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Board of Directors - Public 28Aug2014 - Agenda

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Author: Robert Nesbitt Department: Corporate

of 2 Date produced:29Jul2014 Retention period: 30 years

Board of Directors – Public Session

Meeting to be held on Thursday 28th August 2014 at 09:30 in the Elisabeth Room, Endeavour House, 8 Russell

Road, Ipswich, IP1 2BX (Please note that there is no parking at Endeavour House, but there is ample parking in

Portman Road)

AGENDA

Time Item No

09:30 14.105 Chair’s welcome, apologies for absence and notification of any urgent business.

Apologies:

14.106 Standing Item: Declarations of Interest Verbal

09:35 14.107 To note the minutes of the previous meeting in public, held on 26th June 2014

Attachment A

09:40 14.108 Chair’s report (Gary Page) Attachment B

09:55 14.109 CEO’s report (Michael Scott) Attachment C

14.110 Items For Approval

10:10 i. Risk Register (Jane Sayer) Attachment D

10:20 ii. Board Assurance Framework (Robert Nesbitt) Attachment E

10:30 iii. Patient Safety and Quality Report - (Jane Sayer) Attachment F

10:45 iv. Finance Report Month 04 (Andrew Hopkins) Attachment G

11:00 v. Business Performance Report Month 04 (Andrew Hopkins)

Attachment H

11:15 BREAK

14.111 Items for Debate

11:25 i. None

14.112 Items for Information

11:25 i. Lorenzo update (Leigh Howlett) Dave Huggins in attendance

Presentation

Board of Directors - Public 28Aug2014 - Agenda

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of 2 Date produced:19Aug2014 Retention period: 30 years

Time Item No

11:55 ii. Volunteer service update (Jane Sayer) Attachment I

12:10 iii. Audit & Risk Committee – Chair’s Report 13th Aug 2014 (John Brierley)

Attachment J

12:20 iv. OD and Workforce Committee 26th Aug 2014 (Brian Parrott)

Verbal

12:25 v. Charitable Funds Committee - Chair’s Report 11th August 2014 (Graham Creelman)

Attachment K

12:30 14.113 Any other urgent business, previously notified to the Chair

12:35 14.114 Date, time and location of next meeting

The next meeting in public of the Board of Directors will be held on:

Thursday 23rd October 2014 at 09.30 am at the Kirkley Centre, 154 London Road South, Lowestoft, Suffolk, NR33 0AZ

Note - The AGM will be held on 19th September 2014 at Trinity Park, Ipswich, c. 17.30 (see www.nsft.nhs.uk for details).

12:40 14.115 Motion to pass resolution to hold board meeting in private in order to discuss confidential matters. (Gary Page).

13:00 CLOSE Robert Nesbitt Trust Secretary 19

th Aug 2014

I:\Trust Secretariat\Board of Directors - Public\Public BoD 2014\05. 28 Aug 2014\Agenda PUBLIC BoD 28Aug2014 Final.doc

http://www.nsft.nhs.uk/

Board of Directors -Public 26Jun2014

Confirmed minutes

Version 1.1

Author: Alex Petty

Department: Corporate

Page 1 of 11 Date produced: 11Jul2014 Retention period: 30 years

Confirmed

Minutes of the Board of Directors – Public Session

held on 26th June 2014 at 09:30

in the Captain Paul Watson Room,

Green Britain Centre (formerly Echotech),

Turbine Way, Swaffham PE37 7HT

Present:

Barry Capon (Chair)

Michael Scott: CEO

Leigh Howlett: Commercial Director

Andrew Hopkins: Director of Finance & Performance

Jane Sayer: Director of Nursing, Quality and Patient Safety

Kathy Chapman: Director of Operations – Norfolk & Waveney

Debbie White: Director of Operations – Suffolk

Jane Marshall-Robb: Director of Workforce & OD

John Brierley: Non-Executive Director

Brian Parrott: Non-Executive Director

Stuart Smith: Non-Executive Director

Adrian Stott: Non-Executive Director

In attendance:

Robert Nesbitt: Trust Secretary

Alex Petty: Acting Asst. Trust Secretary (minutes)

Sara Fletcher: DIPC: Physical Health Team Leader (present for Item 14.81iii)

Julian Beezhold: Consultant Psychiatrist (present for item 14.82i)

Chris Hardwell: Deputy Services Manager (present for item 14.82i)

Clive Hudson: Consultant Counselling Psychologist (present for item 14.82i)

Alison Simpkin: Deputy Community Service Manager – Adult (present for item

14.82i)

Imogen Kirk: Team Leader in Adult Social Care (present for item 14.82i)

Jonathan Wilson: Consultant Psychiatrist (present for Item 14.82ii)

Bonnie Teague: Research Manager (present for Item 14.82ii)

Fraser McKay: Communications Officer

Date: 28th

August 2014 A

Item: 14.107


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There were eight governors, 10 members of staff and public, two representatives of Advantage Healthcare, three members of Norfolk County Council and one representative from the EDP in attendance.

Meeting commenced at: 09:30

There was a break at 11:10 until 11:25

Certain items were taken out of order, but for clarity the minutes reflect the agenda

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

Barry Capon welcomed those present including the attending Governors and members of the Campaign. The structure of the meeting, and how questions would be taken from the public was then explained.

There were no notifications of urgent business.

Apologies for absence were received from Gary Page, Graham Creelman, Hadrian Ball and Peter Jefferys.

14.76 Standing Item: Declarations of Interest

There were no declarations of interest.

14.77 To note the minutes of the previous meeting held in public on 24th April 2014

The minutes had been previously approved but the following additional change was requested: Min 14.47: change to read “Brian Parrott asked for clarification about the medical vacancy in the Learning Disability (CAMHS - Child and Adolescent Mental Health) service and asked how much this was a cause for concern.”

The minutes were re-approved for release in accordance with the Freedom of Information Act subject to the above change being made.

14.78 To address any Matters Arising from the minutes of the previous meeting, not covered by the Agenda

i. Min 14.16iii: The report on the flu vaccination plan will come back to the June 2014 public Board meeting. (Jane Sayer)

Although an update was provided at the May 2014 Board of Directors meeting, Jane Sayer re-confirmed that this year NSFT would not be offering staff a day’s leave as part of the flu vaccination plan. Jane Sayer informed the board that the NSFT target was 75%, and that they would be working hard to achieve that.


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14.79 Chair’s report

In Gary Page’s absence, Barry Capon introduced the Chair’s report and invited questions from the board.

Brian Parrott requested that under item 4.2, Key Observations, a discussion was had regarding Woodlands and acute beds. Michael Scott confirmed that these issues would be covered in later reports.

14.80 Chief Executive’s report

Michael Scott introduced his report and said he wanted to highlight three areas:

As part of his recent appointment as Chief Executive, he informed the board that he had visited several services over the past month, especially those in Suffolk namely: Ipswich, Bury St. Edmunds and Newmarket. During these visits Michael Scott reported that he was grateful to have been well received by staff and found them to be proud of the services they worked for.

Michael Scott said he recognised that numbers of out of area beds had been unacceptably high and that it was an area of concern for the Trust, but assured those present that it was being addressed.

Questions and comments were then invited from the public, and received as follows:

It was reported by a member of the Campaign that the services were not safe, that the staff were not proud, that morale was low, and that there was concern over the continued use of agency staff. Michael Scott provided assurance that the Trust was aware of these issues, and recognised that it had the responsibility to put it right.

Concerns were raised about use out of area non-specialist beds, especially for under 18’s and Kathy Chapman agreed to clarify the numbers of under 18s affected.

The question of how the Trust ensured that service users were heard was raised. Michael Scott said that he had spoken with two service users that day, and had had regular dialogue with service users over the past month. The proposal was to engage with service users and obtain their views by both direct personal contact, and via forums and user councils.

Brian Parrott stressed the importance of the Health and Wellbeing boards, and asked about their progress in Norfolk. Michael Scott responded saying that the Suffolk Health & Wellbeing board was functioning well, but that he had yet to attend a board in Norfolk where the Clinical Commissioning Groups (CCGs) were leading on integration items with the support of Norfolk County Council.

14.81 Items for Approval

i. Trust 5 year strategic plan (Leigh Howlett)


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Leigh Howlett presented the 5 year strategic plan, and explained that an early draft version of the working document had been previously circulated and that today’s presentation was in order to gain approval for the final version of the 5 year strategic plan which would be submitted to Monitor on Monday 30th June 2014.

Leigh Howlett described the engagement process that had taken place across the two counties and presented five strategic options explaining that the preferred option would set the Trust’s strategic intention and direction. See slides.

Barry Capon added that the strategic plan was an overview, and whilst comments on the key themes could be made, the plan could not at this point be re-designed. Barry Capon then invited questions from the board:

Stuart Smith said that the Finance & Performance Committee had reviewed the financial envelope and were satisfied with the financial assumptions had been included in the strategic plan. Stuart Smith added that the power of the document was that it put the information, including increased demands and constrained resources, into the public domain.

Brian Parrott said that the plan formed a good strategic basis and requested the following minor amendments:

- ‘Integration of health’ to read, and be referred to as: ‘integration of health and social care’.

- Health & social care to read, and be referred to as: ‘Health and social care economy’.

- Care to be taken over the use of the word ‘rural’ since most people in Suffolk and Norfolk live in small towns.

The above comments were noted by the board.

Brian Parrott added that as a responsible public body, the Trust must acknowledge the reality of the financial situation and reflect it honestly.

Referring to the 4% efficiency figure, John Brierley said that in the absence of payment by results (where income reflects activity) the Trust could be facing a factor of at least 7.5%. Andrew Hopkins said that a key debate had been parity of esteem and whether the Trust could expect a 2% uplift of funding. Andrew Hopkins said that a serious position was being presented: the plan reflected a 4% reduction of cost reduction, and was conservative about assumptions of some funding coming back the other way reflecting parity of esteem. At some point the Trust would go into deficit unless these factors were addressed.

Michael Scott said that it was important to note that the plan was a strategic framework, and the dialogue for its implementation started today. The board did not want to see funding reduce, and that the Trust was reflecting a national situation. Michael Scott said that the board must lobby and work hard to ensure the Trust saw as much resource as possible.

In response to a question asking whether there was anything in the strategic plan about the S75 agreement, and the reduction of social workers in teams


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Michael Scott said that the Trust was already in discussion with Harold Bodmer (Norfolk County Council) about how to integrate services.

Option two (with amendments on the wording and inclusion of social care) was approved by the board. It was confirmed that comments on the draft 5 year Strategic Plan could be emailed to [email protected] and that the plan would be submitted to Monitor by 30th June 2014.

ii. Patient Safety and Quality Report (inc. Safe Staffing update) (Jane Sayer)

Jane Sayer updated the board on the complaints process which had been changed as a result of feedback from governors and Non-Executive Directors. Jane Sayer reported that there had been fewer complaints received in May 2014, but that there were a number of repeat complaints. This was being analysed and results would become available in July 2014. In the future, figures presented would include a denominator so that the relative levels could be judged. Jane Sayer stressed the importance of reserving judgement at this stage saying that variations could also be due to certain teams encouraging feedback more than others. It was confirmed that future analysis would include break down by specific areas.

In response to a question relating to the number of unallocated cases and the implications on patient safety & quality of care, Jane Sayer guided those present through the data presented in the report, including Serious Incidents and Harm-free Care.

Jane Sayer referred to the data in Chart 2: Trust-wide Serious Incidents Reported and said that a final version of the Root Cause Analysis paper would be available soon. Barry Capon added that where there were inpatient deaths and very serious incidents, two Non-Executive Directors were involved in setting the terms of reference for the reviews.

Jane Sayer said of medication errors that there were no harms reported as a result of those recorded, and in response to a question about the increase of medication errors in Suffolk explained that am audit had identified one particular unit where medication had not been recorded to the required standards on the chart. The Trust had provided further training on accuracy and medication recording for the staff concerned, and the service would be re-audited to ensure that there was no recurrence.

Responding to a request to see more information on equality and diversity and a breakdown of complaints data into categories by protected characteristics, Jane Sayer said that this type of detail was sometimes difficult to measure as it had to be offered by the complainant, and wasn’t always provided. Robert Nesbitt added that the under the Equality Delivery System these characteristics would be monitored, but that it was difficult to interpret data when absolute numbers were so small. It was therefore important to draw on qualitative data from people who use the Trusts’ services as well as quantitative and this is one of the Trust’s equality objectives.

Jane Sayer provided an update on the number of assaults in Norfolk, and noted that the incidents reported on Blickling Ward related to an area where patients

mailto:[email protected]


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with dementia could at times be distressed. In response to Stuart Smith’s question on levels of challenging behaviour in learning disability services, Brian Parrott noted the skills with which staff support people who present with these needs in our services.

Jane Sayer reported that level 3 safeguarding training was now up to 92% but that they were continuing to promote it and that the NFST Safeguarding strategy was being in launched in July 2014.

Jane Sayer updated the board on the independent management reviews into the deaths of two patients with learning disabilities who had physical health problems explaining that the reports were expected to be published in late summer 2014.

Jane Sayer said that in preparation for the full Care Quality Commission (CQC) inspections in October 2014, mock inspections were on-going with Governors and Non-Executive Directors’ help.

Regarding safe staffing, Jane Sayer said that this was the first report following on from Hard Truths and set out staffing numbers against establishment. The lack of e-rostering made this difficult but Jane Sayer said she was confident that the reports contained as accurate figures as possible. Jane Sayer explained that NHSP reported a national increase in the need for registered nurses therefore it was sometimes difficult to provide back-fill. The development plan for healthcare assistants was in place and the Trust was actively encouraging staff to report concerns through Datix.

Jane Sayer said that they had agreed to look at how NHSP are encouraged to modify the recruitment process in order to make it more flexible and Brian Parrott added that staff needed to provide NHSP with more warning when registered nurses were needed and that local teams should be as anticipating as possible. Michael Scott said that staffing levels should be decided according to the needs of the patients who were on the ward.

In response to a question requesting clarity on staff establishment at Sandringham Ward, Jane Sayer said that there had been a health and safety review of the unit and staffing requirements had been discussed with the team leader. Jane Sayer confirmed that permanent staff on their establishment had been for 22 patients, although there were now 15 and the permanent establishment was for 12 beds.

Referring to Table 6: mean staffing, actual against establishment, Jane Sayer explained that staff were involved in creating action plans and monitoring them.

Under service user & carer experience, Jane Sayer acknowledged that further work was needed to improve involvement and provided an update on the work currently being undertaken and the upcoming engagement events.

In response to a comment from the public that parents and carers in the youth service had felt in limbo since the merger, and that the Trust needed to go beyond the Youth Council to address service users more widely, Debbie White said she recognised that there was a gap for carers, and that the Trust were working on improving the focus on under 18s. Debbie White continued by


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saying that she would arrange a meeting with CYP Participation Lead, Emma Corlett and the public member concerned.

John Brierley said that the Triangle of Care was designed to improve engagement and support although it was also noted that the Triangle of Care was concerned with the needs of the service user more than those of the carer. Barry Capon requested that Jane Sayer consider this issue as part of the review of the user and carer strategy and for this to return to the Board.

In response to a question on the current travel policy for carers visiting patients placed out of area, Debbie White said that the Trust reimbursed travel costs and that she would send the individual a copy of the policy.

In conclusion Jane Sayer updated the board on the Quality Dashboard and said that she was working with Informatics to develop denominators. Jane Sayer confirmed that the finalised Quality Dashboard would be brought to the August 2014 board.

Action 14.81ii

a. The topic of care for carers, with a focus on Norfolk Carers, to be considered by the board (Jane Sayer to propose date and to lead).

b. Debbie White to initiate contact between Emma Corlett and the member of the public who raised a query about the profile of the Youth Council before next board meeting.

c. Carer Travel Policy to be emailed to the member of the public who raised this query (Debbie White) before next board meeting.

d. Finalised Quality Dashboard to be taken to August 2014 board (Jane Sayer)

iii Infection prevention and control report, and physical health report (Jane Sayer, Sara Fletcher in attendance)

Sara Fletcher presented the third bi-annual report and quarterly update on infection control.

Work was in progress to develop a physical health strategy; Stuart Smith would be the Non-Executive Director of this group, which would report to the Service Governance Committee.

Sara Fletcher said that the CQUIN goals regarding inpatient areas were welcomed, and highlighted that the Trust had achieved its 2013 goal on schizophrenia. Sara Fletcher spoke of the importance of embedding work in the community, and in community teams saying that it was a big part of the work being done. Sara Fletcher further added that her deputy had recently secured a two day a week secondment post to Suffolk CCG.

Sara Fletcher provided an update on education and training, and emphasised that the Trust needed a skilled workforce with staff that recognised when they needed training, and attended accordingly. Sara Fletcher confirmed that the


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Physical Health Strategy Group would be responsible for assessing training needs.

Brian Parrott asked whether, in relation to resuscitation, clinical leads were more engaged and Sara Fletcher confirmed that this was the case.

Sara Fletcher assured the board that repeat incidents such as pressure ulcers were acted on and underwent Root Cause Analysis, a process she was involved in.

John Brierley asked whether GPs should be carrying out physical health checks in the community rather than the Trust. Sara Fletcher said that she was working with CCGs to address this question, including the use of GP SMI registers. It was important to address the poor health outcomes for people with mental health problems and there was a 3 stage approach to primary care involvement but that ultimately the individual patients’ needs needed to be paramount.

In response to a question from the public regarding efforts to prioritise the Trust’s most vulnerable patients Kathy Chapman responded by saying they were looking carefully at the work of Assertive Outreach Teams and national research on the best models. The aim was to ensure that the needs of the most vulnerable service users were addressed. Debbie White added that the FACT (Flexible Assertive Community Treatment) model was in place in Newmarket and whilst not fully implemented was showing encouraging results.

Sara Fletcher provided an update on infection control, confirming that there were no major outbreaks to report. Regarding the 75% flu vaccination target, Sara Fletcher said that support would be needed from across the Trust including Occupational Health & HR to achieve this.

iv. Financial Performance Report for 2014-15 Month 02 (Andrew Hopkins)

Andrew Hopkins introduced the report for Month 02 and said that overall the Trust was on plan, but asked the board to note three main issues:

The first was secondary commissioning and out of area/specialist placements. Andrew Hopkins reported a reduction in figures due to discharges in services, but reported that costs for external acute placements were significantly higher than in the same period last year (April-May).

Regarding pay and temporary staffing Andrew Hopkins said that he had written to Executive Directors requesting a review of the figures in order to reduce the rising costs. Andrew Hopkins added that the high numbers of temporary staff recruited to implement Lorenzo were nationally funded.

Andrew Hopkins said that CIP programme was slightly behind plan, but That the Trust was maintaining a COSRR rating of 3. Andrew Hopkins advised that there was a £4.4m gap (i.e. there was no firm plan in place as yet) and that this had been discussed at the Executives meeting, and proposals would be taken to the Finance & Performance Committee (F&PC).


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Brian Parrott noted that the work of the Suffolk CRHT teams in avoiding admissions and asked whether there was a similar focus in Norfolk. Kathy Chapman said staff were working hard and were under considerable pressure but that the number of adult 18-65 admissions had decreased slightly.

Questions and comments were then received from the public.

Regarding patients travel costs, Michael Scott and Andrew Hopkins confirmed that ambulance costs were covered under the terms of the Patient Transport Contract and paid by the Trust.

Concern was raised regarding the Trusts’ spending rate: current figures totalling £4.5m on out of area placements and £10m on salaries were confirmed by Andrew Hopkins who went on to say that whilst the figures quoted were accurate, the issue of acute placements was not a new one, and had been on-going for the past 12 months. Despite these pressures, the Trust was on plan financially.

Concern was raised regarding the impact of the Trusts’ use of temporary and agency staffing, an example being given of a temporary member of staff who had been in post for two years, but not recruited permanently. Jane Marshall-Robb said that she would be reviewing this.

v. Monitor governance compliance statements (Robert Nesbitt)

Robert Nesbitt explained that Monitor required all Trust boards to confirm their compliance statements, and that he was seeking the board’s review and approval of the statements and mitigations within the report in order to submit them to Monitor by 30th June 2014.

Following a review of the statements, the board approved them for submission to Monitor.

vi. Communication Committee Terms of Reference (Leigh Howlett & Graham Creelman)

Approved.

14.82 Items for Information

i. Care Pathways (including discharge planning) (Kathy Chapman)

Kathy Chapman gave a presentation on care pathways and began by explaining that a year ago there had been no acute mental health out of area placements. Today, there were fourteen.

Referring to admissions, discharges, and length of stay slide data for 18-65 year olds, Kathy Chapman said that there were no more admissions than the year before, and that although the median length of stay looked high, it was actually steady. Kathy Chapman explained that when individual wards were looked at in detail, it became clear that there was a group of patients occupying beds for longer periods of up to 100-200 days, the impact of which was that the beds were not available for new admissions.


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Kathy Chapman said that how to improve this was a question that both the Trust and Commissioners were working on. It was clear that the Crisis Resolution Home Treatment (CRHT) had been under pressure and changes to the ways of working were needed to address this. Kathy Chapman informed the board that as part of the system-wide action plan, Commissioners had provided funding for specific posts to enable the CRHT to focus on their areas. It was recognised that the Trust needed to increase alternatives to admission enabling service users, including those that were homeless, to step down from acute services to more appropriately supported arrangements.

Julian Beezhold presented an example of the sorts of needs which service users had said that this had been chosen as it illustrated themes common to many people.

A further case was presented by Clive Hudson demonstrating the week by week progression, and overall timescales involved in care pathways and discharge planning. Kathy Chapman said that along with Clinical Commissioning Groups and Commissioners, the Trust was learning from these cases and focussing on increasing the flow of patients through wards.

Questions and comments followed:

Brian Parrott said that the presentation showed a slow, progressive ‘one step at a time’ sequence that under the Continuing Healthcare Checklist (CHC) took too long to get from one stage to another. Brian Parrott thought that progress could be more active. Whilst acknowledging this it was also noted that some of the ‘delays’ were actually appropriate and part of the clinical process.

Governor Dr Duncan Double said that the graph data displayed showed the median length of stay as static and queried whether, if this was the case, the problem was due to planning, and so the beds in Norfolk might need to be increased. It was noted that this year had seen investment by the Clinical Commissioning Group, and that there were also plans to increase community services. Michael Scott said that it was also possible to provide appropriate support to some people without admitting them.

Following comment from a member of staff that accessing Central Norfolk beds had been a problem since 2012, Julian Beezhold responded saying that demand for acute beds had actually gone down in Central Norfolk, and that the median length of stay over the past six months had been 23 days per admission in comparison to 25 days per admission ten years ago. Four years ago, the median length of stay was 12 days per admission. Julian Beezhold said that in Central Norfolk, particular factors such as rising numbers of Crisis Team caseloads were a large factor, but that these had reduced from 70 to 40 which was more appropriate.

Concluding the item, Barry Capon summarised the discussion and said that the Board would continue to be kept informed on this important matter.


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ii. Update on Trust research activity (Jon Wilson & Bonnie Teague)

Jon Wilson and Bonnie Teague supported their Research Update Report with a PowerPoint presentation (see slides) and briefly highlighted their proposal to invest in and develop three areas of mental health research, namely: Child & Youth, Adult and Dementia and complexity in later life. Jon Wilson informed the board that a strategy had been developed over the past six months, and that they were seeking board approval and support to implement the plan. Jon Wilson stressed the importance of the Trusts’ participation in national research and emphasised that the sooner the proposal itself was approved, the sooner research grant applications could be made.

Bonnie Teague drew the board’s attention to the research training programme and the launch of Inspire at the end of May 2014: a strategy that involved service users, public and carers in mental health research.

Barry Capon reminded those present that that the presentation came as a result of the board’s request for focus on research, and that the proposal should be fully reviewed by Finance Department before coming back to board for approval.

Action 14.82ii

The research paper costings set out in Jon Wilson and Bonnie Teague’s report to be reviewed by Finance with report and recommendation coming back to August 2014 board (Andrew Hopkins).

14.83 Standing Item: Have the most pertinent items of the agenda have been reviewed adequately and at the beginning of the agenda? (All)

Barry Capon recognised that whilst all important items had been covered, time constraints mean that some items received less than optimal time.

14.84 Any other urgent business, previously notified to the Chair=

There were no other items of urgent business.

14.85 Date, time and location of the next meeting

The next meeting in public of the Board of Directors will be held on:

28th August 2014 at Endeavour House, Russell Road, Ipswich, IP1 2BX from 09:30

Meeting closed at: 13:40

Chair: ……...…..…………………………

Date: ……....…………………………….

Board of Directors – Public 28 August 2014 Chair’s Report

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Author: Gary Page Department: Corporate

Page 1 of 3 Date produced: 20 August 2014 Retention period: 30 years

Report To: Board of Directors - Public

Meeting Date: 28th August 2014

Title of Report: Chairs Report

Action Sought: For Information

Estimated time: 15 minutes

Author: Gary Page, Chair

Director: Gary Page, Chair

Executive Summary:

The report details my most significant meetings and my key observations over the last month.

1.0 Interaction with External Organisations 1.1 I met with Ken Applegate Chair of Norfolk Community Health and Care Trust .

They have recruited a new CEO on an interim basis Roisin Fallon-Williams. 1.2 I met with Chris Lawrence the new Chair of Hertfordshire Partnership Mental

Health Trust. Interestingly they operate with far fewer Board Meetings all of which are in public, they are likely to increase the number of Board meetings but are still likely to operate with substantially less than the 12 we have at NSFT.

1.3 I attended the Independent Advisory Group meeting run by the Norfolk Police

and Crime Commissioner as Mental Health was on the agenda. The Norfolk Constabulary gave a very positive report on improving working relationship with the Trust and especially the impact on having our staff in the control room. Concerns were expressed by the IAG around out of area placements and I provided an update on the progress that we have made.

1.4 I held a further meeting with Suzy Clifford and Dan Pennock from Survivors of

Bereavement of Suicide, we continue to work with them to plan the opening of a third branch in Suffolk. I will also be joining a meeting with David Skevington Assistant Chief Constable Suffolk and SOBS to discuss how the police can be better trained to deal with survivors of suicide.

28th

August 2014

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1.5 I met with Andrea Stribling the Manager of Richmond Fellowship in Suffolk and discussed how we could potentially improve our working relationship which I will take up with Pete Devlin.

1.6 I met with Anna Hughes Chief Executive of Suffolk Mind who is undertaking a

strategic review of were Suffolk Mind should focus its attentions and how it could work more closely with the Trust.

2.0 Interaction with Services and Staff

2.1 I spent the morning with the Crisis Resolution Home Treatment Team based at Hellesdon including visiting service users in the community. I saw first-hand the excellent work that we are doing with some very vulnerable people and the stressful environment that the team continue to work under. The sense I got from talking to people was that things were improving although caseloads remain high.

2.2 I attended the BME Networking meeting where considerable interest was shown in the Trusts Equality objectives and the introduction of Equality leads. 2.3 I met with the new Maeve Heaney NSFT new Legal Counsel. Maeve has been

recruited from private practise and will bring a greater commercial edge to our legal function which will enable us to perform more legal services in house.

2.4 I visited the Learning Disability service at Walker Close with Sue Bridges. Speaking to service users I was very impressed by their very positive comments on the service we provide. However the protracted discussions with commissioners around the service continue to cause considerable uncertainty for the staff and the visit served to remind me of the need to have greater learning disability expertise in the Trust which I have discussed with Roz Brooks.

2.5 I visited the Coastal IDT in Suffolk. The Team appreciates the much improved working environment, but it seems to me that there are on-going pressures particularly around the Enhanced Community Pathway which I have raised with Roz Brooks, together with some issues raised by the admin team.

2.6 I chaired a Private Board of Governors meeting at which we approved the appointment of two new Non-Executive Directors. Tim Newcomb was formerly the Assistant Chief Constable at Suffolk Police with specific responsibilities around Mental health and Marion Saunders from North Norfolk is a trained social worker with wide spread experience around safeguarding and the CQC.

3.0 Service User and Carers Interaction

3.1 Together with Ravi Seenan Equality Manager I met with Ashok Bhatt to discuss how we can improve access to our services for Ethnic Minority Communities in Ipswich.


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3.2 I met with the father of a service user who was unhappy about the level of communication with the Trust which I have followed up on with the relevant Service Manager.

4.0 Key Observations

4.1 The recent management changes involving the Directors of Operations appear to have been well received in Norfolk and Suffolk.

4.2 The Board will be discussing Learning Disabilities in the coming few months which is long overdue and I believe that it is very important that we make some clear decisions in order to ensure that we can properly support this important part of our service

Gary Page Chair 20 August 2014

Board of Directors – Public 28August2014 Chief Executive Report

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Author: Michael Scott Department: Corporate

Page 1 of 3 Date produced: 20 Aug2014 Retention period: 30 years

Report To: Board of Directors – Public


Title of Report: CEO Update



Author: Michael Scott, Chief Executive

Director: Michael Scott, Chief Executive

Executive Summary: This report provides an update on the main issues and activities undertaken by the Chief Executive for the month.

1.0 Corporate Plan:

1.1 A review of the Directors portfolio has been initiated, draft corporate plans, and a review of financial modelling with consultation will commence on the 1 September 2014

2.0 Medical Director appointment:

2.1 I am pleased to confirm that after robust interview an appointment has been made. Dr Solomka has been invited to join the Board from the 1 January 2015. He has already commenced discussions on hand over with our current Medical Director and the identification of any development needs to equip him for the role.

3.0 Julian Housing

3.1 I met with Pip Coker, who has expressed interest in working more closely with our Trust, a proposal which was discussed at the Executive Team meeting. We are continuing to meet to consider this proposal

4.0 Great Yarmouth and Waveney Consultation

4.1 I attended, together with other team members, the option appraisal workshop after the consultation process was completed. Finer details continue to be discussed with Andy Evans, Chief Executive. Their Board meeting due to take place today was stood down and it is anticipated that they will discuss the mental health consultation and commissioning

Date: 28th

August 2014

C Item: 14.109


Version 1.0



intentions during a joint governing body and clinical executive team meeting to be held next month.

5.0 Suffolk User Forum:

5.1 I was invited as guest speaker to the Suffolk User Forum where I met with a number of stakeholders and services users alike.

5.2 I was also invited to meet with Sue Gray, Suffolk MIND Chief Executive at their head office in Hintlesham.

6.0 Introduction into Recovery

6.1 I attended one of the Recovery College training session held all over Norfolk and Suffolk which I would recommend to others in the team to participate if they have not already engaged.

7.0 LNC

7.1 I attended the local negotiating committee where they discussed the committee terms of reference, medical staffing 5-year strategy and general issues.

8.0 Norfolk Police

8.1 I had a very interesting meeting with representatives of Norfolk Constabulary regarding Safeguarding and Harm Reduction. I will be meeting with our representative Terri Cooper-Barnes who works alongside the police at their Wymondham Headquarters next month.

9.0 Senior Management Forum:

9.1 We held the second SMF this month where we held an interactive exercise on the 5-year strategic plan, confirmed the trust objectives, future staff engagement plans, learning from RCA and update plans for the future Care Quality commission visit in October.

10.0 CRHT Visit:

10.1 Having been involved in a CRHT meeting I decided to attend a further meeting and visit some service users in their home environment with one of the team members which gave me an interesting insight to their every-day work and the service user’s expectations.

11.0 Section 75

11.1 We are continuing dialogue with Harold Bodmer regarding Section 75 issues.

12.0 General Medical Council

12.1 I met with Dr Stephen Jones the Core Programme Director for the GMC to discuss NSFT action plans.


Version 1.0



12.2 I also met with the local General Practitioners leads for mental health at their monthly meeting.

13.0 Members of Parliament

13.1 I met with Chloe Smith who continues to show interest in local mental health.

14.0 NHS BME Network Pilot Study

14.1 We have been invited to participate in a study for the Joint Commissioning Panel for Mental Health. 5 mental health providers will join the pilot in a study in using this tool and help address the inequalities issues among BME service users. We have agreed to participate and the first introductory meeting has been held.

15.0 Ministerial visit to Addictions Services:

15.1 I meet with Norman Lamb and members from the Royal College of Psychiatrists who visited the addictions facility and Unthank Road.

16.0 Induction:

16.1 I have also continued my induction, meeting with Kevin James, Chair of the Service User and Carer Council, Nick Hulme, Chief Executive Ipswich Hospital, Anna McCreadie, Director of Adult and Community Services, Suffolk County Council, Mark Easton, Interim Chief Executive of NCHC, Councillor Michael Carttiss, Chair of Norfolk HOSC.

16.2 I also met with the Specialist Commissioning Team, Carol Theobald and

Karen Lockett. 16.3 I made visits to Sandringham and Blickling Wards with our Director of

Operations for Norfolk and Waveney.

17.0 Recommendation:

17.1 The Board is asked to note the content of this report

Michael Scott Chief Executive

Board of Directors - Public 28 August 2014 Risk Register Progress Report

Version 0.1

Author: Neill Paull Department: Risk Management

Page 1 of 3 Date produced: 18August2014 Retention period: 30 years



Title of Report: Risk Register Progress Report



Author: Neil Paull: Risk Management and Security Lead

Director: Jane Sayer: Director of Nursing, Quality and Patient Safety

Executive Summary:

The attached table (appendix 1) highlights the current Trust Risk Register. This paper identifies Risk Management action, reviews, new risks rated at 12 or above and closures which have been approved since June 2014. The Executive team are advised of these risks upon scoring by the Head of Risk & Security Management and should consider at this meeting whether the action plan is sufficient given the impact on the overall business of the Trust, whether they are accepted risks or concerns and if any further risks may have been highlighted. Risks have been grouped into categories. Whilst some overarching risks are shown corporately i.e. Staffing, there are also operational risks that arise and these are shown to ensure appropriate focus is given to the risk at each level. Each recorded risk is reviewed within the Risk Management team weekly and assurance is gathered from the Service Manager of progress. Outcomes of significant risk are discussed with the Trust Board Secretary and recorded on the Board Assurance Framework.

1.0 Risk Movement

1.1 There have been two new risks identified since the last report;

1.1.1 ID 1133 highlights concerns of staffing cover at West Suffolk services, where NHSP staff have been unable to fill the shifts

1.1.2 ID 1136 has been drawn to the attention of the Chief Executive on his visits to some of the Trust wards. The environmental assessments of

Date: 28th

August 2014

D Item: 14.110i


Version 0.1



ligature risks have been reviewed in line with Trust policy Q46. Differences in standards are now being addressed following a programme review by Risk, Estates, Maintenance and Nursing leads.

1.2 In addition, two risks (ID 938 and ID 1070) have reached the target scores and can be removed from the register.

1.3 Patient safety systems risk (ID 863) has been reduced from 12 to 10 and will be monitored as the progress of Lorenzo impacts with the engagement of other services within the Trust.

2.0 Risk Development

2.1 The most recorded risk is still around staffing and indeed there are still high levels of staffing concern recorded on the Datix incident system. This is currently being reviewed with the staff level returns reported to ensure risks are focused on appropriately.

2.2 The Health, Safety and Environmental Lead raises with managers any risk assessments on their operational register at inspection

2.3 Performance review group documents highlight the current risks recorded, the most recent incident reporting trends and current complaints compliance.

2.4 Head of Risk Management and Security and Patient Safety and Complaints Lead have set up some training in September, October and November to deliver learning from claims, complaints and incident events. This will help teams to focus on their current and potential risks.

2.5 Training in identifying and recording risk has taken place with 20 NRP staff and this will be followed up at Health & Safety inspections.

2.6 An overview of the risk register and the dashboard used within the Datix system was presented to the Chief Executive

2.7 The Deputy Director of Finance received training and reviewed the financial risks within the system. Discussions were held with the Risk Management Analyst about progressing risks from local day-to-day risks and overreaching risks affecting a number of areas.

3.0 Risks / Mitigation in relation to the Trust Objectives

3.1 The ligature programme will need to be addressed and presented to the Audit and Risk Committee to ensure there is an understanding by all staff as to which risks can be managed and which need to be removed and pre merger, where there are different solutions in the building and/or design of an environment, the controls that need to be in place for future assessments.

4.0 Recommendations


Version 0.1



4.1 The Board of Directors accept the updated report as progress.

Neil Paull Head of Risk Management and Security.

Background Papers / Information Risk Register, current register attached August 2014. The following feed into to the Risk Register:

Datix Risk Register Dashboard,

Lorenzo Risk Register

ICT Risk Register

Date: 28th

August 2014

Item: 14.110i App 1

record

ID

Name of risk Risk description Locality (Team) Svs / Dept Lead Controls in place Opened Risk

Current

Action Plan /Lead Gaps in assurance

1100 Disaster

Recovery

Capability

The existing infrastructure

design does not include

effective disaster recovery

measures.

ICT Services (Risk

Register)

Commercial

Director

ICT are developing a plan to

procure an interim Disaster

Recovery solution that will give the

Trust time to formulate and

procure a solution that will meet its

long term needs.

07/02/2014

reviewed

4/8/2014

15

This work will be

completed by 31

July 2014.

Reviewed at ICT

Programme Board

RG

1101 Data Backup

Capability

The existing infrastructure

design is not effective

enough to ensure that all

business critical clinical and

corporate data is reliably

backed up

ICT Services (Risk

Register)

Commercial

Director

A project mandate has been

produced to audit and develop the

backup stabilisation plan that

meets recognised industry

standards and methodologies.

Work on backups, including

successful recoveries, have given

ICT staff the assurance that the

likelihood of the risk occurring has

reduced

07/02/2014

reviewed

13/06/2014

15

This work will be

completed by 31

July 2014.

Reviewed at ICT

Programme Board

RG

If key backups fail,

systems are not

recoverable.

1095 ICT

Infrastructure

Failings in aspects of our

core ICT Infrastructure may

result in network, application

or service failures that could

result in a breach in the

availability or integrity of all

clinical or corporate data.

ICT Services (Risk

Register)

Commercial

Director

Fortnightly working group

meetings including operational

management representation.

27/01/2014

reviewed

13/06/2014

12

Linked with

Infrastructure

Rectification

Programme PID.

Risk reviewed at

ICT Programme

Board RG

885 Stability of

ePEX

The historical level of stability

of ePEX gives ICT sufficient

concern that it is prone to

prolonged disruptions that

would result in the non-

availability of clincial records

to its users.

ICT Services (Risk

Register)

ICT Security

Manager

In proactive monitoring tool to be

installed to help ICT monitor

problems. This is not a fix but will

minimise likelihood of disruption.

The monitoring tool has

demonstrated a period of recent

stability

10/04/2012

reviewed

4/8/2014

12

Linked with

Infrastructure

Rectification

Programme PID.

Following ICT

Programme Board,

the title and

desription rewritten

to reflect currnet

situation.

RG

Risk Register August 2014D

ICT RISKS

1

record

ID


Current


938 Clinical &

Patient Admin

Notes

No contemporaneous clinical

notes available due to limited

IT equipment for SWS

Partners to access PC-MIS

Suffolk Wellbeing

(Risk Register)

Deputy Director

of Operation

Suffolk

Some equipment has been

delivered onto sites, plan for

outstanding kit to be placed

agreed for next few weeks,

updates requested from partners.

26/02/2013

reviewed

14/7/2014

4

Monthly monitoring remaining IT issues

seem resolved case

closed

863 Patient

Administration

systems

(Formerly

Lorenzo

Programme)

A lack of involvement from

key stakeholders within the

programme (esp. future state

design activities) may cause

new processes to be rejected

leading to an inability to fully

realise benefits.

Corporate (Risk

Register)

Commercial

Director

Business Change Agent network

established and engaged in

process design work. Workshops

planned 30/5, 2/6 to encourage

further engagement.

Wider comms efforts have begun

now approval has been received.

13/02/2012

reviewed

22/6/2014

10

Execs (esp Ops

Director) to be kept

appraised of levels

of engagement

from staff.

Recruitment to

clinical

engagement leads

roles will provide

more clinical input.

Regular update

reports are

provided

The Lorenzo

programme may be

adversely affected as a

result of the risks

identified within the

programme and

therefore may not

deliver as expected in

terms of cost, quality or

time.

1116 Inability to

deliver clinical

services safely

due to high

number of

vacancies

The Trust currently has 530

vacancies, 413 of which are

being actively recruited to.

Current plan 19 post

appointed to for June 2014

and 113 in July 2014

Human Resources

(Risk Register)

Director of HR Flexible Workforce Strategy which

incorporates the recruitment

strategy (joint strategy with NHS

Professionals) with detailed

implementation plan.

24/04/2014

updated

13/8/2014

from Exec.

meeting

comment

20

Staffing Strategy -

Reported via

Workforce

Development

Splitting clinical and

non-clinical risks

HR RISKS

2

record

ID


Current


1065 Post TSS

impact of

increasing

locality

boundary on

level of patient

demand and

available

service

capacity

Excess service demand

poses risk of; breach of

external waiting time target,

waiting lists (internal and

external), waiting list risks,

reduced capacity to handle

high risk patients, reduced

work quality, lower priority

work deferred (GP meetings,

group work), reduced morale,

increased patient incidents

and patients / GP / carer /

commissioner complaints,

and long working hours an

staff stress, sickness and

turnover

West Norfolk (Risk

Register)

Service

Manager

Regular tracking of patient referral

numbers, status and plans by

senior service team. Develop case

for appropriate staff level and plan

to implement. Fill vacancies with

agency staff in interim, explore

creating interim supernumerary

staff .

20/11/2013

reviewed

6/8/14

12

Monthly update

received 6/8/2014

1133 Staffing

Levels - West

Suffolk

NHSP are unable to fill the

shifts required when put on

the system resulting in

unsafe staffing levels on

occasion across west

inpatient areas.

Centralised recruitment

process has impacted on

ability to be able to recruit

to vacancies.

West Suffolk

(Risk Register)

Service

Manager

Agencies being contacted

directly to block book staff.

Recruitment to be managed at

local level

14/07/2014

12

monthly updates

3

record

ID


Current


1060 Sandringham

Staffing levels.

Sandringham Ward has

moved to it's new staffing

establishment with effect

from 16th September 2013.

The new establishment is

designed to cover 10 in-

patient CLL beds. At present,

22 beds remain open on

Sandringham Ward, with a

mix of CLL and non-CLL

patients. Bed occupancy is

consistently near 100%. The

new staff

establishment designed to

cover 10 beds is insufficient

to provide adequate cover for

the current 22 open beds.

This raises risk issues with

regard to patient and staff

safety, care quality, and

reduced staff resource to

facilitate effective timely

discharge.

Central Locality

(Risk Register)

Service

Manager

Under the management of the

DCLL service line Sandringham

Wd has been subject to a weekly

action plan meeting which has

looked primarily at addressing the

bed status/staffing/gate-keeping

/daily clinical

meetings/engagement with East &

West Localities around Dist

interventions. Progress against

these actions are on track and the

ward is reducing bed capacity

from 22 to 15 by the end of June

'14. Staff recruitment has been

completed.

26/09/2013

reviewed

16/06/14

12

monthly updates of

the action plan

Expected reduction

30/06/2014

1112 Trust

Reputation/

Public

Relations

Current negative media

coverage; Request from

CCG in response to media

coverage and campaign.

Commercial

Development (Risk

Register)

Commercial

Director

Appointed outside agency on

reputation recovery through the

Comms team.

10/04/2014

updated

13/8/2014

16

Committee of the

Board set up .

The proactive approach

is proving effective but

it is not possible to

predict the campaign’s

future activities.

COMMUNICATION

4

record

ID


Current


1090 Overall CIP

delivery.

Financial risk review Corporate (Risk

Register)

Director of

Finance

CIP plan for 2014/15 24/12/2014

reviewed

11/7/2014 16

DoF updating CIP

targets

1093 Norfolk

IAPT/Wellbeing

tender

Failure to win:

- Significant loss of revenue

to the Trust (circa £10-12m)

- Loss of credibility and

reputation

- significantly hinders the

ability of the Trust to grow

business as a specialist in a

growth area

- Allows a competitor to

establish significant business

on our doorstep

- Unknown impact on future

service line tenders being

split from the block contract

- Potential staff liability

- Weakens Trust position for

the future Suffolk

IAPT/Wellbeing tender.

Corporate (Risk

Register)

Commercial

Director

Project team in place reviewing

risk. Pull on lessons learnt from

previous IAPT/Wellbeing tenders

such as Suffolk and Mid-Essex.

21/01/2014

meeting set

for 12/8/2014

12

The April 2014

Investment

Committee

requested that the

executive team

consider a

proposal to

increase bid

capability so as to

reach a 50%

confidence level in

relation to the

Suffolk community

services tender.

Resources to

support improved

bidding capability

have been set

aside for 2014/15

The two year

operational plan and 5

year strategic planning

will identify a resource

plan to support delivery

of the Trust’s agreed

strategic direction

1070 TSS - Suffolk

IDT financial

gaps

Shortfall in the Suffolk

finances:

a) Lack of mitigation plans in

relation to financial gap for

2013/14 14/15 and 15/16

b) Unbudgeted cost of

change i.e. notice periods,

pay protection not covered by

the Transitional fund which

was principally set-up to

safeguard patient safety.

c) Delivery of unbudgeted

services.

Merger/Integration

Programme (Risk

Register)

Director of

Operations

Suffolk

CIP plans for 14/15 are being

finalised and a number of

mitigations have been identified.

Suffolk will be imposing a turnover

rate of 2% on community

vacancies in order to achieve

savings for 14/15

02/12/2013

reviewed

14/7/2014

12

CIP plans for 14/15

and a number of

mitigations have

been identified.

closed 14/7/2014

FINANCIAL RISKS

PATIENT SAFETY

5

record

ID


Current


1062 Bed Pressure Use of 'red leave' bed's to

manage patients locally,

meaning using beds deemed

to be held for patients

considered to be potentially

at risk by inpatient teams.

Increased demands on

staffing to manage high turn

over of service users as well

as protracted time periods

required to manage

applications for OOA

placements as well as

transport issues.

OOA placement usage, this

provides financial pressures

and risk as well as quality

risk.

Extended time periods spent

in S136 suite.

Staff absence impacting

including maternity leave,

staff suspended for

investigation purposes, and

longer term sickness

absence.

Central Locality

(Risk Register)

Deputy Director

of Operations

Norfolk

Recruitment is underway to

additonal posts in BMDFT to

provide 24/7 cover and

Leadership position. Evidence

from weekly reporting is that OOA

placements and lengths of stay is

improving. Use of red leave beds

is under review to ensure

consistent safe use of beds, led by

ASF.

15/10/2013

reviewed

24/7/2014

16

A report is being

developed to

include all metrics

suggested by

Board members

and there is on-

going negotiation

with CCG

regarding

commissioned bed

numbers including

placement of

people delayed in

wards. Executive

team recieves

report weekly from

Deputy Director of

Operations

Further analysis on

admissions by CCG

area is required to

understand whether

there is a pattern

emerging over time and

whether this reflects

demand in previous

years

6

record

ID


Current


1118 NRP Contract

Notice

NRP has been given a final

notice by NCC Public Health.

The areas of concern are

around patient safety (case

loads and learning from

RCAs) and the governance

framework - ensuring that

senior managers are aware

of and actively supporting

NRP.

TADS /NRP (Risk

Register)

Director of

Operations

Norfolk

1. Senior Management to be

present at NRP Quality, Safety

and performance contract meeting

(Directors)

2. An action plan to be planned

and actions commenced in

agreement with commissioners.

3.Immediate targets- to ensure all

staff have received mandatory

training in Suicide prevention and

care planning.

4. To send a workforce report for

NRP to commissioners.

5. To amend and update the RCA

review template and ensure

documentation re staff aware of

content.

6.staff survey on engagement.

7. Restructure of meetings.

07/05/2014

reviewed

24/6/2014

16

Monthly monitoring

1040 Delivery of

Acute services,

Norfolk West

Increased sickness is

evident, therefore putting

pressures on existing staff.

Shifts are not safely covered

without using NHSP or

equivalent

West Norfolk (Risk

Register)

Service

Manager

New Band 5 staff have joined the

acute team in the last 4 weeks.

One more due to start August and

2 newly qualified due to start Sept.

Band 5 x 4 WTE still to be

recruited in to. Band 3 x 2.6 WTE

vacancys. Interview date to be

arranged.

19/06/2013

reviewed

23/7/2014

16

Staffing vacancies

being filled/ SP

Awaiting interview dates

928 Ligature Risks -

Wedgwood

Work on Northgate was not

fully completed to the same

standards as Southgate ward

Suffolk West

Assessment &

Treatment (Risk

Register)

Deputy Director

of Operations

Suffolk

Programme of was due to start

4/8/14

22/11/2012

reviewed

5/6/2014

16

Awaiting progress

lead is on annual

leave

Environmental risks in

Northgate reliant on

staffing and

observations

7

record

ID


Current


1033 Inability to

provide an

individual

practitioner to

every Service

User in Central

Adult

Community

There are a growing number

of unallocated clinical cases

in the Central Locality who

require Care Coordination or

Lead Care Professional

alignment which could result

in a lack of timely intervention

if required.

Central Locality

(Risk Register)

Locality

Operations

Manager

Monthly Caseload Management by

CTL's with each practitioner, focus

on safe discharge to free up

capacity. Exploration of more

efficient ways of delivering

treatment eg clinics, use of a Lead

Care Professional. Transitional

Plan commenced. Regular review

of all unallocated cases by

members of the team and duty

worker in place to take any calls

related to this group. Request to

recruit Agency workers to fill gaps

until recruitment completed

agreed. CCR being completed to

request temporary staffing cover

for teams to enable the

transformational work to be

completed

24/05/2013

reviewed

28/7/2014

15

Weekly reporting

and monitoring

continues with

actions in place to

increase discharge

to enable capacity

to be built into the

teams. Recruitment

to vacanct post

ongoing, a number

of posts in pre

employment stage.

Long Term

Treatment Team,

implementation

phase 1

commenced,

impact should be

noted in next 2

Months.

last recorded

unallocated numbers

awaiting caseload

allocation is 381.

1136 Ligature

Programme

Following 2011 ligature

plans and 2013 Ligature

and Suicide Environment

Policy, June 2014 local

assessments identified

gaps and differences in

systems.

Corporate (Risk

Register)

Risk

Management

and Security

Lead

Programme of review

completed by the Risk

Management and Security Lead

with assistance of Estates and

Maintenance Managers;

Directors of Operations and

Deputy Director of Nursing.

Action plan to be agreed

25/07/2014

12

weekly

monitoring of

progress and staff

awareness

Some significant cost

and timeframe risks

need to be agreed at

Executive level. i.e

window controls

8

record

ID


Current


1099 Meeting Key

Performance

Indicators

Failure of team to meet 24-

hour, 4-hours 72-hours and

28-day targets have resulted

in CCG issuing performance

notice. Financial service and

operational risks.

Suffolk Access &

Assessment Team

(Risk Register)

Locality Service

Manager -

Primary Care

Performance management of

team, regular review of targets,

reporting to executive team. CCG

report satisfactory progress.

28/01/2014

reviewed

12/5/2014

12

Monthly updates

reported - target

date 25th October

2014

1125 System

confidence

A loss of system confidence

affecting sustainability of trust

Corporate (Risk

Register)

Chief Executive This risk is mitigated by:

a. A more structured approach by

the executive team to ensuring

that information that leaves the

organisation is accurate, complete

and contextualised.

b. Executive director time has

been focussed on engaging

proactively with commissioners so

as to understand their concerns

and to address them.

c. Significantly improved

performance on Access and

Assessment targets.

30/05/2014

discussed

13/8/2014

15

a)rules for

meetings

introduced, follow

up of actions and

minutes in a timely

manner, b) more

regular contact with

commissioners

established

including clinical

leads, c) Access

and Assessment

service being

reviewed, d)

Constructive

approach to

dialogue with the

Campaign.

QUALITY and AUDIT

9

record

ID


Current


914 Compliance

with mandatory

training

Low compliance with

mandatory training resulting

in non-compliance with legal

obligations, NHSLA & CQC,

& poorer quality of care

Human Resources

(Risk Register)

Director of

Workforce and

OD

Project work to review and

improve relevance and access to

stat/mand training.

29/08/2012

reviewed

12/8/2014

12

A comprehensive

report to the Board

of Directors was

provided in May.

We continue to

experience a low take-

up of stat/mand training

places.

1109 DOLS

Regulation

Change

Supreme court judgement in

March 2014 widened the

definition of deprivation of

liberty meaning that some

patients may be detained

without correct legal

safeguards.

Governance (Risk

Register)

Trust Board

Secretary

Review group set up with

Safeguard and Legal Service

leads leading to scope issue and

put in place arrangements for

referrals for DOLS assessments

where needed.

28/03/2014

reviewed

20/6/2014

12

Review scope of

those affected/

DR & SB

Supported by

clinical leads

Working group will be

bringing forward

proposals for improved

tracking system.

Key

Removed from current

register

Bold writting Newly recorded risk

REGULATION

10

Board of Directors – Public 28Aug2014 Board Assurance Framework

Version 1.0


Page 1 of 11 Date produced: 21Aug2014 Retention period: 30 years



Title of Report: Board Assurance Framework

Action Sought: For Approval


Author: Robert Nesbitt: Trust Secretary

Executive: Robert Nesbitt: Trust Secretary

Executive Summary:

The BAF has been updated since the July 2014 Board and now includes cross-referencing of the risks to the Trust objectives and, where feasible, timed plans to move the mitigation confidence to green. The risks to our maintaining a CoSRR of 3, evident in the M04 finance report, means that the mitigation confidence level has moved to ‘red’. The ‘Performance’ theme is now focussed on ‘Quality’ (patient safety, experience and clinical effectiveness) and so has been re-named to reflect this. Lorenzo as a strategic risk has been added, as has weaknesses in learning from Root Cause Analysis reports, and the risks that would arise from a critical CQC report (following the planned inspection in October 2014). The annual ligature audit will be considered at the executive team meeting on 20th August 2014. NB: The mitigation RAAG rating is based on Monitor’s Governance Risk Rating system: ‘Red’ (the mitigation is so weak that there is likely risk of a breach to the provider license), ‘Red / Amber’ (the mitigation is such that there are material concerns of a breach to the provider license), ‘Amber Green’ (the mitigation leaves limited concerns of a breach). ‘Green’ (the mitigation is so strong as to mean that there are no material concerns of a breach). Scores shown are ‘Consequence x Likelihood’ as recorded on Datix. The executive owner is not always the risk owner on Datix (this is intentional).

Date: 28th

August 2014

E Item: 14.110ii


Version 1.0



1.0 Staffing (OD and WF Committee)

Relevant Trust objectives:

Implementation of Hard Truths recommendations so agreed inpatient staffing levels are achieved, maintained and published weekly from June 2014.

To agree recording and monitoring process for safe caseloads levels by October 2014.

Delivery of a Workforce and OD strategy.

1.1 Risk. The risk is that shortages of staff impact on safety. Staff sickness exacerbates this problem and remains at c.5.55%.

1.2 Mitigation. Confidence level = red/amber as there are plans in place.

a. Risks associated with cases requiring allocation are being monitored to prioritise resources.

b. The Flexible Working Strategy includes specific measures to improve staffing levels. As it is rolled out the mitigation confidence level should increase.

1.3 Additional actions required. No additional action is required at present.

1.4 Datix ID 1116 (Risk of inability to delivery clinical services due to vacancies) / Owner – 5 x 4 = 20 Jane Marshall-Robb. Datix ID 1133 (NHSP difficulty in covering shifts in W. Suffolk) 4 x 3 = 12. Jane Marshall-Robb.

1.5 Timeline to reach confidence level of ‘Green’

Recording and monitoring of safe caseloads is due by October 2014.

Safe staffing in now published on NHS Choices. Delivery of the Workforce and OD strategy is part of the two year operational plan and five year strategic plan. Subject to business case approval e-rostering will be rolled out by year end with a full implementation date of March 2016.

2.0 System confidence (Finance and Performance Committee)


For the 2014/15 financial year: delivery of all operational targets including receiving 100% CQUIN and the avoidance of any operational and financial penalties from commissioners in the final quarter of the year.

Engage with the wider health economy, third and voluntary sector to ensure the Trust is a known and trusted partner evidenced by a 10% increase in new business with external parties by March 2015, evidenced by financial turnover.

2.1 Risk. A loss of system confidence in the management of the Trust could impact on the ability of the Trust to retain and win contracts, lead to escalated regulatory actions that would impact on management capacity, and could also weaken the


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public’s confidence in the quality of the service. A critical CQC report in October 2014 could weaken patient (and wider) confidence in the Trust.

2.2 Mitigation. Confidence level = Red / Amber as the issues are multi-factorial.

This risk is mitigated by:

a. Prioritisation of meeting performance standards and addressing problems quickly.

b. Positive attempts to reach out to the Campaign so as to find common ground in our joint desire to protect and improve services.

c. Preparation for October 2014 CQC visit to ensure that an accurate picture of Trust services can be evidenced.

2.3 Additional actions required.

None at present.

2.4 Datix ID 1145 (risk of not learning from RCAs leading to repeat incidents) = 3 x 4 = 12. Owner Jane Sayer. Datix ID 1112(Risk of damage to Trust reputation) 5 x 3 = 15 Owner Michael Scott. Datix ID 1144 (Risk of poor CQC report affecting confidence in Trust) 4 x 3 = 12 Owner Jane Sayer.


A greater degree of confidence in the Trust should be established by the financial year end. However, this could be seriously impacted by the CQC inspection and financial performance.

3.0 Quality (a – d Finance and Performance Committee, f Service Governance Committee)


Achieve zero out of area non specialist bed placements by March 2015.

Achieve a positive CQC review in 2014 and effectively addressing any issues that arise as part of this.

Agree recording and monitoring process for safe caseloads levels by October 2014.

3.1 Risk. The risk is that quality is compromised by service performance problems. These include:

a. Out of area capacity placements indicating bed / care pathway pressures in Norfolk and Waveney.

b. The under 18s incorrect referral entry problem (this relates to 28 day referrals) and the Norfolk CAMHS 8 week target breaches. This was reviewed at F&PC and is now resolved.


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c. IAPT access activity in Norfolk, Suffolk and GY&W is below the 2.5% per month trajectory. In Suffolk this is the subject of a contract query notice. This was reviewed at F&PC and is now resolved.

d. The Suffolk Access and Assessment 28 days target (95%) has been missed for April (65%) and May (75%) 2014 and the recovery plan is impeded by high levels of sickness (15%). This was reviewed at F&PC and is now resolved.

e. The strategic risk that Lorenzo does not deliver the quality benefits that the Trust needs to provide safe and effective services.

f. In addition, there are is a risk that learning from Root Cause Analysis reports is not applied adequately across the Trust leading to repeated safety issues.

3.2 Mitigation. Confidence levels a. Bed availability = Red / Amber, e. Lorenzo = Amber/Green, f. RCA learning = Red/Amber a. In relation to Norfolk and Waveney bed availability, The current level of capacity out of Trust placements has come down from a high of 31 in June 2014 and is 10 (on 31.07.14) down from 14 (on 23.07.14). The approach is to consider the whole of the care pathway and this work has started with a review of Access and Assessment. The impact of S.75 and the Cluster 1 – 4 tender and remaining community services is being scoped. e. Lorenzo has a clear programme management structure and is adequately resourced to deliver benefits and to provide early warning of risks. f. RCA reports are improving in quality and in the formulation of recommendations. The DoN and MD now scrutinise every report monthly, identifying key themes and assign appropriate follow up actions with monthly reporting to the Senior Management Forum on learning points. There will be learning events to be held locally for practitioners to attend. There are a range of communication mechanisms lessons learned where necessary changing policy and training, monitoring completion of action plan. Clinical audit reviews how well embedded lessons are.


None at present.

3.4 Datix ID 1062 (Bed management) 4 x 4 = 16 and owner. Debbie White. Datix ID (Lorenzo) 1146 4 x 3 = 12 Leigh Howlett


a) Bed availability – Whilst the process has been effective in reducing out of county beds. The review of A&A will be complete by the end of September 2014. When the scoping work is completed it will be possible to develop a timeline.


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f) RCA learning – the expectation is that the measures above will increase confidence in mitigation to green, with the proviso that human unpredictable behaviour means that a perfectly safe system may never be reached and there has to be a balance of respecting human rights and securing safety. SIs can never be eliminated completely but the measures above should mean that mistakes are not repeated. In order to provide a timeline further debate will be needed to agree what counts as ‘green’ mitigation confidence.

4.0 Public relations (Communications Committee)


We will look for, and exploit, opportunities to work on prevention and anti-stigma by development and delivery of a robust communication plan, evidenced by monthly positive media messages from launch in September 2014.

4.1 Risk. Negative media messages including those related to the MH ‘crisis’ campaign may damage the reputation of the Trust to the extent that service users are put off from seeking support. This could affect patient safety and also feeds into system confidence.

4.2 Mitigation. Confidence = Amber / Red, as the proactive approach is proving effective but it is not possible to predict the campaign’s future activities.

The new public internet site is now live. The staff cascade communications system will be rolled out in September 2014. There is now a more proactive approach to working with local media and engaging with the ‘crisis’ campaign.

A communications plan was reviewed by the Board at its March 2014 meeting and investment in an increased team has been agreed. This investment will also provide mitigation against the risk of poor staff morale (see below) since it includes resources for internal communications.

Additional staff have been employed to remedy short term issues such as the website redevelopment and establish new communication channels. As the new structure comes into place this will strengthen the capacity of the Trust to ensure balanced coverage.

The newly formed Communication Committee is receiving regular reports on the impact of the communication activity. In July 2014 the Trust generated / responded to 93 stories in the media. Of these 52 (56%) were positive as opposed to 17 positive stories in June, an increase of 306%.

Ultimately the key to improved stakeholder perception lies in performance.

4.3 Additional actions required. Development (and funding) of training on social media to improve engagement (service user and staff) and updating intranet information for staff.


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4.4 Datix ID 1112 (Trust reputation 4 x 4 = 16) and owner Leigh Howlett


Communication activity will always require concerted effort given health is a dynamic environment which attracts negative media coverage due to the nature of the issues dealt with.

Regular review of communication activity and impact by the Communication Committee will be used to ensure that progress is maintained and meets the Trust’s objectives.

5.0 Staff morale (OD and Workforce Committee)


1. Delivery of a Workforce and OD strategy which enables:

• improvement in the staff survey so the Trust is not in the bottom 20% of Trusts in any category by the 2016 results.

• Staff friends and family tests show quarterly improvements throughout the year 2014/15 (measured quarterly on a rolling year)

• stable staff turnover levels of 10% by March 2016

• 90% of staff participating have an appraisal and wellbeing review in the last 12 months

• a 50% increase (from the 2013 staff survey baseline) in staff reporting they have had a meaningful appraisal by March 2016

• sickness rates of no more than 4.5% in any area by March 2016.

• all staff undertake key areas of mandatory training with a target of 90% attainment by March 2016.

2. All vacancies recruited to the point of offer within 8 weeks by March 2015.

3. Develop plans to meet seven day services by end of 2014/15 financial year.

4. Roll out of e-rostering across all clinical areas to support delivery of staff staffing by March 2016.

5.1 Risk. Low staff morale impacts on quality of care as well as our reputation as an employer.

From April 2014 the ‘Friends and Family’ test, including three core staff engagement questions, was introduced to monitor progress with staff engagement on a quarterly rather than annual basis. This will report via the OD and WF


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committee. The initial results for Q1 had a response rate of 4.5% which may lead to sample bias but were disappointing with low scores for both recommending the Trust for care and treatment and recommending the Trust as a place to work. These echoed the 2013 staff survey results which were published on 25.02.14. The Q2 survey is has been widely promoted and staff no longer need to enter their assignment number which may increase the return rate.

Workforce Development and Effectiveness measures as shown in the July 2014 Board Performance Report remain at Red other than for episodes of sickness absence and voluntary resignations.

5.2 Mitigation. Confidence = Red. The range of scores between different localities in the staff survey indicates that low engagement and staff morale is not systemic across the Trust, but the underlying factors are complex.

The Trust has developed a staff engagement plan, alongside a joint working group (with staff side) as part of the OD strategy. Major organisational change can be expected to impact on staff morale in the short term, and executive team members have set up staff engagement sessions to provide an opportunity for staff to raise concerns and to understand the rationale for the changes in more detail. Although the TSS changes have been intense this will mean that teams will reach a steady-state more quickly and will be able to build relationships and job satisfaction more quickly.

The staff appraisal and performance management changes that come into effect later this year will assist in ensuring that all staff are clear as to how their objectives contribute to the Trust’s work and receive feedback on their performance.

5.3 Additional actions required. None at present.

5.4 Datix ID 1065 (Post TSS Impact) 3 x 4 = 12 and 1102 and owner Michael Scott.


The Friends and Family Test is quarterly. The early signs are the current F&FT which closes towards the end of August 2014 will have a significantly higher return rate than the first sample. Results will be available one month later. However, the executive team recognise that the challenges in this area are medium to long term issues and so the expectation is that it will take 12 – 18 months for changes now being implemented to feed through into some measurable improvement.

Following the trial of a new central lean recruitment process for three months this is now being rolled out and delivery of the recruitment KPIs is anticipated by March 2016.

Enhanced management of sickness absence will be introduced over the next quarter and the results should be seen by March 2016.


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The review of the first quarter of the appraisal results as part of the Talent Framework is complete and will be reported at OD&WF committee on 26.08.14

The target for a stable turnover rate of 10% is March 2016.

6.0 Maintaining and growing business (Investment Committee)


By October 2014, delivery of a Commercial Strategy to protect current services and develop new business.

Engage with the wider health economy, third and voluntary sector to ensure the Trust is a known and trusted partner evidenced by a 10% increase in new business with external parties by March 2015, evidenced by financial turnover.

6.1 Risk. Loss of income will destabilise the organisation. Loss of key contracts where we are the incumbent, such as IAPT, could also damage our reputation since they could be interpreted as a loss of commissioner confidence.

Developing bids and winning contracts requires an increasingly specialised skill set where demand is variable and where competitors such as Serco are continually raising the bar. Successful bids require evidence of a track record of delivery which has been variable in recent months.

For an organisation of our size it is a challenge to be able to maintain a strong bid capability with the right skills on tap that is also cost-effective during quieter periods.

Bid development teams need access to specialist service knowledge in the context of clinical managers who are already short of capacity.

6.2 Mitigation. Confidence = Red/Amber.

Resources to support improved bidding capability have been set aside for 2014/15. The two year operational plan and 5 year strategic planning will identify a resource plan to support delivery of the Trust’s agreed strategic direction.


The executive team will restructure support to contract and bidding functions in order to provide greater clarity and focus. An update on this work will be provided to the Board by Leigh Howlett at the Board meeting on 28th August 2014.

6.4 Datix ID1093 (Norfolk IAPT / Wellbeing tender) 4 x 3 = 12 and owner. Leigh Howlett.



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The corporate restructure is planned for September / October 2014. In the interim project support and plans are in place for reviewing and securing current / new business in accordance with their own time frames.

7.0 Maintaining CoSRR of 3 from 2014/15 onwards (Finance and Performance Committee)


Delivery of the 2014/15 financial plan so the Trust achieves a COSRR of 3 as a foundation for 2015/16

Delivery of the 2014/15 CIP and capital programmes

Develop a new strategy for procurement by end of 2014/15 financial year

For the 2014/15 financial year: delivery of all operational targets including receiving 100% CQUIN and the avoidance of any operational and financial penalties from commissioners in the final quarter of the year.

7.1 Risk. Trust finances have worsened in M04 with £0.44m deficit for the month and £0.77m YTD. Temporary pay expenditure levels have risen, this month to £2.39m with total YTD expenditure already at £8.46m (this compares to £4.70m YTD for the previous year). There is a discrepancy between those CIP schemes showing at Gateway 5 and actual reductions in expenditure. The risk is that the Trust fails to meet its financial targets and its future stability is jeopardised which impacts on our ability to provide services.

For the period ending June 2014 the Trust had a deficit of £340k (almost £200k worse than plan) including an overspend on locum doctors of £500k.

7.2 Mitigation. Confidence = Red.

Achievement of CIPS is to be managed outside the executive team meeting to allow greater executive director input into identification of and delivery of plans.

CIP schemes at Gateway 1 are to be progressed to Gateway 2 by 15.09.14.

An increased focus on reducing temporary staffing with a revised control total.

Acute out of area (OOA) placements expenditure has significantly decreased this month to £0.18m.

CoSRR remains at 3 for M04.

7.3 Additional actions required. By 31.07.14 additional schemes were to have been brought forward to address the CIPS 2014/15 shortfall. Although there has been some reduction in this pressure through one-off reserve releases, at M04 there remain £2.6m where plans need to be identified (Gateway 0).

7.4 Datix ID 1084 (TSS finances 4 x 4) / 1090 (Overall CIPs delivery 4 x 4) owner Andrew Hopkins.


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The Finance Report for M04 presented at this meeting sets out the actions underway to address these issues and a timed plan will be available to reach green for the September 2014 board.

8.0 ICT weaknesses (Investment Committee)


Delivery of an ICT strategy which supports engagement with service users and carers in a convenient and timely way and makes best use of clinicians time (e.g. reduce travel) by October 2014

8.1 Risk. The risk is that patient safety and business continuity may compromised by weaknesses in ICT components. In February 2014 the investment committee referred a set of ICT risks to the Audit and Risk Committee. These risks centre on i. Core Infrastructure weaknesses, ii. Disaster Recovery Capability, and iii. Data Backup Capability. Since May 2014’s report there has been significant progress on managing this risk with Datix scores falling.

8.2 Mitigation. Confidence = amber/green moving to green as the investment is rolled out.

The Investment Committee on 5th June 2014 received a detailed verbal report from Lloyd Bye (Head of ICT) who said that the Disaster Recovery Risk has been brought down to an acceptable level. For core functionality the updating of software patches is underway and will take approximately six months to complete. For data back-up plans are underway to find an outsourcing solution that is scalable to the Trust’s needs. There will be an independent audit of ICT weaknesses at the end of the calendar year to confirm that these risks have been appropriately mitigated. There is also a rolling programme to replace MS XP with W7 and a warranty is in place to protect XP security over the transition.

Datix shows an end date for the data backup capability risk of 31.10.14. For Disaster Recovery the procurement process has a risk end date of 31.10.14.

8.3 Additional actions required. None at present.

8.4 Datix ID 1101 (Data backup capability) 5 x 3 = 15, 1100 (Disaster Recovery Capability) 5 x 3 = 15, 1095 (ICT infrastructure 4 x 3 = 12) and owner is Leigh Howlett.

9.0 Conclusion

9.1 Board members are to review the above themes and consider whether any additional actions are required to provide assurance on management of the risks.


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9.2 The board is also asked to consider whether there are additional significant risks that have come to light but which are not represented in the BAF at present.

Robert Nesbitt Trust Secretary

Board of Directors – Public 28 August 2014 Patient Safety & Quality Report

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Author: Jane Sayer Department: Trust Management




Title of Report: Patient Safety and Quality Report July 2014



Author: Jane Sayer, Director of Nursing, Quality and Patient Safety

Director: Jane Sayer, Director of Nursing, Quality and Patient Safety

Executive Summary:

This is a report on current quality and patient safety issues. Information is reported on key areas of concern or activity since the last report to the Board in July 2014. The main messages for the Board to note in this report relate to:

Variation in the numbers of SIs reported continues. Improvements in the process for SIs are summarised.

The Trust has signed up to two national initiatives designed to improve patient safety.

Draft reports on unexpected deaths in West Norfolk and NRP services have been received.

Safe staffing report, and key issues in provision of Registered Nurses in some settings.

Implementation of the Friends and Family Test is under way.

1.0 Report contents

2.0 Patient safety indicators, including complaints and compliments, serious incidents, medication incidents, harm free care, absconsions and assaults.

3.0 Safety and quality reports.

4.0 Benchmarking, including CQC visits.

5.0 Safe staffing.

6.0 Service user and carer experience.

7.0 Quality dashboard.

Date: 28th

August 2014

F Item: 14.110iii


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2.0 Patient Safety Indicators 2.1 Complaints and Compliments

In July 2014, 66 complaints were received. Following amendments to the Complaints process in June 2014, with a central acknowledgement function introduced, this high figure has sustained. With a second month of data the Patient Safety & Complaints Team can commence analysis of this trend.

Chart 1: Number of Complaints received monthly from April 2013

2.1.1 Indicators of Potential Emerging Themes and Systemic Issues

Analysis of the complaints received in July do not indicate a new emerging theme or systemic issue. Whilst there are some concentrations of complaints with particular teams, the individual complaints demonstrate differing concerns. The Chief Executive Office now signs all complaint responses, and the Director of Nursing and Quality looks at random samples of responses. The quality has been found to be generally high, and much more personalised than previously. Review by Governors and NEDs in the future is welcomed.

2.1.2 Compliments

Norfolk: 1 compliment

Suffolk : 5 compliments

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26

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Chart to show Complaints received from April 2013

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13-14ave


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2.2 Serious Incidents

During July there were 13 SIs reported.

Alleged patient abuse 2

Other 1

Patient accident 2

Serious Incident by inpatient 1

Serious Incident by outpatient 1

Under 18 admission 1

Unexpected death - community 5

This represents a decrease of 12 since the previous month.

Chart 2: Trustwide serious incidents reported, January 2012 – June 2014

2.2.1 Improvements to the Process of Serious Incident Reporting

The Serious Incident team has been collating feedback on the SI process from a range of sources, including NEDs, clinicians, service users and carers, and commissioners. A presentation to the Strategic Management Forum (SMF) in August collated the Trust’s response to this, and included all the developments since January 2014, including the Board overview process for Level 2 incidents, the appointment of dedicated RCA facilitators, and a new system for monthly feedback of themes to SMF. A summary is included in Appendix 1, and will be discussed in more detail at the September Service Governance Committee.

April May June July Aug Sept Oct Nov Dec Jan Feb March

12 13 14 18 10 14 17 15 17 12 9 11 13 11

13 14 15 7 21 25 8 18 17 9 15 15 8 14

14 15 20 10 25 13

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2.2.2 Inquests Inquests since the last report are detailed in Table 1. Table 1: Summary of Inquests, July 2014

RCA Locality DOD Inquest date Inquest Verdict

389 Suffolk East 30.3.14 16.7.14 Documentary basis: “died from bronchopneumonia occurring against a background of drug use”.

326 Suffolk West 9.11.13 9.7.14 Took his own life

349 Central 4.1.14 15.7.14

He died as a result of dependence on drugs against a background of physical and mental ill health

396 Central 4.4.14 15.7.14

On 1.4.14 she jumped into the River Wensum. She was pulled out, despite attempts at resuscitation she died in hospital on 4.4.14. Her intention at the time was not known.

375 Gt Yar and Wav 7.3.14 16.7.14

Committed suicide while the balance of his mind was disturbed and whilst under the care of the mental health services.

367 NRP 8.2.14 17.7.14 Drug related

377 Central 6.3.14 17.7.14

Voluntarily toppled from railings to his death. At the time of his death he was suffering from a mental illness of long duration and under the care of mental health services.

381 Gt Yar and Wav 16.3.14 6.8.14

He hung himself. His intention at the time is not known.

2.3 Medication Administration Errors

Whilst there has been an increase in Suffolk site reporting, 20 events of non-recording on Avocet were picked up following a two week audit in May/June. Lack of signature does not mean medication was not given, but there is no recording, which is not acceptable practice. The staff will be putting into place a plan that the clinic door should be closed during medication round to prevent disruption, and the following was made aware to staff;

Patients not to be in the clinic during medication round unless directly supervised by a member of staff – this may relate to times when, to promote concordance the individual wishes to watch medication being dispensed or the need for observation that relates to the taking of medication.

Staff to inform patients (via community meeting) of steps to be taken to minimise risk of error.

Medication competencies to be reviewed with all RMNs.

Prescription card audit to be used as means of on-going audit / quality checking. Band 6 / and pharmacy link to complete monthly.


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Other occurrences have been one or two events over several sites. Moderate harm occurred on two occasions (repeated dose and bloods indicating a red result) and resulted in increased observations of those patients as they recovered.

In Norfolk the recorded errors reduced from 12 (May) to 10 (June) to 6 (July), again in most cases it involved one or two incidents each month, with six events occurring on Churchill Ward (two wrong dose, two given after stop date, one given late and one omission). Of these, three separate events occurred within 12 hours. No harm or adverse outcome was caused in these cases. One event resulted in Moderate harm, following a repeated dose, patient became drowsy and paramedics attended, the patient was kept on four hourly observations and recovered. Chart 3: Trust wide medication administration errors, August 2013 - July 2014

2.4 Prescribing Errors

There were no events reported in Suffolk for this period.

Norfolk reported seven events, of which five were near misses as they were noted before an error occurred, no harm resulted in any of these events. Chart 4: Trust wide medication prescribing errors, August 2013 – July 2014

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2.5 Absconsions A number of absconsions from Glaven ward are now occurring when patients are attending the laundry or OT, as there are a number of doors that are fire doors and observation cannot be maintained. Assessment of the fire door has been undertaken by the Fire Officer and Head of Risk Management & Security. Action: costing need to link the door into an alarm system and or operation on the release.

Chart 6: Trustwide absconsions, August 2013 – July 2014

2.6 Assaults

Suffolk recording increased from 4 (May) 11(June) 8(July) with seven events occurring on Lark ward, five of which were between two patients.

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Norfolk reporting remains consistent. Having reviewed the figures for assaults in June, the number of service user to service user assaults in continuing care services accounted for 45% of the total number. Over the last year, assaults in continuing care facilities accounted for 34% of the total number of assaults, with Blickling Ward accounting for a further 18% of all assaults. The Matrons in these services have been asked to work with the Head of Prevention and Management of Aggression to look into the issue further, and develop an action plan. Chart 7: Trust-wide service user to service user assaults, August 2013 – July 2014

2.7 Harm-Free Care

2.7.1 Pressure Ulcers There have been a total of seven developed pressure ulcers across the Trust between April and July 2014 inclusive. Of these, three patients developed four pressure ulcers in July, one of which is a grade 3 pressure ulcer and therefore a serious incident. Root Cause Analysis is conducted on all pressure ulcers with action plans identified to address any deficits. The root cause analysis process is very robust with any lapse in documentation leading to a decision that the wound was avoidable. Focus on education and training will continue and the trend will be monitored. The action for Abbeygate includes refresher training on completing risk assessments. Carlton Court has identified some issues in the timeliness of risk assessments but also comments on the low numbers of staff on the wards and the use of NHSP

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staff: actions include the handover sheets to include skin checks as a reminder to NHSP staff.

It should be noted that there had been no pressure ulcers on Carlton Court wards since September 2013. These recent pressure ulcers affect achievement of the CQUIN goal set by Great Yarmouth and Waveney commissioners which requires five consecutive months with no reported pressure ulcers using the Safety Thermometer tool.

2.7.2 Slips, trips and falls

The physical health team are currently focussing on analysing all aspects of the falls data for the Trust as recorded on Datix. A member of the team is also liaising with the falls lead for Norfolk Community Healthcare services to benefit from her expertise and experience. The team has weekly access to a volunteer who has proved invaluable in developing databases and presenting data in a reportable format.

The initiatives include:

Applying CCG agreed definitions of falls to those reported on Datix, removing those that do not meet the definition. In reality, these are low numbers but allow comparison of NSFT data with other services.

Reviewing the patient data for each report and identifying those who are falling more than twice, ensuring these have had an MDT review

Following up on individual falls where the Datix information has not provided a considered root cause

Updating the Trustwide action plan to include actions to address common themes emerging from the analysis of the falls

Reporting numbers of falls by bed days

The Datix RCA tool has been in use for approximately one year and will be reviewed to ensure it is providing the most useful information. The policy will be reviewed to ensure it supports best practice and provides simple flowcharts and other supporting material. The training opportunities and resources will be reviewed.

In addition, a potential route to access physiotherapy services for specialist work related to falls for East Suffolk where currently no service exists is being followed up with the contracts team.

It is hoped that this work will address the apparent rising trend in reported falls (Chart 8), although the great majority of these are with no reported harm.


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Chart 8 - NSFT Trustwide Slips trips and fall data (STF) – falls per bed days, 2014

The physical health team lead is an active member of both the Norfolk and Suffolk systemwide falls groups which each focus on initiatives to reduce the number of falls across all services and ensure pathways of care are developed to improve continuity of care.

2.7.3 Safety Thermometer (ST)

The national Safety Thermometer tool provides monthly point prevalence data on harm-free care in the later life wards which participate in data submission. As it is a point prevalence survey, it does not correlate with information reported on the incidence of harms, such as pressure ulcers.

In July 2014, the results demonstrated that three patients had harms, within the ST definitions. These were 2 admitted pressure ulcers and 1 deep-vein thrombosis (that is, VTE) on Sandringham ward. This is followed up with the ward and emphasises the importance of carrying out the VTE risk assessments. The Trust had an overall VTE risk assessment compliance of 91% with many wards consistently achieving 100%. Sandringham ward reported 60% compliance.

The Safety Thermometer data on pressure ulcers for the Trust shows an average of approximately 0.7 patients per month (or 0.53%) developing a pressure ulcer across the surveyed wards: a small number of these will have been assessed to be unavoidable. This should be viewed in context of the previously mentioned provisos.

2.8 Alerts Received From Central Alert System, July 2014

Thirteen alerts were received from the central alert system in July 2014, ten of which required no further action, one for which action has been completed, and two with action pending. These are detailed below in Table 2. Table 2: Actions ongoing, July 2014

0.0048

0.0054

0.0062

0.0069

0.0000

0.0010

0.0020

0.0030

0.0040

0.0050

0.0060

0.0070

0.0080

Apr May Jun Jul

Apr May Jun Jul


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Action Ongoing Additional information for Mental Health Units with regards to EFA/2014/002: E-cigarettes, batteries and chargers – action points to be taken forward by the Physical lead for example e-cigarettes to be included on the smoke free strategy. Alert will be discussed at the Health & Safety Committee meeting 14.08.2014 Completion date of alert 29.09.2014 NHS/NPSA/005 Improving medication error incident reporting and learning Completion date 19 September 2014. Action to date: Reminder email sent 24.07.2014 requesting evidence that action points have been considered.

Safety, availability and suitability of equipment- At recent Medical Devices Standards group it was raised by representative from EME (electrical biomedical engineering) at NNUH, Ipswich, Queen Elizabeth, Hospital that currently no contract is in place for routine maintenance of medical devices. That maintenance checks are carried out on good will and because of historical practice. Action to date: no reply received from initial and subsequent emails sent to Procurement lead.

3.0 Quality Reports

3.1 Safeguarding

Training compliance; the Trust is compliant at Level 1 and 2 training, Level 3 training remains on the risk register and the action plan to address this continues. Compliance is expected by December 2014.

The new RCPCH Intercollegiate document which is the document the Trust is measured against in terms of training competencies for safeguarding training has been revised. This will have implications for the Trust and how training is delivered, at what level and to whom. One aspect for the Board to consider is that the Board, including Non-executive Directors, should receive safeguarding training and updates annually.

3.2 Whistleblowing

The Trust has been asked to report to Monitor the number of Bullying and Harassment cases brought through the Public Interest Disclosure route related to bullying by Senior Managers between April 2011 and March 2014. There have been three such cases;

https://www.cas.dh.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=102146


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1. The Trust could not investigate as none of the witnesses would make a formal statement, anonymous or otherwise, and therefore natural justice could not be applied.

2. Investigated; no case to answer. 3. Investigated; informal sanction given.

As a result of these cases the relevant policies are under review by the Governance and Human Resources teams to reflect lessons learnt, and to inform both those who raise concerns and those who deal with them of the correct process for individual cases, support available for all parties and outcome management frameworks.

3.3 Sign up to Safety

Sign up to Safety is a national patient safety campaign that was announced in March by the Secretary of State for Health. The campaign was launched on 24 June 2014 with the mission to strengthen patient safety in the NHS and make it the safest healthcare system in the world.

The Sign up to Safety campaign supports the principles that organisations listen to patients, carers and staff, learn from what they say when things go wrong and take action to improve patient’s safety. Sign up to Safety aims to deliver harm free care for every patient, every time, everywhere. It champions openness and honesty and supports everyone to improve the safety of patients.

Organisations who Sign up to Safety commit to strengthen patient safety by:

Setting out the actions they will undertake in response to the five Sign up to Safety pledges and agree to publish this on their website for staff, patients and the public to see.

Committing to turn their actions into a safety improvement plan which will show how organisations intend to save lives and reduce harm for patients over the next 3 years.

The campaign is based on 5 key safety pledges:

Put safety first. Commit to reduce avoidable harm in the NHS by half and make public the goals and plans developed locally.

Continually learn. Make their organisations more resilient to risks, by acting on the feedback from patients and by constantly measuring and monitoring how safe their services are.

Honesty. Be transparent with people about their progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong.

Collaborate. Taking a leading role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use.

Support. Help people understand why things go wrong and how to put

https://www.gov.uk/government/speeches/sign-up-to-safety-the-path-to-saving-6000-lives

https://www.gov.uk/government/speeches/sign-up-to-safety-the-path-to-saving-6000-lives

http://www.england.nhs.uk/signuptosafety/about/#signs

http://www.england.nhs.uk/signuptosafety/about/#signs


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them right. Give staff the time and support to improve and celebrate the progress.

To sign up to the campaign the Trust needs to set out what actions it will take to

strengthen patient safety by:

Describing the actions the Trust will undertake in response to the five Sign up to Safety pledges and publish these on the Trusts website for staff, patients and the public to see.

Commit to turning proposed actions into a safety improvement plan which will show how the Trust intends to save lives and reduce harm for patients over the next 3 years.

Identify the patient safety improvement areas the Trust will focus on for which the Trust will be supported to identify two or more areas from a national menu of high priority issues and two or more from our own local priorities.

The Trust will announce its intention to Sign up to Safety in August 2014.

3.4 Speak out Safely The Speak out Safely (SOS) campaign led by the Nursing Times aims to encourage NHS organisations and independent healthcare providers to develop cultures that are honest and transparent, and to encourage staff to raise the alarm when they see poor practice, and to protect them when they do so.

The Trust is signing up to this campaign to demonstrate to staff a clear message that it is committed to safe patient care and to empowering staff to raise concerns in the knowledge that they will not suffer as a consequence.

The Trust’s involvement and support of the Speak out Safely campaign will be acknowledged in the SOS section of the Nursing Times website as well as displayed on NSFT Website.

There is no cost to signing up to the campaign and the process to signing up is a straightforward process and is achieved by taking the following steps:

The Trust will display the SOS logo and pledge prominently on the Trust website,

Ensuring that the Trust whistleblowing policy makes explicit that staff will be supported if they raise concerns; that all staff know where they can find the policy; and that it is publicly available rather solely via the Trust intranet.

Once these actions are completed the Trust will email the evidence to the SOS campaign who then acknowledge the Trust’s support and commitment to the campaign.

3.5 Learning Disability Strategy

In preparing for the Monitor declaration on access to services for people with a learning disability, it was identified that the Trust has inconsistent approaches to


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the provision of mental health care for this group. Further work was agreed to address these inconsistencies. Previous audits demonstrated that some excellent work had been undertaken, but that this had not been followed through the Trust merger and TSS process. As a result, the Trust needs to pull together these previous strands of work, and develop much better relationships with service users and carers in developing a meaningful strategy. The Trust is working with the National Delivery Team for inclusion (NDTi) to provide some short-term solutions and then support the development of a strategy within the next six months. Updates will be provided to the Board on this vital piece of work.

3.6 External Review of Unexpected Deaths in West Norfolk

West Norfolk CCG commissioned an external review of ten unexpected deaths from April 2013 in West Norfolk. The draft report on nine of these incidents has been sent to the Trust for data checking, and a final report is expected in September. The locality is developing an action plan in response to the report, with Trustwide learning being carried through by the Patient Safety Team, and this will be discussed at the Service Governance Committee.

3.7 Internal Review of Serious Incidents in Norfolk Recovery Partnership A review of the unexpected deaths in NRP was commissioned by the Director of Nursing and Quality on behalf of the Board in March 2014, commencing in late April 2014. This was in response to an apparent increase in the number of deaths being reported by the newly-commissioned service, although there was no comparison for this trend, as the service had not been operational for sufficient time to provide any baseline data. Despite this, the Board was keen to establish if the number of deaths being reported was within the range expected, and whether there were any operational issues that may have contributed. Being able to implement lessons learned from previous incidents was also an area of concern. Terms of Reference were drawn up and agreed with the NRP management and commissioners, and an external expert appointed to undertake the review.

Although the report was initially due back in July 2014, delays in securing access to incident reports, and then leave by the report author has meant that a draft report was produced in July, and the final report is due by the end of August 2014. NRP managers have seen the draft report, and been informed of findings as the investigation was underway, in order to make any immediate changes required, and to link to the service’s quality improvement action plan. The recommendations in the final report will augment the service’s improvement plan, and form part of quality monitoring by commissioners. This will also be discussed at the Trust’s Service Governance Committee.

4.0 Benchmarking – Evaluation Against National Standards And Reports

4.1 Mental Health Act Commission (MHAC) CQC visits Since the last report the CQC have visited Rollesby ward and the reports for Rollesby and Glaven wards have been received. The issues continue to be the same: recording patients’ rights (Sec 132), and T2 and 3 forms being correct and


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also attached to medicine cards. Reminders have been issued to relevant staff to ensure that this is rectified, and additional checks are being put in place. Glaven ward was felt to breach standards of privacy and dignity due to the poor environment and possible breaches of single sex regulations. A decision was made on the 8th August to re-designate the wards as single gender. Although the gender distribution has largely been equal, this will result in less flexibility in bed availability, so conversion of a room on each ward to an additional bedroom has been commissioned to give greater capacity to manage admissions. It is intended to complete the work needed and change the wards in September 2014.

4.2 CQC Full Trust Inspection

Preparation for the visit is under way and awareness sessions for all staff are taking place as well as benchmarking sessions with team leaders. In addition, the 15 steps framework is being used to assess patient environments and clinical leads are supporting governance to assess their areas. The Fortnightly Focus on one of the five key questions that the CQC will ask is designed to ensure that the awareness and benchmarking is undertaken in manageable sections and an overview has been produced which compares the old Essential Standards with the new Fundamental Standards so that the work undertaken by teams in the past is not lost. A newsletter is being produced and a FAQ list is available on the intranet in a dedicated link. Areas of risk are being collated and reported to the executive team

4.3 Mock CQC Inspections. The mock inspections will continue until September. Inspections undertaken in July are detailed in Appendix 2, and include visits to:

Rose Ward

Reed Ward

HTT, West Suffolk

Bury South IDT

Churchill Ward 4.4 Non-Executive Director Visits

One visit was recorded in July 2014 to the Norvic Clinic, and the findings are detailed in Appendix 3.

5.0 Safe Staffing 5.1. In line with the Government’s requirements as set out in Hard Truths, the Trust

continues to submitted data via the National reporting system Unify 2 with the 3rd


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submission entered on 15th August. The data submitted in August reporting on July’s figures demonstrates a 109% fill rate of planned level. The data reported continues to demonstrate actual staffing levels compared against the ward established figures. This data is reported in Appendix 4. The mean staffing levels against establishment are shown in Table 3 below. A clear example of how the needs of the services can vary against established figures is demonstrated by Rose ward which has shown higher than expected fill rates due to the high number of service users currently on 1:1 observations and a variation in unexpected activities on the ward.

Table 3: Mean staffing, actual against establishment, July 2014

RN % fill against establishment

HCA % fill against establishment

Day shifts 99.8% 122.4%

Night shifts 92.5% 134.2%

The headline fill rate shows a decrease from 102.70% of RN’s by day compared to June but an increase from 88.8% to 92.5% by night. This shortfall continues to be mitigated by increase fill rates of HCA’s which have increase from 117.4% by day and 132% by night in comparison to June.

Identified hotspots via safe staffing reporting include:

Foxhall House average fill rate of RN’s 63.71% in July by day and 54.8% by night

Poppy Ward average fill rate of 75.81% of RN’s by day but achieving 95.2% by night.

Rose Ward average fill rate 75.81% of RN’s by day but achieving 100% at night

A number of areas also report RN’s average fill rates of 80% or under on one or other shift. These include:

Night shifts

Glaven Ward 79%

Acle Ward 74.2%

Whitlingham Ward 50%

Sandringham 80.6%

Blickling Ward 62.9% Day Shifts

6 Airey Close 80.65%

Reed Ward 80.65%

All of the above areas demonstrate over-establishment of support workers in July to mitigate against the lack of RN’s. Monitoring is in place at monthly patient


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safety meeting to monitor for any emerging clinical and safety concerns that could be attributed to lack of staff.

Of note, only 6 Airey Close and Glaven are represented in the staffing concerns Datix reports below. Foxhall, Poppy or Rose Wards have not submitted reports to Datix that would reflect the concerns reported by their average fill rates.

5.2 Reporting of Staffing Concerns via Datix

A total of 148 concerns regarding staffing have been reported in July 2014 compared with 160 reports in June. Of these, the highest reporting category is low staffing levels with 67 reported incidents in this category, a decrease from 94 reports in June. The wards which contributed the highest level of reporting in this category are:

6 Airey Close - 12

Glaven Ward - 7

Lark Ward - 5

Yare Ward - 5

Of the reports received related to staffing concerns, low staffing continued to present the highest trend. A breakdown of categories of the highest reported incidents shown in Table 4: Table 4: Staffing concerns reported in July 2014

Highest Number of Categories Reported

Highest Reporting Areas – Number of Reports

Low staffing levels 67

Central Acute Services - 12 East Suffolk Acute services - 10 6 Airey Close - 12

No or lack of trained supervisory staff - 28

Central Norfolk Acute Services – 11 East Suffolk Acute service - 6

Insufficient regular nursing staff - 10

Central Acute Services - 7 East Suffolk Acute Services -2 Abbeygate - 1

Of the 67 low staffing incidents reported within Suffolk Specialist Services, twelve can be attributed to Number 6 Airey Close. Within East Suffolk Acute Services Lark Ward accounts for a total of five of the ten low staffing concerns reported during July. Glaven Ward accounts for seven of the twelve reports within Central Acute Services.

July has seen an increase from 23 to 28 reports of no or lack of trained staff, eleven of these are within central Norfolk Acute services, with six attributed to


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Glaven Ward. Lark Ward accounts for four of the six reports within East Suffolk Acute Services. Reports received regarding insufficient regular nursing staff has also increased from seven in June to ten in July. Seven reports are attributed to Central Acute Services with five reported from Glaven and two from Rollesby.

Vacancies and short-term staffing issues will continue to be addressed within meetings with NHSP, and when possible, those wards with the most acute staffing issues have been prioritised within recent central recruitment events.

6.0 Service User and Carer Experience 6.1 Service User and Carer Payment Policy

The payment policy and guidelines will be submitted to the Service User and Carer Trust Partnership meeting on 22nd August. The new guidelines will ensure that payments are made promptly and staff, service users and cares are able to complete return reimbursement forms, following the set procedure. The Service User and Carer Trust Partnership will set a review date for the guidance.

6.2 Service User and Care Involvement Strategy Work is on-going to produce the combined service user and Carer involvement strategy. There is a working group of service users, carers, staff and members of our third sector partners to ensure that all work is coproduced. The working group is facilitated by the NSFT Involvement Team, who will put wider consultation processes in place once the draft is complete.

6.3 Interview Process for Service Users and Cares It has been agreed by HR Business Partners and Involvement Team there will be a rota system in place for all rolling recruitment events in central Norfolk and Suffolk. This process will ensure that service user and carer involvement in the interview process is fair and equitable when interviews are rolled out over a number of days. Discussions are on-going with regard to the service user and care input in to a revised recruitment training module and delivery of the module.

6.4 Friends and Family Test As from the 1st January 2015 the FFT will be introduced in all mental health services. The recently published Friends and Family Test Guidance published on 27th July 2014 sets out the guidance for implantation within services. The implementation of the FFT is aligned to a National CQUIN. The FFT data must be submitted to NHS England monthly. The implementation of the FFT is part of a National CQUIN and has a value to the Trust of £214,063 for full implementation before the end of December 2014. Funding of 20% of the patient FFT is to be awarded for partial implementation in services, as per FFT guidance, from 1 October 2014.


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Although the use of digital pens has been welcomed in various parts of the Trust, it is unlikely that the digital pens will provide a long-term solution to the collection and submission for FFT as the FFT has to be available for service users to access 24 hours a day, 7 days a week. Collating the information would also be labour intensive and resource heavy. As a result, the Executive Team have decided to contract an external company to provide the support required to collect the data and provide meaningful information, and the data collection is hoped to start in October 2014.

7.0 Quality Dashboard (Appendix 5)

The Quality Dashboard is still in development; on-going improvements planned in conjunction with the Informatics Team continue. Work has been delayed this month due to leave, so improvements discussed at the Board in July 2014 are now anticipated in September.

8.0 Risks / Mitigation in Relation to the Trust Objectives (Implications for Board Assurance Framework)

8.1 Quality and patient safety issues are fundamental to the delivery of Trust objectives, and the Board’s ability to manage the performance of the Trust. Relevant mitigating action is included above, and residual risks are noted.

9.0 Recommendations

9.1 The Board of Directors is asked to note and approve the contents of this report.

Jane Sayer Director of Nursing and Quality 14th August 2014

Background Papers / Information Appendix 1: Improvements to Process of Investigating Serious Incidents Appendix 2: Mock CQC Visits, July 2014 Appendix 3: NED Visits, July 2014 Appendix 4: In-Patient Staffing, Actual Vs. Budget, July 2014 Appendix 5: Quality Dashboard, Q2, 2014


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Appendix 1: Improvements to Process of Investigating Serious Incidents Since January 2014, a number of actions have been taken in relation to the Trust’s processes of responding to serious incidents. Improvements have been informed by NE D scrutiny of the RCA process, feedback from clinical staff, service users and carers, and feedback from commissioners and Coroners. Reporting and Investigation

Since January 2014, all Level 2 and 3 incidents (In-patient deaths and other high impact incidents) have Director level scrutiny from the outset of the investigation. An Executive and a Non-Executive Director, one of whom must be from a clinical background, meet with the investigation team at the outset of the investigation to agree Terms of Reference. When the draft report is produced, a meeting is chaired by the two Directors, with the investigation team, clinical team, commissioners and other stakeholders to review the process of investigation and agree the final report, including recommendations and an action plan.

Funding for two Band 7 clinicians has been identified to join the Patient Safety team. Seconded from clinical services, these two posts will lead on investigation of Level 1 incidents, and it is anticipated that they will focus on all suicide and suspected suicide incidents. This dedicated resource means that there will be a consistency to these investigations, and clinical services, although still supporting the investigations, will not have to lead these investigations. The facilitator for Norfolk will start in September, and we are recruiting to the Suffolk post currently.

The two initiatives above means that there will be clear identification of timelines at the outset of investigations, ensuring that all incidents are investigated in a timely manner, and that clinical teams will know when to expect feedback and requests for checking of reports prior to finalisation. Since the CCGs started requiring a response within 45 days (April 2014), the Trust has not incurred any fines for late reports.

RCA Facilitators are now asked to consider when to engage family members and carers sensitively, so any questions that may want to ask can be included in the RCA process. Sometimes, the timing may mean that this is too early for the family to think about what they would like to know, so the Trust continues to allocate a family liaison member who can raise issues and questions at any stage.

The Trust now uses a consistent approach for falls and pressure ulcers, which addresses the issues that commonly arise in such incidents.

Reports and Recommendations

From recommendations made, the Trust is considering how to include a more personalised description of the service user in the RCA report, as they may be considered rather cold and clinical.

Facilitators are being asked to consider fewer and SMARTer recommendations that address the root cause of the incident, in order to increase the likelihood of actions that will prevent incidents recurring.

There will be feedback to managers at an early stage regarding professional issues that should be followed up separate to the RCA process. Although the Trust supports a No Blame culture, there are sometimes situations that occur where professional concerns need to be explored, and this is picked up concurrently.

Date: 28th

August 2014

F Item: 14.110iii Appendix 1


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All actions identified as part of an RCA process are followed up until completed, including embedding of lessons.

Learning Lessons

There is a monthly review of RCAs by the Medical Director and Director of Nursing, with themes fed back to the Lead Clinicians and operational managers at the Strategic Management Forum.

Learning events are held locally to inform clinical staff of findings from RCAs

Dissemination of learning is done through management and professional routes, and the embedding of learning is assessed through audit processes.

Themes from SIs are fed into the Trust’s Risk Register and Board Assurance Framework, so there is Board level assurance on embedding of learning through the Service Governance Committee.

Appendix 2: Mock CQC Visits


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DATE Location ISSUES RAISED

02/07/14 Rose Ward, Hammerton Court

Information for service users and carers not visible.

Activity timetable needs review as it appears over ambitious and staff shortages means it is not being delivered.

VTE assessments not completed/documented.

Additional observations training and register was not identifiable and not known about.

Bedrooms are locked so there is no free access. Action plan update requested 08.08.14

03/07/14 Reed Ward, Hammerton court.

Staffing issues?

Compliance with single sex requirements is difficult due to the availability of assisted toilets.

Information for service users and carers is not visible.

Activity timetable needs review as it appears over ambitious and staff shortages means it is not being delivered.

Action plan update requested 08.08.14

10/7/14 HTT West Suffolk

Very positive visit

Staff on occasion will bring drugs back from patients houses either because they have too many and it poses a risk in which cases they will deliver the dose as required or because they have stockpiled drugs which are no longer required and they are brought back for disposal. There needs to be a documented, safe process for recording, transport, storage and disposal; also dispensing if then taking back to patient’s house.

The drug fridge temperature must be recorded according to policy.

10/7/14 Bury South IDT

Staffing levels were mentioned by several staff – it was felt that there was still an impact from TSS affecting vacancy levels; also on sickness levels. One staff member felt that moving teams had left her feeling out of her depth – however this was counteracted by another staff member who had sourced additional training to support herself in her new role.



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Some care plans were not reviewed regularly (standard stated as 6-monthly if nothing has changed), some exceed this – this was stated to be because of high caseload. There was a view that service users are frightened of discharge (and staff members may be reluctant to discharge service users) because of difficulties getting back onto caseload. There was little evidence of discharge planning with CPA review prior to this (although there was evidence of MDT handover from one service to another with a transitional care plan). There was an impression that the service was not recovery focussed. Data protection was brought up as a reason for not involving a carer in care planning. The process for transporting patient medication needs reviewing and standardising with documentation to support risk management. The distance to travel for training was felt to be a barrier – a suggestion that there is a training day when the relevant sessions are brought to the teams (as with safeguarding training on the day of the visit). There are some inexpensive improvements to the environment which could be made which would create a better impression for service users eg rationalising furniture, filling holes and adding art work. Action plan update requested 08.08.14

31/07/14 Churchill Ward Fermoy Unit. Kings Lynn.

Pt 4580282213 – T3 needs to be attached to medicine card.

Please check all section patients’ paperwork is in order.

Female lounge needs a sign.

Inconsistent picture.



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Paperwork:

o Not correctly filed

o Some documents undated, unsigned – crucial

o Risk assessments with no plan

o Risk assessments not completed

o Care plan and risk assessment file – difficult to find – not consistently filed – duplicates.

o Care plans completed with review date but then review not evident

o T2 / 3 forms not on medication

o 132 rights recording

o Care plans not shared / signed

15 Steps – good.

Leaflets:

o Check only the current version is available

o Posters still with N&W on

No social engagement at lunch, otherwise good.

Action plan update requested 08.08.14

Appendix 3: NED Clinical Visits


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Board Member Ward visited Date Personnel seen Comments

Graham Creelman Catton Ward, Norvic Clinic

17 July 2014 Secure Services Manager, Acting Ward Manager, Mental Health Nurse, Service Users and Staff

The ward was calm, with observed good engagement between service users and staff, although the staff were largely agency on this day

There was strong support for the MDT approach which appears to be working well

Praise for the Secure Services Manager as an approachable and engaged leader

Service Users felt the staff were overall helpful, supportive and accessible

The Acting Ward Manager stated the absence of a psychological therapies strategy was becoming a serious issue

Lorenzo needed to take on board that the documentation for secure services is quite different from other areas

It was said that delayed transfers to other areas of the Trust are often caused by “the rest of the Trust” having too little knowledge and understanding of secure services

A perceived lack of activities for service users. The access to music appears to be a general issue.. The Trust might investigate creating a library of varied music on MP3 sticks.

Appendix 4: In-Patient Staffing Actual versus Budget, July 2014

Day Night Day Night

Reg Unreg Reg Unreg

Total monthly planned staff hours

Total monthly actual staff hours







Average fill rate as % of established hours - registered nurses (%)

Average fill rate as a % of established hours - care staff (%)

Average fill rate as a % of established hours - registered nurses (%)

Average fill rate as a % of established hours - care staff (%)

5 Airey Close 930 885 1162.5 1215 232.5 225 465 442.5 95.2 104.5 96.8 95.2

6 Airey Close 930 750 1395 1522.5 232.5 232.5 465 697.5 80.6 109.1 100.0 150.0

7 Airey Close 465 570 1395 1380 232.5 247.5 232.5 315 122.6 98.9 106.5 135.5

Abbeygate 930 937.5 1860 2227.5 465 450 465 660 100.8 119.8 96.8 141.9

Acle 930 877.5 1395 2212.5 465 345 465 855 94.4 158.6 74.2 183.9

Avocet 1395 1282.5 1162.5 1635 465 420 465 877.5 91.9 140.6 90.3 188.7

Blickling 930 960 1860 2340 465 292.5 697.5 1072.5 103.2 125.8 62.9 153.8

Catton 930 997.5 1395 1350 232.5 232.5 697.5 697.5 107.3 96.8 100.0 100.0

Churchill 930 1050 1395 1417.5 465 472.5 465 465 112.9 101.6 101.6 100.0

Drayton 930 1102.5 1395 1507.5 232.5 277.5 465 517.5 118.5 108.1 119.4 111.3

Eaton 697.5 862.5 1162.5 1762.5 232.5 232.5 465 690 123.7 151.6 100.0 148.4

Fernwood 465 457.5 1860 2107.5 232.5 202.5 697.5 930 98.4 113.3 87.1 133.3

Foxglove 465 465 1860 1875 232.5 225 930 765 100.0 100.8 96.8 82.3

Foxhall 930 592.5 1162.5 1875 465 255 465 990 63.7 161.3 54.8 212.9

Glaven 930 952.5 1395 1350 465 367.5 697.5 750 102.4 96.8 79.0 107.5

GYAS 930 937.5 930 1147.5 232.5 442.5 465 585 100.8 123.4 190.3 125.8

Lark 930 1087.5 1395 2032.5 465 390 697.5 1230 116.9 145.7 83.9 176.3

Northgate 1117.5 1290 1057.5 1162.5 217.5 232.5 435 465 115.4 109.9 106.9 106.9

Poppy 1395 1057.5 1162.5 1845 465 442.5 465 772.5 75.8 158.7 95.2 166.1

Reed 930 750 1395 2572.5 232.5 232.5 465 885 80.6 184.4 100.0 190.3

Rollesby 930 1102.5 1395 1995 232.5 270 697.5 1057.5 118.5 143.0 116.1 151.6

Rose 930 705 1395 2917.5 232.5 232.5 465 900 75.8 209.1 100.0 193.5

Sandringham 930 1027.5 1860 2520 465 375 697.5 1185 110.5 135.5 80.6 169.9

Southgate 1395 1537.5 1395 922.5 465 420 465 480 110.2 66.1 90.3 103.2

Sweetbriar 465 487.5 1860 1860 232.5 232.5 465 570 104.8 100.0 100.0 122.6

Thorpe 697.5 570 1162.5 1395 232.5 247.5 465 465 81.7 120.0 106.5 100.0

Walker Close 930 915 1860 1905 465 465 697.5 757.5 98.4 102.4 100.0 108.6

WAS 930 900 930 1042.5 465 450 465 472.5 96.8 112.1 96.8 101.6

Waveney Ward 930 937.5 1395 1372.5 465 457.5 465 502.5 100.8 98.4 98.4 108.1

Whitlingham 930 1027.5 1395 1155 465 232.5 465 697.5 110.5 82.8 50.0 150.0

Willows 1162.5 1245 1860 2805 465 465 697.5 892.5 107.1 150.8 100.0 128.0

Yare 930 885 1395 1530 232.5 240 697.5 712.5 95.2 109.7 103.2 102.2


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Report Published 14/08/2014

Quality and Safety DashboardBy Location and SpecialtyQ2 (Jul) 2014-2015 version 3.0

Page 1 of 6

Report Published 14/08/2014 Risk Management by Locality

Q2 (Jul) 2014-2015 Deliberate Self

Harm Physical Assault Restraint

Slips Trips &

FallsAbsconsions Complaints

Medication

Administration

and Prescribing

Pressure Ulcers

Serious

Incidents (ward

based patients)

Serious

Incidents

(community &

office)

Norfolk Central (Adult) 16 4 27 1 23 2 1

Norfolk Central (Child Family & Young People) 2

Norfolk Central (Older Persons) 2 19 23 45 1 2 2 2

West Norfolk (Adult) (Under 65 / Non Pt related) 5 6 4 2 7 1

West Norfolk (Older Persons 65+) 1 1

Great Yarmouth & Waveney (Adult) 10 8 1 4 1 1

Great Yarmouth & Waveney (CAMHS) 1

Great Yarmouth & Waveney (Older Persons) 5 7 12 2 3 2 1

Norfolk & Waveney Total 34 28 71 62 3 39 7 5 4 4

Suffolk East Assessment/Treatment 13 4 16 10 4 5 1

Suffolk Countywide 4 1

Suffolk East Central IDT 1

Suffolk East Coastal IDT 1

Suffolk East Ipswich IDT 1 6 1 1

Suffolk Specialist Services 13 1 34 5 1

Suffolk West

Suffolk West Assessment/Treatment 7 1 7 16 1 4 1 2

Suffolk West Bury North IDT

Suffolk West Bury South IDT 2

Suffolk Total 34 6 57 31 2 22 7 2 1 2

Norfolk Recovery Partnership 3 1 2 1

Other (Non Trust Incident) 1

Secure Services 18 7 28 3 1 2 4 1 1

Corporate & Support Services

Other Total 21 8 29 3 1 4 4 1 2

Trust Total 89 42 157 96 6 65 18 7 7 8

Data Collated and Published by: Informatics Source of Data: Datix Page 2 of 6

Report Published 14/08/2014 Risk Management by Service Line

Q2 (Jul) 2014-2015Deliberate Self

HarmPhysical Assault Restraint

Slips Trips &

FallsAbsconsions Complaints

Medication

Administration

and Prescribing

Pressure Ulcers

Serious

Incidents (ward

based patients)

Serious

Incidents

(community &

office)

(N & S) Access & Assessment

(N & S) Adult 1 1

(N & S) Adult Acute 43 6 50 6 8 1

(N & S) Adult Community 1 1 2

(N & S) CAMHS/Youth 1

(N & S) Criminal Justice Liason

(N & S) Dementia & Complexity in Later Life (DCLL) 2 24 30 57 3 5 4 2

(N & S) Low Secure Services 7 5 4 2 1

(N & S) Older People Acute Service 1 3 24 2 2

(N & S) Other

(N & S) Youth

Norfolk & Suffolk Total 56 35 87 88 15 7 6 5

(N only) Medium Secure Services 11 2 24 3 2 1

Norfolk Total 11 2 24 3 2 1

(S only) Complexity in Later Life (CLL)

(S only) Enhanced Community

(S only) Neurodevelopmental 1

(S only) Neurodevelopmental Acute

Suffolk Total 1

Other Total 22 5 46 5 1 2

Trust Total 89 42 157 96 6 65 18 7 7 8


Report Published 14/08/2014 Workforce by Locality

Q2 (Jul) 2014-2015

% of

Sickness

Absence

Episodes >=

21 Days

% of Staff

with an

Appraisal in

the Last 12

Months

Annualised

Sickness

Absence

Rate

Turnover

Rates

Vacancy

Rate

Number of Statutory /

Mandatory Training

Elements which are 40%

below compliance

Central Norfolk 12.3% 11.0% 5.8% 14.6% 10.0%

Great Yarmouth & Waveney 11.5% 7.5% 5.0% 17.2% 8.4%

West Norfolk Locality 11.3% 14.4% 6.7% 17.8% 9.3%

Norfolk & Waveney Total

Suffolk East Assessment

/Treatment9.5% 19.4% 5.8% 12.6% 7.9%

Suffolk Wellbeing

Suffolk West

Assessment/Treatment11.8% 11.7% 4.8% 19.3% 21.0%

Suffolk Access & Assessment

Suffolk Total

Secure Services 16.9% 17.2% 8.0% 8.3% 9.0%

Corporate

Trust Total 12.1% 16.4% 5.6% 14.3% 12.4% 13/33

£k Jul Aug Sep Totals

Bank (incl Locum) 731.8 - - 731.8

Agency 1,672.0 - - 1,672.0

Overtime 104.1 - - 104.1

TRUST TOTAL 2,507.9 - - 2,507.9

Total Spend on Temporary Staffing - the total spend on temporary staffing is a

consolidated figure for the whole of the Trust and includes total temporary pay and

overtime pay.

Data Collated and Published by: Informatics Source of Data: ESR Page 4 of 6

Report Published 14/08/2014 Workforce by Service Area

Q2 (Jul) 2014-2015

Workforce Planned

Establishment (Budgeted

FTE)

Vacancy Rate Turnover Rates Absence RateSickness Absence

Episodes >= 21 DaysAppraisals Wellbeing

Corporate Total 769.5 20.8% 15.5% 3.8% 11.4% 19.7% 3.8%

Adult Acute 344.1 13.9% 14.8% 6.6% 13.5% 2.7% 0.3%

Adult Community 227.2 17.7% 23.3% 8.6% 17.3% 5.0% 1.4%

Children & Youth 255.2 6.1% 6.3% 3.5% 7.7% 14.8% 1.5%

Continuing Care 129.2 5.4% 19.5% 4.7% 6.9% 6.9% 1.5%

Iapt/Wellbeing 173.8 9.3% 19.3% 4.7% 11.7% 19.2% 0.6%

Management & Admin 169.4 2.2% 11.4% 4.2% 8.5% 2.7% 0.5%

Older People 264.1 6.0% 20.6% 6.2% 14.9% 22.7% 6.3%

Norfolk Total 1,562.9 9.4% 15.9% 5.6% 11.9% 10.4% 1.8%

Low Secure 175.2 10.3% 9.0% 7.3% 16.5% 12.8% 0.6%


Medium Secure 169.9 6.6% 9.5% 9.9% 17.6% 18.7% 1.8%

Secure Services Total 408.7 9.0% 8.3% 7.9% 16.9% 17.1% 1.0%

Substance Misuse 107.0 7.6% 13.8% 7.8% 14.5% 9.8% 0.0%

Substance Misuse Total 107.0 7.6% 13.8% 7.8% 14.5% 9.8% 0.0%

Adult Acute 264.8 18.5% 9.5% 5.9% 10.1% 15.8% 1.1%

Adult Community 63.8 9.1% 25.6% 5.1% 11.6% 16.5% 1.2%

Children & Youth 85.9 9.4% 26.6% 4.6% 11.4% 9.6% 1.0%

Enhanced Wellbeing 42.3 7.1% 12.5% 3.9% 5.1% 9.2% 0.0%


Neuro-developmental 130.6 4.0% 10.9% 5.0% 7.2% 12.4% 3.1%

Older People 186.3 17.6% 15.5% 5.8% 12.7% 23.8% 0.9%

Suffolk Access & Assessment 67.3 18.2% 6.5% 5.3% 10.2% 80.7% 6.4%

Suffolk Wellbeing Service 102.4 5.9% 3.3% 7.0% 9.8% 16.4% 1.6%

Suffolk Total 1,066.7 12.5% 13.3% 5.7% 10.2% 23.0% 1.9%

Grand Total 3,914.9 12.4% 14.2% 5.6% 12.1% 16.4% 2.1%

Data Collated and Published by: Informatics Source of Data: ESR Page 5 of 6

Report Published 14/08/2014 Risk Management Definitions

Risk Management

Deliberate Self Harm Where a service users harms themselves in any way. i.e. scratching, cutting, overdose, attempted

hanging, strangulation, set light to self etc.

Physical Assault Where one service user makes contact with another

Restraint Where a service user needs to be restrained

Slips Trips and Falls Slip, trip or a fall.

General Comment The data is selected from a pick list on the Datix database, users do not need to type in the

information. The information is updated on the system by the Datix administrator.

Workforce

% of sickness absence episodes

> = 21 days

The total number of staff expressed as a percentage of sickness absence who have a sickness episode

of more than 21 days.

% of Staff with a Wellbeing

interview We have no information on how this is calculated as yet.

% of Staff with an Appraisal in

the Last 12 Months The number of staff appraisals in rolling 12 months.

Annualised sickness absence

rate

The number of full time equivalent (FTE) calendar days lost to sickness absence in a rolling 12 month

period expressed as a percentage of available FTE calendar days in a rolling year.

Number of statutory/mandatory

training elements which are

below 40% compliance.

Number of statutory/mandatory training elements which are below 40% compliance.

Total Spend on Temporary

Staffing

This includes the total staff payments for temporary staff for the month with an additional figure for

overtime.

Turnover Rates Number of leavers (HC) divided by average staff in post over the previous 12 months. Permanent staff

only.

Vacancy Rate (WTE)

The vacancy rate calculation is the percentage of unfilled posts against the budgeted WTE's for the

Trust, in the given month. Finance take the actual WTE's being reported from ESR, so this would include

any WTE's reported for staff who left part month, who also received a payment, and include those who

started part way through the month (assuming that they had been set up on ESR and paid in the

month), and those still employed but on maternity leave or in a nil pay situation.

Workforce Planned

Establishment (WTE)Funded establishment at the end of the month.


Board of Directors – Public 28August2014 2014/15 Financial Performance Report M04

Version 1.0

Author: Adrian Brooke Department: Finance

Page 1 of 4 Date produced: 20th

August 2014 Retention period: 1 year



Title of Report: 2014/15 Financial Performance Report (for the four month period ending 31st July 2014)



Author: Adrian Brooke – Business Accounting & Reporting Manager

Director: Andrew Hopkins, Finance Director

Executive Summary:

The purpose of this report is to inform the Board of Directors of the Trust’s financial performance for the period 1 April 2014 to 31 July 2014. Key headlines for the month include:

A deficit in the month of £0.43m, increasing the year to date deficit at month four to £0.77m.

A reported Continuity of Service Risk Rating (COSRR) of 3 for July.

Temporary staffing expenditure levels rising to a record high of £2.39m in the month bringing the year to date expenditure up to £8.46m.

Overall reduction in the costs for out of area placements, particularly acute out of area (OOA) placements. Specialist placements expenditure (for which the funding from East of England specifically relates) continues to remain within the funded levels.

A turnaround in the cash position during July with the cash held by the Trust now £5.4m higher than planned at this point in the year. Come year end however, the cash position is forecast to be significantly below plan.

Year to date capital expenditure of £1.39m against an original plan of £4.11m.

Date: 28th

August 2014

G Item: 14.110iv


Version 1.0




1.0 Financial Position

The attached power-point document details the overall Trust Financial

Performance as at the end of July 2014. A summarised position is also attached

to this paper in Appendix 1.

The Trust report is reporting a year to date deficit of £0.77m which is £0.62m

behind plan, although because of improved debtor collection a COSRR rating of

3 has been maintained.

The Board of Directors is asked to note that a number of actions are required to

drive improvements in the financial position and maintain a COSRR of 3. The

three most significant areas to address are the overspend on pay and in

particular reducing temporary pay costs, reductions in Out of Area Placements

(both acute and specialist) and improving CIP performance.

The Trust also needs to manage its cash position. Improvements in the above

three areas will drive up cash balances, but the shortfall in cash in the year from

the pushing back of asset sales will also mean a reduction in capital

expenditure in the year, in order that the Trust can continue to maintain a

COSRR of 3.

For budget managers across the Trust this will mean additional controls on

vacancy management and enhanced controls on the authorisation of temporary

staffing and additional controls over the authorisation of non-pay expenditure.

In the longer term the introduction of e-rostering is essential to improve the

management of temporary pay resources.

There is a detailed review of all CIP schemes currently taking place, which will

include the identification of those CIPs that have been agreed and removed

from budgets, bit where expenditure is still being incurred. The non-

achievement of CIP in 2014/15 will have an impact on 2015/16 and detailed

planning, scheme identification and delivery timescales are required in this year

in order to facilitate delivery in 2015/16. The Trust is therefore considering how

that work can be best supported to enable managers to deliver against both

quality and financial targets.

In analysing the Trust’s performance it is interesting to note that the Health

Service Journal (HSJ) recently identified that mental health funding had fallen

nationally for the third year running. Mental health providers have been dealing

with increased demand whilst receiving less and less money each year. This


Version 1.0




has driven up CIP requirements and these have not always been met 100%

year on year, thus leading to a build-up of CIP each year. The reasons behind

that is the need to maintain quality of care and the rising demand and acuity

(level of illness) in our service users, which has increased during the economic

recession. The parity of esteem commitment for mental health needs to be

reflected in resourcing.

The Trust is not the only mental health Trust dealing with such issues – many

Trusts are dealing with increases in acute workload and out of area placements,

recruitment and temporary staffing issues and maintaining quality whilst looking

to reduce costs.

2.0 Recommendation

The Board of Directors is asked to review the report and provide comment on

the suggested actions.

Andrew Hopkins

Director of Finance 20

th August 2014


Version 1.0




Appendix 1 £m unless otherwise stated

Financial Performance for the Period ending July 2014


Date: 28th August 2014 G

Item: 14.110iv Appendix 1

Index Slides 1-2 - Executive Summary

Slide 3 - Key Highlights

Slide 4 - Finance Dashboard

Slides 5-6 - Income

Slides 7-10 - Expenditure – Pay & Non Pay

Slide 11 - CIP

Slide 12 - Capital

Slide 13 - Balance Sheet

Slide 14 - Cashflow

Executive Summary

The Trust is reporting a deficit of £0.44m for the month and £0.77m YTD (year to date). This

is similar to the monthly deficit position reported last month. This YTD variance is now

adverse against the Annual Plan by £0.62m.

Despite the continued adverse position, the COSRR (Continuity of Service Risk Rating) remains

at 3, which is above the 2 that was originally planned for in July.

This is driven by increased cash collection so that Cash held by the Trust this month is

£5.4m higher than planned. This is more of a timing issue rather than a long tern benefit to

the cash position.

The key Income and Expenditure variances are shown overleaf in the waterfall diagram

and discussed in further detail on the following pages.

Given the current run rate of expenditure reflected in the YTD position, there is a

significant risk that the Trust will not achieve the plan for this year and not achieve a

COSRR of 3, unless action is taken to address this position over the remainder of the year.

1

Executive Summary

2

Key Highlights – YTD Position

Specialist placement expenditure for the month (i.e. cost of placements to specialist

providers) in Norfolk has remained at £0.15m. YTD expenditure totals £0.64m bringing

overall levels close to the original plan (see expenditure non pay detail)

Acute out of area (OOA) placements expenditure has reduced by £0.10m this month to

£0.18m as a result of reduced bed-days. YTD costs now total £0.94m. There is no

additional funding for this type of expenditure so these placements are continually being

reviewed with the expectation that these placements cease by end September (see

expenditure non pay detail).

Temporary Pay expenditure levels have risen again, this month to £2.39m with total YTD

expenditure already at £8.46m (this compares to £4.70m YTD for the previous year).

Total YTD activity income is slightly behind plan due to under occupancy provisions and

under achievement of CQUIN targets (see income summary).

CIP (Cost Improvement Plan) continue to remain behind original target, with only £10.8m of

the original £14.7m target progressed through to gateway 5. £3m of this has been met non-

recurrently.

Capital spend is behind plan, which is reflected by the favourable position on depreciation

in the I&E. Current forecast spend is that the Trust will achieve original plans.

Cash held by the Trust YTD is £5.4m higher than planned, however the year end forecast

position is expected to be significantly below plan.

3

Finance Dashboard

4

Feb

Mar

CIP by Gateway

COSRR

Actual Plan Variance

YTD 3 2 1

Forecast 3 3 -

(600)

(400)

(200)

-

200

400

600

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

Monthly Surplus/Deficit £000's

Plan Forecast (Actual)

2.60.9

0.410.8

FY CIP £m

Gateway zero

Gateway one

Gateway four

Gateway five

-

2.0

4.0

6.0

8.0

10.0

12.0

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

Capex £m

Plan Forecast (Actual) Min Max

Income – Summary

5

Year to date Income position Full Year Income position

Annual Actual Variance to Annual Forecast Variance

Plan Annual Plan Plan

£'000 £'000 £'000 £'000 £'000 £'000

Block contracts 58,289 58,049 (240) 174,868 174,736 (132)

Clinical Partnerships 4,715 4,556 (159) 11,863 11,697 (166)

Clinical income-Secondary Commissioning 741 746 5 2,222 2,238 16

Other clinical income 1,346 1,651 305 4,038 5,086 1,048

NHS Mental Health activity Income, Total 65,091 65,001 (89) 192,991 193,756 766

Research and Development 297 980 682 892 1,816 923

Education and Training 1,118 1,136 19 3,353 3,398 45

Misc. Other Operating 2,338 3,599 1,261 7,015 10,037 3,022

Other Operating income, Total 3,753 5,715 1,961 11,260 15,251 3,991

Operating Income, Total 68,844 70,716 1,872 204,251 209,008 4,757

Income – Summary

Health Care Block Contracts – (£240k) lower than plan due to:

• (£182k) under-occupancy provision for CAMHS Tier 4 and Secure Services,.

• (£320k) CQUIN underachievement provision

• £142k increase in Additional Observations for Suffolk CCG’s

• £120k of other contract variations including West Norfolk CCG Psychiatric Liaison

contract.

Clinical Partnerships – (£159k) lower than plan of which:

• (£61k) is the 1.5% reduction in the Section 75 contract and lower than estimated

travel recharges.

• (£25k) reduction in NRP Contract for Section 75 staff transfers

• (£73k) re-phasing of Norfolk Recovery Partnership innovation monies, which will be

recovered by the end of the year.

Other Clinical Income - £305k increase to plan is due to:

• New contracts of £74k (£317k full year effect).

• An additional £242k increase on existing contracts (£886k full year effect).

• an increase in system wide CQUIN £90k (from Suffolk Acute hospitals) less the 40%

underachievement provision (£54k).

• Non contracted activity is down (£59k).

6

Expenditure – Summary

Vacancy levels continue to increase across the Trust, with a total of 485 vacant WTE’s

being reported in July, hence the favourable permanent pay position being reported. The

rise is attributed to additional WTE budget as a result of new services starting as opposed

to reduction in staff numbers, as actual headcount rose in July.

Both bank and agency staff are utilised through NHSP in order to close this staffing gap,

as well as a number of external agencies, including medical locum agencies. The levels of

temporary pay expenditure, however, exceeds the funding available from the vacant roles.

Overall temporary staffing levels increased again this month to £2.39m and YTD now

totals £8.46m.

The return of the social care contract (S75) to NCC from October will present the Trust

with a significant potential cost pressure in the region of £0.9m. This is due to the loss of

income not being met by a reduction in costs.

Significant spend continues on Out of Area Placements, with just under £1m spent YTD

on acute OOA placements. There was a reduction in the month on acute OOA

placements of around £0.1m, reflecting the actions being undertaken by the Trust to

reduce the numbers.

7

Expenditure – Pay 1

Pay costs report an adverse variance YTD

against original plan of £1.38m, and £1.69m

against revised budgets.

The chart shows total spend by pay type. A full

forecast position is currently being refined.

There is £0.29m of ICT agency costs, funded

by the trading accounts income.

Temporary pay is driven by the vacancy level

of 485 WTE’s.

8

The bank and agency ratio (excluding medical

locum agency) has worsened each month this year,

with bank expenditure now accounting for only 37%

of the total bank and agency staffing expenditure

levels, meaning that more expensive agency staff

continue to be utilised instead. This is reflected in

the significant rise once again in agency staff

during July, some of which however is funded

through by trading income and additional CCG

funding.

Expenditure – OOA Placements

Total spend on placements YTD is £2.10m

Specialist placement expenditure in Norfolk accounts for £0.64m of this, however as can

been seen in the graph below, expenditure levels are becoming more stabilised at 0.15m

per month. This expenditure reflects the cost of 10 patients that remain as at the end of

July.

Acute out of area (OOA) placements expenditure has significantly decreased this month to

£0.18m reflecting reduced bed days during July of 351 (June - 511). As at end of July, 8

patients remained. The target is to cease these placements by end September as no

specific funding for these exists. YTD costs now total £0.94m.

To help alleviate the demand on OOA placements the Trust has contracted a number of

community decant beds (currently 4) costing £0.01m during July, funded by the CCG.

OOA Placements (PICU) – Expenditure levels have also dropped this month, from £0.09m

to £0.03m and relate to five patients totalling 41 bed days, against 107 bed days during

June. One patient remained at the end of July. The reduction in costs is partly due to the

utilisation of Suffolk PICU who in turn increased their temporary staffing levels to

accommodate these patients.

NHS Funded care costs for July were in line with expectation and relates to the care of 7

patients. YTD expenditure now totals £0.14m.

9

Expenditure – Non Pay 2 (Placements)

10

CIP

The pie chart below shows that at present there is a shortfall in the expected CIP delivery

at year end compared to original plan, however an improvement is being reported in the

expected overall delivery. It should be noted that this reported improvement is as a result of

the utilisation of reserves and balance sheet provisions, and not true savings schemes

being implemented.

The utilisation of reserves together with a number of other schemes only achieve the

savings target non recurrently. Recurrent schemes will therefore need to be identified to

avoid further shortfalls in future years.

The remaining shortfall is across all areas however direct care services is the main driver.

The pie chart below shows in value terms how much of the CIP is at each gateway. It is

worth noting that Gateway 5 represents removal of budget but current performance shows

that these plans are not being met.

11

Gateway description

Gateway zero

Gateway one

Gateway two

Gateway three

Gateway four

Gateway five Finance validated and signed off on

delivery plan. Budget is fully allocated

or 100% delivery is certain.

No ideas generated

Idea generated and being investigated

Quality impact assessment (QIA)

completed and signed off.

Detailed Plan completed in full. Full

delivery of plan is highly likely.

Detailed Plan signed off in principle

and adoption started. Full delivery is

likely but details not 100% clear.

Capital

12

The capital programme is currently forecast to remain more than 15% below plan until November 2014 due to a large amount of slippage on projects in the first half of the year. The cash position described on slide 14 will also have an impact on the capital programme and will see a reduced spend in 2014/15.

Balance Sheet

At the end of month 4, the Trust held cash of

£17.2m, £5.4m higher than planned. The

variance is predominantly due to a number of

long outstanding debtors being paid in the

month, as reflected in the aged debtor

information, and a low level of capital spend. .

Receivables are now £0.5m behind plan.

Although this is set off against a higher than

anticipated level of accrued income, as a result

of delayed billing.

Net current liabilities are £2.4m higher than

planned, as the Trust is holding higher than

planned level of provisions, for example

against possible HMRC liabilities.

Non current assets are £4.1m behind plan due

to slippage on projects. See capital expenditure

slide for further details.

13

Statement Of Position Annual Plan Actual Variance

(adverse)

Jul-14 Jul-14 Jul-14

£m YTD YTD YTD

Non-Currrent Assets 142.8 146.9 4.1

Current Assets 27.8 20.6 (7.3)

Current Liabilities (29.9) (27.5) 2.4

Non-Current Liabilities (22.7) (21.8) 0.9

TOTAL ASSETS EMPLOYED 118.2 118.2 0.0

Public dividend capital 81.3 80.6 (0.7)

Retained Earnings (Accumulated Losses) 11.2 11.8 0.6

Revaluation reserve 25.5 25.7 0.2

Donated asset reserve - - -

TOTAL FUNDS EMPLOYED 118.2 118.2 0.0

Aged Debtors Q1 Q2

< 30 Days 1,780 819

30-60 Days 329 488

60-90 Days 1,914 32

90+ Days 2,466 1,620

Total 6,489 2,959

Cash flow

The cash balance of £17.25m is £5.42m ahead of the annual plan. This reflects the

payment of several long outstanding receivables and slippage in capital expenditure.

The forecast cash position at year end has been reduced (compared with plan) as the

Trust may have to push back the sale of assets into 2015/16, in order that we achieve

maximum value from those sales. This impacts on cash flow by nearly £4m and will

reduce what the Trust can spend on its capital programme this year.

The forecast is also based on current run rate and so the COSRR is at risk by year end if

actions are not taken to reduce expenditure and improve the liquidity (cash) position of the

Trust

14

Board of Directors – Public 28

th August 2014

Business Performance Report

Version 1 0

Author: Tim Walsh Department: Informatics


August 2014 Retention period: 30 years



Title of Report: Business Performance Report – M04 2014/15


Estimated time: 15 Minutes

Author: Tim Walsh: Business Intelligence Manager

Director: Andrew Hopkins: Director of Finance

Executive Summary:

The Business Performance report shows that the Trust is compliant across all seven of the key performance standards under the Monitor Risk Assessment Framework. This is shown in the Monitor targets section. The Trust is maintaining a Continuity of Service Risk Rating (CoSRR) score of 3.

1.0 Report contents

1.1 The Business Performance Report is submitted to the Board for month 04 2014/15 and contains details of performance against key Monitor Compliance Framework targets and KPIs for Finance, Organisational Delivery, Quality, Safety & Experience and Workforce Development & Effectiveness.

1.2 The Trust is maintaining a Continuity of Service Risk Rating (CoSRR) score of 3.

Date: 28th

August 2014

H Item: 14.110v


th August 2014


Version 1 0




2.0 Monitor Targets

2.1 Monitor Performance Summary

Ref Measure Target Quarter 2 to Date (M04)

M01 CPA patients receiving follow up within 7 days of discharge

95% 100% 100 out of 100 discharges

M02 CPA patients having formal review within 12 months

95% 98% 2,002 out of 2,047 reviews

M03 Minimising Delayed Transfers of Care

7.5% 3.58% 489 delayed days out of 13,644 bed days

M04 Admissions to inpatient services had access to Crisis Resolution and Home Treatment (CRHT) teams

95% 97.9% 141 out of 144 admissions gate-kept

M05 Meeting commitment to serve new psychosis cases by Early Intervention teams

95% 140% 80 new cases against target of 57

M06 Data completeness: Identifiers 97% 99.6%

215,840 valid entries out of 216,708 possible data fields

M07 Data completeness: Outcomes 50% 83%

8,601 valid records out of 10,398 records

3.0 Performance

Director of Operations

Norfolk Summary – Performance against the 72 hour metric is improving. Bed use is slowly decreasing. All 3 CRHTs are functioning well, length of stay is decreasing as well. CAMHS referrals are now going directly to the CAMHS service. The locality should start seeing the impact on the data in the next month.

A&E liaison is at capacity and are still recruiting to posts although out of area placements is still not coming down to the level that the locality would like although there has been an improvement in the position for out of area placements compared to last month.

Suffolk Summary – Performance is holding steady and the locality is focussing on key issues. The work that is taking place in the access and assessment team is being reflected in the improvement in the 28 day referral performance. The priority for the locality will continue to be on meeting the A&A targets and on addressing the IAPT access rates. The teams will also be working to identify where the data completeness metric is not being met and managing the teams accordingly.


th August 2014


Version 1 0




Minimising delayed transfers of care (DTOC)

In July the DTOC position for the trust was reported at 3.58%, well below the 7.5% threshold. Suffolk East were reporting above the threshold at 11.87%in June however in July this had dropped to 8.73%. The number of DTOCs in Suffolk attributable to LD service users also dropped in July from over 4% to 2.6%

The LD service have put actions from the DTOC meeting in place to address this and they are employing an additional person in Suffolk for this purpose.

A significant amount of work is being undertaken in conjunction with social services to look at those delayed because they are awaiting placements in residential care. Of the ten delays reported in the last week of June, three were attributable to the LD service.

The discharge coordinator in West Suffolk has proved to be very effective in facilitating engagement with the county council to help find accommodation for patients being discharged and this post will be mirrored by a new post in East Suffolk with a view to achieving the same benefits.

Meeting commitment to new psychosis cases by Early Intervention (EI)

Performance against the EI target has improved further to 140% in July. This is based on a commitment to identify new EI cases.

All AAT and IDT staff are continuing to use the new process designed to record and identify EI patients and in East Suffolk the service are now confident that this metric will remain on target.

Percentage of qualifying patients with a MHCT cluster (OD07)

In Suffolk the position is improving – the service is identifying areas where outstanding clusters need to be added, targeting Coastal and Central Suffolk where there are issues that need to be worked through. This work is being completed by the Business Support Manager in Suffolk in July and August. At the performance meetings with localities the importance of this metric has been stressed due to the move to cluster based contract for 2014/15.

The service are continuing to target the un-clustered CLL (Care in Later Life) patients because they have the highest percentage of patients without a MHCT cluster. In Suffolk East reports are being sent out to identify invalid clusters and the service is also monitoring referrals coming in from AAT into the IDT to ensure that they have had a cluster added.


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Data quality including timely entry

Each locality has an action plan in place. In the Central locality Smart phones in Adult Community teams are facilitating quicker data entry and a report of performance by team is now available to all localities. The provision of performance by team now means that specific teams who are not meeting the criteria can be identified and managed accordingly by each locality. Included in the action plan for Central locality are:

Daily reminders to clinicians to complete contact sheets

Facility for clinicians to call in contacts for the day

Facility for clinicians to email contacts

Folders for unsigned contacts for CTLs to capture

Admin staff being reviewed to ensure capacity to input contacts daily

In the West locality exception reporting is being generated to identify late contact submissions and these are being addressed with individual practitioners in 1 to 1 management supervision which ensures there are plans in place to address any issues. The locality is also reviewing remote working options including mobile communications devices. All localities are working to a target for 100% completion by the end of October 2014. Percentage of inpatient finished consultant episodes during the period with an ICD10 code and % of patients on CPA at the end of the period with ICD10 code

This metric needs to be discussed with the Medical director and backing is sought to ensure that there is support from the medical colleagues to meet a 100% target in this area. This will be followed up by the locality manager in Norfolk.

Percentage of IAPT patients who have depression and or anxiety disorders who receive psychological therapy

Access continued to be below the 15% trajectory in Norfolk, Great Yarmouth and Suffolk IAPT services.

This is a tough target with a clear action plan to achieve this. The action plan is being reported to CCGs on a monthly basis.

In Norfolk the service was falling below the IAPT access target. Work is taking place in Norfolk looking at clusters 1 to 4 and the activity taking place in these clusters to assess whether the individuals would be appropriate for an IAPT service. The service is seeing an increase in referrals but these numbers are not


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being converted in to accessing the service that is there. A weekly action plan is sent to the CCGs.

As part of the action plan the service is working with large employers, acute hospital sites, working with hard to reach service user groups, creating pop up clinics, partnership working with MIND and identifying low referring practices.

The focus for the service in Norfolk and Great Yarmouth and Waveney is also to work on referrals which have not converted to access.

Average Length of stay

The average length of stay indicator has been updated to report on the length of stay of those in the ward in month rather than looking at those discharged in month alone. This has meant that the figure more accurately reflects the full average length of stay in the wards.

All localities are reporting below the 28 day target on this metric. It may be necessary to review the target based on the revised metric.

Medium Secure Bed Occupancy Rate

Bed occupancy for the medium secure unit has been below target for more than three months. It was reported at 83% against a 90% target. This has been raised with commissioners in terms of whether this lower occupancy would impact on the contract value.

NSFT are not getting the volume of referrals through and it is out of the trusts control as to whether there are service users to admit to the medium secure unit. The service has confirmed that they are not refusing any admissions. Commissioners have been alerted to the low occupancy and they have agreed to work with the trust to address the issue. Waiting times in completed pathways breaching standard and Number of incomplete pathways waiting over 18 weeks

The 18 week breaches are being investigated on a case by case basis in Norfolk and Suffolk localities. The service is still looking at the remit of the CAMHS teams in terms of how they operate with the Access and assessment service in Norfolk. From the 1st July referrals were being triaged straight through to the AAT for assessment with the aim of adding capacity to the AAT and ensuring that there is no delay in the CAMHS referrals receiving specialist assessments.


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Carers Assessments and Reviews (Norfolk County Council Section 75)

Carers assessments were below target in Central Norfolk in July and continued to be low in West Norfolk and Great Yarmouth and Waveney. Training on Care First is being picked up under the Section 75 Transition Project which is currently scheduled to complete on 1st October 2014.

Patient Safety Thermometer(QU14) All localities were reporting at 100% for the patient safety thermometer in July.

Bed occupancy, out of locality and out of area acute placements

As of the 17th July there were 12 out of area placements for Central locality. There was also one Norfolk service user placed in a Suffolk ward. The out of area placements remain high in Central Norfolk and this is monitored daily by the locality manager. Patients from the central locality are also being placed in beds in West and GY&W.

The high levels of bed occupancy in the adult acute areas in Norfolk is reflective of demand.

In East Suffolk the lower bed occupancy in the PICU unit can be attributed to a bed that was unavailable due to the use of the low stimulus area which takes up an additional bed.

Access and Assessment

Norfolk

In July the service achieved 100% against the 4 hour referrals. There were 6 72 hour breaches. The AAT have continued to meet the target and exceeded the 95% target for 4 and 72 hours.

From 1st July all under 14 CFYP (Children, Family and Young People) central referrals went straight to the service which means that they have a basic screening to assess their urgency and then they go through to service line. This will allow the service to identify whether there is any imminent risk.

For under 18s including the backlog, the service has the support from the CFYP service line and the benefits of this should be proven in the coming months. The move to service line has released appointment slots which can be used for the over 18s referrals. For over 18s the service were at 91% in June so were still below the target. The service are continuing with the recruitment of experienced practitioners to the team. In addition to this more medics are also scheduled to join the AAT in August.


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Suffolk

In July the service achieved 100% for 4 hour referrals and 100% for 72 hour referrals against a 98% target. For the 28 day routine referrals the team saw 94.7% of their referrals within standard against a target of 95%.

The service will continue to identify areas for improvement in order to meet the 28 day target. There is high sickness absence within the team which is being worked on by the service managers. There is also work taking place to review how resource is deployed within the team particularly focussing on the role of social workers.

Norfolk Recovery Partnership (NRP) and Suffolk Alcohol Service

All NRP partners continue to work on a remedial action plan to address commissioners concerns regarding the NRP service. The caseload numbers are reducing in NRP and the service are focussing on improving performance in three areas: 1. TOPS reviews 2. Positive discharges 3. Reducing the number of long term clients In terms of TOPS reviews the service had seen a marginal improvement from last month from 64% to 67% against a 90% target. The Community Team Leaders within the service have been asked to provide action plans at the start of August to address these areas of performance.

4.0 Research Performance Indicators

The Key Performance Indicators as set by the National Institute of Health Research (NIHR – DH) are going to be changed for 2014/15 but have not yet been announced nationally. The KPIs are designed to give a reflection of overall research activity and performance for the Trust compared to other Trusts nationally. The Research Manager does not have the new KPIs to report at present.

5.0 Section 75 Partnership

Norfolk

Norfolk County Council's and the Trust's Project Teams are continuing to work on producing a project timescale that will include key milestones for the design of a new integrated health and social care model, staff engagement events, workforce changes and transition plans.


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During July, Norfolk practitioners who hold care coordination or lead care professional caseloads worked with Clinical Team Leads to apply a simple caseload scoping tool to identify whether cases are social care, health care or joint. The project has largely been able to gather this information and now Admin teams are populating a work sheet that will enable the Trust to work with Norfolk County Council (NCC) to create CareFirst records for all social care and joint cases for the 1 October 2014.

Three joint workshops were held during July led by NCC to develop working protocols and processes between the two organisations. Further joint workshops are planned for September around NCC internal processes to understand and shape how they link with NSFT systems and processes.

Suffolk The targeted training to support the implementation of personal budgets for mental health service users across Suffolk (including Waveney) is nearing completion. New procedures are in the process of being phased into to existing operational processes. These new arrangements will be monitored and subject to evaluation and review at agreed periods. With the Care Act 2014 becoming law there are further considerations required on the duties that this new legislation will impose on Suffolk County Council and consequently the impact that this will have on the delegated legal duties conferred upon NSFT through the S75 Partnership Agreement. As well as the service delivery / operational implications of these changes, it will require scrutiny of the existing care documentation that is used to ensure that it is compliant with the changes in law. The timing of this will also need to correspond with the development work going on within the Trust to support the migration to Lorenzo. Lorenzo will need to be configured to take into account the new statutory duties and contract reporting requirements. Work is underway with informatics leads in NSFT & SCC and the Lorenzo Project Lead to support this IT work.

Suffolk County Council, Adult Community Services are in the process of operational transformation as it phases in the new operating model ‘Supporting Lives Connecting Communities’ and continues work on the wider health and social care integration agenda. We, in mental health, are continuously comparing our structures to ensure that the philosophy and underpinning principles of this model is embedded and integrated through our services. It is anticipated that we will continue to an active role in influencing the development of system-wide health and social care integration in Suffolk through representation on the various work programmes.


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6.0 Workforce Development and Effectiveness Headlines

Vacancies

The Trust’s vacancy rate (WD08) is 12.38% to the end of month 4. This represents 484.72 whole time (wte) equivalent vacancies against an establishment of 3,914.19 wte (3,421.55wte in post). This breaks down into a rate of 10.32% in clinical services and 20.82% in corporate and support services (where vacancies are being held and/or temporarily filled pending restructure). Within clinical services, the rate is 12.5% in Suffolk (70.76 wte vacancies) with particular pressure in West Suffolk across Acute, Child and Youth and Older Peoples Services. The rate is 9.37% (146.45%) in Norfolk and Waveney clinical services with particular pressure within the Community teams across the county (running at between 15% to 24% vacancies, West Norfolk being worst affected)

It should be noted that the establishment has increased within the month by 24.34 wte. 5.3 wte of this increase was due to previously under-stated accounting in the budget for Central Norfolk which has been rectified in month 4. 11.2 wte reflects an increase in establishment within Secure Services through conversion of a temporary staffing budget created at the last budget setting. The cause(s) of the remaining 5.56 wte is being explored with Locality Service Managers and Management Accountants but is thought to relate to skill mix changes

Despite 275.79 wte posts being recruited to since January 2014 which is a significant achievement, in light of the increase in establishment and taking account of turnover (see below), the net increase of staff in post in the month is 8.64 wte. It should be noted, however, that the figures are distorted by the negative position of posts appointed versus leavers within corporate and support services (-39.33 wte posts filled since January 2014 within these services)

90% of vacancies (432 wte) are currently being actively recruited to

Turnover

Turnover (WD09) within the Trust is 14.25% to the end of month 4. With the exception of Corporate, this is on a positive downward trend with turnover decreasing in all localities within the month in respect of both voluntary and controlled leavers

Temporary Resourcing

For month 4, the Trust’s total temporary staffing costs equate to 17.95% of all staffing costs

NHSP demand has increased by 12% within the last quarter. This is in line with similar trends reported by NHSP in other mental health Trusts

Fill rates remain fairly stable although an increased agency rate fill reflects the higher demand despite positive recruitment activity (for example, 59 extra workers engaged in June 2014 alone)

Demand related to vacancies is decreasing in line with recruitment activity. Demand related to specialising and sickness remain fairly high but stable.


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Demand for planned leave has increased (doubled between April and June (1,212 shifts in June) which suggests poor operational workforce resource planning

Absence

Overall, the Trusts sickness absence rate (WD01) has marginally increased in the month from 5.55% in June 2014 to 5.59% in July 2014.

The highest absence rate continues to be within Secure Services, however, this has had a positive reducing trend for the last 3 consecutive months (8.20% to 8.01%)

Absence attributable to anxiety/stress/depression accounts for 25.04% of all sickness absence in the Trust and increased in the month by 0.52%. Although the Trust’s Substance Misuse Services continue to have the highest instance of anxiety/stress/depression (35.19% of all sickness absence time lost), the Service also recorded the largest reduction in this performance indicator (-3.45%) for the third consecutive month

Workforce development

Following the change in approach to appraisals from April 2014 with appraisals now linked to incremental dates, of the cohort of 793 staff who should have had an appraisal in quarter 1, only 297 staff are recorded as actually having had one (37.4%). Plans for the current and future cohorts have been discussed by the Executive Team

7.0 Finance

7.1 The Continuity of Service Risk Rating (CoSRR) comprises the trust liquidity ratio and the debt service cover rating. Overall, the Trust maintained a COSRR of 3 in the month, above the planned rating of 2 at this stage in the year. The capital service cover has now dipped below plan to a 2, which has been caused by the fact the Trust is currently operating at a deficit.

The adverse performance for debtors (FM04) has jumped significantly this month to 29.52%, way above the 5% target. This has been due to the vast improvement in the overall debtor’s total, now down from £10.9m to £5.4m. This improvement however is almost all against the more recent debtors (less than 90 days). The creditors performance (FM05) improved in the month with over 90 days outstanding balance more than halving, bringing the performance back within the 5% target, at 2.55%. The remaining creditors over 90 days relate largely to NCC, and these invoices have subsequently been approved for payment, so a further improvement in this performance is expected again next month.

Expenditure on capital projects (FM09) remains significantly behind plan, with only 14.74% of Capital budget being spent to date, compared to the planned level of 46.25%, representing an adverse variance of £2.8m. This slippage is forecast to remain more than 15% below plan until November. Although all capital categories


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contribute to this position, ICT and Estates related projects continue to be the main driver.

An improvement in the overall CIP achievement is reported this month, with a jump in the total percentage to 70.48% of plan. It should be noted that this improvement is as a result of the utilisation of reserves and balance sheet provisions, and not true savings schemes being implemented. The utilisation of reserves only achieve the savings target non recurrently, which is reflected in the limited improvement of the recurrent CIP performance indicator up from 63.20% to 65.88%. Recurrent schemes will therefore need to be identified to avoid further shortfalls in future years.

The continued reliance on temporary staffing has pushed up the adverse performance being reported this month for FM09. The expenditure levels need to be significantly reduced in order to bring the Trust back to a surplus run rate, which in turn will help to improve the capital service cover rating, in order to maintain the COSRR of 3 going forward

8.0 Recommendations

8.1 The Board is requested to consider the Trust’s performance as described within the Business Performance Report.

Tim Walsh Business Intelligence Manager 08

th August 2014


July 2014 version 2.0

NSFT Informatics

1 BPR July 2014 v2.0.xlsx/Front

Monitor

Ref Metric Period Value Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Actual 100% 98% 98% 100%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 98% 97% 97% 98%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 4.05% 4.87% 4.55% 3.58%

Target 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%

Trend

Actual 100% 100% 100% 98%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 79% 89% 133% 140%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 100% 100% 100% 100%

Target 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97%

Trend

Actual 83% 83% 83% 83%

Target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

Trend

Actual 6 6 6 6

Target 6 6 6 6 6 6 6 6 6 6 6 6

Trend

Performance is neither improving or worsening

Performance is worsening

Performance is improving

Self-certification against compliance

regarding access to healthcare for

people with LD

Month

YTD

M07 Data Completeness : OutcomesMonth

YTD

Meeting commitment to serve new

psychosis cases by early intervention

teams

Month

YTD

M06 Data Completeness: IdentifiersMonth

YTD

M01CPA patients receiving follow up within

7 days of discharge

Month

YTD

M03 Minimising delayed transfers of careMonth

YTD

M02CPA patients having formal review

within 12 months

Month

YTD

M04Admissions to inpatient services had

access to CRHT teams

Month

YTD

M08

Trend is calculated using Actual at Month 3 2014/2015 as compared to

the Actual in the current month

M05

2 BPR July 2014 v2.0.xlsx/Monitor

Organisational Delivery


Actual 98% 97% 97% 98%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 4.05% 4.87% 4.55% 3.58%

Target 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%

Trend

Actual 100% 100% 100% 98%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 79% 89% 133% 140%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 100% 100% 100% 100%

Target 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97% 97%

Trend

Actual 83% 83% 83% 83%

Target 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50%

Trend

Actual 97% 97% 98% 98%

Target 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 100%

Trend

OD07

OD01CPA patients having formal review

within 12 months

Month

YTD

OD04Meeting commitment to new psychosis

cases by EI

Month

YTD

OD03Admissions to inpatient services had

access to CRHT teams

Month

YTD

OD02 Minimising delayed transfers of careMonth

YTD

OD06 Data Completeness: OutcomesMonth

YTD

OD05 Data Completeness: IdentifiersMonth

YTD

% of qualifying patients with a MHCT

cluster

Month

YTD

3 BPR July 2014 v2.0.xlsx/Organisational Delivery

Organisational Delivery


Actual 91% 91% 89% 92%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

Actual 98% 98% 99% 100%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

Actual 0.73% 1.60% 2.63% 3.69%

Target 1.25% 2.50% 3.75% 5.00% 6.25% 7.50% 8.75% 10.00% 11.25% 12.50% 13.75% 15.00%

Trend

Actual 51% 50% 53% 50%

Target 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40% 40%

Trend

Actual 81% 82% 83% 79%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Trend

Actual 85% 80% 79% 81%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Trend

Actual 15 16 14 15

Target 28 28 28 28 28 28 28 28 28 28 28 28

Trend

OD15Low Secure Bed Occupancy Rate

(including leave)

Month

YTD

OD14Medium Secure Bed Occupancy Rate

(including leave)

Month

YTD

OD13

% of IAPT patients who complete

treatment and 'move to recovery during

the month

Month

YTD

OD12

% of IAPT patients who have

depression and/or anxiety disorders

who receive psy therapy

Month

YTD

% of inpatient Finished Consultant

episodes during the period with an

ICD10 code

Month

YTD

OD09

Number of contacts recorded on Trust

systems within 3 working days of event

(Last 30 days)

Month

YTD

Trend is calculated using Actual at Month 3 2014/2015 as

compared to the Actual in the current month

OD16Average Length of Stay - Adult Acute

Service

Month

YTD

OD10

4 BPR July 2014 v2.0.xlsx/Organisational Delivery

Quality, Safety and Experience


Actual 100% 98% 98% 100%

Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Trend

Actual 88% 88% 92% 86%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Trend

Actual 67 54 46 64

Target 0 0 0 0 0 0 0 0 0 0 0 0

Trend

Actual 92% 75% 91% 77%

Target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Trend

Actual 97% 100% 97% 100%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

Actual 100% 100% 100% 100%

Target 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Trend

QU04Waiting Times - Number of incomplete

pathways waiting > 18 weeks

Month

YTD

Waiting Times - % of CAMHS patients

seen within standard

Month

YTD

QU14Patient Safety Thermometer

(Development KPI)

Month

YTD

QU05

QU17

% of long-term (over 12 months)

inpatients that have received an annual

health check

Month

YTD

QU01CPA patients receiving follow up within

7 days of discharge

Month

YTD

QU02Waiting Times - % of completed

pathways within standard

Month

YTD

5 BPR July 2014 v2.0.xlsx/Quality, Safety & Experience

Workforce Development and Effectiveness


Actual 5.59% 5.62% 5.55% 5.59%

Target 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76% 4.76%

Trend

Actual 12.17% 11.38% 11.37% 11.36%

Target 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00% 20.00%

Trend

Actual 11.84% 15.51% 11.96% 12.06%

Target 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52% 6.52%

Trend

Actual 24.31% 24.13% 24.52% 25.04%

Target 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17% 16.17%

Trend

Actual 61.60% 49.30% 46.20% 16.44%

Target 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trend

Actual N/A N/A N/A N/A

Target 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trend

Actual 14.00% 11.00% 13.00% 12.00%

Target 33.00% 33.00% 33.00% 33.00% 33.00% 33.00% 33.00% 33.00% 33.00% 33.00% 33.00% 33.00%

Trend

Actual 11.84% 11.59% 12.06% 12.38%

Target 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00%

Trend

WD01 Annualised sickness absence rateMonth

YTD

WD02% of staff with 4 or more absence

episodes (WD2)

Month

YTD

WD03% of sickness absence episodes > = 21

days

Month

YTD

WD04% of sickness absence days attributed

to Anxiety/stress/depression/etc.

Month

YTD

WD05

% of staff with an appraisal since April

2013Month

YTD

WD06

% of medical staff compliance with

planned 2012/13 appraisal timetable

(Cohort 1)

Month

YTD

WD07

Number of statutory/mandatory training

elements which are below 40%

compliance.

Month

YTD

WD08 Vacancy RateMonth

YTD

6 BPR July 2014 v2.0.xlsx/Workforce Development & Eff

Workforce Development and Effectiveness


Actual 15.65% 17.54% 15.69% 14.25%

Target 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00% 10.00%

Trend

Actual 51.34% 49.91% 51.17% 52.27%

Target 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00% 45.00%

Trend

Actual

Target

Trend

Actual

Target

Trend

WD09 Turnover RateMonth

YTD

WD10 % of resignations which are voluntaryMonth

YTD

Trend is calculated using Actual at Month 3 2014/2015 as

compared to the Actual in the current month

WD11Staff engagement - mini survey

(Development KPI)

Month

YTD

WD12Staff in post to caseload ratio

(Development KPI)

Month

YTD

7 BPR July 2014 v2.0.xlsx/Workforce Development & Eff

Financial Management

Ref Metric Period Value Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15Full Year

Outturn

Actual 3 3 3 3

Target 3 3 3 2 2 3 3 3 3 3 3 3 3

Trend

Actual 3 3 3 2

Target 3 3 3 3 3 3 4 4 3 4 4 3 3

Trend

Actual 3 3 3 3

Target 2 2 2 1 1 2 2 2 2 2 2 3 3

Trend

Actual 10.30% 10.12% 21.08% 29.52%

Target 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Trend

Actual 5.10% 4.48% 5.18% 2.55%

Target 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00% 5.00%

Trend

Actual 2.02% 7.19% 11.32% 14.74%

Target 10.96% 22.30% 35.55% 46.25% 56.50% 64.97% 69.86% 75.34% 81.83% 87.21% 92.62% 100.00% 100.00%

Trend

Actual 51.91% 55.11% 55.11% 70.48%

Target 79.91% 81.65% 83.40% 85.15% 86.90% 88.65% 90.54% 92.43% 94.33% 96.22% 98.11% 100.00% 100.00%

Trend

Actual 62.66% 63.20% 63.20% 65.88%

Target 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Trend

Actual 102.84% 105.14% 107.69% 110.34%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Trend

FM09Temporary staffing cost/ notional

budget

Month

YTD

FM07CIPs % of planned CYE (R&NR)

savings achieved

Month

YTD

FM08CIPs % of planned FYE (recurring only)

savings achieved

Month

YTD

FM05

Creditors > 90 days past due account

for more than 5% of the total creditor

balances

Month

YTD

FM06 CAPEX % of plan spentMonth

YTD

FM03 Liquidity ratingMonth

YTD

FM04Debtors > 90 days past due account for

more than 5% of the total debtor base

Month

YTD

FM01 Continuity of Service Risk RatingMonth

YTD

FM02 Capital Service Cover ratingMonth

YTD

BPR July 2014 v2.0.xlsx/FRR_Financial 14_15

Board of Directors – Public Voluntary Services Report

Version 1.0

Author: Adam Chilvers Department: Governance





Title of Report: Voluntary Services update


Estimated time: 15 Minutes

Author: Adam Chilvers – Voluntary Services Officer

Director: Dr Jane Sayer Director of Nursing, Quality and Patient Safety

Executive Summary:

This report provides an update to the board on the current status, delivery model and projected developments of voluntary services. The main points for the Board to note in this report relate to:

The model in which voluntary services is delivered to the Trust has changed from central voluntary service recruitment to locality and service lead recruitment of volunteers.

An update of current voluntary projects and roles

The establishment of a volunteer award, volunteer forum and interactive volunteer page for volunteers and staff.

Establishment of partnership working with local voluntary agencies and educational institutions.

Investing In Volunteers Charter

1.0 Report contents

2.0 Model of voluntary services

3.0 Status of volunteering

4.0 Volunteer projects

5.0 Partnership working

6.0 Investing in Volunteers Charter

7.0 Other development

Date: 28th

August 2014

I Item: 14.112ii


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2.0 Model of voluntary services

2.1 In consideration of the safe and efficient recruitment of volunteers, a new model of volunteer recruitment with appropriate governing procedures has been established.

2.2 Current status of volunteer recruitment has evolved from central volunteer recruitment to locality and service lead volunteer recruitment. The change of process recognises the need for localities to promptly recruit local volunteers and support localities and services in taking ownership for recruiting of volunteers to their service.

2.3 A clear and robust procedure for the recruitment of volunteers is applied by each locality and service. Services have been trained on the safe recruitment and management of volunteers. Training and support will continue within localities and services through direct training to teams, a safe recruitment guide and check-list.

2.4 Teams and services are briefed on the restrictions placed upon volunteer recruitment based upon legislative and national policy guidance. This is to ensure that volunteers are engaging in roles that are appropriately risk assessed and do not detract from roles that are otherwise undertaken by paid members of staff. For this reason, volunteer roles are created to provide support to services which compliments service delivery.

2.5 The voluntary service officer will provide direct assistance and assurance to each locality and service to ensure procedures are followed, as set out within the volunteer policy (Q27), which has also been reviewed as part of the change in process.

2.6 A summary of the new procedure for the recruitment of volunteers is provided (Appendix A).

2.7 Norfolk Recovery Partnership (NRP)

NRP shall continue to remain responsible for the recruitment of volunteers in to this service. NRP currently have their own team of voluntary co-ordinators and associated processes for the recruitment of volunteers.

3.0 Status of volunteering

3.1 As at the end of July 2014, there are 105 active volunteers registered with the Trust who are engaging with voluntary roles. There has been a decrease in the number of registered volunteers due to volunteers moving on to external volunteering roles, students graduating, or volunteers that no longer wish to engage in volunteering. Of note one volunteer has taken up a substantive role within the Trust

3.2 There are currently 28 volunteer applications being processed.


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3.3 Volunteers continue to provide support to staff and contribute to enhancing the quality of service delivery within a wide range of roles, and areas including:

Inpatient services

Forensic services

Carlton Court

Norfolk Recovery Partnership

Governance

Community services

Wellbeing teams

4.0 Volunteer projects

4.1 Volunteer drivers

It is recognised that there is a continuing need to support care givers and immediate family members whose relative(s) currently receive inpatient dementia services from the Trust. Family members and carers play a pivotal role in the promotion and maintenance of wellbeing for those with dementia. There is an identified need for direct family members and/or carers to be provided with support to visit their relative whilst receiving inpatient care from the Trust. For this reason, we are currently setting-up a volunteer service that will aim to support family visits for those who require assistance to visit loved ones adding to the quality of experience and care that the Trust delivers to its patients and carers. It is anticipated that voluntary services will recruit a bank of volunteer drivers to provide transport to family and carers, facilitating a return journey.

4.2 Music Library

Following an inspection from one of the Trust’s non- executive directors to a forensic inpatient service, a need for safe access to music as part of their recovery and wellbeing has been identified from feedback. Voluntary services are currently exploring the establishment of an accessible music library, supported by a bank of Trust volunteers. It is anticipated that volunteers will help with setting-up and maintaining a music library for the forensic service, with the possibility of replicating this within other services in the future

4.3 Volunteer gardening project

Following voluntary services attendance at a local service user and carer forum, feedback from attendees mooted the establishment of recruiting volunteers in to a gardening project. The aim of the project is to engage local partners, organisations, staff and service users in helping to rejuvenate and maintain areas based at the Hellesdon Hospital site, supported by volunteers. One


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participant at the forum discussed the relevance of engaging the wider community in engaging with volunteering with the joint aim of tackling stigma surrounding mental health. It was felt that volunteering could play a central role, with a focus on gardening. Voluntary services are currently engaging with participants from the service user and carer forum to scope this project.

4.0 Partnership working

The voluntary services officer is actively engaging with local volunteer organisations to promote volunteer roles available through the Trust. Local connections have also been made with educational establishments, including City College Norwich and the University of East Anglia to promote volunteering within the Trust, which not only offering valuable skills to the Trust services through volunteering, but offering unique volunteering opportunities to student’s who wish to gain valuable experience engaging with mental health services. It is the aim of voluntary services to engage students with volunteer projects that are currently planned, such as the music library and collecting service user feedback.

5.0 Investing In Volunteers Charter

6.1 Investing in Volunteers is the UK quality standard for good practice in volunteer recruitment and management. This is a benchmark for quality of practice in the management of volunteering within an organisation. Following the initial project meeting held last year, the Trust completed a self-assessment project which identified current practices for the recruitment and management of volunteers and identified areas for improvement. This was completed and approved by the assessor.

6.2 In order to obtain certification, the final stage is for volunteers and Trust staff to continue to engage in a formal inspection by the assessor in September. An outcome of this shall be provided to the Board of Directors next public meeting.

6.0 Other developments Volunteer award

In recognition for the dedication and time that our volunteers give the Trust, its staff, patients and carers, voluntary services has established a quarterly volunteer award. It is the aim of voluntary services to increase the awareness and value that volunteering serves within the Trust. Volunteers within the Trust can be nominated for the volunteer award which will be presented quarterly. All members of staff across the Trust will be able to nominate a volunteer for the award by providing an outline as to why this should be awarded. The volunteer that receives the award shall be published using Trust media, including Insight Magazine, Trust updates and seek approval for the volunteer to be highlighted at the Board of Directors Public Meeting.


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7.1 Volunteer forum

Voluntary services shall establish a volunteer forum for the Trust. The aim of the volunteer forum shall be a formal opportunity for volunteers and volunteer supporters to attend a local forum to discuss opportunities and issues with volunteering within the Trust. We wish to provide our volunteers and volunteer supporters with an opportunity to help develop and improve voluntary services for the Trust and contribute to innovative ways that volunteers can help add to the quality of service delivery. This will also provide a necessary forum for any volunteers or staff who wish to voice any concerns about any aspect of volunteering, to which they seek improvement.

7.2 Supporting volunteer engagement through Information Technology

Voluntary services are currently working on an interactive way of Trust volunteers and services to discuss volunteer issues using the Trust Intranet. This will provide an opportunity to services to share ideas about volunteering, including projects and roles. This will also act as a central resource for volunteers and services to access necessary documentation, advice and guidance, in addition to the support of the voluntary services officer.

8.0 Recommendations

8.1 The Board of Directors to receive this receive and note this report.

Adam Chilvers Voluntary Services Officer

12th August 2014

Background Papers / Information Appendix A


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Appendix A

Board of Directors - Public 13August2014 Audit & Risk Committee Chair’s Report

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Author: John Brierley Department: Corporate




Title of Report: Chair of Audit & Risk Committee’s report – 13th August 2014



Author: John Brierley, Chair

Director: John Brierley, Non-Executive Director

Executive Summary:

The Audit & Risk Committee met on 13th August 2014. A summary of work done is provided.

1.0 Work done:

1.1 The Committee meeting covered matters relating to: IT Infrastructure, Danwood procurement and performance, and a number of confidential reports relating to Declarations of Interest, Conflicts of Interest and the Working Time Directive.

1.2 The meeting was also attended in part by Interim Resilience Manager Ryan Hills to discuss the Emergency Preparedness, Resilience and Response (EPRR) update and approval.

2.0 Matters to be reported to the Board of Directors

2.1 The following issues are reported for consideration by the Board of Directors:

i. The Internal Audit Interim Report was received and considered. The

Committee noted the weak assurance on CQC Essential Standards,

an issue also raised by the Service Governance Committee.

ii. The Committee received and approved the Internal Audit Terms of

Reference and Charter.

iii. The Committee received a report on contracting with Danwood and

resolved that the contract would not be extended to accommodate any

renegotiations. It was agreed that for recompense, renegotiations

would be requested on the remainder of the contract.

Date: 28th

August 2014

J Item: 14.112iii

Board of Directors - Public 13August2014 Audit & Risk Committee Chair’s Report

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Author: John Brierley Department: Corporate


iv. The Committee received and noted the Report on Losses and Special

Payments and expressed concern on the number of single tenders

under SFI’s and lack planning and appropriate arrangements.

v. The Committee noted Monitor’s Consultation on amendments to the

‘NHS foundation trust annual reporting manual 2014/15’ and amended

the Committee’s plan to accommodate the received actions.

vi. The Committee received the EPRR report and approved: the

establishment of the Trust Resilience Planning Group, the EPRR

policy, and the arrangements for the identification of risks associated

with this issue. The Committee also asked that an action plan for

immediate use is prepared for the Executive Director’s approval.

vii. The Committee received a confidential report on the Register of

Declaration of Interests. Internal Audit requested a revised

management response, which would be submitted to the Chair for

response under delegated authority.

viii. The Committee received the Chair’s Report of the Service

Governance Committee and supported the recommendation to review

the quality of information provided to the Service Governance

Committee and if necessary, the Board of Directors.

ix. The Committee received the confidential Counter Fraud Interim

Report and expressed concerns over continued misunderstandings

and or non-compliance with SFI’s and procurement, particularly in

relation to ICT.

.

John Brierley Chair 13

th August 2014

Background Papers / Information

None

Board of Directors – Public Date 28

th August 2014

Chair of the Charitable Funds Committee Report

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Author: Graham Creelman Department: Corporate

Page 1 of 2 Date produced: 19/8/14 Retention period: 30 years



Title of Report: Charitable Funds Committee Chair’s Report

Action Sought: For information


Author: Graham Creelman: Non-Executive Director

Director: Graham Creelman: Non-Executive Director

Executive Summary:

Report of Committee meeting on 11 August 2014 at St Clements Hospital, Ipswich The Committee approved a proposal to begin charging NHS Ipswich and East Suffolk CCGs; NHS West Suffolk CCGs and Great Yarmouth and Waveney CCG (trading as East Coast Community Healthcare) a proportionate share for the administration of their Charitable Funds which are now lodged with NSFT. These costs used to be defrayed by the interest on the funds, which is now negligible. The Committee also agreed to continue discussions with East Coast Community Healthcare (ECCH) for the return to them of responsibility for the Beccles Hospital Fund which, at £1,250,000 is the overwhelming bulk of the funds administered by NSFT. Committee resolutions The Committee heard that there had been no movement on the £1.25 million Beccles Hospital Fund. All previous proposals for this fund, which can only be spent on improvements at Beccles Hospital, have fallen down on the issue of who would pay for any continuing revenue costs of any development at the hospital. This could clearly not be the responsibility of the NSFT Charitable Funds. Kate Gill, representing ECCH agreed that it might be sensible for them to take the funds back, as perhaps a more flexible way of using them could be found. It is not clear whether, under NHS Charity rules, this will be possible. This will be investigated, and conversations will continue. As ECCH are a registered Social Enterprise, rather than directly an NHS body, this may be difficult. The Committee approved a proposal that the various “owners” of the constituent parts of the Charitable Funds should in future be charged a proportion of the costs of administering the funds. This would break down as follows:

Date: 28th

August 2014

K Item: 14.112v

Board of Directors – Public Date 28

th August 2014

Chair of the Charitable Funds Committee Report

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Author: Graham Creelman Department: Corporate

Page 2 of 2 Date produced: 19/8/14 Retention period: 30 years

NSFT £9,436.26 NHS Ipswich and East Suffolk CCGs £6,710.29 NHS West Suffolk CCG £3,039.07 ECCH £3,694.38 These fees are calculated based on the level of expenditure incurred in the previous financial year by each fund, and not the totality of each fund. Welcome Packs Kathy Walsh agreed to investigate whether welcome packs of toiletries and other essentials for patients who arrive in wards with nothing, and with no-one to bring any, could be paid for out of existing NSFT revenue. The Committee had previously agreed that such things were needed, and Hadrian Ball reported to the Committee that Clinical Cabinet had also agreed that this was desirable. The Committee, however, was reluctant to enter into an open-ended commitment to provide money for this if alternative sources of funding could be found. Income and Expenditure The Committee noted the current income and expenditure for the Funds. Total income for the period April 2014 to June 2014 is £26,877. This is £18,000 more than the last quarter. This is due in part to a donation of £10,000 to Newmarket Hospital and donations of £7,600 from the League of Friends. Expenditure in the First Quarter was £19,055.06-slightly more than the previous quarter. The total balance of all funds at the bank is £1,699,515.78 on 30 June 2014. The Committee reviewed the performance of the assets lodged with banks, and agreed that, although returns were pitifully small, there was no obvious alternative. Financial implications If the administration re-charge is approved by all parties, then there will be a financial benefit to NSFT. Quality Implications Properly badged, the use of NSFT Charitable Funds on good causes is an example of our commitment to and engagement with the community. Recommendations The Board is invited to approve the contents of the report, particularly the recommendations relating to the Beccles Hospital Fund and the re-charge of administration costs.

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