nhs west lancashire clinical …...2020/01/28 · 01/20/12 11.10 freedom to speak up policy i paul...

NHS WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING

28 January 2020, 9.30 – 11.30 pm

The Boardroom, Hilldale, Wigan Road, Ormskirk, Lancashire, L39 2JW

15 minutes to be allocated for questions from members of the public based on agenda items.

I – Information D-Discussion DR – Decision Required Members of the governing body will be available after the close of the meeting for

informal discussion, time permitting

Item WLCCGB

Time Agenda item Action Presenter

01/20/1 9.30 Welcome Chair

01/20/2 19.35 Declaration of Interests All

01/20/3 9.40 Minutes of previous meeting held on 26 November 2019 DR Chair

01/20/4 19.45 Matters arising - Action sheet DR Chair

Communication

01/20/5 19.55 Chair’s update I Chair

01/20/6 110.05 Chief Clinical Officer’s update I Mike Maguire

Governance

01/20/7 10.15 Risk management report I Paul Kingan

Operational Management Section

01/20/8 10.25 Integrated business report D Paul Kingan

01/20/9 10.40 Healthier Lancashire and South Cumbria Residential and Nursing Care service specification

I Angela Clarke

01/20/10 10.50 Lancashire and South Cumbria Safeguarding Arrangements Memorandum of Understanding

DR Claire Heneghan

01/20/11 11.00 West Lancashire Partnership Memorandum of Understanding

DR Jackie Moran/ Paul Kingan

01/20/12 11.10 Freedom to Speak Up policy I Paul Kingan

Consent items

01/20/13 111.20 Minutes of sub-committees: - Executive Committee – 12 November – 7 January

2020 - Audit Committee – December 2019 - Finance and QIPP – November 2019

Other minutes/action notes: - West Lancashire Community Safety Partnership –

October 2019 - Joint Committee of CCGs – September 2019

I Chair

Other Business

01/20/14 11.25 Any other business I Chair

Date and Time of Next Meeting – 24 March 2020, 9.30 – 11.30 am, the Boardroom, Hilldale, Ormskirk, L39 2JW

West Lancashire Clinical Commissioning Group Governing Body meeting – 26 November 2019 Page 1 of 6

Minutes DRAFT

Meeting Title: West Lancashire Clinical Commissioning Governing Body Meeting

Date: 26 November 2019

Time: 9.30 – 11.30 pm Venue: The Boardroom, Hilldale, Wigan Road, Ormskirk, L39 2JW

Present: Dr John Caine, Chair Mike Maguire, Chief Officer Paul Kingan, Chief Finance Officer/Deputy Chief Officer Dr Adam Robinson, Secondary Care Consultant Claire Heneghan, Chief Nurse Douglas Soper, Lay Member Steve Gross, Lay Member Greg Mitten, Vice-Chair/Lay Member Dr John (Jack) Kinsey, GP Executive Lead Dr Dheraj Bisarya, GP Executive Lead

In attendance: Cathy Ashcroft, Executive Assistant (minute taker) Jackie Moran, Director of Strategy & Operations

Apologies:

Tony Pounder, Director of Adult Services

Agenda

Item WLCCGB/

Summary of Discussion Action

11/19/01 Welcome and apologies for absence The meeting of the West Lancashire Clinical Commissioning Group Governing Body was opened by Dr John Caine. There were two members of the public present and no questions had been received from the public.

11/19/02 Declarations of interests Dr John Caine reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of West Lancashire CCG. Declarations declared by governing body members are listed in the CCG’s Register of Interests. The register is available either via the secretary to the governing body or the CCG website at the following link: Register-of-interests-Governing-Body-members-March-2019.pdf

Declarations of interest from sub committees.

None declared Declarations declared for this meeting included: None

11/19/03 Minutes of previous meeting held on 24 September 2019 The minutes of the meeting held on 24 September were approved as a correct record.

11/19/04 Matters arising There were no actions arising from the previous meeting to be reviewed.

COMMUNICATION

11/19/05 Chair’s update The report provided members with an update on both strategic and operational issues since the last meeting. Dr John Caine highlighted key areas of interest:

• SEND inspection – a follow-up Lancashire-wide review of SEND is expected in the New Year. Much work has taken place in the past 12 months to make

http://www.westlancashireccg.nhs.uk/wp-content/uploads/Register-of-interests-Governing-Body-members-March-2019.pdf



improvements to the service. Last week, an update at the Health and Wellbeing Board reported that of 94 actions from the first review, 89 have detailed action plans in place and only 5 have not been completed. In West Lancashire a Specialist School Nurse has been appointed and there are improvements in Individual Health Assessments for Looked After Children and the health advice for Education Health Care Plans.

• Urgent care – the Southport System Winter plan has been finalised and submitted to NHS England (NHSE). The CCG is working with social care and the hospital to support patients to return on the Home First pathway, being developed with Southport and Formby CCG from the improved Better Care Fund. A new Falls Lifting service commenced in 1 October, which offers a service via 999 or 111 calls, to assist people who fall in their homes and have no injuries.

In response to a question of whether West Lancashire Carers Association are aware of the Home First pathway and Falls Lifting service, it was felt that they should be aware via the county council’s involvement. This will be verified. The governing body: Noted the contents of the report

JC

11/19/06 Chief Officer’s update The report provided members with an update on both strategic and operational issues since the last meeting. Mike Maguire highlighted key areas of interest:

• Better Care Fund – planning is progressing and priorities are being agreed across West Lancashire and Lancashire. The results of the intermediate care review will influence the process.

• Winter communication – work is taking place with Sefton CCGs to deliver a joined-up message over winter. News releases in line with the national Help us to Help You campaign will be issued and posters will be sent to walk in centres / urgent treatment centres and GP practices. Information will be available in local papers and door drops.

• Mental health – an online digital support service (Kooth) for children and young people is being well received. The ADHD North West charity started in September and 35 children and their families are receiving support. The company Yogi will provide a set of cards for primary school classes to develop relaxation techniques for children. The learning will also be passed on to teachers to continue the exercises. A community recovery and support service has developed from the Community Restart service and will support people with complex mental health problems following discharge from Community Mental Health teams. The support includes physical health monitoring for patients as an objective in the five-year view for mental health.

Greg Mitten will be informed if Kooth is accessible via self-referral. There is a possibility that the service could be directed to parents via a Twinkle House initiative. In addition, information will be provided about what is available for people with a dual diagnosis eg mental health, drugs or alcohol, who will not accept support when presenting with mental health crisis.

It was reported that there are no spiked readings in respect of Australian flu to date, which is one of the three strains included in the vaccine. The importance of vaccinating children was raised to prevent further spread of the virus. Policy currently dictates that if a child misses the vaccine at school an alternative appointment will be made in Preston.

Alison Lumley, Nursing & Clinical Quality Lead, attends meetings about the post flu season outcomes. The data is reviewed and the CCG compares well with other areas. Adam Robinson highlighted the use of Near Patient Testing for


patients presenting with flu like symptoms in A&E departments, which provides a two-hour turnaround for results. This manages the spread of flu to other patients. The governing body: noted the content of the report

GOVERNANCE

11/19/07

Risk Management Monthly Report Paul Kingan presented the risk report, which noted the position in November and was taken as read. The group was still happy with the current format of the risk management report with technical issues in accessing the Smartsheet now being addressed. A summary of risks was suggested. A risk is presented at the Clinical Executive Committee on a monthly basis to review in more detail and consider the risk score. The CCG had a total of 23 risks with 16 scoring 12 or more, which is a decrease of two risks since the last meeting. Three risks had not been updated in the report: CCG44 Acute provider performance, CCG58 Hospital workforce issues and CCG68 Replacement of Haematology Consultant. Seven risks had been RAG-rated red and had been updated:

• Brexit (CCG65) has a score of 16, but will be not commented on until the elections have taken place.

• Acute mental health provision (CCG69) - there is an action plan to address the pressures in Lancashire and to improve flow for those out of area. There is limited funding to resolve service issues.

• Domiciliary care element for continuing healthcare patients (CCG51) remains a risk in terms of the timeliness of assessments. as the CCG relies on the CSU for delivery of the service. Jerry Hawker, from Morecambe Bay CCG, is preparing the final recommendations from the review, to which the CCG contributed.

• Acute Trust Performance (CCG44) – including workforce and finance risks. The CCG is working with NHS England/ Improvement on this issue, which is a national issue, and continues to work with Southport and Ormskirk Hospital NHS Trust (the Trust) and prepare for the winter in terms of flow and community support for patients.

• Financial position (CCG42) – this is discussed in the next report.

• Prescription Ordering Direct (POD) (CCG71) – much work has been undertaken to improve operational risk in the service and a review has been carried out which will address complaints received about the service. It is also evident that there is disparity of service offer. The action plan has been reviewed and is expected to be in place by the end of December. Staffing levels have been resolved, however sickness / absence remains high and the IT, telephony systems and governance are being addressed. The service and staff numbers have rapidly increased and new accommodation is required. It was agreed that future formal discussion should be held at the Primary Care Commissioning Committee. The level of staff available at peak call times and a restructuring of work patterns in order to address non-telephony work such as emails, paper scripts, Docman and necessary training and development is being considered and a call waiting screen has been installed. The existing CSU call system has issues and the alternatives need to be looked into, also on-line requests need to be introduced. Discussion ensued about some issues received by Greg Mitten from patients. Greg Mitten relayed patients’ comments that online ordering is working well and it was felt that once technical issues are resolved, support in the community to encourage digital use would be helpful. The POD review has received 70 responses, which will be themed and presented at the Quality and Safety Committee. The responses will feed into the action plan and provide learning for staff and the organisations.


The three risks which have not been updated are followed up by Chris Brown and all risks are discussed at the Clinical Executive Committee. In respect of the mental health service, it was felt that some remodelling of the service will be required, however the associated costs may be challenging. Discussion ensued about the out of area placements and should patients be repatriated to a local service, savings would be made. The CCG is required to put aside funding for the mental health investment standard (MHIS), which would fund the costs in the mental health action plan. Greg Mitten shared concerns about value for money of local services, as the beds are available but staffing is needed, which requires further investment, eg for those people who do not leave their homes. A local mental health strategy will be available by February 2020 and the Integrated Care System action plan, through the mental health workstream, will be taken to the Joint Committee of CCGs. The governing body: noted the content and progress against plan.

OPERATIONAL MANAGEMENT SECTION

11/19/08

Integrated Business Report (IBR) The report provided summary information on the financial position and activity performance of the CCG to September and the financial position for October. It also included quality and performance analysis for community-based targets for Southport and Ormskirk Hospital NHS Trust. Paul Kingan drew the committee’s attention to the financial position. He then highlighted some key financial and performance areas in the report:

• The CCG is currently forecasting a break-even 2019/20 financial position, however, the risk associated with delivering this target is now quantified at £3.5million and the CCG will be reporting a deficit position in the near future. The CCG is encouraged to implement saving schemes before reporting this position, which are reported to the Finance and QIPP Committee. The financial position is partly due to contractual issues of £1.5m at the start of the year and underlying pressures in prescribing, related to Category M prices and Brexit. The ICS are aware of the position and work is taking place on the recovery plan with Southport system to work on this. There is a £3.9m surplus accumulated over a number of years, but national rules state this cannot be used. The saving schemes are sound, but will take time to deliver the benefits.

• 18-week referral target is achieved and continues to do well at 93%.

• Dementia rate diagnosis is performing well.

• Mental health – targets are largely on track.

• 4-hour waiting times in A&E – the target of 95% is not being achieved. Claire Heneghan will explore the 15% increase in A&E activity and report to the Clinical Executive Committee. The Short Intensive Support Service, Falls Lifting service, Home First scheme and single point of discharge will increase community capacity for West Lancashire.

• 62-day cancer – is achieving 77% against the target of 85%. This involves small numbers and therefore a minor change will have a significant impact. The Trust has adopted a pathway, which has improved the transfer to diagnostics and Lancashire Cancer Alliance are looking at the holistic picture. Early diagnosis and sufficient staff are essential factors to improve outcomes.

• Ambulance target times have not been achieved for Category 1 at 7 mins attendance or and Category 2 at 18 mins. This is a perennial issue for West Lancashire partly due to the geographical area. There is an action plan in place and the AVS and Falls Lifting service should help to reduce this gap. Calls have increased but conveyance reduced, which shows more on the spot treatment.

• Urgent care demand has increased in Wigan, where a reduced rate of the blended tariff is not available.

• Planned care is over-plan.


• Prescribing rates are increasing.

• The QIPP savings table projects a 73% delivery for the full year. The prescribing patterns shows an increase for Beacon Primary Care, however this is due to a number of patients with acquired brain injuries who are from out of area, but treated at a local specialist care home. It was felt the costs should be part of patient’s package. It was noted that it was more difficult each year to identify efficiency saving schemes. The 3% overall savings target was felt to be unachievable. 2% has been achieved, therefore a deficit figure is recorded in the accounts. The CCG is working with Sefton partners in terms of financial recovery, as well as working with the Lancashire and South Cumbria system to implement large-scale initiatives. The importance of including health and social care to achieve patient care is essential. The green paper is out imminently for public health. The governing body: noted the content of the IBR.

11/19/09 Safeguarding Annual Report 2018-19 The Safeguarding Annual Report was presented by Claire Heneghan. The report had been approved at the Quality and Safety Committee held on 22 October. It provides assurance that the CCG is delivering against its statutory responsibilities to safeguard the welfare of children and adults. It outlines the service the safeguarding team provides across Lancashire. Some of the points covered included: changes to the safeguarding board; multi-agency training packages and expertise in team for mental capacity act (MCA); a seven-day service to support a more timely response to unexpected deaths; party to health assessment redesign projects and significant improvements over months; strengthening arrangements across children and young people service in understanding MCA; involved in the change of Deprivation of Liberty to Liberty Protection Safeguards; and quality assurance of out of area placements. The introduction of a safeguarding champion model in primary care had not been progressed to the level hoped, but needs to be embedded in Primary Care Networks. The safeguarding team report to the Quality and Safety Committee meetings and provide good communications and support to the CCG. Greg Mitten commended the team for maintaining the proactive and effecting service despite the pressures. The governing body: noted the annual report

11/19/10 Policies recently approved: Absence management Adoption Annual leave Career break Disciplinary Domestic abuse and the workplace Equality and Diversity Flexible working Grievance Harassment and bullying at work Induction Job evaluation Managing work performance Maternity Ongoing review objectives Organisational change Other special leave Parental leave


Paternity leave Professional registration Recruiting ex-offenders Recruitments and selection Retirement Shared parental leave Substance misuse Training and development Secondment Temporary promotion Compliments complaints and concerns policy – Claire Heneghan confirmed that this policy had been updated after a review by MIAA and NHSE, resulting in an action plan which reflects areas to be addressed. There had been significant learning from both audits, which puts the CCG in a better position to manage patients’ complaints and concerns. A new Patient Experience Manager and Meg Pugh, Head of Communications, will ensure the actions are addressed. Serious untoward incident (SUIs) policy and procedure – the policy has been refreshed with changed timeframes for responses of SUIs, also the management of deaths in custody. Discussion about the communications between organisations took place. Contracts will be updated as appropriate. The governing body: Ratified the above policies and procedures.

11/19/11 Joint Committee of CCGs – Terms of Reference Paul Kingan presented the terms of reference, which the eight CCGs are asked to ratify, following the agreement made at the Joint Committee of CCGs. The joint committee meet to make decisions on two levels: Level 1 the CCG has delegated decision making to the joint committee and level 2 the joint committee recommends a decision to the CCGs’ Governing Bodies. The governing body: approved the adoption of the Terms of Reference (updated as Version 8) ratifying the recommendation of the Joint Committee and noted that a further paper will be presented to the Joint Committee setting out levels of decision-making authority against the agreed work programme.

CONSENT ITEMS

11/19/12 Minutes of sub-committees: - Executive Committee – July – October 2019 - Quality and Safety Committee – October 2019 - Finance and QIPP – July and September 2019 Other minutes/action notes: - Lancashire Health and Wellbeing Board – September 2019 – a letter, sent by

Cllr Shaun Turner, asking member organisations for their top three priorities of work will be forwarded to Jackie Moran.

- West Lancashire Community Safety Partnership – July 2019

The governing body: noted the papers and comments above.

GM

Other business

11/19/13 Any other business - Governing Body meeting dates were approved.

Meeting closed at 10.59 am

Date and time to next meeting: Tuesday 28 January 2020, 9.30 – 11.30 am, The Boardroom, Hilldale, Wigan Road, Ormskirk, Lancashire L39 2JW

of 1

Agenda item no: WLCCGB

West Lancashire CCG Governing Body meeting Action sheet

Action Lead Date required by Action completed

Chairs update In response to a question of whether West Lancashire Carers Association are aware of the Home First pathway and Falls Lifting service, it was felt that they should be aware via the county council’s involvement. This will be verified.

Dr John Caine 28 January 2020

Minutes for information Lancashire Health and Wellbeing Board Aa letter, sent by Cllr Shaun Turner, asking member organisations for their top three priorities of work will be forwarded to Jackie Moran.

Greg Mitten 28 January 2020

Communication – Chair’s Update West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

1

WLCCGB 01/20/05

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

DATE OF BOARD MEETING: 28 January 2020

TITLE OF REPORT: Chair’s Update

BRIEFING POINTS:

Does this report / its recommendations have implications and impact with regard to the following:

A. Commissioning Board’s Aims and Objectives

1. Quality (including patient safety, clinical effectiveness and patient experience) – please outline impact.

No

2. Commissioning of hospital and community services Yes

3. Commissioning and performance management of GP Prescribing – please outline impact

No

4. Delivering Financial Balance – please outline impact No

5. Development of the commissioning group as a commissioning organisation – please outline impact.

Yes

B. Governance – please outline impact

1. Does this report:

• provide the Commissioning Board with assurance againstany of the risks identified in the assurance framework(identify risk number)

• have any legal implications

• promote effective governance practice

• N/A

• No

• No

2. Additional resource implications (either financial or staffing resources)

Yes

3. Health Inequalities. No

4. Equality and Inclusion and Human Rights Requirements – - Has an Equality Impact and Risk Assessment been carried

out?

No

5. Clinical Engagement No

6. Patient and Public Engagement - Has public participation/the ‘13Q duty to involve’ been

considered?

Yes

PAPER PREPARED BY:

PAPER PRESENTED BY:

Meg Pugh, Head of Communications and Engagement

Dr John Caine, Chair


2

WEST LANCASHIRE CLINICAL COMMISSIONING GOVERNING BODY CHAIR’S UPDATE

PURPOSE This report provides an update on both strategic and operational issues of interest to governing body members since the last meeting. Shared Accountable Officer 1. The CCG announced our move to a new model by welcoming a Shared

Accountable Officer, Dr Amanda Doyle on 1 January 2020.

2. This announcement was made in December 2019 following purdah and is

available in full at the below link: https://www.westlancashireccg.nhs.uk/local-nhs-

bids-farewell-to-chief-officer/

3. Dr Amanda Doyle is currently chief clinical officer at NHS Blackpool and Fylde

and Wyre CCGs, and the Integrated Care System (ICS) lead for Lancashire and

South Cumbria.

Urgent care 4. The Falls lifting service went live across Lancashire in October 2019. In West

Lancashire 64% of referrals led to patients remaining at home. This service

refers into falls prevention services and community services locally to help

patients that can be treated out of hospital within the community.

5. A Home First pathway, which was introduced in April 2019, enables patients to

go home with wrap around social care support instead of going to a Care Home

for reablement. Referrals have been steadily increasing and this pathway will

now be supported by additional social care support which has been possible due

to improved Better Care Funding. Age UK hospital aftercare service has also

been helping to support patients on this pathway, allowing integrated health,

social care and voluntary sector support for patients on discharge.

Workforce 6. The CCG has accommodated four Edge Hill University Foundation Year Medical

Students and four have been placed within primary care for two one-week

placements. This will be an ongoing annual commitment for the CCG and

primary care.

7. The Medicine Degree at Edge Hill will commence in September 2020, which will

generate more students into the CCG and primary care.

8. As part of the GROW programme, which aims to create health and social care

workforce for the future, the CCG have been working in partnership with West

Lancashire College and have been successful in securing placements within

primary care for ten of the students that are on the medical programme. The

feedback from both the students and the placements has been very positive so

far.

https://www.westlancashireccg.nhs.uk/local-nhs-bids-farewell-to-chief-officer/

https://www.westlancashireccg.nhs.uk/local-nhs-bids-farewell-to-chief-officer/


3

Mental health

9. Ennerdale Community HUB: The CCG has successfully obtained funding to

develop a mental health centre in Skelmersdale that will provide rapid

assessment and support to West Lancashire residents from 1 February 2020.

The HUB will be staffed 10am to 8pm 7 days a week. The aims of Ennerdale are

to reduce demand on acute care services and also provide services that have an

impact on local suicide rates.

10. The CCG has recently commissioned the services of YOGI, who will provide

emotional wellbeing training and activity cards to every Primary School in West

Lancashire.

11. The CCG and Lancashire and South Cumbria NHS Foundation Trust are hosting

a CAMHS (child and adolescent mental health services) event on Friday 20th

March at Applecast, Newburgh. The purpose of the day is to update people on

the ongoing transformation of Children and Young People’s Mental Health

services and showcase the ongoing work in West Lancashire. Children and

carers are welcome to attend. Further communication to follow.

12. West Lancashire crisis and home treatment teams have recently expanded their

service so that they can provide a 24/7 face to face service. This was previously

only accessible via telephone support after 8pm.

Southport and Ormskirk Hospital Services

13. The CCG is working closely with Southport and Ormskirk Hospital NHS Trust

around several services that have been identified as clinically fragile, such as

diabetes and haematology for example.

14. These services are facing difficulties around workforce due to various factors

such as consultant cover and recruitment challenges. The organisations will

continue to work together, alongside NHS Southport and Formby CCG, to

address possible solutions to ensure quality services remain available and

accessible to patients.

Dr John Caine Chair January 2020

Chief Officers Update West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

1

WLCCGB 01/20/06


DATE OF BOARD MEETING: 28 January 2020 TITLE OF REPORT: Chief Clinical Officer BRIEFING POINTS:



1. Quality (including patient safety, clinical effectiveness and patient experience) – please outline impact.

No

2. Commissioning of hospital and community services – please outline impact.

Yes

3. Commissioning and performance management of GP Prescribing – please outline impact.

No

4. Delivering Financial Balance – please outline impact. No

5. Development of the commissioning group as a commissioning organisation – please outline impact

Yes



• provide the Commissioning Board with assurance against any of the risks identified in the assurance framework (identify risk number)



N/A No No


No

3. Health Inequalities Yes

4. Equality and Inclusion and Human Rights Requirements – - Has an Equality Impact and Risk Assessment been carried out?

No


6. Patient and Public Engagement. Has public participation/the ‘13Q duty to involve’ been considered?

Yes

PAPER PREPARED BY: PAPER PRESENTED BY:

Meg Pugh, Head of Communications and Engagement Dr Amanda Doyle OBE, Chief Clinical Officer


2

WEST LANCASHIRE CLINICAL COMMISSIONING GOVERNING BODY

CHIEF CLINICAL OFFICER

PURPOSE

This report provides an update on both strategic and operational issues of interest to

governing body members in the months since the last meeting.

Strategic planning

1. Following the launch of the NHS Long Term Plan in January 2019, Lancashire

and South Cumbria Integrated Care System (ICS) was required nationally to

submit an ICS strategic plan in response to the long term plan and the local

needs of our population over the next five years.

2. The ICS strategic plan builds upon the eight partnership priorities set out in the

ICS ‘Our Next Steps’ document, to agree the ambition and approach to respond

to the strategic challenges facing our ICS.

3. The strategy also sets out the programmes and plans to deliver against the aims

and objectives of the NHS Long Term Plan and to meet the health and wellbeing

needs of our local population. It outlines a set of priorities for the partner

organisations to pursue over the next five years.

West Lancashire Partnership 4. In February 2020, the partnership is due to publish its draft plans.

5. There will be a phase of engagement which will invite members of the public, and

other stakeholders to share their view on these plans, as well as the broader plan

due to be published by the Integrated Care System (ICS) in Lancashire and

South Cumbria.

Winter communication 6. The CCG continues to advise local residents of local health services they can

access during winter, such as 111, pharmacies and the extended access

scheme.

7. Over Christmas and New Year, we highlighted information such as bank holiday

opening times, reminders for prescriptions, how to access the POD and use

Patient Access.

8. Various news releases have been issues to the local media and advertisements

placed in local door drop magazine Local Life and The Champion newspaper.

Health and wellbeing hubs

9. West Lancashire Borough Council is developing two new facilities in Ormskirk

and Skelmersdale, both of which are scheduled to be complete in early 2022.

They will be positioned as health and wellbeing hubs and will replace existing

facilities Park Pool in Ormskirk and Nye Bevan Pool in Skelmersdale.


3

10. Discussion are taking place between the CCG, NHS England and Improvement

and West Lancashire Borough Council exploring the possibility of the CCG using

some of the space at these hubs in order to offer health and wellbeing services to

the public.

11. The CCG will ensure they involve local patients and Patient Participation Groups

(PPGs) and welcome their views as part of these discussions.

Neighbourhood engagement

12. The CCG held conversations with the community across three neighbourhoods

over the summer 2019.

13. These conversations focused slightly on health but also aimed to draw out what

matters most to local residents.

14. The published report captures a summary of the CCG’s findings and is available

via our website or on request. These views will be considered as part of our

West Lancashire Partnership.

Primary Care Networks (PCNs)

15. The three Primary Care Networks continue to bring practices together, as well as

social care, community services and other colleagues, to work in partnership to

support our local population.

16. The CCG is looking to extend the social prescribing pilot, currently running in

Skelmersdale, across the whole of West Lancashire. This fits in line with the NHS

long term plan and the PCN DES which is to provide 100% funding for Social

Prescribing link workers to work in PCNs.

17. The three Clinical Directors for Primary Care Networks (PCNs) have now been

elected and will begin in post in April 2020; Dr Peter Gregory (Ormskirk), Dr

Rakesh Jaidka (Skelmersdale) and Dr Vik Mittal (Northern Parishes).

18. The CCG continues to have discussions around future GP representation on the

Governing Body.

Dr Amanda Doyle OBE Chief Clinical Officer January 2020

https://www.westlancashireccg.nhs.uk/wp-content/uploads/NHS-West-Lancashire-CCG-Neighbourhood-Engagement-summary-report.pdf

Governing Body Risk Report West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

1

WLCCGB 01/20/07


DATE OF BOARD MEETING:

28 January 2020

TITLE OF REPORT: Governing Body Risk Report

BRIEFING POINTS: The purpose of this paper is to update members on the current situation in respect of assurance framework/risk register



1. Quality (including patient safety, clinical effectiveness and patient experience) – please outline impact

No

2. Commissioning of hospital and community services – please outline impact

No


No



No



• provide the Commissioning Board with assurance againstany of the risks identified in the assurance framework(identify risk number)



Yes (positive impact) as it strengthens our governance practice and helps us identify opportunities to put relevant controls and measures in place


Yes

3. Health Inequalities N/A

4. Equality and Inclusion and Human Rights Requirements – - Has an Equality Impact and Risk Assessment been carried

out?

N/A

5. Clinical Engagement Yes (through

Governing Body Risk Report West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

2

our GP leads and

Chief Nurse)

6. Patient and Public Engagement - Has public participation/the ‘13Q duty to involve’ been

considered?

N/A

PAPER PREPARED BY:

PAPER PRESENTED BY:

Danielle McMillan, Corporate Business Manager

Paul Kingan, Chief Finance Officer

The Risk Management Monthly Report is accessible via the following link:

https://app.smartsheet.com/b/publish?EQBCT=fff1930048aa48e2bc69c45ae36ea552



Integrated Business Report West Lancashire Clinical Commissioning Group Governing Body – 28 January 2020

Agenda item no: WLCCGB 01/20/08

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP GOVERING BODY REPORT

DATE OF BOARD MEETING: 28 January 2020 TITLE OF REPORT: Integrated Business Report BRIEFING POINTS: This report provides summary information on the financial

and activity performance of West Lancashire Clinical Commissioning Group for November 2019 and a financial position for December 2019. Quality and performance analysis is also provided for community based targets and for the Southport and Ormskirk Hospitals.




Yes

The report outlines quality and performance issues relevant to the CCG and describes key actions to address these.


Yes

The report includes financial and activity information in relation to commissioned services and highlights areas of risk and actions.


No

4. Delivering Financial Balance – please outline impact Yes

The report summarises the financial position of the CCG and highlights areas of financial risk.


Yes

This report will support the CCG in developing clear and credible plans.



• provide the Commissioning Board with assurance against any of the risks identified in the assurance framework



Yes

Links to financial risks.


No


Links to health outcomes framework (all five domains)

4. Equality and Inclusion and Human Rights Requirements – Has an Equality Impact and Risk Assessment been carried out?

No


6. Patient and Public Engagement Has public participation/the ‘13Q duty to involve’ been considered?

No

REPORT PREPARED BY: Paul Kingan, Chief finance officer REPORT PRESENTED BY: Paul Kingan, Chief finance officer

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West Lancashire Clinical Commissioning Group Integrated Business Report

January 2020 (Reporting Period November 2019)

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TABLE OF CONTENTS

1 Executive Summary 3

2 Financial Position 4

3 QIPP 8

4 Individual Patient Activity 9

5 Learning Disability and Transforming Care 11

6 RightCare 12

7 Planned Care: Referrals 14

8 Planned Care: eReferrals Service 16

9 Planned Care: Acute Contract 17

10 Unplanned Care: Acute Contract 19

11 Prescribing 21

12 Mental Health 23

13 Quality and Performance

a West Lancashire CCG Performance Dashboard 28

b Southport and Ormskirk Hospitals NHS Trust Integrated Performance Dashboard 30

c Areas of Under-Performance 31

d Patients Waiting by Weeks 34

e Friends and Family Test 36

f Safety Thermometer

37

14 Primary Care 38

15 Patient Complaints 38

16 Serious and Untoward Incident Reporting

38

Appendix 11

1 Criteria Used to Determine Financial Performance RAG Ratings

39

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1. Executive Summary This report provides summary information on the activity performance of West Lancashire Clinical Commissioning Group for November 2019 and the financial position up to December 2019. Quality and performance analysis are also provided for community-based targets and for Southport and Ormskirk Hospitals NHS Trust.

CCG Position Highlights Financial Performance Value

CCG Forecast Position (In-Year Surplus) £0.000m

CCG Forecast Position (Historic Surplus) £3.931m

Quantified Net Risks £3.500m

Risk Adjusted Forecast (Surplus) £0.431m

Better Payments Practice Code >95%

QIPP Forecast Savings (Plan £5.304m) £3.661m

Demand Footprint

GP referrals CCG Other referrals CCG

Planned Care

Total Planned Care PBR CCG Unplanned Care Total Unplanned Care PBR CCG Prescribing

Prescribing Budget CCG

CCG Key Performance Indicators YTD

NHS Constitution indicators Footprint

RTT 18 Weeks wait (Incomplete Pathways) CCG

Accident and Emergency 4 hours CCG

Cancer Waits 62 days CCG

Ambulance Response Times CCG

Other key targets

Friends and Family CCG

MRSA attributable to CCG CCG

C. difficile CCG

Cancer 14-day urgent target –breast CCG

Key information from this report NHS West Lancashire CCG For the 2019/20 financial year the CCG is currently forecasting a break-even financial position, consistent with NHS England requirements. However, the risk associated with delivering this target is now quantified at £3.5m and it is highly likely that the CCG will be reporting a deficit position of this magnitude in the near future. Indicative performance to the end of November 2019 against the planned care element of all contracts is over plan by £55k. The performance over the same period against the planned care element of the Southport and Ormskirk Hospitals NHS Trust contract only is under plan by £238k. Indicative performance to the end of November 2019 against the unplanned care element of all contracts is over plan by £526k. Unplanned care performance for the same period against the Southport and Ormskirk Hospitals NHS Trust contract is over plan by £109k.

Performance issues

The 4-hour Accident and Emergency target continues to be an issue with Southport and Ormskirk Hospitals NHS Trust, Wrightington, Wigan and Leigh NHSFT and Lancashire Teaching Hospitals NHSFT: all are failing the 95% target. North West Ambulance Service have failed to meet the new ARP response time targets for all months of this financial year. The zero tolerance to MRSA bacteraemia was breached in June 2019 with a single case attributable to Liverpool Women’s NHSFT. The CCG is currently exceeding the year to data target for C.difficile infections and it is highly improbable that the year end target will be met.

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2. Financial Position

Budget Expenditure Variance Budget ForecastForecast

Variance

£000 £000 £000 £000 £000 £000

Acute services

Acute 63,428 64,227 799 84,503 85,570 1,067

Ambulance services 2,704 2,704 0 3,606 3,606 0

Sub-total Acute Services 66,132 66,931 799 88,109 89,176 1,067

Mental Health Services

Mental Health 9,910 9,998 88 13,213 13,331 118

Learning Difficulties 1,275 1,288 13 1,700 1,718 18

Sub-total Mental Health Services 11,185 11,286 101 14,913 15,049 136

Community Health Services

Community 13,328 13,983 655 17,773 18,642 869

Sub-total Community Services 13,328 13,983 655 17,773 18,642 869

Continuing Care Services

Individual Packages 8,241 8,143 (98) 10,988 10,858 (130)

Funded Nursing Care 1,170 1,063 (107) 1,560 1,418 (142)

Sub-total Continuing Care Services 9,411 9,206 (205) 12,548 12,276 (272)

Primary Care Services

Prescribing 13,373 13,430 57 17,868 17,945 77

Primary Care (Co-Commissioning) 10,368 10,269 (99) 14,446 14,314 (132)

Primary Care (Other) 1,403 1,360 (43) 1,871 1,813 (58)

Enhanced & Tier 2 Services 722 784 62 963 1,046 83

GP IT 544 402 (142) 726 536 (190)

Sub-total Primary Care Services 26,410 26,245 (165) 35,874 35,654 (220)

Other Budgets

NHS Property Services 644 644 0 1,014 1,014 0

Urgent Care 3,212 3,230 18 4,282 4,306 24

Other Programme Services 1,505 1,584 79 2,007 2,112 105

Running Costs 1,777 1,777 0 2,369 2,369 0

Sub-total Other Budgets 7,138 7,235 97 9,672 9,801 129

Reserves

Reserves (0.5% Contingency) 610 0 (610) 813 0 (813)

Reserves (Other) (1,186) (1,858) (672) (1,581) (2,477) (896)

Sub-total Reserves (576) (1,858) (1,282) (768) (2,477) (1,709)

Total - Commissioning services 133,028 133,028 0 178,121 178,121 0

Planned Surplus 2,949 0 (2,949) 3,932 0 (3,932)

Grand Total 135,977 133,028 (2,949) 182,053 178,121 (3,932)

NHS West Lancashire CCG

Financial Position as at Month 9 (December) 2019/20

Year to Date Full Year

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For the 2019/20 financial year the CCG is forecasting a surplus of £3.931m, in line with that required by NHS England. This surplus has been carried forward from previous financial years and the CCG is expected to maintain it at the same level i.e. to breakeven against its allocated resources for 2019/20. Key points to note are:

Acute Services – The CCG entered an arbitration process with its largest provider, Southport & Ormskirk Hospitals NHS

Trust, regarding charging for the Trust’s Clinical Decision Unit and services falling outside the scope of Payment by

Results (PbR). The outcome of the arbitration has now been received and both parties have been working on

translating this into a contract value and detailed activity plan. The forecast value of contractual activity is expected

to be in the region of £50.5m, £1.5m higher than initially anticipated. It is likely that this risk will be brought into the

financial position at Month 10.

Forecast activity with the CCG’s other providers is higher than contracted levels, most notably with Wrightington,

Wigan and Leigh NHS Trust (£332k), Ramsay Healthcare (£232k) and Lancashire Teaching Hospitals NHS Trust (£146k).

Across all Acute Contracts the CCG is currently reporting a forecast overspend of £1.067m.

Implementation of those QIPP schemes addressing demand for secondary care services (e.g. the Short Intensive

Support Service, procedures of limited clinical value, community cardiology) needs to progress in order contain further

increases in demand for hospital services and facilitate delivery of the CCG’s financial targets in 2019/20 and beyond.

Community Services – The overspend reflects the recategorization of expenditure following the CCG’s Ophthalmology

Services procurement and should be offset by savings in secondary care where the activity was previously undertaken.

The CCG is currently examining the financial impact of this new service in further detail.

Individual Packages – Based on data received from Midlands and Lancashire Commissioning Support Unit the CCG is

forecasting an underspend of £130k. Growth in the number of packages is lower than anticipated. The CCG is

supporting a pan-Lancashire work programme with the objective of redesigning the delivery of these services to

improve quality and value for money.

Funded Nursing Care – Expenditure for April to December is approximately 9.1% lower than budgeted; if this trend is

maintained this will produce an underspend of £142k.

Prescribing – The performance of the Prescribing budget, and the delivery of planned QIPP savings of £1.250m, will

be critical to the CCG delivering its financial targets in 2019/20. However, in line with other Lancashire CCGs, year to

date expenditure is considerably higher than for the corresponding period in 2018/19 (see Section 11) and this now

presents a major financial risk for the CCG, the currently reported forecast overspend of £77k expected to significantly

increase in magnitude by year end.

Reserves 0.5% (Contingency) - As was the case for 2018/19 and previous years, the CCG has created a 0.5%

contingency to manage in-year pressures and risks. Due to the financial pressures on acute contracts detailed above,

the CCG has now fully released the contingency in order to deliver a forecast position consistent with its target.

Reserves (Other) – This is a negative budget – the unidentified portion of the CCG’s QIPP Programme is included here

which, if unaddressed, represents a considerable financial risk to the organisation. This budget also includes discrete

amounts set aside for specific purposes (for example investment in the Third Sector).

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The outcome of the arbitration process with Southport & Ormskirk Hospitals NHS Trust and the level of planned

QIPP savings that remain unidentified represent a considerable financial risk to the organisation. It is highly likely

that the CCG will be reporting a deficit position in the region of £3.5 million next month.

Allocated Resources The CCG’s annual budget for 2019/20 is £182.053m and consists of the following allocations:

In addition to its duty on delivering a breakeven in-year position the CCG has other financial responsibilities: Better Payment Practice Code (BPPC)

The Better Payment Practice Code requires the CCG to pay valid invoices by the due date or within 30 days of receipt of a valid invoice, whichever is later. The CCG’s target is for 95% of invoices (both by value and volume) to be paid within this criteria. Below is the 2019/20 cumulative performance against these requirements:

£000

Opening Programme Allocation 160,268

Opening Primary Care Allocation 14,874

Opening Running Costs Allocation 2,369

Reduction for GP indemnity scheme (428)

Brought Forward 18/19 Surplus/(Deficit) 3,932

Identification Rules (IR) transfers (189)

Excess Treatment Costs (7)

Improving Access Allocations 664

Atrial Fibrillation (AF) Patient Optimisation 77

West Lancashire CCG S&O Support 200

Capital Grant 155

Flash Glucose Monitoring 10

Better Care Fund Support 52

Palliative Care and End of Life Care Services Funding 51

GP IT Infrastructure and Resilience 29

Clatterbridge Lymphodaemia Transfer 1

Charge Exempt Overseas Visitor (CEOV) Adjustments (257)

IR Exercise - Month 8 1920 (4)

Atrial Fibrillation (AF) patient optimisation 2019-20 [Q3 and Q4] 76

Flash Glucose Monitoring Q2 22

Q84 ETTF Revenue 158

Total Resources (as at Month 9) 182,053

Target

Cumulative

Performance to

date

On Target for

Year End

Value 95% 99.63

Volume 95% 98.96

Value 95% 98.75

Volume 95% 98.77

NHS

Non-NHS

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Balance Sheet

£000

Non-Current Assets 9

Cash 136

Accounts Receivable 11,519

TOTAL ASSETS 11,664

Accounts Payable 15,734

Accrued Liabilities 43

TOTAL LIABILITIES 15,777

Retained Earnings incl. In Year (4,113)

Total Taxpayers Equity (4,113)

TOTAL EQUITY + LIABILITIES 11,664

Organisation £000

Lancashire County Council 69

Material Unpaid Accounts Payable Balances

Contractual Disputes

Organisation £000

Lancashire & South Cumbria Foundation Trust 243

This figure is made up of period end accruals, outstanding accounts payable invoices and staff costs including Pensions, National Insurance and other Payroll

deductions. We would not expect to have to report any risks in this area as costs are predominantly accrued into the financial position.

Organisation

Narrative

West Lancashire Psychology invoices. CCG have offered to settle at 50% of their value.

Risks to be Noted

Material Outstanding Accounts Receivable Balances

Narrative

Joint Funded Patient - debt is now 361+ days

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3. QIPP Each year the CCG is required to balance the continually increasing demand for services with a finite amount of resources. Accordingly, the CCG seeks to realise the best value for money from its contracts, whilst also pursuing Quality, Innovation, Productivity and Performance (QIPP) gains. These savings may be either cash releasing or non-cash releasing but need to have a recurrent effect to deliver a sustainable financial benefit.

The CCG’s Financial Plan identified 12 QIPP schemes for 2019/2020 with an aggregate value of £3.473m. However, as the overall QIPP target was £5.304m, £1.831m of proposed savings were not identified. Additionally it is probable that some of the schemes listed below will not deliver all planned savings. The CCG must therefore continue to devise schemes that drive efficiencies to enable it to deliver services within its allocated resources as the level of Unidentified QIPP poses a serious financial risk to the organisation. A description, scheme leads, financial performance (expected savings compared to planned levels) and project status for each are shown in the table below.

Planned

Savings

Actual

Savings

Planned

Savings

Forecast

Savings

£k £k £k £k

1 PrescribingSavings from more efficient and effective

prescribing of medicinesN Baxter P Gregory 938 938 1,250 1,250

Prescribing Hubs expected to deliver most of this savings

target

2 Pain Management

Impact of new service that aims to treat

patients more effectively, using fewer surgical

interventions

C McCabrey V Mittal 375 150 500 250 Service went live in May

3 72 Hour Care Service

Expansion of community service offer for

patients at risk of requiring a hospital

admission

J Moran C Heneghan 188 50 250 250Service commenced October 1st - initial capacity of 3

patients at any one time

4 Individual Patient Activity Reduction in CHC placement costs P Jones C Heneghan 263 0 350 250

Pan-Lancashire work to transform IPA delivery has

commenced. Outline Business Case expected to be ready

for approval by December.

5 Social Prescribing

Social Prescribing Service has been created in

West Lancashire which may impact on hospital

admissions

M Maguire D Bisarya 75 75 100 100

Service initially piloted in Skelmersdale & is now being

developed in the Northern Parishes as part of the SHERIF

proposal.

6Procedures of Limited

Clinical Value

Reduction in such procedures to improve

allocation of CCG resources A Delaney J Kinsey 75 75 100 100

Data has been shared with CCG Executive Committee

members to determine which procedures to address

7Ophthalmology -

Triage/AMD Services

The CCG has commissioned new community

Ophthalmology servicesA Halksworth

V Mittal

R Jaidka188 125 250 150 Services went live during 2018/19

8 EstatesRationalisation of CCG Estate to reduce

charges levied by NHS Property ServicesP Kingan J Caine 151 0 201 200

Former PCT headquarters to be demolished, this has

been paused pending decision on future use of site.

Additionally CCG to challenge historic charges.

9 Community CardiologyReduction in non-elective costs relating to

CardiologyJ Moran C Heneghan 140 0 187 0

Business case in development - start date of scheme to

be confirmed

10Community Dermatology

Service

The CCG is procuring a new technology

enabled community based service to improve

quality and value for money

C McCabrey J Caine 75 0 100 0Procurement process is progressing. However new

service not expected to commence until July 2020.

11 Stroke Rehabilitation Intention to redesign service J Sephton C Heneghan 75 0 100 25Business case in development - start date of scheme to

be confirmed

12 Running Cost EfficienciesSavings required to hit the CCG's running cost

targetP Kingan J Caine 64 50 86 86

Savings options to be explored - 2 staff members have

recently left the CCG

13 UnidentifiedValue of savings not yet attributed to schemes

and as such need to be found in-year- - 1,373 450 1,831 1,000

Pipeline of schemes being developed including FIT

Testing, Consultant Connect and COPD

Total 3,978 1,913 5,304 3,661

% Delivery

Update/Actions Pending

48% 69%

Year to Date Full Year

ID Scheme Name DescriptionManagerial

LeadClinical Lead

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4. Individual Patient Activity

Current Activity

Midlands and Lancashire CSU (MLCSU) provides commissioning support services on behalf of the CCG for Individual Patient Activity (IPA). The graph below shows spend by calendar month for the last two years.

The graph below itemises the spend for 2019/20 by categories of care and compares the spend to 2018/19. To the end of November 2019 total spend on Individual Patient Activity exceeds 2018/19 spend by 3.08%.

The largest spend by category is Continuing Healthcare. The table below illustrates the number and type of packages the CCG has been responsible for over the 12 months to November 2019. At November 2019, this amounted to 118 packages.

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Assessments in an Acute Setting NHS England requires CCGs to ensure that fewer than 15% of all full NHS continuing healthcare assessments take place in an acute hospital setting. This target has been exceeded for the last 12 calendar months.

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5. Learning Disability and Transforming Care West Lancashire CCG commissions a range of learning disability care from various providers in different settings. There is a national effort to ensure individuals with learning disabilities can be cared for in the community rather than in hospitals. This work is driven by 48 Transforming Care Partnerships (TCP) which are made up of groups of Clinical Commissioning Groups. West Lancashire CCG is part of the Lancashire and South Cumbria TCP. West Lancashire CCG Transforming Care efforts are focused on 5 individuals. The information below reflects the situation as at 30/11/2019:

Learning Disability is an area of high cost for West Lancashire CCG. Forecasted costs are in line with last month.

Other IPA refers to individuals whose primary diagnosis is Learning Disability and have a funded package of care, but these individuals are not covered by the Transforming Care Programme. Costs this month increased by £21k due to changes in weekly costs and length of package.

West Lancashire CCG contributes to a Learning Disability Pooled Budget operated by Lancashire County Council. This pooled budget purchases a range of services for residents with a Learning Disability in West Lancashire. Other community services contain elements of community Learning Disability services which are not included in the pooled budget – this is mainly children’s services.

Inpatient Update Two patients remain as ‘Inpatients’. One patient remains at Mersey Care Whalley, following an unsuccessful transition into the Community during 2018. The possibility of moving this patient into periphery housing is currently under review. Currently the care of this patient is covered by a ‘block’ payment of £615k for 2019/20 but these costs are under review and there is an identified additional risk of £230k. The second inpatient was receiving care via a locked rehab bed at Healthlinc House (Elysium Learning Difficulties and Autism); however, following a deterioration in condition they were moved into a Psychiatric Intensive Care bed with Lancashire Care at Chorley Hospital during August 2019. From September 2019 onwards responsibility for funding the care of this patient has moved from West Lancashire CCG to Specialist Commissioning.

Transforming Care Patient Review The CCG is currently undertaking a review of all transforming care patients to ensure that they fall within the commissioning remit of the NHS. The local authority has been informed that this is taking place and that the CCG will no longer be paying for packages of care outside of the remit and that in certain instances may seek to recover backdated costs.

TC Patients Inpatient Community

5 1 4

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6. RightCare RightCare is a national NHS supported programme committed to delivering the best care to patients ensuring that NHS resources go as far as possible and improving patient outcomes. Ensuring patients access to the right care, in the right place and at the right time, enables the NHS to treat patients more effectively, now and in the future. The central principle of RightCare is that it is unacceptable for there to be inconsistencies across the country in the types of care patients receive. By comparing the performance of an individual CCG with a group of ‘peer’ CCGs it is possible to identify the areas of care where a CCG is spending more than anticipated or that patient outcomes are inferior given their population demographics. Although RightCare can identify areas of inefficiency in commissioning by a CCG, its findings are not definitive. Using leading edge medical evidence and delivering practical support helps local health economies understand how resources are allocated to deliver the best care across England. NHS West Lancashire CCG is in the second wave of RightCare rollout to Clinical Commissioning Groups. Annually RightCare applies a series of demographic comparisons across all CCGs and selects the 10 most similar CCGs as the ‘peer’ CCGs for NHS West Lancashire CCG. The table below is the matrix of CCGs allocated as peers to NHS West Lancashire CCG against the financial year the financial data used applied to, ‘peer’ CCGs being highlighted in amber. The table clearly demonstrates that RightCare peers vary from year to year, only three ‘peer’ CCGs occurring in all three financial years. The RightCare algorithm then aligns CCG spend using Programme Budget Categories and identifies areas where NHS West Lancashire CCG could potentially improve patient outcomes or reduce spend significantly. NHS West Lancashire CCG has been allocated a RightCare Delivery Partner whose role is to support the CCG throughout the RightCare process.

Peer CCG Name 2015/16 2016/17 2017/18

NHS Airedale, Wharfedale and Craven CCG x

NHS Bassetlaw CCG x x x

NHS East Staffordshire CCG x

NHS Hardwick CCG x x

NHS Hastings and Rother CCG x

NHS Lincolnshire West CCG x

NHS Newark and Sherwood CCG x x x

NHS North East Lincolnshire CCG x

NHS North Lincolnshire CCG x x

NHS North Staffordshire CCG x x

NHS South Cheshire CCG x x x

NHS South Kent Coast CCG x

NHS South Sefton CCG x

NHS St Helens CCG x

NHS Thanet CCG x

NHS Vale Royal CCG x x

NHS Warwickshire North CCG x

NHS West Cheshire CCG x x

NHS Wyre Forrest CCG x

Financial Year Data used in Rightcare Pack

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Aligned with national requirements and informed by intelligence provided by the RightCare programme, CCGs were initially asked to focus on 3 areas which are listed below. NHS West Lancashire CCG was already engaged in service developments in all three areas.

• Musculo Skeletal System – Elective Spend

• Neurological Problems – Primary Care Prescribing Spend

• Problems of the Respiratory System – Elective Spend and Primary Care Prescribing Spend

NHS West Lancashire CCG has been commended on its efforts in the progress it has made against the main RightCare priorities listed above and has since been looking into what additional opportunities there may be. Four areas were highlighted as potential opportunities to improve outcomes and/or reduce spend. They are as follows:

• Gastrointestinal – we know there are opportunities, specifically around admissions, but further analysis of appropriate data is required. Steps have been taken to improve services through the adoption of the Sefton Dyspepsia Pathway, led by clinical executive Dr Jack Kinsey. Additionally, West Lancashire CCG is working towards increasing community provision for gastroscopies and changing the patient pathway in secondary care by creating a Direct Access route to eliminate unwarranted outpatient activity. It is anticipated that patients requiring consultant reviews following this will be able to enter the normal secondary care pathway. A business case has been approved for the adoption of the faecal immunochemical test (FIT) to reduce the requirements for colonoscopies in secondary care.

• CVD – Non-Elective spend. When looking at the practice level data pack, the extent of opportunity in this area appears minimal. Further analysis of this will allow us to discover if there are any worthwhile opportunities which can be explored further.

• Excessive Menstruation/Total abdominal hysterectomy – the GP Federation is increasing the number of clinics (through the Extended Hours Contract) to meet the needs of our local population. Southport and Ormskirk Hospitals NHS Trust has employed a specialist consultant to deliver menopause advice and treatment, which could help improve outcomes and reduce costs through utilising treatment options other than surgery where appropriate.

• Under 5’s Accident and Emergency attendances – a review of children’s services is underway. An initial scoping report on current services has been written and is currently being reviewed before agreeing next steps.

The NHSE RightCare programme has gained even more momentum since the release of the NHS Operational Planning and Contracting Guidance for 2019/20. There has been a request for a ‘refresh’ of all 3 previous submissions for West Lancashire in MSK, Pain and Respiratory. CCGs are also expected to address variation and improve care in at least one additional pathway for 2019/20 for which Cardiology has been selected, based upon scoping work undertaken recently. In addition, the regional RightCare team are trying to form a baseline for which High Intensity Under (HIU) schemes are currently in place, or are planned, across the Lancashire CCGs. Finally, all systems will work with the NHS RightCare programme to implement National Priority Initiatives (NPI) for cardiovascular and respiratory conditions in 2019/20. Furthermore, the CCG continues to work using RightCare data to identify opportunities and outliers, as and when new data becomes available.

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7. Planned Care: Referrals

The following section provides an overview of referrals to Secondary Care up to the end of November 2019 comparing referrals activity for financial years 2018/19 and 2019/20. In all IBRs produced since November 2017 West Lancashire CCG has excluded referrals to Physiotherapy from this analysis because this data is no longer being returned by Southport and Ormskirk Hospitals as it would distort the overall picture. This approach is consistent with the referrals’ counting methodology (only measuring Consultant Led Services) used by NHS England to monitor CCG performance.

The chart below shows numbers of referrals for West Lancashire CCG across all Lancashire and Merseyside providers. Overall, there has been an increase of 601 (1.55%) in all sources of referrals year to date compared to the same period in the previous financial year.

It should be noted that NHS England monitors CCG Performance against GP written referrals as recorded in the Monthly Activity Report (MAR) rather than using a local return (to MLCSU) for Lancashire and Merseyside providers. As of November 2019, the MAR Position for GP referrals for 2019/20 shows a 2.41% decrease compared to the same period 2018/19. The principal reason for this difference is that MAR only reports on referrals to Consultant Led Services. An additional issue identified is that Ramsay Operations does not supply correct numbers of referrals to MAR and typically understates referrals by 30%. Ramsay has confirmed that their MAR return is incorrect and have explained the source of the error but have not indicated how they intend to correct this. As the majority of GP referral growth experienced by West Lancashire CCG occurs at Renacres Hospital (Ramsay) this discrepancy is significantly distorting these statistics. Work is ongoing to align the two data sources to ensure consistent reporting in future reports. The remainder of comments in this section relate to data supplied by the MLCSU local return.

Referral Source 2018-19 2019-20 Variance Variance %

All 38877 39478 601 1.55%

GP 20080 19599 -481 -2.40%

Hospital 12886 14089 1203 9.34%

Other 5911 5788 -123 -2.08%

Comparison of Referrals Financial Year to Date 2019/20 to 2018/19 -November 2019

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West Lancashire CCGs’ main secondary care provider, Southport and Ormskirk Hospitals NHS Trust, has seen referrals decrease by 0.12% in all sources (26 referrals); GP referrals have decreased by 719 (7.85%) compared to the same period last financial year. The overall market share in total referrals for Southport and Ormskirk Hospitals NHS Trust has decreased by 0.90% compared to the same period last year, while the market share for GP referrals has decreased by 2.54%. It should be noted that much of the increase in non-GP referrals at Southport and Ormskirk Hospitals is driven by internal technical issues regarding the coding and counting of activity, and not by an increase in patient acuity. As an example, the ‘Expert Determination’ regarding the counting of Ambulatory Care Unit Activity meant it was necessary for the Trust to create a Hospital referral into General Medicine for each patient where follow-up activity was necessary.

The specialties with the most significant decreases in GP referrals at Southport and Ormskirk Hospitals are: Urology 25.3% decrease (144 referrals); Pain Management 100% decrease (128 referrals); Ophthalmology 15.8% decrease (115 referrals); Dietetics 87.8%% decrease (108 referrals); General Surgery 11.4% decrease (84 referrals); Trauma and Orthopaedics 18.8% decrease (72 referrals); Rheumatology 25.1% decrease (60 referrals); Gynaecology 5.2% decrease (52 referrals) and Clinical Haematology 27.1% decrease (51 referrals). Significant increases in GP Referrals at Southport and Ormskirk Hospitals are Cardiology 29.2% increase (94 referrals); Dermatology 8.0% increase (82 referrals); Paediatrics 13.2% increase (69 referrals); and Respiratory Medicine 18.1% increase (57 referrals). Our second main provider, Wrightington, Wigan and Leigh NHS Foundation Trust, has seen an 13.4% increase in GP referrals (255) from 2018/19 to 2019/20. The most significant increases in GP referrals have been Trauma and Orthopaedics 24.9% increase (95 referrals); Colorectal Surgery 177.8% increase (80 referrals); Gastroenterology 62.1% increase (41 referrals) and ENT 24.5% increase (40 referrals). The most significant decreases were in Breast Surgery 20.5% decrease (76 referrals) and Respiratory Medicine 25.6% decrease (22 referrals). Overall market share for Wrightington, Wigan and Leigh NHS Foundation Trust total referrals increased by 0.73% compared to same period 2018/19, while the market share of GP referrals has increased by 1.53%.

University Hospitals Aintree Trust has seen a decrease in GP Referrals of 130 (10.4%) when compared to the same period 2018/19. The most significant changes have been Breast Surgery 11.1% increase (50 referrals); Cardiology 71.4% increase (45 referrals); counteracted by Nephrology 69.1% decrease (56 referrals) and ENT 45.3% decrease (39 referrals). Overall market share for University Hospitals Aintree total referrals decreased by 0.34% compared to the same period last year, while the market share of GP referrals has decreased by 0.51%.

St Helens and Knowsley NHS Trust has seen a decrease of 91 GP Referrals (6.89%) when compared to the same period last year. This is mostly attributed to Plastic Surgery 36.9% decrease (44 referrals); Gastroenterology 47.2% decrease (17 referrals); and Breast Surgery 34.1% increase (31 referrals). Overall market share for St Helens and Knowsley Hospitals NHS Trust total referrals remained unchanged compared to same period 2018/19, while the market share of GP referrals has decreased by 0.30%.

Ramsay Healthcare (mainly Renacres Hospital) has seen a decrease of 21 GP referrals (0.6%) for April-November 2019/20 compared to the same period in 2018/19. The main changes in GP referrals are attributed to ENT 32.7% increase (127 referrals); Gynaecology 15.0% increase (72 referrals); Breast Surgery 527.3% increase (58 referrals); Trauma and Orthopaedics 14.2% increase (45 referrals); Pain Management 80.1% decrease (274 referrals) and Urology 14.6% decrease (56 referrals). Overall market share for Ramsay Healthcare total referrals decreased by 0.17% compared to same period 2018/19, while the market share of GP referrals has increased by 0.33%.

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8. Planned Care: eReferrals Service (previously Choose and Book) Performance for November 2019 shows a marginal decline in performance from the 90% level exceeded since May 2018. These figures are considerably above the 2017-18 levels of 70-80% and reflect the ongoing paper referral switch off programme. Southport and Ormskirk Hospitals, the largest receiver of referrals from West Lancashire CCG General Practitioners, was an early adopter of this programme, and from May 2018 was not permitted to accept paper GP referrals. All other local providers were obliged to adopt eReferrals as the only conduit for GP Referrals by the end of September 2018. However, there are still several areas where paper referrals are still allowed, therefore 100% coverage is not anticipated.

The 80% eReferrals target is measured by comparing all new eReferrals for outpatient attendances in a month (numerator) with the number of GP referrals (denominator) reported via the UNIFY Monthly Activity Report (MAR). To allow for dental activity the MAR GP Referrals in the denominator are reduced by 5.2%. eReferrals performance using these measures against month for all financial years since 2016/16 is shown on the graph above. Work to meet the overall aims of improving the efficiency of referral processes for practices and local providers has continued. Input from the Health and Social Care Information Centre (HSCIC) has commenced and they are in the process of compiling reports to identify problem areas that can be addressed to improve eReferrals utilisation as reported using Monthly Activity Return (MAR).

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9. Planned Care: Acute Contract

All Providers

Performance up to the end of November 2019 against the Planned Care Element of the contract is shown below. This shows the Planned Care Element of the contracts is over plan by £55k. The greatest variances are seen in Elective Spells (under plan by £96k); Outpatient Procedures (over plan by £110k) and Outpatient First Attendances (over plan by £57k).

Southport and Ormskirk Hospitals NHS Trust

Performance up to the end of November 2019 against the Planned Care Element of the contract is shown below. This shows that the Planned Care Element of the contract is under plan by £238k, the most significant Point of Delivery variances being in Daycases (under plan by £229k) and Outpatient First Attendances (under plan by £23k).

The underperformance in Daycases is driven mainly by staffing issues, an acute shortage of anaesthetists means the hospital is unable to schedule a significant number of procedures.

The most significant variances at specialty level are Ophthalmology with an underperformance of £165k; General Surgery with an underperformance of £140k; Pain Management with an underperformance of £93k and Gynaecology with an underperformance of £84k. There is a significant overperformance in Trauma and Orthopaedics of £125k. The underperformance in Ophthalmology is believed to be a result of the Ophthalmology Tier 2 service which went live in April 2018. The principal reason for the underperformance in Pain Management is because Southport and Ormskirk Hospitals do not have the resources to provide this service at levels comparable to previous years. Currently this service is closed to new referrals (since November 2018) and the Trust is providing a minimal service for ‘legacy’ patients. The 2019/20 plan for Pain Management was based upon 2018/19 out-turn, a period where the Trust was providing a service and, despite the lack of a service, the Trust was unwilling to reduce the 2019/20 plan in this specialty. No patients have been transferred from Southport and Ormskirk Hospitals to the i-Help Tier 2 service to date.

Plan Actual Variance Plan Actual Variance

Daycase 10140 10208 68 £6,977,916 £6,929,838 -£48,078

Elective 1465 1357 -108 £4,849,582 £4,753,713 -£95,869

Elective Excess Bed Days 249 306 57 £66,759 £82,464 £15,704

Outpatient First Attendance 20479 20883 404 £3,490,331 £3,548,028 £57,697

Outpatient Follow Up Attendance 47588 47412 -176 £3,981,371 £3,997,088 £15,717

Outpatient Procedure 21413 21955 542 £3,004,971 £3,114,800 £109,829

Diagnostic Imaging 11360 11881 522 £1,078,166 £1,078,004 -£161

Grand Total 112693 114002 1308 £23,449,096 £23,503,936 £54,840

Activity Cost

Point of Delivery (POD)

Planned Care to Month 8 (November) 2019/20- All Providers


Daycase 5177 4839 -338 £2,793,696 £2,564,341 -£229,355

Elective 556 514 -42 £1,495,099 £1,476,110 -£18,990

Elective Excess Bed Days 63 92 29 £17,070 £24,316 £7,246

Outpatient First Attendance 8106 8019 -87 £1,421,457 £1,398,613 -£22,844

Outpatient Follow Up Attendance 22200 21608 -592 £1,943,040 £1,933,507 -£9,533

Outpatient Procedure 12694 12967 273 £1,742,012 £1,767,696 £25,683

Diagnostic Imaging 5392 5535 143 £524,210 £533,636 £9,426

Grand Total 54188 53574 -614 £9,936,586 £9,698,219 -£238,367

Planned Care to Month 8 (November) 2019/20- Southport and Ormskirk Hospitals


Activity Cost

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All Other Providers

Performance up to the end of November 2019 against the Planned Care element of the contract is shown below. This shows the Planned Care element of the contract is over plan by £293k. This is caused primarily by overperformances of £251k at Ramsay Operations; £117k at Lancashire Teaching Hospitals NHSFT and £75k at St Helen’s and Knowsley Hospitals NHST, these being partially balanced by underperformances of £107k at Royal Liverpool and Broadgreen Hospitals NHST and £106k at Wrightington, Wigan and Leigh NHSFT.

The overperformance of £251k at Ramsay Operations (UK) is principally in Trauma and Orthopaedics (£172k); Ophthalmology (£80k) and ENT (£70k). This is partially offset by underperformances in Pain Management (£72k); Urology (34k) and Gynaecology (£13k). These movements are consistent with changes to GP referrals. The majority of the overperformance (£170k) is at Renacres Hall Hospital. The principal causes of the overperformance at Lancashire Teaching Hospitals NHSFT are overperformances in Gastroenterology (£39k); Colorectal Surgery (£23k); Breast Surgery (£23k) and Dermatology (£23k).

The main causes of the £64k overperformance at St Helens and Knowsley Hospitals NHST are Plastic Surgery (£85k); Physiotherapy (£21k) and Breast Surgery (£19k). Balancing these overperformances are the significant underperformances in Trauma and Orthopaedics (£30k); Dermatology (£13k) and Clinical Haematology (£12k). The principal cause of the underperformance at Wrightington, Wigan and Leigh NHSFT are Trauma and Orthopaedics (£174k underperformance) and Breast Surgery (£59k underperformance).


Wrightington, Wigan and Leigh NHSFT 14409 14059 -350 £3,589,654 £3,483,788 -£105,866

Ramsay Operations (UK) 9513 9948 435 £2,751,001 £3,002,127 £251,126

Aintree University Hospitals NHSFT 8824 8687 -137 £1,622,448 £1,586,739 -£35,710

St Helens and Knowsley Hospitals NHST 6064 6820 756 £1,176,525 £1,251,516 £74,991

Royal Liverpool and Broadgreen Hospitals NHST 5369 5252 -117 £1,031,467 £924,347 -£107,120

Lancashire Teaching Hospitals NHSFT 3426 4017 591 £637,604 £754,302 £116,698

Other 10900 11645 745 £2,703,810 £2,802,898 £99,088

Grand Total 58505 60428 1923 £13,512,511 £13,805,717 £293,206

Planned Care to Month 8 (November) 2019/20- All Other Providers

Provider

Activity Cost

*Includes points-of-delivery as per Tables 2a and 2b

Key Risks and Actions Southport and Ormskirk Hospitals are performing below plan for planned care to date in 2019/20. This is principally caused by a marked underperformance in Daycases which has been attributed to a shortage of anaesthetists. If this point of delivery is discounted then Planned Care is currently running close to planned levels, and if the Daycases issue could be resolved this would represent an increased cost pressure on West Lancashire CCG. During the planning exercise for 2019/20 West Lancashire CCG were encouraged to add significant growth to the Planned Care elements compared to 2018/19 out-turn and this growth is currently being exceeded except for Daycases. The assumption during the planning process was that this growth would be organic, caused by repatriation of activity that had previously been taken up by the Independent Sector. There is no evidence at this point that activity is being repatriated from the Independent Sector – in fact the reverse, Planned Care spend has grown significantly at Renacres Hospital.

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10. Unplanned Care: Acute Contract

All Providers

Performance up to the end of November 2019 against the Unplanned Care element of the contract is shown below. Overall, the Unplanned Care element of the contract is over plan by £526k. There are significant variances at a Point of Delivery level, notably overperformances of £1041k in Non-Elective Spells and £301k with Non-Elective Non-Emergency Spells. The indicated underperformances against the Emergency Care Blended Tariff Adjustment and Non-Elective Threshold Adjustment are simply technical corrections built into the 2019/20 Tariff arrangements that become applicable if a provider overperforms significantly.


Performance up to the end of November 2019 against the Unplanned Care element of the contract is shown below. Overall, the Unplanned Care element of the contract is over plan by £109k. Within this overperformance Non-Elective Spells are overperforming by £820k; Non-Elective Non-Emergency Spells are overperforming by £120k; Accident and Emergency is underperforming by £91k and Non-Elective Short Stay Spells are underperforming by £61k.

The Emergency Care Blended Tariff Adjustment is a new feature of the 2019/20 Tariff, and for West Lancashire CCG is only applicable to the Southport and Ormskirk Hospitals contract. Essentially for the Emergency Care Points of Delivery the Trust and Commissioner agreed an annual value for the contract, this acting as a threshold. Should the cost of activity exceed the threshold value, the Commissioner pays 20% of the activity value above the threshold. Should the cost of activity be less than the threshold value (highly unlikely in this case) the commissioner is obliged to pay 80% of the value of the underperformance. With the Southport and Ormskirk Hospital Contract for 2019/20 there was the added complication of the NHS England determination regarding the Clinical Decision Unit activity which did not favour West Lancashire CCG. To simplify reporting, it was agreed to incorporate this adjustment into the threshold value. This is the reason for there being a planned adjustment on this line of the report. The underperformance of £543k on this line reflects the overperformance of £680k on other Unplanned Care lines that influence the blended tariff adjustment.


Accident and Emergency 24938 25069 131 £3,971,629 £3,974,269 £2,640

Ambulatory Care Unit 447 172 -275 £165,986 £71,428 -£94,558

Non-Elective 7932 7843 -88 £16,089,484 £17,130,505 £1,041,021

Non-Elective Short Stay 1671 1592 -79 £1,241,128 £1,165,037 -£76,090

Non-Elective Excess Bed Days 2403 1732 -672 £616,895 £462,074 -£154,821

Non-Elective Non-Emergency 888 936 48 £2,033,394 £2,334,393 £300,998

Non-Elective Non-Emergency Excess Bed Days 73 194 121 £17,520 £67,743 £50,223

Emergency Care Blended Tariff Adjustment 0 0 0 -£351,360 -£894,984 -£543,624

Non-Elective Threshold Adjustment 0 0 0 -£28,822 -£28,822 -£0

Grand Total 38352 37538 -814 £23,755,855 £24,281,644 £525,790

Unplanned Care to Month 8 (November) 2019/20- All Providers


Activity Cost


Accident and Emergency 18904 18455 -449 £3,052,188 £2,961,173 -£91,015

Ambulatory Care Unit 447 172 -275 £165,986 £71,428 -£94,558

Non-Elective 5870 5716 -154 £11,555,159 £12,375,486 £820,327

Non-Elective Short Stay 1189 1104 -85 £825,578 £771,412 -£54,166

Non-Elective Excess Bed Days 1705 1333 -372 £436,028 £355,530 -£80,497

Non-Elective Non-Emergency 755 749 -6 £1,647,515 £1,767,498 £119,983

Non-Elective Non-Emergency Excess Bed Days 44 99 55 £9,983 £42,243 £32,260

Emergency Care Blended Tariff Adjustment 0 0 0 -£351,360 -£894,984 -£543,624

Grand Total 28,915 27,628 -1,287 £17,341,075 £17,449,785 £108,710

Unplanned Care to Month 8 (November) 2019/20- Southport and Ormskirk Hospitals


Activity Cost

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All Other Providers Performance up to the end of November 2019 against the Unplanned Care element of the contract is shown below. Overall, the Unplanned Care element of the contract is over plan by £417k. The most significant variances amongst the major providers are at Wrightington, Wigan and Leigh NHSFT at £567k over plan and Aintree University Hospitals at £134k under plan.


Wrightington, Wigan and Leigh NHSFT 4368 4950 582 £2,835,672 £3,402,801 £567,129

Aintree University Hospitals NHSFT 2170 1982 -188 £1,379,628 £1,245,626 -£134,003

Lancashire Teaching Hospitals NHSFT 563 592 29 £447,436 £437,684 -£9,752

Royal Liverpool and Broadgreen Hospitals NHST 557 529 -28 £422,780 £434,186 £11,406

St Helens and Knowsley Hospitals NHST 573 617 44 £324,874 £294,456 -£30,418

Other 1207 1240 33 £1,004,389 £1,017,107 £12,718

Grand Total 9438 9910 472 £6,414,779 £6,831,859 £417,080

Unplanned Care to Month 8 (November) 2019/20- All Other Providers

Provider

Activity Cost

*Includes points-of-delivery as per Tables 3a and 3b

Key Risks and Actions

Accident and Emergency data at Southport and Ormskirk Hospitals is subject to ‘coding lag’. It is anticipated that as November coding moves from first to final reconciliation point the HRGs will become more expensive. Based upon experience it is anticipated this £91k underperformance will become a £50k underperformance. The ‘peer’ review system adopted by Southport and Ormskirk Hospitals is expected to increase the overperformance of the Non-Elective Spells by £40k for October. The effects of these coding issues will be partially ameliorated by the Blended Tariff adjustment. Of greater concern is the indicated overperformance of £820k in Non-Elective Spells. Activity in this point of delivery is 2.6% below plan while costs are 7.1% above plan, indicating an increase in casemix costs of 10.0%. This is particularly concerning as this activity has occurred during the Spring/Summer months when ‘cheaper’ unplanned care activity occurs. Southport and Ormskirk Hospitals have indicated that changes to clinical practice have resulted in therapies being delivered to patients at an earlier point in spells and that although this may be driving up the cost of hospital admissions benefits are expected downstream in terms of more timely discharge of patients and better patient outcomes. The blended tariff adjustment is minimising the financial effects of these changes in 2019/20. However, West Lancashire CCG must anticipate these changes having a significant effect on 2020/21 contract values. The adjudication regarding the contract dispute between West Lancashire CCG and Southport and Ormskirk Hospitals has resulted in an increase in 2019/20 costs of approximately £400k relating to Trust ‘admissions’ via the Clinical Decision Unit. It should be noted that for 2019/20 the Trust did not receive approval to count all activity as being admissions, but that for 2020/21 they can do so. West Lancashire CCG should either make provision for an additional £500k of CDU costs in 2020/21 or continue to challenge the clinical appropriateness of patients being ‘admitted’ to CDU. Further investigation should be made of the continuing rise in emergency care at Wrightington, Wigan and Leigh Hospitals.

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11. Prescribing

To address the West Lancashire CCG Medicines Management duties as defined by the National Prescribing Centre’s Medicines Management Competency Framework, West Lancashire CCG has set up a Medicines Management Committee (MMC). The MMC’s remit encompasses all systems, policies and procedures designed to ensure the safe, secure and cost-effective use of medicines. The table below shows the spend against prescribing budget for Lancashire CCGs for the financial year to October 2019/20.

West Lancashire CCGs’ prescribing spend to the end of October 2019/20 is significantly higher, £338k (3.38%), than the corresponding period in 2018/19.

Budget Spend Variance Variance %

Blackburn with Darwen £14,450,605 £15,175,684 £725,079 5.02%

Blackpool £16,824,763 £18,494,699 £1,669,936 9.93%

Chorley and South Ribble £14,381,150 £15,875,945 £1,494,795 10.39%

East Lancashire £32,501,697 £35,150,064 £2,648,367 8.15%

Fylde and Wyre £17,206,364 £18,954,703 £1,748,339 10.16%

Greater Preston £15,387,506 £16,825,069 £1,437,563 9.34%

Morecambe Bay £27,036,892 £30,100,596 £3,063,704 11.33%

West Lancashire £9,518,810 £10,344,379 £825,569 8.67%

Grand Total £147,307,787 £160,921,139 £13,613,352 7.16%

CCG Spend Year to Date - October 2019/20

CCG

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The table below shows the average prescribing cost year to date per APU (Astro Prescribing Unit – a weighted population to take account of the differing prescribing costs with age and gender) for Lancashire CCGs. West Lancashire CCG has the third lowest cost per APU of the eight Lancashire CCGs but has demonstrated the third largest increase in spend per APU across the region.

The table below shows that the spending by individual GP Practice per Astro Prescribing Unit differs widely. Several practices are still spending significantly above the CCG wide average and this has been identified as a potential area for future savings. The Medicines Management team anticipates assisting practices in identifying the cause of these spend differences. It is acknowledged that some practices may have higher prescribing costs because of individual high-cost patients.

2018/19 2019/20 Variance

Blackburn with Darwen £25.97 £26.36 1.51%

Blackpool £27.29 £27.55 0.95%

Chorley and South Ribble £22.02 £22.46 2.02%

East Lancashire £24.80 £25.22 1.71%

Fylde and Wyre £23.63 £23.98 1.48%

Greater Preston £23.33 £23.20 -0.58%

Morecambe Bay £21.08 £21.68 2.83%

West Lancashire £22.79 £23.19 1.73%

Spend per APU Year to Date - October 2019

CCG

Spend

Spend

per APU Budget* Spend Variance

Spend per

APU

Potential

Saving

P81112 Beacon Primary Care £1,424,602 £25.78 £1,475,940 £1,608,666 £132,726 £28.00 £270,696

P81039 Manor Primary Care £436,784 £26.98 £421,271 £425,764 £4,493 £25.45 £36,094

P81646 Lathom House Surgery £444,948 £24.65 £423,428 £456,924 £33,496 £24.69 £25,958

P81208 Excel Primary Care £1,392,661 £22.88 £1,351,254 £1,478,694 £127,439 £24.22 £57,230

P81084 Hall Green Surgery £712,491 £23.28 £689,943 £735,978 £46,035 £23.60 £9,910

P81014 Ormskirk Medical Practice £913,989 £23.75 £875,364 £895,502 £20,138 £22.94 £0

P81674 Stanley Court Surgery £482,692 £21.88 £460,217 £518,711 £58,494 £22.56 £0

P81096 Parbold Surgery £634,617 £21.23 £621,427 £682,913 £61,486 £21.91 £0

P81136 Dr A Bisarya £225,054 £22.11 £217,976 £223,474 £5,497 £21.87 £0

P81138 Burscough Family Practice £259,445 £21.16 £241,113 £256,801 £15,688 £21.58 £0

P81710 Tarleton Group Practice £707,547 £20.75 £772,912 £883,489 £110,577 £21.20 £0

P81201 Ashurst Primary Care £372,578 £22.47 £359,974 £364,397 £4,423 £21.04 £0

P81045 The Elms Practice £438,446 £19.47 £415,725 £463,540 £47,814 £20.88 £0

P81041 Parkgate Surgery £611,972 £20.50 £574,116 £774,864 £200,748 £20.30 £0

P81695 Aughton Surgery £483,728 £19.79 £459,325 £474,398 £15,073 £19.27 £0

West Lancashire CCG GP Practice Prescribing Performance 2019/20 to October 2019

Budget to October 2019 is calculated as 58.6885 % of Total 2019/20 Budget.

Table does not include all prescribing spend and budget - only active GP Practices are included.

Potential Saving is the reduction in spend year to Date if the practice performed at the CCG average spend per APU.

2018/19

Prescriber NameCode

2019/20

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12. Mental Health

Lancashire Care Foundation Trust

The contract value for Lancashire Care Foundation Trust (LCFT) mental health services is £11.7m. The LCFT contract includes Inpatient and Community mental health services. The table below summarises activity with LCFT for West Lancashire CCG patients during 2019/20 by month up to the end of November 2019.

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

ADHD Contacts 10 18 23 23 15 21 25 24 159

Adult Ward Occupied Bed Days 153 180 124 162 219 283 317 291 1,729

Adult/PICU Ward Admissions 8 8 5 7 5 5 6 3 47

Adult/PICU Ward Discharges 8 10 4 5 7 2 7 6 49

CMHT - Older Adult Referrals 3 0 0 0 0 0 0 0 3

CMHT - Older Adult Contacts 89 63 67 65 30 53 49 52 468

CMHT - Adult Contacts 382 404 403 459 462 397 454 447 3,408

CMHT - Adult Referrals 7 10 4 44 19 18 14 13 129

Community Restart Teams - Accepted Referrals 0 20 0 1 0 0 1 0 22

CRHT Face to Face Contacts - 18 to 65 113 152 112 119 89 10 10 10 615

CRHT Face to Face Contacts - Below 18 4 6 5 3 0 0 0 0 18

CRHT Face to Face Contacts - Over 65 0 0 8 6 1 0 0 0 15

CRHT Teams - Referrals 39 41 31 31 23 21 22 12 220

CRHT Telephone Contacts - 18 to 65 78 90 69 69 46 19 17 45 433

CRHT Telephone Contacts - Below 18 1 0 3 0 0 1 0 0 5

CRHT Telephone Contacts - Over 65 0 2 4 1 6 0 0 3 16

Criminal Justice Liaison - Contacts 24 24 9 5 13 15 20 18 128

Eating Disorder Service - Contacts 80 70 55 62 81 62 72 77 559

Eating Disorder Service - Referrals 12 2 6 10 9 5 8 7 59

Eating Disorder Service DNAs - Follow Up Contacts 9 8 6 5 8 14 10 11 71

Eating Disorder Service DNAs - New Contacts 1 3 1 0 0 0 0 0 5

Hospital Liaison Contacts 1 0 0 0 0 0 0 1 2

Hospital Liaison Referrals 1 0 0 0 0 0 0 0 1

MAS Teams - Contacts 229 234 217 202 213 269 269 299 1,932

MAS Teams - Referrals 46 62 38 51 45 52 57 57 408

Older Adult (Dementia) Inpatient Ward Discharges 0 0 0 1 0 0 1 0 2

Older Adult (Dementia) Ward Occupied Bed Days 31 124 60 52 50 84 82 125 608

Older Adult (Dementia) Inpatient 90 Day ReAdmissions 0

Older Adult (Dementia) Inpatient Ward Admissions 1 0 0 0 1 1 2 1 6

Older Adult (Functional) Inpatient Ward Discharges 0 1 0 1 1 1 0 0 4

Older Adult (Functional) Ward Occupied Bed Days 85 124 69 114 81 45 57 90 665

Older Adult (Functional) Inpatient Ward Admissions 1 0 1 1 0 0 2 0 5

PICU Ward Occupied Bed Days 19 124 30 15 89 119 102 43 541

PICU Wards - Transfers In 1 0 0 1 2 3 0 0 7

RITT Contacts 176 216 187 232 214 247 240 190 1,702

RITT Referrals 2 24 20 19 12 20 23 15 135

Year to

DateMetric

Quarter 1 Quarter 2 Quarter 3 Quarter 4

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Dementia

For 2016/17 the Dementia Diagnostic Rate Target was monitored against a fixed estimate of the number of patients with dementia (Prevalence); this figure is based upon population profile. For 2016/17 this figure was estimated at 1483 patients. From 2018/19 onwards NHS Digital is monitoring against an estimate of Prevalence based on the current CCG registered population.

The CCG Diagnostic Rate Target is that at least 67% of patients with dementia have been diagnosed. Because the population with dementia suffers significant mortality it is necessary to maintain referrals to the Memory Assessment Service (MAS) to ensure that the CCG Diagnostic Rate Target is maintained.

The table below shows performance against the CCG Dementia Diagnostic Rate Target.

West Lancashire CCG is holding a strong position against the target of 67% for Dementia Diagnosis Rate. It should be noted that these numbers are from the NHS Digital web site and are adjusted for any GP Practices where monthly diagnosis data is not available. To obtain a diagnosis of dementia for a patient it is necessary for GP practices to refer patients to the Memory Assessment Service (MAS) operated by Lancashire Care Foundation Trust. For West Lancashire CCG MAS waits have begun to reduce dramatically recently due to the older adult service stopping unnecessary annual reviews and, as of week commencing 8 May 2018, anyone referred to the MAS will be offered an appointment within two weeks. This will be the best performance in Lancashire. The table below summarises MAS performance for West Lancashire CCG patients in 2019/20.


1105 1091 1109 1106 1095 1104 1081 1094

1502.6 1505.3 1510.5 1513.8 1515.9 1522.4 1525.3 1521.7

73.54% 72.48% 73.42% 73.06% 72.23% 72.52% 70.87% 71.89%

Memory Assesment Service Metric Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Number of referrals to MAS 46 62 38 42 45 50 60 57

Number of referrals accepted by MAS 35 54 35 41 34 44 57 56

Number of referrals rejected by MAS 11 4 1 1 11 6 3 1

Number of assesments by MAS 32 30 28 28 38 42 50 44

Average (mean) wait to assesment (weeks) 4.9 5.1 5.7 7.1 6.0 5.6 3.9 3.3

Waiting list at month end 41 63 56 65 47 45 37 43

Average (mean) wait to diagnosis (Weeks) 16.9 18.3 18 17.9 15.6 17 17 15.3

Number diagnosed 45 36 53 50 27 37 41 33

Number diagnosed with dementia 28 21 34 40 19 30 30 26

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Practice Level Information

Practice level diagnosis rates are no longer produced by NHS Digital but provide a useful guide to progress against target. They indicate practices where the diagnostic rate is lower than anticipated which could indicate a lower than normal rate of referral to the MAS. To carry out this analysis the percentage of the CCG over-65 population registered with each practice is used to factor the CCG level of prevalence.

Care Programme Approach (CPA) follow-up within 7 days

Research demonstrates that patients are more likely to commit suicide in the immediate days following discharge from a Mental Health Acute bed. Therefore, discharge is followed up with a meeting with a Mental Health Professional within 7 days of discharge to reduce this risk. (LCFT have a desirable 48-hour target). The national target is that 95% of all discharged patients are seen within 7 days. The table below summarises Lancashire Care Foundation Trust activity for West Lancashire CCG patients during 2019/20. The low numbers being discharged will mean that even one fail will mean NHS West Lancashire CCG will fail the national target for that month.


Patients

Aged 65 Yr+

% of CCG

Patients 65+

Share of CCG

Prevalence

Diagnosis

Rate %

Beacon Primary Care 193 194 196 192 197 200 191 204 2837 11.57% 176.03 115.89%

Ormskirk Medical Practice 142 148 151 150 152 150 149 145 2449 9.99% 151.96 95.42%

Parkgate Surgery 135 134 141 140 138 134 130 129 2271 9.26% 140.91 91.55%

Lathom House Surgery 51 53 52 51 49 48 47 47 1111 4.53% 68.94 68.18%

Aughton Surgery 63 63 60 57 54 55 55 57 1373 5.60% 85.19 66.91%

The Elms Practice 63 65 61 62 58 57 54 56 1350 5.50% 83.77 66.85%

Hall Green Surgery 72 70 73 73 73 72 75 74 1833 7.47% 113.74 65.06%

Stanley Court Surgery 45 47 49 50 50 54 54 53 1323 5.39% 82.09 64.56%

Burscough Family Practice 33 30 31 28 25 25 28 28 719 2.93% 44.61 62.76%

Manor Primary Care 21 22 24 28 26 24 24 26 682 2.78% 42.32 61.44%

Parbold Surgery 69 69 72 72 69 76 70 70 1883 7.68% 116.84 59.91%

Excel Pimary Care 106 101 103 105 107 111 107 105 2825 11.52% 175.29 59.90%

Dr A Bisarya 17 16 17 18 18 18 17 18 573 2.34% 35.55 50.63%

Tarleton Group Practice 68 66 66 67 68 68 68 69 2525 10.30% 156.67 44.04%

Ashurst Primary Care 13 13 13 13 11 12 12 13 770 3.14% 47.78 27.21%

Number of Registered over 65 Patients with a Dementia Diagnosis 2019/20 GP List Size as of November 2019

GP Practice

Dementia Diagnoses as of November 2019

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

Eligible Current Month 9 14 5 3 10 5 9 7

Sucessful Current Month 9 14 5 3 10 5 7 6

Current Month 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 77.8% 85.7% 95%

Year to Date 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 96.4% 95.2% 95%

Sucessful Rate

26 | P a g e

Adult Psychological Therapy (Mindsmatter) For Adult Psychological Therapy, the number of patients with a need (Prevalence) is estimated at 13908. This is defined as the number of West Lancashire CCG patients who have depression and/or anxiety disorders. This is a local estimate based upon the Psychiatric Morbidity Survey.

The table below summarises the year to date performance for West Lancashire CCG patients with the Lancashire Care Foundation Trust IAPT service.

The Access Rate national target is for 19.0% of patients with a need to have been referred to the Lancashire Care IAPT service during the financial year 2019/20. This is an increase over the previous targets of 16.8% (2017/18) and 15.0% (2016/17) – this equates to 225 patients per month is 2019/20.

The Recovery target is that at least 50% of patients completing treatment with the IAPT service will be considered ‘recovered’. This is calculated as:

(Number moved to Recovery)/ (Number Completed Treatment – Number not at Caseness)

Patients not at Caseness are defined as patients who on entry to the service were below the clinical cut off point for psychometric scoring measures for both depression and anxiety. Because recovery is measured against these criteria these patients are excluded from the recovery calculation. Reliable Improvement is defined as patients who demonstrate a statistically significant improvement in psychometric scoring measures for either depression or anxiety between the beginning of treatment and being discharged by the IAPT service.

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

Current Month 201 185 250 172 184 205 219 229 225

Year to Date 201 386 636 808 992 1197 1416 1645

Current Month 17.0% 15.6% 21.1% 14.5% 15.6% 17.3% 18.5% 19.4% 19.0%

Year to Date 17.0% 16.3% 17.9% 17.1% 16.8% 16.9% 17.1% 17.4% 19.0%

Completed Treatment 120 96 81 97 88 83 118 76

Moved to recovery 55 45 30 46 45 42 62 34

Not at Caseness 10 7 4 3 7 5 7 6

Current Month 50.0% 50.6% 39.0% 48.9% 55.6% 53.8% 55.9% 48.6% 50.0%

Year to Date 50.0% 50.3% 47.1% 47.6% 49.0% 49.7% 50.8% 50.6% 50.0%

75 67 46 64 61 54 91 54

6 weeks or less 196 182 248 173 181 201 215 227

7 to 18 weeks 5 3 2 1 3 4 2 1

Greater than 18 weeks 0 1 0 0 0 0 2 1

Current Month < 6 weeks 97.5% 97.8% 99.2% 99.4% 98.4% 98.0% 98.2% 99.1% 75.0%

Year to Date < 6 weeks 97.5% 97.7% 98.3% 98.5% 98.5% 98.4% 98.4% 98.5% 75.0%



6 weeks or less 165 90 76 90 83 79 114 75

7 to 18 weeks 5 5 5 7 5 4 3 1

Greater than 18 weeks 1 1 0 0 0 0 1 0





Referrals

Access Rate

Recovery

Referral to receipt of

welcome call from

Service

Referral to Discharge

from Treatment

Reliable Improvement

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Referral to Treatment times in the preceding table relate to the wait between referral to the IAPT service and the welcome call made by the service to the client. These are the waits that patients often refer to when speaking to their GP. Following the welcome call, patients are allocated to one of three waiting lists. The time between allocation and the start of treatment Is shown in the table below.


Less than 6 Weeks 154 130 145 155 142 170 169 1516 to 17 weeks 55 72 41 24 38 8 29 5418 Weeks and Over 0 0 1 1 0 0 0 0Current Month < 6 Weeks 73.7% 64.4% 77.5% 86.1% 78.9% 95.5% 85.4% 73.7% 75.0%Year to Date < 6 Weeks 73.7% 69.1% 71.7% 75.1% 75.8% 78.9% 79.8% 79.0% 75.0%Current Month < 18 weeks 100.0% 100.0% 99.5% 99.4% 100.0% 100.0% 100.0% 100.0% 95.0%Year to Date < 18 Weeks 100.0% 100.0% 99.8% 99.7% 99.8% 99.8% 99.9% 99.9% 95.0%

Waiting List Profile








Less than 6 Weeks 234 203 240 270 234 274 258 226 0 0 0 06 to 17 weeks 171 187 128 86 116 54 75 95 0 0 0 018 Weeks and Over 19 28 61 47 41 35 38 38 0 0 0 0Current Month < 6 Weeks 55.2% 48.6% 55.9% 67.0% 59.8% 75.5% 69.5% 63.0% 75.0%Year to Date < 6 Weeks 55.2% 51.9% 53.3% 56.6% 57.2% 59.9% 61.2% 61.4% 75.0%Current Month < 18 weeks 95.5% 93.3% 85.8% 88.3% 89.5% 90.4% 89.8% 89.4% 95.0%

Year to Date < 18 Weeks 95.5% 94.4% 91.5% 90.7% 90.5% 90.5% 90.4% 90.3% 95.0%


Psychological Wellbeing Practitioners

Cognitive Behavioral Therapists

Counsellors

All Services

28 | P a g e

13. Quality and Performance 13a West Lancashire CCG Performance Dashboard

YTD


Actual 86.05% 95.25% 93.93% 93.75% 92.34% 96.53% 96.30% 95.18% 93.77%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

Actual 53.57% 81.48% 93.75% 93.94% 85.00% 100.00% 94.29% 90.00% 87.18%

Target 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00% 93.00%

Actual 100.00% 94.12% 95.00% 100.00% 93.65% 95.59% 98.77% 94.03% 96.41%

Target 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00% 96.00%

Actual 100.00% 100.00% 100.00% 91.67% 100.00% 100.00% 78.57% 100.00% 95.29%

Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

Actual 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Target 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00%

Actual 90.00% 100.00% 100.00% 93.33% 100.00% 94.44% 94.44% 100.00% 96.46%

Target 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00% 94.00%

Actual 77.42% 75.00% 70.00% 90.91% 66.67% 83.33% 72.22% 81.48% 76.95%

Target 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00% 85.00%

Actual 0.00% 0.00% 100.00% 100.00% 100.00% 77.78% 82.76%

Target 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00% 90.00%

Actual 10:04 09:44 09:58 09:41 09:48 10:20 09:57 09:47 09:55

Target 07:00 07:00 07:00 07:00 07:00 07:00 07:00 07:00 07:00

Actual 08:01 07:46 07:51 07:55 07:43 07:50 07:53 07:41 07:50

Target 07:00 07:00 07:00 07:00 07:00 07:00 07:00 07:00 07:00

Actual 32:17 28:38 26:46 30:30 25:56 28:29 30:52 33:29 29:41

Target 18:00 18:00 18:00 18:00 18:00 18:00 18:00 18:00 18:00

Actual 25:12 22:20 22:19 23:57 21:10 22:18 22:48 25:25 23:13

Target 18:00 18:00 18:00 18:00 18:00 18:00 18:00 18:00 18:00

Ambulance

Category 1 Calls - Average (mean) Response TimeWest Lancashire CCG

North West Ambulance

Service NHS Trust

Category 2 Calls - Average (mean) Response TimeWest Lancashire CCG

North West Ambulance

Service NHS Trust

% of patients receiving 1st definitive treatment for cancer w ithin 2 months (62 days) West Lancashire CCG

% of patients receiving treatment for cancer w ithin 62 days from an NHS Cancer Screening Service West Lancashire CCG

% of patients receiving subsequent treatment for cancer w ithin 31 days (Surgery) West Lancashire CCG

% of patients receiving subsequent treatment for cancer w ithin 31 days (Drug Treatments) West Lancashire CCG

% of patients receiving subsequent treatment for cancer w ithin 31 days (Radiotherapy Treatments) West Lancashire CCG

West Lancashire CCG

% of patients seen w ithin 2 w eeks for an urgent referral for breast symptoms West Lancashire CCG

% of patients receiving definitive treatment w ithin 1 month of a cancer diagnosis West Lancashire CCG

Cancer Waiting Times

% Patients seen w ithin tw o w eeks for an urgent GP referral for suspected cancer

MetricReporting

Level

2019/20

Q1 Q2 Q3 Q4

Preventing People from Dying Prematurely

29 | P a g e

YTD


Actual 18 23 7 4 8 1 6 67

Target 0 0 0 0 0 0 0 0

Actual 93.19% 93.51% 93.26% 92.62% 92.49% 92.75% 92.61% 92.20% 92.83%

Target 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

Actual 1 1 0 0 0 1 0 0 3

Target 0 0 0 0 0 0 0 0 0

Actual 2.83% 3.59% 4.37% 4.56% 3.49% 3.13% 3.40% 2.18% 3.48%

Target 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00% 1.00%

YTD


YTD 0 0 1 1 1 1 1 1 1

Target 0 0 0 0 0 0 0 0 0

YTD 1 4 6 8 11 16 21 23 23

Target 1 3 4 6 8 10 12 14 14

Actual 83.79% 85.02% 85.44% 89.17% 87.78% 88.59% 85.15% 82.35% 85.88%

Target 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00% 95.00%

Actual 7,075 7,338 7,044 7,656 7,124 7,275 7,545 7,974 59,031

Target 7,035 7,586 7,258 7,508 7,027 7,274 7,478 7,238 58,404

Actual 7,558 7,536 7,437 7,582 7,336 7,519 7,605 7,506 60,079

Target 7,120 7,357 7,120 7,357 7,357 7,120 7,357 7,120 57,908

Actual 4,674 4,510 4,368 4,566 4,449 4,579 4,903 4,703 36,752

Target 4,334 4,651 4,492 4,703 4,439 4,492 4,651 4,386 36,148

Ensuring that People Have a Positive Experience of Care

MetricReporting

Level

2019/20

Q1 Q2 Q3

Mixed sex accommodation breaches - All Providers West Lancashire CCG

Q4

EMSA

Referral to Treatment RTT - No of Incomplete Pathw ays Waiting >52 w eeks West Lancashire CCG

% of patients w aiting 6 w eeks or more for a diagnostic test West Lancashire CCG

Referral to Treatment (RTT) & Diagnostics

% of all Incomplete RTT pathw ays w ithin 18 w eeks West Lancashire CCG

HCAI

Treating and Caring for People in a Safe Environment and Protect them from Avoidable Harm

MetricReporting

Level

2018/19

Q1 Q2 Q3 Q4

Accident & Emergency

4-Hour A&E Waiting Time Target (Monthly Aggregate based on HES 17/18 ratio) West Lancashire CCG

Number of MRSA Bacteraemias West Lancashire CCG

Number of C.Diff icile infections. West Lancashire CCG

A&E Attendances: Type 1

Southport and Ormskirk

Hospitals NHST

Wrightington, Wigan and

Leigh NHSFT

Lancashire Teaching

Hospitals NHSFT

30 | P a g e

13b Southport and Ormskirk Hospitals NHS Trust Integrated Performance Dashboard

Nov 18 Dec 18 Jan 19 Feb 19 Mar 19 Apr 19 May 19 Jun 19 Jul 19 Aug 19 Sep 19 Oct 19 Nov 19 Q3 Q4 Q1 Q2 Q3 YTD Target

18 Weeks - Ongoing - % <18 Weeks - Trust 96.2 % 95.8 % 94.8 % 94.6 % 94.5 % 94.2 % 94.2 % 93.6 % 92.7 % 92.6 % 93.4 % 93.3 % 93.3 % 95.8 % 94.5 % 93.6 % 93.4 % 93.3 % 93.3 % 92.0%

A&E - Left Department Without Being Seen Rate (LWBS) - Trust 2.60 % 2.30 % 3.10 % 2.10 % 2.50 % 2.50 % 2.10 % 2.80 % 2.90 % 3.10 % 2.70 % 2.90 % 3.60 % 2.40 % 2.57 % 2.47 % 2.90 % 3.25 % 2.83 % 5.00%

A&E - Time to Initial Assessment - 95th Percentile - Trust 24 20 23 23 24 23 20 18 19 19 19 20 24 22 23 20 19 22 20 15

A&E - Time to Treatment - Median - Trust 77 86 98 79 97 76 76 75 82 88 73 76 94 74 91 76 81 85 80 60

A&E - Total Time - 95th Percentile - Trust 762 635 880 937 900 965 914 876 745 656 824 984 1061 740 906 918 742 1023 878 240

A&E - Total Time in A&E - 4 Hour % - Trust Overall 89.55 % 89.59 % 84.88 % 85.87 % 84.02 % 84.78 % 85.68 % 85.14 % 88.84 % 87.77 % 88.57 % 84.59 % 82.70 % 88.92 % 84.89 % 85.21 % 88.40 % 83.63 % 86.01 % 100.0%

A&E - Total Time in A&E - 4 Hour % - RVY01 76.91 % 78.36 % 68.29 % 69.44 % 65.62 % 69.23 % 71.18 % 72.28 % 77.74 % 76.46 % 77.52 % 69.92 % 66.64 % 75.84 % 67.73 % 70.89 % 77.23 % 68.29 % 72.67 % 100.0%

A&E - Unplanned Re-attendance Rate (within 7 days) - Trust 5.70 % 6.11 % 5.58 % 5.56 % 5.62 % 5.63 % 5.76 % 5.84 % 6.00 % 5.68 % 5.59 % 5.58 % 6.42 % 5.77 % 5.59 % 5.74 % 5.76 % 6.01 % 5.82 % 5.00%

ALOS - Elective - Trust 0.21 0.20 0.26 0.30 0.32 0.27 0.29 0.30 0.31 0.29 0.17 0.38 0.40 0.23 0.29 0.29 0.26 0.39 0.30 0.37

ALOS - Non-Elective - Trust 3.91 3.61 3.86 3.57 3.64 4.09 4.22 3.82 3.76 3.58 3.50 3.48 3.44 3.72 3.69 4.04 3.62 3.46 3.73 4.3

ALOS - Overall - Trust 2.23 2.30 2.30 2.13 2.20 2.40 2.49 2.26 2.30 2.18 2.04 2.12 2.25 2.21 2.21 2.38 2.18 2.18 2.25 2.3

Cancelled Operations - % of Total Electives in Month 0.31 % 0.18 % 0.91 % 0.69 % 0.65 % 0.36 % 0.34 % 0.32 % 0.33 % 0.09 % 0.19 % 0.36 % 0.25 % 0.21 % 0.75 % 0.34 % 0.20 % 0.31 % 0.28 % 0.29%

Cancer 14 Day - Urgent GP Referral Suspected Cancer 95.4 % 95.1 % 93.2 % 98.2 % 97.5 % 94.5 % 95.0 % 94.8 % 93.8 % 92.3 % 96.4 % 95.8 % 95.0 % 96.3 % 94.8 % 94.0 % 95.8 % 94.6 % 93.0%

Cancer 31 Day - Decision to Treatment 98.3 % 97.5 % 98.4 % 98.6 % 100.0 % 100.0 % 95.6 % 98.4 % 100.0 % 94.0 % 95.3 % 100.0 % 98.7 % 99.0 % 98.2 % 96.8 % 100.0 % 97.8 % 96.0%

Cancer 31 Day - Subsequent Treatment - Drug Therapy 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % NTR 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 98.0%

Cancer 31 Day - Subsequent Treatment - Surgery 100.0 % 100.0 % 100.0 % NTR 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 100.0 % 94.0%

Cancer 62 Day - GP Referral to Treatment 70.5 % 71.6 % 79.8 % 70.9 % 81.2 % 69.6 % 79.5 % 78.0 % 78.9 % 75.3 % 82.0 % 74.5 % 78.0 % 77.1 % 75.9 % 78.9 % 74.5 % 77.0 % 85.0%

Cancer 62 Day - Screening Referral to Treatment NTR 100.0 % NTR 50.0 % NTR 0.0 % 50.0 % NTR 70.0 % NTR 60.0 % 0.0 % 100.0 % 50.0 % 16.7 % 66.7 % 0.0 % 50.0 % 90.0%

Diagnostics waiting time: percentage >= 6 weeks - All Tests 1.41 % 1.80 % 2.73 % 1.26 % 2.67 % 2.82 % 4.14 % 5.32 % 4.09 % 3.72 % 2.57 % 2.16 % 0.87 % 2.47 % N/A 4.12 % 3.50 % 1.51 % 3.31 % 1.0%

DSSA Breaches - Trust 5 15 31 51 37 32 37 14 14 17 11 14 15 24 119 83 42 29 154 0

HR - Agency Staff Costs 6.68 % 6.75 % 8.14 % 8.95 % 9.86 % 7.93 % 8.41 % 7.49 % 8.10 % 8.68 % 9.35 % 9.27 % 9.40 % 6.85 % N/A 7.94 % 8.71 % 9.34 % 8.58 % 4.00%

HR - Sickness Absence Rate - Trust 5.94 % 5.86 % 6.39 % 5.81 % 5.15 % 4.85 % 4.93 % 5.05 % 5.28 % 4.86 % 4.32 % 4.94 % 5.56 % 6.02 % 5.78 % 4.94 % 4.83 % 5.25 % 4.98 % 4.00%

IC - Clostridium Difficile - Trust 2 0 0 3 1 3 2 3 2 3 1 5 2 2 4 8 6 7 21 36

IC - Incidence of MRSA - Trust 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 27

IC - MRSA Screening - Elective Admissions - Trust 100.00 % 99.00 % 99.00 % 99.00 % 100.00 % 100.00 % 99.00 % 99.00 % 99.00 % 99.00 % 99.60 % 100.00 % 99.00 % 99.70 % 99.33 % 99.33 % 99.20 % 99.50 % 99.32 % 100.0%

IC - MRSA Screening - Emergency Admissions - Trust 94.00 % 90.00 % 93.00 % 93.00 % 92.00 % 91.00 % 92.00 % 93.00 % 93.00 % 90.00 % 90.00 % 94.00 % 90.00 % 92.70 % 92.67 % 92.00 % 91.00 % 92.00 % 91.63 % 100.0%

Mortality - HSMR 12 Month Rolling Total - Trust 112.30 112.00 102.90 98.70 94.80 96.30 98.30 95.40 91.00 112.00 94.80 95.40 91.00 91.00 90

Mortality - HSMR Monthly - Trust 91.30 105.30 84.70 81.50 82.80 121.00 102.10 62.70 70.00 90.80 83.00 95.27 70.00 88.95 90

RM - Never Events in Year - Trust 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 0

RM - Patient Falls - by 1,000 bed days 6.0 6.0 6.5 5.8 5.2 5.4 5.2 5.9 5.1 5.3 5.5 5.1 6.7 5.8 5.8 5.5 5.3 5.9 5.5

RM - Steis Reportable Incidents - Trust 2 3 4 6 3 4 5 5 6 8 4 5 3 15 13 14 18 8 40 0

Stroke/TIA - Stroke 90% Stay on ASU 73.08 % 80.95 % 78.79 % 42.86 % 48.72 % 58.97 % 69.77 % 56.67 % 84.85 % 70.59 % 78.95 % 90.00 % 64.52 % 75.60 % 57.00 % 62.50 % 78.10 % 77.05 % 71.58 % 80.0%

Stroke/TIA - TIA - High Risk Treated within 24Hrs 8.70 % 25.00 % 27.27 % 12.50 % 14.29 % 6.25 % 19.67 % 10.87 % 15.89 % 60.0%

TV - Hospital Acquired Grade 2 Pressure Ulcers 10 5 6 2 8 8 10 2 4 4 2 6 13 18 16 20 10 19 49 18



TV - Hospital Acquired Pressure Ulcers - Grades 3-4 0 0 1 1 0 1 1 0 3 0 2 2 3 18 2 2 5 5 12 10

VTE Prophylaxis Assessment - Trust 97.37 % 97.17 % 98.34 % 98.62 % 96.54 % 98.47 % 97.75 % 97.08 % 98.67 % 98.48 % 96.68 % 96.85 % 96.79 % 97.50 % 97.82 % 97.77 % 97.96 % 96.82 % 97.60 %

2018/19 2019/20 2018/19 2019/20

31 | P a g e

13c Areas of Under-Performance for West Lancashire CCG The year to date performance of several indicators is failing to meet the national targets at the end of November 2019. The detail below is presented by indicator for each of these areas with actions identified as required and ongoing, seeking to improve performance.

For each underperforming indicator year to date to November 2019 there is a sparkline graph which shows the monthly performance over the previous 12 months. Months where the indicator achieved target are represented by a green line; underperformance by a red line and the target by a blue line. The vertical amber line represents the division between 2018/19 and 2019/20 financial years.

The West Lancashire CCG Business Intelligence team is investigating local areas of underperformance and how this compares to the performance of our local peer CCGs.

Cancer Waiting Times

% of patients seen within 2 weeks following an urgent referral for breast cancer symptoms

12

Mo

nth

s A

ctiv

ity

Target: 93% Current Performance YTD: 87.18%

Current Issues: This target was not met for West Lancashire CCG patients between December 2018 and May 2019. Year to date performance is severely affected by performance in April and May with a combined total of 18 breaches. In the remaining six months there has been a total of 12 breaches. Performance in November 2019 (90%) did not meet target, all the recorded breaches occurring at Wrightington, Wigan and Leigh NHSFT. The principal issues YTD have been with Liverpool University Hospitals NHSFT, where the service has been under severe pressure. Year to date there have been 15 breaches at Liverpool University Hospitals and 9 breaches at St Helens and Knowsley NHST. A major influence on performance in 2019/20 has been the reduction in access for breast cancer services at Wrightington, Wigan and Leigh NHSFT. It would appear from e-referrals that this service is now returning to normal activity levels.

Improvement Plans: At Liverpool University Hospitals NHSFT additional staff (two consultants and a GP with Special Interests) have been recruited. Recent activity indicates that performance for this metric is returning to an acceptable level.

% of patients receiving 1st definitive treatment for cancer within 2 months (62 days).

12

Mo

nth

s A

ctiv

ity

Target: 85% Current Performance YTD: 76.95%

Current Issues: Target has only been met on one occasion in the last 12 months, performance for July 2019 at 90.91% exceeding target. Year to Date performance is still significantly low for this metric. Of the three Trusts that experienced breaches for West Lancashire CCG Patients in November Southport and Ormskirk Hospitals (93.33%) achieved the target while St Helens and Knowsley Hospitals (50%) and the Clatterbridge Cancer Centre (40%) both failed to meet the target. Year to date 28% of all breaches (16) have occurred at Southport and Ormskirk Hospitals where target achievement has been 84.41%, while Clatterbridge Cancer Centre has been responsible for 14 breaches while only achieving 58.84%. it must be noted that some patients at Clatterbridge will be subject to delays in care being referred on from another NHS provider and that the complexity of cases referred to Clatterbridge also leads to a higher level of non-attendances.

Improvement Plans: There is a considerable amount of improvement work across the Cheshire and Merseyside and Lancashire regions relating to prevention, early diagnosis and pathway improvement. Examples include Southport and Ormskirk Hospitals NHST becoming a rapid diagnostic centre for Vague Symptoms and West Lancashire CCG introducing FIT testing. Pathway improvement is also being undertaken for lung and colorectal cancers.

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Ambulance

Indicator: Ambulance Response Times CCG

12

Mo

nth

s A

ctiv

ity

Target: 7 Minutes < Category 1 18 minutes < Category 2

Current Performance YTD: 9:55 Category 1 29:41 Category 2

Current Issues: The rural nature of West Lancashire means that achievement of the 7-minute target will always be problematical. North West Ambulance Service (NWAs) have provided a performance overview which demonstrates significant improvements against most indicators. This is against a background of increased demand, overall demand being 1.7% above plan and call volumes 6.5% above plan in the first quarter of 2019/20. For Category 1 calls, performance in November 2019 failed to meet the 7-minute target with an average response time of 9:47 minutes for West Lancashire CCG; the secondary target of 90% of all calls being met within 18 minutes was also not achieved. NWAS overall performance for Lancashire CCGs also failed to meet both these targets.

For Category 2 calls, performance in November 2019 failed to meet the 18-minute target with an average response time of 33:29 minutes for West Lancashire CCG; the secondary target of 90% of all calls being met within 40 minutes was also not achieved. NWAS overall performance for Lancashire CCGs also failed to meet both these targets.

Improvement Plans: There is a Contract Improvement Notice with NWAS which was issued by the Strategic Planning Board for Ambulance services. NWAS have a Performance Improvement plan. This includes new vehicles; Urgent Care (different emphasis to Emergency care) training for Paramedics; a roster review; a recruitment plan (to improve the Paramedic to Emergency Medical Technician ratio); changes to allocations and call pick up times. Overall the NWAS improvement trajectory is on track. Highlights of the performance changes compared to 2018/19 include: calls increased by 7.6%; Hear and Treat increased by 20%; See and Treat increased by 17% and Conveyance reduced by 0.7%.

EMSA

Mixed Sex Accommodation Breaches – All Providers

12

Mo

nth

s A

ctiv

ity

Target: 0 Current Performance YTD: 67

Current Issues: There have been 61 Mixed Sex Accommodation Breaches at Southport and Ormskirk Hospitals up to the end of October 2019. This means the annual target of 0 breaches cannot be met.

Improvement Plans: This activity relates to Critical Care and Stroke patients at Southport and Ormskirk Hospitals, reconfiguration of Stroke Care Facilities has been investigated, however, the changes have not proved practicable. The Chief Nursing Officer, England has recently (27th September 2019) indicated changes to the reporting of Mixed Sex Accommodation Breaches to be implemented from January 2020 onwards. These changes address some of the underlying counting issues at Southport and Ormskirk Hospitals, and should result in an improvement in the reported performance.

Referral to Treatment (RTT) and Diagnostics

Number of Incomplete RTT pathways exceeding 52 weeks.

12

Mo

nth

s A

ctiv

ity

Target: 0 Current Performance YTD: 3

Current Issues: Although the headline figure for Number of Incomplete RTT Pathways exceeding 52 weeks is 3, these represent only two patient pathways. One of these pathways was a Gynaecology patient at Liverpool Women’s NHS Foundation Trust which breached in April and May 2019, the pathway being completed in June 2019.The second pathway is a Cardiology patient at Blackpool Fylde and Wyre Hospitals which breached for the first time in September 2019, the pathway being completed in October 2019.

Improvement Plans:

33 | P a g e

% of patients waiting 6 weeks or more for a diagnostic test.

12

Mo

nth

s A

ctiv

ity

Target: 1.0% Current Performance YTD: 3.46%

Current Issues: Southport and Ormskirk Hospitals are the primary cause of this underperformance, primarily within Cardiology concerning echocardiography and ultrasound tests. Underperformance increased steadily since initially breaching the 1% target in December 2016, peaking at 5.88% of patients waiting over 6 weeks for a diagnostic test in May 2017. The Trust has attributed the more recent increases in waiting times to changes to the tax regime – making it not viable for Consultants to operate additional diagnostic clinics. Following Performance has improved in recent months but is still outside of target.

Improvement Plans: Delays in diagnostic tests have been raised via the Combined Commissioning Forum and the Trust was tasked with providing a recovery trajectory for this target which has been received. Southport and Ormskirk Hospitals have agreed to subcontract routine ultrasound tests to Renacres Hospital (Ramsay Operations UK) beginning in August 2019 and it is anticipated this should free clinical resource for other diagnostic testing.

Accident and Emergency

4-Hour Accident and Emergency Waiting Time Target

12

Mo

nth

s A

ctiv

ity

Target: 95.0% Current Performance YTD: 85.88%

Current Issues: Performance is consistently below the 95% target, primarily driven by poor performance at Southport Hospital. It should be noted that the actual performance of the Accident and Emergency department at Southport Hospital is considerably worse than this figure and is flattered by the inclusion of performance figures from the Children’s Accident and Emergency Department at Ormskirk Hospital and the Ormskirk Walk in Centre. Performance against the 4-hour standard is acknowledged as a national issue. Southport and Ormskirk Hospitals are reporting a 15% increase in demand. However, changes to pathway within the Accident and Emergency department particularly recording all GP referred patients as Accident and Emergency attendances are partially responsible for this growth. West Lancashire CCG increases in Accident and Emergency attendances are in accordance with national trends. However, analysis of attends at Southport Accident and Emergency department have indicated most of the growth relates to Southport and Formby CCG patients.

Improvement Plans: The improvements in Accident and Emergency target performance at Southport Hospital are identified as being caused by the new modular extension and opening the new assessment areas. At present the Trust is choosing to triage patients who are likely to be present in Accident and Emergency for more than four hours (but are unlikely to be admitted) awaiting diagnostic tests into the new (eight bed) Clinical Assessment Unit and count the activity as an ‘admission’. Although this reduces the number of patients recorded as spending more than four hours in Accident and Emergency, it is not in fact reducing time spent in Accident and Emergency by the patients and the increase in recorded admissions is a significant cost pressure for West Lancashire CCG. The 2019/20 winter plan has been drafted for approval at the Accident and Emergency Delivery Board. The plan for West Lancashire includes Home First, the development of a single point of contact for discharges, Falls Lifting Service and Short Intensive Support Service (SISS). Collectively these schemes will release eight beds across the system. West Lancashire CCG will increase intermediate care beds during the winter months, however: this is ‘business as usual’ for the CCG. It is anticipated the additional Intermediate Care provision will release 6 further acute beds making the West Lancashire CCG contribution fourteen acute beds. These measures will help bridge the system community provision shortage of approximately forty beds as identified by Venn Consultancy. Southport and Ormskirk Hospitals’ plan includes improvements to Nursing staffing levels, additional resources for older people and efficiency improvements related to discharge and flow.

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13d West Lancashire CCG Patients Waiting

To understand how many patients are still waiting for procedures or outpatient appointments, the numbers of patients waiting for all incomplete pathways for all Trusts have been included in the graph below. More detailed reports on RTT waiters are available via Aristotle spotlight reports.

For West Lancashire CCG patients: in November 2019, there were 8511 patients in total with an Incomplete Pathway. Of these, 7848 (92.21%) are under 18 Weeks and 663 over 18 Weeks.

The table below shows the providers with the highest number of incomplete patient pathways for West Lancashire CCG patients in November 2019. Of these providers five have achieved the 92% target. The best performer is Ramsay Operations (UK) with 99.5%. Southport and Ormskirk Hospitals NHS Trust, the most significant Secondary Care provider for West Lancashire CCG, achieved 92.3%.

Although West Lancashire CCG experienced a decline in 18-week Referrals to Treatment performance during 2016/17 and 2017/18, this pattern is reflected both nationally and for other local CCGs. The table below shows West Lancashire CCG performance for 2019/20 compared to other local CCGs.

It should be noted that the West Lancashire CCG 18 weeks Referrals to Treatment performance has been declining significantly over the last 12 months and is now approaching the 92% target. This is principally because of a deterioration in performance at Southport and Ormskirk Hospitals.

Trust

Under 18

Weeks

Over 18

Weeks Total

% Under

18 Weeks

Southport and Ormskirk Hospitals NHS Trust 3645 306 3951 92.3%

Ramsay Operations (UK) 953 5 958 99.5%

Wrightington, Wigan and Leigh Hospitals NHSFT 774 55 829 93.4%

Aintree University Hospital NHSFT 656 109 765 85.8%

St Helen's and Knowsley Hospital Services NHS Trust 553 29 582 95.0%

Royal Liverpool and Broadgreen University Hospitals NHS Trust 257 31 288 89.2%

Lancashire Teaching Hospitals NHSFT 221 54 275 80.4%

The Walton Centre NHSFT 161 21 182 88.5%

Fairfield Hospital 140 2 142 98.6%

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

Chorley and South Ribble CCG 87.4% 88.0% 87.9% 86.9% 87.1% 87.2% 86.9% 86.9% ###### ###### ###### ###### 87.3%

Greater Preston CCG 88.0% 88.9% 88.5% 87.4% 87.4% 87.5% 87.7% 86.7% ###### ###### ###### ###### 87.7%

Liverpool CCG 86.4% 86.6% 86.7% 86.9% 86.6% 86.8% 86.3% 85.8% ###### ###### ###### ###### 86.5%

South Sefton CCG 89.5% 89.6% 88.5% 88.2% 87.2% 87.8% 87.0% 86.1% ###### ###### ###### ###### 87.9%

Southport and Formby CCG 93.0% 93.5% 92.8% 92.0% 91.1% 91.7% 91.6% 91.3% ###### ###### ###### ###### 92.1%

West Lancashire CCG 93.2% 93.5% 93.3% 92.6% 92.5% 92.8% 92.5% 92.2% ###### ###### ###### ###### 92.8%

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The table below indicates the RTT achievement by specialty for Lancashire CCG patients at all providers in November 2019. Overall the 92% target was not achieved in seven specialties (Respiratory Medicine, Cardiothoracic Surgery, Neurology, General Surgery, Other [Not reported individually], Plastic Surgery and Gynaecology).

The table below shows the specialties at the main providers where the 92% target was not achieved for West Lancashire CCG patients in November 2019. Figures indicate the total number of pathways with a wait exceeding 18 weeks RTT and current RTT achievement.

Specialty RTT Achievement

Patients waiting

beyond 18 weeks

Respiratory Medicine 82.84% 23

Cardiothoracic Surgery 84.21% 3

Neurology 86.27% 28

General Surgery 87.25% 83

Other (Not reported Individually) 88.18% 175

Plastic Surgery 89.78% 14

Gynaecology 90.06% 65

Ophthalmology 92.21% 47

Cardiology 93.06% 25

ENT 93.66% 41

Urology 94.60% 21

Gastroenterology 95.44% 22

General Medicine 95.54% 5

Trauma and Orthopaedics 95.56% 74

Dermatology 96.04% 30

Rheumatology 96.37% 7

Geriatric Medicine 100.00% 0

Other (Not reported Individually) 134 83.70% Gynaecology 49 84.59% General Surgery 42 86.09%

Cardiothoracic Surgery 1 50.00% General Surgery 4 83.33% Urology 2 86.67%

Cardiology 8 90.12% Respiratory Medicine 3 91.43% Other (Not reported Individually) 13 91.98%

Trauma and Orthopaedics 19 72.46% Gastroenterology 8 75.76% Respiratory Medicine 17 80.00%

Ophthalmology 25 80.16% General Surgery 13 84.88% ENT 6 85.00%

Dermatology 13 86.32%

General Surgery 3 81.25% Trauma and Orthopaedics 1 83.33% Urology 3 84.21%

Rheumatology 2 87.50% Plastic Surgery 9 91.35%

Trauma and Orthopaedics 10 71.43% Urology 3 72.73% Other (Not reported Individually) 6 88.68%

General Surgery 4 88.89% Dermatology 5 90.38%

Dermatology 1 66.67% Neurology 7 66.67% General Surgery 12 69.23%

Gynaecology 5 70.59% Trauma and Orthopaedics 4 77.78% Cardiology 2 80.00%

ENT 6 80.65% Plastic Surgery 4 84.00% Other (Not reported Individually) 6 85.71%

General Medicine 4 87.10% Gastroenterology 1 88.89% Urology 2 90.00%

Neurology 21 88.46%

The Walton Centre NHSFT


Wrightington, Wigan and Leigh Hospitals NHSFT

Aintree University Hospital NHSFT

St Helen's and Knowsley Hospital Services NHS Trust

Royal Liverpool and Broadgreen University Hospitals NHS Trust

Lancashire Teaching Hospitals NHSFT

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13e Friends and Family Test

The poor response rates to the Friends and Families Test at Southport and Ormskirk Hospitals NHS Trust has been challenged repeatedly by commissioners over the last 2 years. This situation has improved significantly October and November 2019. Prior to October 2019 the Accident and Emergency response rate was below 5% and is now running at 25% (double the national average) while that for Outpatients was below 1% and is currently above 20%. The improvement is attributed to the Trust engaging Healthcare Communications UK Ltd to manage their Friends and Families Test communications.

- Recommended

- Not recommended

November 2019

Inpatient & Daycases

A&E, Walk-in-Centres and

Minor Injuries Units

Outpatients

Friends and Family Test

This month there were 5869 responses to the

Friends and Family Test.

The charts below show the breakdown of responses between those

that would recommend and those that would not recommend these

services to a friend or family member.

Ambulance

Maternity

Community Health

*All data shown relates to Southport & Ormskirk NHS Hospitals Trust only, except for Ambulance

(NWAS only), Mental Health (LCFT only) and GP (West Lancashire GP's only)

Mental Health

Staff (Q2 19/20 Results)

GP

Work

94% 2%

89% 6%

95% 3%

0%0%

94%

94% 3%

82% 9%

95% 2%

64% 16%

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13f Safety Thermometer On one day each month, Hospital Trusts are required to check to see how many of their patients suffered certain types of harm whilst in their care. This measure is known as the Safety Thermometer. The Safety Thermometer looks at four harms: pressure ulcers; falls involving patient harm; blood clots and urine infections for those patients who have a urinary catheter in place. This helps Trusts to understand where they need to make improvements. The graph and table below indicate the percentage of patients at each Trust who did not suffer harm in any of the four categories.

Southport and Ormskirk Hospitals NHS Trust appear to have normalised their position following a significant increase in harms between March and July 2019. This increase was evident across all four categories of harms. This issue has been raised with the Trust via the Information Sub-Group of the Combined Contract and Clinical Quality Meeting (CCQRM) and is being investigated by Business Intelligence Colleagues at the Trust.

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14. Primary Care Parbold Surgery is in Special measures following 3 visits by the Care Quality Commission (CQC) with the practice being rated as ‘requires improvement’. The Elms Surgery is rated as ‘requires improvement’ following a recent CQC report, this resulting in a surveillance level of 2 (minor concerns) being applicable. All other West Lancashire CCG GP practices are at surveillance level 1 (routine monitoring). West Lancashire CCG offers additional support to GP practices where the CQC have identified concerns. During November 2019 West Lancashire CCG GPs raised two issues with the CCG: single examples regarding appointment availability and a discharge letter.

15. Patient Complaints

Patient contacts/complaints for West Lancashire CCG are processed by Midlands and Lancashire Commissioning Support Unit who report on a quarterly basis. Due to capacity issues within the team a report was not received by the CCG for Quarter 2. Highlights from the Quarter 3 report that is currently in draft will be included in next month’s IBR and will include a summary of Quarter 2. The West Lancashire CCG policy that details complaints handling has recently been updated and re-issued and includes recommendations made following audits by both the Mersey Internal Audit Authority (MIAA) and NHS England (NHSE). A Senior Complaints Manager joins West Lancashire CCG in January 2020.

16. Serious Untoward Incidents Serious Incidents for NHS West Lancashire CCG are processed by Midlands and Lancashire Commissioning Support Unit who report on a quarterly basis. Highlights from the Quarter 3 report will be included in the CCG’s Integrated Business Report next month. The Contract Performance Notice currently in place due to issues with the timeliness of Serious Incident reporting within Southport and Ormskirk NHS Trust was reviewed in November. Although improvement has been noted in recent months the CCGs agreed to keep the Notice in place until the end of Quarter 4 to ensure this improvement can be sustained. The Serious Incident Policy has recently been updated and re-issued.

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Appendix 1 Criteria Used to Determine Financial Performance RAG Ratings The RAG ratings under the Financial Performance section of the Executive Summary (Page 3) are determined according to the following criteria:

HLSC Older People’s Nursing and Residential Care Home service specification West Lancashire Clinical Commissioning Group Governing Body Meeting – 28th January 2020

1

WLCCGB 01/20/09


DATE OF BOARD MEETING: 28th January 2020 TITLE OF REPORT: HLSC Older People’s Nursing and Residential Care

Home service specification BRIEFING POINTS:

The attached service specification has been developed across all partner organisations within in Lancashire and South Cumbria Integrated Care System to provide standardisation of care and service provision across the Regulated Care Sector. The current draft version (v10) has been amended and developed following multiple conversations with Local Authorities and CCGs in Lancashire and South Cumbria as well as key stakeholders including care home providers and care home managers. A distribution list for the document is included. The Joint Clinical Commissioning Board have endorsed the specification, however sign off is now required by each of the 8 CCG boards and the Local Authority Executives. It is anticipated that the service specification will be implemented by April 2020.




• Standardisation should improve quality.

Yes


No


No



No

HLSC Older People’s Nursing and Residential Care Home service specification West Lancashire Clinical Commissioning Group Governing Body Meeting – 28th January 2020

2






Yes


No

3. Health Inequalities No


Yes

5. Clinical Engagement

• Document has been distributed widely and consultation has been undertaken.

Yes

6. Patient and Public Engagement - Has public participation/the ‘13Q duty to involve’ been considered?

• Document has been distributed widely and consultation has been undertaken.

Yes


Angela Clarke, Quality Facilitator for Vulnerable Adults (WLCCG) Angela Clarke, Quality Facilitator for Vulnerable Adults (WLCCG)

Service Specification – Care homes - Lancs & South Cumbria Updated 21/01/20

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Introduction & All Outcomes

Workstream: Regulated Care: Finance, Markets Contracts & Procurement

Date: 18/9/19 Release: Draft v10

Author:

Liz Williams ([email protected])

Owner:

Steve Thompson ([email protected])

Deadline for agreement:

31/3/20

Aim:

For Review and Agreement

Notes: Please note the term (Localisation) has been used to note areas where each Local Authority/ CCG commissioner will need to personalise the contract. Distribution This document has been distributed to: Regulated Care Finance, Markets, Contracts and Procurement Subgroup Regulated Care Programme Group Regulated Care Quality of Care Group Regulated Care Workforce Group Provider representatives Midlands & Lancashire CSU Contracts, Continuing Healthcare & Individual Patient Assessment teams ICS Palliative Care Workstream ICP Leads across Lancs & South Cumbria 8 Lancashire & South Cumbria CCGs NHS England Care Quality Commission Health and Social Care Partnership Lancashire Healthwatch Care providers Service user representative groups, e.g. Lancs LGBT, Older peoples forum, Age UK, Alzheimer’s Society, Carers network Additional Consultation has been undertaken with experts from within: Lancashire Care Foundation Trust East Lancashire Hospitals Trust Lancashire County Council (LCC) Social Work Team Leaders LCC Mental Capacity Act Leads LCC Quality, Performance & Improvement Leads


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Residential and Nursing Care Specification

1. INTRODUCTION

1.1. This document sets out the care specification and standards, which apply to the (Localisation) contract for the Provision of Older Adults Residential & Nursing Care Services. 1.2. The Commissioners are committed to the development of a range of care services in which the Local Authority and Clinical Commissioning Groups and independent providers work in a spirit of consultation, co-operation and partnership to ensure that appropriate services are available to meet the needs of (Localisation) Lancashire people. 1.3. This document sets out agreed Service User focused outcomes in line with the Care Quality Commission’s The Fundamental Standards and in the context of other legal requirements and key national best practice guidance.

2. LEGAL REQUIREMENTS AND CONTEXT

2.1. The Agreement places an obligation on the Provider to comply with all legislation and regulations relevant to the provision of the services. 2.2. This Specification reflects how the Provider supports the Commissioners in meeting the requirements of the Care Act 2014 for the care and support needs of people in a care home to ensure that services:

• provide quality and choice;

• are sustainable;

• innovate to meet the diversity of outcomes for people; and

• deliver cost-effective outcomes. 2.3. The Person-Centred Outcomes in the specification relate to how Service Users’ wellbeing can be assured whilst supporting person-centred care and support. Wellbeing is defined as follows in line with Care Act guidance:

• personal dignity (including the way people are treated and helped)

• physical and mental health and emotional wellbeing

• protection from abuse and neglect

• control over day to day life (including making choices about the way care and

support is provided)

• participation in work, education, training and recreation

• social and economic wellbeing

• domestic, family and personal relationships

• suitability of living accommodation

• the individual’s contribution to society

https://future.nhs.uk/gf2.ti/-/839042/43980517.1/PNG/-/2017_HLSCFullColourLogo.png


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2.4 Collaboration between the Commissioner and Provider is important. This includes the workforce and people with care and support needs, carers and families, facilitating the Commissioner in meeting Care Act requirements.

2.5. The Providers’ adult safeguarding policies and procedures will reflect the statutory guidance and the (Localisation) Lancashire Safeguarding Adults policy with the clear aim to support the reduction or removal of safeguarding risks as well as to secure any support to protect the adult and, where necessary, to help the adult recover and develop resilience. A partnership approach will encourage proportionate responses and improve the involvement of Service Users themselves in the decision-making and involvement in prevention and developing resilience for themselves. 2.6. The Provider shall be registered with the Care Quality Commission (CQC) in accordance with the Health and Social Care Act 2008 and comply with all related requirements. The service offered to the Commissioner shall not exceed the “Type of Service” and “Specialism/Services” registered. 2.7. National Performance Indicators that apply relate to the Department of Health Adult Social Care Outcomes Framework (ASCOF) as follows: Service User views on the service relating to: -

• how much control they have over their daily life

• how they feel about themselves because of the way they are treated and helped

• how clean and presentable they feel

• the food and drink they want and when they want it

• feeling safe

• how much social contact they have

• spending time together doing the things they value and enjoy 2.8. Active engagement and openness between Commissioners and Providers is also important for meeting duties relating to potential “Business Failure” (meaning an event such as the appointment of an administrator, the appointment of a receiver or an administrative receiver) or “Service Interruption” to the whole of the regulated activity, meaning an imminent jeopardy and there is no likelihood of returning to a “business as usual” situation in the immediate future, leading to the need for joint action by the Commissioner and the Provider. In these situations, the Provider and all parties will cooperate fully as identified by the Commissioner. 2.9. The Social Care Institute of Excellence (SCIE) Think Local Act Personal partnership provides guidance for social care and health. 2.10. The National Institute for Health and Care Excellence (NICE) provides guidance, advice and information services for health, public health and social care professionals. 2.11 The Code of Conduct for healthcare support workers and adult social care workers provides guidance for the standards of conduct expected of workers. 2.12. Public Health England provides guidance on matters such as infection control, Resuscitation Council UK and Royal Pharmaceutical Society Guidelines. 2.13. From time to time, the Commissioner may seek the Provider’s agreement to comply with the standards and recommendations issued by any relevant professional or by the National Institute for Health and Social Care Excellence (or any other equivalent body). 2.14. The Provider will comply with General Data Protection Regulations 2016 (GDPR) shown in Appendix 1


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2.15. Whilst the Commissioner aims to refer Providers to good practice guidance in this specification, the Provider is expected to know and keep up to date with best practice. 3. OUTCOME BASED SERVICES 3.1. The aim of an outcome-based approach is to shift the focus from tasks and processes to the impacts of these on Service Users. Success by achievement of individual outcomes will be evidenced primarily but not exclusively by the satisfaction levels of Service Users and their carers and their experiences in the service and the impact on their wellbeing. 3.2. Achievement of the individual outcomes identified in the Service User’s care and support plan shall ensure that Service Users: -

• are valued – involved, more in control, listened to, told what is happening, given choices, at the

centre of what is happening to them

• retain their strengths and independence – ensuring that an individual’s quality of life is maintained by keeping active and alert, maintaining mobility/physical health, maintaining hygiene, maintaining social contact and keeping safe and secure

• are supported through change - e.g. post-operatively, at the end of their lives and in situations where poor care or self-care has resulted in a reduction in their independence

• are safe – services are well managed and provided by staff who work competently with Service Users because they are appropriately trained and supervised to take person centred approaches.

(Localisation - Cumbria) 3.3. Guidance on the banding of Service Users’ needs is detailed in the Council’s Care Home Banding Guidance which may be amended from time to time. This guidance is intended to support wider assessment of Service User needs and the Provider will therefore have regard to this guidance in delivery of the Services. (Localisation - Cumbria) 3.4. The current Care Home Banding Guidance is included at Appendix 2

3. SERVICE STANDARDS AND MONITORING

4.1. The Council has responsibilities under the Care Act 2014 to ensure that the services delivered to people in a care home:

• provide quality and choice;

• are sustainable;

• innovate to meet the diversity of outcomes for people; and

• deliver cost-effective outcomes. 4.2. The Provider will supply information on request so that the Commissioner can inform its commissioning activities and work with the sector to achieve these outcomes. 4.3. The following Service Standards have been developed and will be used as the basis for monitoring the Service provided:

• 4.3.1. The Person-Centred Outcomes set out in Section 5 of this Specification;

• 4.3.2. (Localisation) The Council’s “Quality and Outcome Measures – What does good care look like” which are included at Appendix 3

• 4.3.3. The Framework for Enhanced Health in Care Homes;

• 4.3.4 (Localisation) Lancashire Safeguarding Adults Board; and


page 5 of 56

• 4.3.5. Any other quality requirements set by the Council, the CCG or any other relevant professional or regulatory body.

4.4. The Provider is required to demonstrate that the Service Standards are being achieved. The Commissioner will seek evidence of this via a number of methods, including (Localisation) the Contract and Quality Monitoring tool and quality assurance visits. 4.5. There is an expectation that the Provider will take into account other good practice standards and guidance not included in the Service Standards and will strive for continuous improvement of the Service. 4.6. Where the Provider is delivering care to Service Users under Dementia banding the Provider will work towards nationally recognised good practice standards such as King’s College, Stirling University or equivalent. (Localisation) 4.7. The Provider will fully participate in and co-operate with the Council’s multi-agency quality, performance and improvement planning (qpip) process, this may include; attending meetings, providing information, production and implementation of a service improvement action plan and facilitating service reviews with the multi-agency quality improvement team. The process may change from time to time, guidance on the current process is shown at Appendix 4 (Localisation – Cumbria) 4.8. The Provider will complete e-forms upon request and submit electronically to the Commissioner via the contract and quality monitoring system. 4.9. The Provider will supply vacancy information to the Commissioner upon request in the format requested by the Commissioner. 4.10. The Provider will share the results, action planning and improvements made through internal quality monitoring processes including those detailed at Outcome 29: Quality Assurance.


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Contents – Person Centred Outcomes Outcome 1 - Provider Service Information Outcome 2 - Pre-admission Assessment/Needs Assessment Outcome 3 - Care and Support Planning/Person Centred Care and Record Keeping Outcome 4 - Meeting Needs and Outcomes/Continual Evaluation/Review Outcome 5 – Short-term Care Outcome 6 - Provision of and Access to Health and Social Care Outcome 7 - Meeting Communication Needs Outcome 8 - Medication Management Outcome 9 - Privacy, Dignity and Respect Outcome 10 - Autonomy, Choice, Independence and Fulfilment Outcome 11 - Rights Outcome 12 - Diversity, Equality and Individuality – Expression of Beliefs Outcome 13 - Dementia/Mental Health Outcome 14 - Managing Behaviour that Challenges Outcome 15 - Social Contact, Activities and Community Contact Outcome 16 - Pressure Area Care, Tissue Viability and Wound Management Outcome 17 - Nutritional Care Outcome 18 - Complaints Outcome 19 - Safeguarding Adults Outcome 20 - Safe Working Practices/Health and Safety Outcome 21 - Infection Prevention and Control (IPC) Outcome 22 - Accident/Incident Reporting Outcome 23 - End of Life Care/Dying and Death Outcome 24 - Staff Recruitment and Retention Outcome 25 - Staffing Levels and Workforce Planning Outcome 26 - Staff Induction and Training/Education Outcome 27- Staff Supervision and Appraisal Outcome 28 - Management and Leadership Outcome 29 - Quality Assurance Outcome 30 - Financial Procedures/Personal Finances Appendices Appendix 1 - Processing, Personal Data and Data Subjects Appendix 2 – (Localisation) Cumbria County Council Care Home Banding Guidance & Tables: Physical Frailty, Memory, Cognition & Behaviour Appendix 3 - (Localisation) Cumbria Quality and Outcome Measures – ‘What does good care look like?’ Appendix 4 - Provider Information – Quality Improvement Process Appendix 5 - Monthly reporting criteria


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5.1. PERSON CENTRED OUTCOME 1

5.1.1. An introductory visit for individuals, their family or friends shall be facilitated by the Provider upon request. 5.1.2. Where a period of short-term care has been requested by the Commissioner, the Provider will assess suitability and negotiate a placement. 5.1.3. Service Users will have private single accommodation (unless shared accommodation is requested by choice) which they call their own to use as and when they wish. Service Users are offered a reasonable choice about the nature of the room which may include personalisation and the ability to lock their room, in line with Mental Capacity Act. 5.1.4. Service Users will be encouraged to bring personal possessions into the care home, including small items of furniture where practical. Arrangements will be put in place by the Provider for the recording of Service User’s property and secure storage for valuables, and the Service User and/or representative is informed of any items unable to be stored dependent on the Provider's level of insurance cover. 5.1.5. The Provider shall produce a Service Users Guide which will state what is available within the service to assist people in deciding if the care home is right for them (e.g. indoor and outdoor facilities, social and community activities, cultural aspects, opportunities for education or work, recreation and leisure, IT and electronic communications). The Service User Guide will state how the Provider intends to meet specific needs, including aids and adaptation, what Service Users can expect by way of quality and how the Provider can show they are achieving this. Details of any additional services and costs not covered by Commissioner fees should also be clearly communicated with the Service User through the Provider's procedures. 5.1.6. This Specification and attached Contract and takes precedence over the home’s own Contract. The Provider's own contract should be in line with the attached Contract and Specification.


5.2.1. New Service Users, including those receiving short periods of respite, will be admitted only based on a full and holistic assessment undertaken by a competent person to satisfy themselves that the service can meet the needs and wellbeing outcomes relating to the level of care they require. Such assessments where possible should involve the prospective Service User, his/her representatives (if any) and relevant professionals.

Provider Service Information Service Users have the information they need to exercise informed choice about where to live and have the opportunity to visit and assess the quality, facilities and suitability of the

home prior to admission.

Pre-admission Assessment/Needs Assessment Service Users are only admitted on the basis that the home has carried out a comprehensive pre-admission assessment in order to demonstrate that they can meet their assessed and ongoing needs.


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5.2.2. Following admission, the Provider will build on the assessment referred to in 5.2.1 to develop a personalised care and support plan, which determines the Service User’s self-care and includes functional abilities, physical, emotional, social, mental health and spiritual needs. 5.2.3. Where, during the period of stay a significant change in the level of need or service arises for an individual Service User, the Provider shall review and update relevant care plans, risk assessments and dependency levels. If the change in level of need impacts on service demand the Provider shall also inform the Commissioners within 7 days. A re-assessment of the individual’s needs shall then be undertaken by the Adult Social Care Teams and/or relevant Health Professional with timescales explained at the time the referral is accepted 5.2.4. Where an admission has been agreed by the Provider as an emergency, the full assessment and interim documentation will be completed within 48 hours of the admission. 5.2.5. Any additional resources needed to meet a Service User’s needs will be recorded and progressed, for example, bespoke equipment or referrals to Health Professionals. 5.2.6. Where admissions are funded by the Commissioner, the Provider’s assessments will be based on the Commissioner's assessments and care and support plans. If adequate information is not provided by Commissioners, the Provider will notify the Commissioner at the earliest opportunity. 5.2.7. Any requirement for Deprivation of Liberty Safeguards will be identified and referred to the Commissioner. The Provider is responsible to undertake the request for authorisation and the Provider will, where possible, apply for authorisation in advance of the admission. (Localisation) Applications are to be sent securely by email to the Local Authority’s designated inbox email address: [email protected] as amended from time to time. 5.2.8. It is the Provider's responsibility to review Deprivation of Liberty Safeguard applications regularly and inform of any changes to circumstances which may affect the application or its urgency. Additionally, it is the Provider’s responsibility to follow up outstanding applications and document accordingly. 5.2.9. The Provider shall record what accommodation is accepted by the Service User and any change must be agreed by the Service User and/or their representative. 5.2.10. The Provider will confirm prior to admission with Commissioners, Service Users, or their representatives, their fees and any additional costs or supplementary fees on top of the Commissioner's agreed rates. Documentary evidence of funding arrangements and agreements will be kept for review as required. 5.2.11 The Provider will confirm prior to admission with self-funding service users the possibility that a top-up will be applied if their savings falls below the threshold and a commissioning organisation takes on the funding responsibility. 5.2.12. The Provider shall have a register of all Service Users within the home including room numbers, funding authority, next of kin and General Practitioner details. Such information must be kept up to date and be accessible upon request by the Commissioner if this is required.


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5.3.1. Following a comprehensive assessment, individual risk assessments will be undertaken, and person-centred care and support plan produced for all identified and potential needs, promoting self-care and independence. A Service User who has the capacity to decide may not wish to eliminate risk, so risk management will be proportionate and a reasonable response to a risk which doesn’t interfere with the Service User’s desire to live the quality of life they wish.

5.3.2. Care documentation will be clear, legible and up to date. Where possible, support plans will not be hand-written, they will be in an appropriate format and of a length that staff are able to read and process the information. Care and support plans will be provided to the Commissioner on reasonable request. 5.3.3. Care documentation will follow the process of assessment, planning, implementation and evaluation and provide clear, concise and directive information that reflects the care required to meet the Service User’s individual needs. Care and support plans shall include goals for independence and maintaining Service Users’ abilities. Care and support plans and risk assessments will be reviewed as a minimum on a monthly basis or as and when the Service User’s needs change. 5.3.4. All nursing documentation will be concise and accurate and will meet Nursing Midwifery Council Guidelines for Record and Record Keeping. 5.3.5. All records, including care records, daily records and charts must be legible to the reader, made at time of care delivery, or as soon as possible within reason, and in chronological order. 5.3.6. All documentation must reflect good practice guidance and meet legal requirements. It should also include relevant evidence-based nursing knowledge and current clinical guidelines both nationally and locally where appropriate to Service User needs. 5.3.7. Service Users and/or their representatives, including advocacy support, must be involved in the production of care and support plans and invited to attend care review meetings. Care and support plans will explicitly identify whether the Service User has consented to the plan. Where the Service User is unable to consent to the plan, the Provider will demonstrate they have followed the principles of the Mental Capacity Act, with documented evidence to demonstrate decision specific mental capacity assessment and how a best interest decision was made. 5.3.8. All Service User records will be stored in a secure place and will be available to appropriate staff. Records will be up to date, adhere to professional record keeping standards and be constructed, maintained and used in accordance with GDPR, the Data Protection Act 1998 and other statutory requirements. The Provider will describe in their Privacy notice what data they hold and how Service Users can have access to their records and information held about them by the Provider. 5.3.9. The Provider will undertake monthly audits of care and support planning and record keeping in order to demonstrate the accuracy, quality and consistency of information,

Care and Support Planning/Person Centred Care and Record Keeping Service Users’ ongoing health and social care needs are set out in individual person-centred care and support plans. Service Users’ rights and best interests are safeguarded by the Provider’s record keeping policies and procedures.


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measure the outcomes of care and ensure that risks to Service Users are minimised. Where actions have been identified through audit, the Provider will record and demonstrate that appropriate action has been taken including lessons learnt. 5.3.10. The Provider will ensure there is provision for a range of equipment necessary to meet Service User assessed needs and shall allow for variations in height, weight and size of Service Users. Risk assessments will be completed by a competent individual and, where bespoke equipment is needed, implementation will include a demonstration of the use of equipment, reducing risks as far as possible. Service Users will be included in the assessment, where practicable, to support understanding of how and why equipment is used. Care will be taken to ensure a Service User’s privacy and dignity is maintained.


5.4.1. The Provider will be able to demonstrate the ability to manage and respond to the assessed needs and outcomes of Service Users living in the home to ensure they receive the appropriate care, support and treatment in a timely manner. 5.4.2. Documentation and measurable outcomes will be maintained to clearly evidence the continual evaluation and review of Service Users’ needs. 5.4.3. Where evaluation and review indicate a change in the Service User's health and/or Social Care needs, the Provider shall make referrals through appropriate pathways to Health and/or Social Care Professionals for assessment. The Provider will document details of referrals, advice and/or recommendations made within the Service User's care records and relevant care and support plans are updated accordingly. 5.4.4. The Provider will ensure that staff individually and collectively have the skills, experience and qualifications to deliver the services and care which the home reports it will provide. 5.4.5. Specialised and appropriate services, including equipment will be offered and provided where assessed as needed. Where Service Users refuse equipment, the Provider will follow the principles of the Mental Capacity Act and retain evidence of appropriate assessments.


5.5.1 Short-term care arrangements may be requested by the Commissioner in a number of circumstances, including, but not limited to:

a) As time-limited alternative whilst a longer-term care package is sought to meet the

Meeting Needs and Outcomes/Continual Evaluation/Review Service Users and their representatives know that the home they enter will endeavour to meet and continue to meet their needs and agreed outcomes.

Short-term Care Service Users receiving short-term care are supported to meet their identified outcomes and are supported to move on to alternative services at the end of the agreed placement period


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Service User’s needs;

b) Where the Service User requires a more in depth and on-going assessment of their circumstances or the agreement of their assessment by the Commissioner. Reasons may include:-

• Need for long term residential or nursing home care;

• Assessment of mental capacity for specific decisions related to their care;

• Resolution of family issues; or

• Safeguarding concerns surrounding the Service User’s departure.

c) Where a Service User is admitted for a prescribed period of rehabilitation and/or therapy, the Service User may receive support from the NHS including occupational therapy and physiotherapy and other Health and Social Care professionals as appropriate to meet agreed outcomes.

d) In order to provide respite, for a prescribed period of time, for the Service User or their

Carers.

5.5.2 It should be recognised by the Provider that short-term care in a care home can be a particularly difficult time for Service User and they will require extra support and reassurance during this period of great change. Providers should ensure that Service Users are kept fully informed at all times. 5.5.3 The Provider shall comply with this specification in the same manner as a long-term placement and shall meet any specifically identified outcomes such as those included in this clause. 5.5.4 Particular consideration should be given to Service Users with dementia care needs having short-term care or placements, which should be seen as an opportunity to spend time with people who will be interested in them as individuals and provide stimulating opportunities to try new things and make new memories where possible. Short-term care for prescribed periods (also known as respite care) 5.5.5 Short-term placements should be approached in a way to support Service Users, families and carers in maintaining important relationships, maintaining and developing new skills, and should underpin and sustain the overall wellbeing of both individuals and families. Care and support should be flexible and individualised.

5.5.6 Where placements are planned in advance Service Users and their carers and families should be given the opportunity to talk about their expectations and individual outcomes so that the benefits of a short stay in the care home are maximised.

5.5.7 At the end of a short-term placement, the Provider shall support both the Service User and the Commissioner to manage a smooth transition to the next service or location. Any relevant care planning information will be shared on request with the Commissioner and any alternative care provider identified to support the Service User.

Short-term care for prescribed periods of rehabilitation and/or therapy 5.5.8 The Provider will co-operate and work alongside with rehabilitation and therapy services being delivered at the care home. Service Users care and support plans will adequately reflect the programme of rehabilitation and therapy or the requirements for achieving independence outcomes with clearly evidenced continual evaluation and review. It


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is expected that care and support plans will be reviewed on a more frequent basis appropriate to the type of stay and identified care needs and outcomes.

5.5.9 The Provider will ensure that staff individually and collectively have the skills, experience and qualifications to meet the identified outcomes and support identified needs.


5.6.1. Service User's health, independence and wellbeing will be promoted, monitored and maintained and referrals will be provided in a timely manner to relevant primary care and specialist health and social care services to meet assessed individual need. 5.6.2. Service User's physical, psychological and mental health will be proactively monitored, and early preventative and restorative care provided or arranged in order to improve health, promote independence and wellbeing and maintain their quality of life including: -

• Tissue viability and the management of wounds, as appropriate

• Continence management including the management of urinary catheters and stoma care

• The management of malignant and long-term conditions including but not limited to, Ischaemic Heart Disease, Stroke/TIA’s, Diabetes, Chronic Airways Disease and Asthma, COPD, Parkinson’s Disease and Multiple Sclerosis

• Health promotion, screening and preventative care

• Infection prevention and control

• Maintenance of mobility, functional ability and falls prevention

• Pain management

• End of life care

• Nutritional screening and support including the management of Service Users who suffer with dysphagia or require PEG feeding

• Oral health care including preventative care where the Service User needs carer support and access to appropriate dental services.

5.6.3. The Provider will provide care and support to Service Users to manage multiple long-term conditions in line with NICE guidance. 5.6.4. Service Users and/or their representatives are involved in decision making around care and health intervention. 5.6.5. The Provider will cooperate and implement reasonable recommendations made by relevant health and social care professionals. 5.6.6. Service Users shall have access to specialist health and social care aids and equipment according to assessed need and the Provider shall ensure staff are trained and assessed as competent in the safe usage of this equipment. The Provider shall ensure that they adhere to the requirements of the Commissioner’s equipment policy.

Provision of and Access to Health and Social Care Service Users receive appropriate evidence-based health and social care and have access to community services and specialist input to meet their assessed needs and maximise their health, independence and wellbeing.


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(Localisation) Add reference 5.6.7. The Provider will facilitate Service Users to have regular health checks including specialist and medical reviews of their health and medication and proactive screening and management of chronic disease processes. 5.6.8. The Provider will facilitate where appropriate access to digital systems, assistive technologies/ telehealth equipment in order to improve the functional ability of Service Users with long term conditions and support them to manage their condition and promote independence. Where telemedicine is in commissioned the Provider must engage with the service. 5.6.9. If support is required for Service Users to access appointments, wherever possible a relative, friend, or representative should take the Service User to such appointments. Where this is not possible, the Provider may be given the option to charge the Service User for an escort for planned health appointments. The Provider has the ultimate responsibility to enable Service Users to attend health appointments outside the Home. Health appointments do not solely mean NHS appointments in hospital. They can include dentist, primary care, optician, etc. 5.6.10. In no circumstances shall charges be applied to unscheduled visits to hospital, e.g. following a fall or collapse. In such circumstances, the Provider will undertake a risk assessment and determine if the Service User is able to attend hospital without an escort. Handover information will be comprehensive and will adhere to local hospital transfer pathway guidance, e.g. Red bag scheme. 5.6.11. The Provider shall inform the Commissioner where the Service User remains in hospital for 4 weeks or more 5.6.12 The Provider will co-operate with the requirements of Red Bag schemes, where available, and ensure that the Service User has the appropriate documentation and personal items with them on entry to hospital, as required by the Commissioner. 5.6.13 The Provider will co-operate with hospital initiated discussions to prepare for a service user’s discharge from hospital.


5.7.1. Communication will be conducted in a way that is understandable to the Service User and in a way in which they can make themselves understood based on their individual needs. Service Users say that the way they are communicated with makes them feel better about themselves. If required, referrals will be made to advocacy services to facilitate this process. 5.7.2. The communication needs of each Service User will be identified and include recognition of primary language, visual, hearing and cognitive difficulties. The Provider will ensure they find sources of information and advice and understand how to deal with any difficulties relating to communication.

Meeting Communication Needs Communication with Service Users is conducted in a way that maximises their independence, choice, control, inclusion and enjoyment of rights.


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5.7.3. Communicating in inclusive ways will be dependent upon: -

• A Personalised care and support plan using accurate information on how to get

communication right for each Service User. This may be in the form of a communication passport

• Staff awareness and knowledge of a range of resources that support inclusive communication approaches.

• Having and using a range of resources that support inclusive communication

• Enabling the use of digital media e.g. Skype or other similar communication method

• Support from management and senior staff

• Use of relevant external support when required, e.g. Speech and Language Therapy

• Understanding primary language if English is not the Service User’s first language 5.7.4. The Provider and staff will communicate and provide information in a format that each Service User and/or their representative can understand. 5.7.5. Service Users will be supported to interact with others and express themselves in line with their individual preferences.


5.8.1. The Provider will have clear policies and procedures which demonstrate recognised best practice. 5.8.2. The policies will make it clear who is accountable and responsible for using medicines safely and effectively in the care home. The policies will be evidence based and include the principles of: -

• Sharing information about a Service User’s medicines including when they transfer to another care setting

• Accurate and up to date recording keeping and (E)/MAR charts

• Identifying, reporting and reviewing medicines-related problems

• Keeping Service Users safe (safeguarding)

• Accurately listing a Service User’s medicines (medicines reconciliation)

• Medication review

• Safe handling of medicines and controlled drugs including ordering, storage and disposal

• Self-administration

• Care home staff administration of medicines including ‘when required’ medication

• Staff training and competence requirements

• Covert administration

• Homely Remedies/Minor Aliments

Medication Management Service Users are protected and supported by the Providers policies and procedures for the management and administration of medication.


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• Palliative care

• Verbal orders, and communication with prescribers including adverse reactions

• Administration via a feeding tube

• Correct use of infusions and injection devices in care homes with nursing

• Monitored Dosage Systems and Compliance Aids. 5.8.3. In care homes with nursing, responsibility for medicines administration may be delegated to care staff who will be appropriately trained and assessed as competent. Any delegation must be detailed in a care plan. When the Provider is advised it is not appropriate to delegate medicine administration it must not be delegated. Registered nurses will remain accountable for medicines administration in the home and should provide supervision to care staff undertaking the task. 5.8.4. All Registered Nurses and other relevant staff will complete a medicines management assessment as part of the induction process and provide evidence of ongoing continuing professional development in medicines management. 5.8.5. The Provider will regularly assess and provide documentary evidence of the competency of all Registered Nurses and other relevant staff in the management of medication to ensure that practices are compliant with the standards outlined in the policies and procedures. 5.8.6. Information and advice will be sought from a pharmacist, where appropriate, in relation to administering, monitoring and reviewing medication. 5.8.7. The Provider will ensure that they have an up to date list of medications for each Service User at the start of service delivery. 5.8.8. The Provider will support Service Users to take medicines independently or administer medicines when they are unable to do so. 5.8.9. Records will include details of any capacity assessments and Best Interest decisions made on behalf of any Service User lacking capacity to consent to medication. 5.8.10. Any arrangements for covert medication must be made in accordance with Mental Capacity Act guidance and NICE guidelines. Such arrangements will be clearly documented including medical recommendations, capacity assessment and best interests decision-making record. Where covert medication is given, this will clearly be recorded in the care and support plan and reviewed on a monthly basis. 5.8.11. Any self-administration of medication by Service Users will be undertaken within a risk management framework and suitable lockable facilities provided. 5.8.12. Service Users’ medication will be reviewed with their General Practitioner six monthly or more frequently as required. The Provider will support, co-operate with and provider information for the service users medication reviews. 5.8.13. Medication Administration Records (MAR charts) will be audited monthly to provide an audit trail of stock control and storage of medicines including monitored dosage systems and evidence that correct procedures have been followed. 5.8.14. Audits will include monitoring the administration, recording and disposal of medicines. Audits will be robust and comprehensive and identify that measures are in place to ensure safe practice such as: -


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• The use of photographs to identify that medicines are being administered to the right Service User (when consent is given by the Service User)

• Specimens of staff signatures to identify care staff or the Registered Nurse responsible for the administration of medication

• The correct and accurate completion of (E)/MAR charts

• Satisfactory procedures for transcribing medication onto MAR charts and recording dosage changes onto MAR charts which include obtaining countersignatures from another registrant or competent health professional.

5.8.15. The Provider will monitor the effect of each Service User’s medication and act if their condition changes including side effects and adverse reactions. In addition to this requirement, the Provider will request Service Users taking anti-psychotic medication are reviewed to assess for benefit within four weeks of antipsychotic initiation, which will be evidenced in the care and support plan. 5.8.16. The Provider shall have arrangements in place to record and report drug related incidents including findings of their service review and lessons learnt in order to reduce the risk of repetition, and follow local safeguarding guidance if the threshold is met 5.8.17. Service Users will be notified of any errors in relation to the administration of their medication or their representative, and appropriate medical advice will be taken. 5.8.18. Records will be maintained to reflect the safe disposal of medication.


5.9.1. The Provider will promote a culture that reflects and demonstrates that Service User privacy, dignity and respect is embedded in the beliefs and values of the service. Service Users will say they exercise choice and control and feel better about themselves because of the way they are treated. 5.9.2. There will be suitable facilities available and staff practices will always enable modesty and protect privacy, particularly when supporting them with their personal care needs. 5.9.3. Staff will uphold Service Users right to confidentiality and the protection of personal information relating to communication and recording. This includes any method of communication individual to the Service User. 5.9.4. Service Users will be cared for in a polite and courteous manner and agreement will be reached with them regarding how they would prefer to be addressed. 5.9.5. Care and support will aim to exercise choice and control and promote the Service User’s self-confidence, self-esteem, sense of belonging and wellbeing, and maximise their individual abilities. 5.9.6. Service Users will be treated as individuals, receiving a personalised service encouraging choice and control. They will be listened to and supported to express their

Privacy, Dignity and Respect Respect towards Service Users means they are supported and treated in a way that makes them feel better about themselves


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needs and wishes. 5.9.7. Staff will not make judgemental statements about the lifestyle or standards of any Service User, either in verbal or written communication. 5.9.8. Service Users will be facilitated to make and receive personal phone calls in private. This will include provision for those who are unable to use a phone independently. 5.9.9. Providers will promote contact between Service Users and their family/friends both in person and over the telephone or by other means.

5.9.10. Where the Provider considers contact between a Service User and any visitor is having a detrimental impact on their well-being, or where visitors are having a disruptive influence on support, those health and social care professionals involved will be notified, and Safeguarding considered. Where risk management requires restrictions on contact with any particular Service User, the Provider will contact the health and social care professionals involved, principles of the Mental Capacity Act will be followed, any best interests’ decision shall be recorded with appropriate consideration given to the Service User’s right to private and family life. 5.9.11. The Provider will nominate a Dignity Champion within the home, evidence will be available that evaluation has taken place on a regular basis to evaluate and ensure that quality of service that respects a Service User's dignity is being provided e.g. audits or observations.


5.10.1. Service Users shall be encouraged, supported and empowered to make independent choices as individuals in order to determine their needs, beliefs, culture, identity, preferences and values. 5.10.2. Service Users shall be supported and empowered to make decisions for themselves and the Provider will take all practicable steps to assist them to make informed decisions. 5.10.3. A Service User’s ability to make their own decisions will be assumed unless assessed as otherwise, in accordance with the requirements of the Mental Capacity Act (2005). Service Users shall have the right to think and act without having to refer to others, including the right to decline support. 5.10.4. The Provider will ensure that all staff understand how the Service User’s right to autonomy, choice, independence and fulfilment is maintained within the context of the Mental Capacity Act (2005), Deprivation of Liberty Safeguards and other current legislation. Examples could be through training, supervision and team meeting discussions. 5.10.5. Service Users will identify the people they wish to be involved in their life (e.g. partners, relatives, friends) and state how they would like them involved and consent to sharing information will be explicitly gained and recorded. These people will be provided with adequate and timely information so they can be involved in accordance with the Service

Autonomy, Choice, Independence and Fulfilment Service Users are assisted to express informed choice and control over their daily lives and supported in maintaining their personal identity, individuality and independence.


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Users’ wishes, which will be reviewed 5.10.6. Service Users and/or their relatives and friends shall be informed of how to contact external agencies (e.g. advocates), who will act in their interests. 5.10.7 Service Users will have a range of information available to assist them to make informed choices about all aspects of their life. 5.10.8 The Provider will ensure that staff support Service Users to access a range of meaningful activities of their choice both within the home and the community.

5.10.9 The Provider will ensure that staff are trained to enable Service Users to maintain their independence.

5.10.10 The Provider will actively listen to the Service User and ensure all their rights are upheld. 5.10.11 The Provider will actively seek the views of the Service User to ensure that they feel they have autonomy, choice, independence and fulfilment. 5.10.12. The Provider will ensure that Service User feedback is proactively gathered to support development of the service and there is evidence that this has been actioned. This could include regular Service User's meetings, consultation on available activities and menu options.


Rights Service Users’ legal rights are respected, protected and upheld.

5.11.1. Service Users are individuals, irrespective of their living situation. They retain all their legal rights and entitlements as individuals when they enter a care home and shall be helped to exercise those rights. This includes participation in government elections and other civil processes. 5.11.2. Service Users human rights under the Human Rights Act 1998 shall be promoted, regardless of their capacity to consent to the support arrangements. Where Service Users do not have capacity to consent to their support arrangements, Providers will conduct all support in accordance with the Mental Capacity Act including:

• Appropriate best interests decision making for any care interventions

• Appropriate respect for private and family life, and the need to refrain from interfering with contact between Service Users and their family/friends without appropriate legal process being followed

• Compliance with Service Users right to liberty and the Deprivation of Liberty Safeguards including

• Granting urgent authorisations where permitted by the legislation and the Deprivation of Liberty Code of Practice


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• Making requests for standard authorisations for all Service Users to whom the Deprivation of Liberty Safeguards apply in a timely manner, including renewal applications where applicable. Such applications to be made by secure email to the designated inbox (see section 5.2.7)

• Co-operating with and sharing necessary information with assessors instructed as part of the authorisation process and appointed Relevant Persons Representatives and Independent Mental Capacity Advocates

• Complying with any conditions placed upon standard authorisations

• Notifying the Supervisory Body of any change in circumstances which would require a review of the authorisation

5.11.3. When a Deprivation of Liberty Safeguards authorisation is granted, the Provider must provide the relevant person information of their rights (including the right to challenge the authorisation), both orally and in writing. This information will also be given to the relevant person’s representative. 5.11.4. The Provider is responsible for requesting a further standard authorisation, prior to an authorisation ending, if they consider that the Service User will still need to be deprived of their liberty after the authorisation ends. There is no statutory time limit on how far in advance of the expiry of the authorisation the Provider can apply for a renewal. However, it needs to be far enough in advance for the renewal authorisation to be given before the existing authorisation ends. The Provider must inform the relevant person they have done this. 5.11.5. The Provider will record the name and contact details of the relevant person’s representative in the Service User's care and support plan. The Provider is also required to monitor how often the representative visits. If they have concerns that the representative has not been having an appropriate level of contact with the person to enable them to offer effective support, they will consider informing the Supervisory Body. 5.11.6. Service Users shall be assisted to exercise their right to be a full citizen in whichever way they choose. 5.11.7. Service Users’ rights will be written into the Provider’s statement of values, aims and objectives. 5.11.8. Service Users will have formal mechanisms to be consulted about the running of the home, e.g. residents’ meetings 5.11.9. Service Users will have the right to take risks. Risk taking is a normal part of everyday life, so Service Users shall be involved in agreeing any controls or interventions that may be put in place. Risks shall be fully assessed and reasons for actions clearly documented. 5.11.10. Referrals shall be made to Independent Mental Capacity Advocates where appropriate.


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5.12.1. The Provider will understand and be committed to promoting a culture for both Service Users and staff which reflects and demonstrates that diversity, equality and individuality is embedded in the beliefs and values of the service adhering to the Equality Act 2010. 5.12.2. A strategic approach will be adopted by the Provider in delivering education to staff so that they understand the: -

• Organisation’s aims and objectives

• Relevant policy provisions

• Difference between acceptable and unacceptable behaviour

• How personal attitudes and values can affect behaviour

• Role they play in making the management of diversity a reality

• Meaning of diversity including cultural

• Meaning and impact of discrimination in the workplace. 5.12.3. Service User's beliefs and values will be considered throughout the Provider's assessment process and recorded in the appropriate section of the care and support plans. The Provider will have adequate processes in place to communicate Service Users’ individual needs with the staff throughout the home.


5.13.1. The Provider shall ensure staff are aware and understand difficulties experienced by Service Users with dementia and mental health issues and how best to support that person. These can relate to emotional and psychological changes including fluctuating mood and disorientation, which may also affect their normal pattern of behaviour and functional ability. 5.13.2. Symptoms of aggression, confusion and disorientation may be as the result of dementia or mental disorder or due a delirium/toxic confused state due to infection, dehydration, constipation or the side effects of medication. Providers shall monitor these aspects to assist with differentiating between causes and symptoms and Service Users shall be referred to a General Practitioner for a physical health review and subsequently where appropriate the GP will refer to a specialist mental health assessment in line with NICE guidelines. 5.13.3. Care and support planning will be completed in collaboration with the Service User

Diversity, Equality and Individuality – Expression of Beliefs Service Users live in an environment that is committed to promoting a culture which respects diversity, equality and individuality and their experiences reflect this commitment.

Dementia/Mental Health/Learning Disabilities Service Users whose emotional or mental wellbeing are affected by memory or cognitive impairment or similar condition are assured that the care and support they receive promotes their quality of life.


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and appropriate representative and shall reflect the impact of these symptoms and direct staff how to meet the Service User's individual outcomes and needs. 5.13.4. Staff shall consider Service Users’ sense of reality from moment to moment and respond in a way that is meaningful to them and support them to safely express themselves. 5.13.5. Staff shall monitor for changes in a Service User's condition and look for behavioural cues that may indicate a change being required. This may be in the way that care and support is provided or a deterioration that may require a referral to the General Practitioner. 5.13.6. The Provider shall ensure staff work as part of any multi-agency team to support Service Users to include effective liaison with primary mental health services and the Service User's General Practitioner. 5.13.7. Providers shall recognise when their service may need additional support or a more specialised service to meet the needs of Service Users and refer this to the appropriate support services for a review to be instigated in a timely manner. 5.13.8. The Provider shall ensure accurate and person-centred documentation is maintained and is available in a timely manner, staff will receive appropriate and relevant training to complete paperwork. 5.13.9. The Provider shall adapt the physical layout and facilities within reason, day to day routines and staff culture within their service so it allows for a suitably flexible and stimulating environment for each Service User and supports their individuality, their sense of reality, and their mental and emotional wellbeing. This includes religious beliefs and practice and privacy and dignity around sexuality.

5.13.10. The layout and facilities will help Service Users to understand and make use of all spaces and facilities. It will support Service Users’ abilities and maximise their independence; limiting the impact of their disabilities and minimising confusion and distress. 5.13.11. Security and other safety arrangements for the building, garden and other areas and activities will mean that Service Users freely use facilities whilst being protected from harm. 5.13.12. The Provider will ensure that there are opportunities for Service Users with memory and/or cognitive impairment to access the outdoors on a regular basis where this is beneficial to their wellbeing. If the home has a garden, it should to be maintained in such a way that it can be utilised safely by all Service Users. 5.13.13. The Provider shall organise staff to allow time for supporting Service Users in groups or one-to-one to include, where relevant, connections to social network, community facility or external environment that is meaningful to them. Evidence of this shall be clearly recorded. 5.13.14. The Provider shall arrange for the environment, surroundings, daily routine and the way staff behave to uphold the mental and emotional wellbeing of Service Users, inline with current best practice guidance. 5.13.15. The Provider will ensure that staff have the necessary training, skills and knowledge of people's individual needs and behaviour in order to deliver effective person-centred care including and not limited to;

• Interpersonal skills in communication including non-verbal


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• Adapting own behaviour to promote relationships

• Build meaningful interactions to include promoting empathy and unconditional positive regard, maintaining Service User's personal world, identity, personal boundaries and space

• Recognise the signs of anxiety and distress resulting from confusion, frustration or unmet need and respond by understanding the events the Service User is experiencing and diffusing their anxiety with appropriate therapeutic responses

• Monitoring and effectively reviewing the effects and side effects of specialist medications e.g. anti-psychotic medication

• Meaningful occupation/activities and stimulation as a part of effective therapeutic intervention and care and avoiding isolation. Understanding the changing nutritional care needs of those with dementia and providing services and support in a flexible, person-centred manner

• Being flexible about the physical layout, facilities and routines

• Effective management of behaviours that challenge and how agitation and aggression is a method of communicating unmet need

• Risk assessment and management, emphasising freedom of choice and reasonable risk taking

• Promoting social and community networks and relationships. 5.13.16. Where appropriate, the home has a lead, for example a Dementia Champion, to role model, coach and embed training into practice, and to monitor the quality of dementia care.


5.14.1. The Provider shall ensure the application of practice that focuses on person-centred and positive support to Service Users whose behaviour challenges in line with good practice guidance. 5.14.2. Positive Behaviour Support shall be planned in a proactive way that reduces the likelihood of behaviours that challenge happening. There will be a focus on preventative strategies, identification of early warning signs and plans will show staff how to support Service Users in an individual way that meets their needs. The care and support plan will direct staff on how best to respond to a Service User when they are displaying behaviours that challenge which supports de-escalation of the situation. 5.14.3. The Provider must work in line with the principles of the Mental Capacity Act 2005; all forms of restrictions and restraint will be proportionate to the harm being prevented and in the Service User's best interest where the Service User lacks the capacity to make the decision. The Provider will consider a Deprivation of Liberty application. 5.14.4. Interventions used to control behaviours that challenge shall always be the least restrictive for the minimum amount of time and only considered when all other options have

Managing Behaviours that Challenge Service Users who present behaviour that challenges services are supported in a way that helps them to communicate and to safely deal with situations they find difficult.


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been exhausted. Physical restraint and medical intervention for behaviours that challenge will always be discussed and documented with all parties involved. 5.14.5. The Provider will ensure that where physical restraint is necessary, that techniques and approaches pose the least risk to the Service User and staff are supported in understanding individual approaches. 5.14.6. The Provider will ensure staff are suitably trained and competent in implementing proactive and preventative strategies to manage and de-escalate situations where individuals display behaviours that challenge. Where physical restraint is required for Service Users, the Provider must ensure staff receive regularly updated training, at least annually, in line with NICE guidelines and a relevant industry best practice, such as the Restraint Reduction Network (RRN) Training Standards. 5.14.7. Following incidents where restraint has been used, the Provider shall have a clear process for recording and debriefing for the staff team and involve the service user where this is possible. This will provide opportunities to reflect on the practice, to learn from situations and how similar incidents could be prevented. Where appropriate, changes to the Service User's care and support, staff approaches or referrals to Professionals will be clearly documented. 5.14.8 Where there is involvement from external health professionals, the care and support plan will be based on any assessment and/or recommendations. The care and support plan will identify what behaviours need to be addressed based on what is important for the Service User and an assessment of risk. An understanding of the reasons for these behaviours shall be determined with the Service User and others involved in their life. 5.14.9. The Provider will support Service Users to be involved in all aspects of their care and support planning wherever possible, taking into consideration their individual needs and functioning. Where they are unable, an appropriate representative will be involved, and documentation should be clear. 5.14.10. The plan shall involve, as relevant, appropriate Local Authority and Health Teams and Professionals involved in the Service User's care and support e.g. (Localisation) General Practitioner, Community Learning Disability Team, Community Mental Health, Rapid Intervention and Treatment Team (RITT), Recovery Team for Older People, CHESS team, Dementia In-Reach Team, Intensive Support Team or Community Adult Asperger’s Service. The Provider will ensure there is evidence of on-going multi-disciplinary working and effective liaison with specialist services. 5.14.11. The care and support plan shall include procedures to be followed after an incident of behaviours that challenge to include a description of how the Service User is likely to look and behave as they recover, along with details of the support the Service User requires at this time. 5.14.12. The care and support plan must consider all aspects of the Service User’s life including life story work to inform how to meet their physical, mental, social and emotional wellbeing and how this has an impact on their behaviour. The plan will identify what behaviours need to be addressed based on what is important for the Service User including an assessment of risk. 5.14.13. The care and support plan shall be recorded to ensure all those providing support use a consistent approach including: -

• a description of the Service User’s behaviour


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• a summary of the most probable reasons underlying the Service User’s behaviours that challenge

• proactive and preventative strategies • reactive strategies

• incident briefing

• monitoring and review arrangements

• implementation arrangements

• who was involved in devising the plan 5.14.14. Separate risk assessments and plans will be devised as necessary for specific situations (e.g. car journeys, around food). 5.14.15. Care and support plans shall be reviewed and updated on a regular basis and at other times when there is a change that may impact on Service Users or following an incident of challenging behaviour. 5.14.16. A risk assessment of the impact of potential incidents of behaviour that challenge on staff and other service users needs to be taken into consideration, using the lessons learnt to ensure that the home has appropriate staffing levels to deliver the care required.


5.15.1. Service Users will be supported to spend time, of their choosing in a way that is meaningful and stimulating for them via activities made available by the Provider and those accessed by the Service User themselves. This may include leisure and recreational activities in and outside the home, which suit their needs, preferences, aspirations, lifestyle, choices and capacities. Service Users will be empowered to increase and maintain confidence, enhance self-esteem and to minimise social isolation. Evidence of this will be recorded in care and support plans. 5.15.2. Service Users will be encouraged to exercise their lifestyle, cultural and spiritual beliefs through both planned and spontaneous activities. 5.15.3. Staff facilitating group or individual activities will be appropriately trained and skilled to deliver effective and meaningful activities that are suitable to meet individual needs and supports the Service User to maintain their independence. 5.15.4. Consideration of meaningful activity provision will be given to Service Users with needs which means they may not be able to fully participate in activities without support. This could include dementia and other cognitive impairments, those with sensory impairment, those with physical disabilities or learning disabilities and Service Users who are unable to access communal areas within the home. 5.15.5. The Provider will support Service Users to access available resources from

Social Contact, Activities and Community Contact Service Users are supported to spend their time in a way that matches their preferences, and meets their needs for social, cultural, religious, educational and recreational participation.


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organisations with specialist knowledge and expertise. 5.15.6. Where appropriate, comprehensive life histories will be undertaken in partnership with the Service User and/or their representative and a plan of care developed so that past and present life experiences, along with priorities for the future, can be agreed and met. The Provider should be able to evidence attempts to undertake and any refusals to undertake life history work. 5.15.7. Service Users will be supported to have visitors, in line with their wishes and links with family, friends and local community will be in accordance with individual preference. 5.15.8. Up to date information about activities in and outside the home will be available to all Service Users in formats that meet the needs of individuals. 5.15.9. Service Users’ participation in activities will be recorded and evaluated regularly to ensure that outcomes and Service User needs continue to be met. 5.15.10. Service Users will be fully involved in activities planning in the home and have opportunities to influence the range of activities offered by the Provider. 5.15.11. Service Users will be supported to be involved in community groups, should they indicate a preference to do so, in order for them to be able to influence the wider health and social care agenda. 5.15.12. Where the Provider provides transport for the Service Users for purposes not covered by their assessed need, e.g. Home mini-bus for private outings, the Provider may agree a reasonable rate of payment for the transport. If external transport is used, e.g. taxi, the Service User is expected to pay for such transport. 5.15.13. The Provider will make every effort to connect with the local community to support the development of new connections. 5.15.14 The Provider will engage with the relevant community/neighbourhood teams (where appropriate) and assist residents to access to a wide range of health, social care and community-based support and services within the Lancashire and South Cumbria locality.


5.16.1. The Provider shall have up to date policies and procedures to support tissue viability and wound management practice. The Provider will ensure that staff have evidence of training and embed requirements in their practice and have a pressure care champion to deliver training for staff.

Pressure Area Care, Tissue Viability and Wound Management Service Users receive care that supports healthy tissue viability and wound management. (Localisation) Delivery of elements of this Outcome will differ for Homes registered with the Care Quality Commission to provide nursing care and those registered as a residential home. The latter will receive support from local District Nursing Teams, who will work within their own organisational policy.


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5.16.2. The Provider will provide Service Users with care and support to prevent and manage pressure ulcers in line with NICE good practice guidance and other preventative models of recognised pressure prevention methodology. 5.16.3. Tissue viability interventions and wound management shall be overseen by competent Registered Nurses (either employed by the Provider or through community nursing services) with up to date knowledge and skills in the prevention, assessment and management of pressure ulcers and management of wounds. 5.16.4. Wound management will consider Service User's individual needs, preferences and compliance with both treatment and the care and support plan. Clear communication of essential information will enable the Service User to make informed decisions about their care. 5.16.5. Wound care documentation will be descriptive and directive incorporating a holistic assessment of the Service User's individual health needs, links into risk assessment, predisposing factors, include a rationale for the selection or change of a treatment or dressing and document clinical outcomes. Documentation will include planned preventative strategies and plans for reassessment. 5.16.6. The Provider will complete an examination of skin integrity on admission to the home, when transferred to or from hospital or where injuries e.g. bruising, red areas, pressure ulcers, cuts, wounds or burns are identified. Findings of the examination will be recorded on a body map, and if relevant a safeguarding alert will be made as required by local guidelines 5.16.7. Wound assessments and care and support plans will include: -

• The location and measurement (grade and dimensions) of the wound demonstrated by a wound map and photograph (with the Service User's consent or documentation around BIA/LPA)

• A record of any underlying or undermining intrinsic and extrinsic factors that may have contributed to the wound for example general health status, malnutrition, systemic disease, poor mobility or medication

• A description of the colour or appearance of the wound bed and status of the surrounding skin, including any undermining/ tracking sinus or fistula

• A record of any exudate, pain or malodour

• A rationale to support the selection of a treatment or dressing which may be determined by the type and position of the wound, the amount of exudate, pain, odour, any known allergies, the Service User's compliance/concordance with the dressing and the frequency of dressing changes. The wound will be evaluated and reviewed at each dressing change and documented accordingly.

5.16.8. Wound care documentation will clearly document clinical outcomes and provide a chronological history of the progress or deterioration of the wound demonstrating regular evaluation and review and any specialist input or referral. 5.16.9. Care homes without nursing will liaise with the relevant health professional if they have any concerns in relation to skin injuries and pressure areas/pressure area care and will follow the guidance provided. This may include advice in relation to (but not exclusively) hygiene, repositioning regimes or appropriate equipment to be used. Such guidance will be clearly documented in the care and support plan.

5.16.10. An appropriate and evidence-based risk management tool shall be used to assess


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risk and where necessary an action plan put in place. A baseline risk assessment shall be undertaken within six hours of admission to the home and reviewed regularly thereafter. 5.16.11. Staff will be trained to identify Service Users most likely to develop pressure ulcers and will be competent to recognise pre-disposing risk factors as a part of both the pre-admission assessment and on-going assessment process.


Nutritional Care Requirements 5.17.1. The Provider will ensure that Service User's nutritional care needs are considered which will also support independence and facilitate an enjoyable mealtime experience, assessments should include but not limited to the following areas:-

• Personal aids and equipment

• Day to day choices of food and drink

• Food and fluid consistencies

• Special dietary requirements

• Food and beverage preferences

• Where Service Users wish to eat each meal, at what time and with whom

• Good physical positioning

• Cultural, ethical/moral and religious beliefs

• Level of assistance required which may include encouragement as well as physical support

• Special occasions to be celebrated 5.17.2. Nutrition and hydration risks and needs, including allergies and intolerances, will be included as part of the holistic pre-admission assessment. See Outcome 2 for further information on pre-admission assessment. This information should be regularly updated and reviewed as more person-centred information is gathered, preferences change or medical/nutritional needs change. 5.17.3. All staff must follow the most up-to-date nutrition and hydration assessment for each Service User, the Provider shall have a process in place to notify staff of any changes to diet and hydration needs including nutritional care requirements, modified textures. Care plans should be updated at the time of these changes to be reflective of current need. 5.17.4. Providers must follow Service Users’ consent wishes if they refuse nutrition and hydration unless a best interest decision has been made under the Mental Capacity Act. Other forms of authority, such as advance decisions, should also be considered. 5.17.5. Consideration and recognition will be given when Service Users are coming to the end of life phase, as nutritional needs change and reduce according to disease progression. During this phase all staff will ensure that good mouth care and comfort is a priority. 5.17.6. Service Users will be supported to maintain good oral hygiene to promote comfort,

Nutritional Care Service Users have enjoyable mealtime experiences that meet their individual needs and that mean they eat what they like when they want it.


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increase appetite, enable ease and safety of eating and drinking, avoid infection and improve overall quality of daily living. Nutritional Screening 5.17.7. On admission to the service, the Provider will nutritionally screen all Service Users using the Malnutrition Universal Screening Tool (MUST) or appropriate alternative tool. This will be reviewed on a monthly basis as a minimum (excluding those identified from a Multi-Disciplinary Approach as requiring End of Life care) or sooner when there is a clinical concern or change in need. 5.17.8. Where Service Users are found to be at medium or high risk of malnutrition, their care plan will clearly outline what specific support is required and all care and catering staff will be made aware of actions to take. 5.17.9. Strategies and actions to manage the risk of malnutrition and dehydration will be individual to the person but should include consideration of:-

• Food and drink fortification

• Documenting and monitoring food and fluid intake

• Nourishing drinks and homemade supplement drinks

• Increase in frequency of food and drink being offered

• More regular nutritional screening and weighing

• Referrals to other Professionals as appropriate including General Practitioner, Speech and Language Therapist, Registered Dietician and / or Occupational Therapist

5.17.10. Where completion of food and fluid charts are included in a Service User's plan of care, information should be recorded as accurately as possible and should be used as part of the review process to determine if further interventions are required. Staff should respond in a timely manner to address concerns or issues identified. Charts should include the following information but not limited to:-

• Details of food and drink offered and taken including type and quantities

• Information on how food and drink has been fortified

• Food and drink refused

• Alternate options offered

• Individual fluid target and fluid totals

• For some Service Users recording urine output and bowel movements may also be necessary

5.17.11. As part of the Provider's governance process, the accuracy of nutritional screening using MUST or equivalent tool should be audited quarterly and where required, any areas for improvement identified should be actioned. 5.17.12. Providers will ensure that equipment and scales used to measure Service User's weight and height are suitably and regularly calibrated and maintained in order to provide reliable and accurate measurement. Dietary Supplements and Thickeners 5.17.13. Prescribed dietary supplements and thickeners will be used in accordance with the medication policy and subject to the terms of the prescription. The International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines and framework to standardise the terminology and definitions to describe texture modified foods and thickened fluids will be followed.


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5.17.14. If food or fluid texture is required to be modified, then catering and care staff will be aware of the relevant descriptor recommended by the Speech and Language therapist. Menus 5.17.15. Menus and meals will reflect the ethnic, social, cultural and religious needs of the Service Users and include general programmes of events e.g. Pancake Day, Passover etc. 5.17.16. Menus will offer adequate hot and cold choices appropriate to the needs of the Service Users e.g. dysphagia needs or service users requiring finger foods. Menu cycles will be over a minimum of three weeks, seasonal and all meals and snacks will be recorded. 5.17.17. Service Users will have a choice of meal options each day and where required, will be offered support to make their choices in line with their assessed needs. 5.17.18. The Provider will actively involve Service Users in the development of menus and ensure they are provided with opportunities to give regular feedback on this e.g. choice, variety, availability, presentation quality and quantity. 5.17.19. Information about allergens used within the food made and served will be available and updated as and when menu changes occur and when suppliers/brands of ingredients change. Meal Times 5.17.20. Mealtimes should be enjoyable experiences and promoted as a social activity. Dining rooms and other eating areas should be pleasant, environments conducive to eating that are welcoming, clean, tidy and free from malodours. Dining spaces need to reflect the needs of Service Users.

5.17.21. If the nutritional care requirements highlight assistance or encouragement to eat and drink is required, it shall be provided ensuring sensitivity and respect for Service Users’ dignity and individual abilities. Enough staff will be available to support those in need of assistance and/or encouragement to eat. 5.17.22. Service Users will be enabled and encouraged to serve themselves where assessed as able and safe to do so; a family style food service will be encouraged. 5.17.23. Food, including that which is texture modified, will be presented in an appetising way that respects dignity. 5.17.24. Protected meal times (an environment conducive to Service Users enjoying their meals and being able to safely consume their food and drink without being interrupted by non-urgent activities) will be encouraged, Service Users will be able to invite friends and family to join them but will not be disturbed by other interruptions e.g. GP’s, hairdressers etc. 5.17.25. Snacks or other food should be available between meals for those who prefer to eat 'little and often'.

Hydration 5.17.26. Water must be available and accessible to Service Users at all times. Other drinks will be made available periodically throughout the day and night and Service Users will be


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encouraged and supported to drink. Suitable adjustments should be made for seasonal changes. 5.17.27. Staff will be aware of the possible early warning signs and symptoms of inadequate hydration and take appropriate action to address these signs, based on the presentation of the person. Actions should be undertaken to counteract warning signs such as pushing fluids through a range of high fluid content alternatives and contacting the GP where this is felt necessary. Training 5.17.28. The Provider will ensure staff receive appropriate induction and ongoing training to enable them to carry out their role effective supporting effective management and monitoring of Service Users’ dietary and hydration needs including but not limited to:-

• All care and catering staff will be trained in the importance of good nutrition and hydration, how to recognise the signs of poor nutrition and hydration and how to promote adequate nutrition and hydration.

• All staff responsible for undertaking nutritional screening will be trained in the use of the validated screening tool e.g. MUST.

• Staff involved in the handling, preparation of food or assist at mealtimes receive training in Food Safety and Hygiene.

• Where appropriate to the needs of the Service Users within the home, additional training may be required such as diabetes management, thickened fluids, dementia, chronic illness or management of swallowing difficulties.


5.18.1. The Provider will operate a complaints procedure. This will be easily accessible and allow Service Users, their carers or advocates to make a complaint, raise concerns or appeal. Response times / expectations are clearly stated within the complaints procedure. 5.18.2. The Provider shall demonstrate a positive and open attitude to complaints and facilitate verbal or written complaints to be made or made on behalf of the Service User and shall not seek to obstruct, delay or interfere with the Service Users’ rights in this regard. 5.18.3. The Provider will ensure that all complaints are thoroughly investigated by a competent person and records are kept demonstrating how they have been managed, a timescale for responses and how Service Users are informed of the outcome including their level of satisfaction. 5.18.4. Actions taken or changes made as a result of concerns, complaints or grievances to address problems and shortfalls will be identified within and across the organisation. Such action will also include learning and improvements implemented as a result of complaints and concerns and will be audited on a regular basis for themes and trends.

Complaints Service Users and their relatives and friends are confident that their complaints and concerns will be listened to, taken seriously and acted upon effectively without any negative impact.


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5.18.5. The Provider shall provide contact details for other relevant organisations for Service Users to escalate complaints outside of the Provider’s organisation. 5.18.6. The Provider will record compliments and use them to learn from positive experiences.


5.19.1. The Provider will have robust procedures in place for safeguarding Adults at Risk and responding to concerns (including “whistle-blowing”) of abuse/neglect to ensure the safety and protection of Service Users.

(Localisation) 5.19.2. The Provider’s procedures will reflect the local Safeguarding Adults policy. The

Provider will ensure a copy of the local Safeguarding Adults policy and Procedures is

available and accessible to all staff (Localisation) For Lancashire Safeguarding Adults Board organisations this includes the Guidance for Safeguarding Concerns

5.19.3. The Provider’s employees will follow the procedure set out in their organisations’

policy and that of the Local Safeguarding Adults Board immediately if they suspect that a Service User or otherwise dependent person has suffered any form of abuse or is otherwise thought to be at risk.

5.19.4. The Provider will clearly display in formats accessible to all what service users, staff

and visitors should do to report any suspected abuse. 5.19.5. Preventative practice will be in place to support safeguarding, including employment,

management and security of the environment. 5.19.6. The safety and wellbeing of the Service User will be paramount and, in the event that

an alleged abuser is a member of staff or a volunteer, action will be taken immediately to ensure the protection of Adults at risk(s) from the possibility of further abuse while an investigation is carried out. This will also apply where the alleged abuser is the Registered Manager/Person in charge.

5.19.7. The Provider will co-operate fully in any safeguarding enquiries and comply with any

agreed requirements of a safeguarding/risk management plan which may include a referral by the Provider to the Disclosure and Barring Service and/or the Nursing and Midwifery Council. Failure to comply with procedures or outcomes/actions from safeguarding enquiries may be regarded as a fundamental breach of the (Localisation) contract.

5.19.8. Training in Safeguarding, including whistleblowing, will be explicitly included in

induction and ongoing training for all staff and volunteers employed by the Provider and updated every three years.

5.19.9. The Provider will ensure that systems within the home protect Adults at Risk in

accordance with the legal requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.

Safeguarding Adults Service Users live in an environment where they are confident that the Provider will take practical measures to prevent harm from occurring and will safeguard them in a way that supports them in making choices and having control about how they want to live.

http://www.lancashiresafeguarding.org.uk/lancashire-safeguarding-adults/resources/guidance-for-safeguarding-concerns.aspx


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5.19.10. The Provider’ management practices ensure controls will be instigated to protect

victims of alleged abuse/neglect from alleged perpetrators during investigations. 5.19.11. The Provider will ensure whistle-blowers are protected from adverse treatment. 5.19.12. The Provider will seek advice at the earliest possible opportunity if they are unsure if

a concern should be raised through the safeguarding procedures. 5.19.13. The CQC must be notified of incidents and events that are required to be reported to

them. 5.19.14. The CQC must be notified under its health and safety regulation when someone has

suffered harm. 5.19.15. The Provider should pay due diligence to the duty of candour and offer apology in

accordance to this. 5.19.16. The Provider will offer the opportunity following the conclusion of safeguarding

enquiries if the Service User or their relative wishes to make a complaint. They will also be given the option of referral through to independent advocacy, eg (Localisation:

http://www.government-online.net/advocacy-services-for-lancashire-county-council/) (Localisation) 5.19.17. The Provider will actively engage with the LSAB Safeguarding Adult Reviews (SAR)

as appropriate; enabling staff, where relevant, to attend and contribute to practitioner events and facilitate sharing and embedding of any learning that may result.


5.20.1. The Provider will ensure that staff are provided with accredited risk management, health and safety, moving and handling and falls prevention training. Moving and handling refresher training or competence assessment will be provided yearly as a minimum. Refer also to clause 5.26.15 regarding staff training. 5.20.2. The Provider will have clear processes in place for the prevention and management of falls. 5.20.3. Serious untoward accidents and incidents, COSHH and RIDDOR will be reported to the appropriate body, for example, Health & Safety Executive, Health Protection Agency and the Care Quality Commission. (Localisation) Add a Local Authority/ NHS lead to report into if appropriate. 5.20.4. Individual risk assessments relating to the health, safety and welfare of Service Users must be completed and reviewed regularly.

Safe Working Practices/Health and Safety The health, safety and welfare of residents and staff is promoted and protected. Procedures are in place to ensure the safety of Service Users in the event of an emergency.

http://www.government-online.net/advocacy-services-for-lancashire-county-council/


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5.20.5. Assessments, planning and delivery of care will be based on risk assessments and include measures to mitigate risks to Service Users, this will be reviewed and amended to address changing needs or practice. 5.20.6. The Provider will ensure the decontamination of medical devices, maintenance of reusable equipment and appropriate use and disposal of single use equipment. 5.20.7. There will be evidence of awareness of Department of Health Medical Device Safety Alerts. 5.20.8. Fire precautions shall be in place and include Fire Safety Training for all staff and conform to HM Government guidelines, ‘Fire Safety, Risk assessment, Residential Care Premises 2006’ or subsequent guidelines. 5.20.9. A Fire Risk Assessment shall be in place which is reviewed annually or when there is a significant change to your premises or Service Users. Fire safety records shall be maintained and used to manage compliance with fire safety law. 5.20.10. The Provider shall maintain a Fire Emergency Plan and Evacuation plan appropriate to the establishment and the Service User group. The Provider will ensure that Service Users, staff and visitors are aware of an emergency plan and escape routes. 5.20.11. For Service Users who are not able to reach a place of safety unaided or within a satisfactory period in the event of an emergency, the Provider will create Personal Emergency Evacuation Plans (PEEPs), where possible in conjunction with the Service User to agree what type of assistance is needed and appropriate arrangements put in place. PEEPs will be reviewed on an ongoing basis, every six months, or if there is a change to the Service User's needs for example health, mobility, medication or behaviour. 5.20.12. A trained First Aider will always be on duty. 5.20.13. The Provider shall ensure that all staff, including temporary or agency, are aware of the procedures for dealing with medical emergencies and calling emergency services. 5.20.14. The Provider shall maintain a business contingency plan which protects the Service Users who use the service in the event of an emergency, e.g. loss of power, loss of heating, sudden staffing shortage, flood, and which clearly designates roles and responsibilities of employees on duty. The Provider will ensure all staff are fully aware of their individual and collective roles in the procedures to adopt in the event of an emergency. 5.20.15. The Provider will have a written procedure for dealing with situations where a Service User is missing which includes informing the Registered Manager (or their representative) immediately and the Police. At the earliest opportunity the relatives will also be informed, even if the Service User has subsequently returned. (Localisation) Add representative from the Council/NHS who also needs to be informed 5.20.16. The Provider will have a written health and safety policy and organisational arrangements for maintaining safe working practices which are evident and understood by Service Users and staff.

5.20.17. The physical environment will be fit for purpose and safe for Service Users and staff. 5.20.18. The Provider will ensure that equipment is available to Service Users and that they adhere to key legislation relating to Equipment Safety, ensuring that equipment is well maintained and visually checked before use, any defects, damage or wear is reported and


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actioned.


5.21.1. The Provider shall ensure that policies or procedures are in place to protect Service Users, staff and visitors from Health care Associated infection (HCAI). These should include:-

• Environmental hygiene

• Optimum hand hygiene in accordance with WHO 5 moments and adherence to ‘Bare Below the Elbows’ when carrying out personal or clinical care

• Safe handling and disposal of clinical waste

• Managing accidents, dealing with spillages, especially body fluid spillages

• Provision, wearing and disposal of personal protective equipment and clothing

• Service User hygiene including hand hygiene

• Cleaning and decontamination of reusable equipment

• Management of laundry and soiled/infected linen

• Management and disposal of sharps and inoculation injury

• Reporting of Health Care Acquired Infections (HCAI’s) and engagement in the Post Infection Review process

• Management and notification of infectious diseases, including outbreak control

• Clinical procedures compliant with aseptic technique

• Safe procedure for the collection and storage of specimens

• Management of indwelling devices

• Staff training and education including IPC lead and Care Champion. IPC induction and mandatory training

• Prevention and control of Legionella bacteria including an up to date Legionella assessment with a plan of preventative maintenance to include monthly testing and recording.

5.21.2. Infection control procedures will be explicitly referred to within all staff job descriptions, induction, development and on-going training for all staff. The Provider will have a designated lead/link person for infection prevention and control 5.21.3. The environment will be designed and managed to minimise reservoirs for micro-organisms and reduce the risk of cross infection to Service Users, staff and visitors. The premises should be kept clean, hygienic and free from offensive odours throughout. Laundry facilities should be housed in a separate room which is not to be used for any other purpose. The room should have a dirty to clean workflow system. Sluice facilities should not be housed within the laundry. 5.21.4. The Provider will comply with optimum hand hygiene in accordance with WHO 5 moments and adherence to ‘Bare Below the Elbows’ when carrying out personal or clinical care Hand washing facilities will be prominently sited in areas where infected material and/or and health and social care waste are being handled and this will include liquid soap and disposable hand towels. Service User hygiene including hand hygiene will be promoted.

Infection Prevention and Control (IPC) Service Users reside in a clean environment where standard precautions and safe practice ensure that avoidable infections to Service Users, staff and visitors are prevented.


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5.21.5. Protective equipment will be available and worn for all aspects of care which involve contact or potential contact with blood or body fluids or where asepsis is required. 5.21.6. All Service Users’ equipment will be cleaned and maintained appropriately to prevent cross infection. 5.21.7. A local outbreak policy will be in place for the surveillance, recognition, control and management of infection and outbreaks with information available to Service Users and their visitors. Staff will be trained and aware of actions to take including reporting to Public Health England. All infection outbreaks will be reported to Public Health England within two days of an outbreak. 5.21.8. Notifiable diseases and infections that could be a potential risk to others will be recorded and reported to Public Health England, local Environmental Health and the Care Quality Commission in accordance with local arrangements. 5.21.9. An annual Infection Prevention and Control assessment will be completed, and an action plan developed to address any areas of non-compliance. 5.21.10. Monthly audits will be undertaken to determine best practice is maintained and include incidence/prevalence rates for HCAI wound infections, urinary tract infections, notifiable infections, antibiotic prescribing, hand washing and decontamination of equipment. Audits will be carried out to ensure staff follow correct infection prevention and control measures. 5.21.11. The Provider will have a policy/guidance for staff on transfer of information relating to infections when Service Users are admitted to hospital or another care environment to ensure that information related to infections will be shared with other health and social care providers. 5.21.12. The Provider will engage in the Post Infection Review for specific infections as required.


5.22.1. The Provider’s policies will reflect the procedures to be undertaken following an accident or incident and staff, including agency and any temporary staff, are fully aware of the processes. 5.22.2 The Provider will have a policy around what actions will be taken following an injury. Regular checks on staff awareness of said policy will be undertaken through staff 1 to 1's/supervisions/PDR and Team Meetings. 5.22.3 The Provider will adhere to reporting procedures as required by the commissioner

Accident/Incident Reporting The safety and wellbeing of Service Users is assured through the Provider’s Accident and Incident Reporting processes. Lessons are learnt from accident/incident/near miss reporting processes


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5.22.4. All accidents and incidents will be comprehensively and contemporaneously documented. Within a care home with nursing, such records must be completed or countersigned by a registered nurse. Additional records, such as falls diaries and behavioural charts will be implemented and maintained daily/weekly/monthly as appropriate to support ongoing monitoring and management. These records will be audited regularly by the Provider's management team/nominated individual to ensure that consistency and accuracy of information is maintained and to be reviewed regularly against risk assessment records. 5.22.5. Details of accidents and incidents will also be recorded within Service Users’ daily records together with information to reflect the Service Users’ health, safety and wellbeing. This information will be audited regularly by the Provider's management team/nominated individual to ensure that consistency and accuracy of information is maintained, and appropriate risk assessment reviews are carried out as part of a Service User's care and support plan. 5.22.6. Injuries, including bruises that are sustained following an accident or incident, shall be fully documented, using body maps where possible. Treatment required following an accident or incident will be clearly documented, including the precise treatment and support and any necessary health or social care professional input i.e. Paramedics, District Nurses, General Practitioner, Community Psychiatric Nurses. 5.22.7. From audits undertaken in respect of accidents and incidents a comprehensive monthly analysis will be undertaken and documented to identify themes, patterns or trends in order to investigate and put in place timely measures to minimise or prevent such events reoccurring. 5.22.8. Repeated accidents and incidents, such as falls or aggressive behaviour, will be referred to specialist health and/or social care professionals to seek support and guidance in managing such situations effectively and in the best interests of the Service User. This will evidence a dynamic approach which attempts to pre-empt hazards/potential triggers and a proactive response before an incident occurs. All contact with external professionals will be recorded and any advice or guidance given will be reflected within a Service User's care and support plan updates.


5.23.1. End of Life care relates to the last 12 months of life. Good end of life planning will ensure that the Service User’s wishes are acknowledged and recorded and that the Service User remains at the centre of all decisions. The Provider will have a policy which reflects NICE quality standards QS13 end of life care for adults and QS144 care of dying adults in the last days of life. 5.23.2 The Provider will work with other health care professionals and in particular, GP’s to pro-actively identify Service Users who may be approaching the end of life and support a

End of Life Care/Dying and Death Every person living in a care home gets the high-quality, genuinely compassionate care they should expect, and that through the care and support that they receive, live as well as possible until they die


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regular coordinated review of care. (Localisation) Each Local Authority/CCG to add equivalent clause for Lancashire/Blackpool/Blackburn with Darwen 5.23.3. The Cumbria Partnership Do Not attempt Cardio-Pulmonary Resuscitation (DNACPR) Policy (https://cdn.cumbriapartnership.nhs.uk/uploads/policy-documents/Do_Not_Attempt_Cardio_Pulmonary_Resuscitation_DNACPR_Policy_POL-001-067V2.pdf) is in place which complies with the legal requirements of the Mental Capacity Act (2005) and ethical guidance issued by the BMA/RCN and Resuscitation Council (UK 2007), including guidance for DNAR using the recognised documentation within Cumbria. 5.23.4. The Provider shall ensure that the appropriate planned comfort, support and compassion is provided to Service Users when it is recognised that they are entering the end of life phase. Sensitive open and honest communication will take place with the Service User, and all decisions will be taken in line with their wishes which will be appropriately reviewed with the Service User and their family or representative should the Service User wish. Any advance care and support plan wishes will also be considered at this time. This will include decisions made by the Service User about their care or treatment. The home will respect a Service User's advance care plan and offer support to meet any dying wishes wherever possible. 5.23.5 The Provider will support timely return of patients from hospital to their home when it has been identified they are approaching the end of life and their preference for place of care is the home. 5.23.6. Service Users will be referred in a timely manner to specialist services, in line with local referral policies where required. 5.23.7 The Provider will have the equipment, where appropriate, to support care at end of life for e.g. syringe drivers and be able to evidence that staff trained to be able to use the equipment 5.23.8. The Provider shall provide a quiet and comfortable private space for Service Users and those people who are important to them, to remain close in the last days of life. Relatives and partners will be able to spend as much time with Service Users as they wish in line with Service Users’ individual preferences, and where possible accommodation and refreshments will be available for relatives who want to stay/sleep overnight at the home. 5.23.9. All deaths will be managed with dignity and propriety and Service Users’ spiritual needs, rites and functions will be observed. There will be systems in place to ensure, when death is expected, that Service Users do not die alone unless it is their wish.

5.23.10. Where Service Users require end of life or palliative care, an assessment will be co-ordinated by an appropriately trained nurse to assess whether the right care can be provided by the existing Provider, or by other relevant professionals, and any changes required are actioned in a timely manner. All assessments will be subject to continuous ongoing review. 5.23.11. The nursing assessment will involve advance care planning (ACP) where possible, to determine Service Users’ wishes, indicating personal preferences concerning place of care and death, in agreement with carers and family and will include Service Users’ wishes relating to resuscitation, if this is stated. Utilise nationally or locally recognised ACP tools and documentation. 5.23.12. Sensitive and compassionate end of life care be co-ordinated and delivered in accordance with Service Users’ personal care and support plan. Service Users’ end of life care will be planned to include relatives or important people in their lives if desired, so that


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Service Users and relatives know what will happen and are able to prepare. 5.23.13. Clear, accurate and dignified records will be maintained and meet the standards for record keeping of the relevant professional groups. 5.23.14. A keyworker will co-ordinate Service Users’ care pathway and ensure continuity of care including out of hours support. 5.23.15. The home has an end of life champion who has a clearly defined role and is supported to carry out their duties effectively. 5.23.16. The home will have a plan in place for respecting and remembering the Service User after they have passed away. 5.23.17. The care pathway will include care after death and information on support agencies and bereavement counselling. 5.23.18. There will be a policy and procedure in place for the verification of death and verification of expected death (if appropriate by competent registered nurse). 5.23.19. The Provider will ensure compliance with the National Institute for Clinical Excellence NICE 2011 End of Life Care Standard for Adults QS13 and that all staff have access (where relevant) to specialist training including the QCF Level 3 Award in Awareness in End of Life Care which will:-

• Support the development of an open culture and awareness towards death and dying

• Facilitate collaborative learning and promote a supportive, palliative approach to end of life care

• Ensure that practitioners have the skills and confidence to talk with all Service Users and relatives/ carers about end of life care and how to document these discussions

• Prepare practitioners clinically and raise their awareness of cultural and ethical considerations

• Assist in the identification of Service Users who may be approaching the final stages of life

• Ensure care evolves as a part of a systematic, multidisciplinary care pathway and optimise the quality of care providing a seamless approach

• Ensure that systems are in place to reduce the risk of Service Users being inappropriately admitted to hospital at the end of life.

5.23.20. Staff will be appropriately trained to manage the processes and procedures sensitively, to ensure Service Users are treated with dignity and respect and receive appropriate care and symptom relief. 5.23.21. Practitioners/ staff will require specific training for Service Users who are cognitively impaired or require complex care e.g. Dementia, Motor Neurone Disease or Learning Disabilities. 5.23.22. The Provider will keep up to date with current and new approaches to end of life care. 5.23.23. On-going supervision will be provided to staff to support them and to provide an opportunity to consider and reflect upon their own cultural beliefs, values and attitudes to death and dying and enable staff as a team to reflect on care and dying within the home. Wellbeing of staff will be considered, and bereavement counselling promoted.


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Learning from and continuous quality improvement will be integrated into the home’s communication strategy. 5.23.24. The Provider as a minimum will be able to demonstrate that they have a strategic approach to managing end of life care with policies in place reflecting local and national guidance and education for staff. 5.23.25. The Provider will notify the Commissioner without delay about the death of a Service User and inform the Care Quality Commission.

5.23.26. The Mental Capacity Act 2005 guidance is to be followed.

5.23.27. When a Service User dies in the home where there is either an authorised Deprivation of Liberty Safeguard in place or an application submitted to the Local Authority, the Provider will comply with the relevant legislation and guidance. The current guidance can be found here: http://www.mentalcapacitylawandpolicy.org.uk/wp-content/uploads/2017/03/GUIDANCE-No16A-DEPRIVATION-OF-LIBERTY-SAFEGUARDS-3rd-APRIL-2017-ONWARDS.pdf 5.23.28. Information will be available for the Service User and their families in an accessible format.


Staff Recruitment and Retention Staff employed are fit and competent to meet the health and welfare needs of Service Users.

5.24.1. The Provider will operate a robust staff recruitment and selection procedure, in line with CQC regulations, which takes all reasonable steps to ensure that all individuals employed, including volunteers, those appointed through an agency and workers from other countries, are in all respects appropriate persons to work with vulnerable people. This includes all individuals employed in the home including and not limited to maintenance, cleaning, personnel, kitchen and administrative staff. A written policy and procedure shall be in place to reflect this practice. 5.24.2. The Provider will adhere to all equal opportunities and wage legislations and will be expected to embrace the principles of equality and diversity. 5.24.3. The Providers’ staff recruitment and selection procedure must include a Disclosure & Barring Service (DBS) check at the appropriate level in accordance with the Safeguarding Vulnerable Groups Act 2006 requirements. Photographic evidence of the staff member will be included on file and checked against a passport, driving licence or photo ID.

http://www.mentalcapacitylawandpolicy.org.uk/wp-content/uploads/2017/03/GUIDANCE-No16A-DEPRIVATION-OF-LIBERTY-SAFEGUARDS-3rd-APRIL-2017-ONWARDS.pdf

http://www.mentalcapacitylawandpolicy.org.uk/wp-content/uploads/2017/03/GUIDANCE-No16A-DEPRIVATION-OF-LIBERTY-SAFEGUARDS-3rd-APRIL-2017-ONWARDS.pdf


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5.24.4. Providers employing staff who are required to obtain permission to work in the United Kingdom either directly or through an agency must ensure that employees have received clearance to work, have the necessary permits and relevant documentation available prior to employment; copies of which must be evidenced in their personal file for inspection and monitoring purposes. 5.24.5. When recruiting staff, the Provider shall ensure that at least two appropriate written references are taken up one of which must be from the individual's last employer and shall demonstrate the means by which the suitability of all staff has been assessed. Where the reference provided only gives dates of employment the Provider must be able to demonstrate that all attempts have been undertaken to ensure a safe system of recruitment. The Provider shall include documented evidence of telephone contact with previous employer. 5.24.6. Staff will go through a full recruitment process including completion of an application form which provides complete employment history and addresses any gaps in employment history. 5.24.7. Staff, including those whose first language is not English, must have the personal qualities and caring attitudes which enable them to relate well to Service Users and carers, as well as the required skills in spoken English, written literacy and numeracy to do the tasks required for caring for and supporting Service Users. 5.24.8. Contemporary evidence of professional registration/PIN number checks will be obtained for all qualified nursing staff employed and regularly reviewed. 5.24.9. Providers shall maintain a personnel file for every employee which evidences all required documentation for inspection and monitoring purposes. Such documentation will include evidence of a written record of interview to demonstrate the applicant’s suitability for the post.

5.24.10. Providers employing agency staff will obtain a staff profile prior to commencement of the employment. This will include photographic ID, relevant skills and competencies for the position, qualifications, professional registration and an up to date training record.

5.24.11. Providers employing volunteers in the home will ensure volunteers are fit and competent to meet the health and welfare needs of Service Users. This will include photographic ID, relevant skills and competencies for the position, professional registration and an up to date training record and a Disclosure & Barring Service (DBS) check at the appropriate level in accordance with the Safeguarding Vulnerable Groups Act 2006 requirements.


Staffing Levels and Workforce Planning Service Users are supported to achieve their maximum life potential and care needs by the provision of the appropriate level of professional expertise and skill mix.

5.25.1. The Provider’s staffing levels will enable the Provider to meet all the service


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standard requirements as detailed in this specification, both day and night, with the right competency, skills and experience, and to build in flexibility and promote sustainability of the workforce 5.25.2. The Provider must be able to fully evidence the method used for determining staffing levels in the home, for example by utilising or developing a staff ratio to service user dependency tool. 5.25.3. Staffing levels must be based on the dependency needs of all the Service Users, will be reviewed on a regular basis and evidence made available to ensure and demonstrate that they reflect the changing needs of the Service Users. 5.25.4. Staff numbers and skill mix will be matched to all Service Users’ needs and reflect a high quality of care provision. 5.25.5. In determining the level and frequency of professional nursing expertise and intervention required (in care homes with nursing) the Provider will demonstrate the following:-

• The level, frequency and quality of time and intervention provided by a registered nurse undertaking actual care delivery, including clinical/technical or therapeutic activities on the Service User’s behalf, is enough to meet their assessed needs and provide the ongoing management of care interventions

• The level and frequency of supervisory skills required by a registered nurse for teaching, guiding, advising, supporting and monitoring both Service Users and staff is enough to meet the Service User’s assessed needs and promote and maintain standards of care

• The Registered Nurse providing nursing care demonstrates the skills, knowledge, clinical judgement and expertise to accurately assess and manage the stability and predictability of the Service Users’ health.

5.25.6. The Provider will have contingency plans–also included within the Provider’s Business Continuity Plan/Policy - in place to cover staff absence, sickness, annual leave and succession planning and will provide to the Commissioner on request.


Staff Induction and Training/Education Service Users are cared for and supported by professionally inducted, trained, and competent staff, utilising best practice and this will be reflected in the standard of care that they receive.

5.26.1. The Provider will ensure that there is a staff induction, training and development programme, which will meet core skills training standards and include dementia, end of life and person-centred care training, which can be accessed through Skills for Care’s Education and Training Frameworks. Where registered nurses are employed, NMC Code of Professional Conduct Practice Guidance will be followed. These expectations will be clearly included in written policies and procedures to reflect a commitment to a supportive working and learning environment.

5.26.2. The Provider will ensure that staff new to care enrol on the Care Certificate within twelve weeks of commencing employment. All existing staff will be able to demonstrate that they also meet the standards of the Care Certificate.


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5.26.3. The Provider will ensure that all staff working within the home are fully trained and assessed as competent to meet the individual needs of Service Users including all mandatory training and specialist and clinical education. 5.26.4 The Provider will ensure training provided, both internally and externally, is of high quality and that content is appropriate and is evidence based to reflect up to date specialist and social care and clinical guidance. 5.26.5. The Provider will undertake a training needs analysis for all staff which is reviewed regularly and updated and formulated into staff personal development plans. 5.26.6. The Provider must have an appropriate and deliverable training matrix in place that clearly identifies and timetables training and development needs of all staff within the home. 5.26.7. The Provider will be able to demonstrate assessment of staff competency and performance management and documented evidence will be made available; this could be through observations, supervision and appraisal processes or feedback from staff, Service Users or relatives. Where identified or required, the Provider will provide learning and development opportunities. 5.26.8. The Provider will ensure that staff understanding of training given is checked regularly through observation and supervision, including discussion at staff meetings, ensuring knowledge is embedded so that staff are confident to apply learning in their areas of work and that opportunities are offered for staff suggestions and feedback on running of the home and Service User needs. 5.26.9. Where there are identified concerns related to social care practice or the clinical practice competencies of individual employees this will be effectively managed by the home with evidence of the provision of mentorship and supervision. 5.26.10. Staff in charge of the home unsupervised will have the appropriate level of clinical and management competencies. 5.26.11. Where a Provider employs a newly qualified registered nurse or registered manager, they will ensure that preceptorship/ mentorship is provided for the first six months in post. 5.26.12. Providers who support student nurse placements and nurses’ registration and adaptation programmes will be able to provide evidence of accreditation with a participating University. 5.26.13. Providers supporting candidates undertaking Nursing Adaptation Programme placements will ensure appropriate mentoring and provision of the required period of protected learning in accordance with Nursing and Midwifery Council requirements. 5.26.14. Providers will have a system in place to confirm new employees have successfully completed induction competencies prior to completion of the probationary period. 5.26.15. Staff will not commence duties unsupervised until they have been assessed as competent for the role. 5.26.16. The Provider will be responsible for determining that the training provider is suitably qualified and that the content of the courses meets the requirements of Adult Social Care Services.


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5.26.17. Learning undertaken by individuals prior to employment with the Provider shall not give automatic exemption to the training requirements. 5.26.18. Casual staff/trainees and student workers will be subject to the same requirements of all permanent staff. 5.26.19. When booking or recruiting Agency Staff for the home, the Provider must ensure that individuals are suitably trained to meet the needs of the individual Service Users and ensure a full induction has been provided. The Provider must be able to demonstrate safe recruitment of agency in line with good practice guidance from the Lancashire Safeguarding Adults Board (LSAB).


Staff Supervision and Appraisal Service Users are cared for by staff who are suitably and regularly supervised, monitored, supported and appraised and this will be reflected in the standard of care that they receive.

5.27.1. A written policy and procedure will be in place to support the Provider’s practice regarding supervision and appraisal. 5.27.2. All staff will receive formal supervision, including clinical supervision, where appropriate, in accordance with the Provider’s policy. Where appropriate, staff must be supervised until they can demonstrate required/acceptable levels of competence to carry out their role unsupervised. Supervision and appraisal sessions will be documented. 5.27.3. Staff will receive appropriate ongoing or periodic supervision in their role to make sure competence is maintained, and at least six times per year. 5.27.4. Supervision will be systematically used to guide the work of staff, to reflect upon their work practices and as a means of support for staff to facilitate good practice, and better outcomes for the Service Users they support. Casual staff including agency staff, trainees and student workers will receive proportionate supervision support and review. 5.27.5. Service Users are supported to contribute to the supervision of their care staff. 5.27.6. Supervision and appraisal sessions will be documented. 5.27.7. Clinical supervision will be a critical element in the provision of safe and accountable nursing practice and inextricably linked to professional development. It is an exchange between practising professionals to enable the development of professional skills. It is also an opportunity to reflect on practice and necessary to enable practitioners to establish, maintain and promote standards and innovations in practice in the best interest of Service Users. 5.27.8. Robust appraisal systems will be in place and all staff receive an annual appraisal/personal development review. 5.27.9. Supervisors will be trained and supported in their supervisor role.


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5.27.10. Staff that require membership of a professional body in order to practice will provide evidence of continued registration as part of the appraisal process. Employees will support the requirements for the Nursing and Midwifery Council (NMC) Revalidation in their supervision and appraisal processes. 5.27.11. Poor performance or staff conduct is identified, challenged and managed and documentary evidence made available to demonstrate that appropriate support has been provided and action taken. 5.27.12. The Provider must make a referral to DBS where the required conditions are met, this applies even when a referral has also been made to a safeguarding team or professional regulator and following dismissal/resignation during any investigations. Current guidance can be found on https://www.gov.uk/guidance/making-barring-referrals-to-the-dbs


Management and Leadership The service is led so that individual Service User outcomes are achieved and sustained for the whole time Service Users live within the home.

5.28.1. The Provider will take responsibility for the leadership through the Registered Manager as well as their own investment of finance, interest and time. 5.28.2. The philosophy within the service is person-centred and promotes the benefits of open, trusting and collaborative relationships between staff, Service Users and their social and professional networks.

5.28.3. The Provider shall ensure that the home is managed is such a way that it complies with all requirements under the Health and Social Care Act 2008 and the Care Quality Commission (Registration) Regulations 2010, or any amending legislation. 5.28.4. The Provider promotes a clear understanding of the organisations purpose, values and vision and encourages learning and innovation by rewarding reflection, creativity, flexibility and positive risk management. 5.28.5. A manager shall be appointed and registered with the Care Quality Commission or will have applied to be registered with the Care Quality Commission within three months of commencement of employment within the home. 5.28.6. The Manager clearly demonstrates up to date knowledge and skills, leadership, competence and experience to effectively manage the home on a daily basis and has a sound understanding of the requirements set out in the contract terms and conditions and Service Specification. 5.28.7. The Manager will have experience to the equivalent of, or qualification in, or be working towards QCF Level 5 Diploma in Leadership in Health and Social Care within three months of appointment and completed within two years. 5.28.8. The Provider and Manager will keep up to date with good practice guidance in quality and ensure that this is shared and acted on throughout the service, where

https://www.gov.uk/guidance/making-barring-referrals-to-the-dbs


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appropriate reviewing policies and procedures in line with changes. 5.28.9. The Manager maintains and demonstrates personal and professional competence and credibility in line with current practice and will ensure they delegate appropriately with clear lines of accountability. 5.28.10. The Manager is a self-directed role model, committed to practice development and improving the care of Service Users, providing formal support, coaching and mentoring of all staff. 5.28.11. The Manager will ensure that staff will work collaboratively as an effective team in a culture of openness, promoting mutual support and respect with an appreciation of each other’s roles. 5.28.12. The Provider shall ensure the following are in place to effect the continuous and sustained delivery of the service: -

• Proactive and reactive support so that the manager can competently meet all requirements of the service

• Contingency arrangements that plan for potential failure or service interruption

• Business planning so that continuity of the service is ensured and to assure those who rely on the service that it will continue to be provided

• Adequate programme so that the fabric of the building, fixtures and fittings, decoration and furniture is maintained and in good order.

5.28.13. The Provider shall co-operate with the Commissioner in times where the contingency plans require a joint response to interruptions, including reasonable requests for information. 5.28.14. The Provider will ensure processes and procedures are in place that promote continuous improvement within the home, both proactively and reactively. 5.28.15. The Manager will ensure that Service User views are at the core of quality monitoring and assurance arrangements. Feedback is sought from Service Users, Families, Staff and Professionals and there is evidence that Service User's views and experiences are acted on to shape and improve the home and culture. 5.28.16 The Provider will inform the Commissioner when the Registered Manager post is made vacant or appointed to. 5.28.17 The Providers representatives, including the Proprietor, Directors, Senior Managers and Registered Manager are fit and competent to meet the health and welfare needs of Service Users.


Quality Assurance Continuous quality improvement systems are in place to ensure the home is run in the best interests of Service Users, demonstrates the quality and consistency of information, measures Service User outcomes and ensures that risks to Service Users are minimised.


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5.29.1. The Provider will have quality assurance and monitoring systems in place which:-

• Seek the views and experience of Service Users, relatives, friends and health and social care professionals, incorporating community contacts: e.g. schools, faith visitors, friends, where possible.

• Enable realistic assessment of the services provided.

• Support evaluating and learning from current practice to drive continuous improvement and manage future performance.

5.29.2. All staff will be actively involved in the quality assurance and monitoring processes. Quality services will be recognised as a motivating force and staff will strive for continuous improvement and best practice. 5.29.3. Quality Assurance will demonstrate: -

• Measurable organisational improvement

• Training that provides staff with the skills and tools to analyse problems and working processes

• Staff who are empowered and supported to make positive changes (analysing dilemmas/problems and suggesting solutions)

• Positive attitudes and working relationships

• Continuous building on good practice

• Introduction of new procedures. 5.29.4. All Registered Nurses will participate in clinical audit and reviews of clinical care in accordance with Nursing and Midwifery Council guidance. 5.29.5. Providers will be required to assist Commissioners in evaluating the quality of effectiveness, not only of the care to the individual Service Users but also compliance with the Contract Agreement. This will be undertaken on a schedule and by means as defined by the Commissioner. 5.29.6. The Provider will have a robust governance and auditing process which encompasses the following audits on a regular basis in line with their organisational policy;

• Care records, care and support plans and record keeping

• Medicines management

• Training

• Falls

• Infection prevention and control, including health care acquired infections (HCAI’s)

• Medical device management

• Nutritional screening and support

• Tissue viability and wound care practice

• Accidents, incidents and complaints (including safeguarding alerts)

• Hospital Admissions

• Call bell responses if such technical systems are in place. 5.29.7. Findings from audits, inspections, assessments and reviews are clearly documented, trends are analysed, and details of actions taken including the responsible person and timescales for completion are documented. This information is used to support continuous


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improvements within the service. 5.29.8. The Provider will have effective processes in place to ensure learning from information such as safety incidents, near misses, investigation findings or feedback takes place to make sure action is taken to improve safety and quality across relevant parts of the service. 5.29.9. Staff and Service User and/or representatives’ meetings will be used as a forum to identify, take stock and reflect on areas for improvement. Such forums demonstrate that the home will be committed to involving and encouraging others to be included and listened to in the day to day running of the home. 5.29.10. A variety of feedback systems will be used which are suitable for the Service User group. These will be recorded, analysed objectively and published. Examples include:

• Verbal

• Written

• Observational tools

• Symbols/pictures

• Built into activities

• Group

• One to one (enables safe disclosure)

• External evaluation e.g. citizen checker, or at least assessors that are not part of day to day services.

5.29.11. The Provider will have a governance framework where responsibility and accountability are understood at all levels of the Provider organisation to ensure governance arrangements are properly supported. The Registered manager is supported by board / trustees, the Provider and other Managers where appropriate to deliver high standards of care and drive continuous improvement.


5.30.1. Service Users’ personal allowances must not be included as part of the fees. The Service User will retain control of their own money except where they state that they do not wish, or lack capacity and safeguards are in place to protect the Service User. 5.30.2. Providers shall ensure that all staff that handle money on behalf of Service Users clearly understand the procedure for receipting and recording all transactions. All such transactions, and recording thereof, will be audited regularly by the nominated individual for the service and/or significant other associated with the service e.g. Proprietor/Director. 5.30.3. The Provider will ensure that all staff understand how the Service User’s right to autonomy, choice, independence and fulfilment is maintained within the context of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards in relation to any financial

Financial Procedures/Personal Finances Service Users are safeguarded by the accounting and financial procedures of the home. Service Users decide how to spend their money in the knowledge that personal finances are safeguarded by robust controls and audit procedures in the home.


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management issues. 5.30.4 Service User monies and related financial items (e.g. bank cards, cheque books etc.) will be kept in a place of safety e.g. a safe, by the Provider where requested by the service user. 5.30.5 The Provider will ensure a policy is in place regarding the personal finances of service users, and if any activity relating to Service Users finances is considered to be illegal appropriate bodies will be informed. Provider HR/Personnel codes of conduct will reflect this, and due process and protocol will be followed in respect of any such activity.

Appendix 1 Processing, Personal Data and Data Subjects

Subject matter of the processing

Processing personal data and special category personal data for the provision of residential care services to service users

Duration of the processing

As set out in the main body of the contract

Nature and purposes of the processing

Processing: the obtaining, recording or holding the information or data or carrying out any operation on the information or data, which include:


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• organisation, adaptation or alteration of the information or data,

• retrieval, consultation or use of the information or data,

• disclosure of the information or data by transmission, dissemination or otherwise making available, or

• alignment, combination, blocking, erasure or destruction of the information or data. Purpose:

• to safely and effectively deliver the terms of The Contract and Specification,

• statutory obligations

• employment processing directly linked to service delivery

• such other purposes as the Purchaser may notify to the Provider from time to time Type of Personal Data • Health & Care Services ID

• Given Names

• Preferred Names

• Gender

• Marital Status

• Address

• Previous Address

• Date of birth

• NI number

• NHS number

• GP

• Professional Involvement

• Name, age, gender, contact of relationships

• Name, age, gender, contact of dependants

• Telephone number

• Next of Kin

• Legal representation

• Disability

• Languages

• Ethnicity

• Images

• Health & Medical

• Sexuality

• Religion

• Employment history

• Advocates

• Financial Agents

• Emergency contacts

• Power of Attorney

• Advanced decisions

• Authorised representative

• Contextual information for care delivery

• Personal preferences

• DoLs information

• Reviews

• Safeguarding Adults meeting minutes

• Multi Agency Review minutes

• Contact details for people listed in this section

• Allergies

• Sensory Impairment

Categories of Data Subject

• Service Users

Plan for return and destruction of the data once the processing is complete UNLESS requirement under union or member state law to preserve that type of data

As per The Contract

Appendix 2

(Localisation) Cumbria County Council Care Home Banding Guidance

This guidance is intended to support wider assessment of Service User needs and the Provider should

therefore have regard to this guidance in delivery of the Services.

The bands are:


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• Residential

• Physically Frail – Residential & Nursing*

• Residential Dementia

• Nursing* Dementia

*Funded Nursing Care (FNC) assessed and paid for by the relevant CCG.

The Care Home Banding Guidance consists of two tables of need; Table 1: Physical Frailty and Table 2:

Memory, Cognition & Behaviour.

Each table has three levels of care dependency; Low dependency (columns A), Moderate dependency

(columns B) and Higher dependency (columns C).

Table 1 is reviewed to indicate whether the Physically Frail band applies, then Table 2 to indicate if the

Dementia band applies.

Table 1 demonstrates that:

• Providers of Residential care will need to support Service Users with moderate needs that generally

fall below those within column (C). (Service Users may some exhibit needs as set out in column (C)

in these cases the ASC assessment will determine the overall level.)

• Providers of Physically Frail Care will need to support Service Users with high levels of dependency

such as those set out in column (C)

Table 2 demonstrates that:

• Providers of Residential Dementia will be required to support Service Users with high levels of

dependency such as those set out in columns (B) & (C)

• The Nursing Dementia band will apply to Service Users who have met the criteria for Nursing Care

and have higher levels of dependency as established above.

Needs listed in each of the tables are indicative of the level of care to be provided within Care Homes and

are not exhaustive. It is recognised that Service Users may display needs across bandings, in these cases

the Social Worker’s professional judgement will prevail.

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(Localisation) CUMBRIA COUNTY COUNCIL CARE HOME BANDING GUIDANCE TABLE 1: PHYSICAL FRAILTY

Low dependency (A) Moderate dependency (B) Higher dependency (C)

Providers of Residential Care will need to support Service Users with moderate needs that generally fall below those within column (C). Service Users may some exhibit needs as set out in column (C), in these cases the ASC assessment will determine the overall level. Providers of Physically Frail Care will need to support Service Users with high levels of dependency such as those set out in column (C) Needs listed below are indicative of the level of care to be provided within Care homes and are not exhaustive.

Communication Needs assistance to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing.

Regular assistance and encouragement to communicate needs. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.

Unable to regularly and reliably communicate their needs, even when all practicable steps to assist them have been taken. The person has to have most of their needs anticipated because of their inability to communicate them.

Mobility/ personal care

Assessed as being at high risk of falls Able to transfer with a Standaid or independently onto commode for example (transfer only). Occasionally requires 2 carers for moving & handling

Occasionally requires hoisting at times i.e. in the presence of infection/illness.

Not able to consistently weight bear. Regularly able to cooperate with moving and handling and personal care. Occasionally requires 2 carers for moving & handling

Needs to be hoisted for all transfers. Requires 2 carers to support with moving and handling the majority of the time. Due to risk of physical harm or loss of muscle tone or pain on movement needs careful positioning and is unable to cooperate. Requires regular turns and or positioning to meet specific pressure care needs. Full intervention and practical support with all personal care tasks. Regular assistance required during the night time

Nutrition Needs supervision, prompting with meals and may need feeding /support with feeding of meals Able to finger feed and use a spouted cup Requires a specialised diet – diabetic, adjusted food and fluids (thickened, pureed etc.)

Regular one to one assistance prompting and or active assistance with eating and drinking Specialist diet as directed by Speech and Language Therapist i.e. soft diet, fork mashable, stage 1,2 & 3 fluids.

Changes in consciousness

History of altered states of consciousness but effectively managed and there is a low risk of harm.

Occasional episodes of altered states of consciousness that require the supervision and intervention of a carer or care worker to minimise the risk of harm.

Regular episodes of altered states of consciousness that require the supervision of a carer or care worker to minimise the risk of harm/ occasional episodes that require skilled intervention to reduce the risk of harm.

NOTES: By occasional we mean something that happens from time to time i.e. infrequently or irregularly. By regular we mean something that happens uniformly and frequently

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(Localisation) CUMBRIA COUNTY COUNCIL CARE HOME BANDING GUIDANCE TABLE 2: MEMORY, COGNITION & BEHAVIOUR

Low dependency (A) Moderate dependency (B) Higher dependency (C)

Providers of Residential Care will need to support Service Users with needs that generally fall below those within column (B). Service Users may some exhibit needs as set out in columns (B) & (C), in these cases the ASC assessment will determine the overall level. Providers of Residential Dementia will need to support Service Users with high levels of dependency such as those set out in columns (B) & (C) The Nursing Dementia band will apply to Service Users who have met the criteria for Nursing Care and have higher levels of dependency as established above. Needs listed below are indicative of the level of care to be provided within Care homes and are not exhaustive.

Behaviour Some incidents of behaviours with a risk assessment that indicates that the behaviour does not pose a risk to self, others or property or a barrier to intervention. The person is compliant with all aspects of their care.

Incidents of behaviours that follow a predictable pattern that can be managed by care workers to maintain a level of behaviour that does not pose a risk to self, others or property Occasionally non-complaint during personal care input

Regular behaviours that poses a risk to self, others or property. Full practical support with personal care and engages in daily non-compliance Risk of retaliation from others due to level of behaviour the Service User presents i.e. invading personal space

Cognition Cognitive impairment that requires some supervision, prompting and/or assistance with daily living activities. Some awareness of needs and basic risks is evident. Some supervision, prompting or assistance with more complex activities of daily living, e.g. finance and medication. Occasional difficulty with memory and decisions/choices requiring support, prompting or assistance. At risk of wandering to due impaired orientation Some direction to facilities required but can sequence tasks such as using the toilet for example requires some prompting to ensure personal care/hygiene but still retains practical abilities

Is usually able to make choices appropriate to needs with assistance. However, the individual has limited ability even with supervision, prompting or assistance to make decisions about some aspects of their lives, which consequently puts them at some risk of harm, neglect or health deterioration.

Cognitive impairment that could include frequent short-term memory issues and maybe disorientation to time and place. Awareness of only a limited range of needs and basic risks. Finds it difficult, even with supervision, prompting or assistance, to make decisions about key aspects of their lives, which consequently puts them at high risk of harm, neglect or health deterioration.

Psychological/ Emotional

Requires daily reassurance to promote their emotional wellbeing Respond to prompts and reassurance in periods of anxiety and distress Requires prompts to motivate self towards activity and to engage in care planning, support and/or daily activities.

Mood disturbance or anxiety symptoms or periods of distress which do not readily respond to prompts and reassurance

Mood disturbance or anxiety symptoms or periods of distress that have a severe impact on the individual’s health and/or well-being. Requires reassurance several times a day to promote their emotional wellbeing Withdrawn from any attempts to engage them in care planning, support and daily activities.

NOTES: By occasional we mean something that happens from time to time i.e. infrequently or irregularly. By regular we mean something that happens uniformly and frequently

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Appendix 3 (Localisation)

Cumbria Quality and Outcome Measures – ‘What does good care look like?’

1 Promoting Independence - the care and support needs of Service Users are met in a way that enables each to achieve their own personal goals, promotes their wellbeing and enables them to live as active and fulfilling lives as possible.

1.1 Evidence of systems and practice that demonstrates Service Users have contributed to their own goal or outcome setting based on individual strengths and what is important to them

1.2 Evidence that Service Users have been provided with any aids or equipment they may need to support them to undertake tasks of daily living as independently as possible and they know how to use it

1.3 Evidence that consideration is given to Service Users’ sensory needs and any equipment that will enhance communication and engagement

1.4 Evidence that the physical environment enhances independence

1.5 Evidence that there is sufficient flexibility within systems and routines, which allow Service Users the necessary time to complete any activity independently

1.6 1.7

Evidence of timely and responsive care, e.g. early intervention and support for mental health, occupational therapy etc, referring to external support from specialist agencies Evidence of working with statutory agencies to be responsive to the changing needs of Service Users to overcome barriers and focus on rehabilitation, recovery and progression.

2 Choice and Dignity – Service Users are able to exercise choice and decision making, and are treated with respect, dignity, kindness and compassion. The individuality of each person is recognised and promoted.

2.1 Evidence that Service Users have contributed to the development of their care and support plan and subsequent reviews or updates. Where there is a lack of capacity there is evidence that their relative or advocate has been involved with the opportunity to review or update

2.2 Evidence of systems that demonstrate that Service Users are involved in decision making at an individual and group level. Where there is a lack of capacity there is evidence that their relative or advocate has been involved with the opportunity to review or update

2.3 Evidence of how Service Users are supported to take positive risks and where they are deemed to lack capacity to make a specific decision, appropriate advocacy is made available to them

2.4 Evidence that Service Users are able to exercise choice about different aspects of their daily living routine, and that their choices have been acted upon

2.5 Evidence that Service Users and their relatives are encouraged to provide feedback without prejudice on the service they receive

2.6 Evidence how the service supports Service Users to make decisions, respects and acts on their decisions and resolves problems and disagreements

2.7 Evidence that Service Users are enabled to maintain and develop their own personal identity

2.8 Evidence how the service is responsive to Service Users’ individuality, ethnicity, religion and sexuality

2.9 Evidence how the culture within the service supports staff members to spend non task centred time with Service Users with time to talk and listen.

3 Social Inclusion and Meaningful Activity – Service Users are supported to maintain and develop relationships to the degree they wish to within the service, with their family and friends, as well as with their local community. Individual and group activity is tailored to the Service User’s interests and goals.

3.1 Evidence of a range of activities tailored to both individual and group activity

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3.2 Evidence of flexibility around how and when activity or engagement takes place, ie, not just at rostered times when an activity coordinator is present

3.3 Evidence of how the service supports Service Users to retain or develop personal relationships with family, friends and the community

3.4 Evidence of how members of the local community are encouraged to engage with the service and ‘bring the local community into the service’.

4 Safety and Security – Service Users are able to live in safety, free from abuse or neglect and are supported to take and manage positive risks

4.1 Demonstrate an understanding of what being safe means to each Service User and how this has been decided

4.2 Evidence of robust procedures and systems to maintain and review the safety of Service Users

4.3 Evidence of clear reporting mechanisms for reporting concerns about a Service User’s safety or wellbeing, and evidence how this is communicated to both staff and visitors

4.4 Evidence of a robust Safeguarding and Whistleblowing policy which reflects the Cumbria and Pan Lancashire Safeguarding Procedures

4.5 Evidence that all staff have received training on Safeguarding Adults and Children and that knowledge and understanding is continuously reviewed and refreshed

4.6 Evidence of knowledge and understanding of the Mental Capacity Act 2005 and ADDENDUM 2007 of the Mental Capacity Act and recognise when it applies to Service Users in the service – including who to contact for more information

4.7 Evidence that Service Users are supported to take positive risks and knowledge of who should or could assist in the decision making process.

5 Positive workforce culture and effective leadership – The service is delivered by a competent, confident and highly motivated workforce. Leadership is visible, proactive and connected to service outcomes.

5.1 Evidence how the service supports a workforce culture that is open, positive and respectful

5.2 Evidence how the service supports the workforce to share ideas and views, or air concerns

5.3 Evidence how the organisational culture is supportive and embraces the importance of spending time with Service Users and their relatives (non- care delivery time)

5.4 Evidence of good working conditions, opportunities for learning and skills progression

5.5 Evidence how the leadership within the service supports the workforce and values their role and contribution

5.6 Use of activities to build relationships and engage more freely with Service Users

5.7 Evidence how leadership is visible, proactive and connected to service outcomes

5.8 Evidence of robust mechanisms in place to support the leadership function

5.9 Evidence of a clear mission statement and of policies and procedures in place that reflect and underpin the service aims, culture and leadership.

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APPENDIX 4 (Localisation)

Provider Information – Quality Improvement Process

At times a reactive response will be necessary to address quality concerns that have been identified. The Council’s Quality and Care Governance Framework categorises quality concerns into three levels: Level 1: Focused Intervention or ‘Sustaining improvement’ Level 2: Broader Focus Intervention or ‘Requires Improvement’ Regulator rating Level 3: Large Scale Intervention, ‘Inadequate’ Regulator rating or Service Closure/De-registration Interventions will support the market to achieve/deliver high quality care and support, and enable quality monitoring via a broad range of methods as appropriate.

A Level 3 concern would trigger a multi-agency Quality Improvement process.

Level 3 may be triggered by a culmination of significant concerns or safeguarding issues accompanied by regulatory or other care quality failings, an overall ‘Inadequate’ rating from the Regulator or Service Closure/De-registration. A Level 3 could also be triggered through failure to meet improvements at Level 2.

The Provider will co-operate fully in the quality improvement process and comply with all requirements, including; attending meetings, providing information, production and implementation of a service improvement action plan and facilitating service reviews with the multi-agency quality improvement team. Failure to comply with procedures or outcomes/actions may be regarded as a fundamental breach of the Framework Agreement.

The Provider will be invited to an initial Quality Improvement meeting and the areas of concern will be highlighted. The meeting will include a range of relevant agencies, for example Clinical Commissioning Group (CCG), the Regulator (CQC), Cumbria County Council (CCC), Continuing Healthcare team (CHC) and the Provider. The initial letter will detail the attendees expected. Meetings will be minuted and details confidential to the attendees, unless approved for wider sharing by the Chair.

Meetings are likely to take place every 4-6 weeks to monitor progress and identify any new areas of concern or barriers to improvement.

A service improvement action plan will be required from the Provider, to address the areas of concern with appropriate actions, responsible party/lead and timescales. The action plan will form the basis for all activity and support, and details relating to progress or barriers will be recorded on the plan, thereby creating an ongoing evidential log of progress.

All Level 3 interventions are discussed and approved by a multi-agency Quality and Care Governance group including CCC, CCG and CQC who meet at least bi-monthly. There will be a collaborative approach to support providers to achieve required improvements and to hold Providers to account where there have been systematic failures.

When the concerns have been remedied and the action plan completed within the agreed timeframe, the multi-agency group will validate and the Level 3 Quality Improvement Process will be closed. The group may recommend ongoing actions to maintain quality improvement which could be via Level 1 monitoring.

Should the multi-agency group recommend a service suspension as part of the Quality Improvement Process, or should the Provider elect to voluntary suspend, this will be formally communicated to the relevant Assistant Director/ Senior Management Team for authorisation to formally suspend the service.

Where a Service is to close or de-register, a multi-agency coordinated approach will be taken to manage the process with care and due diligence. This may be due to Provider failure, or planned in response to market changes or demand. The process will maintain regular contact with all stakeholders to ensure action plans are drawn up, agreed and met.

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APPENDIX 5 (Localisation) Cumbria County Council Independent Care Home Management Information Form See below for indicative Contract and Quality Monitoring System Questionnaire:

Contract & Quality

Management system Monitoring Form_Example.pdf

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Collaborative Commissioning Board

Date of meeting 12th November 2019

Title of paper HLSC Older Peoples Care Home Service Specification

Presented by Steve Thompson, Director of Resources, Blackpool Council

Author Caroline Waddington, Liz Williams, MLCSU

Agenda item

Confidential No

Update

This is the planned second paper regarding the review of the HLSC older peoples care homes service specification which was agreed in principle in August CCB meeting. The original paper was received with the following decisions: Clinical Commissioning Board (CCB) very much welcomed the work that the Regulated Care working group had done in pulling this draft together. In terms of decisions sought: 1. contents of the paper were noted and supported 2. approach to secure collective agreement supported 3. agreed delivery period supported 4. Adele Thornburn was nominated (in her absence) as an appropriate commissioner to

support the process including knowledge of primary care support to be incorporated 5. final version of service spec to return to CCB in Nov or Dec, “the earlier the better” for

planning to implement. Decisions needed from CCB: -

• Agree final draft of the HLSC joint older peoples care home service specification v10

• Agree collective acceptance of the specification across 8 CCGs and 3 Local Authorities (not including Cumbria County Council, as an early version of the service specification is already in place)

• Agree to support the sign off process of the Specification through the partner organisation they represent by March 2020 or identify a named individual within their own organisation to facilitate sign off by this deadline.

• Agree that the service specification must be available to issue alongside the NHS new framework contract from 1st April 2020. The specification will be implemented as contracts become ready for renewal from April 2020 onwards. Blackburn with Darwen Council, Blackpool Council and Lancashire County Council to rollout in line with their contract renewal after April 2020.

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Since August the following actions have taken place:

• HLSC wide survey sent to all care providers via provider forum networks – one response has been received from a collaboration making up approx. 20% of care sector providers, plus a further eleven individual replies.

• HLSC wide service user networks survey– comments from Healthwatch received

• Collation into themes for provider engagement event – all comments from the survey were listed and sent to potential attendees prior and post event.

• Open invitation to a Provider engagement event to discuss specification

• On 23rd September 2019 a provider engagement event took place with 30 care providers, Local Authority representatives, CCG representatives, CQC, NHS England, facilitated by MLCSU.

• Key Themes discussed were: a. Contracts b. Financial impact assessment of the service specification requirements, eg

appointments c. Reviews/audits frequency d. Support wanted for providers – staff training, standardised tools e. Clarity for equipment requests

• All items discussed in the meeting were listed and a response was sent to key stakeholders and sector representatives following the event

• Further amendments have been made to the specification following these engagement activities and actions are being taken to source dependency tools /supervision standards for providers and to review response times to care homes from health colleagues, e.g. referrals into services SALT, mental health etc.

• Version 10 and amendments were sent to all key partners for final review and no further comments received.

2.

HLSC_older_people_care_home_Service spec.v10.doc

Recommendations 12/11/19

1 For CCB to note the contents of the paper and review the final draft of the HLSC

service specification v10 2 For CCB to agree an approach to secure collective agreement and local

implementation of the HLSC service specification in line with contract renewal for older people’s services, through November’s CCB for sign off.

3 To nominate an individual in each CCG/Local Authority to facilitate sign off following appropriate local governance processes, to be completed by March 2020.

4 The service specification must be available to issue alongside the NHS new framework contract on 1st April 2020. The specification will be implemented as contracts become ready for renewal from April 2020 onwards.

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Background - Paper reviewed in CCB 13/8/19

Purpose of the paper

The Regulated Care Workstream – Finance, Markets, Contracts and Procurement Sub-group have agreed a draft Healthier Lancashire and South Cumbria older peoples care home service specification. The collaboration on the work has taken place with colleagues and experts in CCGs, NHSE, Local Authorities, ICS, Trusts and care representatives, this latest draft is currently out for further consideration from care providers and other stakeholders. This paper is to inform the Collaborative Commissioning Board and agree the next steps for the service specification - to ensure there is clear understanding about the purpose of this work, gain commitment and reach agreement on the process for adopting a final version of the specification across the 8 CCGs and Local Authorities, working to a timeline of November/December for a final paper for agreement through CCB. This paper is to set the scope for this work and ask for commitment to the timeline and decisions proposed. Decisions needed from CCB:

1. Note the contents of the paper and support delivery of a HLSC joint older peoples care home service specification

2. Support an approach to secure collective agreement across 8 CCGs and 3 Local Authorities (not including Cumbria County Council, as an early version of the service specification is already in place)

3. Inform and expediate speedy implementation of the service specification within the agreed delivery period.

4. If required for CCB, nominate an appropriate responsible CCB member to support any agreed process.

5. Agree whether a final version of the service specification needs to be returned for final sign off – agree a date in November or December 2019.

Executive summary

Delivery of a Healthier Lancashire and South Cumbria Older Peoples Care homes service specification is guided by the Care Act 2014, NHS long term plan and NHS England Enhanced Health in Care Homes Framework (EHCH). The NHS Long Term Plan includes a commitment to upgrade NHS support to all care home residents. Across Lancashire and South Cumbria there are over 800 providers of regulated care, employing 46,000 staff, equal to the number of staff in NHS and with a considerably larger bed population of 17,000 in care homes alone, far higher than that of acute care, without accounting for the care providers delivering of care in the home. Delivery of MDT approaches in health and care significantly reduce the impact on acute settings. One in seven people aged 85 or over are living permanently in a care home, however evidence indicates many of these people are not having their needs properly assessed and addressed.

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The framework for Enhanced Health in Care Homes (EHCH) is based on a suite of evidence-based interventions, which are designed to be delivered within and around a care home, and which can be applied to all care providers in a coordinated manner to make the biggest difference to recipients of care. The framework identifies seven core elements of the model and how they can be commissioned to deliver joined-up services, one of which is - Joined-up commissioning and collaboration between health and social care.

HLSC’s joint service specification approach is to give clarity and efficiency to HLSC and to providers who would have a common delivery requirement for the same care commissioned by different organisations and a common set of performance indicators, and potentially, harmonised performance monitoring with less duplication of effort.

Other initiatives already rolled out across HLSC include the Contract and Quality monitoring tool to allow HLSC wide sharing of care homes quality data, the Capacity tracker to allow for ease of access to care bed vacancies and the championing of the Data Security and Protection Toolkit (DSPT) to allow personal identifiable information to be shared securely across NHS mail between health and social care partners.

Recommendations

6. For CCB to note the contents of the paper and review the initial draft of the HLSC

service specification v7 – recognising that wider engagement with providers and service users is continuing, with a final version of the specification anticipated to be available as of November 2019.

7. For CCB to agree an approach to secure collective agreement and local implementation of the HLSC service specification in line with contract renewal for older people’s services providers, through one of the following approaches: a) Agree the service specification and processes via this paper, not resulting in

another review in CCB November b) Agree the service specification final paper should be brought to CCB in November

2019, CCB has authority to agree rollout on behalf of all 8 CCGs c) Agree the paper will come to November’s CCB for sign off, followed by individual

CCG/LA sign off and governance processes, to be completed by March 2020 8. For CCB to note that implementation of the service specification must be available

alongside the NHS new framework contract on 1st April 2020. The specification will be implemented as contracts become ready for renewal from April 2020 onwards.

Final_All

Outcomes_Service specv7.doc

Introduction The NHS Long term plan requires delivery of the Enhanced Health in Care Homes Framework (EHCH), one of the seven key elements is: Joined-up commissioning and collaboration between health and social care - Shared contractual mechanisms to promote integration.

The HLSC joint service specification objective is: A single contract specification between health and social care for the same Regulated Care service with the same provider. The aim is to rationalise requirements for care home providers to support the delivery of quality services for the service users in Lancashire and South Cumbria. The service

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specification is an amalgamation of different specifications to a clear single set of requirements to be commissioned irrespective of whether this sits within a Local Authority or NHS contract. Background The need for a Healthier Lancashire and South Cumbria service specification was initially identified in 2017 by the HLSC Regulated Care Workstream to strengthen partnership working and enhance quality as part of a package of collaboration across health and social care across the footprint. Healthier Lancashire and South Cumbria’s Care home service specification has been developed with the aim of simplifying care delivery across health and social care, meaning that the same service standards will be expected from commissioners, irrespective whether they are Local Authority or NHS. The service specification also has the aim of reducing the time needed to spend on administrative tasks and consolidating reporting requirements, allowing for more time to be spent with service users. The EHCH framework applies equally to people who self-fund their care and to people whose care is funded by the NHS or their local authority: everyone has the right to high quality NHS services. The EHCH drives equitable quality provided by each service as designated by commissioners. All the original service specifications from the various organisations across Lancashire and South Cumbria were reviewed and a working group, reporting into the Regulated Care Finance, Markets, Contracts and Procurement Subgroup, was formed to achieve a consensus view and a single amalgamation of requirements. An early decision was made to base the specification on the current Cumbria specification as this was the most recently delivered as part of contract renewal in March 2017 and it was agreed a person-centred outcomes based approach would be best practice. Colleagues and experts from Local Authorities, CCGs, ICS, LCFT, ELHT and NHSE have reviewed each outcome to ensure it reflects the requirements of each organisation. We have shared an early version of the service specification with colleagues from CQC to ensure that the expectations of the service specification are within the requirements of regulatory ‘good’ care. Early iterations of the draft have already been shared with some providers via the Regulated Care Finance, Markets and Contracts and Procurement Sub-group, and the Health and Social Care Partnership, with the latter agreeing to act as a critical friend. A survey has been issued to capture feedback from care providers and the wider system if stakeholders would like to comment further. Healthwatch have agreed to review the specification from a service users’ viewpoint and service user representative groups have been asked to comment via the survey. It is important to note that the service specification is not a contract, this service specification will sit alongside the NHS/ Local Authority contract which will remain the same and continue to set out the local terms and conditions expected from each Local

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Authority or NHS organisation. The service specification will be implemented across Lancashire and South Cumbria in a phased approach in line with contract renewal.

Governance and reporting (list other forums that have discussed this paper)

The work to develop the service specification has been undertaken by a task and finish group consisting of representatives from the four Local Authorities, CCGs and CSU. This group was established under the Regulated Care Finance, Markets, Contracts and Procurement Sub-Group which who report back into Regulated Care Programme group, whose membership contains wider representation across health and social care and provider representation, and which in turn reports into the Healthier Lancashire and South Cumbria governance structure. Governance of the agreement to deliver the service specification lies within each organisation, however all organisations (with the exception of Cumbria) will use the centralised Contract and Quality Management System to monitor performance and quality data. Each Local Authority and CCG will use the HLSC service specification alongside their own contract, which will be rolled out as contracts are renewed.

The work has been ongoing and reviewed in Regulated Care Finance, Markets, Contracts and Procurement Sub-Group meetings since December 2017, in addition to Health and Social Care Partnership, Regulated Care meetings – Programme Group, Quality Sub-Group, Workforce Sub-Group, and care provider forums. Upcoming key delivery dates are as follows:

1. Provider engagement event – September 2019 2. Final service specification available – November 2019 3. CCB agreement of final service specification – November/ December 2019 4. Completion of CCG/Local Authority governance processes – March 2020 5. Implementation of service specification in line with contract renewal – April 2020

Conflicts of interest identified

In the past concerns have been raised regarding working with different requirements from different commissioners. The intention is that it is not a change to the requirements of each organisation, rather it is an amalgamation of different specifications to a clear single set of requirements to be commissioned irrespective of whether this sits within a Local Authority or NHS contract. An early version of the service specification has been shared with colleagues from CQC to ensure that the expectations of the service specification are within the requirements of regulatory ‘good’ care, and have been shared with some providers via the Regulated Care Finance, Markets, Contracts and Procurement group, and the Health and Social Care Partnership, with the latter agreeing to act as a critical friend. The current draft of the service specification is being shared with the provider networks and a provider engagement event will be held in September 2019. A communications and engagement plan has been developed to meet the following objectives

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• To engage and gather feedback from providers, and service users’ representative groups.

• To ensure feedback from the providers is fed into the task and finish group to facilitate changes as appropriate.

• Facilitate the role out of the service specification to the regulated care sector so it becomes business as usual.

• To engage with and keep informed our service users, partner organisations and stakeholders

• Actively engage with providers of care to increasingly demonstrate our decisions are in partnership

With all of the engagement in mind, we do not expect any additional conflicts of interest to arise

Implications

If yes, please provide a brief risk description and reference number

YES NO N/A Comments

Quality impact assessment completed

Y Under review

Equality impact assessment completed

Y https://app-0cx.uassure.co.uk/EIA/EIADetail?id=213

Privacy impact assessment completed

Y No personal details required

Financial impact assessment completed

Y No financial impact required

Associated risks Y See EIA

Are associated risks detailed on the ICS Risk Register?

Y

Lancashire and South Cumbria Safeguarding Arrangements Memorandum of Understanding West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

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WLCCGB 01/20/10



TITLE OF REPORT: Lancashire and South Cumbria Safeguarding Arrangements Memorandum of Understanding

BRIEFING POINTS:

NHS West Lancashire CCG Governing Body received a paper in May 2019 setting out proposals for the three Safeguarding Children Boards, with whom the CCGs are aligned, to be replaced by new arrangements called Safeguarding Partnerships. The Local Authority, Police and CCG have joint accountability for local safeguarding arrangements through the Partnerships. The statutory requirements for Adult Safeguarding Boards remained unchanged.

Under the new arrangements each local authority and CCG remained responsible for fulfilling its own statutory and legislative duties to safeguard and promote the welfare of children. The new arrangements were to be supported by changes in the framework for health commissioning and greater collaboration of CCGs across the ICS area.

Clinical Commissioning Groups are responsible for the provision of effective clinical, professional and strategic leadership for safeguarding, including quality assurance of arrangements through contracts with providers. They are also responsible for securing the expertise of the Designated Professionals. Maintaining these mandated requirements through changes to safeguarding statutory requirements and within the emerging ICS structures and arrangements of CCGs has been essential.

Lancashire and South Cumbria Designated Professionals have been working collectively with NHSE (National and Regional team) to develop a transformational model to meet these requirements. A Lancashire and South Cumbria Safeguarding Health Executive Board (children and adults) has been formed as a mechanism to allow for a collective voice to influence and drive safeguarding decisions and provide representation to the Partnerships. Membership includes NHSE, CCG Chief Nurse’s, Provider Executive Nurse Leads and Designated Nurses for the Lancashire and South Cumbria footprint.

In addition a Collaborative Health Forum within each ICP is to be established to support safeguarding arrangements across wider health partners including Primary Care. The Collaborative Forum will be chaired by the Designated Nurse ensuring connectivity to the Safeguarding Health Executive Board and subsequently the newly formed Safeguarding Childrens Partnerships and Adults Boards.

Under the model the collaborative network of Designated Professionals has been formalised through a hub and spoke model across the ICS/CCG’s/ICP’s with portfolio leadership arrangements for key strategic responsibilities and work streams. This model will facilitate greater flexibility to meet demands including the challenge of working across the geographical boundaries of Lancashire and South Cumbria.


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This model and way of working needs to be underpinned by an ICS Memorandum of Understanding between the CCGs and the Health Safeguarding Executive Board. The Memorandum, attached overleaf, provides assurance to CCGs that their statutory duties and responsibilities for adults, children and looked after children will be maintained under the new arrangements.






4. Delivering Financial Balance – please outline impact




• provide the Commissioning Board with assurance against any ofthe risks identified in the assurance framework (identify risknumber)




3. Health Inequalities


X

5. Clinical Engagement


PAPER PREPARED BY:

PAPER PRESENTED BY:

Lorraine Elliott, Designated Lead Nurse Safeguarding Adults and Mental Capacity Act and Louise Burton, Designated Lead Nurse Safeguarding ChildrenClaire Heneghan, Chief Nurse


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SAFEGUARDING:

MEETING STATUTORY DUTIES AND RESPONSIBILITIES.

A MEMORANDUM OF UNDERSTANDING

Between

BLACKBURN with DARWEN CLINICAL COMMISSIONING GROUP

BLACKPOOL CLINICAL COMMISSIONING GROUP

CHORLEY & SOUTH RIBBLE CLINICAL COMMISSIONING GROUP

EAST LANCASHIRE CLINICAL COMMISSIONING GROUP

FYLDE & WYRE CLINICAL COMMISSIONING GROUP

GREATER PRESTON CLINICAL COMMISSIONING GROUP

MORECAMBE BAY CLINICAL COMMISSIONING GROUP

WEST LANCASHIRE CLINICAL COMMISSIONING GROUP

NORTH CUMBRIA CLINICAL COMMISSIONING GROUP


2

MEETING THE STATUTORY DUTIES AND RESPONSIBILITIES FOR DESIGNATED

PROFESSIONAL FUNCTIONS: A MEMORANDUM OF UNDERSTANDING FOR THE

CCGS

1. PURPOSE

This Memorandum of Understanding sets out the working arrangements across Lancashire

and South Cumbria safeguarding networks to enable the Clinical Commissioning Groups

(CCGs) to meet their statutory and constitutional safeguarding duties and responsibilities for

safeguarding adults, children and looked after children.

This Memorandum of Understanding promotes a clinical collaborative network approach to

safeguarding and in so doing aims to increase the resilience and strengthen the role of the

designated nurse and professional leads whilst enabling greater flexibility to meet existing

demands.

The success of the clinical collaborative approach to safeguarding is Interdependent on the

commitment of the CCGs to:

• Retain accountability for safeguarding arrangements

• ensure that safeguarding is identified as a priority area of work

• support the role and function of the Designated Professionals to deliver portfolio work

streams

• support the development of a single safeguarding team of Designated Professionals

which is aligned to future CCG structures

This MOU will continue to develop as transitional plans are implemented. This will include

developments for safeguarding resource and arrangements across the ICP’s.

2. PERIOD OF THE AGREEMENT

The MOU will commence on XXXX subject to ratification of MOU across all CCG’s.

This Memorandum of Understanding may be terminated by written agreement by any party

giving notice of six months.. Due to the nature of significant transition for safeguarding

arrangements this MOU will be reviewed bi-annually or earlier as needed.

3. PRINCIPLES OF UNDERSTANDING - INCLUDING CCG RESPONSIBILITIES

• The CCG retains accountability for statutory constitutional safeguarding functions and

responsibilities

• It will be the responsibility of the CCG to ensure that the lines of accountability for

safeguarding are clearly demonstrated within their governance arrangements

• Wherever delegated the Executive lead for Safeguarding will represent the ICS, CCG’s

and safeguarding networks with support from the nominated Designated professionals,

for example at the Safeguarding Partnership and Adult Safeguarding Boards

• Each CCG will commit appropriate resource for designated nurses and professional

leads to Lancs and South Cumbria safeguarding network in accordance with the

Intercollegiate Documents and population needs

• Initially designated nurses and professionals leads will continue to be employed by the

respective CCG’s until transition to a single CCG is agreed

• The designated nurses and professional leads will come together as one safeguarding

network to deliver the safeguarding functions in a hub and spoke arrangement across

the ICS/ICP systems.


3

• The CCG’s will be supported by the designated nurses and professional lead’s team to

ensure statutory responsibilities for safeguarding are met

• As part of the safeguarding network and governance therein, the designated nurses and

professionals will have the authority to represent the safeguarding system where

appropriate, and within job role and function.

• Although designated nurses and professional leads are aligned to specific localities they

will work collaboratively and flexibly across the ICS to meet demand, promote resilience

and utilise expertise to ensure maximum efficiencies and effectiveness

• Planned leave and short- term sickness will be accommodated within the network;

longer term absence will be discussed with individual CCGs to determine a resolution.

4. PARTIES TO THE MEMORANDUM OF UNDERSTANDING

This is an agreement between the clinical commissioning groups across Lancashire and

South Cumbria ICS.

BLACKBURN with DARWEN CLINICAL COMMISSIONING GROUP

Signed: …………………………. Designation …………………… Date ……..

BLACKPOOL CLINICAL COMMISSIONING GROUP


CHORLEY & SOUTH RIBBLE CLINICAL COMMISSIONING GROUP


EAST LANCASHIRE CLINICAL COMMISSIONING GROUP


FYLDE & WYRE CLINICAL COMMISSIONING GROUP



4

GREATER PRESTON CLINICAL COMMISSIONING GROUP


MORECAMBE BAY CLINICAL COMMISSIONING GROUP




NORTH CUMBRIA CLINCAL COMMISSIONING GROUP

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

Adoption West Lancashire Partnership Memorandum of Understanding (MOU) West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

1

WLCCGB 01/20/11


DATE OF BOARD MEETING: 28 January 2020 TITLE OF REPORT: Adoption West Lancashire Partnership

Memorandum of Understanding (MOU) BRIEFING POINTS:

A Memorandum of Understanding (MOU) has been prepared that sets out the principles that will govern the way in which the partners to the West Lancashire Partnership ((WLP) will work with each other in the development of the partnership. An MOU is not a legally binding document, rather it seeks to set out how business will be conducted in a partnership.




Yes

The MOU will be considered in the development, implementation and review of WLP Quality Initiatives.


Yes

The MOU will be considered in the development, implementation and review of hospital and community services – as necessary.


Yes

The MOU will be considered in the commissioning and performance management/review of GP prescribing

4. Delivering Financial Balance – please outline impact Yes

The MOU will support the development, implementation and review of services that are designed to promote better working and efficiencies.


Yes

The implementation of this MOU will support the development of the group as a commissioning organisation by ensuring that opportunities to work across the WLP are fully considered when developing and reviewing commissioning intentions .






Yes No Yes

Adoption West Lancashire Partnership Memorandum of Understanding (MOU) West Lancashire Clinical Commissioning Group Governing Body Meeting – 28 January 2020

2

This MOU will support the evolution of the role of the CCG in the community.


No


The policy will support the implementation of initiatives to reduce health inequalities.


Yes

This has been carried out by the MLCSU Equalities Team

5. Clinical Engagement Yes

The policy was considered, supported and recommended for onward ratification by the Governing Body at the Clinical Executive Meeting held on 21st January 2020


Yes

The MOU, if approved, will be added to the CCG’s policy framework and implemented accordingly in public participation and involvement initiatives.


Ruth Fairhurst, Head of Corporate Governance Paul Kingan, Chief Finance Officer and Deputy Chief Officer/ Jackie Moran Director of Strategy and Operations

1

WEST LANCASHIRE PARTNERSHIP

MEMORANDUM OF UNDERSTANDING (MoU)

PROPOSED PRINCIPLES

THE PARTIES TO THE MOU

Parties to the MoU will be the West Lancashire Partnership Executive and Neighbourhood

Partnership Members ‘Parent’ Organisations:

• Lancashire Care NHS Foundation Trust

• Lancashire County Council

• NHS West Lancashire Clinical Commissioning Group

• Primary Care Networks represented by the Clinical Directors for each area (x3)

• Southport and Ormskirk NHS Hospitals Trust (Associate Member)

• Virgin Care

• West Lancashire Borough Council

• West Lancashire Council for Voluntary Services

• West Lancashire GP Federation

• Relevant Neighbourhood Partnership Representatives from each of the three areas –

tbc by each area – not already included (above)

THE PROGRAMME

This MoU covers a period until March 2021 which is referred to as the “shadow

period”. Within this however the West Lancashire Partnership has some underpinning

milestones as the MCP model mobilises and matures. These milestones are that the

Partnership aims to operate in virtual form from Nov 2019 until March 2020. At this point

the Partnership aspires to move into partial form. This will be dependent on testbed

schemes, drawn from the Partnership’s agreed priorities, being ready to allow a testing of

the underpinning clinical, financial and business model. Moving to a “full” state will be

dependent on changes to statute.

The focus will be on integration and innovation in out of hospital health, wellbeing and care.

To deliver this vision the parties to the West Lancashire Partnership will implement the

agreed workstream outcomes as agreed by the Partnership at place (West Lancashire) and

neighbourhood (Ormskirk, Skelmersdale and the Northern Parishes) level.

Each of these workstreams will have attendant work programmes –that will include key

outcomes and outputs, timescales attached to their achievement, governance (decision

making) arrangements (delegated or reserved) and key responsible officers.

2

GOVERNANCE ARRANGEMENTS

Establish a Partnership Board (the West Lancashire Partnership Executive) to oversee both

the ‘place’ level programme and the contribution of ‘neighbourhood’ level workstreams

from Ormskirk, Skelmersdale and the Northern Parishes to the overall West Lancashire

programme.

The West Lancashire Partnership Executive will be deemed to be ‘the West Lancashire

Partnership Board’

The parties may - if there is a unanimous decision to do so – establish a Joint Committee or

Committees to enable delegated decisions (if agreed by each party to this agreement in line

with each organisation’s approved (as amended) Scheme of Reservation and Delegation) to

be taken – if desired - to speed up the implementation of agreed workstream priorities.

The parties agree to respect the legal personality of each member organisation, and their

individual legal duties and obligations according to each organisation’s legal status.

The Parties will each use their reasonable endeavours to work together to meet the

requirements of the Partnership’s workstreams based on the Agreed Principles and in line

with the agreed Timetable.

Each Party confirms that it has not entered into and will not enter into any arrangements or

negotiations with any third party concerning the implementation of the West Lancashire

Partnership or neighbourhood workstreams without the express written consent of the

other Parties. This provision shall be binding on the Parties for the duration of this MoU.

The Parties shall ensure that their officers, employees, agents, advisers and other

representatives comply with the undertakings in this clause.

DURATION OF MEMORANDUM OF UNDERSTANDING

The MoU will remain in force for the duration of the programme.

The MoU will be reviewed at regular intervals and no less than twice per annum by the

Project Board and – as necessary – through the ‘parent’ organisations of each party to this

agreement.

AMENDMENT OF MEMORANDUM OF UNDERSTANDING

The MoU may only be amended if there is a unanimous decision by the parties to this

agreement and – as necessary – through the ‘parent’ organisations of each party to this

agreement.

TERMINATION OF MEMORANDUM OF UNDERSTANDING

The MoU can be terminated at any time during the lifetime of the programme if there is a

unanimous decision to do so by all parties to this agreement.

3

LEAVING THE PARTNERSHIP

If a member organisation deems it necessary to leave the West Lancashire Partnership, this

should be provided in writing to the Chair of the Partnership three calendar months in

advance of the date of the intended leaving date.

This period of notice to quit the partnership will ensure that the West Lancashire

Partnership has sufficient time to understand the consequences of the resignation on the

future sustainability of the programme, and to take all necessary governance decisions to

update the MoU and programme management arrangements; and in exceptional

circumstances, to consider how the partnership should be terminated.

CONFLICT AND DISPUTE RESOLUTION

If a member organisation gives notice to leave the West Lancashire Partnership in the

manner outlined above, or verbalises their intention to do so to the Independent Chair, or

the Interim Managing Director of the Partnership, an independent review meeting will be

offered to the parties to establish the reasons for the intended resignation from the

Partnership, and to establish, using conflict resolution methods, if the resignation can be

avoided, and what reasonable steps can be taken to do so to preserve the partnership

arrangements for the benefit of the communities served.

RISK MANAGEMENT

The West Lancashire Partnership work programme - at place and neighbourhood levels - is

focused upon improving Out of Hospital Care (OOH) to improve community and patient

outcomes by: realigning existing resources and/or redesigning services in a multi-agency

setting (place and neighbourhood) to make the most effective use of partnership resources.

In so doing, the West Lancashire Partnership will develop a risk management strategy to

assess, share and put in place mitigating actions to minimise the risk to the communities

and patients and to members of the West Lancashire Partnership.

SCHEME OF RESERVATION AND DELEGATION

In the 18 months of operation of the West Lancashire Partnership in ‘shadow’ form i.e.,

from September 2019 to March 2021 there will be a presumption that decisions taken to

pursue a course of ‘transformative’ action at the West Lancashire Partnership Executive

and/or at neighbourhood level, will request the approval of each of the parties parent

organisations directly affected by the recommendation before a West Lancashire

Partnership ‘strategic and transformative’ programme of work is considered to have been

approved.

Alternatively, the parties may – as set out above – choose to establish joint committee

arrangements where a clear scheme of reservation and delegation will operate according to

4

the nature of decisions to be taken by parties to the MoU to delegate and reserve defined

decision making powers.

It should be noted that all statutory parties to this MoU will retain overall responsibility for

the discharge of (all) their statutory functions, including those that have been delegated to

joint committee arrangements and outlined in relevant partner organisation’s Schemes of

Reservation and Delegation.

INDICATIVE WORK PROGRAMME

This has been agreed at the West Lancashire Partnership Executive and will be the basis

upon which the West Lancashire Partnership Programme will evolve.

This programme is the basis upon which the partnership has been formed and will be the

central document against which the partnership measures the achievement of its stated

objectives.

Any fundamental amendment to the workstream objectives and outcomes contained in the

Work Programme will require the unanimous approval of the Board (the West Lancashire

Partnership Executive); and/or the ‘parent’ organisations of the West Lancashire Partnership

member organisations as necessary (in accordance with organisational Schemes of

Reservation and Delegation).

The workstreams at ‘place’ level will be strategically focused:

• Collective accountability (governance)

• Financial model

• Communications and engagement

• Care co-ordination and population health management

• Protecting good physical and mental health (behaviour change)

• Stimulate, sustain and innovate around the care sector (care homes and

domiciliary)

• Workforce

• IT enabled

Whereas the workstreams for each neighbourhood will be more locally focused to respond

to neighbourhood priorities (that in turn will contribute to the achievement of place-based

priorities):

• Protecting good physical and mental health (behaviour change)

• Stimulate, sustain and innovate around the care sector

• ‘Grow our Own’ workforce development

• Care co-ordination and population health management

5

THE WEST LANCASHIRE PARTNERSHIP STRUCTURE

The West Lancashire Partnership Executive

The West Lancashire Partnership Executive is the overarching Board for the partnership and

as such will be responsible (in the shadow phase: November 2019 to March 2021) for

overseeing the implementation of the West Lancashire work programme and

recommending transformative changes to services and or/their funding to the directly

affected ‘parent organisations’; or making decisions through a Joint Committee – as set out

above.

The West Lancashire Partnership will be representative of both the ‘place’ (West Lancashire)

and the ‘neighbourhoods’ (Ormskirk, Skelmersdale and the Northern Parishes) therein.

The Neighbourhood Partnerships

Each of the three Neighbourhood Partnerships for Ormskirk, Skelmersdale and the Northern

Parishes will shape neighbourhood proposals to transform the health and wellbeing of the

communities served according to local priorities. The Neighbourhood Partnerships will be

representative of their neighbourhoods and according to local priorities.

The Neighbourhood Partnerships will make recommendations for transformative change in

their communities to the West Lancashire Partnership, and if supported, these will be

decided upon either (a) by reference to the relevant ‘parent’ organisations for approval, or

(b) through a Joint Committee established by the West Lancashire Partnership.

The Primary Care Networks and Clinical Directors

The three Primary Care Networks (PCNs) will each bring together the GP and allied health

community to identify new ways of working to increase capacity in primary care and to

reduce the flow of demand to acute services.

The Clinical Directors of each of the three PCNs will be members of the relevant

Neighbourhood Partnership, and all three Directors will be represented on the West

Lancashire Partnership Board.

The PCNs may also nominate additional network representatives to attend relevant

Neighbourhood Partnership meetings according to local priorities.

SUPPORT TO THE WEST LANCASHIRE PARTNERSHIP

In the shadow period of operation, NHS West Lancashire CCG has agreed to facilitate the

development of the partnership by designating it’s Director of Strategy and Operations as

interim Managing Director of the Partnership, who will be supported by a small team of CCG

staff during that time, and who will oversee multi-agency teams to bring the West

Lancashire Partnership work programme to fruition.

6

It is expected that partners will identify key personnel to take a full and active role in the

partnership at ‘place’ and at ‘neighbourhood’ level to bring about transformative change for

the benefit of the West Lancashire community.

ACCOUNTABILITY AND REPORTING ARRANGEMENTS

The West Lancashire Partnership is a partnership of individual organisations assembling with

a common purpose and focus for that area and the three identifiable neighbourhoods of

Ormskirk, Skelmersdale and the Northern Parishes within it.

The partnership exists through the express approval of its constituent partners (outlined

above), and by implementing changes that are approved through a Joint Committee, or by

recommending a course of action to relevant ‘parent’ organisations.

The representatives of the ‘parent’ organisations represented at various levels of the West

Lancashire Partnership will be accountable to those organisations and will formally report

on the work of the West Lancashire Partnership through the ‘parent’ organisations

governance structure following each meeting of the West Lancashire Partnership.

OVERVIEW AND SCRUTINY ARRANGEMENTS

The work of the West Lancashire Partnership will be subject to the Overview and Scrutiny

arrangements of each partner organisation; and the West Lancashire Partnership will

produce an Annual Report on it’s work and achievements that will be provided to each

‘parent’ organisation which may be incorporated into those organisation’s Annual Reports

and be subject to public scrutiny.

WLP 31/10/19

WLCCGB: 01/20/12


GOVERNING BODY REPORT


TITLE OF REPORT: Freedom to Speak Up policy

Summary of further changes to NHS West Lancashire CCG HR Policies

Policy Reference Recommendation Key Changes (if any)

Freedom to Speak Up HR29 Review in two years or sooner in line with legislation

Further minor change made following approval at Execs on 10 December 2019 Section 6.2 Following a CCG self -assessment audit undertaken by the CCG Safeguarding Lead Nurse for the Safeguarding Boards, a reference has been added to this section with regards to Safeguarding concerns with a link to the Safeguarding Policy posted on the CCG website.

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FREEDOM TO SPEAK UP POLICY

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Document Reference: HR29

Document Title: Freedom to Speak Up Policy

Version: 001

Supersedes: Any previous Whistleblowing Policy

Author: Midlands and Lancashire CSU HR Team

Authors Designation: Midlands and Lancashire CSU Transition HR Policy Lead

Consultation Group: Clinical Executive Committee

Date Ratified: 14 January 2020

Review Date: 5 July 2021

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Table of Contents

1. Speak up – we will listen 4

2. What concerns can I raise 4

3. Feel safe to raise your concern 4

4. Confidentiality 5

5. Who can raise concerns? 5

6. Who should I raise my concern with? 5

7. Advice and support 5

8. How should I raise my concern? 6

9. What will we do? 6

10. Raising your concern with an outside body? 6

11. Communicating with you 6

12. How will we learn from your concern 6

13. Monitoring and Review 7

14. Equality Statement

15. Raising your concern with an outside body 7

16. Making a Protected Disclosure 7

Annex A Process for raising and escalating a concern 9

Annex B: Voicing Your Concerns Record Form 10

Annex C: Equality Impact Assessment 13

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1 Speak up – we will listen

1.1 Speaking up about any concern you have at work is really important. A relevant

concern can relate either within the workplace or externally, in relation to danger,

risk, malpractice or wrong doing which affects others.

1.2 This may be a specific concern regarding some danger, fraud or other illegal or

unethical conduct that affects others, how the CCG delivers its services or how it

affects patient services. It is vital that you know how to speak up as it will help us to

keep improving the working environment for our staff and services for all patients.

1.3 You may feel worried about raising a concern, and we understand this. But please

don’t be put off. In accordance with our duty of candour, the CCG is committed to an

open and honest culture. We will look into what you say and you will always have

access to the support you need.

2 What concerns can I raise?

2.1 You can raise a concern about risk, malpractice or wrongdoing you think is harming

the service we commission. Just a few examples of this might include (but are by no

means restricted to):

• unsafe working conditions

• inadequate induction or training for staff

• suspicions of fraud (which can also be reported to the counter-fraud team)

• a bullying culture (across a team or organisation rather than individual instances of bullying).

• failure to comply with legal obligations

• damage to the environment

• unsafe patient care

• lack of, or poor, response to a reported patient safety incident

2.2 Remember that all employees and workers, including clinical and non-clinical

registered professionals within the NHS have a duty to report a concern under the

circumstances set out in this policy. If in doubt, please raise it.

2.3 Don’t wait for proof. We would like you to raise the matter while it is still a concern. It

doesn’t matter if you turn out to be mistaken as long as you are genuinely troubled.

2.4 This policy should not be used to raise concerns of a personal nature for example

complaints relating to a management decision or matters of individual conscience

where there is no suggestion of wrong doing but an employee or worker is, for

example, required to act in a way which conflicts with a deeply held belief. These

matters should be dealt with using the relevant alternative procedure, for example,

the Grievance Procedure.

3 Feel safe to raise your concern

3.1 If you raise a genuine concern under this policy, you will not be at risk of losing your

job or suffering any form of reprisal as a result. We will not tolerate the harassment

or victimisation of anyone raising a concern. Nor will we tolerate any attempt to bully

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you into not raising any such concern. Any such behaviour is a breach of our values

as an organisation and, if upheld following investigation, could result in disciplinary

action.

3.2 Provided you are acting honestly, it does not matter if you are mistaken or if there is

an innocent explanation for your concerns.

4 Confidentiality

4.1 We hope you will feel comfortable raising your concern openly, but we also

appreciate that you may want to raise it confidentially. This means that while you are

willing for your identity to be known to the person you report your concern to, you do

not want anyone else to know your identity. Therefore, we will keep your identity

confidential, if that is what you want, unless required to disclose it by law (for

example, by the police). You can choose to raise your concern anonymously,

without giving anyone your name, but that may make it more difficult for us to

investigate thoroughly and give you feedback on the outcome.

5 Who can raise concerns?

5.1 Anyone who works (or has worked) in the NHS, or for an independent organisation

that provides NHS services can raise concerns. This includes agency workers,

temporary workers, students, volunteers and governors.

6 Who should I raise my concern with?

6.1 In many circumstances the easiest way to get your concern resolved will be to raise it

formally or informally with your line manager. But where you don’t think it is

appropriate to do this, you can use any of the options set out below in the first

instance.

6.2 If raising it with your line manager does not resolve matters, or you do not feel able to

raise it with them, you can contact one of the following people:

• Quality Chief Nurse

• Financial Matters Chief Finance Officer

• HR or Staffing Matters Head of People Services

• Medicines Management Matters Head of Medicines Management

• Fraud Bribery or Corruption Matters Anti-Fraud Manager

• Maladministration Chief Officer

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Where there is any indication that there could be a safeguarding issue, advice must be sought from the CCG Safeguarding Designated Lead Nurse who will provide guidance and support any agreed action/escalation through the Local Safeguarding Board policies and procedures. The Safeguarding Team contact details are found in the CCG Safeguarding Children and Adult Policy. The CCG’s Safeguarding Children and Adult Policy is available to view on the West Lancashire CCG’s website - here

6.3 If you remain concerned after this, you can raise your concerns through the:

National Director: Transformation and Corporate Operations in the capacity of NHS England’s appointed Freedom to Speak Up Guardian via the email: [email protected] .

6.4 All these people have been trained in receiving concerns and will give you

information about where you can go for more support.

6.5 If for any reason you do not feel comfortable raising your concern internally, you can

raise concerns with external bodies, listed on page 8.

7 Advice and support

7.1 Details on the local support available to you can be obtained by contacting HR

Services on [email protected] or contacting the Freedom to Speak Up

Guardian on [email protected]

7.2 However, you can also contact the Whistleblowing Helpline for the NHS and social

care, your professional body or trade union representative.

8 How should I raise my concern?

8.1 You can raise your concerns with any of the people listed above in person, by phone

or in writing (including email).

8.2 Whichever route you choose, please be ready to explain as fully as you can the

information and circumstances that gave rise to your concern.

9 What will we do?

9.1 We are committed to the principles of the Freedom to Speak Up review and its vision

for raising concerns and will respond in line with them (see Annex B).

9.2 We are committed to listening to our staff, learning lessons and improving patient

care and the services we commission. On receipt the concern will be recorded and

you will receive an acknowledgement within two working days. The central record will

record the date the concern was received, whether you have requested

confidentiality, a summary of the concerns and dates when we have given you

updates or feedback.

https://www.westlancashireccg.nhs.uk/resources/policies-and-procedures/

mailto:[email protected]

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10 Investigation

10.1 Where you have been unable to resolve the matter quickly (usually within a few days)

with your line manager, we will carry out a proportionate investigation – using

someone suitably independent (usually from a different part of the CCG) and properly

trained – and we will reach a conclusion within a reasonable timescale (which we will

notify you of). Wherever possible we will carry out a single investigation (so, for

example, where a concern is raised about a safety incident, we will usually undertake

a single investigation that looks at your concern and the wider circumstances of the

incident). The investigation will be objective and evidence-based and will produce a

report that focuses on identifying and rectifying any issues and learning lessons to

prevent problems recurring.

10.2 We may decide that your concern would be better looked at under another process;

for example, our process for dealing with bullying and harassment. If so, we will

discuss that with you.

10.3 If your concern suggests a Serious Incident has occurred, an investigation will be

carried out in accordance with the Serious Incident Framework.

10.4 Any employment issues (that affect only you and not others) identified during the

investigation will be considered separately.

11 Communicating with you

11.1 We will treat you with respect at all times and will thank you for raising your concerns.

We will discuss your concerns with you to ensure we understand exactly what you

are worried about. We will tell you how long we expect the investigation to take and

keep you up to date with its progress. Wherever possible, we will share the full

investigation report with you (while respecting the confidentiality of others).

12 How will we learn from your concern?

12.1 The focus of the investigation will be on improving the service we provide for

patients. Where it identifies improvements that can be made, we will track them to

ensure necessary changes are made and are working effectively. Lessons will be

shared with teams across the CCG, or more widely, as appropriate.

13 Monitoring and Review

13.1 This policy and procedure will be reviewed periodically by Human Resources in

conjunction with operational managers and Trade Union representatives. Where

review is necessary due to legislative change, this will happen immediately.

13.2 Implementation and operation of this policy will be monitored on an annual basis by

the MLCSU Leadership Team.

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14 Equality 14.1 In applying this policy, the CCG will have due regard for the need to eliminate

unlawful discrimination, promote equality of opportunity, and provide for good relations between people of diverse groups, in particular on the grounds of the following characteristics protected by the Equality Act (2010); age, disability, sex, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic.

15 Data Protection

15.1 In applying this policy, the Organisation will have due regard for the Data Protection

Act 2018 and the requirement to process personal data fairly and lawfully and in

accordance with the data protection principles. Data Subject Rights and freedoms will

be respected and measures will be in place to enable employees to exercise those

rights. Appropriate technical and organisational measures will be designed and

implemented to ensure an appropriate level of security is applied to the processing of

personal information. Employees will have access to a Data Protection Officer for

advice in relation to the processing of their personal information and data protection

issues.

16 Raising your concern with an outside body

16.1 Alternatively, you can raise your concern outside the organisation with:

• NHS Improvement for concerns about: I. how NHS trusts and foundation trusts are being run

II. other providers with an NHS provider licence III. NHS procurement, choice and competition IV. the national tariff

• Care Quality Commission for quality and safety concerns

• NHS England for concerns about: I. primary medical services (general practice)

II. primary dental services III. primary ophthalmic services IV. local pharmaceutical services

• Health Education England for education and training in the NHS

• NHS Protect for concerns about fraud and corruption.

17 Making a ‘protected disclosure’

17.1 There are very specific criteria that need to be met for an individual to be covered by

whistleblowing law when they raise a concern (to be able to claim the protection that

accompanies it). There is also a defined list of ‘prescribed persons’, similar to the list

of outside bodies on page 7 & 8, who you can make a protected disclosure to.

17.2 To help you consider whether you might meet these criteria, please seek

independent advice from:

Speakup.direct - confidential advice service

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Speakup direct (which replaced the national whistleblowing helpline at the end of 2017)

provides free, independent and confidential advice to all staff and contracted workers within

health and social care. While the helpline cannot investigate concerns, it can provide

invaluable advice on whether your concern is indeed whistleblowing and talk you through the

process to ensure it is followed correctly. The helpline is also able to advise on how you can

escalate the concern with a prescribed body if needed.

Telephone: 08000 724 725.

Web: www.speakup.direct/contact-us/

Public Concern at Work.

PCaW is a charity that provides free, confidential legal advice to people who are concerned

about wrongdoing at work and not sure whether, or how, to raise their concern.

Telephone: 020 7404 6609

Web: www.pcaw.org.uk

Email: [email protected]

http://www.speakup.direct/contact-us/

http://www.pcaw.org.uk/

mailto:[email protected]

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Annex A:

Process for raising and escalating a concern

Step one

If you have a concern about a risk, malpractice or wrongdoing at work, we hope you will feel

able to raise it first with your line manager. This may be done orally or in writing.

Step two

If you feel unable to raise the matter with your line manager for whatever reason, please

raise the matter with an individual detailed at clause 6.2 of this policy.

This person has been given special responsibility and training in dealing with whistleblowing

concerns. They will:

• treat your concern confidentially unless otherwise agreed

• ensure you receive timely support to progress your concern

• escalate to the board any indications that you are being subjected to detriment

for raising your concern

• remind the organisation of the need to give you timely feedback on how your

concern is being dealt with

• ensure you have access to personal support since raising your concern may be

stressful.

If you want to raise the matter in confidence, please say so at the outset so that appropriate

arrangements can be made.

Step three

If these channels have been followed and you still have concerns, or if you feel that the matter is so serious that you cannot discuss it with any of the above, please contact the CCG GP Chair. Step four

You can raise concerns formally with external bodies.

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Annex B

Voicing Your Concerns Investigation Summary Template

Voicing Your Concerns Record Form

Stage 1 – To be completed by the Manager receiving the concern

1. Date concern raised/disclosed……………………………………………………....

2. Person receiving the concern

Name…………………………. Job Title………………………………..

Email…………………………. Contact Number………………………

3. How Received: by letter/email date of letter/email…………………….

by telephone date………………. time……………..

by visit date………………. time……………..

anonymous date………………. time…………….

4. Does the person(s) raising the concern agree to reveal their identity? Yes/No

(If yes, individual to sign here)…………………….

5. Individual’s Personal Details (to be recorded only with the person(s)’s consent)

Name………………………... Job Title…………………………….

Dept/Team………………… Organisation……………………….

Contact Number……………. Email Address……………………..

6. Nature and type of concern (the wording of which should be agreed by both the individual

raising the concern and the manager receiving the concern

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………….

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The CCG is committed to achieving the highest possible standards of service for the benefit

of patients, employees, service users and visitors. Where standards are not as expected, we

want to learn and welcome the opportunity to address issues as early as possible and make

improvements swiftly.

The CCG is committed to ensuring that, in accordance with the Public Interest Disclosure

Act 1998, individuals raising concerns will be protected from detrimental or unfavourable

treatment and victimisation.

7. Outcome of initial discussion (to include details of triage and if required referral to

alternative more appropriate policy or senior member of staff)

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………….

8. Details of any relevant litigation relevant to this concern (e.g. breach of Data Protection

Act) …………………………………………………………………………………………

…………………………………………………………………………………………

Step 2 – To be completed by the Investigating Officer

9. Investigating Officer Details

Name………………………….. Job Title………………………. Contact Number………………

Email………………………….. Date of referral………………..

10. Details of agreed actions: Date taken:

At this stage a copy of this record should be emailed to the People and Organisation

Development Team

11. Acknowledgement letter sent to the individual who raised the concern: date……………..

(including expected timescale for completion by the Investigating Officer)

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Findings

12. What has been identified as the principal causes of the concern?

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

13. Is the concern justified? Yes/No

14. Suggestions for Improvements/Changes to Policy or Procedure, including the VFreedom

to Speak Up Policy and Procedure.

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

15. Do you think improvements are justified? Yes/No

If yes, how in your opinion may procedures/systems/policies be reasonably amended?

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………….

16. Are there changes that outside agencies/suppliers could make? Yes/No

If yes, what changes do you recommend/suggest?

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

17. Results of Investigation to individual raising concern informed by letter

Date…………….

Outcome reported to the People and OD Team Date…………….

Outcome reported to the Freedom to Speak Up Guardian Date……………. by People and

OD Team

18. Copy of this form to Monitoring Officer Date…………….

19. Additional Information

…………………………………………………………………………………………

…………………………………………………………………………………………

of 14

Annex C

Equality Impact Assessment

1

West Lancashire CCG Clinical Executive Committee ¶ Action and Notes – 12/11/19

Record of Attendance

Member 30/04/19 28/05/19 11/06/19 18/06/19 25/06/19 09/07/19 30/07/19 20/08/19 17/09/19 22/10/19 29/10/19 12/11/19

Adam Robinson H H H

Claire Heneghan H H H

Doug Soper

Greg Mitten S S S S S

Jack Kinsey H H

Jackie Moran H H

Jo Debacker

John Caine

Mike Maguire H H

Paul Kingan H

Steve Gross

Dheraj Bisarya H

Key

Attendance

Non-Attendance (sickness, holiday, unknown)

Attended meeting/course on behalf of CCG

2

Item Discussion and decisions Action Officer Due Date

Attendees Minutes

Dheraj Bisarya – GP Executive Lead (Chair) Adam Robinson – Secondary Care Consultant Doug Soper – Lay Member Jack Kinsey – GP Executive Lead Jo Debacker – Practice Manager Paul Kingan – Chief Finance Officer Mike Maguire – Chief Officer Steve Gross – Lay Member Greg Mitten – Lay Member Claire Heneghan – Chief Nurse John Caine – GP Chair Jackie Moran – Director of Strategy and Operations Jill Gardner – Administration Officer

Item 1 - Apologies, Roles & Descriptions

No apologies were noted.

Item 2 - Declaration of Interest

The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at Clinical Executive Committee meetings which might conflict with the business of NHS West Lancashire Clinical Commissioning Group. Declarations declared by governing body members are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link: Declaration of Interest

Declarations of interest from sub committees: None declared. Declarations of interest from today’s meeting: Dheraj Bisarya, GP Executive Lead, declared an interest in Item 7, Tier 2 Gastroscopy Service as he knows Dr Sharma both on a personal and professional level. As there would be a financial gain, Dheraj was asked to leave the room for the discussion and the Chair be passed to the Chief Officer for this item.


https://wlccg.sharepoint.com/AdDocs/Meetings/Executive%20Committee/Agendas%20&%20Minutes%202019/03%20%20March%202019/19%20March%202019/Draft%20Minutes%20and%20Action%20Notes%2019%20March%202019.docx


3

Item 3 - AOB Doug Soper, Lay Member, and John Caine, Chairman, provided an update on the Shared Accountable Officer role. A formal interview was undertaken and the panel recommended the position of Shared Accountable Officer be offered to Amanda Doyle, Chief Clinical Officer and Chief Officer, Blackpool and Fylde & Wyre CCG. This position will be shared with Blackpool and Fylde and Wyre CCGs and a Memorandum of Understanding (MoU) has been drafted for consideration between the 3 CCGs. A recommendation for the appointment of Amanda Doyle to this position from January 2020, will be taken to the Governing Body on 26 November 2019 and approval will also be sought Simon Stevens, Chief Executive, NHSE/I.

Strategic and Service Re-design

Item 4 – Risk Management

CCG68 – Replacing Haematology Consultant There are workforce issues around haematology. A consultant at Southport Hospital had left earlier in the year and cover is currently being provided via Aintree Hospital in terms of 1WTE by 2 doctors, however, 1 doctor is due to leave. The Clinical Executive Committee agreed the risk should remain at the current score of 12 and be consolidated with Risk CCG58, Workforce Issues in Hospital. CCG58 – Workforce Issues in Hospital Workforce recruitment and retention are affecting the service provision at Southport Hospital. There are still significant vacancies in the Trust and it is taking time to recruit into these positions. The Clinical Executive Committee agreed for the risk to be amended to include Safety & Resilience as the draft pre consultation business plan does not address these issues. The current consequence is to be raised to 4, therefore the overall risk will be increased to 16.

Item 5 – West Lancashire Partnership MoU

Jackie Moran, Director of Strategy and Operations, invited comments from the Clinical Executive Committee regarding the West Lancashire Partnership Memorandum of Understanding (MoU). Parties to the MoU will be West Lancashire Partnership Executive and Neighbourhood Partnership Members ‘Parent Organisations’.

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The paper has been forwarded to all parties to ask for agreement to work together on the workstreams. The Clinical Executive Committee agreed no changes were required to the paper and for this to be taken to the Governing Body meeting being held on 26th November 2019 for approval.

Paper to be presented to the Governing Body on 26.11.19

Item 6 – Tier 2 Gastroscopy Service

Dheraj Bisarya had declared an interest in this item as referenced above and left the room for the discussion. The Chair was passed to the Chief Officer.

Jo Sephton, Service Redesign Manager, presented the paper on Tier 2 Gastroscopy Service. This paper provided further information following the decision to defer an agreement to extend the Tier 2 Gastroscopy Service at the Clinical Executive Committee on 30th July 2019. The current providers are being supported by Alimentary Solutions with service continuity and succession planning as a clinician delivering the current service is retiring. The scoping equipment currently being used is dated and starting to impact on service delivery. The providers have indicated that the costs for the replacement of this equipment would be absorbed by the provider if the current contract was to novate to Alimentary Solutions. The current providers are requesting a contract term of 5 years as this would ensure service development opportunities are achieved and targets met. At present, the CCG are not currently meeting any of the national endoscopy targets. Further savings could also be met if triage of referrals is implemented. Should the contract novate, the provider has agreed to a flat rate charge of £315 per procedure for gastroscopies and flexible sigmoidoscopy with or without biopsies. After a detailed discussion, the Clinical Executive Committee recommended a 3 year contract. This will be taken to the Governing Body on 26 November 2019 for agreement. All voting members agreed to the above recommendation. Dheraj Bisarya returned to the room and the chair was passed back to him.

Paper to be presented to the Governing Body on 26/11/19 for approval

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Item 7 – Complaints Review

Meg Pugh, Head of Communications and Engagement, presented the Complaints Review Action Plan. An independent external review of the Complaints process was recently carried out by MIAA and based on their recommendations the following actions have been undertaken:

• Recruited a Senior Patient Experience Manager to act as a Single Point of Contact (SPC)

• Created a patient complaint leaflet

• Customer Care training session to be delivered to CCG staff

• Refined timeframes so these are in line with national guidance of 40 days for all complaints

At present Customer Care, Midlands & Lancashire Commissioning Support Unit (MLCSU) are delivering the service for a sum of £11,000 but are requesting an additional amount of £50,000. It was agreed in the meantime, to request further information to justify these costs. After discussion, the Clinical Executive Committee agreed an Option Appraisal looking at costs both internally and externally and would not agree to the increased costs from the CSU at present.

Meg Pugh to request further information to justify increase of costs

Item 8 – S & O subcontract with Renacres for Injections

Jenn Greenhalgh, Senior Finance Manager, updated the Committee regarding the subcontract with Renacres Hospital. There is an outstanding issue around a new subcontract arrangement that Southport Hospital have put in place with Renacres Hospital to start seeing legacy patients for injections. To date, there have not been any West Lancashire patients sent to Renacres from Southport Hospital so InHealth have requested whether this can be stopped with immediate effect, and instead for patients to transfer directly to InHealth. Mike Maguire, Chief Officer, has written to Southport Hospital to request this. It was confirmed these patients would be phased through to InHealth as long as they could definitely provide the capacity for transition. The Clinical Executive Committee agreed to the above and Jenn Greenhalgh is to liaise with InHealth to finalise details.

Jenn Greenhalgh to liaise with InHealth to finalise details

6

E-meeting

Item 9 - Notes from previous meeting 29 October 2019

The notes of the meeting held on 29 October 2019 were accepted as an accurate record subject to an amendment to the wording in Item 2, Declaration of Interest and the wording of the action point in Item 6.

Next meeting The next meeting will take place on Tuesday 19 November 2019, 9.00am - 12.00 noon.

1

West Lancashire CCG Clinical Executive Committee – Actions and Notes – 19/11/19

Key

Attendance Non-attendance (sickness, holiday, unknown)



Member 11/06/19 18/06/19 25/06/19 09/07/19 30/07/19 20/08/19 17/09/19 22/10/19 29/10/19 12/11/19 19/11/19

Adam Robinson H H H

Claire Heneghan H H H

Doug Soper

Greg Mitten S S S

Jack Kinsey H H

Jackie Moran H H

Jo Debacker

John Caine

Mike Maguire H

Paul Kingan H

Steve Gross

Dheraj Bisarya H

2


Attendees In attendance Minutes

Dheraj Bisarya – GP Executive Lead Adam Robinson – Secondary Care Consultant Doug Soper – Lay Member Greg Mitten – Lay Member Jack Kinsey – GP Executive Lead Paul Kingan – Chief Finance Officer Mike Maguire – Chief Officer (Chair) Claire Heneghan – Chief Nurse John Caine – GP Chair Jackie Moran – Director of Strategy and Operations Phil Winnard – Mental Health Lead Kim Williams – Children’s Review Lead Charlotte McAllister – Urgent Care Lead Linda Scales – Administration Officer


Steve Gross – Lay Member Jo Debacker – Practice Manager



Declarations of interest from sub committees: None declared. Declarations of interest from today’s meeting: Greg Mitten declared an interest in agenda item 6 – Interim Plan for the Ennerdale Unit. As Chief Officer of West Lancashire CVS he is aware of the work of the Birchwood Centre, developers of the Ennerdale Project, as they are





3

fellow members of the local VCFSE sector, but he does not have any contractual, financial or governance arrangements with them. The interest was considered significant but not fundamental. Phil Winnard declared an interest in item 6 – Adult AHDD options paper. His wife undertakes work on behalf of Psychiatry UK and this interest was deemed to be fundamental. The Chair agreed that should Phil present the paper then leave the room if discussion ensued.

Item 3 - AOB There was no other business.


Item 4 – Breast surgery within Greater Manchester

Richard Mundon, Director of Strategy and Planning, and Chris Knights, Deputy Director of Strategy and Planning, attended the meeting to present the case for reconfiguration of breast services in Wigan. Richard took the meeting through the previously circulated paper and explained that currently Wigan provides one of only three symptomatic and asymptomatic breast services in Greater Manchester and provides tertiary screens services for South Lancashire. They also deliver services to West Lancashire patients who are GP referred. Currently provision can be withdrawn for West Lancs GP referrals if demand increases in Greater Manchester (GM). By entering into a contract WWL believe they can stabilise and formalise the process of opening up to take GP referrals within a provider and commissioner framework. Richard described how the service currently operates and is delivered and after a detailed discussion which included clinical issues, cancer pathways, safeguards and governance, patient choice, volume and demand for the service, capacity to deliver the service, workforce, contracting with an out of boundary organisation, performance targets, tariffs and investment. Richard concluded that whilst WWL sits on the GM conurbations they have a responsibility to the broader population. Richard confirmed that GM as a whole are looking at technical advance with AI platforms. Mike Maguire, Chief Officer, brought up some operational concerns regarding some orthopaedic patients who are directly referred to WWL by GPs and

4

therefore bypass the joint MSK service. Richard agreed that WWL should not be accepting patients without Joint Health Assessment and if they did so would not be paid for that activity. The discharge pathway in terms of Wigan community services and cross border issues was also raised. Richard agreed to look into these issues. WLCCG agreed to provide further information regarding volume and demand for the breast service and also on the community discharge issues and upon receipt WWL agreed to provide a more detailed proposal for the breast service and a formal response to the community discharge problems and the orthopaedic issues by the end of November.

JM to provide information.

Item 5 – Risk Management Report

Paul Kingan, Chief Finance Officer, presented the Risk Management Report. It was noted that the Risk Register requires updating prior to the Governing Body meeting on 26 November 2019. It was agreed to consolidate Risk CCG68 replacing haematology consultant and the emerging risk of only one consultant within the dietetic service with Risk CCG 58 Workforce issues in hospital . Claire Heneghan, Chief Nurse, is considering the emerging risk relating to the impact of prison and probation guidance on learning disabled patients. It was debated whether the emerging risks commentary was required in the report and it was subsequently agreed to remove this section going forward. It was noted that the Risk Register was subject to continuous review whereas the monthly risk management report narrative was at a point in time and therefore didn’t always reflect the current position. Paul Kingan will pick this up with Chris Brown.

To amend and update the risk report and register prior to Governing Body on 26/11/19 Paul Kingan to discuss with Chris Brown

Item 6 – Update of ADHD services

Jackie Moran, Director of Strategy & Operations, explained that there was a need to understand the direction of travel and content going into the mental health schemes as this would inform decision making in future estates meetings. Phil Winnard, Mental Health Lead, provided a summary of the paper and explained the problems across the Integrated Care System (ICS) and locally. There is a 3 year waiting list for initial assessment within West Lancashire.

5

Interim Plan for Ennerdale

The leap annual assessment process was discussed and questions arose regarding the unfeasibility of the scheme and the problems encountered which has led to the scheme being paused. Pressure on the service includes increasing number of patients requiring assessment, lack of investment, disparity of funding, recruitment and workforce and shared care arrangements. The contract, funding, investment and budgets were discussed in detail. General discussions followed in terms of what other options are available and what the future could bring and the difficulties that people experience living with the condition. Phil spoke about the model and level of consultancy cover and issues affecting ADHD nurses and what it takes to recruit them. It was agreed that Phil would approach the ICS to produce a wider strategic report on the issues at Lancashire level. An update of the interim plan for Ennerdale was shared. It was previously agreed by the Clinical Executive Committee to fund the scheme with £7.5k to give 3 months support to develop a model. The new proposal will benefit the West Lancashire population with a Community Hub based in Skelmersdale providing rapid support. People in crisis often do not have a diagnoseable mental health condition but have significant and immediate needs. The model will be operational 7 days a week with a timetable of interventions including social prescribing, recovery college, support for victims of childhood trauma, substance abuse, debt service, housing issues, bereavement counselling, memory assessment, physical assessment, approved mental health practitioners, citizens advice, pastoral support and bookable rooms made available to other agencies. The proposed model should assist in taking pressure of the acute services. A bid for £120k under winter pressure funding has been applied for which if granted will contribute towards the next 12 months and allow the model to be built up from charitable funds. If this funding was received then the CCG would pas it on to Birchwood. Jackie Moran spoke about behaviour change and how this model could fit in with the MCP and it was agreed that there needs to be a strategic view to ensure that services are integrated and not fragmented.

6

Milestones and gateways

Deferred due to time constraints. To be agenda’s January 2020

Item 7 Children’s Review Provision of Urgent Care Health Hubs

Kim Williams provided a verbal update on the development of children’s review strategy, as follows:

• The long term plan the move towards an MCP have been considered

• West Lancs is an outlier and has a high use of urgent care for paediatrics

• The strategy has to link in with CAMHS and LD services

• Intelligence gained from a questionnaire at the Walk In Centre, Emergency Department and focus groups in Skelmersdale include:

o Data tells us people are self-referring to paediatric ED o Mothers are trying hard not to attend ED but the system forces

them down this route as access to primary care is limited, 111 refer people to ED and the community are working against and establish culture

o Efforts should be focussed in the upstream to prevent attendance at ED

• 2 main concerns for attending paediatric ED are respiratory and gastro

• A respiratory event has taken place and we need to look at getting diagnoses right, how to use treatment and triggers – if conditions are managed properly upstream then people are less likely to attend ED

• There is a lot of joined up work around the correct use of inhalers including teaching parents to use inhalers with children, meeting school nurses, the council are keen to get support workers on board. Input with nurseries is needed

• One of the biggest issues for gastro is the 0-1 age group with feeding problems. There are some incorrect diagnoses and more engagement with health visitors is needed. More work around looking at milk intolerances of the 5 year plus children. We need to look at medicines optimisation and work with allergy networks who have experience and there needs to be buy in across the system from all GPs and health visitors.

• PCNs need to understand what their vision is around children in the future as currently they see less children as they are sucked into ED

Charlotte McAllister, Urgent Care Lead, provided a verbal update on the provision of urgent care hubs. As the committee are aware there is national mandate to move from Walk-in centres to Urgent Care Health Hubs.

7

Various options are being considered for the Walk-in Centre in Skelmersdale and further consideration needs to take into account the Children’s Strategy, currently under development, in terms of using the walk-in as a potential resource for children, however, adults will also use the centre. Discussion followed around different scenarios for the new model and on what the focus could and should be and how culture change is influences to reflect provision of future services. Jackie Moran questioned how do we get from where we are now to where the future vision is. We need to understand the current and future demographics and ensure the estates strategy is informed. It was agreed more engagement was need before the new model can be developed and CCG officers will undertake a scoping exercise to get a feel for what is needed.

Item 8 – IBR Paul Kingan commented that there are some strong messages within the IBR of heading towards a deficit and still showing a breakeven position in line with national guidance. He confirmed that budgets aren’t massively overspent and it’s the shortfall in QIPP, pressure on prescribing and the arbitration result that will contribute towards the deficit. Planned and unplanned care performance remain steady. It was agreed to drill down into the RTT 18 week target to understand the slippage.

E-meeting

Item 9 - Notes from previous meeting 29 October 2019

The notes of the meeting held on 12 November 2019 were accepted as an accurate record subject to amendments at Item 3 – AOB relating to the phrasing of the recommendation to appoint Amanda Doyle and Item 6 Tier 2 Gastroscopy Service removing the sentence “with a 2 year extension to comply with relevant guidelines”.

Next meeting The next meeting will take place on Tuesday 10 December 2019, 10.30 - 12.00 noon.

1


Key




Member 18/06/19 25/06/19 09/07/19 30/07/19 20/08/19 17/09/19 22/10/19 29/10/19 12/11/19 19/11/19 10/12/19

Adam Robinson H H H

Claire Heneghan H H H H

Doug Soper

Greg Mitten S S H

Jack Kinsey H H

Jackie Moran H H

Jo Debacker

John Caine

Mike Maguire H

Paul Kingan H

Steve Gross

Dheraj Bisarya H

2



Dheraj Bisarya – GP Executive Lead (Chair) Adam Robinson – Secondary Care Consultant Doug Soper – Lay Member Jack Kinsey – GP Executive Lead Paul Kingan – Chief Finance Officer Mike Maguire – Chief Officer John Caine – GP Chair Jackie Moran – Director of Strategy and Operations Steve Gross – Lay Member Jo Debacker – Practice Manager Carol McCabrey – Senior Service Redesign Manager Becky Cope – Project Officer Adelle Halksworth – Contracts Manager Linda Scales – Administration Officer


Greg Mitten – Lay Member Claire Heneghan – Chief Nurse



Declarations of interest from sub committees: None declared. Declarations of interest from today’s meeting: None declared.

Item 3 - AOB There was no other business.





3


Item 4 – Risk Management

CCG66 – WLP Development Jackie Moran, Director of Strategy & Operations, updated the meeting on whether establishing the WLP detracts from manging the risk of delivering the CCGs statutory requirements and targets. The risk was entered on the register in January and has been monitored since. There is a feeling that the behaviour change workstream is rather slow due to its complexity and the WLP agenda is a little cumbersome. The aim is to achieve partnership buy in so that all organisations take ownership of the current workstreams. There was hypothetical discussion around the outcome of the general election and how the result could affect the work of the CCG. The aim is to continue to work with our partners developing joint workstreams and reduce the current risk score of 12 to the target of 8 by March next year. The CCG must deliver on what we have to do and can’t compromise on lines of accountability. CCG07 – Failure to Deliver Service Priorities Paul Jones, Head of Finance, updated the meeting regarding the risks in failing to deliver service priorities. There are some QIPP schemes which are more successful whilst other schemes take longer to deliver. It should be noted that barriers included capacity to push through schemes and PMO needs streamlining so that only relevant, achievable QIPP schemes are open. Jackie suggested bringing a proposal back to Clinical Execs next year on selected QIPP priorities once a clear vision has been established, which will need clearly feeding up to NHSE as they will expect all QIPPS to be met.

Bring QIPP priorities to CEC next year

Item 5 – Lymphoedema Update Management Report

Carol McCabrey, Senior Service Redesign Manager, explained the current pathway for lymphoedema patients. She tabled data for children and adults registered within West Lancashire who are accessing the service. Her aim is to update the Committee around the current provision and contract and ask for advice to recommend a way forward.

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After the community tender process this service now sits with LCFT. The CCG is receiving requests to fund treatment, although this should already be covered via the contract with LCFT. Carol has spoken with Jimmy Brash, Director of Care, St Catherine’s Hospice, who deliver the service, and there are discrepancies as their activity is not marrying up to IFR referrals. The main referrers for adults are specialist nurses and GPs so there are issues with the pathway. The service at St Cath’s is under pressure and there are issues with equipment that is not ideal for non-cancer related patients with a requirement for £8k to address this. There are also staffing concerns in terms of turnover. Adam Robinson, Consultant, spoke about the clinical issues surrounding treatment of lymphoedema. General discussion then followed around how referrals are made and the funding for this cohort of patients. It was agreed to unravel and unpick the funding stream to identify where this money sits as it should have moved with the service. Carol confirmed that St Cath’s were pleased to have the discussion as they are concerned about financial resources to continue delivering care to local residents. Carol stated that Woodlands and Marie Curie have served notice on their lymphoedema schemes which adds further pressures to St Cath’s. It was agreed to unpick the funding stream and then bring back recommendations in January 2020.

Paul Jones to unpick the funding stream and then Carol McCabrey to present recommendations to CEC in January

Item 6 – POD Update

Jackie Moran, Director of Strategy & Operations, provided an update on the POD. Dheraj Bisarya, GP Lead, referred to a recent letter circulated to practices and explained how they felt it was inappropriate to give such short notice to service changes which affect practices. A meeting has now been arranged for 17 December 2019 with Claire Heneghan, Chief Nurse, and the Skelmersdale practices. Jackie has already meet with the practices.

5

A live action plan has been developed which is constantly updated. The quick win actions are now complete, resulting in better staff morale. There is a fundamental issue with the Memorandum of Understanding with inequitable offers to practices which needs to be addressed. Intermittent issues with the phone lines remain. However, in the short term, it is business as usual. Communications regarding Christmas arrangements will shortly be circulated. Patients need to be encouraged to use patient access, electronic prescriptions and dedicated pharmacies. Jo Debacker confirmed that, pre POD, certain practices hadn’t operated a telephone system for ordering prescriptions in 10 years. The initial set up of the POD was discussed along with accountability and alternative options of provision. Future developments and solutions should be in collaboration with the Federation and Officers of the CCG and recommendations will be brought back to Clinical Execs in due course.

Recommendations to be brought back to CEC in due course

Item 7 – 3rd Sector Investment

Jackie Moran, Director of Strategy & Operations, provided an overview of the two circulated papers: 1. Annual Contract Review of Third Sector Services 2 Annual Review of Social Prescribing and West Lancashire Carers She confirmed that the paper 2 had not been circulated to Greg Mitten, Lay Member, due to a conflict of interest. Jackie asked the Committee to consider the papers and any questions would be addressed at the next Clinical Executive Committee meeting to be held on 17 December 2019. If it was recommended, Services would require a 3-month termination period. Jackie highlighted:

• The work undertaken to produce the reports.

• It is anticipated most contracts will be extended and increased by the inflation rate.

• Previous ICS MH winter monies funding is shown.

6

• Stroke Association – note the increase and also note that a separate business case for community stroke services is being developed.

• Acacia Counselling – low use of service.

• Pulse – 25k from MH winter monies.

• Crossroads activity going down. It was noted that an end of life review is being carried out – the recommendation is to extend for 3 months only.

Actions:

• Queens Court - look at level of reserves in the accounts for last year.

• Provide an update on where the £100k community funding has been committed and assurance that the money is being used effectively.

• Identify how much activity the Stroke Association will provide for early supportive discharge process.

Social Prescribing and West Lancs Carers Report The recommendation is to integrate delivery of the adult carers, social prescribing and PCN social prescribers and have one scheme. It was suggested to bring Greg Mitten into future discussions, but not be able to vote.

Papers to be amended to reflect the actions for meeting on 17.12.19 Questions at CEC on 19.12.19

E-meeting

Item 8 – HR29 Freedom to Speak Up Policy

The policy was recommended for ratification.

Recommended for ratification at the next Governing Body meeting

Notes from previous meeting 19 November 2019

The notes of the meeting held on 19 November 2019 were accepted as an accurate record subject to amendments as follows:

• Item 7 – last paragraph replace “Jackie Moran” with CCG officers.

• Item 6 – Milestones and gateways – Action: agenda in New Year. Item 4 – WWL - Mike Maguire will make contact for update.

Agenda for early 2020 – Phil Winnard Mike Maguire

Next meeting The next meeting will take place on Tuesday 17 December 2019, 10am - 11.30am at West Lancs College, Skelmersdale.

1


Key




Member 25/06/19 09/07/19 30/07/19 20/08/19 17/09/19 22/10/19 29/10/19 12/11/19 19/11/19 10/12/19 17/12/19

Adam Robinson H H H

Claire Heneghan H H

Doug Soper

Greg Mitten S H H

Jack Kinsey H H

Jackie Moran H H

Jo Debacker

John Caine

Mike Maguire H

Paul Kingan H H

Steve Gross

Dheraj Bisarya H

2



Dheraj Bisarya – GP Executive Lead Adam Robinson – Secondary Care Consultant Doug Soper – Lay Member Jack Kinsey – GP Executive Lead (Chair) Paul Kingan – Chief Finance Officer Mike Maguire – Chief Officer John Caine – GP Chair Jackie Moran – Director of Strategy and Operations Steve Gross – Lay Member Jo Debacker – Practice Manager Carol McCabrey – Senior Service Redesign Manager Sarah Derbyshire – Strategic Lead for Transforming Care and Complex Cases Lead Phil Winnard, Mental Health Lead Adelle Halksworth – Contracts Manager Becky Cope – Project Support Officer Linda Scales – Administration Officer


Greg Mitten – Lay Member Paul Kingan – Chief Finance Officer



Declarations of interest from sub committees: None declared. Declarations of interest from today’s meeting:

Dr Kinsey, Dr Bisarya and Jo Debacker declared an interest in Item 7 Social





3

prescribing as the GP Federation, of which their practices are members, retains the overall responsibility for the contract. The interest was deemed significant but not fundamental. They were allowed to listen and contribute to the discussion but not vote.

Item 3 - AOB Estates The WLP meeting scheduled for 7 January 2020 has been cancelled and it was therefore agreed to hold a Clinical Executive Committee meeting on this date to discuss the strategic review of estates and infrastructure opportunities prior to the Programme Board Meeting in January 2020. Update on organisational structure Jackie Moran, Director of Strategy and Operations, confirmed she had spoken with Amanda Doyle and had provided her with the current structure and explained roles and responsibilities. Amanda Doyle was happy with the information and further information on running costs and allowances will be provided. Conversations continue with HR in terms of structure and roles.

LS to circulate diary invite


Item 4 – InHealth Hospital Transition Proposal

Carol McCabrey, Senior Service Redesign Manager, attended the meeting to update the Committee on the transfer of legacy patients from Southport and Ormskirk Hospitals (S&OH) and to seek agreement on the most appropriate pathway to progress this cohort of patients. S&OH have pressures and are struggling to recruit any anaesthetists and want to divest themselves of the pain legacy patients. There are two pathways available, one via Renacres Hospital and the other directly to InHealth Pain Management Service (IPMS). The financial implications of both pathways were discussed and whilst costs are sunk there could be higher additional costs incurred from Renacres for further procedural treatment in contrast to those incurred by IPMS. There are 321 legacy patients, however, all organisations are querying this number. Carol confirmed that this activity was included in the initial contract so we are not exceeding any ceiling. InHeath are willing to triage and read through patients notes to ascertain how many patients will actually need treatment and incur a cost and any costs will

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be dripped as patients are seen. Locations for surgeries are also being explored to increase capacity. Mike Maguire, Chief Officer, suggested the new Ophthalmology Unit in Skelmersdale could be a suitable site. The Clinical Executive Committee confirmed their preferred option is to approve the shift of legacy patients to IPMS directly thus avoiding potential additional costs associated with the Renacres Hospital pathway.

It was agreed to use IPMS for legacy patients

Item 5 – Risk Management Report

Jackie Moran, Director of Strategy and Operations, confirmed that there had been little change to the Risk Management Report since the previous month. There was discussion around Brexit in terms of the possibility of the risk increasing in view of the result of the general election. However, it was agreed the risk remains the same until there is government activity. Claire Heneghan, Chief Nurse, and Sarah Derbyshire, Strategic Lead for Transforming Care and Complex Cases confirmed that the risk relating to the MM judgement remains financial. A legal challenge could result in WLCGG being liable to fund a resident in a hospital bed and also in a community placement. The CCG and local authority have agreed to request an interim order to request an independent assessment. An outcome of the independent assessment should be available by April 2020. Doug Soper, lay member, queried how double funding could be possible to which Claire confirmed the legalities around the MM judgment.

Item 6 – Community Paediatric Service

Sarah Derbyshire took the Committee through her previously circulated report which seeks to explain the risk due to the Community Paediatric services being under immense pressure. The 0.6 wte consultant post has been advertised twice and failed to recruit. The service is beginning to see improvement, with a locum in post and the cost is being funding from slippage. However, this is not sustainable long term as the cost of funding a locum is excessively high. The measures put in to address the problems have improved the situation:

• overdue health assessments for looked after children have improved

• 1.5% decrease in prescribing of melatonin and a 4% decrease in cost reduction over the past 5 months.

• 7.7% decrease in prescribing from the paediatric clinics

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• Twinkle House sleep clinic is preventing referrals and reducing prescribing

Sarah confirmed the recruitment of paediatric consultants is a national pressure. In terms of filling the vacancy, other staff grade options were discussed including staff grade doctors and specialist nurses. Sarah stated it is critical to maintain the services to comply with our statutory obligations and which is also key to the SEND review. Steve Gross, Lay Member, requested numbers to support the percentages to get a better understanding of the improvements. Further discussion ensued around the positive impact of Twinkle House, recruitment, finances, staffing, conditions of funding, current caseload and withdrawal of services. The Clinical Executive Committee requested that a full report including:

• full financial implications

• numbers against percentages to understand improvements

• clearly detail all statutory requirements; and

• clarification why it’s a “must” This will then be considered within the budget book alongside all other financial considerations and commitments at the Finance and QIPP meeting. Claire Heneghan reminded the meeting this service is a statutory requirement. It was agreed the risk would remain as is on the Risk Register.

More detailed report to be presented at Finance & QIPP meeting

Item 7 – 3rd Sector Investment

Jackie Moran, Director of Strategy & Operations, brought back the reports, submitted at the Clinical Executive Committee the previous week: 1. Annual Contract Review of Third Sector Services 2 Annual Review of Social Prescribing and West Lancashire Carers The Committee discussed and reviewed each contract and the outcomes are noted as follows: Alzheimer’s Society - £110,486 The Clinical Executive Committee agreed to recommend to the Governing Body to defer the decision to approve the continuation of the service pending

Deferred until January 2020

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further information on performance data to demonstrate value for money and the extent of the service received in West Lancashire compared to consistency of provision with other CCGs in the region. Information on operating reserves and a service specification will be obtained. Crossroads Care North West - £40,394 The Clinical Executive Committee agreed to recommend to the Governing Body to extend the service for three months from April 2020 within the current funding envelope for 2019. This will tie in with the end of life review at the end of February 2020. Queenscourt Hospice - £100,000 The Clinical Executive Committee discussed and agreed to recommend to the Governing to maintain the current level of funding for Queenscourt Hospice for one year at £100,000 from April 2020. Stroke Association - £8,087 The Clinical Executive Committee are aware that the current stroke service model is under review as a priority identified in the NHS Long Term Plan. A range of proposals have been offered by the Stroke Association which will form part of a business case for an Integrated Community Neurorehabilitation Service (ICNS) for West Lancashire. The Clinical Executive Committee therefore agreed to recommend to the Governing Body to roll-over to 2020 the financial commitment of £8,087 to contribute towards the cost of the ICNS. West Lancs Counselling Service - £22,060 The Clinical Executive Committee agreed to recommend to the Governing Body to maintain the current levels of funding for the Bereavement Counselling service for two years at £22,060.50 from April 2020. Acacia Counselling This scheme commenced in August 2020 for 1 year and figures are not yet available. The Clinical Executive Committee agreed to recommend to the Governing Body to agree to await activity data but consider this service whilst making decisions on the other services.

pending further information

Agreed to extend for 3 months within current funding Agreed Agreed to roll-over funding Agreed Noted

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Palliative and End of Life Care Funding The Clinical Executive Committee agreed to recommend to the Governing Body that delegated authority not be granted and that any recommendation to use monies from the £51k allocation is brought back to the Clinical Executive Committee to consider within the budget book for palliative and end of life care funding. Pulse. The Clinical Executive Committee were asked to note that the bid for £10k of winter pressure funding has been secured for Pulse. Social Prescribing and West Lancs Carers As noted earlier (Item 2), Dr Jack Kinsey, Dr Dheraj Bisarya and Jo Debacker declared an interest in this time and did not take part in the decision making. Dr Kinsey passed the chair to Mike Maguire. The social prescribing service has been running as a pilot in Skelmersdale since April 2018. The GP Federation retains the overall responsibility for the contract. The data provided demonstrates the success of the service and the intention is to roll out the social prescribing service across the whole of West Lancs. Jackie reported that an integral part of the PCN contract allows each PCN to recruit a social prescribing link worker which means by the end of year 5 there could be as many at 15 social prescribers. The PCN Clinical directors have indicated they are willing to include these workers in the social prescribing service as it is rolled out across West Lancashire to make it a rounder service. West Lancs Carers Service has evolved and more recently has been working closely with the Social Prescribing service. Both services are delivered by WLCVS and they have provided costings to run an integrated service for 2020/21. It was agreed that more detailed financial information was required and further meetings have been arranged to understand the scope of the integrated service.

Delegated authority not granted Noted

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Whilst it was agreed that there is definitely a benefit to patients who use social prescribing, there is currently no evaluation or feedback mechanism in place to evidence this. It was agreed to bring back a more detailed report to support the proposal to integrate the services. Mike Maguire passed the Chair back to Dr Kinsey.

A more detailed report to be produced on integrating the services

Item 8 – Ennerdale Proposal

Phil Winnard, Mental Health Lead, reported that the bid for mental health winter monies in the sum of £120k had been successful and the funding secured. This funding will enable the set-up of Ennerdale Community Hub to provide crucial support for people in crisis. The service is now being mobilised at speed. Discussions ensued in relation to the set up and operation of the hub and the other agencies that will be providing services.

The Clinical Executive Committee recommended agreeing payment terms for the service with the Chief Finance Officer and confirmed their recommendation that that the funding is ring fenced for this particular mental health service.

E-meeting

Notes from previous meeting 10 December 2019

The notes of the meeting held on 10 December 2019 were accepted as an accurate record.

Next meeting The next meeting will take place on Tuesday 7 January 2020 9am – 12pm.

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Key




Member 09/07/19 30/07/19 20/08/19 17/09/19 22/10/19 29/10/19 12/11/19 19/11/19 10/12/19 17/12/19 07/01/20

Adam Robinson H H H

Claire Heneghan H

Doug Soper

Greg Mitten H H

Jack Kinsey H H

Jackie Moran H H

Jo Debacker

John Caine

Mike Maguire

Paul Kingan H H

Steve Gross

Dheraj Bisarya H

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Amanda Doyle – Accountable Officer Dheraj Bisarya – GP Executive Lead (Chair) Adam Robinson – Secondary Care Consultant Claire Heneghan – Chief Nurse Doug Soper – Lay Member Jack Kinsey – GP Executive Lead Paul Kingan – Chief Finance Officer Jackie Moran – Director of Strategy and Operations Steve Gross – Lay Member Jo Debacker – Practice Manager Greg Mitten – Lay Member George Hurst – Estates Lead Karen McNally – Administration Officer


John Caine – GP Chair



Declarations of interest from sub committees: None declared. Declarations of interest from today’s meeting: Dr Bisarya and Jo Debaker declared an interest in Item 4 Estates Schemes, since they are situated in buildings affected by the schemes. There is an indirect financial interest due to the likely increase in revenue to fund the schemes. It was agreed that the role of chair be transferred to Dr Jack Kinsey





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for this item who decided that the interests were significant but not fundamental. Dr Bisarya and Jo Debaker are allowed to listen, contribute and vote in the discussion. George Hurst declared his employment with Bolton CCG who have been appointed as the preferred partner for the ICS. The role does not impact on any decision related to item 4 but is declared for reasons of transparency.

Item 3 - AOB It was advised that detailed notes for item 5, Chairs Role, will be used for feedback to the Primary Care Network membership meeting later today. Jackie Moran highlighted the urgent need for a decision regarding Social Prescribing. The service and its costs have suffered from a lack of clarity regarding the source of future funding. There is concern that staff will move onto new opportunities if the situation is not resolved. Jackie Moran will share a paper detailing the costs with John Caine and Paul Kingan. The Clinical Executive Committee agreed to delegate the decision about the future of the service to the Primary Care Commissioning Committee.

Share costs for Social Prescribing with John Caine and Paul Kingan Present the Social Prescribing paper to the Primary Care Commissioning Committee

Jackie Moran Jackie Moran

Operational

Item 4 – Update on Estates Schemes

George Hurst, WLCCG Estates Lead provided an update on the estate schemes and aims for the next 12/24 months. It was highlighted that it has been difficult to define future requirements due to the fragmented way in which requests are currently received. As a result, some assumptions have been made and the risks measured. The implementation plan for 2019/20 was shared. It was noted that the sustainability review of Southport and Ormskirk Hospital Trust presented some challenges. Key dates of note include;

• Local asset review completed October 2019

• Capital bids for Ormskirk, Skelmersdale and Birleywood submitted in Lancs and Cumbria December 2019

• High level estate plan for submission to NHSE by March 2020

• Full estates and infrastructure plan by Summer 2020 It was acknowledged that capital allocation has been difficult over the past 18 months both at local and national levels. However, governance and systems

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are now in place for teams to respond and move projects forward. Project teams are established for Birleywood, Skelmersdale, Ormskirk, Burscough and Tarleton. Utilisation reviews are ongoing, and utilisation has increased in all buildings. Currently there is no system in place for monitoring room bookings. A pilot booking system is to be trialled at Sandy Lane Health Centre from February/March 2020 which, if successful, will be useful in the future. It was noted that investment in a bigger system to include community buildings, etc would be necessary in the future if VOID space is to be reduced. Revenue to work on the hubs has been received from Lancashire and South Cumbria. External firm Rider Levett and Bucknall have been reviewing capacity requirements for Ormskirk and Skelmersdale and conversations have taken place with GP’s to determine practice needs. A review of the North will commence in late January 2020. Additional areas such as demographic changes and housing growth have also been fed into room requirements. A series of workshops have taken place for the Local Asset Review which has provided a good baseline of resources. The review includes both clinical and non-clinical space. The detail will be fed into the estate strategy for the next 5 years. It was advised that a mechanism to identify future need is required. The WLCCG estate scheme status was reviewed. It was noted that resources will be required to support implementation of the schemes. Talks are taking place with Lancashire and South Cumbria estates team to determine support available for WLCCG. The PID for Birleywood is completed with Option 1 the preferred model. Six possible developers have been identified. The procurement route will be set out and brought back to the Clinical Executive Committee in due course. It was stressed that this is not a PFI contract. Maintenance charges and adhoc changes to the building can be amended under the scheme by the facilities management provider. The Clinical Executive Committee agreed to approve the PID. Work is ongoing with West Lancashire Borough Council (WLBC) in relation to the Primary Care Hubs. A capacity review has been carried out by external consultants Rider Levett and Bucknall and the information is currently with the architects for costing. The schedule of accommodation has been agreed with

Procurement route for Birleywood PID to be presented to the Clinical Executive Committee

George Hurst

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all GP’s in Ormskirk. A decision regarding the Skelmersdale hub has yet to be reached. The Clinical Executive Committee discussed the possible options and agreed to endorse option 7, Walk-in-Centre with additionality. It is not possible for WLCCG to formally commit to the Primary Care Hub scheme before the Final Business Case which presents a considerable risk to WLBC. WLCCG are examining this in detail to see how the risk can be minimised. Ultimately the decision to proceed in partnership on the scheme lies with WLBC. A meeting to discuss red line issues will take place with WLCCG and WLBC on 10.01.20. In summary, the Clinical Executive Committee agreed to;

• Proceed with the PID for Birleywood

• Continue with the Primary Care Hub scheme for Ormskirk

• Consider options for the Primary Care Hub scheme in Skelmersdale

Proceed with Birleywood PID Continue with Ormskirk Primary

George Hurst George Hurst

Strategic

Item 5 – Chairs Role

The Clinical Executive Committee confirmed they had read the ‘Recruitment of CCG Clinical Chair’ paper ahead of the meeting. The document detailed the options available following the unsuccessful appointment of the CCG Clinical Chair. The current chair tenure will expire on 31.03.20. The GP executive leads advised that colleagues had reported issues with the voting process due to the LMC change from postal to electronic correspondence. It was agreed that this should be discussed at the Membership council meeting in the afternoon. The Clinical Executive Committee highlighted the importance of the role of the chair and suggested that the Membership be asked to consider keeping the current chair in post until 31.03.2021. Recruitment of the 2 GP Clinical leads was also discussed considering the current financial position of the CCG. Dr Amanda Doyle will lead a discussion with the Membership Council in the afternoon to consider if this should go ahead.

Discuss recruitment of the CCG Clinical Chair at the Membership Council Discuss recruitment of the 2 GP Clinical leads with the Membership Council

Chris Brown Amanda Doyle

Next meeting The next meeting will take place on Tuesday 14 January 2020 10am – 12pm.

West Lancashire Clinical Commissioning Group Audit Committee – 3 December 2019 Page 1 of 5

Minutes DRAFT

Meeting Title: West Lancashire Clinical Commissioning Group Audit Committee

Date: Tuesday 3 December 2019

Time: 2.00 – 4.00 pm Venue: Boardroom, Hilldale, Wigan Road, Ormskirk

Present: Douglas Soper, Lay Member (Chair) Greg Mitten, Lay Member Dr Adam Robinson, Secondary Care Doctor

In attendance Paul Jones, Head of Finance Paul Kingan, Chief Finance Officer Ann Gregory, Anti-Fraud, MIAA Fiona Hill, Internal Audit, MIAA Sandra Cudlip, Internal Audit, MIAA Alex Walling, External Audit, Grant Thornton Andy Smith, External Audit, Grant Thornton Cathy Ashcroft, Executive Assistant

Apologies: Dr Jack Kinsey, GP Executive Lead Claire Heneghan, Chief Nurse

Agenda

Item Summary of Discussion Action

1. Welcome, Introductions and apologies for absence Doug Soper welcomed all present to the meeting of the Audit Committee. Apologies were noted as above.

2. Declarations of interests Doug Soper reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of West Lancashire CCG. Declarations declared by governing body members are listed in the CCG’s Register of Interests. The register is available either via the secretary to the governing body or the CCG website at the following link: Register-of-interests-Governing-Body-members-March-2019.pdf

No declarations of interests were raised at the meeting.

3. Minutes from the previous meeting The minutes of the meetings held on 3 September were approved as a correct representation of the discussions.

4. Matters arising The action sheet was updated. Paul Jones was asked to recheck IR35 compliance when further work is awarded to suppliers.

5.

Assurance framework and risk register The report for November was presented at the Governing Body meeting on 26 November. There is a total of 23 risks, with 16 risks scoring 12 or more. Seven of the risks are rated red. CCG71 Concerns regarding the POD – this is the highest scored risk (20) and has been subject to much discussion in the CCG. Claire Heneghan is leading on the action plan and operational arrangements are being bolstered. The




issues include staff training, sickness, safety and governance. The operating procedures have been improved and more staff recruited. Once the issues are resolved there is a plan to move to the service to a provider organisation within primary care. CCG42 In year financial balance – this is on the agenda. CCG51 CHC patients receiving domiciliary care – this is a Lancashire-wide risk relating to the timeliness of reviews. Jerry Hawker is leading on this work and a plan will be implemented very soon with approximately 12 months to complete. There are approximately 150 packages for West Lancashire CCG excluding nursing care. CCG69 Acute mental health – the risk relates to the flow of patients through the system and some patients being placed out of the area. There is an action plan, which ties with the Northumberland Tyne and Wear NHS Trust review. CCG44 Acute Trust Performance – this risk captures finance, performance and safety issues at the Trust. The risk will not be resolved until after the reconfiguration of the two hospital sites, but the CCG will continue to support the Trust. CCG65 Brexit – this will be discussed after Purdah. CCG58 – Workforce issues at the Trust. Concern was expressed for the financial risks across the country. It would seem some organisations receive allocations eg finance recovery fund, and that there is net risk in the system not yet apparent. NHS England /Improvement are looking at the wider risk and in the next quarter the financial positions will be clearer. The auditors were asked if they were seeing more organisations in financial difficulty. Andy Smith confirmed that the commissioning sector is moving towards a similar situation to the acute sector with significant financial deficits arising. In respect of the ‘deep dive’ into individual risks, this will be useful to review the rationale of scores. A new Corporate Services Manager commences in January 2020, who will take the risk register forward. The Audit Committee: noted the monthly risk management report.

Internal Control

6. Internal Audit

• Progress report Fiona Hill presented the progress report, which provides an update to the Audit Committee in respect of the assurances, key issues and progress against the Internal Audit Plan for 2019/20. The following report is in progress:

• Primary Care Delegated Commissioning – Contract Oversight & Management the Terms of Reference is being finalised.

The summary table has changed since the last report and now shows the level of severity of actions.


The follow-up recommendations were highlighted:

• Learning Disability Pooled Budgets (2015/16) and Personal Health Budgets (2016/17). Both are still relevant and have been discussed with Paul Kingan and a contact identified to discuss historic learning disability cases.

• Complaints Management - an action plan is being delivered with a complaints lead being appointed to start in January 2020. MIAA are satisfied that this work is proceeding at pace.

• Care home quality

• Conflict of Interest

• Primary Care Medical Commissioning and Contracting – Governance Review – of the two outstanding recommendations one is now complete and the other almost complete.

Reviews planned for quarter 4 onwards are as follows:

• Conflicts of Interest;

• Pan Lancashire STP arrangements – Governance;

• Financial Flows – Neighbourhoods;

• Data Protection and Security Toolkit;

• Assurance Framework; and

• Follow-up. There are currently no changes to the audit plan

The Audit Committee: noted the progress report.

• MIAA Insight Fiona informed the Committee of future courses aimed at CCGs. There is a Governance and Risk Network (GARNet) Meeting on Thursday 12 December 2019 at Weightmans LLP, Liverpool. ‘Learning from Inquests and the Role of the Medical Examiner’ and ‘DPA/GDPR - The Increasing Number of Claims Against Trusts’. The information will be circulated. The Collaboration at Scale event had been well received. In the absence of the CCG at the event, the slides would be provided for information.

The Audit Committee: noted the content of the report.

7. Local Counter Fraud

• Progress report Ann Gregory presented the report which outlined the work undertaken between September to October 2019. The main headlines were shared as follows: Work is progressing to plan. An area outstanding relates to Standard 1.4 of the Standards for NHS Commissioners 2019-20, where fraud risk should be embedded in the corporate risk register. A meeting between Ann Gregory and the CCG in January will consider the options available as outlined by Paul Bell previously.

An anti-fraud reminder alerting staff to the ongoing threat of ESR spear-phishing attacks was included with the October salary payslip message. This fraud entails the fraudster accessing staff bank details, but measures have been put in place to prevent changes if the user is not logged on from an NHS network. A case was cited where a colleague’s salary was diverted to another bank account.

The Audit Committee: noted the progress report.


8. External Audit

• Progress report The Committee welcomed Alex Walling, who replaces Andy Smith. Alex is the Engagement Lead for CCGs in the South West, where she is currently exposed to a variety of issues. This will provide good comparison for issues in the North West and at West Lancashire CCG. Andy Smith presented the progress report, which demonstrated progress at 22 November 2019. In respect of ongoing work from the 2018-19 plan, all auditors were required to carry out a mental health investment standard audit, to determine the proportion of funding being channelled into the service. It was felt that the guidance for this audit was very rigid and was being applied retrospectively to previous periods. Therefore, there are a few issues arising from the exercise such as the CCG not providing a reason for the unreconciled difference between the non-ISFE and accounts figures. Paul Jones explained that the guidance for the exercise requires more prominence on the non-ISFE figure, however this does not lend itself for reconciliation. Accordingly the CCG have issued a qualified opinion. The draft review will be shared with the CCG to discuss, however a final report cannot be issued until NHS England / Improvement agree it can be released. It was suggested that a more relevant question is has the CCG received value for money by NHSS/I, rather than has there been enough funding spent on mental health services. Paul Jones felt the evidence in would be in the CCG’s annual report. Work will be undertaken by the CCG and the auditors to agree the wording of the opinion. Andy Smith highlighted the regulatory challenge, which has escalated over the last few years leading to an increase of days in the plans to meet this demand. All auditors are considering their budgeting charges and Grant Thornton is entering the third year of the contract with an option to extend. An increase in fees of 15% is expected for the provider sector, with a lower increase in the commissioning sector. The proposed increased charge will be known in the New Year. An event for finance teams around planning for annual accounts and financial reports will take place. Further information can be brought back to the next meeting. The embedded links within the report did not work, therefore a different format of the report will be considered for the next meeting.

The Audit Committee: noted the content of the reports

AS/AW

9. Losses and special payments There were no losses and special payments to note.

10. Single tender waivers (STW) There were a number of single tender waivers presented for comment. All had been approved by the chief officer and chief financial officer. Assurance had been received that all contractors are paid within policy eg not in excess of £400 per day. The Ryder Levett and Bucknal daily rate is less applicable as the quote is based on rates from the SBS framework. The Audit Committee: noted the single tender waivers.

11. Gifts and hospitality – October 2019 Paul Kingan presented the current gifts and hospitality register for October 2019.


Register of interests – September 2019 Paul Kingan presented the current declarations of interests register for the governing body. It was agreed that it would be useful if the declarations of members included the work undertaken within the companies in which they hold an interest. This can be actioned when requesting declarations of interest and checked on their receipt. A review of declarations of interests and of gifts and hospitality is taking place for staff, CSU embedded staff, contractors, governing body and committee members. The Audit Committee: noted the reports.

CA

12. Financial position update Paul Kingan informed the group that there is a £3.5m risk in the projected financial position. There is a recovery plan to mitigate the risk, however it is anticipated this will not improve greatly. The regime used for acute Trusts to report their deficits to regulators now applies to CCGs. This lengthy process includes a Grip and Control sheet with 119 actions to be answered. The cash position is satisfactory as money had been returned from Southport and Ormskirk Hospital NHS Trust (the Trust) this year after historic arbitrations, producing a cash flow benefit. A financial plan will return to a meeting in early spring.

13. Governance arrangements for MCP and related transitional issues Paul Kingan explained the direction of travel citing the commissioning road map, which works towards a single CCG in Lancashire by April 2021. There will be a new interim shared Accountable Officer in January, who will input on how we take things forward. The CCG is working on relationships and partnerships in West Lancashire and is looking to retain the majority of staff in local positions. Work continues with the Trust on their recovery plan with a system recovery plan and relevant meetings in place.

14. Draft workplan for 2020-21 The dates which coincide with the CCGs Primary Care Commissioning Committee meetings in 2021 will be moved to ensure full attendance.

Any other business

15. Date and time of next meetings Tuesday 11 February 2019, from 1.30 – 3.00 pm in the Boardroom, Hilldale.

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West Lancashire Finance, QIPP & Estates Committee Meeting Notes and Actions 12 November 2019

Item Discussion and decisions Actions Responsible officer

Due Date

Attendees In Attendance

Chair - Mike Maguire – Chief Officer Doug Soper – Lay Member Paul Kingan – Chief Finance Officer John Caine – Chair Paul Jones – Head of Finance Dheraj Bisarya – GP Executive Lead Claire Heneghan – Chief Nurse Jackie Moran – Head of Contracting, Performance & Quality Greg Mitten – Lay Member Jack Kinsey – GP Executive Lead Adam Robinson – Secondary Care Consultant George Hurst, Estates Strategy Contractor Doug Brierley, Graduate Finance Trainee Jill Gardner - Administrator

Apologies Stephen Gross – Lay Member Jen Greenhalgh – Finance Manager


Declarations declared by governing body members are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the governing body or the CCG website at the following link. Declaration of Interest

Declarations of interest from sub committees : None declared. Declaration of interest from today’s meeting :


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Dheraj Bisarya, GP Executive Lead, declared an interest in Item 9, Birleywood - Estates Update. It was deemed this should be recorded as significant but not fundamental and Dheraj was allowed to stay for the discussion.

Item 3 - Notes of previous meeting 10.09.19. Matters arising / summary of actions

The notes and actions from the meeting held on 10 September 2019 were accepted as an accurate record. Matters arising/summary of actions : Due to time constraints, the actions were not discussed. These will be re-circulated to the members. Greg Mitten, Lay Member, queried whether the Southport Hospital contract had been signed. Paul Kingan, Chief Finance Officer, confirmed this had been agreed but not signed. A review has been carried out of the Activity Management Plan with a view to understanding the contractual implications. This review highlighted :

• If Prior Approval Schemes are in place and a provider is not complying with them the commissioner is within their rights to impose a financial sanction. It was discussed challenging Wrightington, Wigan & Leigh on Prior Approval Schemes.

• If parties have agreed an Activity Planning Assumption relating to waiting times, it would be reasonable for parties to agree an Activity Management Plan requiring the provider to reduce activity levels and allow average waiting times to increase back to the agreed level.

Item 4 – Financial Position

Paul Jones, Head of Finance, presented the 2019/20 Financial Position Update. Paul confirmed the CCG will report a breakeven financial position, but with a £3.5m risk adjusted deficit which includes the impact of Southport & Ormskirk arbitration £1.5m, Unidentified QIPP £1.25m, Budgetary pressures on Prescribing £500k and Acute £250k.

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The realistic position could be an additional £2m over and above the risk adjusted position which takes the total deficit to between £3-5m. The CCG are seeking to navigate a process in order to be permitted to declare a deficit.

Item 5 - Recap on Finance Sessions and Recovery Plan

Dougie Brierley, Graduate Finance Trainee, updated the Committee on the Financial Recovery sessions recently held. These sessions focussed on reviewing CCG budgets, line by line and identified actions which would either reduce spend or outline new savings opportunities. Wrightington, Wigan & Leigh (WWL) – analysis shows some GP practices are referring patients straight to WWL instead of referring via MCAS. Aintree Hospital – a breakdown of activity shows 20% of Aintree Drug spend is categorised as “Other”. The possibility of using cheaper alternative drugs can be explored. A meeting has been arranged with SpaMedica to discuss further. Ramsey & Fairfield - £469k has been spent on Procedures of Limited Clinical Value (PLCV). The CCG to decide whether to stop funding. Peripheral Providers – Examination of the NHS contract reveals a commissioner can not enforce a cap on a PbR contract, but can influence activity by using activity management provisions in the contract. The CCG to decide if they wish to invoke activity management provisions. Brookside post – the CCG are funding this post, but believe LCFT should be funding this. Medisec – the CCG pay for the licences as per previous PCT agreement. If LPRES moves forward, the Medisec system may not be required.

Letter to be drafted to providers to advise CCG will not fund patients referred directly to themselves. Letter to be drafted to GPs to ensure patients are referred to MCAS in the first instance

Letter to be drafted to relevant provider asking them to assume funding To give notice on Medisec

Paul Kingan Claire Heneghan/ Dheraj Bisarya Paul Kingan Mike Maguire

November 2019 November 2019 November 2019 November 2019

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Prescribing – to be monitored over the next 6 months and action taken as necessary to keep expenditure under control. Paul Kingan, discussed the 2019/20 Potential Mitigations Return. Calderstones Hospital - there are recurrent costs of £600k for high cost patients. It is felt NW Specialist Commissioning Team should fund this. MIAA also wish to carry out a review of the case notes. It was agreed to arrange a separate meeting to discuss further. NHS Property Services – this is a historic debt and a proposed cash settlement is to be made.

Action Plan to be agreed

Meeting to be arranged to discuss further.

Nic Baxter CH/JMo/DS/JC/MM

November 2019 November 2019

Item 6 – Adhoc spend Decision

Paul Kingan advised the committee members a process is required to be put in place regarding ad hoc spend within the CCG. Paul is considered implementing a Spend Log which will be administered by the Finance Team. This will be for unplanned spend with a limit in place of between £5,000 - £50,000.

Item 7 – Changes to In-Year Financial Forecast

Paul Kingan, Chief Finance Officer, discussed the protocol for changes to an In-Year Financial Forecast. The protocol for any changes to organisational forecasts during 2019/20 will now be applied to CCGs. A formal process has been put in place and is to be followed in any case where an adverse variance to plan is expected.

Item 8 – Southport System Recovery Plan

The CCG currently reports its financial position as part of the Lancashire control total. However, we are also firmly involved in the Southport & Ormskirk Health Economy Financial Planning. At present, this is in the region of £25m net financial risk on top of the £25m deficit control target. If the CCG were to bring in its own forecast deficit, this figure would increase by a range of £3-5m.

Item 9 – Estates Update

Dheraj Bisarya had declared an interest in this item as referenced above.

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George Hurst presented an Estates update and discussed the slides with the committee members. Key points included :

• West Lancs CCG Scheme status including outstanding requirements, expected completion dates and project stage of all schemes to date.

• Financial Overview – Estates Schemes. This showed there is an overall increase of £397k over baseline.

• Procurement update PCCs

• Birleywood – Finance Committee to agree option and then produce PID.

Item 10 - AOB

No further business was discussed.

Next Meeting

The next meeting will take place on 10th December 2019, 9.00am.

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WEST LANCASHIRE COMMUNITY SAFETY PARTNERSHIP HELD: 15th October 2019 Commenced 9.30 am Finished: 10.45 am

PRESENT:

Name Agency

Andrew Hill WLBC (Deputy Chair)

Jenny Jones WLBC

Karen Edwards Lancashire Constabulary

Ian Jones Lancashire Constabulary

Ellie Kanoun Lancashire Constabulary

Mark Lamb LF&RS

Fay Sherrington EHU

Katherine Slater OPCC

Des Foster Young Addaction

Arthur Kaddu EHSU

Andy Roberts NPS

Donna Tuccio Lancashire Constabulary

Rachel Johnson Lancashire Constabulary

Gwen Bleasdale The Liberty Centre

Michelle Dacre Cumbria and Lancashire CRC

Liz Hopkins Inspire CGL

Irene O'Donnell LALC Secretary

Annette Ellsion Skem Probation NPS

Claire Fox LCC

Tim Grose LCC

Abdul Kheratkar LCC Community Safety

Steven Eastwood Wigan Athletic FC

1. WELCOME AND INTRODUCTIONS

The Chairperson welcomed colleagues to the meeting and introductions were made. 2. APOLOGIES

Apologies for absence were received from Cliff Owens and Kevin Maher. 3. MINUTES OF LAST MEETING/MATTERS ARISING

The minutes of the last meeting were agreed as a true and accurate record.

4. STREET GAMES INITIATIVE

Steven Eastwood from Wigan Athletic Football Club attended to give an overview of the street games initiative which has been set up in Skelmersdale. Currently 2 centres have been piloting the initiative, Digmoor on a Wednesday & Tanhouse on a Friday where staff from Wigan Athletic along with the Police have been trying to engage with those most vulnerable in the communities. The Police games van has been deployed and refreshments have been provided and there is now an average attendance of 20-30 youths.

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Early Action and Wellbeing are due to start providing support to the events and Young Addaction are also due to attend. The funding for the sessions is due to finish at the end of October, however Steven was hopeful of getting further funding until August 2020 which would then mean that they would have reached the timescales to become eligible for FA funding for 2 years.

Ian Jones advised that there may be funding available through LANPAC and requested that Cliff Owens liaise with Ellie Kanoun in relation to this. Steven also advised that lighting for the outdoor areas may become an issue over the coming months as there are some overgrown trees, LCC staff agreed to take this issue back to try and address with their relevant staff. Fay Sherrington advised that students at the university may be interested in assisting with this project as part of their volunteer work and she agreed to liaise with Cliff Owens about the outcome of any discussions.

The Chair thanked Steven for his briefing.

5. PERFORMANCE MONITORING

The Chair invited partner agencies to provide a verbal overview of current performance. Written performance reports were submitted by Lancashire Constabulary, Lancashire Fire & Rescue Service & the Liberty Centre.

Rachel Johnson began with an overview of the crime figures submitted by Lancashire Constabulary giving some context to the figures. Ian Jones then gave an operational policing update including information about the rise in ASB & the use of funding for a boxing club in Ormskirk which similar to the street games has been put in place to try to engage with local youths who may otherwise commit acts of ASB.

Ian also provided an update in relation to a new Task Force which will see 4 officers deployed to West Lancashire to target known repeat offenders/crime areas to try to address the recent targeted crime issues in Skelmersdale, these officers will be in post from November. An update was given on the policing plan for mischief night and the plans agreed for a place of safety for any youths rather than officers taking them to custody. Ian then introduced Ellie Kanoun to the group, Ellie will be taking up the Neighbourhood's Inspectors post on a temporary basis.

Andrew Hill advised that there had been 17 new Anti-Social Behaviour cases since the last meeting of this group and although most are relatively minor issues, 1 case has resulted in the eviction of a council tenant which has been a productive result for the team.

Gwen Bleasedale advised that there is a new campaign called 'Don't be a bystander' which is encouraging people to talk about any concerns they have and the campaign is currently being used on car parking tickets in the borough. Gwen also spoke about a Safe Teens project in relation to a sexting toolkit and she will report back at the next meeting on the results from that work.

Liz Hopkins advised that Inspire now has a hub in the Pulse in Skelmersdale Concourse. Footfall has fallen at the Westgate Site, possibly due to the new Concourse site. There has been an increase in alcohol related referrals & information relating to cuckooing of vulnerable residents but people within the communities are passing information which is a positive thing.

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6. CSP FUNDING UPDATE

Andrew Hill provided the Partnership with an update against the CSP’s funding allocation for 2019/20 and how this has been spent. If any members have any further ideas that would meet the funding criteria for the CSP then they should contact Cliff Owens to discuss further.

7. BRIGHT SPARX PLANNING

Andrew Hill advised that the Bright Sparx Action Plan is a multi-agency response coordinated by Cliff Owens on behalf of the CSP to address the annual rise in ASB during the bonfire period which includes mischief night. 6 Community action days are planned where partner agencies will be working in the communities to offer help and support, specifically with skips for removal of waste. The police games bus will try to engage with the local children during the events. The Go4it events are again planned for the 3rd & 4th November at Skelmersdale Fire Station where there will be lots of activities to keep younger members of the community off the streets. Tim Grose advised that his team will be supporting the event over the 2 nights. .

8. COUNTY LINES DRAMA PRESENTATIONS

Sergeant Andy Bramhall was unable to attend the meeting but other members of the group gave a brief overview on the Alter Ego County Lines drama presentations which will be delivered into all West Lancashire secondary schools throughout October 2019. The presentation looks at child criminal exploitation and gives the children the information they may need to recognise the signs and prevent their involvement. Feedback has been very positive. Media campaigns ran both prior to and during the presentations to try and highlight the campaign to parents.

9. DOMESTIC ABUSE SERVICES PROVIDED BY THE LIBERTY CENTRE

Gwen Bleasdale updated the group on the work of the Liberty Centre including providing information on workshops that are being run as part of 10 week courses for survivors looking at self-esteem, identifying vulnerabilities and parenting after abuse. This is being done in conjunction with other services such as Lancashire County Council. Gwen also provided an update on the proposal to develop a further property in Skelmersdale for families who have been affected by domestic violence to use as a stepping stone before moving on. It is hoped that this may be available from early 2020.

10. CHILDREN AND FAMILY WELLBEING SERVICE UPDATE Tim Grose provided an update to the group on the current work from the CFWS including numbers of referrals and the changes that will be made as part of a restructure based on a Hertfordshire model. Tim agreed to provide an update on this at the next meeting of this group.

11. WELCOME WEEK REVIEW Andrew Hill updated the group on the action plan for Welcome Week and the work that has been carried out including representation at the welcome fair for students and visits to over 200 student properties in Ormskirk, advising students about noise

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nuisance and how to be a good neighbour. This year has seen a record low with only two noise complaints received, neither of these were about noise from the University but from residential premises and have been dealt with. Faye Sherrington added that from the Universities perspective the work from partner agencies had been extremely successful and she thanked all those involved. Andrew Hill advised that Cliff Owens will be conducting the evaluation and will share the completed document with the colleagues.

12. ANY OTHER BUSINESS Andrew Hill advised the group that the Lancashire Wellbeing Partnership were no longer taking on new cases and were only dealing with already ongoing issues, however he would like to highlight the significant difference the service made to the community, helping 3159 residents and thanks from this group should be noted. 13. DATE & TIME OF NEXT MEETING To be confirmed.

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Notes of the Joint Committee of Clinical Commissioning Groups (JCCCGs)

Thursday 05 September 2019, 13:00-15:00

South Ribble Borough Council, Civic Centre, West Paddock, Leyland, Lancashire, PR25 1DH

Present

Phil Watson Independent Chair JCCCGs

Dr Richard Robinson Clinical Chair East Lancashire CCG

Geoffrey O’Donoghue Lay Member Chorley and South Ribble CCG

Dr Geoff Jolliffe GP and Clinical Chair Morecambe Bay CCG

Doug Soper Lay Member West Lancashire CCG

Dr Gora Bangi Chair Chorley South Ribble CCG

Jerry Hawker Chief Officer Morecambe Bay CCG

Roy Fisher Chair Blackpool CCG

Paul Kingan Chief Finance Officer West Lancashire CCG

Dr Adam Janjua GP and Acting Chair Fylde and Wyre CCG

In Attendance

Peter Tinson Chief Operating Officer Fylde Coast CCGs

Andrew Bennett Executive Lead Commissioning Lancashire and South Cumbria ICS

Kirsty Hollis Deputy Chief Officer East Lancashire CCG

Paul Hinnigan Lay Member, Governance Blackburn with Darwen CCG

Tim Almond Senior System Manager – Urgent Care

Morecambe Bay CCG

Andrew Harrison Chief Finance Officer Fylde Coast CCGs (attended for Item 8)

Cathy Gardener East Lancashire CCG(attended for Item 8)

Donna Parker Service Redesign Support Manager

East Lancashire CCG and Blackburn with Darwen CCG (attended for Item 8)

Elaine Johnstone

Chair, Commissioning Policy Development and Implementation Group (CPDIG)

Midlands and Lancashire Commissioning Support Unit (attended for Items 6)

Roger Parr Chief Finance Officer East Lancashire and Blackburn with Darwen CCGs

Denis Gizzi Chief Officer Chorley & South Ribble CCG and Greater Preston CCG

Amanda Doyle Chief Officer Lancashire and South Cumbria ICS

Andy Curran Medical Director Lancashire and South Cumbria ICS

Jane Cass Locality Director Lancashire and South Cumbria ICS

Edward Fletcher Commissioning Manager Cumbria County Council

Neil Greaves Head of Communications and Engagement

Lancashire and South Cumbria ICS

Gaynor Jones Executive Assistant Lancashire and South Cumbia ICS

Apologies

David Bonson Chief Operating Officer Blackpool CCG

Graham Burgess Chair Blackburn with Darwen CCG

Louise Taylor Executive Director for Adult Lancashire County Council

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Services and Health and Wellbeing

Steve Thompson Director of Resources Blackpool Borough Council

Debbie Corcoran Lay Member for Public and Patient Involvement

Greater Preston CCG

Katherine Fairclough Chief Executive Cumbria County Council

Dr Sumantra Mukerji Chair Greater Preston CCG

Lawrence Conway

Gary Raphael Executive Lead - Finance Lancashire and South Cumbria ICS

Julie Higgins Chief Officer East Lancashire and Blackburn with Darwen CCGs

Andrew Bibby Assistant Regional Director of Specialised Commissioning (North)

NHS England/NHS Improvement

Gary Hall Chief Executive Chorley Borough Council

Neil Jack Chief Executive Blackpool Borough Council

Sakthi Karunanithi Director of Public Health and Wellbeing SLT Support

Lancashire County Council

Simon Burnett Deputy Director of Leisure and Wellbeing

West Lancashire Borough Council

Kevin Toole Lay Member Fylde and Wyre CCG

A. Standing items

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Welcome and Introductions The Chair welcomed members to the regular business meeting of the Joint Committee of Clinical Commissioning Groups (JCCCGs) held in public. The Chair, E Johnstone and A Bennett held a 30 minute pre-meeting with a member of the public to enable questions to be raised on the agenda. Members were reminded that the business today was being live-streamed and recorded so that decisions are accessible and available to members of the public following the meeting, on the Lancashire and South Cumbria (L&SC) YouTube channel.

2.

Declaration of Interests None reported.

3.

Notes of the meeting held on 02 May 2019 Following a minor amendment on page 4, Item 7, third paragraph ‘assessments’ amended to ‘reassessments’, the notes were agreed as a correct record.

4.

Items of any other business None reported.

5.

Lancashire and South Cumbria Urgent and Emergency Care Strategy (L&SC UEC) Tim Almond, Senior System Manager, Urgent Care, attended the meeting on behalf of the Urgent Care Network to provide an update on the refreshed UEC transformation work programme in Lancashire and South Cumbria. T Almond demonstrated the purpose of the report, the aims, the local priorities, key achievements and deliverables in line with the requirements of the national NHS Long Term Plan.

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The content of the report provided a clearer indication on local drivers and the need for change within the Integrated Care System (ICS) footprint. It also provided information on the national work surrounding clinical access, targets and access standards. The core of the document described all elements of the health and social care economy and the innovation to drive the improvement narrative throughout the strategy. Feedback on the intentions had been received along with clarity around performance figures at an ICS level. T Almond welcomed any questions, comments and thoughts. P Tinson welcomed a review of urgent treatment centre provision and requested the inclusion of different models of primary care, extended access in different ICPs and shared learning around increasing utilisation of appointments logged. D Soper agreed with the direction of the strategy but questioned the quality and reliability of the data in relation to monitoring emergency admissions and improving same day discharge. T Almond informed the Joint Committee that standardisation of data is being considered. A Bennett questioned predicting patterns of demand for urgent care and asked when the national review of access to national standards will be concluded. T Almond informed the Joint Committee that work is ongoing within NHS Improvement in predicting activity and factoring in soft metrics to improve accuracy. The Joint Committee was asked to note the content of the refreshed UEC Strategy and locally agreed priorities. RESOLVED: that the Joint Committee noted the content of the report.

Improving Population Health

6.

Commissioning Policies Elaine Johnstone attended the meeting to provide the Joint Committee with a review of seven intervention-specific commissioning policies by the Commissioning Policy Development and Implementation Working Group (CPDIG), responsible for the oversight of the process submitted to the Joint Committee for approval and ongoing programme of policy review. E Johnstone described the changes made to each individual policy, mainly around the clarity of wording. The policies had been drafted to align current policy criteria with NHS England’s Evidence Base Intervention (EBI) Guidance. It was recommended that the Joint Committee ratify the following collaborative commissioning policies that will replace any existing CCG policies once approved:

a) Tonsillectomy b) Surgical release of trigger finger c) Surgical management of gynaecomastia d) Management of otitis media with effusion using grommets e) Surgical Treatment of carpal tunnel syndrome f) Breast reduction surgery g) Removal of benign skin lesions

The Chair asked for questions and comments. G Jolliffe asked if the policy for the removal of benign skin lesions was consistent with the application of the policy for general practice and if it could be flagged to general

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practice. E Johnstone informed the Joint committee that it is the expectation that a policy that is ratified by the Joint Committee applies to all clinicians across the whole of L&SC. From a question raised on when a policy becomes effective, E Johnstone informed the Joint Committee that the date at which a patient is referred is the date at which to consult a policy. The Policy Development Group will discuss this subject further in due course. E Johnstone noted a request for annual feedback on the extent of compliance for the Joint Committee to assess. RESOLVED: that the Joint Committee ratified the seven intervention-specific commissioning policies that will now proceed to implementation.

7.

Individual Patient Activity (IPA) programme J Hawker provided an update on the progress of the current IPA activity across L&SC to support a case for change that builds on previous information presented to the Joint Committee in May 2019. The approach to IPA across L&SC was evident in terms of the scale of challenge presented. Two primary objectives were noted: to improve the current performance of the existing IPA services and for the IPA Programme Board to bring forward proposals around the future commissioning and operation of IPA services and Continuing Health Care (CHC). A formal paper will be brought to the Joint Committee by the end of the calendar year, regarding long-term proposals for the management of IPA services. Work is continuing to build on extensive programmes of work around best practice across the north of England looking at CHC systems. Progress has been made over the last few months in terms of improving the education, training and understanding of the CHC process. The current position on Personal Health Budgets (PHBs) was provided. Support from the Joint Committee was sought to recommend that current funding is extended to year-end. The Joint Committee approved the proposed Joint Disputes Resolution Protocol and agreed that delegated authority is to be given to the IPA Board for final ratification. J Hawker thanked the teams involved on developing the financial intelligence and bringing together clear plans on how to improve the experience of people accessing the IPA services and in ensuring collectively, the eight CCGs are compliant with the national expectations in terms of the NHS Continuing Health Framework and quality standards for IPA services. The Chair asked if there were any questions or comments. G Jolliffe raised a question on levelling variation of spend within CCGs. The Joint Committee was informed of three levels of spend. National evidence shows a complex mix of areas and profiles of people accessing CHC services. P Tinson observed that local authority costs had not been included and asked if local authority partners had agreed to provide information to give a more holistic picture. J Hawker informed the Joint Committee that local authorities have been active in their work with the IPA Board.

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D Soper asked for thoughts on capping individual high cost packages of care. J Hawker drew attention to the NHS long term commitment to the personalisation agenda in providing care with the best use of resources. It was reported that there is clear evidence in using PHB to improve the experience of the patient. The Chair asked the Joint Committee to vote on the following recommendations:

• Note the ongoing performance position and current level of improvement action and ensure individual CCG Governing Bodies are full sighted on the current risks associated, including potential additional investment requirements to address (appendices A-E)

• Note progress and actions to develop proposals on both new commissioning and operational delivery models for IPA services due to be presented before end of the year (appendices A-E)

• Endorse the recommendation of the IPA Programme Board to continue and increase the level of non-recurrent funding to ensure CCGs continue to comply with the duties to promote and provide PHBs. Note: The decision whether to extend the PHB investment remains under the statutory duty of individual CCGs (appendix F)

• Approve the proposed Joint Disputes Resolution Protocol set-out in appendix G and delegate authority to the IPA Programme Board to sign-off any minor non-material amendments at the September board meeting. This is to allow parallel approval processes with the Local Authorities.

RESOLVED: that the Joint Committee endorsed the recommendations.

8.

Ophthalmology Project Initiation Document (PID) A Harrison, Chief Finance Officer for Blackpool and Fylde and Wyre CCGs attended the meeting in his capacity as the executive lead for planned care commissioning across the ICS. A Harrison introduced colleagues, K Gardner and D Parker, leads on the process for the PID for Ophthalmology planned eye care. The Joint Committee is asked to approve the PID that had been constructed by the CCG’s Commissioning Support Unit and ICS colleagues in support of harmonising standards, measures and outcomes for eye care pathways, in particular, age related macular degeneration, glaucoma and cataracts; the PID includes a series of touch points and governance steps to the goal of common standards, metrics and outcomes. The next step is to facilitate both clinical and pubic engagement in the process which, if approved, will be undertaken by the group made up of CCG led lead commissioners supported by ICS and Integrated Care Partnership (ICP) programme colleagues. The Chair asked if there were any questions or comments. Dr Bangi asked if there was a solution to the Avastin debate. A Harrison informed the Joint Committee that at this stage the PID is looking to seek to generate those standards, outcomes and measures of which the treatment of either Avastin or other drugs will be taken as an option and to determine the best approach. A Curran informed the Joint Committee that the Pharmacy Medicines Optimisation Programme is currently looking at this area. D Soper noted the omission of data for Morecambe Bay and West Lancashire. A Harrison advised that the intention is to collect all data. Colleagues from Morecambe Bay are involved and West Lancashire are involved less so, in the process. G Jolliffe asked what the ambition is for achieving consensus amongst practicing ophthalmologists across ICS and highlighted potential challenges with clinicians

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regarding single use drugs. A Harrison advised that this will be further discussed at the upcoming clinical engagement event to seek the best possible solution. G Jolliffe asked for firm direction for providers across the system. The Chair asked the Joint Committee to agree the following recommendation:

• To approve the PID to support the ICS-wide creation of standards, measures and outcomes for ophthalmology care pathways across the Clinical Commissioning Groups.

RESOLVED: that the Joint Committee approved the ophthalmology PID.

9.

Terms of Reference (TOR) Review J Hawker provided two visions of the TOR to consider (Section 2, Version 1 and Section 3, Version 2) taking into account the legal duties of individual statutory bodies and the Joint Committee and taking significant steps forward to recognising the move to system working and our future as set out in the NHS Long Term Plan. J Hawker highlighted the need for the Joint Committee and the individual eight CCGs to be explicitly clear around delegated authority to the Joint Committee and the extent this applies to the Work Programme; subject to the TOR being agreed, J Hawker recognised that the Joint Committee Work Programme needs to be refreshed. The recommendation is for the Joint Committee to adopt Version 2 to go forward to the eight CCGs for final sign-off. The Chair asked if there were any questions or comments. D Soper requested an amendment to Version 2 paragraph 3.2; the CCGs named in paragraph 5 are not named in paragraph 1.5. Also, ‘STP’ Board to be amended to ‘ICS’ Board. G Jolliffe motioned to adopt the progressive nature of Version 2. A Doyle commended the amount of work that has gone into the review and supported endorsing Version 2. RESOLVED: that the Joint Committee accepted and recommended Version 2 to be adopted by the eight CCGs.

10.

Any other business None reported. The Chair declared the formal meeting closed.

11.

Questions from the public Mr J Clayton, Chorley Hospital Campaign Group member, asked for clarity on the longevity of Personal Health Budget funding. A Doyle informed Mr Clayton that there is not a shortfall in funding for individually assessed self-care needs.

Date and time of next meeting: 07 November 2019, 13:00-15:00, Morecambe Bay CCG, Lancaster. 02 January 2020, 13:00-15:00 05 March 2020, 13:00-15:00