and skills development

X X X X

Brexit X

Other Risks Requiring Focus

Organisational capacity to deliver on all our commitments

X X X X X

Business Continuity and Emergency Planning

X X

Interoperability of IT systems across health care.

X X X

Page 5 of 6


The Risk Team has worked with Executive sponsors to transfer the areas of risk identified in the Risk and Opportunities Universe 2019/20 onto the Trust risk register. Under the new framework the scrutiny and management of risks has been delegated by the Trust Board to the Audit Committee via the bi-monthly Risk and Assurance Report. The general risk register information and assurance is now delivered through the Audit Committee as per the current Terms of Reference with the Trust Board focussing on Board level risks alone. The revised process ensures that risks against the Trust Strategy and Trust Objectives are described, assessed and scored appropriately, risk targets are set and appropriately measured and that risk appetite in relation to these risks is understood and effectively managed. Executive risk owners have accepted and approved the risks. The risks are detailed in the Board Assurance Framework (Appendix one). To ensure focus on the current position the Board Assurance Framework will be contemporaneous in presentation. Quarterly projected action plans will accompany each risk and will reflect the progressive journey of mitigation. 4. CONCLUSION

There are currently 137 risks open on the risk register from a variety of sources 15 of which are currently mapped against the Board Assurance Framework. Further details can be found in the Board Assurance Framework (Appendix one). 5. RECOMMENDATION The Trust Board is asked to;

Discuss and note the content of the Board Assurance Framework.

Note the current position with regards to progress and actions taken to mitigate the risks contained within the Board Assurance Framework as we enter Quarter four 2019/20.

Note the role of the Audit Committee in fulfilling its delegated responsibility for ensuring effective identification and management of Trust wide risks and associated mitigation.

To be assured that the Board Assurance Framework for 2019/20 will deliver an effective internal system of control as laid out in the Trust’s Annual Governance Statement.

Gail Briers Chief Nurse & Deputy Chief Executive

Page 6 of 6


Appendix 2

Key

High/Strategic Risk Areas Other risks requiring particular focus this

year

Routine systems and risks which require

periodic review

Opportunities identified

Risk & Opportunities Universe 2019/20External

Internal

Stable/known

Emergingareas

Core externalrisks

Core operations Business change

The Trust

Corporate and Board Governance

Core Financial Controls

Health & Safety

IT/ Data System Security

Workforce Planning & Skills

Development

Transformation and Improvement plans

Quality Governance, Serious Incidents, Complaints & Risk

Management

Safeguarding

Infection Prevention

V4 – after leadership day CG

Growing Demand Outstripping

Capacity within available funding

linked to long term plan

Opportunities from market consolidation

Better Use of Data to enable management decision making

Brexit

Interoperability of IT systems across health

care

Compliance and Inspection frameworks

Spreading good practice learning from

others

Changes to commissioning arrangements

Inconsistent delivery of core services across boroughs

Organisational Capacity to

deliver on all our

commitments

CQC Action Plan

Availability of workforce

Partnership & Consortium

Place based systems

GP Federations and primary care services

Business Continuity and Emergency

Planning

Staff Health and Wellbeing

Changing/New

Board Assurance Framework The board assurance framework sets out a list of strategic,

and other high level risks, current mitigating actions and

internal and external assurances. The board assurance

framework identifies further mitigating actions to be taken for

each risk area.

Risk ID This refers to the reference number that Datix will assign to

the risk

Owner A risk owner is the person who has been given the authority

to manage a particular risk and is accountable for doing so

Risk type Risks may be strategic or operational (see definitions below)

They can also be clinical, non-clinical or financial. If the risk

could be categorised under more than one type please choose

the most significant

Description Each risk should be written in the format:-

There is a risk of ….due to …….leading to ……

Controls A control is any measure or action that modifies risk. Controls

include any

policy, procedure, practice, process, technology, technique,

method, or

device that modifies or manages risk.

Once a risk has been recognised, risk owners should consider

what controls already exist.

Adequacy of controls These can be judged as excellent, good, fair or limited.

Gaps in controls Even allowing for any controls in place to mitigate against the

risk gaps may remain either in controls or in any assurances

designed to provide evidence that the risk is being controlled

and monitored

Inherent risk This is the risk rating before any controls are taken into

account

Risk Score/Rating This is based on the Trust's 5 by 5 risk matrix measuring the

likelihood and consequences of risks being realised

The first risk recorded in Datix allowing for application of

existing controls.

Current risk score The current risk rating takes into account progress against the

action plans

Target risk score This refers to the residual risk rating i.e. when the risk has

reduced to a level which is acceptable to the Trust and can

therefore be closed

Target date Date by which actions are expected to be completed; controls

and assurances are sufficient; and the risk is expected to reach

it's residual or target rating and therefore is expected to close.

Date reviewed This refers to the date of the current risk review

Strategic objective Here the risk is linked to one of the Trust's High Level

Objectives

Source of risk This can be a variety of things including:- did the risk result

from one incident or several incidents; risk assessments,

external recommendations we risk not achieving; risk of not

meeting objectives etc.

Action plan The action plan can include actions to mitigate against the risk

by improving controls or assurances, either to eliminate the

risk altogether or to reduce the risk to it's target rating

Progress against action plan Here progress against the action plan is recorded

RAG rating Green - the action plan is on target to deliver within the

planned expenditure and timescale

Amber - the action plan has or is predicted to depart from

planned expenditure and/or timescale and there is agreed

action to bring it back on plan

Red - the action plan has or is predicted to depart from

planned expenditure and/or timescale and there is no agreed

action to bring it back on plan

Risk Types

Strategic risk Strategic risks are those that arise from the fundamental

decisions that directors take concerning an organisation’s

objectives. Essentially, strategic risks are the risks of failing to

achieve these business objectives. Those risks that if realised

could fundamentally affect the way in which the Trust exists or

provides services in the next one to three years. These risks

should they occur will have a detrimental effect on the

achievement of one, some or all of the Trust's strategic

objectives. The risk realisation will lead to material failure, loss

or lost opportunity

Operational risk Operational risks – risks connected with the internal

resources, systems, processes, and employees of the

organisation. Those risks that if realised would increase the

likelihood of a strategic risk realising.

Consequences Remote < 1% Possible 20%

chance

Likely 60%

chance

Highly likely

90% chance

Certain

Insignificant 1 2 3 4 5

Minor 2 4 6 8 10

Significant 3 6 9 12 15

Serious 4 8 12 16 20

Major 5 10 15 20 25

Description Financial Patient/Staff

Safety

Business

Continuity

Reputation Corporate

Objectives

Regulatory/

Legal

Insignificant <£0.25m No Harm <0.5 days No media

Interest

<5% variance No breach/action

likely

Minor £0.25>0.5m Low Harm 0.5>1 day Minor Media

Interest

5-10% variance Potential

Breach

£0.5>1m Significant Harm 1>7 days Headline Local

Media Interest

10-25%

varianceSignificant

Breach

Serious £1m>2m Serious/Perman

ent Harm/Death

7>30 days National Media

Interest

25-50%

variance

Serious Breach

Major >£2m Multiple

Death/Pandemic

>30 days Media Campaign >50% variance Major Breach/Legal

or Regulatory

Action

Escalation Table

1-3 Low Risk Score

3-6 Low risk Score

8-12 Medium Risk

Score

15-25 High Risk

Score

Likelihood / probability of repeat

Risks can usually be treated by local managers within their budgetary constraints and

Risks can usually be treated by local managers within their budgetary constraints and

Risks at this level will be recorded on the Trust Wide Risk Register and can usually be treated by

Heads of Service/Business Managers. These risks will be discussed at the Business Stream QPR

All high level risks must be entered on to the Trust Wide Risk Register and be authorised,

reviewed and treatments agreed/confirmed by the responsible Director and Assistant Director

Stra

tegi

c Th

eme

1. We will deliver

quality safe and

efficient services with

a highly skilled and

motivated work force

2. We will deliver

whole person care

through targeted

growth

3. We will retain our

values and our culture

4. We will engage

with our communities

and staff to deliver


5. We will play an

active role in place

based care systems to

maintain whole person

focussing on high

clinical standards

6. We will grow and

develop the Trust at

scale being seen as an

equal partner in any

system wide

collaboration.

High Strategic Risk Area

Changes to commissioning

arrangementsX X X X X

Availability of work force X X X X X

Growing demand outstripping

capacity within available

funding linked to long term

plan.

X X

Quality Governance

Arrangements (including

serious incidents, complaints,

risk management )

X X

Transformation and

Improvement plans.X X

Staff Health and Wellbeing X XInconsistent delivery across

BoroughsX X X

Attraction and retention of

staff to the TrustX X

Workforce planning and skills

development X X X X

Brexit X

Other Risks Requiring Focus

Organisational capacity to

deliver on all our

commitmentsX X X X X

Business Continuity and

Emergency Planning X X

Interoperability of IT systems

across health care.X X X

ID Opened OwnerStrategic

ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board

Description Controls

RAG Rating

of Adequacy

of Controls

Gaps in ControlInitial

Rating

Current

Rating

Target

Rating

Last BAF

RatingTarget Date Date of review

RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2507 21/06/2019 Jason Brannon

2

3

4

5

Strategic

Development

and

Transformation

Tracy Hill

Peoples Strategy

Annual

Workforce Plan

Workforce

Strategy

Development

Group

Operational

Leadership

Meeting

Structures

There is a risk that we do not

have sufficient internal

capacity to cover key

leadership positions and high

risk professional positions as

they arise due to the skill of the

existing workforce leading to

an inability to deliver safe

services in line with the NHS

Long Term Plan.

Lift as you climb leadership strategy

in place.

Board Talent and succession profile in

place.

Leadership talent and succession

profile for band seven plus roles.

Over 150 band 7+ staff have been

talent mapped

Launch of empowering leaders

programme, over 100 staff will have

undertaken this training by financial

year end.

Commissioning of external masters

level leadership training.

Good Lack of clear coordinated plan at

trust wide level to address gaps

within high risk professional

positions.

Lack of internal

promotion/progression.

No existing strategy in response

to deficits within each high risk

professional position.

12 12 8 12 31/03/2020 17/01/2020 Green ↔ ↔

2508 21/06/2019 Damian Byrne

1

2

3

Trust Board Tracy Hill

Peoples Strategy

in place. Staff

Turnover and

Recruitment

reported via

monthly

Performance

Data.

There is a risk that we will not

have an available workforce to

deliver quality safe and

efficient services due to

national staff shortages and

challenges with the attraction

and retention of staff leading

to a failure to provide 'Good'

core services within

standardised pathways.

The Head of AHPS presented a paper

with action plan to the Workforce

Strategy Group in July 2019, which

outlines a number of actions to be

taken to help better engagement

with the AH workforce which could

help aid retention.

The Trust is currently exploring the

use of an new innovative system to

help monitor and manage sickness

absence in the organisation. A pilot is

planned for late 2019 and will be a

system being used to support both

managers and staff in ensuring robust

adherence to sickness absence

processes and procedures, which has

been proven in other Trusts to

significantly lower sickness absence

rates.

Good More work is needed to be done

focusing on AHP retention (over

20%) and more focused

attraction and recruitment

activity is required for other

areas - ie: community nursing

The Trust remains an outlier for

high sickness absence levels and

the Trust continues to develop

health and well being

approaches to support reducing

this.

16 16 8 16 31/03/2020 09/01/2020 Green ↔ ↔

2509 21/06/2019 Clare Dooley1

6Trust Board Gail Briers

NWBH Audit

committee has

delegated

authority to

report to Trust

Board. Annual

Business

Continuity and

EPRR report

presented to

board.

There is a risk that the Trust

will be unable to successfully

coordinate command and

control during business

continuity, critical incident and

major incident due to a lack of

trained resource proportionate

to Trust size leading to an

inability to fully discharge its

EPRR duties and deliver core

business safely.

Major Incident Policy in place. Major

incident Procedure in place. Self

assessment in line with NHS England

Emergency preparedeness, resilience

and response core standards

assurance framework demonstrates

substantial compliance in key areas.

Major Incident and Business

Continuity Workshops have taken

place (in Oct 2019) attended by on-

call rota members which provided

procedures/templates to support

local business continuity plans.

Good Current exercise and testing

schedule does not meet the

requirements of the framework.

Inability to demonstrate

compliance with strategic and

tactical responder training. An

exercise is being scoped (topic,

date and format) and will take

place before 31/3/20.

12 6 3 9 31/03/2020 17/01/2020 Green ↓ ↓

Risks to Delivering the Six Strategic Themes


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2511 24/06/2019 Andrea Snagg1

3Trust Board Tracy Hill

Peoples strategy

Workforce

strategy

development

group

Health and

Safety Group

There is a risk to staff health

and wellbeing due to

operational pressures

contributing to reduced

motivation and staff feeling

unsupported leading to higher

levels of sickness and absence,

increased turnover within the

workforce along with an

inability to retain high calibre

talent.

Promoting attendance policy in place.

Access to Occupational Health (OH

Drs, Nurse, Physiotherapists,

Counsellors/Therapists).

Health and Wellbeing advisor in post

(0.4 WTE) who is responsible for

coordinating Health and Wellbeing

initiatives across the Trust.

Influenza vaccination programme in

place.

Access to Gym facilities on some

sites.

Exit interviews.

Staff opinion survey.

Absence listening events.

Anti bullying campaign.

Good Insufficient dedicated Health

and wellbeing advisor resource

(0.4 WTE for the Trust)

Lack of clarity in respect of the

Health and wellbeing champion

roles and expectations.

No Mental Health Plan for Trust

staff

Capacity and demand mismatch

between Occupational Health

staff resource and service

demand.

Current Occupational Health

Service is structured towards

reactive responses to health and

wellbeing as opposed to

proactive prevention.

Trust wide engagement strategy.

9 9 6 9 31/03/2020 03/01/2020 Green ↔ ↔

Trust Board

1

4

5

6

Asim Patel21/06/20192510 31/03/2020 17/01/2020 Green ↔ ↔1261212

Engagement with the wider local

health economies and differing

priorities across Boroughs.

Multiple and different

information sharing solutions

adopted by the Boroughs

resulting in increased resourcing

and cost pressures.

Lack of consistent and defined

approach to sharing of mental

health and community data with

shared record platforms.

GoodRiO clinical information system roll-

out completion across the Trust has

reduced number of clinical

information systems used across the

Trust and provided a platform to

interact with other information

systems. A Trust Integration Engine

has been procured, an

implementation plan is in

development.

Standardised electronic discharge

summaries and correspondence

letters are being delivered directly to

GP practices.

Trust is participating in integration

and interoperability projects across

Boroughs which include eXchange

(Cheshire and Merseyside

Information Sharing Platform), St

Helens Cares, Wigan ShareToCare,

and Warrington Together to connect

clinical information systems across

organisational boundaries.

The Trust implemented a solution to

link patient details from RiO and

IAPTus, the clinical information

system used in the Trust's Improving

Access to Pyschological Therapy

(IAPT) services.

The Trust is working with

commissioners and other partner

organisations to ensure there is a

universal understanding.

There is a risk of being unable

to provide safe and effective

care due to a lack of

interoperability and integration

of digital systems and services

across clinical boundaries

leading to a detrimental impact

on patient care, clinical safety

and the Trust’s reputation.

This risk and its

associated

actions will be

monitored by the

Digital

Transformation

Board.

Simon Barber


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2512 24/06/2019Denise

Richardson

1

5Trust Board Gail Briers

Quality Strategy.

Trust Quality and

Performance

Report.

Delegated

Authority to

quality

committee on

the oversight of

serious incidents.

Trust QSSG

There is a risk of boroughs

delivering their local clinical

governance frameworks

inconsistently due to changes

in leadership and meeting

structures leading to possible

variation in effectiveness of

assurances across the

boroughs.

Established policies and procedures

for all core functions within

Governance.

Weekly Borough and weekly

Corporate PSP Functions. Established

meeting structure in place from floor

to board. Established Borough

Leadership Teams.

Heads of Clinical Quality now in post.

Monthly oversight and scrutiny of

quality and performance data.

Care collaborates commissioned with

ACD accountability in response to

preventing harm and positive patient

experience.

Processes in place for monitoring

fundamental standards.

Good Further developments to the

Governance interface between

boroughs and Corporate

services is required to ensure

the benefits of the changes in

meeting structures and the

leadership review can be

realised in full.

12 12 8 12 31/03/2020 17/01/2020 Green ↔ ↔

Green ↔ ↔24/06/2019Lee

McMenamy12 4 12 01/03/2020 17/01/2020

There is a risk that growing

demand will outstrip the

capacity within the available

funding linked to the long-term

plan leading to longer waiting

times.

Trust contracts will only reflect

additional required access and

targets in line with the long-term plan

and 5YFV if commissioners have

agreed additional investment

Local borough patient access meeting

provides assurance that patients are

being seen within a timely manner.

Any medium to long term gaps in

assurance are escalated through to

the risk register. New monthly patient

access meetings have been launched

to ensure compliance against the

Trust policy is maintained. Financial

implications due to increased

demand are monitored monthly

through Trust Operational

Performance Report. Meetings with

commissioners regularly take place to

review impact of growing demand.

Actions taken by Executive Directors

and Senior Leaders to address

services where increased demand

isn't meeting capacity.

Where required Bank and Agency

staff are being recruited to ensure

patients are seen and treated in

appropriate timeframes.

Good Trust wide Patient Access to be

refreshed and continue to be

rolled out across each Borough.

Lack of staff availability leading

to gaps in service delivery.

Robust capacity and demand

analysis to understand growth

areas.

Lack of investment from

commissioners will impact on

the Trusts ability to deliver the

Long-Term plan.

1225131

5Trust Board John Heritage

Trust Operational

Performance

Report

Board Assurance

Framework


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2514 24/06/2019Sarah

Waterworth

2

4Trust Board John McLuckie

CIP programme

set out in March

Budget Paper.

Monthly Finance

paper to Board.

There is a risk that the Trust

may not deliver its planned

efficiencies as part of its

transformation and

improvement plan and

consequently may not meet its

Control total, leading to the

loss of provider sustainability

funding and reputational

damage.

The Cost Improvement Programme

and associated risk is set out in the

2019/20 financial plan.

The Cost Improvement Programme is

monitored and reported to the Board

on a monthly basis via the newly

created finance paper.

The Cost Improvement Process and

structures have been revisited and as

a result the Cost Improvement Group

has been split into two meetings to

provide strategic focus and increase

accountability - The Transformation

and Improvement Strategy Group

and the Transformation and

Improvement Delivery Group. Terms

of reference have been reviewed and

the Delivery Group is chaired by the

Director of Operations and

Integration. The Transformation and

Improvement Strategy Group reports

to the Executive Leadership Group.

Good As at January, and as described

in the month 9 Finance report, it

is considered quite likely that

Mersey Care will support the

Trusts financial position in 19/20

and as such the risk has been

reduced to a score of 12.

20 8 16 16 31/03/2020 17/01/2020 Green ↓ ↓

2515 24/06/2019 Tim McPhee

1

2

5

John Heritage

There is a risk that inconsistent

delivery of services across

boroughs will negatively

impact on the quality of

services provided by the Trust

leading to an inability to

delivery contractual and

quality requirements.

Development of Clinical Collaborates

to support consistent delivery of

services.

Patient Access and Patient Flow

Groups established at Trust level and

being established at Borough level to

drive consistency.

Engagement in the 6 places.

Executive Director relationship leads

and engagement by Borough Teams.

Good Lack of updated SOP's in

services across the Trust.

Inconsistency in Borough

Leadership meeting structures

to drive a consistent approach

to service delivery.

Differential commissioning

across the patch.

8 8 4 8 31/03/2020 06/01/2020 Green ↔ ↔

2516 24/06/2019 Simon Barber

1

2

4

5

6

Simon Barber

There is a risk that we do not

have the organisational

capacity to deliver on all our

commitments due to the large

number of priorities created

both internally and externally,

leading to a potential failure to

deliver on all the objectives

within our strategy and

supporting strategies.

Strong governance framework to

Trust Board on the delivery of the

objectives within our strategies.

Directors and Deputies Group have

commenced discussions around

priorities and limiting the amount of

improvement work/objectives we

take on at any one time to ensure

sustainable delivery.

Trust Board has supported that

approach following discussion at

Board Development session in

August.

Good There are no gaps in control

currently identified.

12 8 4 8 31/03/2020 17/01/2020 Green ↔ ↓


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2615 17/01/2020 Simon Barber

1

2

4

5

6

Simon Barber

There is a risk that the

transaction with Mersey Care

brings about unintended

consequences leading to an

impact on the Trust’s ability to

continue to deliver high quality

care to patients.

The following areas are all reviewed

monthly by the Operational

performance meeting, the Exec

performance meeting and Trust

Board:

Staff -

•Recruitment

•Retention

•Attendance

Quality measures

In addition there is a Transaction

Board with Mersey Care that takes

place monthly.

There are no gaps in control

currently identified.

10 10 4 31/03/2021 Green ↔

2269 17/10/2017Maloney,

Lindsey

Halton Mental

Health and LD

Services

Chief Operating

Officer

There is a risk of damage to the

Trust's reputation, enhanced

contract performance

monitoring and poor patient

experience due to not being

able to sustain current service

provision for Attention Deficit

Hyperactivity Disorder for

adults as a result of high

service demand and a lack of

robust patient flow system

leading to an inability to safely

and effectively high quality

care to adults with Attention

Deficit Hyperactivity Disorder.

Weekly review of waiting times and

new referrals with the responsible AD

and Operations manager.

Improvements in medicine

management/ prescribing practice,

skills and capacity.

Regular communications with CCG's

Fair

No agreed access policy or

standard operating procedures.

Patient pathway is non

compliant with NICE.

lack of effective shared care

protocols.

No effective waiting list

management and patient flow

system.

No NMP practitioner in the team

no agreed job plan with

consultant

15 15 6 12 31/03/2020 09/01/2020 Red ↑ ↔

Additional BAF Risks


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2483 25/02/2019 McPhee, Tim

Management

and

Miscellaneous

John Heritage

There is a risk of delay and

inability to meet contracted

response times for assessment

team service users due to:

1. Demand outstripping

capacity within the team

2. Referrals being sent which

are not suitable for secondary

care which then require triage

3. Lack of sufficient staffing

4. Ineffective system-wide

patient flow

leading to an increase in

complaints and serious

incidents.

MDT's now operating across all

assessment teams Monday-Friday 9-

5.

Business case for Crisis model has

been agreed in wigan and C & M.

Business continuity plans in place in

Wigan & St Helens.

New model and operating procedure

agreed at CLG.

New electronic GP referral form has

been agreed and developed with

mandated fields and is in use in

Wigan and St Helens to ensure allow

teams to make appropriate clinical

decisions.

Brief Biopsychosocial Assessment

developed and built in RiO

comprehensive Biopsychosocial.

Assessment developed and built in

RiO.

new safety plan developed and built

in RiO.

Limited

Capacity cannot meet the

demand.

A large proportion of referrals

are redirected following triage

as they are not suitable for

secondary services delaying

patient care and wasting

resource.

Self-referrals are treated as an

emergency until triage has been

completed as risk is unknown ,

which is increasing the demand

on a 4 hour response time.

No ability to provide crisis

intervention within the teams

but high demand for crisis

response.

clinical supervision is not being

carried out in all teams due to

capacity.

Staff are able to assess risk but

there is no training available

which allows staff in these

teams to learn about risk

management or brief

interventions.

16 16 8 16 01/04/2020 10/01/2020 Amber ↔ ↔


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

12 31/03/2020 17/01/2020 Amber ↑2493 13/05/2019 Ryan, Angela

Halton Mental

Health and LD

Services

Chief Operating

Officer

There is a risk that Halton Think

Wellbeing is unable to meet

current demand due to an

increasing number of vacancies

and an inability to recruit

Psychological Wellbeing

Practitioners (PWPs) and High

Intensity Therapists (HITs) to

replace these gaps, leading to

deteriorating performance,

increased waiting lists and

times and unmonitored clinical

risks.

Currently employed staff (including

HITs) are prioritising telephone

triages as this is felt to be the most

clinically at risk service user group,

this is unfortunately leading to the

waiting list levels at Step 3.

0.8wte PWP agency is currently in

place (commenced in post April

2019).

0.6wte PWP returning from maternity

leave January 2020.

Overtime is being offered, at present

(as of November 2019) 3x Wigan

Think Wellbeing staff and 1x Halton

and Warrington EIT staff (with the

appropriate qualifications) are

supporting with this offer.

Attempts are being made to organise

a contract with ICS Digital to provide

telephone triages for the service, this

is an external provider however they

are accredited and able to support

this piece of work. At present this is

being raised within the Trust due to

the need for tendering/waiver in

relation to the governance around

offering this contract out. If this is

implemented, current triage waiting

list would be eradicated and ICS

Digitial would be able to support the

improvement of the prevalence

target. Further to this, the current

HITs would then be able to return

their attention to the Step 3 waiting

list and work towards reducing this.

Funding 4 trainee PWPs with the

underspend from vacancies with the

hope that they will remain with the

service on qualifying and fill the

current Band 5 vacancies. It is

expected that they will support the

reduction of the waiting lists at Step 2

whilst completing their training.

Limited

Main gap in controls is the on-

going process to secure the

contract with ICS Digital, the

Trust will need to complete a

tendering/waiver process for

this to be implemented.

External organisations (i.e.

Warrington, Liverpool, etc.) that

provide IAPT services have

banded HITs at Band 7, this is

resulting in our current Band 6

HITs leaving to work with

organisations paying more for

the same role.

12 16 4 ↑


ThemeSpeciality

Executive lead

title

Existing

Assurance to

Board


RAG Rating

of Adequacy

of Controls


Rating

Current

Rating

Target

Rating

Last BAF


RAG rating

against

action plan

Change

since last

report

Change

against

initial rating

2607 16/12/2019 Ryan, Angela

Halton Mental

Health and LD

Services

Chief Operating

Officer

There is a risk of not being able

to deliver safe, quality care on

the inpatient units at Halton

(Bridge and Weaver Ward) due

to a high number of vacancies

of qualified nurse posts as well

as 2 x maternity leaves which

may lead to increased

incidents, staff sickness, low

morale and decreased quality

of care delivered to service

users.

-Rosters complete 6 weeks in

advance.

-Any uncovered shifts put to bank

-Use of regular agency nurse already

to cover some shifts on Weaver

Ward.

-Regular safety huddles between

leadership and ward staff

-Action plan complete and on risk

register and escalated through ADFair

Although adverts out there is

little interest to apply for jobs.

Not able to cover all shifts even

with bank and agency.

No MDT review nurse on vast

majority of shifts which will

impact on patient flow.

No deputy manager

supernumerary time leading to

reduction in quality and

managerial functions within the

team.

Use of bank and agency may

jeopardise the safe utilisation of

the Self Harm Pathway on

Weaver Ward.

20 16 4 30/09/2020 16/12/2019 Green ↓

Risk 2507 - Strategic Objective/High strategic

Risk area

Owner Jason Brannan

Risk Description There is a risk that we do not have

sufficient internal capacity to cover key

leadership and high risk professional

positions as they arise due to the skill of

the existing workforce leading to an

inability to deliver safe services in line with

the NHS Long Term Plan.

Overall RAG Rating

Action to be taken Progress Completed

Q1 2019-20

Analysis of senior leadership

workforce

Talent and succession mapping of

leadership roles 8a and above has been

undertaken. Report to the executive

leadership team highlighting gaps and high

risk posts.

Board session conducted in June for

Directors and Direct reports. Paper will

be prepared for September Board.

Commencement of talent and succession

mapping for leadership roles at band 7 and

high potential staff at band 6

Business Partners establishing local

talent boards in Boroughs to build a

matrix that will be aggregated on a

trust wide basis.

Delivery of employing leaders programme

for cohort 1

Course has been advertised for 90

places across the Trust. High level of

interest. 3 Cohorts will run in financial

year, commencing 09 September 19.

Q2 2019-20

Expansion of Empowering Leaders

programme

Commissioning of an external delivery

partner to increase delivery capacity; that is

quality assured for consistent delivery of the

programme

Delve OD have been identified as the

delivery partner. Delivery commenced

09/09/19.

Identification of an educational partner to

deliver MSc/MBA leadership programmes,

that are funded via the apprentice levy to

support staff 8a and above who have no

leadership qualification

Discussions have taken place with

operational colleagues on how the

apprentice levy can be used for MSc

programmes, and how this may be

delivered locally

Refresh of Lift as You climb to ensure to

align with external educational partner

This piece of work has been moved to

Q3

Identification of 8a staff that are able to

commence MSC/MBA training in quarter 3.

Talent mapping has been undertaken and

over 150+ band 7 upwards individuals have

been talent mapped.

Talent grid developed to identify

suitable staff

Commissioning of an external delivery

partner funded via the apprentice levy to

support leadership development at band 5

and 6 level, through the Essentials for

Managers programme to expand access to

staff.

Paper presented to Workforce

Strategy Group on how this could be

utilised with Southport and Ormskirk

College as the lead provider.

Discussions taking place with

operational colleagues

Expand coaching access to all staff, to

support development access.

Q3 2019-20

Implement externally commissioned

services

Planned commencement of increased

access to Essentials for Managers,

Empowering Leaders and MSc/MBA level

training to ensure three leadership layers

have appropriate provision.

Implement talent pools for high potential

staff, who are identified as key for retention

and promotion.

Q4 2019-20

Review of strategy Review of all leadership and high risk

professional gaps to ensure strategy is

effective.

Risk 2508 - Strategic Objective/High strategic Risk area

Owner Damian Byrne

Risk Description There is a risk that we will not have an available worforce to

deliver quality safe and efficient services due to national staff

shortages and challenges with the attraction and retention of

staff leading to a failure to provide 'Good' core services within

standardised pathways.

Overall RAG Rating


Q1 2019-20

Continuation of monthly nursing

recruitment events for inpatient teams

These continue and have seen more offers of employment to

staff

Yes

Analysis of information to determine

gaps in community nursing. Paper to

Workforce Strategy Group in June

2019

Paper sent to WSG and plan of action determined to focus on

hotspot of St Helens and community nursing. Meeting

scheduled with recruitment and ST Helens reps in August

2019.

Yes

Focus on AHP staff and work needed

to improve retention for this staff

group. Paper to Workforce Strategy

Group in June 2019

Paper presented to WSG by Head of AHPS in July. Action

plan drafted and will move forward over coming months.

Yes

Implement staff engagement plans

within all Boroughs Staff engagement plans being led by HRBP's in all boroughsYes

Q2 2019-20



These continue and have seen more offers of employment to

staff, As at end of October 2019 there are now only 12wte

vacancies for registered nurse posts on our inpatient wards.

yes

Begin 2nd Cohort of students from

Edge Hill partnership project. 'Earn as

you learn, job on return'.

2ND Cohort of 8 students commenced 21st October. Yes

Review preceptorship programme for

nursing staff to aid retention. This remains a key piece of work but has been delayed due

to sickness absence No

Q3 2019-20



Pilot a flexible self rostering pilot for 3

months across one of our inpatient

units.

Q4 2019-20



Evaluate flexible self rostering pilot

and develop if applicable a plan for

2020.


Risk area

Owner Clare Dooley

Risk Description There is a risk that the Trust will be unable

to successfully coordinate command and

control during business continuity, critical

incident and major incident due to a lack of

trained resource proportionate to Trust size

leading to an inability to fully discharge its

EPRR duties and deliver core business

safely.

Overall RAG Rating


Q1 2019-20

Mapping exercise of gaps within the

EPRR Standards. Yearly Assurance

return due October 2019

Head of Resilience Safety and Security

completed the 6 month check of the EPRR

Standards and identify gaps within the Trust.

Concerns raised with head of Intergrated

Goverance

Initial discussion with Head of Intergrated

Goverance to highlight this – meeting to be

scheduled.

The submission document is now

drafted and largely completed. The

areas of concern have now been

addressed with the exception of

updated training for oncall managers.

Common scenarios and responses are

now also included in the oncall SOP.

Training dates are being scheduled for

September 2019.

The Trust has insufficient and

inappropriate resource, proportionate

to its size , to ensure it can fully

discharge its EPRR duties.

Paper to be drafted by Head of Intergrated

Goverance and Head of Resilience Safety

and Security to the Board to request

additional resource which reflects safe

levels and resilience. Meeting to be

scheduled.

Review of current position discussed

with the Chief Nurse. Options paper

due however slippage as the LSMS is

absent from work. Additional support

now being sourced through an agency.

Q2 2019-20

12month improvement plan drafted Head of Intergrated Goverance and Head of

Resilience Safety and Security to produce a

12month improvement plan

not started as yet due to LSMS being

off sick. Update 6.9.19: additional

support being arranged via an agency

who will work via our bank as an 8B.

This will provide additional capacity and

support for the work to be undertaken.

Due to commence 9.9.19 and will

undertake an induction. Areas of

priority for work will be agreed as part

of the workplan.

Policy and Procedure updates Awaiting outcome of addition resource

request. Currently on the Head of Resilience

Safety and Security work programme

they remain in place and in date. Out of

hours SOP now approved and in place

but subject to regular update.

Q3 2019-20

Schedule of training Awaiting outcome of addition resource

request

Business continuity training sessions

are underway - 2 sessions completed

to date with attendance from all

boroughs.

Major incident awareness training

completed and was attended by

representatives from all boroughs.

More sessions are planned for both

areas and will be extended to include

all corporate and clinical services.

Establishment of EPRR group Awaiting outcome of addition resource

request. Currently on the Head of Resilience

Safety and Security work programme after

the Debrief for the IT and Phone outage

incident in January 2019.

Mapping exercise completed to identify

which boroughs and teams have

existing business continuity plans in

place. Existing plans are being

reviewed by local services to confirm

they remain fit for purpose. Teams

without a plan are currently in the

process of developing these. It is

expected that these will be completed

by the end of quarter 3 2019/20.

Q4 2019-20

Schedule of Exercise Awaiting outcome of addition resource

request

6 month review Head of Intergrated Goverance and Head of

Resilience Safety and Security to review the

EPRR Standards and review the Trust

position.


Risk area

Owner Asim Patel

Risk Description There is a risk of being unable to provide

safe and effective care due to a lack of

interoperability and integration of digital

systems and services across clinical

boundaries leading to a detrimental impact

on patient care, clinical safety and the

Trust’s reputation.

Overall RAG Rating


Q1 2019-20

Creation of integration development

plan, outlining deliverables and

timescales

Integration activities identified. Not all

timescales confirmed, pending approval of

captial spend to procure Rio integration

solution (Conexes)

Completed

Deployment of eCorrespondence

solution to deliver electonic letters

and discharge summaries to GP

practices

Completed

Q2 2019-20

Initial engagement with eXchange

programme, to share/view clinical

documentation with organisations in

Cheshire and Merseyside

Attendance at initial scoping meeting and

assessment of required work underway.

Technical requirements yet to be identified.

Engagement ongoing with the eXchange

programme.

Initial engagement has taken place

and the informatics team are working

in delivering to the specification.

Engagement ongoing with the

eXchange programme.

Contribution to St Helens Shared

Care Record and access for NWBH

staff

Data validation testing near completion to

ensure contributed data is correct and

clinically safe to use. Work underway to

allow NWBH staff access to the system.

This remains on track to be completed by

the end of quarter 2.

Completed

Q3 2019-20

Admission, Discharge and Transfers

(ADT) messaing from RiO to the

Electronic Prescrbing and Medicines

Administration System

Work underway to setup the discharge

notifcations from Rio to the electronic

prescribing system allowing for medication

orders to be completed. This work has

been rescheduled from Q2 to Q3 because

of delays with deployment of the Rio

upgrade.

Procurement of Rio integration

(Conexes) to enable data sharing with

other systems

Revised costings provided by the system

supplier. Capital business case to be

developed.

Capital business case developed and

approved by trust board.

Contribution to Wigan Share to Care

record and access for NWBH staff

Engagement with Wigan Share to Care

programme and system suppliers. Same

solution as the St Helens Shared Care

record, therefore, data extraction and

system access requirements already

understood. On track for completion within

Q3.

Q4 2019-20

Implementation of Rio integration

(Conexes) with other systems

Creation of Conexes development plan

underway.

Contribution to eXchange and access

for NWBH staff

Awaiting confirmation of technical

requirements and implementation plan.


Risk area

Owner Andrea Snagg

Risk Description There is a risk to staff health and wellbeing

due to operational pressures contributing to

reduced motivation and staff feeling

unsupported leading to higher levels of

sickness and absence, increased turnover

within the workforce along with an inability to

retain high calibre talent

Overall RAG Rating


Q1 2019-20

Review capacity/demand mismatch

between OH staff resource and

service delivery

Business case submitted Approval received to recruit 1.0 FTC nurse

to replace existing associate nurse.

Recruit to advert for approved posts Job advert closing date 14th June 2019 Advert extended as no applicants.

Implement H&WB provision across

Trust footprint

Annual plan of proactive activity

commenced.

Good uptake for the NHS Games events

that have been run over the summer with

NWB winning both running events and the

netball.

Stress Management rolling

Programme

Annual plan of proactive activity

commenced.

6 week stress management course

continues to be delivered along with 2 hour

bite-sized stress busting sessions.

Q2 2019-20

Mental Health plan to be written and

disseminated.

Plan will form part of the wider H&W plan

which will be developed from the outcomes

of the NHSi Workforce NHS Diagnostic

Tool.

H&WB Strategy Workshop completed on 13th August and

NHS H&W Framework Diagnostic Tool

completed. This is now being written up to

support the development of an action plan.

H&WB Champions - clarify

role/expectations

Following successful recruitment to

posts from Q1 - review service

delivery and close gaps in KPIs

No suitable applicants identified. Advert

extended.

Stress busting sessions offered

accords Trust footprint

There is increasing demand for there 2 hour

stress busting sessions which provide bite

sized advice/support within the workplace.

The sessions are available to all areas and

are specifically offered to areas where high

levels of stress have been identified. There

is currently only 1 therapist delivering these

sessions which will affect capacity to deliver

should volume of requests increase.

Q3 2019-20

Winter flu campaign Plan in place and regular meetings are

scheduled in to drive and monitor progress..

Review Health & Wellbeing activity

across Trust footprint. Assess

dedicated resource requirement.

Evaluate Service delivery/KPIs

following the recruitment of Band 6

FTC

Deliver session on the Essentials for

Managers Course

Commenced June 2019 - to provide

managers with tools/information regarding

OH&WB

Q4 2019-20

Review of strategy/Mental Health Plan Review of gaps to ensure strategy is

effective.


Risk area

Owner Denise Richardson

Risk Description There is a risk of boroughs delivering their

local clinical governance frameworks

inconsistently due to changes in leadership

and meeting structures leading to possible

variation in effectiveness of assurances

across the boroughs.

Overall RAG Rating


Q1 2019-20

Finalisation of the Risk Universe Currently ongoing, will be finalised

following receipt of the June Board

Assurance Framework

Identify any immediate action and

agree entering plans to mitigate and

manage any concerns

1. We are developing a Governance safety

huddle.

2. A review of the quality schedules and

work schedules to deliver against internal

and external requirements including

meeting schedules.

3. Considering options for Governance &

Quality Business Partners to be aligned

with boroughs to support the Leadership

Teams.

4. Recruitment to Governance Head of

Service post and stabilisation of workforce.

5. Local Borough Leadership review is

finalised with the introduction of Heads of

Quality which have local governance within

their role descriptions.

1. Update 8.8.19 governance huddle

now in place on a weekly basis.

2. review of quality schedules

completed but remains subject to

review.

3. Review of governance structures

has been commissioned to be led by

NF. A business case for change will

need to be formulated for

consideration.

4. not complete - day to day

management and leadership being

reviewed.

4. Initial conversations held through

Trust QSSG. Workshops being

planned.

Q2 2019-20

Undertake a baseline assessment of

current borough clinical governance

processes and procedures and agree

scope of any improvement actions

required

safety huddles have been reviewed to

consider best arrangements for

effectiveness.

Quality schedules have now been

reviewed and monitoring effectiveness

through QSSGG - quality schedules

inform the internal and external QSSG

meetings agendas and the quality

forum agenda.

Identify ways to strengthen the clinical

governance interface between local

boroughs and corporate governance.

Day-to-day leadership and

management review and action plan

is ongoing. Decisions made to recruit

two band 5 Governance Manager

posts; one successfully recruited

07/11/2019 and the remaining post

will go back out to advert. The interim

Head of Governance is in post; a

decision has been made for the post

to remain in place going forwards. The

Chief Nurse and Deputy Director of

Governance are considering future

plans in relation to the ACD for

Governance post. The Band 7 Patient

Experience Manager post has been

recruited to and will commence w/c 18

November. The Band 7 interim Risk

Manager post has been recruited to

and a phased uptake of post has been

commenced. The respective current

vacant PA posts will now be recruited

to before the end of Q3 2019/20.

Identify any immediate action and

agree entering plans to mitigate and

manage any concerns

day to day management and

leadership being reviewed - plans for

the week being arranged as part of

the safety huddle.

New format for governance report is

now being developed which will

includes sections for borough

leadership teams to populate with

progress against actions and in

response to quality data and

information. This will strengthen the

borough oversight. ACD's in

Knowsley, St Helens and Wigan have

agreed to pilot this; to discuss at

QSSG whether this should be piloted

across all boroughs.

The initial date for the local

Governance workshop was scheduled

for 4 November 2019 however this

has been rescheduled due to

unforeseen circumstances.

The principles of an updated borough

Governance report has been agreed

to and a workshop has been planned

for December 2019 with a completion

date for the end of Q3 2019/20.

Q3 2019-20

Complete agreed actions and

feedback on progress.

1. Safety huddles now embedded.

2. An exercise is underway with

regard to the rationalisation of the

schedules under commissioned

services quality contracts following an

action from the Dec 19 Quality Forum.

We are working with commissioners

to review and align the respective

CCGs quality schedules to produce a

streamlined Trust wide schedule

which all CCGs will sign up to for

2020/21.

3. Leadership arrangements - 2

Interim Heads of Governance are now

in post,revised leadership structure

with accountabilities has been agreed

but is subject to review following the

retirement of the Chief Nurse and

changes to the Exec Team portfolio.

Patient Experience Manager is now in

post. Recruitment is ongoing for the

vacant PA posts.

4. The Governance workshop is being

rescheduled.

5. Draft of new Governance report

has been produced and reviewed.

Agreed that the new report will be

used in shadow form for Q4 2019/20

to enable the review prior to launch for

2020/21. The Trust is continuing to

consult with CCGs on the content.

Q4 2019-20

Evaluation of the actions to

demonstrate improvements

Once the workshop in Q3 with

borough leadership teams has been

completed, the contract quality

schedules have been approved and

the borough governance report is

launched in Q4 this risk can be

reviewed with a view to reducing the

score to 8 and therefore achieving

target to enable the risk to be closed.

Risk 2513 - Strategic Objective/High strategic Risk area

Owner Lee McMenamy

Risk Description There is a risk that growing demand will outstrip the

capacity within the available funding linked to the long-

term plan leading to longer waiting times.Overall RAG Rating


Q1 2019-20

Review 2018/19 activity per team

compared to 2017/18

Highlight area's were activity is

greater than year previous and above

contractual plan

Highlight any area's above 10%

growth

Cross reference activity and waiting

list reviews with budgets spends for

2018/19 and new/changes in service

specifications

10.8.19 Review of activity and cross reference of

overspend in CHS completed, Review of overspend in MH

completed, awaiting activity data set to cross reference,

expected to be completed by M5

Completed

RAG rate all area's of over

performance and place in priority

order

10.8.19 CHS completed Completed

Q2 2019-20

In area's were significant over

performance has been achieved,

individual borough to complete option

appraisal reports on what additional

investment is required and where

efficiencies or reduction in service

specifications can be undertaken

safety.

10.8.19 District nursing services currently being externally

reviewed,

ADHD review paper sent to commissioners for review

MSK Knowsley - business case currently with

commissioners

15.11.19 Further area's identified include: Centre of

Independent Living, Orthotics and LLAMS wards

Completed

Q3 2019-20

Following approval, papers to be sent

to local borough contract review

meetings for discussion

Community Health Services:

District Nurse Review: The review has now been completed

and recommendations have been put forward, an action

plan is being formulated and the progress will be monitored

through the patient Journey Group.

Centre of Independent Living: Discussions with the CCG

and Trust CFO continues to understand the financial impact

and for further funding requests.

Orthotics A full service review is being undertaken in light of

new premises being sought, this in turn will reduce costs.

this is likely to conclude in quarter four of 2019/20.

Mental Health Services

LLAMs Inpatient units: Weekly review of staffing will

continue to try and drive down costs and maintain patient

safety

ADHD: Notice given to CCG's that the mid Mersey service

will cease on the 31st March 2020. The Wigan service has

now been awarded the appropriate financial envelope

Partial Completed

If approved by CCG's development

plans to be formulated and

implemented by March 2019

ADHD Service Wigan is on track for new models of care to

be implemented in April 2020

Completed

If papers not approved, formal exec to

exec meetings to be conducted to

plan resolution

Discussions with appropriate CCG's have either concluded

(ADHD) or ongoing in regards to additional investment.

Partial Completed

Q4 2019-20

New service specifications to be

implemented

Community Health Services:

District Nursing Review: In light of the contract termination

of the St Helens service, the recommendations of the

review will be implemented in Knowsley borough only, a

Transformation group has now been set up and is working

through the implementation of the actions. It is anticipated

that the transformation work will continue into 2020/21 with

an aim to complete by the end of quarter three, any future

shortfalls in funding will then be discussed with the CCG's.

Furthermore additional funding has been granted as part of

the winter planning monies from December 2019 to March

2020.

Centre of Independent Living: Discussions with the CCG

and Trust CFO continues regarding the ongoing funding of

the CIL. Additional monies have been granted as part of the

Winter Funding agreements

Orthotics: The service has been given notice on its current

accommodation and it is expected that the service will

move into new accommodation in April 2020. As part of this

service relocation new service agreements need to be in

place and these are currently being worked on.

Mental Health:

ADHD: Demobilisation of the mid Mersey service continues,

with an expected end date of the 31st March 2020. The GM

service mobilisation of the new service specification

continues with a proposed launch of the 1st April 2020

Partial Completed

10.8.19 Review of Community health services has been

undertaken and highlighted a number of area's for review.

Mental health data set yet to be completed, expected to be

completed by M5

Completed


Risk area

Owner Sarah Waterworth

Risk Description There is a risk that the Trust may not

deliver its planned efficiencies as part of its

transformation and improvement plan and

consequently may not meet its Control

total, leading to the loss of provider

sustainability funding and reputational

damage.

Overall RAG Rating


Q1 2019-20

Monitor Delivery of CIP through T&I

Delivery and Strategy Group

Reported monthly Completed for Months 1 - 3

Ensure any schemes deemed

medium or high risk are being

progressed through the planning

cycle as appropriate

Detailed plans are being developed where

necessary for full QIA assessment. Risk

profile to be updated where appropriate.

As at Month 3 £188k of schemes are

assessed as high risk.

Completed for months 1 - 3

Q2 2019-20

Monitor Delivery of CIP through T&I

Delivery and Strategy Group

Reported monthly Completed for Months 1 - 6

Complete detailed forecast for each

scheme for the full year to identify any

mitigation requirement

In progress - due to be completed 16

September

Completed

Ensure any schemes deemed

medium or high risk are being

progressed through the planning

cycle as appropriate

The 3 final schemes for detailed QIA

approval are being presented to CLG on 9

September

Completed

Progress any opportunities for non

recurrent mitigation to minimise

impact of the risk

The Trust has been pursuing a VAT refund

form the HMRC that has now been

finalised. £1.5m has been included as non

recurrent CIP for 19/20

Completed

Complete Trust forecast exercise to

ensure identification of additional

financial pressure and that

appropriate actions can be planned

and implemented to address these.

Presented to Trust Board in September Completed

Q3 2019-20

Monitor Delivery of YTD CIP and

forecast through T&I Delivery and

Strategy Group

Reported monthly Completed for Month 7- 9

Continue to identify and forecast

pressures and plan and implement

appropriate actions to minimise the

requirement for financial support.

Ongoing - reported through monthly

performance cycle. Financial risk in

forecast position is reported to be reduced

by approx £500k at month 9 from previous

forecasts.

Completed for Month 7 - 9

Progress discussions for financial

support to ensure the Control and

therefore PSF is achieved

Ongoing

Q4 2019-20


Risk area

Owner Tim McPhee

Risk Description There is a risk that inconsistent delivery of

services across boroughs will negatively

impact on the quality of services provided

by the Trust leading to an inability to

delivery contractual and quailty

requirements.

Overall RAG Rating


Q4 2019-20

Align Care Collaboratives to patient

Journey Programme

06.1.20 Work is ongoing

Develop and Implement SOPS 06.1.20 Think well being SOP work is

ongoing plan to complete by March 20

On call managers Procedure. Draft

discussed at partnership forum on 29.11.19

Equality Impact Assessment completed

and sent to Governance team on 03.01.20.

To be circulated for partnership forum to

ratify on 28.01.20

Assessment Team Procedure has been

approved at CLG on 11.11.19. However,

QIA not completed. Impact assessments

have now been completed and sent to

Clinical Director J Hiley for advice on

whether procedure needs to be considered

with completed impact assessments.

Crisis response home treatment SOP will

be completed for wigan go live January 20,

this is to be used for mid mersey also

Administration Hub structures to be

developed and rolled out trust wide

06.01.20. Ongoing, plans are in place but

there is likely to be some slippage into Q1.

07.11.19 Knowsley hub has gone live.

qualitative feedback has been collated and

feedback to operations group on 05.11.19.

10.8.19 Knowsley, Halton and part of St

Helens Hubs have been scoped, planned

and expected to be implemented by

October 2019. Remainder of St Helens

services, Warrington, Wigan and Sefton

Hubs currently being scoped out.

Roll out new patient access platform 06.01.20 - Refinements have taken place:

• District Nursing Target to move from 4

weeks to 6 weeks – All boroughs

• Treatment Rooms Target move from 4

weeks to 8 weeks – Trust

• BFPS – Move Target to 40 Weeks – Trust

Target

• Knowsley - CYPMHS Knowsley – to 6

weeks

• ASD – St Helens – 12 weeks to 18 weeks

• Total Patients Column – Move so next to

%age in /out target columns

07.11.19 Platform available on IMP and

has been partially built for routine patients,

is being tested by teams and refined

based on feedback.

Implement framework for Trust wide

reporting compliance against patient

access target 92%.

10.1.10 Borough's report to Director of

operations who chairs Trust patient access

meeting. Director of Operations reports to

the Operations Group. Plan in place to

report to ELG and Trust Board.

Q1 2019-20

Roll out of Trust patient access

meeting

07.11.19 First trust wide patient access

meeting took place on 08.10.19. Next

meeting due to take place on 19.11.19.

28.8.19 Patient access meetings have

been booked and are due to start on

10.9.19.

10.8.19 Meetings to commence in August

utilising exisiting frameworks, with plan to

utilise new information platform from

October.

08.10.19

Develop Patient Flow Meeting

infrastructure

07.11.19 - Meeting took place on 22.10.19

and Terms of reference were drafted by

Lee McMenamy. John Heritage to take

over as chair and meeting planned for

19.11.19

28.8.19 First Patient Journey meeting was

held on 13.8.19.

22.10.19

Administration Hub structures to be

developed and rolled out trust wide

07.11.19 Knowsley hub has gone live.

qualitative feedback has been collated and

feedback to operations group on 05.11.19.

10.8.19 Knowsley, Halton and part of St

Helens Hubs have been scoped, planned

and expected to be implemented by

October 2019. Remainder of St Helens

services, Warrington, Wigan and Sefton

Hubs currently being scoped out.

Q2 2019-20

Patient Flow work plan to be

presented at Operatrions Group

28.8.19 Patient Journey work plan was

presented to operations group on 6.8.19

6.8.19

Scope current position for SOPs 07.11.19 - ongoing

Devise plan to develop SOPS 07.11.19 - Plan in place to develop SOPS

for following teams / areas;

Assessment Team Go live December 20

Crisis response Home Treatment Teams -

Go live January 20

Think Well Being Go live March 20

On call managers - Go live January 20

Bed management - Go live April 20

Roll over to Q3 as further work is on going

to develop more SOPS

Build new patient access platform

28.8.19 new patient access platform has

been partially built and is on track to be

built by October

Q3 2019-20

Roll out new patient access platform 10.1.20 Roll over to Q4

07.11.19 Platform available on IMP and

has been partially built for routine patients,

is being tested by teams and refined

based on feedback.

Develop SOPS 10.1.20 Roll over to Q4

07.11.19 Think well being SOP has been

drafted and is in process of being amended

by Team managers.

On call managers SOP requires Equality

Impact Assessment. Information was

received from HR on 06.11.19.

Assessment Team SOP has been

amended and is due to go to CLG on

11.11.19 for approval.

Crisis response home treatment SOP will

be completed for wigan go live January 20,

this is to be used for mid mersey also

Assessment Team - Has been amended

and is due to go to CLG to be ratified on

11.11.19

CAMHS - Trust wide Referral mangement

in CYPMHS approved at operations group

on 5.11.19

Align Care Collaboratives to patient

Journey Programme

10.1.20 Roll over to Q4

07.11.19 J. Hiley has aligned care

collaboratives. T. McPhee to present to

care collaboratives on 15.11.19 patient

journey priorities

Risk2516 - Strategic Objective/High strategic

Risk area

Owner Simon Barber

Risk Description

There is a risk that we do not have the

organisational capacity to deliver on all our

commitments due to the large number of

priorities created both internally and

externally, leading to a potential failure to

deliver on all the objectives within our

strategy and supporting strategies.

Overall RAG Rating


Q1 2019-20

The Operations Group has requested

that each borough carries out an audit

of all the meetings that the Borough

Leadership Teams attend.

Meeting matrix has been completed for

each Borough which is in the process of

being complied into a Trust wide map to

identify opportunities to rationalise internal

and external meeting attendance.

The Directors and Deputies Group

meets to discuss the number of

"objectives" the Trust has in terms of

corporate objectives, enabling

strategy objectives, improvement

initiatives etc and to consider what

part they play as leaders in

contributing to the organisational

stress this complex and numerous

situation creates.

Meeting took place on 23 May and was very

productive

The Directors and Deputies Group

considers whether a different

approach - fewer objectives, would

reduce the stress on the organisation.

Meeting took place on 23 May and was very

productive

Q2 2019-20

Following the completion of a Trust

Wide map of external and internal

meetings an exercise to rationalise

meeting attendance will take place.

The exercise will clarify and

rationalise attendance within external

meetings where appropriate in order

to increase internal capacity.

Overall Map of external meetings created

and being discussed with AD’s and

Leadership Teams to agree which are the

essential “external meetings” and which

meetings we can support AD’s and

Leadership Team members not to attend to

create required capacity.

The Directors and Deputies to agree

their "top 4" priorities/objectives for

19/20

Done at 25 July meeting.

At the Board Development Day

discuss with full board the approach

of doing the "top 4" things well rather

than trying to deliver on dozens and

partially achieving.

Agreed with Board at meeting on 7 August.

Q3 2019-20

Update prepared and delivered to

Trust Board that identified that a

number of objectives would not be

progressed at Trust level. This is

within the report prepared by Director

of Strategy and Organisational

Effectiveness.

The concept of “Do Less, Do Better”

was discussed at the December

Leadership Group and presented to

JCNC in December.

There is now broad agreement to this

approach which will be further

developed as part of the 2020/21

objective setting process in Q4

Q4 2019-20

At the Directors & Deputies meeting

on January 22 A fewer number of

objectives will be agreed for 2020/21

than we have previously, better

matching aspiration to capacity

Risk 2269 - ADHD Service

Owner Lindsey Maloney

Risk Description There is a risk of damage to the Trust's reputation, enhanced contract

performance monitoring and poor patient experience due to not being able

to sustain current service provision for Attention Deficit Hyperactivity

Disorder for adults as a result of high service demand and a lack of robust Overall RAG Rating


Quarter 1 2019/20

Work with Commissioners regarding

a financially sustainable, safe and

effective service.

Chief Operating Officer communicated with commissioners on 12/04/19

regarding the future of the service as it is unsustainable in its current form

with the current investment. Halton Leadership are developing a business

continuity plan with the intention of ceasing the acceptance of new referrals

from 01/06/19.

The Director of Operations took an ADHD exit strategy paper to the Mid-

Mersey Mental Health Alliance for further discussion with the Clinical

Commissioning Group on 4 June 2019 where an outcome for the service

was reviewed.

Apr 2019

Jun 2019

Quarter 2 2019/20

To work with commissioners to

develop an exit strategy.

Exit strategy to be developed with Director of Operations and Integration

which will then be presented to the CCG. Strategy outlines service to stop

referrals from September 2019 and implement plans for those who have

been referred and already in service.

The Director of Operation and Integration presented: “Ceasing of ADHD

Services Trust Wide” at the Mid Mersey Health Alliance meeting.

The proposals in the report were to stop receiving new referrals in

September 2019 and cease by March 2020. The current service is not

sustainable and requires extra funding. The biggest risk is who will prescribe

ADHD medication as GP’s cannot prescribe it.

NWBH suggested an alternative model involving GP’s and shared care.

It was noted that ADHD is not a statutory service and those individuals with

other mental health needs will be treated for those needs and there will

always be a small cohort of patients with complex needs so they would be

assessed on a case by case basis.

At the end of the discussion the Director of Operation and Integration

agreed to look at pausing referrals to the service from 1 September until 1

October 2019

Jul-19

Quarter 3 2019/20

Continue to work with the CCG's

regarding the exit strategy

Chief Operating Officer and Finance Director sent a letter to all the CCGs to

explain that the Trust will be closing down the service by March 2020, this

included stopping referrals from the 1st November to ensure we are able to

safely implement the exit strategy. Wigan are continuing to build a separate

service based on additional funding from their CCG which will be

implemented from April 2020.

There has been a task and finish group set up to address the closing of the

service and ensuring safe exit plan. This includes members of Mid-Mersey

CCG's and NWBH representatives. Meetings held fortnightly

A further letter was sent to mid Mersey CCG’s to advise a revised date to

close to referrals, this was to allow CCG’s time to communicate to GPs and

referrers. The letter referenced the risks and poor quality of the current

service as it is currently commissioned. The service ceased accepting

referrals from 17th Nov 19. NWBH comms team have liaised with CCGS

communication team representatives. A meeting was held between NWBH

and CCG representatives on 20th Nov 19 to affirm the exit strategy and

agree a comms plan and agree the content of the communication to service

users. It was agreed that complaints will be dealt with collectively and

referred to the most appropriate organization dependent upon the nature of

any complaint. CCGs requested ‘business as usual’ in that we continue to

see those service users currently in service and continue to prescribe for

these service users until closure of the service in March 20. Each CCG is

exploring alternative provision post March 20 and are aware that there will

still be a large cohort of service users on the waiting list that will require

ADHD assessment.

Fortnightly meetings with mid Mersey CCGs continued.

Wigan leadership team continue to work with their commissioners regarding

the mobilisation of a Wigan ADHD service.

The four Mid Mersey CCGs have not yet secured any arrangements with

any alternative provider post 31st March 2020.

This poses clinical risks for service users as there are no arrangements for

anyone to take over prescribing responsibilities from when we plan to cease

the service on 31st March 2020. We are currently prescribing for

approximately 235 individuals.

Dec-19

Quarter 4 2019/20

Cease the provosion of the mid-

mersey service by 31 March 2020During the meeting held on 8 January 2020, the NWBH Deputy Director of

Finance represented the financial details of the original business case as it

appeared that the CCG's believed that we were asking for more investment

than we actually were. NWBH did advise that all four CCG's would have to

invest to ensure a safe and efficient service.

Halton CCG confirmed that they have still not secured an alternative

provider.

Warrington CCG stated that they have an interim plan which has been

approved with primary services.

Helen Meredith, Chief Nurse for Knowsley had a discussion with the NWBH

Director of Integration and Operations to offer assurance that their aim is

for a new provider to take over the prescribing of existing patients and

would like us to continue to prescribe until the date of transfer, given the

assurance the Director of Integration and Operations has agreed that we

will do this. They are going to let us know asap the arrangements for the

new provider and this will be done through the working group.

Mar-20

2483

Owner Tim McPhee

Risk Description There is a risk of delay and inability to meet

contracted response times for assessment team

service users due to

1. Demand outstripping capacity within the team

2. Referrals being sent which are not suitable

for secondary care which then require triage

3. Lack of sufficient staffing

4. Ineffective system-wide patient flow

leading to an increase in complaints and serious

incidents. 5. Increase in

harm occuring evidence through PSP cases.

Overall RAG Rating


Quarter 1 2020-21

Go live in Knowlsey, Warrington and Halton

with Assessment processes

Crisis Response Home Treatment

Pathways Go live 1.4.20

Quarter 4 2019-20

Wigan crisis response home treatment Go

Live 27.1.20 with 24/7 service

10.1.20 Four Band 6 vacancies still not

recruited.

SOP due for completion mid January.

Cheshire & Merseyside CRHT Implement

phase 1 a 24/7 service 31

10.1.20 3 Band 7 clinical leads have been

recruited so the trust now have one for each

borough where teams operate.

Recruitment underway for Band 6 practitioners

although this is a risk.

Consultation has ended with staff and letters to

be sent to all those affected to advise of next

steps.

Go Live with PDSA in Wigan 27.1.20 10.1.20 Wigan staff gone live with paper version

of assessment forms on 6.1.20. Planned for full

implementation from 27.1.20

Focus sessions booked for wigan team

Go live with PDSA in St Helens 3.2.20 10.1.20 - On track to go live

Staff training booked for 27.1.20

Reporting - Ensure appropriate monitoring

of new Processes is in place

10.1.20 Letter has been drafted to send to

commissioners and will be sent to Director &

Clinical Director of Operations and integration

on 13.1.20

RiO - Build products and implement into live

system

10.1.20 Detailed process maps have been built

Super users have been trained in Wigan & St

Helens

January

Products due to go live 27.1.20

Implement new referral forms

10.1.20 Referral forms have been built and will

be sent to CCG's to build into their systems.

Awaiting timeframe.

Publish Trust wide procedure on Intranet

10.1.20. Policy has been drafted and sent to

SP.

Local SOPs have been developed.

Trust wide procedure. Impact assessments

have been completed and sent to governance

team. Awaiting final ratification

Quarter 3 2019-20

New MHAT pathways to be developed Pathways developed and presented in Patient

Journey meeting 22.10.19.

MHAT pathways to be presented to CLG

11.11.19.

Presented to CLG 11.11.20

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MHAT products to be developed including

external referral form, GP windscreen, brief

biopsychosocial and biopsychosocial

assessments and validation form

Products developed, circulated with MHAT

managers, CCG leads and GP partners for

feedback

Products to be presented to CLG 11.11.19.

Presented to CLG 11.11.20

Products to be developed within RiO Currently being developed. To be complete and

ready for testing/walkthrough December 2019.

NWBH informatics to develop a referral form to

be compatible with GP informatics. Awaiting

estimated completion date.

MHAT Standard Operating Procedure to be

completed to reflect new patwhays and

processes

MHAT SOP modified by NWBH Clinical Leads

and Operations, circulated with MHAT

managers for feedback and to be presented to

CLG 11.11.19.

Internal and external communication plan to

be developed

Current options around presenting at upcoming

PLT forums for Wigan and St Helens being

explored.

Presentation and poster currently being

developed.

Training package to be developed for intitial

roll out to Wigan and St Helens

To be developed by the end of November.

Quarter 2 2019-20

Quarter 1 2019-20

New Standard Operating Procedure and

Governance structures to be implemented

by End of May

10.7.19 SOP has been drafted circulated for

feedback and comments received back.

Presented to assessment team managers on

21.6.19. Issues were raised by teams so a

further meeting is planned on 18.7.19 to present

detailed guidance based on feedback.

Assessment team review completed and

presented to CLG and Quality Committee.

Recommendations accepted.

Ongoing

Quarter 4 2018-19

Business continuity plans are in place in the

Wigan and St Helens Borough.

10.7.19 High number of SI's (11) in Wigan in

June. To be discussed at Wigan SLT on

12.7.19.

1) Full BC plan implimented in St Helens and

Wigan. 2)

Re organisation of functions across boroughs

not in buisness continuity to ease pressure on

St Helens.

Ongoing

New electronic GP referral form has been

agreed and developed with mandated fields

to be sent to all GP's with a view to

decommissioning the fax machines with

effect from the end of April 2019.

10.7.19. Teams in St Helens and Warrington

are live. NWBH have been mandated to use

new national electronic referral system by April

2020 which will therefore replace this system.

1) Go live dateagreed in St Helens of 1st April.

2)Being addedd onto GP System on 1st April.

3) Planned go live in Wigan 31st April

Ongoing

Introduction of the brief screening tool in

Wigan and St Helens which allows referrals

to be managed quickly and redirected where

appropriate.

1) Use of brief screening tool being implimented

in Wigan and St Helens.

Completed

Chief Operating Officer to convene a Trust

wide crisis workshop to agree the Trust

crisis model in line with the C&M model.

1) Meeting with COO, Chief Nurse and kep

stakeholder to discuss way forward.

Completed StHelens Ongoing Wigan

A Trust wide review group has been

established to review short term process

across the assessment team function.

10.7.19. Next meeting arranged for 18.7.19

1)Regular meeting taking place.

Ongoing

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To commision a review of assessment team

form and function .

A review is to commence on 25th March for two

weeks. Operational

Issues for Review:

What are we doing about self-referrals

Who owns Trust wide risk

Should we have a duty practitioner to screen to

determine priority level. Products

needed for Review

Updated SOP around referral what we do take

and don’t clarity on criteria.

Duty review functions,form and pathways.

Including telephone triage.

Paper on Governance structures for task and

finish group to streamline and ensure senior

oversite of work streams.

Completed

Risk 2493

Owner Angela Ryan

Risk Description There is a risk that Halton Think Wellbeing is

unable to meet current demand due to an

increasing number of vacancies and an

inability to recruit Psychological Wellbeing

Practitioners (PWPs) and High Intensity

Therapists (HITs) to replace these gaps,

leading to deteriorating performance,

increased waiting lists and times and

unmonitored clinical risks.

Overall RAG Rating


Quarter 3 2019/20

To reduce triage waiting list Business case and contract has been agreed

for ICS digital to assist with completing triages

in January and February.

New process regarding triage DNA and

cancellation appointments to be discussed and

agreed with team and Senior Leadership team

to reduce triage waiting list.

Staff to contact DNA's within 10 minutes of

appointment and offer to complete the

appointment over the phone.

New process in relation to DNA and cancelled

appointments to be agreed with Step 2 and

Step 3 staff for implementation in January.

Reduce DNA rate for triage appointments.

Admin to send letter explaining appointment is

available. Client is required to contact service

within one week to arrange appointment.

Discharged if no contact within one week.

December 19

December 19

December 19

December 19

Ongoing

To reduce waiting list in Step 3 To inform Step 3 staff that they will stop

completing triage appointments in January and

will pick up new Step 3 clients.

Offer initial 6 sessions then review. If not

achieved reliable change in that time consider

discharge. Discuss in supervision. Review

sessions/effectiveness moving forwards.

December 19

To provide clear guidance around

DNA and cancellation policies which

will to be utilised across the Trust

All staff to be informed of the guidelines

regarding DNA and cancellations. If client

DNA – to be sent text giving 24 hours to

contact service. If no contact within 24 hours

discharge. Repeated cancellations need to be

discussed in supervision and number of

acceptable cancellations to be agreed across

IAPT services in the Trust.

Dec-19

Clear guidance regarding the

number of clinical contacts per

week.

Required contacts will be provided to every

member of staff in line with working hours.

This will be monitored in managerial

supervision.

Jan-20

Due to NHSE staffing paper, come

April APWPs will no longer be able

to provide support on Silver Cloud.

Service to consider using ICS to deliver Silver

Cloud once they have completed triage's to

remove current triage waiting list.

Mar-20

Quarter 4 2019/20

To reduce triage waiting list Fist 60 clients have been transferred to ICS for

triage.

Another 60 will be transferred in February

Staff to contact DNA's within 10 minutes of

appointment and offer to complete the

appointment over the phone.

DNA and cancelled appointments will be

utilised for clients on the triage waiting list.

Triage appointments will be completed by Step

2 staff. Step 3 staff who will offer welcome

calls in the cancellation and DNA appointment

slot. These calls will be 30 minutes long.

06/01/2020

February 2020

January 2020

January 2020

To reduce waiting list in Step 3 Step 3 staff will increase their case load

All new Step 3 clients will be offered initial 6

sessions then review. If not achieved reliable

change in that time consider discharge.

Discuss in supervision. Review

sessions/effectiveness moving forwards.

January 2020

January 2020

All staff to implement DNA and

Cancellation policy and guidance.

If client DNA – to be sent text giving 24 hours

to contact service. If no contact within 24

hours discharge. Repeated cancellations need

to be discussed in supervision and number of

acceptable cancellations to be agreed across

IAPT services in the Trust.

Ongoing

Staff to deliver required number of

contacts

1 WTE is required to have 60 positive contacts

per month or 720 hours per year. 1 WTE staff

to book in 1008 hours worth of planned

contacts. Team Manager and Lead Clinical

Psychologist to monito through supervision

Ongoing

To increase flow and reduce waiting

times

Service to consider using ICS or other external

agencies to deliver Silver Cloud in the future.

Ongoing

Risk 2607

Owner Angela Ryan/Mark O' Farrell

Risk Description There is a risk of not being able to deliver safe, quality

care on the inpatient units at Halton (Bridge and Weaver

Ward) due to a high number of vacancies of qualified

nurse posts as well as 2 x maternity leaves which may

lead to increased incidents, staff sickness, low morale

and decreased quality of care delivered to service users.

Overall RAG Rating


Quarter 3 2019/20

To review all inpatient units across Halton

and Specialist Services directorates and

ensure that they are safely staffed due to

increased level of vacancies.

Deep dive completed on all inpatient units in relation to

safer staffing requirements.

To place both units at the Brooker Centre on the risk

register, rating 16 (serious) due to the amount of vacant

shifts that are uncovered under the current

establishment.

Senior Leadership have met with Unit Managers to

develop an action plan and have identified Operational

Manager as lead. As part of the action plan, Operational

Manager, Matron and Unit Managers to hold twice

weekly meetings to review rosters and escalate safety

concerns.

Safer staffing report to be completed for Directors in

order to provide updated informatio, initiaves and

progress to date. To provide options going forward.

Dec 19

Dec 19

Dec 19

Ongoing

As soon as Team Manager has been

notified of potential vacant post, this post

will be advertised immentantly.

Numerous adverts and various recruitment iniatives

have been utilised i.e. local media cover, social meda,

recruitment drives. This has resulted in a small

response. Interviews have taken place, however

applicant have withdrawn.

Last recruitment event in November 2019, three

applicants all offered posts, however, two only qualify in

September 2020 and one needs to complete

revalidation in order to renew NMC registration.

Nov 19

Nov 19

Quarter 4 2019/20 Action Plan and updates from 7/1/20 Ongoing as

per action

plan

Monthly meetings with Senior Leadership

team and Unit Managers.

Meeting held on 8/01/2020. Action plan updated.

Options identified for Safer staffing report to be

completed in month.

Ongoing

(report

completed

end Jan 20)

Twice weekly meetings with Operational

Manager, Matron and Unit Managers to

review staffing levels, skill mix and acuity on

both inpatient units and ensure that they are

safely staffed due to increased level of

vacancies.

These meetings have commenced and future dates

diarised. Action log detailing concerns and actions.

All identified vacant shifts have been offered to bank

and agency staff.

Secured a 3 month fix term agency qualified nurse to

work nights across both units.

ACD and AD to attend units regaularly and meet with

staff.

Ongoing

Jan 20

Ongoing

HR Business Partner, Communication

Business Partner, Operational Manager and

Matron to refresh the communication

recruitment strategy and hold local

recruitment.

Recruitment advert refreshed and communicated

through social media, local media and local colleges

and universities.

HR Business Partner identified venue and date for local

recruitment day.

Ongoing

Ongoing

Page 1 of 32 20/1740 High Level Objectives 2019/2020 – Quarter three update


Item

No

.

20/1

740

TITLE OF REPORT High Level Objectives 2019/2020 – Quarter three update

PRESENTED BY Tracy Hill, Director of Strategy & Organisational Effectiveness

AUTHOR(S) Tracy Hill, Director of Strategy & Organisational Effectiveness

REPORT PURPOSE


To provide an update on the status and position of each objective following Trust Board and senior management discussions relating to the priority areas for delivery in 2019/2020




X


growth X

We will plan an active role in place-based care systems to







Audit Committee

Quality Committee



Other Group Name:

This content has not been considered elsewhere X

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) Y


All risks


The Trust Board is asked to: Note the information within this paper and direct any action in relation to its content.




27 January 2020

High Level Objectives 2019/2020 – Quarter three update

1. INTRODUCTION This paper is presented to Trust Board following the agreement in March 2019 of the High Level Objectives for 2019/2020. It should be noted that this is the third update to Trust Board on performance against the 2019/2020 objectives. Additionally, information is provided through regular updates as part of the normal course of Trust Board business. This includes the Commercial report, reports received from Trust Board sub committees, reports received from the Executive Leadership Group and progress papers and presentations with a specific spotlight, for example, the People and Quality Strategies. This update presents the status and position of each objective following Trust Board, and senior management discussions relating to the priority areas for delivery in 2019/2020. It provides the following information;

Progress with each objective, and the position at the end of quarter three – December 2019

Where progress with the objective is not on track, the recovery actions to be taken

The assurance offered to the Trust Board, by the accountable officer, of the expected successful, timely delivery of the objective.

2. PROGRESS WITH OUR 2019/2020 HIGH LEVEL OBJECTIVES Appendix 1 provides details of the position at the end of December 2019. 3. RECOMMENDATIONS The Trust Board is asked to:

Note the information within this paper and direct any action in relation to its content. Tracy Hill Director of Strategy and Organisational Effectiveness


Trust objectives 2019/2020 Update at the end of

Quarter Three


Trust objectives 2019/2020 – Update at the end of Quarter Three

Owner

We will deliver quality, safe and efficient services with a highly skilled and motivated workforce.

Quarter 2 update

(July/Aug/ Sept.)

Quarter 3 update

(Oct/Nov/Dec.)

If progress is not on track, or

has been refocused,

further actions to be

taken

Assurance offered

Director of Operations and Integration / Deputy Director of Finance

1 By July 2019, we will have identified those services which do not make a positive contribution to the organisation and, by September 2019, have agreed with commissioners a plan to address.

During Q2 we have continued to engage with our commissioners in relation to the Trust Adult ADHD, inpatient Learning Disabilities Unit and the Knowsley equipment stores. It is anticipated that the ADHD service will close at the end of March 2020. A redesign of the inpatient care model for patients with a learning disability has begun and is expected to be

Progress with this objective continues. Centre of Independent Living: Discussions with the CCG and Trust Chief Finance Officer continue regarding the ongoing funding of the CIL. Additional monies have been granted as part of the Winter Funding agreements Orthotics: The service has been given notice on its current accommodation and it is expected that the service will

I can assure the Board that this objective has been met, with the work outlined continuing in 2019/2020

Page 5 of 32

20/1740 High Level Objectives 2019/2020 – Quarter three update

Owner


Quarter 2 update

(July/Aug/ Sept.)

Quarter 3 update

(Oct/Nov/Dec.)


has been refocused,


taken

Assurance offered

completed in early 2020. In addition a review of district nursing services has been completed and recommendations are being formulated into a transformation plan, it is expected that these works will continue into early 2020.

move into new accommodation in April 2020. As part of this service relocation new service agreements need to be in place and these are currently being worked on. Mental Health: ADHD: Demobilisation of the mid Mersey service continues, with an expected end date of the 31st March 2020. The Greater Manchester service mobilisation of the new service specification continues with a proposed launch of the 1st April 2020

Page 6 of 32


Owner


Quarter 2 update

(July/Aug/ Sept.)

Quarter 3 update

(Oct/Nov/Dec.)


has been refocused,


taken

Assurance offered

Director of Operations and Integration / Clinical Director of Operations

2

By June 2019, as a result of internal intelligence and external inspection, we will have identified services which need additional and focused support to improve their performance and develop a plan to do so during the year.

In addition to the areas highlighted, the Trust has concluded District Nursing Services also require further assistance and targeted support. As part of the strategy for improvement a patient journey forum has been established to project manage the transformation programs. Both 0-19 and Adult Mental Health have devised a strategy plan with associated work program and these are currently being undertaken. The Trust has commissioned an external provider to undertake a review of district nursing

District Nursing Review: In light of the contract termination of the St Helens service, the recommendations of the review will be implemented in Knowsley borough only, a Transformation group has been set up and is working through the implementation of the actions. It is anticipated that the transformation work will continue into 2020/21 with an aim to complete by the end of quarter three, any future shortfalls in funding will then be discussed with the CCG's.

I can assure the Board that this objective has been met, with the work outlined continuing in 2019/2020

Page 7 of 32


Owner


Quarter 2 update

(July/Aug/ Sept.)

Quarter 3 update

(Oct/Nov/Dec.)


has been refocused,


taken

Assurance offered

services. This review has been concluded and the recommendations are now being formulated into a program of works.

Furthermore additional funding has been granted as part of the winter planning monies from December 2019 to March 2020.

Chief Nurse and Deputy Chief Executive

3 By June 2019, as part of our Suicide Prevention Strategy, we will have reviewed our suicide prevention and risk assessment training, involving service users, families and carers to ensure we provide staff

Suicide awareness

training available for

all staff with high

level of uptake.

Suicide prevention

group monitors

actions contained

within suicide

prevention action

plan.

The Suicide

awareness training

has been undertaken

by 93% of staff

across the trust.

The delivery

of “STORM” training

on a monthly basis is

ongoing.

The Trust have

commissioned

I can assure the Board that this objective is currently on track and at this stage cannot foresee any reason why the objective won’t be fully achieved.

Page 8 of 32


Owner


Quarter 2 update

(July/Aug/ Sept.)

Quarter 3 update

(Oct/Nov/Dec.)


has been refocused,


taken

Assurance offered

with the skills and knowledge to support those with a chronic risk of suicide. We will embed and achieve full implementation of this training programme by 31 March 2020.

‘Connecting with

People’ to deliver our

suicide and self harm

mitigation training,

using a train the

trainer approach that

has been informed

by evidence based

principles.

Deputy Director of HR & OD /Chief Information Officer

4 During 2019/20, in order to improve staff experience and productivity, we will identify resources and training to support staff to be digitally competent.

The draft digital strategy was presented to the Trust Board in September 2019 that outlined the approach to increase the digital competency of the workforce. A digital curriculum was provided in the draft digital strategy and the contents and structure is being developed in

Staff experience will be improved through the rollout of new devices across the Trust in Q4. (Devices have been procured in Q3).

Productivity and staff efficiency is improving as Skype for Business gets embedded with the Trust.


Page 9 of 32


Owner


Quarter 2 update

(July/Aug/ Sept.)

Quarter 3 update

(Oct/Nov/Dec.)


has been refocused,


taken

Assurance offered

conjunction with Mersey Care NHS Foundation Trust. A resource plan to deliver the components of the digital curriculum is being developed.

A training needs analysis questionnaire is being developed that will be conducted in Q4 to understand the baseline of staff’s current digital competencies.

Page 10 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)

If progress is not on track, or has been refocused, further actions to

be taken

Assurance offered

Chief Operating Officer / Medical Director / Chief Nurse and Deputy Chief Executive

5 By October 2019, following engagement with our senior leaders, we will have developed a definition of whole person care to share with key internal and external stakeholders.

Rio optimisation to focus on improving task element of Rio to promote delivery of holistic care. The physical health collaborative will focus on priority areas.

This objective has been refocussed to adult mental health and community nursing.

I can assure the Board that this objective has been refocused, with actions being monitored and on track.

Page 11 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)


be taken

Assurance offered

Director of Operations and Integration

6 By March 2020, we will have engaged with patients, services users and carers to co-create clinical service models to support the delivery of whole person care.

During Q2, as part of the service redesign in our Wigan borough’s adult mental health services, both public and service users have been involved in designing the new models of care. In addition, as part of the Transforming Care program for our patients with learning disabilities, service users and carers are actively part of the redesign programs. These programs are expected to continue throughout the year.

Wigan Boroughs transformation into a crisis mental health service continues and recommendations from service users are incorporated into the transformation action plan Ongoing engagement with service users continues in relation to the future of LD inpatient and community services. It is anticipated that public consultation of the service changes will occur during Q4 and Q1 of 2020/21

I can assure the

Board that this

objective is currently

on track and at this

stage cannot foresee

any reason why the

objective won’t be

fully achieved.

Medical Director

7 By September 2019, we will have developed an Engagement Strategy for Primary Care in

We have now produced a co-developed primary care engagement strategy for GPs in the first instance. Implementation, monitoring and evaluation of this strategy will begin in

Objective met

Page 12 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)


be taken

Assurance offered

partnership with GP leads, recognising the important role primary care will play in the delivery of integrated whole person care within place-based systems. We will measure this through targeted feedback from GPs and their wider primary care teams.

October 2019 and continue.

Page 13 of 32


Owner We will retain our values and culture.

Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)

If progress is not on track, or has been refocused,


taken

Assurance offered

Deputy Director of Human Resources and Organisational Development

8 During 2019/20, in order to improve the employee experience, we will work with staff to develop ‘our promise’, which is clear about expectations of one another in order to live our values and behaviours every day.

Discussions have taken place with CEO and Director of Strategy and Organisational Effectiveness in Q2 - It has been agreed this objective will be paused. This is due to national work/ priorities 1. ‘Making the NHS the best place to work’ 2. Design of an organisational NHS staff promise

Not required, objective not being progressed further.

Deputy Director of Human Resources and Organisational Development

9 Throughout 2019/20, we will create and commit to team charters where our

The Team Charter toolkit has been designed and signed off in principle. Pilot approach is planned with a broad selection of

Pilots continuing

across a number of

teams in the Trust.

Formal review of the

pilots and toolkit

I can assure the Board that this objective is currently on track and at this stage cannot foresee any reason why the objective won’t be

Page 14 of 32



Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

Trust behaviours are recognised, supported, celebrated and challenged on a daily basis.

borough/ward teams in Q3. Evaluation of the pilot is planned for Q4. The toolkit will be made available to all managers of teams to access and utilise before the end of Q4. The toolkit will form part of a wider set of resources aimed at supporting people managers across the Trust in Q1 2020.

taking place w/c 9

March and discussion

on next steps planned

w/c 23 March; to

implement feedback

and agree the next

areas for rollout.

fully achieved.

Deputy Director of HR & OD / Chief Nurse and Deputy Chief Executive

10

By July 2019, a formal evaluation of the Kingsley Ward pilot ‘coaching for a safety culture’ will be undertaken

Evaluation has been completed with statistically significant improvement noted. Plans are for this development to be available across our priority areas - Adult mental health and community nursing.

Objective met

Page 15 of 32



Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

and a development plan completed for Trust-wide sharing of the success.

Page 16 of 32


Owner We will retain our Values and

Culture

Q2 Update

(For information)

Q3 Update

(Required)

If progress is not on track, or has been refocused, further actions to be taken

Assurance Offered

Deputy Director of HR & OD

11

Throughout 2019/20, we will develop and support cultural champions to increase staff engagement and demonstrate our continued commitment to cultural change

Staff engagement strategy has been created and socialised with members of the Workforce Strategy Group for feedback. Further exploration with our Corporate Communication team is due to be completed in Q3. Discussions have been initiated (Q2) to explore the creation of a ‘Colleague Engagement Working Group’ to ensure connectivity and delivery of communication and engagement plans for staff.

Draft engagement strategy produced, refinement needs to take place to include the ‘digital engagement’ strategy.

Discussions with CEO in relation to where ‘functional responsibility’ for engagement sits have taken place.


Page 17 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered


12

By December 2019, we will have identified services or pathways currently delivered by the Trust which can be delivered through alternative delivery models in the future and have agreed a plan to progress these.

This objective can be closed as completed. This activity will now translate to business as usual and where opportunities arise for pathways to be redesigned or services delivered in different ways, this will be undertaken as part of our normal approach to operational service delivery.

Objective met

Page 18 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

Chief Operating Officer / Deputy Director of HR & OD / Chief Nurse and Deputy Chief Executive / Medical Director

13

By March 2020, we will have one per cent of our workforce employed in peer support worker roles across the organisation.

We have identified a number of roles – 12 wte in phase 1 -that will be recruited to as peer support worker roles. The process to recruit will start in October 2019 and we anticipate post-holders starting from January onwards. External training has been commissioned to be delivered for those in peer support roles and we have also identified and developed internal team readiness training for teams where peer support roles will be deployed.

14 individuals have been offered posts across the Trust as part of phase 1 with start dates agreed for February 2020. Phase 2 recruitment will be finalised by the end of January 2020. Team readiness training has been commissioned and delivered and peer support training commissioned and will be delivered in February for those recruited in phase

I can assure the Board that

this objective is currently on

track and at this stage cannot

foresee any reason why the

objective won’t be fully

achieved.

Page 19 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

Chief Operating Officer / Medical Director

14

By September 2019, we will have introduced an ‘innovate to improve’ process to enable staff from all services to access resources to pilot new ways of delivering improved and more efficient services.

Given the future strategic direction of the Trust, it has been agreed by the executive team and the wider directors and deputies group that this will not be an objective that should be prioritised, to enable capacity and resource to strengthen successful delivery in other priority areas.

Objective not being progressed.

Chief Operating

15

Throughout 2019/20,

All contracts have been signed. The

Mobilisation of new investment in

I can assure the Board that

this objective is currently on

Page 20 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

Officer / Chief Finance Officer

we will work with our commissioners to develop a plan to deliver the aspirations of the NHS Long Term Plan, including working together to agree the required investment to achieve the increase in access and waiting time trajectories.

Chief Finance Officer and Chief Operating Officer continue to work with commissioners to progress discussions. Since the last update, additional funding has been secured to support the delivery of Crisis Resolution Home Treatment Team provision across mid-Mersey (Warrington, Halton, St Helens & Knowsley). This will begin to be mobilised from October 2019 in a phased approach, based on the NHSE Transformation funding secured until full mobilisation of the model by March 2021. In Wigan,

Mental Health Crisis Resolution Home Treatment services in Wigan and across Cheshire and Merseyside are being mobilised in line with the plan. Mobilisation progress is reported through the Patient Journey group which reports into the Operations Group monthly and in turn to the Trust Board via the Executive Leadership Group report.

track and at this stage cannot

foresee any reason why the

objective won’t be fully

achieved.

Page 21 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

mobilisation of the new model will start from October 2019 with full mobilisation of the model expected by early 2020. In addition, new funding has been secured to develop a Wigan Borough ADHD service that will ensure the service is NICE compliant and has the necessary resource to deliver the activity required. This will be operational from April 2020.

Page 22 of 32


Owner

We will play an active role in local place-based care systems to maintain a whole person care focus and high clinical standards.

Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

Chief Executive

16

We will actively participate in the continued development of place-based care systems across our geography, working towards locally integrated provider models.

Progress continues to be made in each of the boroughs where place-based plans are being developed.

These will be incorporated into the two ICS plans and submitted to NHSI/E in accordance with national timescales.

A member of the Executive Leadership Team supports each of the boroughs in terms of attendance at the senior place-based meetings.

In addition the CEO chairs the Provider Alliance in both Warrington & Halton.

In addition to the Q2 update, the Trust has been involved in the creation of Place based plans through its involvement in Health and Wellbeing Boards, Place Boards or Place Provider Alliances. The plans were submitted to NHSI/E in September to meet the national timescales and were endorsed by Trust Board in November 2019. The Trust has been involved in the creation of the two System level plans

The objective is on track to be delivered.

Page 23 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

through the Greater Manchester Provider Federation Board and the Cheshire & Merseyside System Management Board. Both were submitted in accordance with the same timescales.

Clinical Director of Operations and Integration

17

By March 2020, the heads of quality will have actively led the successful delivery of the objectives within the quality strategy pillars with: All

Steady progress on increasing compliance with clinical supervision has been demonstrated with the quarter 2 position exceeding the 40% target. The Making Families Count training has now been completed with approximately 170 attendees from across the Trust. A

Continued progress on increasing compliance with clinical supervision has been demonstrated with the quarter 3 position achieving the 60% target.


Page 24 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

clinical staff accessing clinical supervision

A consistent involvement of families and carers in the investigation and lessons learned around adverse incidents and complaints processes

NWBH Steering Group meeting is planned for 25 October to plan the next steps, key priority work areas and spread across the organisation.

Deputy Director of

18

By March 2020, we

This objective can be classed as completed

Objective met

Page 25 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

Estates will have developed, with our partners, place-based estates plans to support the delivery of integrated place-based working.

as the Trust continues to engage with partners across the local place based systems via the five place based Strategic Estates Groups that operate. The Trust will continue to input and support the ongoing development of the locality placed based plans.

Chief Operating Officer / Chief Nurse and Deputy Chief Executive / Medical Director

19

By September 2019, we will have agreed with our acute trust partners how we will work together to support the delivery of joined up

Ongoing Executive to Executive relationships will continue with St. Helens and Knowsley Teaching Hospitals NHS Trust as a result of the existing sub-contract in place. Other relationships will be managed and developed via the ongoing engagement at ‘place’ across

Objective met.

Page 26 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



taken

Assurance offered

pathways of care.

Warrington, Halton and Wigan.

Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)


further actions to be taken

Assurance offered


20 By March 2020, we will capitalise on ‘what sets us apart’ in terms of our flexible approach to partnership working and have developed new services.

The Trust has continued to work with system partners to support the ongoing delivery of services in ways that challenge traditional delivery methods. Examples of this relate to the ongoing,

The Trust continues to be an active member of the Prospect Partnership (including leading the Clinical Reference Group and weekly Management Team).

The IAPT service in St Helens was


Page 27 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



Assurance offered

“Prospect Partnership” for the delivery of low and medium secure mental health services. In addition, the Trust is also working with NHS St. Helens CCG as a medium-term stability partner for the delivery of IAPT services in St. Helens following recognition by commissioners and the current NHS provider that the current service and delivery model is not sustainable.

successfully mobilised in line with the plan agreed with commissioners at the end of November. Service

Transformation and

improvement work has

started with the team,

led by the Trust IAPT

clinical lead and the

Operational Manger

for St Helens IAPT.

Chief Executive

21 We will actively participate in our two

The CEO sits on the Cheshire & Merseyside Partnership

The Q3 position remains the same as Q2.

The Chief Executive will continue to work with all partners to actively participate in our two

Page 28 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



Assurance offered

integrated care systems, playing our part to ensure that, by March 2020, investment in mental health and community services referenced in the NHS Long Term Plan is beginning to deliver the desired results.

System Management Board. In addition the CEO sits on the Greater Manchester Provider Federation Board and, along with the CEO from Greater Manchester Mental Health Trust and Directors from Pennine Care, maintains the importance of Mental Health & Community investment across GM. Mental Health is one of four key workstreams for

integrated care systems.

Page 29 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



Assurance offered

the GM Provider Federation Board The Medical Director sits on the Greater Manchester Mental Health Delivery Board and is the Lead for Children’s Mental Health across GM.


22 By December 2019, we will have identified the services where we have the clinical and operational expertise to provide leadership at scale across the Greater Manchester

During Q2, as a result of the system leadership role the Trust plays in relation to the roll out of the Personality Disorder Pathway across Greater Manchester, the Trust worked with GM partner Trusts to bid for a GM model of Personality Disorder service

Work continues with partners across the Greater Manchester system to develop the pan-GM Personality Disorder pathway with stepped implementation across GM, based on funding allocations, from April 2020 onwards The Trust has now taken lead/system


Page 30 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



Assurance offered

and Cheshire and Merseyside health and care partnership footprints and have developed a plan with our partners to provide this system leadership.

across the sub-region. This would bring a more consistent approach to the delivery of Personality Disorder services. The objective will continue to be delivered as part of our on-going approach to the delivery of services where opportunities arise.

responsibility for the Cheshire and Merseyside Community Specialist Perinatal services working with Cheshire and Wirral Partnership and Mersey Care.

Chief Operating Officer / Chief Nurse and Deputy Chief Executive / Medical Director

23 By December 2019, we will have developed formal strategic partnerships with relevant local

Work continues with Salford University to develop commercial and delivery opportunities. A workshop is planned in

The workshop did not take place and has been postponed and will be re-arranged before the end of the financial year to continue to progress our partnership with Salford University.

I can assure the Board that this objective, whilst slightly behind plan, will be achieved by year end.

Page 31 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



Assurance offered

universities to support joint ambitions in the areas of clinical training and education, knowledge transfer and new commercial opportunities. We will measure the success of our partnerships through a range of indicators, including increased training placements and successful opportunities

November to take forward the initial list of areas identified for potential partnering opportunities.

Page 32 of 32


Owner


Q2 update

(July/Aug/Sept.)

Q3 update

(Oct/Nov/Dec.)



Assurance offered

to bid in collaboration for new work.

Page 1 of 2

20/1741 Focus on Patient Access and Patient Journey work-streams


Item

No

.

20/1

741

TITLE OF REPORT Focus on… Patient Access and Patient Journey Workstreams

PRESENTED BY John Heritage, Chief Operating Officer Lee McMenamy, Director of Operations

AUTHOR(S) John Heritage, Chief Operating Officer

REPORT PURPOSE


The Trust Board will receive a presentation on Patient Access and Patient Journey work-streams. The priorities of the two work-streams are:

Patient Access ensure that all patients requiring access to all our services are managed safely, efficiently, consistently and in a timely way.

Patient Journey to ensure that we are clear as a Trust when someone access our services how we will support them and what that support will look like. Patient Journey will concentrate in the first phase on a number of specific projects.




X


growth X








Audit Committee

Quality Committee Patient Access – 11 September 2019 Patient Journey – 9 October 2019



Other Group Name:



Page 2 of 2

20/1741 Focus on Patient Access and Patient Journey work-streams

THIS REPORT RELATES TO A RISK ON THE BOARD ASSURANCE FRAMEWORK (Y/N) Yes


2513

1, 5 There is a risk that growing demand will outstrip the capacity within the available funding liked to the long-term plan leading to longer waiting times.

2515 1, 2, 5 There is a risk that inconsistent delivery of services across Boroughs will negatively impact on the quality of services provided by the Trust leading to an inability to deliver contractual and quality outcomes


The Trust Board is asked to: Receive the presentation.

Patient Access &

Patient Journey

Presented by: John Heritage, Chief Operating

Officer and Lee McMenamy, Director of Operations

and Integration

Date: 27 January 2020

Patient Access

Objectives

• All services will have a target wait time for a new patient

appointment.

• 92 per cent of patients on the waiting list waiting for a new patient

appointment will have waited less than the agreed target time.

• Patients will have access to the most up-to-date waiting times.

• Patients will not have their appointments cancelled more than once

by the Trust.

• Text Messenger Reminder service for all community appointments.

• Admin hubs will be in place for all boroughs and services, offering a

single point of access for patients.

Initial Patient Access Process

Benefits to Patients

• Know how to access the service they need through one single point

of access.

• Know what the target waiting time is for an appointment with the

service they need.

• Be seen within the target waiting time for the service they need.

• Be communicated with at each stage of their route into the service

they need – from the point of referral.

• Be less likely to have their appointment cancelled.

• Have confidence the support will be there when they need it to keep

them safe.

Benefits to the Delivery of Care

• Be better able to meet the needs of our patients.

• As a member of a borough administration team, have more

structure, cover and flexibility in their role.

• As a clinician, they will spend less time on managing referrals, being

freed up to focus their time on patient care.

• Have the confidence they can more easily identify and address

issues to reduce impact on patients.

• Have improved relationships with referrers.

What has been achieved so far

• New Patient Access Policy & Procedure completed and rolled out

• All services now have expected waiting times

• New Information Management Platform to aid monitoring

• New performance measures introduced

• Administration Hubs in Knowsley, St. Helens & Halton Boroughs

• Single points of access in Knowsley (2 Hubs)

• Text Messenger Reminder service in 30% services, this means

patients get a text when the appointment is booked and 48hrs &

24hrs before their appointment.

Patient Journey

Objectives

• For services to be consistent, wherever they are delivered across

the Trust.

• To be clear about the interventions we provide by having agreed

standard operating procedures for all services and to articulate the

skill mix required to deliver these services.

• To drive service and clinical improvement which will improve our

offer and the experience of our patients.

• To reduce mental health inpatient admissions and support more

people to be cared for in the community.

• To contribute to suicide reduction & improve quality

• To modernise approaches and models of care, making use of

available technology.

Benefits to Patients

• Have a consistent, positive experience wherever they receive care,

including the discharge process.

• Receive the care they need in a timely manner.

• Have access to Mental Health support teams 24 hrs per day.

• Be able to remain at home and receive mental health care in the

community, without being admitted to hospital.

• If admitted into hospital, have the least restrictive care provided in

the their local area.

• Have more continuity in their care, seeing the same community

nurse consistently.

• Have confidence the support will be there when they need it to keep

them safe.

Benefits to Care Delivery

• Have more clarity about their role and work pattern.

• Be working in the same way as colleagues in the same role in other

areas of the Trust.

• Improvements to their work-life balance through more flexible

working.

• Be delivering a more efficient service with less duplication.

• As a community nurse, have more time to focus on caring for their

patients.

• Have greater access to specialist staff working within their locality.

What have we done so far.

• Trust wide review of Mental Health Assessment Services. New

pathways designed in light of new crisis care models.

• Began pilot implementation in Wigan Borough

• Review of inpatient units staffing skill mix and clinical pathways.

• New staffing model designed and implementation currently being

planned

• New least restrictive and positive behaviour support model

developed for inpatients wards

• Review of community nursing services staffing and models of care

has been undertaken, Recommendations being formulated into

action plan for implementation.

Documents

Trust Board Meeting Agenda Board...Agenda Trust Board Part 1, 27 January 2020 Page 1 of 2 Timing Number Item Enclosure Item Presenter Action of the Board Public and Patient Focus 9.00