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AGENDA FOR

Board of Directors Meeting Date: Wednesday 29 July 2020 Time: 11.00am – 1.00pm

Venue: Meeting to be held by ZOOM

PLEASE NOTE – due to the COVID-19 outbreak the Trust has taken a decision to hold this meeting virtually, which will permit the Trust to implement social distancing by reducing face-to-face meetings in favour of meetings by using Zoom.

As part of the Trust’s commitment to openness and accountability, members of the public are able to join the meeting via Zoom, but will need to apply in advance to do so as the address for the Zoom meeting will not be put on the public website. Should you wish to join this meeting please email Paula Murphy, Corporate Governance Manager via [email protected] for details and observation guidelines.

All papers will be published on the website together with the minutes of the meeting when they become available. Members will be expected to have read all the papers prior to the meeting.

No. Item Lead Details Time

A A1 Welcome B Fraenkel Verbal to note 11.00am

B Board of Directors Business

B1 Member’s Apologies: A Oates; T Bennett; Attendee’s Apologies:

B Fraenkel Verbal to note 11.02am

B2 Declarations of Interest

B Fraenkel Verbal to note

B3 Minutes of the Meeting held on : a) 19 June 2020 (Accounts – virtual by email) b) 24 June 2020

B Fraenkel Paper for decision

B4 Board of Directors Log / Action Plan B Fraenkel Paper to note B5 Matters Arising B Fraenkel -----

B6 Chairman’s Report

B Fraenkel Paper to note 11.05am

B7 Chief Executive’s Report

J Rafferty Paper to note 11.10am

B8 Trust Response to COVID-19 – Update

T Bennett/ E Darbyshire / A Oates / N Thomas

Paper to note

11.25am

B9 Board Assurance Framework N Thomas Paper for discussion 11.40am

C Our Services

C1 Safety Report N Thomas Paper for discussion 11.50am

C2 COVID-19 Executive Performance Report N Smith Paper to note 12 noon

C3 Annual Reports: a) Safeguarding b) Revalidation (Nursing) c) Revalidation (Medical)

S O’Hear S O’Hear N Thomas

Papers to note

12.10pm

D Our People

No Items

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mailto:[email protected]

E Our Resources

E1 Annual Audit Letter N Smith Paper to note 12:20pm

F Our Future

No Items

G Our Governance

G1 Board Committee Minutes (including Chairs’ Reports) a) Audit Committee (May 2020); b) Quality Assurance Committee (May 2020); c) Resources Committee (June 2020); d) People Committee (June 2020)

P Williams G Thomason N Williams A O’Dwyer

Paper to note 12.25pm

H End of Meeting Actions

H1 Risk Reflection All 12.30pm

H2 Reflection on the meeting and whether any issues need to be referred to a Board Committee

All 12.35pm

H3 Any Other Business Members 12.40pm

Opportunity for Questions from the Public (20 minutes) Please note – normally Mersey Care’s Public Meeting of the Board of Directors is a meeting held in public, rather than a public meeting in which the public may participate. However in light of COVID-19 outbreak, the trust has taken a decision to hold this meeting virtually, which will permit the trust to implement social distancing by reducing face-to-face meetings across the trust in favour of meetings by phone / video conferencing. In making this decision, the trust has taken account of the letter from NHS England / Improvement’s Chief Operating Officer of 28 March 2020 entitled Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pressures, which states:

“while under normal circumstances the public can attend at least part of provider board meetings, Government social isolation requirements constitute ‘special reasons’ to avoid face to face gatherings as permitted by legislation”

As part of the Trust’s commitment to openness and accountability, members of the public are able to join the meeting via Zoom, but will need to apply in advance to do so as the address for the Zoom meeting will not be put on the public website. Should you wish to join this meeting please email Paula Murphy, Corporate Governance Manager via [email protected] for details and observation guidelines. Unfortunately the Trust is not in a position to provide equipment, technical advice or support for members of the public wishing to observe this meeting using Zoom.

The papers for meetings will continue to be posted on the Trust’s website and minutes of the meetings – including any questions and answers to Board papers raised by members of the Board – will also be published on the website

Should you wish to ask a question about the issues addressed in any of the papers for this meeting, please address your question to the Trust Secretary ([email protected]) and the trust will endeavour to respond to you within 21 days.

We hope your recognise that we are doing this to help protect both our staff and members of the public by reducing the opportunities for transmission through social distancing during the COVID-19 outbreak. The trust will review this decision on a regular basis taking account of national guidance.

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The Board of Directors is invited to adopt the following resolution: ‘That the Board hereby resolves that the remainder of the meeting to be held in private, because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted’. [Section (2) of the Public Bodies (Admission to Meetings) Act 1960]

Dates of Future Meetings:

• 30 September 2020

• 25 November 2020

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Status of these minutes (check one box):

Draft for Approval: ☒ Report to: Board of Directors

Formally Approved: ☐ Meeting Date: 29 July 2020

MINUTES OF THE MEETING OF THE

Board of Directors – held via email Date: Friday 19 June 2020 Time: ----

Venue: Virtual by email – responses requested by 12noon, Tuesday 23 June 2020

Name Job Title (Division/ Organisation*) *if not Mersey Care

Present: Beatrice Fraenkel Murray Freeman Gaynor Hales Aislinn O’Dwyer Gerry O’Keeffe Pam Williams Nick Williams Joe Rafferty Neil Smith Trish Bennett Noir Thomas Elaine Darbyshire Louise Edwards Amanda Oates

Chairman Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Chief Executive Executive Director of Finance / Deputy Chief Executive Executive Director of Nursing & Operations Medical Director Executive Director of Communications & Corporate Governance Director of Strategy Executive Director of Workforce

In Attendance: Andy Meadows Sarah Jennings Paula Murphy

Trust Secretary Deputy Trust Secretary Corporate Governance Compliance Manager

Apologies Received: - -

ISSUES CONSIDERED 2020

1. Board Members were asked to consider the annual report and accounts for approval

using the virtual meeting by email process as the documents needed to be submitted by midday on Thursday 25 June.

2. In order to provide sufficient time to collate and finalise the documents, which was being done remotely by staff, members of the Board were being asked to approve these documents before the Board meeting being held on Wednesday 24 June 2020.

3. It was intended that final copies will be presented to the Board for the 24 June meeting,

so they can be published as part of the Board meeting papers.

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A1

a) ANNUAL REPORT & PROVIDER LICENCE SELF CERTIFICATIONS STATEMENT

4. The Board were asked to consider and comment on the Trust’s Annual Report for 2019/20 and note that, with the exception of the foreword and some of the tables in Chapter 14 (which had been updated), this Annual Report had been reviewed by the Audit Committee in the last few days and had been recommended to the Board for its approval. The Board were also being asked to approval the Provider Licence Self Certification following their provisional approval at May 2020’s Board of Directors, again this had also been considered by the Audit Committee.

b) ANNUAL ACCOUNTS FOR THE YEAR ENDED 31 MARCH 2020

5. The report was provided in order to confirm the outcome of the External Audit review of the 2019/20 Annual Accounts, present the final 2019/20 Annual Accounts and Letter of Representation to the Board and to seek approval of the 2019/20 Annual Accounts and Letter of Representation ahead of submission to NHS Improvement on 25 June 2020.

6. Mrs Williams responded, stating that the documents had been considered by the Audit Committee and approved for recommendation to the Board. The Committee had noted it’s thanks to all involved for their work on this, particularly in such challenging times. Mrs Williams noted that there were subsequently only minor changes to these final versions of the documents and confirmed that she was happy to approve the documents as set out in the recommendations.

7. Mr O’Keeffe, Miss O’Dwyer, Mrs Hales, Dr Freeman, Mr Smith, Dr Thomas all confirmed their approval of the documents via email.

8. Miss O’Dwyer added that it was an excellent Annual Report.

Action ANNUAL REPORT

Lead Timescale Status

Recommendations approved by the Board, namely: • Consider and approved the Annual Report for

2019/20; • In light of considering / approving the annual report

and annual accounts, to also consider and finally approve the Provider Licence Self-Certification Statements.

Further actions required: • None identified.

Action

ANNUAL ACCOUNTS Lead Timescale Status

Recommendations approved by the Board, namely: • Approve the 2019/20 Annual Accounts and Letter of

Representation for the year ended 31 March 2020.


11. There were no further items of business.

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12. The meeting closed.

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Draft for Approval: ☒ Report to: Board of Directors

Formally Approved: ☐ Meeting Date: 29 July 2020


Board of Directors – held via Video Conference Date: Wednesday 24 June 2020 Time: 10am-11am

Venue: Video Conference


Present: Beatrice Fraenkel Murray Freeman Gaynor Hales Aislinn O’Dwyer Gerry O’Keeffe Pam Williams Nick Williams Joe Rafferty Neil Smith Trish Bennett Noir Thomas Elaine Darbyshire Louise Edwards Amanda Oates

Chairman Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Chief Executive Executive Director of Finance / Deputy Chief Executive (from item B8) Executive Director of Nursing & Operations Medical Director Executive Director of Communications & Corporate Governance Director of Strategy Executive Director of Workforce

In Attendance: Chris Lyons Mandi Gregory Matt Copple Paul Smith Garrick Prayogg Hilary Tetlow Chris Muzavazi Salome Mare-Walsh Andy Meadows Sarah Jennings Paula Murphy

Director of Corporate Transformation Staff Side Representative Lead Governor Governor Governor Governor Health Care Support Worker CRHT Team Manager (for agenda item C3 only) Trust Secretary Deputy Trust Secretary Corporate Governance Compliance Manager

Apologies Received:

ISSUES CONSIDERED 2020 A1 WELCOME

1. Mrs Fraenkel welcomed all to the video conference meeting of the Board of Directors, and outlined the etiquette for the meeting.

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2. In light of the COVID-19 outbreak, the meeting was being held via video conference to facilitate social distancing and therefore no members of the public were in attendance, however arrangements would be reviewed going forward to consider how the public could participate.

B1 APOLOGIES FOR ABSENCE

3. There were no apologies for absence received for this meeting.

B2 DECLARATIONS OF INTEREST

4. Mrs Hales advised the Board that she was currently working for Liverpool Women’s Hospital as Interim Director of Nursing.

5. No declarations of interest were made.

B3 MINUTES OF THE MEETING HELD ON 20 MAY 2020 6. The previous minutes were accepted as an accurate record.

7.

Action Lead Timescale Status

Recommendations approved by the Board, namely: • Approve the minutes of the previous meeting.


B4 BOARD OF DIRECTORS LOG/ ACTION PLAN

8. The Board noted the action log.

9. Mr Meadows confirmed that work was continuing to identify to most appropriate method of permitting members of the public to observe public Board meetings via Zoom. It was likely that the Board would seek applicants to join the Zoom call and invitations would be sent to those applicants.

10.


Recommendations approved by the Board, namely: • Note the action log.


B5 MATTERS ARISING

11. There were no matters arising.

C1 COVID-19 UPDATE

12. Mrs T Bennett provided the Board with a verbal update stating that nationally, the Government had reduced the alert level from 4 to 3 which was good news, however

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Mrs T Bennett emphasised that the NHS remained at level 4 - major incident, and would continue to do so for the foreseeable future. There remained a need to respond to unwell/unmet demand and this meant potentially dealing with the unknown. There would also be capacity issues for staff in order to be able to implement the restart of services, which was a complex issue.

13. Looking at the level of virus and outbreaks in the country, these numbers would still be considered as a major incident; however things were progressing in the right direction. There was a reduction in hospital admissions for COVID-19 although there were still outbreaks across the country. There had been 3 patient deaths reported to the Board previously. Hospital acquired infections were also still a concern.

14. In relation to care homes, Mrs Bennett advised that the Trust had provided support in respect of 71 outbreaks. Currently the Trust were managing 4 outbreaks, 3 of which were on their second outbreak. Sefton had reported 28 outbreaks.

15. Staff Antibody tests were being provided and results so far were comparable to other Trusts across the patch. Supplies of PPE (personal protective equipment) were good and the current sickness rate for staff was just over 11%. Mrs Bennett stated that the Trust recognised the complexity of the situation and the anxiety it brought.

16. Miss O’Dwyer acknowledged the significant amount of work undertaken and thanked the teams for their hard work. In relation to staffing, Miss O’Dwyer queried the situation in relation to quarantining, recognising that restrictions were easing in the next couple of weeks, including travel. Mrs Oates confirmed that the Trust were following national guidance, stating that Government advice remained in relation to only essential travel. We are stating that no staff should go abroad, however should they chose to go, they would need to take unpaid leave or use additional annual leave to cover their two week quarantine period upon return. The Trust were however encouraging staff to take their annual leave as part of their health and wellbeing. There was also the potential of a backlog of annual leave and the Trust would be increasing the allowance to carry over remaining leave to the next financial year where appropriate.

17. Dr Freeman referred to the care home sector and the subsequent media coverage regarding lack of preparedness and queried how the Trust would respond should the number of cases rise again. Mrs T Bennett confirmed that the Trust had learned much over recent weeks in relation to the care home sector. The Trust were able to support the sector with PPE and good infection control guidance. There was now a better understanding of outbreak management and the Trust continued to work closely with other organisations in terms of capacity.

18. In response to Mrs Hales, Mrs Bennett confirmed that the Trust were undertaking significant antibody testing, however the track and trace system was very different. Mrs T Bennett stated that in her opinion, this was not yet embedded or clear enough. Mr Rafferty agreed, adding that the Trust had a good level of social distancing and where this was not possible the Trust were utilising PPE effectively and were maintaining communication with staff.

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19. Mrs Bennett added that where there has been an impact to organisations resulting from track and trace, this had been due to staff meeting in communal areas and it was vital to reiterate the importance of social distancing.

20. Replying to a question from Mrs Fraenkel, Mrs Bennett confirmed that there had been no outbreak of COVID-19 in the prison. Some symptomatic patients/prisoners had been identified, but there had been no outbreak of infection. The service continued to follow all guidance and there were sufficient supplies of PPE as per any other service.

21. Mr O’Keeffe stated that society and the Government were driving toward normality, however within senior levels of the NHS there was an expectation of an increase and sought clarity on the Trust’s preparedness should another wave of infection hit. Mr Rafferty confirmed that the Trust remained vigilant and would not lessen controls. It was important to ensure staff took annual leave for their own wellbeing and each trust in Cheshire and Merseyside were in phase 3 planning between now and 31 March 2021. A critical part of that included assumption around COVID and re-establishing lives/living with COVID. Mr Rafferty confirmed that should there be another peak; the Trust would know exactly what to do and be able to do it better. The Trust have an adjusted focus, moving away from dealing with the pandemic and re-establishing services as much as possible, including getting critical services up to a level.

22. Mr Rafferty stated that each local authority was now establishing its tracking and isolation approaches and the NHS will be in a position to respond very rapidly should another wave hit.

23. In response to Mrs Williams, Mr Rafferty confirmed that the Trust’s winter planning will wrap into the pandemic/recovery phase 3 planning.

24. Mrs Fraenkel thanked Mrs Bennett and the team for the management of the situation whilst maintaining standards consistently across the Trust.

25.


Recommendations approved by the Board, namely: • Note the verbal update.


C2 NORTH WEST BOROUGHS STRATEGIC CASE

26. Mr Smith provided an update in relation to the revised strategic case for the proposed acquisition of North West Boroughs by Mersey Care stating that this had been agreed by the Joint Transaction Board and the Trust’s Resources Committee. If this Strategic Case was approved by both Boards today, a full business case would follow.

27. Mr Lyons referred to the front page of the report, noting that this should have ticked/included reference to the equality and human rights analysis, confirming that on impact assessment, the transaction would promote and advance quality.

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28.


Recommendations approved by the Board, namely: • Approve the submission of the strategic case to NHS

Improvement / NHS England (subject to any amendments required after reviewing the full un-redacted version in the Private Board meeting)


C3 BAME / PHE Report (presentation)

29. Mrs Oates introduced Mr Chris Muzavazi and Mrs Salome Mare-Walsh and shared a set of slides with the Board outlining the support offered to our BAME staff and colleagues with protected characteristics. The detail in the slides covered:

• An introduction from the Chairman • COVID-19 Research for BAME • COVID-19 and our Workforce • What we have done so far • What we are planning • Link to Public Health England’s document: Disparities in the risk and outcomes of

COVID-19 • Risk flow chart • Public Health England’s suggested introductions • 5 ambitions for BAME networks • Roger Kline – What now for NHS staff race discrimination – suggestions • Revised Governance Process Equality & Inclusion • Voice of the BAME Network – Christopher Muzavazi (Chair) and Salome Mare-

Walsh (Vice Chair)

30. Mrs Fraenkel welcomed Mr Muzavazi and Mrs Mare-Walsh, stating that this was an area where the Board was entirely committed to understanding more, noting that the vast majority of Boards across NHS organisations were not reflective of the BAME community.

31. Mrs Oates stated that the Board commitment was evident and that the Board needed to think about the meaning of racism and engage with the BAME Network, acknowledge, apologise where appropriate and act on this knowledge. The Board and all colleagues should consider, ‘do we know enough about racism in society and indeed, in our own lives’.

32. Mrs Oates stated that COVID-19 had exposed significant differences and outlined to

the Board issues highlighted via the Network, specifically in relation to BAME staff and gaps in terms of learning and lack of proactive action. Mr Rafferty and Mrs Oates had written to all BAME staff individually and work continued across Networks.

33. Mrs Oates stated that NHS Improvement/England had provided a list of ambitions of the Network, including Freedom to Speak Up guardians, and Mersey Care were privileged to already have a Network in place.

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34. Mrs Oates stated that as a Board it was important to build equality and inclusion into

the design of everything we do, however there would need to be resources aligned to this. The Network had recognised that we as a Board, are championing their cause and will strive to take this forward.

35. Mrs Oates referred to Roger Kline, who some Board members will recall had worked

with the Trust previously. Mr Kline had provided some suggestions for the Board to consider including establishing a new Board level committee inclusive of equality and inclusion, therefore the Board had approved the creation of a People Committee which met for the first time on 19 June 2020 for a planning meeting.

36. Mr Muzavazi thanked the Chair for her remarks and for the opportunity to speak to the

Board, stating that the BAME Network wished to express gratitude to the Board for its support. Mr Muzavazi particularly offered thanks to Mrs Oates who had been working tirelessly to address issues from the BAME community.

37. Mrs Mare-Walsh stated that she also wished to thank the Trust for baring the cost of

Vitamin D testing for most senior BAME staff in the Trust, even though there was no evidence to support the link with lack of Vitamin D. Mrs Mare-Walsh welcomed the opportunity for BAME staff to work alongside the Freedom to Speak Up guardian, noting it was good for BAME staff to be able to speak directly to someone from a similar background who would better understand the issues faced by staff. Thanks was also offered to the Organisational Effectiveness Team for supporting emotional wellbeing with offers of support within psychological interventions, which was overwhelming.

38. Mr Muzavazi sought the Board’s support for more resources, stating that there was a

need to put time and resources into the Workforce Race Equality Scheme (WRES) programme, given what had been learned from COVID-19.

39. Mrs Fraenkel thanked all who were part of this initiative and thanked Mr Muzavazi and

Mrs Mare-Walsh for their gracious comments to the Board and asked how they thought the Board could further develop themselves. Mrs Oates stated there were lots of ideas currently and these will be put into writing to enable a more meaningful conversation on 1 July 2020 when the Chairman and Chief Executive join the meeting.

40. Mr Smith confirmed that the Trust would find the resources required in order to support

this programme.

41. Mr Copple stated that Governors would welcome an invitation to any of these meetings and Mr Prayogg offered his help in any capacity. Dr Till welcomed the excellent progress and collaboration.

42. Mrs Mare-Walsh left the meeting at this point.

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43.


Recommendations approved by the Board, namely: • Note the presentation.


C4 ESTABLISHING A CHARITY

44. Mrs Darbyshire sought Board approval for a proposal for the Trust to establish its own charity – the Mersey Care NHS Foundation Trust Charity. By establishing a NHS charity, the Board of Directors as the legal body would become the corporate trustee for the charity and Mrs Darbyshire highlighted the process to the Charity Commission and the governance arrangements that needed to be established to oversee the charity.

45. Mrs Darbyshire stated that the Trust had closed its charity in 2009 due to admin costs; however there was a case to re-establish a charity in order to benefit from significant donations made to the NHS Charities during the pandemic. The rationale for a charity will be to support mental health, population health and also to support suicide prevention of our population and campaigns will be run underneath the charity. If the Board approve this proposal, an application will be submitted to the charity organisation by July 2020.

46. Mr O’Keeffe stated that following a meeting with Mrs Darbyshire he was supportive of this action.

47. Mr Williams sought clarity in relation to Trustees of the charity. Mr Meadows confirmed a paper would be taken to the Audit Committee outlining how this would be managed day to day, however confirmed that Board members will become a Trustee as a corporate body.

48.


Recommendations approved by the Board, namely: • consider and approve the proposal to establish the

Mersey Care NHS Foundation Trust Charity in the manner described in this paper, including the establishment of a Charitable Funds Committee as a committee of the Board of Directors;

• consider and approve the updating of paragraph 6.9, Annex 9 (Standing Orders for the Practice and Procedure of the Board of Directors) of Trust’s Constitution to reflect the Board’s Committees, recommending to the Council of Governors that they also approve this change at their next meeting;

• permit the Director of Social Inclusion and the Trust Secretary to apply to the Charity Commission to register the charity.

Further actions required: • Report to the Audit Committee in relation to

management of the MCT Charity;

E Darbyshire (A Meadows)

Aug-20

On Aug-20 Audit Agenda

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C5 a) Annual Report

b) Annual Accounts

49. Both reports had previously been considered by the Audit Committee and the Board via the Virtual by Email process.

50. Following this, some amendments had been made and Mr Meadows confirmed that an updated Annual Report had been circulated to the Board yesterday along with a request for permission to add electronic signatures where appropriate.

51. Both the Annual Report and Annual Accounts had been approved by the Board.

52.


Recommendations approved by the Board, namely: • Approve the amended 2019/20 Annual Report

circulated by email on 23 June 2020; • Grant permission to add electronic signatures where

appropriate; • Approve the 2019/20 Annual Accounts and letter of

Representation circulated by email on 23 June 2020


C6 HEALTH SAFETY AND WELFARE POLICY (SA07)

53. Mrs Darbyshire provided the updated Health Safety and Welfare policy for the Board’s approval.

54.


Recommendations approved by the Board, namely: • Agree the content and suitability of the Health Safety

and Welfare Policy.


D1 RISK REFLECTION

55. Mrs Fraenkel referred to the potential requirement to include a separate risk in relation to BAME in the Board Assurance Framework. Mrs Oates confirmed that an action from the People Committee included a review of this issue with Dr Thomas reviewing from a patient perspective and Mrs Oates reviewing from a staff perspective.

56. No further items were raised.

D2 REFLECTION ON THE MEETING AND WHETHER ANY ISSUES NEED TO BE REFERRED TO A BOARD COMMITTEE

a) Report in relation to management of MCT Charity to be provided to the August 2020 Audit Committee (reflected in the minutes/action above);

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57. No further items were raised.

D3 ANY OTHER BUSINESS

58. Mr Prayogg asked if the Trust had formally agreed a public statement in relation to the Black Lives Matter agenda. Mrs Oates thanked Mr Prayogg for this important question and confirmed that Mr Rafferty had already included this in his weekly blog and BAME staff had been written to individually, however the Board will further reflect on this and consider if there is something more it can do. Mrs Fraenkel concurred, stating that whatever the statement, it must be reflective and from the heart. Mrs Oates agreed to discuss this further with Mr Prayogg outside of the meeting.

59.


Further actions required: • Review potential to issue formal public statement in

relation to Black Lives Matter agenda;

A Oates

Jul-20

Jul-20



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Date of Meeting Agenda Item Action Executive Lead Operational

Lead

Proposed Date of

Completion

Item Status Comments

31 July 2019 - Public Board Meeting

F1-Life Rooms Update Life Rooms update report to Board of Directors in November

Exec Lead: E Darbyshire Operational Lead: M Crilly

01/11/2019 (deferred to May 2020)

not due

Update to be provided to Board in March 2020 in addition to Life Rooms Strategy. Deferred to May to allow external input. Further deferred due to COVID-19 outbreak but update provided to Board in May 2020.

May 2020 Public Board Meeting

B9-Board Assurance Framework

Report to Audit Committee in relation to the two increased risks and the planned cohesive approach to address

N Thomas F Westhead Aug-20 Not due On Aug 2020 Audit Ctte Agenda

May 2020 Public Board Meeting

C1-Safety Report

Update in relation to non compliance with the Trust's Learning from Deaths policy and identified issues in relation to quoracy of the Mortality Review Group to be included in the next report to the Board

N Thomas Jul-20 To be included in Jul-20 Safety Report to the Board

June 2020 Public Board Meeting

C4-Establishing a Charity Report to the Audit Committee in relation to management of the MCT Charity E Darbyshire A Meadows Aug-20 Not due On Aug-20 Audit agenda

June 2020 Public Board Meeting

D3-AOBReview potential to issue formal public statement in relation to Black Lives Matter agenda

A Oates Jul-20 Jul-20

KEY

Public - Board of Directors - Action Log

31 July 2019 - Public Board Meeting

20 May 2020 - Public Board Meeting

TO ACTIONONGOINGCOMPLETED

24 June 2020 - Public Board Meeting

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Report to: Board of Directors Meeting Date: 29 July 2020 This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

Chairman’s Update

Accountable Director(s): Beatrice Fraenkel, Chairman Report Author(s): Sarah Jennings, Deputy Trust Secretary

Alignment to Strategic Objectives:

Our Services ☒ Integrate Services ☒ Improve population health ☒

Continuous improvement (STEEP)

Our People ☒ Become an employer of choice ☒

Progress our Just and learning Culture goals

☒ Work side by side with service users and carers

Our Resources ☒ Achieve financial

sustainability ☒ Invest in digital technology ☒ Improve our estate ☒ Transform

Corporate Services

Our Future ☒ Develop Provider Alliances ☒

Accelerate research and development

☒ Commercialise our knowledge

Alignment to the Quality Domains:

STEEEP ☐ Safe ☐ Timely ☐ Effective ☐ Efficient ☐ Equitable ☐ Person-centred

CQC ☐ Safe ☐ Responsive ☐ Effective ☐ Caring ☒ Well-led

Purpose of Report: To allow members of the Board of Directors to receive an update from the Chairman on:

- Meetings and events attended in the reporting period; - Non-Executive Directors visits to services; - Appointment of Louise Edwards as an Executive Director; - An update on the Council of Governors

Recommendation: The Board of Directors is asked to: 1) note the Chairman’s Report.

Previously Presented to: Committee Name Date (Ref) Title of Report Outcome / Action

Do the action(s) outlined in this paper impact on any of the following issues? Area Yes If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Operational Performance ☐ Provider Licence Compliance ☐ Legal Requirements ☐ Resource Implications ☐

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐

Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☐ ☒ Events and Meetings

1. Since my previous report to the Board of Directors in March 2020 I have attended a series of meetings both local and national which have resulted in a significant amount of shared learning and have been invaluable in building and strengthening relationships with other organisational leaders.

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6. At a national level attended the Board of NHS Providers and the Finance Committee of the Board virtually in addition to the NHS Confederation Mental Health network.

7. I have attended a weekly online meeting of all mental health/community trust Chairs In England to discuss specific topics, with an expert speaker, facilitated by the Mental Health Network. I also continue to join a weekly virtual meeting hosted for all NHS Chairs and Non-Executive Directors by the Good Governance Institute to pick up on matters of shared importance and with supporting experts. Both these regular meetings are extremely helpful in sharing and disseminating ideas and learning from as well as understanding much more about the diversity of our populations across the country.

8. Other regular meetings I continue to attend virtually include:

a) bi-weekly meetings with the Chief Executive;

b) weekly meetings with our Non-Executive Directors;

c) regular meetings with NHS Liverpool Clinical Commissioning Group and Liverpool City Council in respect of the One Liverpool Project;

d) fortnightly teams meetings the Regional Directors;

e) regular contact with Local Chair colleagues;

f) attendance at listening events with staff led by Trish Bennett, Executive Director of Nursing and Operations;

g) attendance at many online webinars and seminars connected to developing thinking about health service delivery, economic regeneration and many associated topics.

9. As the risks associated with COVID-19 continue, as a Trust we continue to take steps to avoid face to face meetings.

Non-Executive Director Visits to Services

10. In light of the on-going risks associated with COVID-19, all Non-Executive Director visits will be suspended for the next few months. This decision will be kept under active review.

Louise Edwards Appointed as Executive Director

11. On the 9 July 2020, the Remuneration and Terms of Service Committee approved the appointment Louise Edwards as an Executive Director.

12. We are delighted that Louise is now a voting member of the Board and this reflects the importance the trust places on its strategic planning and the substantial programme of work ahead as we grow and acquire different services.

Council of Governors

13. At the end of September 2020 a number of our Governors will reach the end of the terms of office. These are:

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a) Paul Allen [staff constituency];

b) Sayed Ahmed [staff constituency];

c) Tracey Cummins [staff constituency];

d) Garrick Prayogg [public constituency];

14. I would like to take this opportunity to thank Paul, Sayed, Tracey and Garrick for your valuable contribution as a Governor.

15. Feedback Questionnaires will be circulated to Governors finishing their terms above to ensure we learn from their experience on the Council of Governors.

16. In addition to the above four seats that will become vacant, we have the following existing vacant seats:

a) Service User and Carer Constituency – One Seat

b) Staff Constituency (Nursing) – One Seat

c) Public Constituency (Ribble Valley) – One Seat

17. We have given much thought to the decision regarding holding Governor elections at the current time in light of COVID-19 and have also been reviewing the decisions made by other Foundation Trusts during this time in respect of elections. As such, we have made the decision to proceed with the elections as planned.

18. The next formal elections will commence in July 2020 to fill 7 seats on the Council of Governors. As such, a draft timetable for these elections is in place to seek nominations between 30 July 2020 and 17 August 2020 as outlined below:

Election Stage Dates Notice of Election / nomination open Thursday, 30 Jul 2020 Governor Awareness Sessions (x3) 1 Aug – 17 Aug 2020 Nominations deadline Monday, 17 Aug 2020 Summary of valid nominated candidates published Tuesday, 18 Aug 2020 Final date for candidate withdrawal Thursday, 20 Aug 2020 Notice of Poll published & Distribution of Voting Packs Thursday, 3 Sep 2020 Close of election Thursday, 24 Sep 2020 Declaration of results Friday, 25 Sep 2020

19. As you will be aware, we ordinarily hold a series of Governor Awareness Sessions

across our geography to provide further information and support to those individuals interested in standing for election.

20. In light of social distancing measures and the continue risks in respect of the COVID-19 outbreak it would not be appropriate for us to do this face to face. We will however arrange three online (Zoom) sessions which interested individuals can book on to.

21. I will report to the Board on the outcomes of the elections in due course.

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Report to: Public Board of Directors Meeting Date: 29 July 2020 This Report is provided: ☒ for a decision ☐ to note / for information ☐ as a consent item

Chief Executive’s Update

Accountable Director(s): Joe Rafferty, Chief Executive

Report Author(s): Andy Meadows, Trust Secretary Sarah Jennings, Deputy Trust Secretary




Our People ☐ Become an employer of choice ☐


☐ Work side by side with service users and carers

Our Resources ☐ Achieve financial


Corporate Services



☐ Commercialise our knowledge


STEEEP ☒ Safe ☐ Timely ☐ Effective ☐ Efficient ☐ Equitable ☐ Person-centred

CQC ☒ Safe ☐ Responsive ☒ Effective ☐ Caring ☒ Well-led

Purpose of Report: To allow members of the Board of Directors to consider a range of issues that impact on the Trust through receiving an update on key issues of interest / information arising that are not already covered in other papers to this meeting,

Recommendation: The Board of Directors is asked to: 1) note the contents of this paper; 2) join Simon Stevens, chief executive officer of the NHS, in his call

for more systematic action to tackle the underlying causes of health inequality and the pursuit of high quality care for all;

3) commit itself to being held account for our progress in these matters and continue to engage with our networks to ensure we work with colleagues to identify and co-produce high impact actions, interventions and measures;

4) approve the proposed amendment to Annex 9 of the Constitution outlined as outlined in para 35 of this report.



Operational Performance ☐ . Provider Licence Compliance ☐ Legal Requirements ☐ Resource Implications ☐

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more ☐ ☒ ☐

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favourably than any other? Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☐ ☒ NATIONAL ISSUES

COVID-19 Major Incident Arrangements Still In Place

1. The NHS is still subject to a level 4 major incident in respect of the COVID-19 Outbreak. This means that Mersey Care, like all NHS organisations across England, is subject to command and control arrangements in respect managing both the response to, and the recovery from, the outbreak.

2. In light of these command and control arrangements the Trust is subject to instruction and guidance that it is required to adhere to. Details of this NHS guidance can be found on NHS England’s website at https://www.england.nhs.uk/coronavirus/

3. An update on the Trust’s response to the COVID-19 outbreak is included on today’s agenda.

The Road to Renewal: Five Priorities for Health and Care

4. The Kings Fund have published a piece which sets out five priorities to help guide the approach to renewal across health and care reflecting on lessons learnt from the COVID-19 outbreak, the biggest challenge the health and care system has faced in living memory.

5. According to the report, the first months of the COVID-19 outbreak have shown many aspects of the health and care system at its best. Health and care workers have responded with outstanding dedication and skill; clinicians and managers have gone above and beyond to rapidly develop new ways of delivering services safely; hospitals have joined forces to offer mutual aid and ensure continued provision of essential services; and in some areas NHS, local government and other local services have worked together like never before to co-ordinate their responses and support communities.

6. But the events of recent months have also exposed glaring issues and in some cases exacerbated existing shortcomings:

a) people who have been worst affected by the virus are generally those who had worse health outcomes before the pandemic, including people from ethnic minority communities and those living in poorer areas. Following on from England’s poor record on life expectancy, COVID-19 has exposed the deep inequalities that exist between different population groups and areas of the country, neglected at significant cost over the past decade;

b) COVID-19 has laid bare the weaknesses in a social care system that has been underfunded and overlooked for too long. The sector was neglected by the government at the start of the pandemic, with tragic consequences for service users, families and staff, and unacceptable numbers of deaths;

c) years of poor workforce planning, weak policy, lack of national leadership and fragmented responsibilities have resulted in a workforce crisis across both health

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https://www.england.nhs.uk/coronavirus/

and social care. Already under enormous strain, staff have now had to work through the demands of the pandemic; the impact on their wellbeing should not be underestimated;

d) following the longest funding squeeze in its history, before the pandemic NHS services were already running hot all year round with little capacity to spare, and deep cuts in local authority budgets had left the social care system on its knees.

7. The Kings Fund have set out a series of proposal in order to ensure the health and care system meets the significant challenges to restoring services, not only in hospitals, but also in social care, primary care, mental health and community-based services including:

a) a step change on inequalities and population health – quick development of a cross-government strategy on health inequalities, inequalities reduction should be a central focus for all local health and care partnerships and a more ambitious approach to improving population health and reducing health inequalities;

b) lasting reform for social care - urgent addressing of short-term funding pressures, escalation of proposals for longer-term investment and reform as an immediate priority and a wider reform underpinned by better pay, conditions and training for the social care workforce.

c) putting the workforce centre stage - concrete steps to improve recruitment and retention, better support for staff wellbeing and leaders at all levels in health and care to prioritise developing cultures of compassion, inclusion and collaboration;

d) embedding and accelerating digital change in the wake of recent progress - rapid evaluation of approaches and measures taken during the pandemic is needed to inform future digital change, digital infrastructure and tools need to be built with transparency and involvement from the public and health and care staff and take steps to prevent digital technologies entrenching or widening health inequalities

e) reshaping the relationship between communities and public services - health and care services should understand and work with communities’ priorities, needs and strengths and local health and care systems should take steps to safeguard the role of voluntary and community organisations.

8. The full report is available here.

Workforce Race Inequalities and Inclusion in NHS Providers

9. The Kings Fund have published a report into the workforce race inequalities in the NHS through exploring how three NHS provider organisations have sought to address these inequalities and develop positive and inclusive working environments.

10. According to the report, the NHS has one of the most ethnically diverse workforces in the public sector. However, year after year, ethnic minority staff report worse experiences in terms of their lives and careers, when compared with white staff and people from an ethnic minority background are under-represented in senior positions in the NHS.

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https://www.kingsfund.org.uk/publications/covid-19-road-renewal-health-and-care

11. Three NHS trusts were selected where there are promising signs of positive change in terms of race inequalities and inclusion: Bradford District Care NHS Foundation Trust, Calderdale and Huddersfield NHS Foundation Trust and East London NHS Foundation Trust.

12. All three case studies implemented similar interventions aimed at addressing race inequalities and inclusion, including:

a) staff networks;

b) ensuring psychologically safe routes for raising concerns (specifically by appointing Freedom to Speak Up Guardians);

c) enabling staff development and career progression.

13. In combination, these interventions could support ethnic minority staff in feeling their organisations were committing to making positive changes. The implementation of these interventions was largely perceived as beneficial, however the Kings Fund observed there was potential for some staff to react negatively to them. The interventions made it safer to talk about race, but this inevitably raised some ugly truths about behaviours between colleagues. Leaders at all levels play an important role in supporting and resourcing race equality and inclusion initiatives and addressing resistance and issues as and when they occur.

14. The report summaries the learning as follows:

a) approaches to race equality and inclusion are not ‘one size fits all’. There is a lack of proven interventions and it is down to individuals and organisations making a concerted effort at a local level to iterate the approach that ‘works’ for them;

b) addressing inequalities and inclusion needs to be an ongoing, ‘moment-by-moment’ activity that engages with and responds to people’s lived experiences.

15. The full report published in July 2020 is available here.

LOCAL ISSUES

Independent Investigation into Former Liverpool Community Health NHS Trust

16. In February 2018 the Independent Review into Liverpool Community Health NHS Trust (LCH), led by Dr Bill Kirkup, was published. Following its publication, NHS England wrote to all those organisations who had taken responsibility for the former LCH’s services and asked them to review the management of serious reviews, bullying and whistleblowing cases by the former LCH (reflecting two of the recommendations from this Review). Mersey Care, as the organisation who has assumed responsibility for the majority of the former LCH’s services completed this exercise and reported its findings to NHS England in April 2019

17. Partly in response to Mersey Care’s findings on the management of serious incidents, in June 2019 the then Minister of State for Health, Stephen Hammond MP, announced that an Independent Investigation into patient safety and deaths at the former LCH. This was to be chaired by Dr Bill Kirkup

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https://www.kingsfund.org.uk/publications/workforce-race-inequalities-inclusion-nhs

18. On 17 July 2020 the secretary to the Liverpool Community Health Independent Investigation, Oonagh McIntosh, wrote to the Chair and Chief Executive, together with a range of stakeholders (including family members, local MPs, other local providers, etc.) to inform people that the Investigation’s terms of reference had been published in Parliament and that Dr Kirkup will be leading a Panel Investigation, the panel members being:

a) Julian Brookes – Governance;

b) Dr Kern Clancy – Registered Nurse;

c) Christine Gifford – Information Expert including GDPR and Data Protection;

d) Brenda King – Nurse Consultant;

e) Dr Mary Piper – Prison Healthcare.

19. The terms of reference can be found at Appendix A. The Independent Investigation will be liaising with the Trust to confirm its evidence gathering processes and other arrangements in the coming weeks. The Investigation in mindful that the NHS is currently focussing on the COVID-19 response. Further information will also be available in the Investigation’s website, which will be launched soon.

Our Pursuit of Equality

20. Staff will have seen in our communications over the past weeks our clear and unequivocal call for all of us to understand that black lives matter today and always. This message has not changed. We are resolute in our stance that any form of racism or other forms of discrimination, harassment and victimisation is unacceptable. Discrimination is damaging and destructive and this must change. At Mersey Care, we stand with people everywhere who experience racism or discrimination in any form, and we have chosen to speak out here again against this injustice.

21. This is especially important as it is increasingly clear that COVID-19 is having a disproportionate impact on our black, Asian and minority ethnic (BAME), older, male and disabled patients, friends and colleagues. And this in turn has brought into stark and urgent focus the layered impacts of years of disadvantage and inequality. So it is clear that it is important for us to take action to protect people, including our colleagues, by doing everything we can.

22. Our first step has been for us to develop an effective risk assessment approach; engaging with colleagues in the staff networks (BAME, LGBTQ+, Women, Dyslexia and Dyspraxia) has played (and will continue to play) an important role in this.

23. Following ongoing engagement with the BAME staff network around the outcome of emerging research, including Public Health England’s report on disproportionate outcomes in relation to COVID-19, we developed and introduced an additional enhanced safety assessment to consider other risk factors and ensure that additional mitigating measures and actions could be put in place to support colleagues. This aims to support people in feeling physically and psychologically safe.

24. The enhanced safety assessment was developed in consultation with analyst support from a BAME colleague and the BAME staff network was engaged in the development

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of this assessment tool. Roll out of training for BAME staff and managers on the use of the enhanced safety assessment commenced on 18 June 2020. We are also conducting a wider equality impact assessment (EIA) of our workforce to understand the impact of COVID-19 on those with protected characteristics that fall into other at-risk groups and categories and take action to support them.

25. As part of our COVID-19 command and governance structures we established the ethical cell where decisions are made about the vulnerable colleagues risk assessment and the enhanced safety assessment, this is chaired by Dr Arun Chidambaram (Operational Medical Director) and has BAME colleague representation.

26. Our aim is to assure a culture of continued dialogue and authentic and sustainable support to help make sure that outcome, intervention and protection measures are real, relevant and based on personal circumstances. For example, we have extended carer’s leave arrangements to ensure that people who need it, have adequate time and space to be able to support their families and loved ones if required. We have put in place additional supportive measures where possible, some examples include: vitamin D deficiency tests for BAME colleagues over 55 and prioritising COVID-19 antibody test. We have also introduced an additional Freedom to Speak Up Champion, Talia Thomas from the BAME Staff Network, to encourage BAME staff to speak up and raise concerns.

27. We will be issuing a survey to understand the impact of COVID-19 on staff and their families and analysing the results from an equality perspective. We also aim to sign up to the Race at Work charter this requires us to:

a) appoint an executive sponsor for race (Amanda Oates has volunteered to undertake the role of executive sponsor, with full Board support);

b) capture ethnicity data and publicise progress;

c) commit at Board level to zero tolerance of harassment and bullying;

d) make clear that supporting equality in the workplace is the responsibility of all leaders and managers;

e) take action that supports ethnic minority career progression;

28. We aim to recruit a colleague to fill the vacant chair role in the Disabled Staff Network and continue to engage with colleagues on their experiences, management and impact of COVID-19, and introduce ‘catalyst conversations’ across all of our staff networks (BAME, LGBTQ+, Women, Dyslexia and Dyspraxia).

29. We must join Simon Stevens, chief executive officer of the NHS, in his call for more systematic action to tackle the underlying causes of health inequality and the pursuit of high quality care for all and agree that faster action is needed on the reality of the racism and discrimination experienced by many colleagues working in the NHS.

30. The Board must commit itself to being held account for our progress in these matters and we will continue to engage with our networks to ensure we work with colleagues to

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identify and co-produce high impact actions, interventions and measures. Our Board committees and Board of Directors will regularly be reviewing progress.

Liverpool City Region Listens: Our Recovery

31. Steve Rotheram, Metro Mayor of the Liverpool City Region, has launched a public engagement exercise to listen to local people’s priorities, to help shape the Liverpool City Region’s ambitious plans for economic recovery. The proposed plan will set out how we will respond to the impact of the Coronavirus Pandemic for the whole city region and will be submitted to central government later this month.

32. The plan builds on the city region’s Local Industrial Strategy, which was the subject of extensive public engagement through the Metro Mayor’s “#LCRListens” scheme, which brought in a new approach to involving local residents in shaping the future of our city region.

33. Local residents are now invited to take part in an online #LCRListens survey, giving local people the opportunity to comment on key elements of the draft economic recovery plan to help the City Region “Build Back better”

34. Further information is available at https://LiverpoolcityregionalCA.researchfeedback.net/s.asp?k=159403145017

Constitution

35. The Board of Directors approved the creation of a charity – the Mersey Care NHS Foundation Trust Charity – at its meeting in June 2020. As part of the governance arrangements to oversee the charity, an additional Board Committee has to be established – the Charitable Funds Committee. Board members are therefore asked to consider an amendment to Annex 9 (Orders for the Practice and Procedures of the Board of Directors) of the Constitution to reflect the establishment of the Committee – the change is detailed in Appendix B. This amendment will be considered by the Council of Governors of their meeting on 22 July 2020.

36. As members are aware, all changes to the Constitution need to be considered and approved by both the Board of Directors and the Council of Governors.

END

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https://liverpoolcityregionalca.researchfeedback.net/s.asp?k=159403145017

INDEPENDENT INVESTIGATION OF PATIENT SAFETY INCIDENTS AND DEATHS AT LIVERPOOL

COMMUNITY HEALTH NHS TRUST

TERMS OF REFERENCE Background and Powers:

1. Community health services are rarely at the forefront when the NHS is being considered or discussed, and often seem to be low on the list of NHS priorities. Yet these services are vital to the care of patients, particularly the growing number who have longer-term health problems and they are essential to the proper functioning of hospitals general practice and mental health services. They deserve more attention. 2. In February 2014, Rosie Cooper MP raised questions about the management of the Liverpool Community Health NHS Trust (the ‘Trust’) with the Secretary of State for Health and with the Prime Minister. This followed whistleblowing concerns from staff at the Trust. Rosie Cooper MP had also witnessed staff under significant pressure trying to provide appropriate patient care when her own father was a patient in an intermediate care ward run by the Trust. 3. An Independent Review chaired by Dr Bill Kirkup CBE was established. The Review Report, published on 8 February 2018, found significant failings in the Trust from November 2010 to December 2014, the period covered by the Review’s terms of reference. The Review Report may be accessed here. 4.The Secretary of State noted that the Review Report described how over-ambitious cost improvement programmes as part of a bid for foundation trust status placed patient safety at risk, leading to serious lapses in care and widespread harm to patients. A culture of bullying meant that staff were afraid to speak up and safety incidents were ignored or went unrecognised. 5. Stakeholders were contacted, and their responses were taken into consideration when framing these terms of reference. The Secretary of State has therefore appointed Dr Kirkup to chair an Independent Investigation of historic patient safety incidents and deaths at the Trust. 6. The Independent Investigation is: established under the general duties and powers of the Secretary of State

for Health and Social Care in Parts 1 and 2 of the NHS Act 2006; founded on the principle that the public interest demands that the failings

uncovered at the Trust should never be repeated; and:

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https://improvement.nhs.uk/documents/2403/LiverpoolCommunityHealth_IndependentReviewReport_V2.pdf

is designed to recommend measures that will protect the public against seriously improper conduct.

7. Accordingly, the Independent Investigation will be required to obtain and review evidence from all relevant organisations and individuals. It is therefore incumbent on organisations and individuals to assist by providing information including documents, written and oral evidence including, where relevant, personal data, in order that the Investigation can deliver these Terms of Reference. Remit of the Independent Investigation 8. The Independent Investigation will be conducted over three stages. Stages 1 and 2 will identify individual serious patient safety incidents that had not been reported or adequately investigated by the Trust and undertake a series of historic, mortality reviews. 9. Stage 3 will fully investigate those individual serious patient safety incidents identified from the previous stages to determine the scale of deaths and patient harm and identify local and national learning. 10. The Independent Investigation will also advise regulators where, in the opinion of the Panel, the systems, processes and senior leadership within the Trust may have adversely contributed to the safe delivery of patient care. It will identify any themes, trends or issues that may require further investigation.

a) establish the nature and scale of deaths and patient harm at the Liverpool Community Health NHS Trust between 2010 and 2014 and the action taken at the time by the Trust and other organisations;

b) determine the lessons, both local and national, which need to be

understood and followed in order to reduce the risk of similar deaths and patient harm in future.

11. The Independent Investigation will produce and submit to the Secretary of State for Health and Social Care and to the Minister of State for Health and Social Care a report, with recommendations, which will be published in Parliament. 12. If information is obtained in the course of the Independent Investigation, it will report any instances of apparent collusion or other conduct of concern (including conduct that indicates the potential commission of criminal or disciplinary offences) to the relevant employer(s), professional or quality regulator(s), and/or the police for their consideration. The Investigation does not have the power to impose disciplinary sanctions or make findings as to criminal or civil liability. 13. The Independent Investigation will aim to submit its Report in Winter 2021.

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Work of the Independent Investigation: 14. The Chair will appoint expert members and a staff team (Secretariat) with appropriate experience in order to help deliver these Terms of Reference. 15. The Independent Investigation will engage with former patients, families and staff to understand their concerns and take written and oral evidence as deemed necessary. 16. The Independent Investigation will put in place confidentiality agreements with individuals and organisations in order to facilitate sharing of information with the Investigation. The Independent Investigation will also agree with individuals and organisations where their information is considered for publication, and will, before publication, notify individuals and provide them with an opportunity to respond to any significant criticism proposed for inclusion in its Report. 1 July 2020

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Appendix B Proposed Changes to the Constitution

1. The following changes are proposed to the Version 8 of the Trust’s Constitution

following the establishment of the Charitable Funds Committee.

2. Annex 9 (Orders for the Practice and Procedures of the Board of Directors) – in light of the establishment of the Mersey Care NHS Foundation Trust Charity approved at the Board of Directors in June 2020, to make the following change to Section 5 (Arrangements for the Exercise of Functions by Delegation) relating to Committees Established by the Board, namely :

a) paragraph 6.9.6 – to add a new paragraph about the Charitable Funds Committee with the following text:

“Charitable Funds Committee

A charitable funds committee will be established and constituted by the Board as the ‘Corporate Trustee’ for the Mersey Care NHS Foundation Trust Charity to (i) apply scrutiny and constructive challenge to the Charity's financial information and systems of control, including the annual accounts, (ii) provide assurance to the Board of Directors that the administration of charitable funds is distinct from its exchequer funds and compliant with legislation and Charity objective.”

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Trust Response to COVID-19 - Update

Accountable Director(s):

Trish Bennett, Executive Director of Nursing and Operations Noir Thomas, Executive Medical Director Elaine Darbyshire, Executive Director of Communications, Corporate Governance and Estates

Report Author(s): Collated by the Corporate Governance Team from information provided by Teams across the trust









Corporate Services





STEEEP ☒ Safe ☒ Timely ☒ Effective ☒ Efficient ☒ Equitable ☒ Person-centred

CQC ☒ Safe ☒ Responsive ☒ Effective ☒ Caring ☒ Well-led

Purpose of Report: To provide members of the Board of Directors with some further information about the Trust’s response and recovery activities in respect of the COVID-19 outbreak. Further information is also provided in other reports submitted to July 2020’s Board meeting.

Recommendation: The Board of Directors is asked to: 1) note the contents of this report



Operational Performance ☒ The Trust is responding to the COVID-19 outbreak in line with command and control arrangements established by NHS England in line with their declaration of a level 4 major incident Provider Licence Compliance ☐

Legal Requirements ☒ Resource Implications ☒

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☒ ☐ ☐

Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☐ ☒ If answered ‘YES’ to either question, please include a section in this report explaining why

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EXECUTIVE SUMMARY

1. The purpose of this report is to outline the Trust’s response to the COVID-19 outbreak. This report should be read in conjunction with:

a) Item B9: Board Assurance Framework – updated to reflect risks relating to COVID-19;

b) Item C1: Safety Report - which includes information on COVID-19 related incidents;

c) Item C2: Executive Performance Report - updated to reflect a range of indicators relating to COVID-19.

2. In response to (i) national guidance issued by Government or NHS England / Improvement (NHSE/I) or (ii) the unprecedented demand due to COVID-19, the Trust has made changes to its services / the way in which it provides services. These decisions have been overseen by the Trust’s COVID-19 response and recovery command and control arrangements (outlined below). Currently the Trust is working hard to re-established those services impacted or provide them in new ways. The latest information on the Trust’s services is available on our website (www.merseycare.nhs.uk) or by clicking here.

UPDATE

COVID-19 Major Incident Arrangements Still In Place

3. The NHS is still subject to a level 4 major incident in respect of the COVID-19 Outbreak. This means that Mersey Care, like all NHS organisations across England, is subject to national, regional and local command and control arrangements in respect managing both the response to, and the recovery from, the outbreak.

4. In light of these command and control arrangements the Trust is subject to instruction and guidance that it is required to adhere to. Details of this NHS guidance can be found on NHS England’s website at https://www.england.nhs.uk/coronavirus/

5. As such Trish Bennett remains as the Executive Lead for the Trust’s COVID-19 response supported by the COVID-19 Strategic Coordination Group (together with Tactical Coordination Groups within each clinical division and across the corporate teams) and Neil Smith is the Executive Lead for the COVID-19 recovery activities supported by the COVID-19 Recovery Coordination Group (together with the clinical, resources and workforce cells). All these activities are supported by the Ethical Cell, which is chaired by Arun Chidambaram (Operational Medical Director).

6. The Trust has also reviewed and continues to review these incident management arrangements, including the battle-rhythm (i.e. frequency and types of meetings) in response to the COVID-19 pressures felt by both the Trust and the local health and social care systems.

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http://www.merseycare.nhs.uk/

https://www.merseycare.nhs.uk/about-us/news/coronavirus-changes-to-mersey-cares-services/

https://www.england.nhs.uk/coronavirus/

Overview of the Trust’s Response since March 2020 (Trish Bennett)

7. Sadly, there had been three COVID-19 related deaths on Irwell Ward at Clock View due to an outbreak on the ward in the early months of the Trust response. Due to changes in how we provide inpatients services, (e.g., the availability of testing, the use of Personal Protective Equipment (PPE) and the curtailing of visiting, etc) we have been able to reduce COVID-19 community-acquired infections.

8. Under new national guidance issued in the last two months, and in response to changes in inpatient care across the NHS, any COVID-19 outbreak involving two or more patients who have been on a ward for two weeks or more is now regarded as a hospital-acquired infection and has to be reported to the Board and our regulators (and is potentially subject to scrutiny by our regulators). Since the guidance has changed the Trust has had one such outbreak which was effectively managed and did not result in a patient death. The Trust continues to be vigilant in protecting both its patients and staff

9. In March the Trust saw absence levels around 25%, which was a mixture of sickness, shielding and isolation. As testing has increasingly become available and the prevalence of COVID-19 appears to have reduced as a result of the lockdown and social distancing, these absence levels have reduced to around 10%. Although welcome, this is still higher than the absence levels normally experience by the Trust (i.e., between 6-7%)

10. Through the outbreak the Trust has been receiving regular Personal Protective Equipment (PPE) deliveries and has not suffered significant shortages. Moving forward we have sufficient PPE to meet the Trust’s requirement, even taking account of the fact we are now re-establishing our services.

11. As a key stakeholder in the local health and social care systems and the local communities we serve, we are conscious of the prevalence of COVID-19 and the demand that creates. So, for example, whilst the infection rate in Liverpool is currently 5 in 100,000 of the population - which was a positive reduction into single figures - Members will note that Blackburn with Darwen has one of the highest levels in England and is subject to additional lockdown provisions. Members will be aware this can potentially impact our services at Whalley, particularly as two-thirds of the staff who work at Whalley have Blackburn with Darwen postcodes. The Trust continues to closely monitor this situation.

12. As has been mentioned at the start of this report, services reduced earlier in the outbreak are beginning to be re-established, with the assessment of clinical spaces being prioritised as the Trust ensures COVID-19 safe environments for service users and staff. This work is being undertaken by the estates team, with the lists of prioritised spaces providing by the clinical divisions

13. As members of the Board will be aware from national media reports, COVID-19 has not gone away. The Trust is now planning for a possible surge in relation to a potential second wave of the virus simultaneously with winter flu. The flu campaign will begin earlier this year, starting in early September 2020. As such the Trust will need to

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ensure we have appropriate arrangements in place for living with COVID for the foreseeable future

COVID Safe Environments

14. The estates team, together with the health and safety team and the infection prevention and control team have been working against prioritised lists of services, provided by the clinical divisions, to ensure that the buildings used by staff and service users for service user facing services are COVID safe environments. This has involved mitigating works such as installing screens, identifying safe navigation around these premises and providing face masks / hand sanitation for these premises (again in line with national guidance) . Given that the Trust provides services from over 120 buildings this has been a significant effort from everyone concerned.

15. The Trust is now starting to address undertaking the same assessment and mitigating works in respect of its non-patient facing premises, which is why mainly those teams within the Trust’s corporate services division are still being asked to work from home, although there are some exceptions which have been COVID safe environment assessed (e.g. the pharmacy and some Life Room based services). In light of changes to the Government’s guidance, this is being reviewed and updated communications are being developed for all staff next week.

Visiting

16. Like all local NHS providers we have had to suspended visiting, although the Trust has approved visits by exception throughout the outbreak in line with guidance specifically for individuals suffering from cognitive impairment and / or learning disability / autism for whom not having face-to-face visits would be considered excessively distressing.

17. The Trust has pursued, wherever possible, the offer of virtual visiting by video-link in all other areas. The Trust has taken a cautious line on wider face-to-face visiting given the risk of re-introducing COVID-19 into ward areas, especially during times when community COVID-19 transmission has been high.

18. The Trust has aligned the opening for wider visiting with all other NHS providers in the North West, both acute and mental health providers. In considering the Trust’s policy on visiting, we do recognise the conflict between managing COVID-19 risk and its impact on individual rights and entitlement to visiting.

19. With the easing of lockdown in the community, and the phased reintroduction of visiting into care homes the Trust recognises that we will now have to move towards opening to wider visiting in all inpatient areas. As such plans are being developed by each site (in outdoor areas, where possible and in designated areas indoors) to facilitate a visiting programme in a safe, proportionate and controlled manner so that risk associated with increasing footfall is minimised. These arrangements are just in the process of being rolled out.

Risk Assessments for Staff

20. As Members will be aware, national guidance has asked that trusts undertake COVID-19 risk assessment for staff, particularly prioritising those groups that may be more

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vulnerable such as Black, Asian and Minority Ethnic (BAME) staff. Risk assessments have been offered to all staff, with the latest take-up rates as follows:

a) 30% of all staff have so far completed the risk assessment (i.e., 2,232 out of a total of 7,442 staff);

b) of those risk assessment completed, 52% have been completed by staff known to be ‘at risk’, with mitigating steps being instigated as necessary (i.e., 1,227 staff);

c) 81% of these risk assessment have been completed by staff known to be BAME.

Staff Engagement Programme

21. The Chair, Chief Executive and several members of the Executive Team continue to join team’s virtual Skype meetings across the Trust. In additional meetings such as the Collaborative Leadership Forum have now been moved from face-to-face meetings to Skype calls.

22. Over the summer months we have identified Our Big Four themes for staff engagement as part of the Trust’s four month journey to business better than usual: these are:

23. In July this will involve the following activities:

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24. Staff engagement for Our Big Four also includes content relating to inclusion. For example in July, all managers are being asked to follow the “Team Recovery Tips”. One of the tips is that all managers have a check-in conversation with each of their team members focused on their COVID-19 experiences and any support they need in relation to any protected characteristics that they hold.

25. Several members of the BAME Staff Network have requested a coach in response to a targeted offer made during COVID-19 lockdown and all have now been successfully paired up. Some members of staff have requested a BAME coach, which has highlighted a need to recruit and train more BAME coaches to the Mersey Care Coaching Pool (as the Trust has had to link in with external coaches to meet this need). We plan to deliver a Coaching Certificate programme in the autumn to address this need.

26. The BAME Staff Network has also been offered a “Team Time” (virtual Schwartz Round which is a form of Reflective Practice) which they choose to decline at this time. The Womens’ Staff Network have accepted the offer of a “Team Time” session.

Communications

27. Over the past few months the Trust’s Communications Team have effectively managed and delivered a host of complex messages in a fast moving environment helping to ensure that accurate up-to-date information has been available for staff, patients, service users, and their families. In fact the results of the recent Emergency Preparedness, Resilience and Response (EPRR) survey of those involved in the Trust response to the pandemic show that all groups reported that internal and external communications were effective. Responders welcomed additional measures put in place by the communications team. Positive feedback was also received in relation to

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the timeliness and accuracy of actions, information and decisions shared between the strategic and tactical groups.

28. The work supported the Trust’s overarching of aim of delivering safe and effective care in the most appropriate ways. The team has supported clinical services and helped to minimise time delays in getting key information out to both internal and external audiences. This work has included regular connection with the media, national, regional and local health system and adherence to the new protocols and requirements set by Government, the Department of Health and Social Care and other regulators in order to enhance and protect the Trust’s reputation and standing. The infographic on the next page demonstrates some of the depth and breadth of this important work.

Council of Governors and Board of Directors Governance Arrangements

29. Throughout the COVID-19 response the Trust has maintained its Council and Board assurance and reporting arrangements, although meetings have been held virtually and not face-to-face, so as to ensure lockdown and social distancing in line with both Government policy and guidance issued by NHSE/I.

30. Initially meetings were held either by teleconference or using a virtual by email process, whereas now meetings takes place virtually by Zoom. Although members of the public have not been able to access Public Board of Directors meetings as usual, since May 2020’s Board meeting the Trust has liaised with the Council of Governors to ensure that representative of the Governors have been able to observe Board

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meetings. From today’s meeting we are also making provision for members of the public to apply to join meetings by Zoom.

31. Moving forward our governance arrangements will continue to be adapted to meet the requirements of the Trust in line with Government and NHSE/I guidance. For example we are exploring options as to how we can broadcast our Annual General Meeting / Annual Members Meeting on 30 September 2020 (the same day as our Board meeting). Details of how we have been managing the Council’s and Board’s (and its Committees) meeting arrangements have been regularly reported to the Board.

EQUALITY IMPACT ASSESSMENT

32. National guidance has asked that NHS organisations undertake risk assessments for vulnerable staff, particularly from a BAME background. The Trust has undertaken this work with the advice and support of the BAME Staff Network.

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Board Assurance Framework V1 (July 2020) Accountable Director(s): Noir Thomas , Executive Medical Director Report Author(s): Frank Westhead, Trust Risk Manager


Our Services ☒ Integrate Services ☒Improve population health ☒


Our People ☒Become and employer of choice ☐


☒Work side by side with service users and carers

Our Resources ☒

Achieve financial sustainability ☒

Invest in digital technology ☒ Improve our estate ☒ Transform

Corporate Services

Our Future ☒Develop Provider Alliances ☒


☒Commercialise our knowledge




Purpose of Report: • To present the Monthly Risk Report for the Boardsconsideration.

• To provide assurance that the strategically significant risks arebeing actively managed.

Recommendation: The Board are asked to: 1) Confirm that the risks are being identified and managed

appropriately. 2) Identify any risks that need to be escalated as part of the Board

Assurance Framework. 3) Approve the inclusion of a new risk onto the BAF for the Infection

Prevention Assurance Framework.

a. (Draft): If there are gaps in the Infection prevention and control AssuranceFramework for the Trust, increasing the risk of transmission, resulting indisruption to service delivery, patient and staff harm, reputational damage andpotential liability.



Operational Performance ☒ The Board will have significant assurance for operational performances.

Good governance standards require that the trust has robust risk management and assurance process which provide significant assurance to the Trust Board, and through them to our regulators.

Provider Licence Compliance ☐ Legal Requirements ☒

Resource Implications ☐


Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☒ ☐

If answered ‘YES’ to either question, please include a section in this report explaining why

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Ref Standing BAF Risks Exec ScoreOur Service

S.1

Failure to make quality care more consistent will result in quality issues for the people we serve and

sustainability issues for the organisation

Trish Bennett /

Noir Thomas12

S.2

Failure to implement more preventative and integrated models of care means that we are unable to manage

rising levels of demand, workforce and financial pressures Trish Bennett12

S.3

Failure to understand the needs in our population means that we are unable to design services to effectively

meet those needs.

Louise

Edwards15

S.4

Failure to deliver transformational change in our community services results in less efficient and effective out

of hospital care. Trish Bennett12

Our People

P.1

Failure to implement our People Plan and create a compelling place to work results in continued staffing

pressures and impact of quality of services. Amanda Oates12

P.2

Failure to adopt new roles and ways of working leads to a widening gap between the needs of the population

and our model of care. Amanda Oates12

P.3

Continued overspend in our medical staffing costs limits our ability to make more effective use of our

resources. Noir Thomas15

Our Resources

R.1

Failure to implement our digital strategy will affect our ability to meet future demand, workforce and financial

challenges. Neil Smith8

R.2

Failure to ensure that corporate services effectively support the needs of the clinical divisions limits our

effectiveness All6

R.3

Failure to achieve the cost savings required in corporate services leads to financial pressures which limit our

ability to make good use of our resources. Neil Smith15

R.4 Lack of high quality reliable data limits our ability to take intelligence-led decisions. Neil Smith 6

R.5 Failure to ensure we have ‘buildings that work for us’ limits our ability to deliver our new models of care.

Elaine

Darbyshire8

Our Future

F.1

Ineffective working with partner organisations results in failure to improve outcomes and reduce inequalities

for the people we serve.

Louise

Edwards12

F.2

Not being a good partner in integrated care systems limits our ability to make sure our service users and our

communities needs are addressed.

Louise

Edwards9

Ref Community Division Risks Exec Score

330

(New Risk) There is a risk that patients will not be able to access either a booked urgent clinical appointment or

a domiciliary visit in a timely manner due to reduced capacity within the phlebotomy service and not being able

to get through to CMO phone line, resulting in potential patient harm Trish Bennett15

1373

If the CEDAS data quality and PPM arrangements with contractor Ross Care lead to patients using un serviced

equipment, breaching HSE regulations and putting patient safety at risk.

(Risk down form a 16) Trish Bennett

12

Ref Local Division Risks Exec Score

LOC.124

If service users gain access to an ignition source then there is an increased risk of arson incident, accidental fire

occurring, damage to property and disruption to services.

(Risk down from a 20) Trish Bennett15

LOC.113

If there are unfilled Consultant Psychiatrist vacancies within the Local Division then there is a risk that the

quality and safety of care is being compromised. Trish Bennett16

LOC.143

If increased demand in inpatient treatment outstrips capacity and flow then this may lead to delays in

treatment, pressures on community and acute services and a risk to patient safety.


LOC.154

If the ADHD Service is not appropriately funded then service users' clinical needs may not be met due to

insufficient resources and delays in assessment Trish Bennett16

LOC.152

If Talk Liverpool are unable to recruit to vacancies then service users may encounter delays in obtaining

therapy and the service could fail to meet the agreed access target of 19%. Trish Bennett16

LOC.170

If the Local Division is unable to adhere to Government Guidance in the shielding of vulnerable in-patients then

this may lead to their possible increased exposure to COVID-19 and their further decline of physical health.

(Risk down from a 12) Trish Bennett

12

CV-14

If weekly prescribing and reduced supervised taking of medications, leads to an increased risk of patients

overdosing, increased harm and potential death.


Impact

Ref Secure & Spec LD Division Risks Exec Score

S&SpLD 01

If the Division's qualified nurse vacancies continue to exceed Trust target, it could impact on staffing levels and

competence at ward level.

(Risk raised from a 12)Trish Bennett

16

C-S&SpLD 13

(New Risk) If organisational change process is not resumed effectively, then it could impact on staff sickness

and turnover, competence at ward level, financial pressures Trish Bennett16

Ref Corporate Division Risks Exec Score

PS.8

If a lack of training and standardisation means that clinical staff do not have sufficient competency to carry out

a risk assessment this could lead to serious incidents that result in harm to patients including service users

taking their own lives. Noir Thomas15

CV-1

If the Trust doesn’t have effective and sufficient resources during the Covid19 outbreak to provide priority

mental and physical health services, leading to an increased risk of harm to service users and staff. Trish Bennett15

IPC.01

If there are outbreaks of infection in areas with inadequate isolation facilities, then there may disruptions in

service delivery and the quality of care may be compromised.


Covid Impacted Risk (Yellow Border) Risk Score Reduced Risk Score Raised

Ref Project Risks Escalated onto the BAF Exec Score

New Risk SHP.045 There is a significant risk that the ongoing Covid-19 restrictions result in Kier being unable to attend site, and/or

undertake the required site works, leading to a delay in completion, which could be significant.Elaine

Darbyshire20

LOC.124 (Reduced) Score 15

SHP.045 Score 20

1373 (Reduced) Score 12

LOC.113 Score 16


LOC.154 Score 16

LOC.152 Score 16

S.3 (Score 15

P.3 Score 15

R.3 Score 15


LOC.147 Score 15

CV-14 (Reduced) Score 10

PS 8 Score 15

CV-1 Score 15

S.1 Score 12

S.2 Score 12

S.4 Score 12

P.1 Score 12

P.2 Score 12

F.1 Score 12

S&SpLD 01 (Raised) Score 16

F.2 Score 9

C-S&SpLD.13 (New Risk) Score 16

R.1 Score 8

R.5 Score 8

R.2 Score 6

R.4 Score 6

330 (New Risk) Score 15

IPC.01 (Reduced) Score 12

0

1

2

3

4

5

6

0 1 2 3 4 5 6Impact

Likeliho

od

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EXECUTIVE SUMMARY

1. This report contains the Standing Strategic BAF risks identified by the Trust Boardaligned to the Operational Plan and the high scoring fifteen and above risks fromacross Mersey Care NHS Foundation Trust and the four divisions, including Corporate,Local, Secure and Specialist Learning Disabilities and Liverpool and South SeftonCommunity Care Divisions and escalated project and programme risks.

Emerging Risk

2. Emerging risks are risk which have been highlighted as a concern, but are awaitingsign off by the appropriate governance body. Once approved the risk will appear infuture reports.

a) (Emerging Risk - Trust Wide): If due to Covid-19 the level of annual leaveentitlement allowed to be carried over into the next financial year is increasedcreating an extra financial burden on the Trust and increased pressure onservices.• Risk noted at the Corporate Tactical meeting on the 18th June, due to potential

financial impact of government guidance to allow increased annual leave to becarried over.

b) (Emerging Risk – Secure and Specialist LD): If routine annual physicalhealthcare checks for community LD service users are not happening, then it couldlead to missed opportunities to treat physical health conditions sooner andpreventable deaths.• High scoring risk in draft on the system awaiting approval at divisional level.• Risk reviewed at Executive Safety Huddle on the 20th and score agreed at 16.

Risk to be finalised by Secure Governance before being added to the BAF.

c) (Emerging Risk – Trust Wide): Levy Fund - Due to the impact of Covid19, theTrust has been unable to commence the required number of annualapprenticeship starters. Since April the Trust has had to ‘pause’ a significantnumber of monthly payments to education providers, so that frontline staff couldreturn to clinical practice. This has resulted in there being a highlighted risk ofclawback from central Government of any unspent funds.• Risk is currently being developed to identify the financial level of impact of the

funds being clawed back.

d) (Emerging Risk – Trust Wide): Covid Funding – Risk is being developed with theContract, Strategic and the Finance teams to understand the risk of emergencyCovid funding being withdrawn and the potential impact on the recovery plans forthe Trust.

e) (Emerging Risk – Local): If we do not fully understand and anticipate a COVID-19 related surge in mental health need, there is a risk that our community mentalhealth services will be unable to meet this new demand.

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f) (Emerging Risk – Community): If we do not fully understand and plan for thepotential effects of a second peak of COVID-19 alongside the winter influenzaseason, there is a risk that community health services will be unable to meetheightened demand.

3. A new risk to monitor the Infection, Prevention and Control Assurance Framework hasbeen requested to be placed onto the BAF by the Deputy Director of Nursing.(Draft): If there are gaps in the Infection prevention and control Assurance Frameworkfor the Trust, increasing the risk of transmission, resulting in disruption to servicedelivery, patient and staff harm, reputational damage and potential liability.

If approved by the Trust Board the risk will be developed further by the Trust RiskManager and the IPC for inclusion onto the BAF.

4. The chart table below gives a snapshot of the current breakdown of risks across thedivisions broken down by severity. Secure and Specialist LD Division have the highestnumber of risks, due to the merger of the Secure and Specialist LD’s registers, whichshould start to reduce through good housekeeping and the merger of similar risks. TheLocal Division currently have the highest number of Extreme (15+) BAF level risks.Please note that the figures do not include draft risks which are waiting sign off by thevarious governance groups.

Risk Snapshot 17th July 2020

5. Of the 237 current risks, 39 are marked on the Covid risk register and monitored andreported weekly through the Exec Sitrep.

Covid Risk Snapshot 14th July 2020

6. Currently, there are 24 risks identified in the Board Assurance Framework, down from29 in the last reporting period. Of the 25 risks 19 have been noted as being impactedby Covid-19 (ie. both increasing risk, decreased risk or impacted timeframes).

7. Please see Appendix A (Table 1 & 2) for a short update on each risk in the BAF. Theimpact of Covid-19 on the risk might not necessarily change the risk score asincreased pressures in one area might be offset by a change of process in another.

The current BAF consists of:

Corporate Services Division Risk Register 9Liverpool Community 5Local Services Division Risk Register 12Secure and Specialist Learning Disability Division 13Grand Total 39

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a) 14 strategic risks identified by the Board, of which 13 are noted as been impactedin some way by Covid-19.

b) 09 Strategically significant divisional risks with a score of 15 or above.• 1 Liverpool and South Sefton Community Division Risks with 1 noted as having

a potential impact from Covid-19.• 4 Local Division Risks, of which 4 are noted as being impacted by Covid-19.• 2 Secure and Specialist LD Division risks of which 1 is noted as Covid related.• 2 Corporate Risks, with both noted as being impacted by Covid-19.

c) 1 Strategically significant programme risk with a score of 15 plus, impacted byCovid-19.

8. Of the current fourteen strategic risks identified by the Board for 2020/21 (Table 1 -Appendix A), two were raised in May due to Covid-19 and two reduced.

a) (Raised Risk due to Covid-19): Failure to understand the needs in our populationmeans that we are unable to design services to effectively meet those needs. RiskScore 15 raised from a 12

b) (Raised Risk due to Covid-19): Ineffective working with partner organisationsresults in failure to improve outcomes and reduce inequalities for the people weserve. Risk Score 12 raised from a 9

c) (Risk Reduced due to Covid-19): Failure to implement our digital strategy willaffect our ability to meet future demand, workforce and financial challenges. RiskScore 8 reduced from a 12

d) (Risk Reduced due to Covid-19): Failure to ensure that corporate serviceseffectively support the needs of the clinical divisions limits our effectiveness. RiskScore 6 reduced from an 8

9. The one highest scoring risks identified by the Liverpool and South Sefton CommunityDivision (Table 2 - Appendix A) is pressure on the Phlebotomy Service. The CEDASPPM risk regarding delayed service of equipment has been reduced and removed offthe BAF.

a) (New Covid-19 Risk): There is a risk that patients will not be able to access eithera booked urgent clinical appointment or a domiciliary visit in a timely manner dueto reduced capacity within the phlebotomy service and not being able to getthrough to CMO phone line, resulting in potential patient harm. Risk Score 15

10. The four highest scoring risks identified by the Local Division (Table 2 - Appendix A)are adhering to the smoking policy and fire risk, which as been reduced following areview at the Local Governance Group in July and delays to services in both theADHD and Talk Liverpool. The Addiction Service weekly prescription risk, shielding

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risk and increased demand for inpatient beds have been reduced and removed off the BAF. a) (Reduced): If service users gain access to ignition source then there is an

increased risk of arson incident, accidental fire occurring, damage to property and disruption to services. Risk Score 15 reduced from a 20.

b) If there are unfilled Consultant Psychiatrist vacancies within the Local Division then there is a risk that the quality and safety of care is being compromised. Risk Score 16.

c) If the ADHD Service is not appropriately funded then service users' clinical needs may not be met due to insufficient resources and delays in assessment. Risk Score 16

d) If Talk Liverpool are unable to recruit to vacancies then service users may

encounter delays in obtaining therapy and the service could fail to meet the agreed access target of 19%. Risk Score 16

11. The two highest scoring risks identified by the Secure and Specialist LD Division (Table 2 - Appendix A) are qualified nurse vacancies continue to exceed Trust targets and a risk regarding the delay to the organisation change process due to Covid-19. a) (Risk Raised): If the Division's qualified nurse vacancies continue to exceed Trust

target, it could impact on staffing levels and competence at ward level. Risk Score 16

b) (New Risk): If organisational change process is not resumed effectively, then it could impact on staff sickness and turnover, competence at ward level, financial pressures. Risk Score 16

12. Two high scoring risks identified by the Corporate Division (Table 2 - Appendix A) are competency and standardisation of clinical risk assessments and the ability of the Trust to cope with the outbreak. The infection control risk which was raised due to a number of ward based outbreaks as now been lowered. a) (Covid-19): If the Trust doesn’t have effective and sufficient resources during the

Covid19 outbreak to provide priority mental and physical health services, leading to an increased risk of harm to service users and staff. Risk Score 15

b) If a lack of training and standardisation means clinical staff do not have sufficient competency to carry out a risk assessment, leading to serious incidents that result in harm to patients including service users taking their own lives. Risk Score 15

13. One strategically significant programme risks have been escalated by the MSU Programme Group.

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a) (Covid-19 Risk): There is a significant risk that the ongoing Covid-19 restrictions

result in Kier being unable to attend site, and/or undertake the required site works, leading to a delay in completion, which could be significant. Risk Score 20

14. 5 risks have been reduced in the last reporting period (June / July 2020) and removed off the BAF. See (Appendix A Table 3). a) (Loc.143 Local – Reduced): If increased demand in inpatient treatment outstrips

capacity and flow then this may lead to delays in treatment, pressures on community, acute services and a risk to patient safety. Risk Score 12 Reduced from a 16 (Risk Impacted By Covid-19)

b) (IPC.01 Corporate – Reduced): If there are outbreaks of infection in areas with inadequate isolation facilities, then there may disruptions in service delivery and the quality of care may be compromised. Risk Score 12 Reduced from a 15 (Risk Impacted By Covid-19)

c) (LOC.170 Local – Reduced): If the Local Division is unable to adhere to Government Guidance in the shielding of vulnerable in-patients then this may lead to their possible increased exposure to COVID-19 and their further decline of physical health. Risk Score 12 Reduced from a 15 (Risk Impacted By Covid-19)

d) (1373 Community - Reduced): If the CEDAS data quality and PPM arrangements with contractor Ross Care lead to patients using un serviced equipment, breaching HSE regulations and putting patient safety at risk. 1373 Risk Score 12 reduced from a 16 (Risk Not Impacted By Covid-19)

e) (CV-14 Local - Reduced): If weekly prescribing and reduced supervised taking of medications, leads to an increased risk of patients overdosing, increased harm and potential death. Risk Score 10 reduced from a 15 (Risk Impacted By Covid-19)

Frank Westhead Trust Risk Manager July 2020

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Table 1 – Standing BAF Risk Identified by the Board Appendix A BAF

Our Service

Reference Risk Type Title Controls Executive

Owner Impact

Likelihood Date

Identified

Initial Risk

Rating

Current Risk

Rating

Target

Score Target Date

Initial Target Date

Next Revie

w Date

S.1 Quality

Failure to make quality care more consistent will result in quality issues for the people we serve and sustainability issues for the organisation

Pursuit of Clinical Excellence and implementation of Quality and Safety. Accreditation Framework across the Trust. Focus on delivery of CQC ‘good’ as a minimum across all services

Trish Bennett /

Noir Thomas 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 14/07/2020: Risk reviewed by action lead and no noted changes to risk. Quality agenda and CQC preparations slowed during the refocus of resources during the current emergency and the remodelling of some services. The focus is now on building in a quality and patient safety agenda to monitor the changes. Risk score to remain the same while processes to monitor quality and risk are being reviewed and implemented.

S.2 Quality

Failure to implement more preventative and integrated models of care means that we are unable to manage rising levels of demand, workforce and financial pressures.

Clinical strategy priorities implementation of more preventative and integrated care models, reducing the risk of people going into crisis and enabling them to take greater control of their own health and wellbeing.

Trish Bennett 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 14/07/2020: Risk reviewed by action lead and no noted changes to risk. Care models have been changed and reprioritise to deal with the current emergency situation and the current demand on services. The risk will be monitored going forward as the Trust moves into the recovery phase.

S.3

Quality

Failure to understand the needs in our population means that we are unable to design services to effectively meet those needs.

Working with partners through Provider Alliances and the Lead Provider Collaborative will support us to have a richer shared picture of the needs of the population upon which we can act. Focus on service user experience as a priority for the Board.

Louise Edwards 5 3 06-Mar-

2020 12 15 8 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 17/07/2020: Reviewed by action lead. Working with the BI team and the Strategy Unit to model how and when future demand might manifest and help us to consider mitigating actions which will inform the recovery plan. Draft report for MH completed on the 15th July. Once the modelling work is finalised the risk will be reviewed, but initial indication is the risk will stay high due to the expected increases in demand being highlighted by the modelling work.

S.4 Quality

Failure to deliver transformational change in our community services results in less efficient and effective out of hospital care.

Community integration priorities include further deployment of integrated care teams aligned to Primary Care Networks and the transformation of community mental health services with a focus on highly effective out of hospital care.


2020 12 12 8 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 17/07/2020: Reviewed by action lead with no noted change to the risk score. Integration and transformational work has been reduced as resources are reprioritised during the current emergency. The risk will be monitored going forward as the Trust moves into the recovery phase and service changes such as the digitisation of care are reviewed as part of the integration of services.

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Our People

Reference Risk Type Title Controls Executiv

e Owner Impact Likelihood

Date Identifi

ed

Initial Risk

Rating

Current Risk

Rating

Target

Score

Target Date

Initial Target Date

Next Review

Date

P.3 Finance Continued overspend in our medical staffing costs limits our ability to make more effective use of our resources.

Implementation of our plans to address workforce fundamentals and our Just and Learning Culture increases our reputation as an employer of choice.


2020 15 15 10 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 15/07/2020: Reviewed by action lead with no noted change to the risk score. Noted by Executive Lead that the score remains relatively unchanged under COVID19. Recruitment as slowed slightly, but oversees recruitment is continuing over Skype and the changes to clinical processes has slightly reduced pressure on Locums.

P.1 Quality

Failure to implement our People Plan and create a compelling place to work results in continued staffing pressures and impact of quality of services.

Clear priorities are set out in our People Plan to get the basics right for staff and offer continuous development. Monitoring through new People and Culture Committee.

Amanda Oates 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update:

Impacted By Covid-19: 14/07/2020: A number of emerging risks have been identified around track and trace, student nurses and levy funding. Although the Trust sickness and self isolating rate for the Trust 11.6% is down from its peak in April pressure is still present in the system and it is currently unclear of the effects of the changes to shielding at the end of July. Risks have been identified which impact Nationally the People Plan has been delayed due to Covid-19, which as pushed back one of the milestones of implementing the plan which is to review the implementation of the Trust’s people plan alongside the national strategy. Meeting to be set up with HR senior management and the Trust Risk Manager to review in more detail the risk’s associated with the People Plan and the impact of Covid. Also to be discussing a number of sub risks under the BAF risk, such as workforce capacity, forecasting , training and the disparity of COVID amongst BAME staff. The risk score was reviewed by the responsible Exertive and currently remains a 12.

P.2 Quality

Failure to adopt new roles and ways of working leads to a widening gap between the needs of the population and our model of care.

Effective workforce planning and support to teams to embed new integrated ways of working. Development of new roles and assessment of clinical competencies in support of new care models

Amanda Oates 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 17/06/2020: Further implementation and expansion of a number of HR systems as been put on hold due to Covid-19, however a number of systems to support home working have been implemented quicker such as electronic payslips. Workforce function have also been reprioritised to support the Trust’s Covid-19 and away from long term workforce planning. The risk score was reviewed by the responsible Exertive and currently remains a 12.

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Our Resources


Owner Impact likelihoo

d

Date Identifi

ed

Initial Risk

Rating

Current Risk

Rating

Target

Score

Target Date

Initial Target Date

Next Review

Date

R.3 Finance/Quality

Failure to achieve the cost savings required in corporate services leads to financial pressures which limit our ability to make good use of our resources.

Corporate transformation programme including collaboration to generate economies of scale and strategic investment to automate processes. Neil Smith 5 3 06-Mar-

2020 15 15 10 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Risk not Currently Impacted by Covid-19: 18/06/2020: Risk mitigated in the short term due to national block contracts settlement for April to July 2020. Noted that the risk should stay as a 15 due to the reoccurring nature of the risk. The risk will be reviewed once the revised financial framework for the financial year 20/21 and beyond is received and its implications understood by the Trust.

R.1

Finance/Quality

Failure to implement our digital strategy will affect our ability to meet future demand, workforce and financial challenges.

Prioritised digital tools developed in partnership with clinical divisions offering a range of solutions which can be drawn down to support model of care. Development of productivity return on investment analysis in year ahead.

Neil Smith 4 2 06-Mar-2020 12 8 8

31-Mar-2021

31-Mar-2021

28-Aug-2020

Update:

Impacted By Covid-19: 10/07/2020: Requirements for home working identified in the recent Digital Display Assessments have been identified and are being procured and planned for with team managers and IT. This should enable safe long term home working practices for an extended period of time. As previously reported, there has been rapid expansion of some digital services across the Trust ahead of expected timeframes; in response to the need to facilitate home working and provide digital solutions which enable social distancing both operationally and patient facing (e.g. – infrastructure upgrades, kit deployments, virtual consultations, skype, etc.) However there were other planned developments which were paused due to c-19. Digital projects and programmes will resume as far as the ongoing situation allows, but digital priorities will also be reviewed through the Trust’s recovery work stream and new divisional priorities. Risk score reduced from a 12 to 8 due to increased use of digital platforms during the outbreak.

R.2

Quality

Failure to ensure that corporate services effectively support the needs of the clinical divisions limits our effectiveness

Implementation of operating principles for corporate services and development of effectiveness measures.

Elaine Darbyshire

/ Neil Smith/

Amanda Oates

3 2 06-Mar-2020 8 6 4

31-Mar-2021

31-Mar-2021

28-Aug-2020

Update:

Impacted By Covid-19: 14/07/2020: Reviewed by action lead with no noted change to the risk score. Appointment of the Trust's Deputy Chief Executive as lead Executive Director for Trust’s recovery will align resource and ownership to the various areas that support recovery post Covod-19. The Executive Director of Communications and Corporate Governance will lead a 'Resources Group' to ensure that corporate services are as effective and efficient as possible and both support the needs of clinical services and also deliver the trust's statutory duties to full effect. The risk was lowered to reflect the continued reprioritisation of Corporate services to support the Trust’s response to Covid-19, with continued oversight by tactical, strategic and other groups. Risk lowered from an 8 to a 6.

R.5 Quality Failure to ensure we have ‘buildings that work for us’ limits our ability to deliver our new models of care.

Prioritisation within Estates Strategy of actions to support integrated care at 30,000 to 50,000 population level and to remove dormitory wards.

Elaine Darbyshire 4 2 06-Mar-

2020 8 8 4 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update:

Impacted By Covid-19: 17/06/2020: During lockdown work on planning for the developments within the Estates Strategy has slowed due to availability of clinical and estates staff to develop plans. Going forward plans will need to be reviewed in the light of any emerging guidance post Covid19 on environmental requirements. The Estates Steering Group, jointly chaired by the Executive Director of Communications & Corporate Governance and the Executive Director of Nursing & Operations, oversees this work and reports into the Resources Committee regularly. Risk to remain unchanged but will reviewed once new guidance is released and its impact on the Trust reviewed. Risk score reviewed by the risk lead and remains unchanged.

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d

Date Identifi

ed

Initial Risk

Rating

Current Risk

Rating

Target

Score

Target Date

Initial Target Date

Next Review

Date

R.4 Reputational / Quality

Lack of high quality reliable data limits our ability to take intelligence-led decisions.

Implementation of Digital Strategy including new data warehouse and analytical tools to support insight Neil Smith 3 2 06-Mar-

2020 6 6 3 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update:

Impacted By Covid-19: 10/07/2020: The BI Team are working closely with the Strategic and Contract teams to model the potential demand on the Trust as we move into the recovery phase. The IPI / Digital team are continuing to support clinical divisions to improve data accuracy around contacts recording through a number of projects e.g. though ensuring that Attend Anywhere standard operating procedures include guidance on recording of contacts within the clinical information systems. The teams are also working with clinical divisions and Infection Control to enable capture of Covid-19 related information to support local and national reporting requirements. The teams are working with the divisions and recovery cell to provide baseline data to support demand and capacity modelling in light of Covid-19; this also includes initial modelling of the impact of a potential surge in demand on bed numbers. The IPI / Digital team and iMerseyside have developed a questionnaire and dashboard to look at the experience of patients using the Attend Anywhere solution. The team has amended the content of executive performance reporting to enable the organisation to be sighted on key pieces of intelligence relating to Covid-19 whilst maintaining line on sight on key performance indicators. In addition to this, there has been some work undertaken with community division to develop a new dashboard to support operational and strategic decision making in light of Covid-19. All of this work continues alongside of data gathering and reporting requirements.

Our Future



d

Date Identifi

ed

Initial Risk

Rating

Current Risk

Rating

Target

Score Target Date

Initial Target Date

Next Review

Date

F.1

Quality

Ineffective working with partner organisations results in failure to improve outcomes and reduce inequalities for the people we serve.

Leadership of Provider Alliances in Liverpool and Sefton and of Lead Provider Collaborative for secure services. Louise

Edwards 3 4 06-Mar-2020 9 12 6

31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 16/07/2020: Reviewed by action lead and risk score remains at a 12. The risk was reviewed last month and raised by the action lead from a 9. Partnership working has been tested by the current COVID pressures, showing the system is not at the level of maturity the Trust would have hoped for. This increases the likelihood that we won’t achieve the beneficial impact for people that we would wish for.

F.2 Quality /

Reputational

Not being a good partner in integrated care systems limits our ability to make sure our service users and our communities needs are addressed.

Operational Plan is aligned to expectations set out in NHS Long Term Plan. Provider Alliances form foundation for providers to collaborate and develop integrated care systems

Louise Edwards 3 3 06-Mar-

2020 9 9 6 31-Mar-2021

31-Mar-2021

28-Aug-2020

Update: Impacted By Covid-19: 16/07/2020: As with risk F.1 partnership working has been tested by the current COVID pressures, showing the system is not at the level of maturity the Trust would have hoped for.

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Table 2: Fifteen Plus Divisional / Programme and Project risks raised up into the BAF Liverpool and South Sefton Community Divisional Strategically Significant Risks with a score of 15+

Reference Risk Type Title Controls Exe Owner Impact likeli

hood

Date Identifie

d

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Revie

w Date

330 (New Risk) Quality

There is a risk that patients will not be able to access either a booked urgent clinical appointment or a domiciliary visit in a timely manner due to reduced capacity within the phlebotomy service and not being able to get through to CMO phone line, resulting in potential patient harm

If patient can't be seen within time frame, domiciliary visit will be offered where possible (if not patient will be offered Talks with Commissioners re extending 24 hour KPI to 72 hours Looking in to extra clinic at Childwall site Looking at extending hours at South Liverpool Treatment Centre

Trish Bennett 3 5 18-May-

2020 15 15 3 31-Jul-2020

31-Jul-2020

06-Aug-2020

Update:

Risk Impacted By Covid-19: 28/06/2020: Risk returned to the Executive Safety Huddle on the 29th June. Drive through at Hunter Street available from 29/06/2020. Hotline to go live 29/06/2020 for GPs to contact service re patients who need urgent blood test within 24 hours. Blocked appointments available at Kensington and Breeze Hill with clinics extended until 7pm. Establishing capacity and demand reporting to support both escalation of challenges to monitor day to day operations. Aims to reduce risk down further:

• Challenge a reduction in appointment slots in Drive Thru and Clinics – Sheffield Model 4 mins. • Move to paperless system to avoid delays in clinic when patients do not have blood form. • Reduce footfall in patient’s homes through ICN supporting blood testing for routine blood monitoring. • Working with ICE, IMersey and SPC to build an alternative to CMO Booking Line

Local Division Strategically Significant Risks with a score of 15+

Reference Risk Type Title Controls Exe

Owner Impact likelihood

Date Identified

Initial Risk

Rating

Current Risk

Rating

Target Score

Target Date

Initial

Target

Date

Next Revie

w Date

LOC.124 (Reduced)

Quality/Reputat

ional

If service users gain access to an ignition source then there is an increased risk of arson incident, accidental fire occurring, damage to property and disruption to services

Service users are informed prior to admission and on admission that the Trust adopts a Smoke Free Policy Service users are encouraged to stop smoking and offered a range of non-smoking solutions and support. Smoking Assessment in place. Environmental sweeps and observation process in place on the wards. Fire detection devices in place & Fire drills undertaken on a six monthly basis. Fire Wardens/Marshalls in place and on-going training in place. Fire Risk Assessment undertaken on a yearly basis. Smoking bins placed back in court yard E cigarette trial in Broad oak

Trish Bennett 5 3 14-Dec-

2017 8 15 5 30-Nov-2020

30-Jun-2018

12-Aug-2020

Update: Risk not impacted by Covid-19: 08/07/2020: Risk reviewed at the Local Governance Group in July and reduced from a 20 to a 15. Initially raised last year due to a monthly spike in fires. Incident data is showing the number of fire related incidents have now reduced, so it was agreed that the risk could be reduced to the pre spike score of 15. Risk is to be reviewed at the Local Safety Huddle on the 13th July and will be scheduled to return to the Executive Huddle in August.

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Reference Risk Type Title Controls Exe

Owner Impact likelihood

Date Identified

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial

Target

Date

Next Revie

w Date

LOC.113 Quality

If there are unfilled Consultant Psychiatrist vacancies within the Local Division then there is a risk that the quality and safety of care is being compromised.

Monthly medical management review meetings regarding budget and recruitment continue to take place. Further work is being undertaken as part of the transformation programme to review caseload numbers. Currently, locum staff are used to cover vacancies Recruited ten Physician Associates to cover traditional roles carried out by junior and career grade Dr’s. Progress in writing the Job Descriptions for the CMHT posts and Vacancy Authorisation Forms (VAF). Medical recruit plan continues to be progressed with some recruitment to new posts, but internal candidates only.


2020 12 16 8 30-Apr-2021

31-Dec-2017

12-Aug-2020

Update: Impacted By Covid-19: 08/07/2020: There has been an impact with recruitment being slowed down with COVID-19 arrangements, however this as been offset with the changes in clinical processes meaning services require less Locum cover. The Division is still holding interviews and will progressing with most of the planned recruitment. This obviously may change depending on how the COVID-19 situation progresses.

LOC.154 Quality/ Finance

If the ADHD Service is not appropriately funded then service users' clinical needs may not be met due to insufficient resources and delays in assessment

Operational Managers/ Meeting Financial Sustainability Meeting Data collection via RiO Contracts Meetings

Trish Bennett 4 4 13-Feb-

2019 16 16 8 30-Aug-2020

13-Feb-2020

12-Aug-2020

Update: Risk not Impacted by Covid-19: 08/07/2020: Consultant still due to start in August increasing consultancy time for the service, at which point the risk score will be reviewed.

LOC.152 Quality/ Reputat

ional

If Talk Liverpool are unable to recruit to vacancies then service users may encounter delays in obtaining therapy and the service could fail to meet the agreed access target of 19%.

Social Media and Marketing Event arranged for 2019 Silver Cloud software obtained Agency staff and nursing Bank Linking with Liverpool John Moore's University around training package for Assistant Psychological Wellbeing Practitioners (PWP) •Away-Day Event •CPD •Supervision


2019 16 16 8 31-Jul-2020

30-Sep-2019

12-Aug-2020

Update: Risk Impacted by Covid-19: 08/07/2020: The service as continued with its recruitment, however the service as noted a delay in appointing and a reduction in applications, which potentially is down to the current outbreak. Agree that the risk score should remain at a 16, but will be monitored.

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Secure and Specialist LD Division Strategically Significant Risks with a score of 15+


hood

Date Identifie

d

Initial Risk

Rating

Current Risk

Rating

Target Score

Target Date

Initial Target Date

Next Revie

w Date

S&SpLD 01 (Raised)

Quality/ Regulatory/ Reputational

If the Division's qualified nurse vacancies continue to exceed Trust target, it could impact on staffing levels and competence at ward level

•Ongoing proactive recruitment •'Grow your own' initiatives utilised •New staff invited to register with Additional Staffing •Ward Managers meet daily to address staffing •Clinical Service Managers meet periodically with matrons to review gender, grade&skill mix across wards •On call system to respond to immediate shortfalls •Mobilisation of staff within specialties Thresholds in place for escalating concerns Contingency Planning Support from ward managers at all times of the day •Secure-specific control - Inpatient Manager on-call rota, used during periods of shortfall

Trish Bennett 4 4 09-Dec-

2019 12 16 8 31-Mar-2023

31-Mar-2023

30-Jul-2020

Update:

Risk Not Impacted By Covid-19: 15/06/2020: This was a pre COVID risk, and despite ongoing recruitment the vacancy rate continued to increase, with staff leaving the service (mainly due to retirement) and new services coming on line that required additional qualified nursing staff. The recruitment plan for the Division, including Rowan View, highlighted vacancies in the region of 60 qualified nurses and 36 Nursing Assistants and with the suspension of the organisational change process there was an increased risk of Rowan View’s opening being delayed because of insufficient qualified nursing staff. On this basis the likelihood score was raised from a 3 to a 4, raising it into the BAF.


hood

Date Identifie

d

Initial Risk

Rating

Current Risk

Rating

Target Score

Target Date

Initial Target Date

Next Revie

w Date

C-S&SpLD 13 (New Risk)

Quality, Finance,

Reputational

If organisational change process is not resumed effectively, then it could impact on staff sickness and turnover, competence at ward level, financial pressures

•Rowan View Workforce Plan •Recruitment Plan •Organisational Change Implementation Plan •Communication Strategy •Health & Wellbeing Support Plan


2020 16 16 12 30-Sep-2020

30-Sep-2020

27-Jul-2020

Update:

Risk Impacted By Covid-19: 15/06/2020: This is a new risk related to the impact of COVID 19 on the Rowan View organisational change process and is linked to the existing divisional risk SLDD 80 (Rowan View organisational change pre Covid) and S&SpLD 01 (qualified nursing vacancies pre covid). Noted that all actions listed against this risk are in progress. The revised R&R paper was due to be considered by the MSU Steering Group in June before being taken to the next meetings of the Trust’s R&R Group and Executive Team for sign off. This risk will be reviewed again in the next month and/or after the outcome of the R&R proposals was known.

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Corporate Division Strategically Significant Risks with a score of 15+

Reference Risk Type Title Controls

Executive

Owner Impact

Likelihood Date

Identified

Initial Risk

Rating

Current Risk

Rating

Target Score

Target Date

Initial

Target

Date

Next Revie

w Date

PS 8 Quality/

Reputational

If a lack of training and standardisation means that clinical staff do not have sufficient competency to carry out a risk assessment this could lead to serious incidents that result in harm to patients including service users taking their own lives.

- Level 1 and level 2 core training - Delivered wither face to face or available as an e-learning package - Modules are delivered by Quality Improvement staff member - Over 400 staff members have completed the risk assessment modules within the suicide prevention package. - Trust Policy


2019 15 15 5 01-Sep-2020

01-Oct-2019

15-Aug-2020

Update:

Risk Impacted by Covid-19: 08/07/2020: Risk reviewed by action lead with no change to current score. Score will reviewed following the role out of e learning in August. Staff who have already been trained will be offered a refresher. Alongside running through the training this will also identify a ‘key element’ highlighting approach; so as they can get specific messages across to their staff in relation to risk assessment aspects. The Perfect Care Team are also be running additional Skype training sessions to capture managers and deputies to aid the rollout of training. The competency section to the training will be linked into the current PACE developments and the team are working to get a reporting sections added to ‘Your Supervision’ for competency based monitoring to allow reporting through the Bit. There will be a launch for all the risk training on 10 September to coincide with world suicide prevention day.

CV-1 Financial/Quality/Regulatory/Reputational

If the Trust doesn’t have effective and sufficient resources during the Covid19 outbreak to provide priority mental and physical health services, leading to an increased risk of harm to service users and staff.

Command and control processes put in Business Continuity and Impact Assessment plans for all divisions Plans to be reviewed as part of confirm and challenge workshops Working from home to reduce footfall. All non essential training to be rescheduled Staffs support line to be set up. Digital solutions such as Skype to Business and extended VPN capacity, being rolled out Pressure testing exercise to be carried out on the 20th March. Clinical staff in the Corporate Division to be identified in case of redeployment.


2020 20 15 10 30-Aug-2020

30-Aug-2020

21-Jul-2020

Update: Risk Impacted by Covid-19: 25/06/2020: Risk reviewed with IPC Lead and remains at the current score. Score will be monitored moving forward for potential impact of Track and Trace on the workforce absences.

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Programme Project Strategically Significant Quality Risks with a score of 15+

Programme

Reference

Risk Type Title Controls

Exe Owner

Impact

Likelihood Date

Identified

Initial Risk

Rating

Current Risk

Rating

Target Score

Target Date

Initial

Target Dat

e

Next Review

Date

Secure Campus (Secure Health Park)

SHP.045 Financ

e / Quality

There is a significant risk that the ongoing Covid-19 restrictions result in Kier being unable to attend site, and/or undertake the required site works, leading to a delay in completion, which could be significant.

Solicitors working through guidance to understand liability. Option paper being developed to consider: Condensing the trusts 12 week commissioning period, keeping the 12 week period and moving the opening back to October, beginning commissioning before the handover from Kier is complete, moving Scott clinic over before Whaley to allow org change to complete. P21+ framework in place gives the trust additional protection Good relationship with Kier is enabling us to work together on solutions All parties to follow government guidelines, company and Trust policies, and to take all sensible precautions, ensuring staff safety. All parties to record all affected activities using the agreed contract processes.

Elaine Darbyshi

re 4 5 15-Apr-

2020 20 20 10 30-Jun-2020

30-Jun-2020

23-Jul-2020

Update: Risk Impacted by Covid-19: 18/06/2020: Score reviewed by project team and remains unchanged. Project currently delayed by 2-3 weeks due to Covid-19 restrictions, but this could increase over the next 2 months. Any delay will increase capital costs and double running costs and could easily exceed £300k (which is 0.5% of the project budget). No assurance at this stage as to how long the delay will be, and how much it will cost and whether we will incur all the cost or whether Kier will pick up some/all of the cost.

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Table 3: Risks in the last reporting period reduced and removed off the BAF

Reference Risk Type Title Controls

Executive

Owner Impact Likeli

hood

Date Identifie

d

Initial Risk

Rating

Current Risk

Rating

Target Score

Target Date

Initial

Target

Date

Next Revie

w Date

LOC.143 (Reduced) Quality

If increased demand in inpatient treatment outstrips capacity and flow then this may lead to delays in treatment, pressures on community and acute services and a risk to patient safety.

Daily Bed Management Meetings and escalation process of conference calls if pressure on beds is at a peak. Raised through Executive Safety Huddle when increase in admission leads to inability to admit patients. RADAR/Delayed Discharge Meetings weekly Review process in place for medical colleagues to review service users who have had a stay of 30, 60, 90 days. Out of area placements, Stepped Up Care, YMCA beds Red 2 Green

Trish Bennett 4 3 19-Nov-

2018 12 12 6 31-Aug-2020

31-Mar-2019

12-Aug-2020

Update: Risk Impacted by Covid-19: Risk reviewed by the Local Governance Group on the 08th July and reduced to a 12. Flow is being to be re-established and an additional 20 beds have been re-introduced. An Inpatient Model Workshop is arranged for the 03-08-2020. Risk score was examined and should be reduced to Likelihood 3 x Impact 4 = 12.

Corporate IPC.01

(Reduced) Quality

If there are outbreaks of infection in areas with inadequate isolation facilities, then there may disruptions in service delivery and the quality of care may be compromised.

Hand sanitizer at doorways. IPC audit of application and use of PPE. Increased swabbing of staff Use of block shift for bank staff to reduce cross site transmission. Enhanced cleaning by FMA staff, including 2hr cleaning of touch points. Long term estates strategy in place to replace parts of the Mersey Care Estate that do not have adequate isolation facilities - All new builds will have full en-suite facilities. Commodes in place in all areas. Bed management admitting- utilising other sites where possible. Support policies, care plans and guidelines to manage outbreaks are in place. All areas have an Infection prevention and control link practitioner PPE available for all staff in all clinical areas


2017 9 12 6 30-Jul-2020

30-Mar-2019

30-Jul-2020

Update: Risk Impacted By Covid-19: 03/07/2020: Risk reviewed and lowered from a 15 to a 12. There are currently no patients on Acorn Ward who have the Covid 19 infection. Irwell Ward has 1 patient with the Covid 19 infection and came out of outbreak measures on the 2nd July 2020.

LOC.170 (Reduced)

Quality

If the Local Division is unable to adhere to Government Guidance in the shielding of vulnerable in-patients then this may lead to their possible increased exposure to COVID-19 and their further decline of physical health

Service users are encouraged to practice self-isolation and social distancing practices as per Government Guidance. Vulnerable service users have been identified. Service users identified to shield or displaying COVID-19 symptoms are nursed in side room. PPE is available for shielded service users if they need to leave their bedroom area. The number of beds in inpatient wards has been reduced to adhere to social distancing guidance. I-Pads have been provided to support service users in maintaining contact with relative. Cleaning Schedules increased.


2020 15 12 4 30-Jul-2020

30-Jul-2020

12-Aug-2020

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Update: Risk Impacted by Covid-19: 08/07/2020: Risk reviewed by risk lead and reduced from a 15 to a 12. No COVID positive cases on Inpatient Wards currently. Admission Wards continue (Admission Wards comprises of en-suite single bedrooms. Service users will be tested for COVID prior to transferring to other wards within the Local Division.)

Liverpool South& Sefton 1373

(Reduced)

Quality

If the CEDAS data quality and PPM arrangements with contractor Ross Care lead to patients using un serviced equipment, breaching HSE regulations and putting patient safety at risk.

Action plan in place Data cleansing Bank staff team (3 members / bank staff working plan) deployed to contact all 2300 patients holding 3420 items of serviceable equipment

Trish Bennett 4 3 20-Aug-

2018 16 12 8 30-Sep-2020

31-May-2019

31-Jul-2020

Update: Risk Not Impacted By Covid-19: 03/07/2020: Risk update presented at Divisional Safety Huddle as a Part A on 17/06. Agreement that risk score can be reduced to 12 due to no incidents of harm or complaints being received into the service. Service is continuing to work with Ross Care and CSS to data cleanse. Risk is due to be presented to the Executive Safety huddle on the 13th July.

Local CV-14

(Reduced)

Quality / Reputati

onal

If weekly prescribing and reduced supervised taking of medications, leads to an increased risk of patients overdosing, increased harm and potential death.

Risk added on due to change in processes in the Addiction Service Due to the COVID-19 outbreak - Addiction Service developed risk grading for patient at greater risk of overdosing. - Providing some daily scripts for high risk patients - Allowing a designated person to pick up the script for a patient

Trish Bennett 5 2 03-Ap-

2020 15 10 10 31-July-2020

30-May-2020

12-Aug-2020

Update: Risk Impacted by Covid-19: 01/07/2020: Discussion took place with Team Manager. Risk score was reviewed and should be reduced to Likelihood 2 x Impact 10 = 10. Risk has, therefore, met it's target risk score. Risk will remain on the register currently for monitoring. Risk to be discussion with Addictions Management Team and clarity to be obtained from Community Pharmacies (around their current position) prior to considering closure of risk.

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Report to: Board of Directors Meeting Date: 29 July 2020

This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

Safety Report

Accountable Director(s): Noir Thomas, Executive Medical Director Panchu Xavier, Director of Patient Safety

Report Author(s): Joanne Bull, Associate Director of Patient Safety


Our Services ☐ Integrate Services ☒ Improve population health ☒







Corporate Services






CQC ☐ Safe ☒ Responsive ☒ Effective ☒ Caring ☒ Well-led

Purpose of Report: To provide members of the Board with an overview of assurance on a range of patient safety issues, clearly outlining issues of concern/good practice.

Recommendation: The Board are asked to: 1) Discuss the report 2) Identify any new risks 3) Identify any further assurances it requires


Do the action(s) outlined in this paper impact on any of the following issues?

Area Yes If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Operational Performance ☒ The Board will have significant assurance for operational performance. Good governance standards require that the trust has robust risk management and assurance process which provide significant assurance to the Committee, and through them to our regulators.

Provider Licence Compliance ☐

Legal Requirements ☒ Resource Implications ☐


Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☒ ☐ If answered ‘YES’ to either question, please include a section in this report explaining why

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EXECUTIVE SUMMARY

1. The Safety Report for this reporting period takes account of the safety information arising during the Covid19 pandemic situation.

2. A significant part of the teams work in the past 6 weeks has been focussed upon

mortality reviews particularly around the review of the covid related deaths of people with learning disabilities undertaking both rapid reviews and accelerated reviews for completion in 3 weeks versus the usual 3 months

3. In relation to incident data this report compares 2019 and 2020 to enable us to review

if the current pandemic is having an effect on staff capacity to report adverse events. 4. This would be a concern as we would be unaware if the service was becoming unsafe.

A detailed review has been commissioned by the CCG as an assurance report that the Trust continues to operate safely.

5. Whilst this is a brief high level oversight of incident data the current picture is that our

services continue to report adverse incidents at a rate consistent with previous calendar year.

6. Reviewing reported incidents apparent increased severe harm rates can be explained

by the learning disability deaths and pressure ulcers; both these incident categories are under continued review.

7. Whilst this comparative on numbers demonstrates no significant shift when analysed

by the National Reporting Learning System the data will be analysed bed occupancy rates as a comparative so with reduced bed days may demonstrate an increase in harm although this should also be reflected against comparative Trusts.

8. The annual report on serious incidents is due to be reported to QAC in July 2020,

however, due to Covid-19 this has been delayed. The delay is due to the status of a number of RCAs which have either been paused or on-hold due to the pandemic situation.

9. As yet a full recovery timeline for each RCA has not been finalised but a number have

come off hold and initial review and timeline development is underway. The detail/status for each open RCA will be detailed later in the report.

10. With regards to the annual report this will be in a position to report at the next QAC in

September 2020 11. There were 17 newly reported STEIS incidents in May and 27 in progress or paused 12. There are 5 high level inquiries (external reviews) being monitored with 2 level 3

external reviews in the process of being commissioned by NHSE 13. 265 deaths reported overall, a reduction from April 2020 when 569 deaths were

reported. 38 deaths reported as related to Covid-19. 14. Total number of Structured Judgement Reviews triggered between for this period 18

(including 4 LD deaths and one possible SI)

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15. For inquests more than double the number of new inquests in month not covid related and 43% increase on open inquests compared to last year.

16. Development of claims led quality improvement programmes this period focussing on

health and safety associated with scalds from hot drink swilling 17. There has been a significant reduction in complaints and concerns during this COVID-

19 period. The complaints team have been focussing on resolving all complaints and concerns received to take the pressure off the Divisions who may have not had capacity to review complaints during this time.

BACKGROUND 18. Following a review of the assurance processes and recommendations to improve the

governance processes across the organisation a Safety Framework was developed and the Safety report supports the assurance of this process.

PATIENT SAFETY INCIDENT (PSI) REPORT: OVERVIEW OF INCIDENT DATA UP TO AND INCLUDING 31 MAY 2020

19. The graph below (figure1) shows all incidents across the Trust reported between 1 January to 31 May for both 2019 and 2020. Comparing these two periods enables us to review if the current pandemic is having an effect on staff capacity to report adverse events.

20. This would be a concern as we would be unaware if the service was becoming unsafe.

A detailed review has been commissioned by the CCG as an assurance report that the Trust continues to operate safely.

21. This report will endeavour to explain any significant variation to establish if it is directly

related to Covid or it is part of an emerging pattern/trend. 22. Therefore we will review the period prior to the pandemic and the reference period 16

March 20 to 31 May 20 as the ‘pandemic period’. 23. When we reviewed incident reporting early in the pandemic period the number of

reported incidents did not appear to be showing any significant variation on last year’s reporting. However, as this period continues we can see from figure 1 that from April and May we can see a diminution in the number of reported incidents.

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Figure 1

Table 2

Jan Feb Mar Apr May Total Variance between 2019 and 2020

Community 2019 877 784 802 911 829 4203 2020 988 988 835 1011 912 4734 +13%

Local 2019 1234 1148 1084 1080 1428 5974 2020 973 897 900 956 1015 4741 -21%

Secure 2019 589 516 503 664 631 2903 2020 631 501 578 594 650 2954 +2%

SLD 2019 539 378 459 448 409 2233 2020 453 373 412 314 358 1910 -14%

24. Table 2 above provides the reporting numbers by Division and the variance at Divisional level.

25. The Community Division are reporting more incidents; and this is appears to be a

month on month increase both pre and post Covid. 26. The biggest variance in incident reporting levels are within Local Division. They are

reporting fewer incidents consistent across the five month period, with an overall reduction of 21% across the period. However, smoking infringements account for 94% reduction on the previous year; 1566 incidents in 2019 versus 103 in 2020. Smoking infringements are not a current concern so if we remove this category we can actually report an increase in incident reporting of 13%.

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27. The majority of incidents are reported via inpatient services so occupancy has been

considered as an influencing factor, which has been reduced over the pandemic period. Table 3 below is the percentage change for each month with average occupancy levels for all inpatient areas. Given the reduced occupancy we can see a pattern of improved reporting.

Table 3

LOCAL DIVISION Jan Feb Mar Apr May

Variance of incident reporting month on month between 2019 and 2020 – Local Division

16% 1% 11% 7% 29%

Occupancy Levels

90.03% 89.06% 80.54% 70.93% 73.30%

NB Occupancy report from Ward Occupancy – not adjusted for Covid-19 removal of beds

28. Table 4 profiles the variance month on month between 2019 and 2020 based on the top 10 inpatient reporters. As we can see from Table 4 across the 5 month period we can see the three wards with a significant reduction on the number of reported incidents, however, this trend appears to be pre Covid. There does not appear to be any wards showing a marked decrease in incident reporting during the height of the Covid outbreak.

Table 4

LOCAL DIVISION Total No of Incidents

Variance between months 2019v2020

Ward 2019 2020 Jan Feb Mar Apr May Av Boothroyd/Dunes Ward 278 187 -33% -28% -48% -49% 21% -31%

Dee (Female) 350 276 -55% -24% 288% -19% -63% -21%

Brunswick Ward 213 179 -31% 37% -55% -44% 19% -16%

Harrington Ward 245 263 79% 5% -32% 10% 15% 7%

Acorn Ward 205 247 8% -36% 0% 24% 129% 20%

Albert Ward 231 325 144% 9% 79% 39% -16% 41%

Alt Ward (Admission) 131 197 -50% -3% -14% 71% 222% 50%

Park Unit/Pine Ward 250 219 8% 39% 57% 41% 115% 51%

Windsor House Inpatient 67 108 240% 186% -56% 44% 18% 61%

Morris (Male) 104 191 225% 29% 4% 41% 222% 84%

29. Table 5 profiles the variance month on month between 2019 and 2020 based on the top reported incident types with ‘smoking infringements’ removed.

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30. The following increases in incidents have been noted during the Covid period with highest reporters being:

• Aggression by Patient on Staff or Other

i. Acorn ii. Albert

• Aggression by Patient on Patient i. Dee ii. Albert

• Slip Trip or Fall by Service User i. Acorn ii. Dunes

• Deterioration in Health i. Acorn

• Planned Intervention i. Harrington

• Incident involving medication i. Alt ii. Albert

Table 5

LOCAL DIVISION Total No of Incidents


Incident Type 2019 2020 Jan Feb Mar Apr May Av Self Harm

555 485 -22% -6% 57% -28% -34% -13%

Aggression by Patient on Staff or Other

354 525 81% -2% 9% 100% 88% 48%

Aggression by Patient on Patient

158 251 45% 25% 11% 29% 229% 59%

Service Provision

116 72 -34% -39% 6% -30% -71% -38%

Slip Trip or Fall by Service User

110 115 -35% -23% -32% -9% 223% 5%

Missing Patient

73 51 36% -35% -6% -55% -80% -30%

Deterioration in Health

72 92 -36% 0% 67% 23% 77% 28%

Planned intervention

67 64 -50% 36% -25% 0% 50% -4%

Incident Involving Medication

45 47 -9% 14% -54% 67% 60% 4%

Property Related

38 38 -50% -17% 50% 22% -9% 0%

Medication Errors

37 26 -60% 0% -56% 33% -50% -30%

31. This information was discussed at the last and Strategic Patient Safety and Improvement Group and the issue of the use of Dynamic Assessment of Situational Aggression (DASA) was discussed as a strategy to address the increased incidence of aggression.

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32. SLD are showing a reduction in incident reporting but this could be due to overall contraction of services that has been occurring over the past year, in particular the closure of IPC Slaidburn. If we adjust the figures removing IPC Slaidburn the actual variance is 5% reduction on last year which is consistent with contraction of services and the reducing restrictive practice initiative.

33. Table 6 reviews incidents by type the incident categories in red show variance on last

year that may be Covid related. Positively self harm and staffing levels are reduced. There is an increase in incidents in:

• Clinical Care related to the Star Unit • Violence to Patient increases on 1&2 Woodview • Medication related to Pharmacy services • Security of Property relates to Maplewood occupational therapy

Table 6

SLD Total No of Incidents


Incident Type 2019 2020 Jan Feb Mar Apr May Av Violence To Staff 561 669 -10% 16% 26% 36% 40% 19% Self Harm 362 315 9% 7% -38% -43% -15% -13% Staffing Levels 255 243 -9% 154% 60% -98% -62% -5% Disruptive Behaviour (No Victim)

296 178 -44% -53% -35% -44% -21% -40%

Clinical Care 90 121 37% 17% 65% -21% 125% 34% Violence To Patient 94 80 -58% -23% -25% 29% 58% -15% Personal Accident (Patient)

63 33 -93% -54% -10% -46% -17% -48%

Security Other 61 35 29% -50% -50% -75% -78% -43% Medication 43 49 -43% 50% 0% -29% 111% 14% Security Of Property 37 30 17% 50% 67% -71% -64% -19%

34. Figure 2 below outlines the top reported incident categories trust wide adjusted for the removal of IPC Slaidburn and Smoking Infringements. As can be seen there is increased reporting across all incident categories with the exception of self-harm, which is positive outcome from the focussed piece of work through CfPC with the women’s services with the aim of reduction of self-harm.

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Figure 2

35. The graph below (figure 3) is the figures reported during the pandemic period of 16 March to 31 May comparting 2019 to 2020 (adjusted for IPC and smoking infringements). Again, no significant variation on reporting rates.

Figure 3

36. The graph below (figure 4) is the figures for top 10 incident categories for the period 16 March 19 to 31 May 2020 as can be seen an increase in patient death and violence to staff but decrease in self-harm.

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Figure 4

PROFILE OF PATIENT HARM

37. The graph below (figure 4) shows all incidents resulting in harm by severity across the Trust reported between 1 January to 31 May for both 2019 and 2020. Comparing these two periods the most notable change is in the ‘severe harm’ category a 46% increase from 2019. There is an 18% decrease in ‘moderate harm’. The increase in ‘severe harm’ category incidents is just within Community and SLD.

Figure 5

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38. Within Community Division there are 103 incidents of ‘severe harm’ in 2020 compared

to 74 in 2019; of which 97/103 are ‘pressure ulcer and wound care’ as previously discussed due to change nationally in the reporting criteria for pressure ulcers in April 2019.

39. However, if we review figures for April and May for 2019 (n27) and 2020 (n47) which

have had the same reporting criteria there is still a significant increase. Is this due to improved understanding of the reporting criteria or more harm needs further exploration, particularly as this increase correlates with the Covid period.

40. This level harm is predominantly reported across district nursing teams with the

following teams as the highest reporters of severe harm pressure ulcers. • District Nursing Croxteth • District Nursing Everton • District Nursing Maghull • District Nursing Seaforth & Litherland

41. All pressure ulcers are subject to a ‘being open’ review so these findings form part of the routine reviews within the Community Division

42. The same graph (figure 6) for the pandemic period 16 March to 31 May 2020

comparing 2019 to 2020 again does not show any significant variance in harm rates other than the ‘severe harm’ category which as previously explained is due to pressure ulcers and reporting of learning disability deaths.

Figure 6

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43. For SLD the ‘severe harm’ is attributable to reporting of deaths by the Community LD

Teams inputted under the category of ‘clinical care’. Table 7 profiles the reported deaths by month. Learning disability deaths are the subject of oversight by NHSE through the accelerated Learning Disability Death Review (LeDeR) programme. A deeper analysis of people with learning disability deaths is planned for presentation at Executive Safety Huddle 13 July 2020. Learning from the rapid reviews of learning disability deaths is discussed later in the report. However, to note that there is nothing to suggest in these deaths that are attributable to any acts or omissions in the care provided by the Community LD teams.

Table 7

2019 2020 Death - Natural Causes Total 1 19

Jan 1 4 Feb - 1 Mar - 3 Apr - 8 May - 3

Death – Unexpected Total - 3 Jan - 1 Apr - 1 May - 1

Grand Total 1 22

44. The tables (tables 8 to 11) below give an overview of incident category with highest levels of reported harm and within this pandemic period 16 March 2020 to 31 May 2020; compared to the same period in 2019 for each of the divisions.

45. Table 8 outlines the Community Division’s profile of harm related incidents specifically

during the pandemic period. As previously discussed pressure ulcer and wound care is the highest rated incident causing harm with an increase during the pandemic period. The other notable increase in harm is with medication errors, which needs exploring in more detail.

Table 8

Liverpool & South Sefton Community Division 2019 2020 Pressure & Wound Care 664 619

• Severe Harm 33 59 • Moderate Harm 200 117 • Low Harm 431 443

Slip Trip or Fall by Service User 34 26 • Severe Harm 2 - • Moderate Harm 2 5

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Liverpool & South Sefton Community Division 2019 2020 • Low Harm 30 21

Treatment Problems 25 26 • Moderate Harm 20 10 • Low Harm 5 16

Medication Errors 5 16 • Moderate Harm - 5 • Low Harm 5 11

Sexual Health 34 9 • Low Harm 34 9

Total 823 750

46. Table 9 outlines the Local Division’s profile of harm related incidents specifically during the pandemic period. The areas highlighted in red are the incidents demonstrating increased harm during the pandemic period.

Table 9

Local Division 2019 2020 Self Harm 83 164

• Severe Harm 6 3 • Moderate Harm 8 33 • Low Harm 69 128

Slip Trip or Fall by Service User 38 73 • Severe Harm 1 1 • Moderate Harm 8 18 • Low Harm 29 54

Aggression by Patient on Patient 16 37 • Severe Harm 1 - • Moderate Harm 1 3 • Low Harm 14 34

Accident or Injury to Service User 14 18 • Moderate Harm 4 5 • Low Harm 10 13

Deterioration in Health 35 14 • Moderate Harm 19 8 • Low Harm 16 6

Patient Death 20 12 • Death Caused by incident 20 12

Aggression by Patient on Staff or Other 2 10 • Death Caused by incident - 1 • Low Harm 2 9

Total 233 362

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47. Table 10 outlines the Secure Division’s profile of harm related incidents specifically during the pandemic period. The area highlighted in red are the incidents demonstrating increased harm during the pandemic period, which is a low level increase in ‘low harm’ self harm.

Table 10

Secure Division 2019 2020 Self Harm 71 83

• Severe Harm 1 - • Moderate Harm 18 16 • Low Harm 52 67

Accident or Injury to Service User 9 9 • Moderate Harm 2 3 • Low Harm 7 6

Deterioration in Health 6 8 • Severe Harm - 1 • Moderate Harm 1 4 • Low Harm 5 3

Inappropriate Behaviour 5 5 • Moderate Harm 1 - • Low Harm 4 5

Aggression by Patient on Patient 5 4 • Moderate Harm - 3 • Low Harm 5 1

Service Provision - 3 • Moderate Harm - 1 • Low Harm - 2

Slip Trip or Fall by Service User 3 3 • Moderate Harm 1 - • Low Harm 2 3

Total 106 121

48. Table 11 outlines the SLD Division’s profile of harm related incidents specifically during the pandemic period. The areas highlighted in red are the incidents demonstrating increased harm during the pandemic period, which is a low level increase in ‘low harm’ violence to staff and the increase in reported deaths for people with learning disabilities.

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Table 11

Specialist Learning Disabilities Division 2019 2020 Violence To Staff 136 165

• Low Harm 136 165 Self Harm 90 49

• Low Harm 90 49 Disruptive Behaviour (No Victim) 57 38

• Moderate Harm 2 - • Low Harm 55 38

Clinical Care 26 20 • Severe Harm - 15 • Moderate Harm 2 1 • Low Harm 24 4

Violence To Patient 16 12 • Low Harm 16 12

Personal Accident (Patient) 12 7 • Low Harm 12 7

Total 387 312

COVID RELATED INCIDENTS

49. Table 12 below gives an overview of the covid-19 related incidents reported in 2020 it is difficult to undertake a detailed analysis of type of incident and level of harm so there is an exercise planned to undertake detailed data cleansing on the covid-19 related incidents to better classify and explain the level of harm and hospital acquired infection.

Table 12 Feb Mar Apr May Jun Total Corporate Services 1 1 3 5 Liverpool & South Sefton Community 12 62 147 46 10 277 Local Division 3 29 108 70 21 231 Secure Division 16 20 3 1 40 SLD 1 4 14 29

50. Whilst this is a brief high level oversight of incident data the current picture is that our services continue to report adverse incidents at a rate consistent with previous calendar year. Reviewing reported incidents apparent increase severe harm rates can be explained by the learning disability deaths and pressure ulcers; both these incident categories are under continued review.

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51. Whilst this comparative on numbers demonstrates no significant shift when analysed

by the National Reporting Learning System the data will be analysed bed occupancy rates as a comparative so with reduced bed days may demonstrate an increase in harm although this should also be reflected against comparative Trusts.

SERIOUS INCIDENTS

52. The annual report on serious incidents is due to be reported to QAC in July 2020, however, due to Covid-19 this has been delayed. The delay is due to the status of a number of RCAs which have either been paused or on-hold due to the pandemic situation.

53. As yet a full recovery timeline for each RCA has not been finalised but a number have

come off hold and initial review and timeline development is underway. The detail/status for each open RCA will be detailed later in the report.

54. With regards to the annual report this will be in a position to report at the next QAC in

September 2020. 55. Following discussion at the Strategic Patient Safety and Improvement Group table 13

below highlights the key improvement priorities arising.

Table 13

Areas for Improvement Escalated through SPSIG by Divisions Community Local Secure • Pressure ulcer prevention • Reducing Harm via Safer • Developing and maintaining

the oversight of the clinical and professional competencies for staff within the community division with a view to the development of structured training needs analysis

• End of life care pathway • Patient safety dashboard –

development continues planned to go live across community services April 2020.

After consultation across the Division the following areas for improvement have been agreed:

• Assaults on Staff • Self Harm • Absent Without Leave

There are two open IT systems issues directly impacting on Secure Mental Health’s incident reporting: Incident data is not transferring in full from PACIS to DATIX and Datix coding.

56. There have been 17 serious incidents (table 14) reported on StEIS between 1 May 2020 and 31 May 2020.

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Table 14

Liverpool & South Sefton Community Division 1

Delay in treatment 1

Local Division 8

Adult unexpected death 6

Fall 1

Found on Ground 1

Secure Division & SPLD 8

Allegations Against Staff 2

Deterioration of Physical Health 2

Keys and Other Locking Mechanisms 1

Ligature 1

Other self harm 1

Weapon Discovery 1

Grand Total 17

Status of RCA’s

57. For Local Division there are a total of 21 serious incidents with investigation commenced or on hold or with the CCG awaiting closure.

Table 15

Category Status No

Fall x 3 Thematic Review Commenced 3

Patient Death Review on HOLD - police investigation

Hill Dickinson to be instructed

2

Alleged sexual abuse of a Review commenced by Hill Dickinson 1

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Category Status No

child

Possible Homicide/ Unexpected death

Possible closure on 72 hour Coroner Conclusion (misadventure) sent to CCG

1

Possible suicide RCA on-going 1

Unexpected Death RCA On Hold with police 1

Possible suicide Structured Judgement Review 12

Total 21

58. For the Community Division there are a total of 4 serious incidents where investigation commenced or on hold or with the CCG awaiting closure.

Table 16

Category Status No Unstageable Pressure Ulcer 72 Review being resubmitted for closure 1 Natural cause death with concern about care RCA multi agency 1

Delay in Treatment RCA Level 2 1 Severe delay in treatment RCA 1

59. 6 RCA’s are with the CCG awaiting review and confirmation that they can be closed on Steis or if further information is required.

60. Engagement is taking place with the CCG and Divisions to review when the

investigations will recommence. 61. Secure & SPLD have two incidents open on LCCG Steis.

Table 17

Category Status No Assault

HD Instructed

1

Patient Death On Hold Merseyside Police/Coroner 1

62. There is 5 high level enquiry action plans being monitored by the CCG. Due to Covid

implementation of remaining actions has been delayed. Agreement with CCG to extend due dates is in progress.

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63. Of these 5 NHSE have commenced the commissioning of 2 Level 3 external reviews 64. Duty of Candour was applied to 5 notifiable patient safety incidents in May 2020, 4

deaths of which 2 were natural causes one of which was during an inpatient stay and one with gaps in care and 2 suicides and an IG breach.

65. The two suicides and the inpatient death were in the local division, the death where

gaps in care were identified was in the community division and the IG breach is from Prison health in the secure division.

Table 18

Death 4 natural causes 2 suicide 2 Moderate harm IG breach 1

LEARNING FROM DEATHS AND MORTALITY REVIEW MAY 2020

66. Overall 265 deaths were reported by the clinical divisions in May 2020 including 4 deaths of those with a Learning Disability reported on Ulysees. The charts below demonstrate the make up of deaths reported as unexpected and expected and the progress made with mortality screening.

67. During May 2020 the Mortality review team have continued to focused on triage of all

Mental Health and Learning Disability deaths (figure 7), those deaths which were unexpected and those deaths identified as linked to Covid-19 infection of which 38 were reported.

• All Mental health deaths (65 during this period) • All unexpected deaths (24 during the reporting period) • All LD deaths (4 during the reporting period, all in scope) • All deaths where staff indicated a concern (1 during the reporting period)

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Figure 7

68. There were 86 deaths screened and 14 of these met one of the specified ‘red flags’

indicating more in depth review for a Structured Judgement Review was required. This is a 16.2% conversion rate from screening to SJRs which reflects the circumstances of those screened, with an upsurge in potential suicides noted, similar to incidence during May in previous years. This is being explored to identify any underpinning themes as this phenomenon is not completely understood.

69. Serious Incident reviews are currently on hold with agreement from Liverpool CCG due

to the Covid-19 outbreak. The MIPs will be completing SJR for all deaths reported to StEIS for the current time as an interim review alongside divisional 72 hour reviews to establish learning. Decisions regarding progress to full SI review will follow discussion with the CCG.

Figure 8

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70. SJR’s are considered by the Mortality MDT. Outcomes from SJR’s are shared directly back to teams involved and where necessary further actions are recommended to divisional teams including development and circulation of Quality Practice Alerts.

71. Due to full LeDeR reviews being suspended it was agreed that the MIPS would

undertake a SJR for all LD deaths. All 4 LD deaths that occurred in May 2020 have therefore progressed to SJR.

72. The Trust has supported the wider system across Liverpool and Sefton to undertake

rapid reviews of learning disability deaths as part of the LeDeR programme; table 19 identifies the learning coming from the national LeDeR team following the rapid reviews. These are being included in the future LeDeR reviews.

Table 19

Themes Issue

Communications • Inconsistent use of hospital passports • People with severe learning disability particularly impacted

in terms of communication needs and new environments. Specialist support • Some patients receive one to one support in the

community and contractual arrangements did not allow staff to follow the person.

• Cover / support for staff that have symptoms and there are workforce pressures

Cause of death / death certification

• Some death certificates had Down’s Syndrome identified as the cause of death.

Public Health • High volume of people with a learning disability have co-morbidities including underlying conditions such as obesity, high cholesterol and diabetes.

DNACPR • High use of DNACPR. • Decision to put a DNACPR in place did not always include

the family/carers

73. Building on the rapid reviews the Trust is supporting Liverpool and Sefton to undertake accelerated LeDeR reviews for those deaths identified as being covid related and having emerging concerns.

74. This is 10 cases with reviews completed within 3 weeks versus the usual 3 months

with a deadline of 8 July 2020. INQUEST DATA APRIL AND MAY 2020 75. There were 23 new inquests reported in this period which is above the average when

compared to 2019 – 2020 which was 10 new inquests per month on average 76. The breakdown of the new inquests by Division:

• Local: 22 • Secure: 0 • Community: 1

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77. Of note: • 4 concerned hanging – all at the service user’s home address. • 1 concerned the death of a service user where notes indicating an intention to

end his life were found at the scene. • 1 concerned a suspected overdose. • 1 concerned deliberate incisions to service user’s arms.

78. The number of open inquests currently being managed and waiting for a conclusion at

the end of May 2020 is 87. Comparing the number of open inquests at the end of May 2019 (61) to May 2020 shows an increase of 43 % in activity in the 12 month period.

79. The breakdown of the open inquests by Division: • Local: 76 • Secure: 9 • Community: 2

80. Of the 87 open inquests staff attendance will be required at 21 as at the end of May

2020. The staff will be supported by the trust Legal team prior to the inquest in terms of reviewing all the evidence, any concerns raised by family/the Coroner and when attending the hearing itself.

81. The breakdown of the inquests at which staff attendance is required by Division: • Local: 12 • Secure: 9 • Community: 0

82. There were 22 conclusions in the period, consisting of:

• Accidental: 1 • Alcohol/Drug related: 9 • Narrative conclusion: 5 of which: • 2 involved hanging • 1 involved head injuries following the service user being hit by a train • Natural causes: 6 • Suicide: 1 (hanging)

83. The breakdown of the conclusions by Division:

• Local: 20 • Secure: 0 • Community: 2

84. There were no Regulation 28 Prevent Future Death reports issued by the Coroner to

the trust in this period.

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CLAIMS 85. Open Claim Status is detailed in figure 9 below. Figure 9

86. The legal team are in the process of drafting a new claims SOP for claims management to improve engagement with divisions, reporting and evidencing learning outcomes.

87. Learning: Hot Beverages - Following the admission of liability of two claims involving hot drink swilling (1) Patient on Staff (2) Patient on Patient.

88. Authorisation for a Task & Finish Group to review practice and standard operating

procedures for provision of hot beverages.

COMPLAINTS

89. There has been a significant reduction in complaints and concerns during this COVID-19 period. The complaints team have been focussing on resolving all complaints and concerns received to take the pressure off the Divisions who may have not had capacity to review complaints during this time.

Figure 10

2 10

31 29

8

010203040

CorporateServices

LiverpoolCommunity

Services Division

Local Division Secure Division SpecialistLearning

DisabilitiesDivision

Total

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Figure 11

90. During May, 6 complaints were received that required a formal investigation, four of these have been placed on hold in line with the business continuity policy for complaints, and 2 have been allocated an investigator. The complaints related to visiting arrangements, palliative care, diagnosis, medication, confidentiality and communication. 4 were from the Local Division, 1 from Secure and 1 from the Community Services Division.

91. There are 34 complaints currently on hold, however it is anticipated that all complaint

reviews will resume at the end of June.

92. The complaints team are currently looking at piloting a ‘PALS Plus’ process in line with the Just and Learning Culture and will liaise with the divisions to look at how managers can review complaints within their own areas and meet with complainants to feedback the findings, being accountable for any actions and learning arising from the complaint; this will be done with the support from the Complaints Co-ordinators.

93. 93 concerns were received, 18 of these were requests for advice and information.

Care and treatment, staff attitude, medication, discharge arrangements and detention were themes of concerns that were able to be resolved without the need for a formal investigation. There are also individual service users who are in regular contact with the PALS officers that will have an impact on the number of concerns logged.

94. The Local Division received the highest number of concerns (60) during May although

13 were requests for advice and information. There were several concerns raised regarding mediation within Arundel and North Liverpool CMHT. Detention and discharge arrangement continue to be a theme on inpatient wards.

95. There were no themes within the Secure Division, examples of the types of issues

raised included property, meals nursing care, policies and procedures. 96. There were no themes within the Community Services Division; examples of the types

of issues raised included staff attitude, care and treatment, CHC and appointments. It is noted that the team received several calls regarding the Phlebotomy service (in June) as there has been a reduction in this services resulting in patients experiencing delays getting through.

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PATIENT EXPERIENCE

97. The local and secure division have continued to complete the in patient surveys but due to the changes in the delivery of community services in both the local and community divisions this has impacted on the access to patients and the ability to undertake surveys. The FFT has been suspended in the community setting by NHSE.

Table 20

EMERGING CONCERNS / RISKS / ESCALATIONS 98. SOP – Reporting Life threatening occurrences

Following a recent incident involving an unexpected death, it was identified that a new Standard Operating Procedure is being drafted by the Patient Experience Team to support staff with ‘Reporting to Police and Careline life threatening occurrences’ - organisationally.

99. Annual Leave

A new risk has been identified Carrying over leave entitlement and the organisational impact.

100. Return of Year 2 Students

Secure & Local Division have identified an emerging issue in relation to the return of 75 Year 2 Student Nurses (x30 Secure; x44 Local and x 1 Community).

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COMPLIANCE AGAINST THE CQC’s DOMAINS – SAFE 101. The Safety Report provides assurance of the Trust’s Quality and Safety Framework

and it’s commitment to using best practice, improvement science, digital technology and performance monitoring to reduce and prevent risks and harm.

COMPLIANCE AGAINST THE CQC’s DOMAINS – WELL LED 102. The development of the safety report ensures the QAC has clear oversight and

effective processes to analyse and monitor safety performance concerns, understand trends and drive improvement to prevent harm.

GAPS IN ASSURANCE / NEXT STEPS 103. The Safety Report is evolving with the Quality and Safety Framework to improve on

current reporting and ensure a standardised robust safety management and governance process across all divisions organisation wide.

SIDE BY SIDE WITH SERVICE USERS / CARERS / STAFF 104. The report itself documents service change and improvements. Those improvements

will have service level co-produced implementation plans.

Joanne Bull Associate Director of Patient Safety Dr Noir Thomas Executive Medical Director 1 July 2020

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Executive Performance Report Week Ending 19th July 2020

Accountable Director(s): Neil Smith, Executive Director of Finance Report Author(s): Asim Patel, Chief Information Officer









Corporate Services

Our Future ☐ Develop Provider Alliances ☒






Purpose of Report: To provide members of the Board a summary of Trust performance to Week Ending 19th July 2020 against Regulatory, Key Operational and COVID-19 related measures.

Recommendation: The Board is asked to: 1) Note the assessment of performance against Regulatory, Key

Operational and COVID-19 related measures.


Council of Governors 22 July 2020

Executive Performance Report Week Ending 19th July 2020


Operational Performance ☒ Yes - The impact is anticipated to be positive and to provide assurance of compliance with operational performance metrics, NHS provider licence and legal requirements.

Provider Licence Compliance ☒ Legal Requirements ☒ Resource Implications ☐



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Week Ending 19th July 2020

WeeklyExecutive Performance Report

(COVID-19)

The Weekly Executive Performance Report is an interim report, it has replaced the daily executive report introduced in response to Covid-19. This weekly report forms part of the Trust’s continued Covid-19 response and is utilised to inform Divisions in relation to current performance in key identified areas and is also reviewed and discussed at the Operational Management Group, chaired by

the Executive Director of Nursing and Operations. This interim report has been established and includes additional Covid-19 related measures and other key operational metrics.

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NHS Oversight Framework Monthly MetricsTarget/ Latest National

Median Available Peer Posiion Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

Mental Health Friends and Family Test: (% positive) 90.32% 90.37% 92.73% 89.23% 88.43% 90.11% 90.89% 88.91% 89.09% 92.00% 88.24% 90.57% 92.48%

Community Friends and Family Test: (% Positive)96.95% 97.30% 95.82% 98.40% 97.50% 94.93% 95.90% 97.60% 97.74% 96.81% 97.80% 98.70% 97.85%

Care Programme Approach 7 day Follow Up 95% / 96.49% 96.23% 96.43% 100.00% 96.36% 93.68% 96.49% 96.61% 100.00% 95.95% 90.74% 98.46% 95.45% 96.40% 93.33% 100.00% 97.37%% clients in settled accommodation (Local Reporting) 61% 49% 70.31% 72.38% 68.63% 67.60% 65.97% 64.69% 64.23% 63.67% 53.43% 46.60% 35.91% 49.07% 50.23% 51.61% 52.11%% clients in employment (Local Reporting) 8% 7% 5.90% 5.77% 5.23% 5.23% 4.86% 4.72% 4.98% 5.04% 4.67% 4.21% 3.68% 4.29% 4.71% 5.18% 5.22%Patient Safety Alerts not completed by deadline 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Occurrence of any Never Event (Rolling 6 Month) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Admissions to adult facilities of patients who are under 16 years old 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Sickness (In-month) 4.98% 6.39% 6.53% 6.64% 7.02% 7.28% 7.02% 7.50% 7.71% 8.14% 8.56% 8.01% 7.65% 8.90% 9.31% 7.64% 7.08%Turnover (In-month) 0.72% 0.73% 0.63% 0.67% 0.64% 0.92% 0.91% 1.23% 0.69% 0.79% 0.79% 0.81% 0.70% 1.18% 0.70% 0.71% 0.42%Proportion of Temporary Staff 3.99% 4.59% 3.29% 3.47% 3.59% 3.80% 4.02% 4.31% 4.24% 4.21% 4.24% 4.31% 4.30% 4.10% 3.87% 3.75% 3.98%First episode of psychosis begin treatment with a NICE-recommended package of care within 2 weeks of referral (Part B - MHSDS Dataset) 60% From April 2020 74% 61% 54% 59% 61% 66% 63% 70% 70% 75% 70% 74% 74% 75% Provisional

78%Provisional due

Aug 2020Accident and Emergency Maximum waiting time of four hours from arrival to admission/ transfer/ discharge 95% 99.40% 99.98% 100.00% 100.00% 100.00% 99.73% 99.91% 99.70% 99.53% 99.91% 99.75% 100.00% 100.00% 100.00% 100.00%IAPT - Proportion of people completing treatment who move to recovery (Internal Reporting) - Monthly 50% 49.50% 38.61% 36.35% 44.77% 47.29% 50.38% 50.15% 50.15% 45.13% 46.42% 46.68% 42.77% 42.55% 33.70% 35.83% 49.84%IAPT - Waiting time to begin treatment (from IAPT minimum dataset) within 6 weeks 75% 99.21% 98.86% 99.15% 99.51% 98.94% 96.85% 95.15% 98.72% 99.20% 99.00% 99.10% 98.95% 99.20% 98.90% 97.68% 98.65%IAPT - Waiting time to begin treatment (from IAPT minimum dataset) within 18 weeks 95% 82.18% 100.00% 99.86% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%Inappropriate Out of Area Placement (In-Month) Q1 2020-21 - 60 0 0 0 0 0 0 0 0 0 0 0 0 5 19 0Potential under-reporting of patient safety incidents -2 Standard Deviation -1.27Data Quality Maturity Index (DQMI) - MHSDS Dataset Score - 36 items 95% 79.00% 84.50% 84.20% 87.00% 87.40% 87.40% 89.20% 89.30% 89.20% 90.00% 88.20% 89.70%Capital Services Capacity 2019/20 Year End Plan - 2 3 3 2 2 2 2 2 2 2 2 1Liquidity Days 2019/20 Year End Plan - 1 1 1 1 1 1 1 1 1 1 1 1Income and Expenditure Margin 2019/20 Year End Plan - 1 3 3 3 2 2 2 2 2 2 2 1Income and Expenditure Margin Variance (based on original plan) 2019/20 Year End Plan - 1 1 1 1 1 1 1 1 1 1 1 1Agency Spend 2019/20 Year End Plan - 2 2 2 2 2 2 3 2 3 3 3 3

NHS Oversight Framework Quarterly Metrics Target Peer Posiion Q1 2019 Q2 2019 Q3 2019 Q4 2020 Q1 2020IAPT - Proportion of people completing treatment who move to recovery (from IAPT minimum dataset) - Quarterly 50% 49.50% 39.82% 49.13% 47.23% 44.03% 39.23%

Staff friends and family test % recommended - care 80.89% 71.96% 74.39% 74.66% 80.08% Submission Suspended

Written complaints per 1,000 staff – rate 17.85 9.16 7.23 7.31NHS Oversight Framework Annual Metrics 2017-18 2018-19 2019-20 2020-21

Care Quality Commission - Community Mental Health Survey 7.47 7.05 6.88

Staff Survey - Staff Engagement Theme 7.0 7.1

Support and Compassion - Average % (Internal Interpretation of the Metric)In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from…Q13a. Patients/ Service Users, their relatives or other members of the publicQ13b. ManagersQ13c. Other ColleaguesLOWER IS BETTER

17.13%

Team Work - Average % (Internal Interpretation of the Metric)To what extent do you agree or disagree with the following statements about your work?Q4h. The team I work in has a set of shared objectivesQ4i. The team I work in often meets to discuss the team's effectivenessHIGHER IS BETTER

72.51%

Inclusion - Rank (Internal Interpretation of the Metric)Q14. Does your organisation act fairly with regard to career progression / promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age? (Higher is better).Q15b. In the last 12 months have you personally experienced discrimination at work from any of the following? Manager / team leader or other colleagues. (Lower is better)

46.01%

Inclusion - The BME Leaderships ambition (WRES) re: Executive appointments.A query has been raised with NHS England and NHS Improvement in relation to the construction of this metric. Interal Intepretation of the Metric has been applied using the latest WRES submission.

0%

Notes

2. The peer position represents the latest peer position available from NHS Improvement, Model Hospital and does not necessarily represent the latest data position reported. The peers included are: Cheshire and Wirral Partnership NHS Foundation Trust, Cumbria Partnerships, North West Boroughs Healthcare NHS Foundation Trust, Greater Manchester Mental Health NHS Foundation Trust, Lancashire Care NHS Foundation Trust, Pennine Care NHS Foundation Trust, Bridgewater Community Healthcare NHS Foundation Trust and Wirral Community NHS Foundation Trust.

TargetLower Limt: 6.34 Upper Limit: 7.37

Combined MH/ LD and Community Trusts: 7.1

Average Combined MH/ LD and Community Trusts: 17.80%




No ratings from April 2020 - August 2020 as per COVID-19 Interim NHSi

Arrangement

Reporting will be

available Early 2021

Submission Suspended

NHS Oversight Framework 2020-21

1. The metrics above use national data where available, however, if this is unavailable for the latter months of reporting internal data is used until such time that the national data becomes available. The national median is the latest data available within NHS Improvement, Model Hospital. The change in data/national median could result in a different Red, Amber, Green rating being reported.



Latest Data available relates to September 2019Latest Data Available

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Our Services

Executive Lead: Trish Bennett

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Executive Summary – NHS Oversight Framework 2020 and Our Services Accountable Director: Trish Bennett, Executive Director of Nursing and Operations Local Division – Donna Robinson, Chief Operating Officer Divisional Waiting Times Update 1. The division is currently finalising the baseline report which will then be used to calculate the

“suppressed” demand within the Community Mental Health Services for contacts, referrals and waiting times. This will enable the division to understand the service gap when redesigning the service through the recovery phase. The strategic unit are running alongside that to use the data to predict the potential surge in demand. The division will be in a better position to respond to the recovery phase at the end of July when the Strategy unit has completed their work.

Clients in Settled Accommodation (%) and Clients in Employment (%) 2. The % of Clients in Settled Accommodation has improved since February 2020 (39.83% Local

Division Position) to May 2020 (57.82% Local Division Position), despite the impact of COVID-19 but remains below the National Median (61%).

3. The % of Clients in Employment has also improved since February 2020 (4.12% Local Division

Position) to May 2020 (5.80% Local Division Position), again despite the impact of COVID-19 outbreak but remains below the National Median (8%).

Improving Access to Psychological Therapies - Proportion of people completing treatment who move to recovery 4. Recovery has improved in month to 49.8%. Drop Outs continue to affect the recovery figures.

However there has been a reduction in the number of patients that drop out of the service with more patients completing their full course of treatment. Recovery rates for those patients who were referred after the lockdown commenced have shown recovery rates of 54.8%.

5. IAPT service has transformed its model of care to deliver phone, online and virtual one to one psychological interventions for its service users. The service has revised its governance with increased numbers of staff working from home, this has shown an improvement on previous month’s data. The service has recorded more attended appointments compared to the same period last year and as a result have reduced internal waiting lists by just over 1300 patients.

6. Work continues within the service to improve and maintain recovery rates to achieve the required

50%. Of all the patients who completed their full course of treatment with the service 87% recovered. This is an improvement from last month.

7. All those waiting over 18 weeks on current waiting lists are being contacted, if they ask to be

discharged then this will impact on recovery if the service users have not met the required scores.

Improving Access to Psychological Therapies - The number of people who have entered psychological therapies (at the end of the reporting quarter) as a proportion of prevalence 8. In line with the increase in referrals, Access numbers have also increased in month to 660 (444

in May), this equates to 0.74% in month.

9. The focus on Access continues within the service, and daily updates are sent to the team detailing the current position. Initial Telephone Assessment availability slots are monitored daily

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to ensure the service can meet the current demand. Due to the lack of referrals into the service, it is expected that this will continue for the coming months.

10. Self Referrals via General Practitioners (GP) have increased again from 158 to 196 in month. GP Referrals have remained at a similar level to last month, 16 up to 17 in June. Online referrals have also increased from 342 in May to 486. This is now slightly higher than the average for the previous 12 months of data (482 average).

11. Due to COVID-19 the service has updated the Talk Liverpool website to let people know that the service remains open and to encourage referrals to offer support. The service has sent communications to Trusted Partners, CCG Colleagues and GP's to explain the new ways of working and to set expectations of the service. The service will continue to update all of our social media platforms to detail how to refer and what will happen once patients have made the referral.

Care Programme Approach 48hr and 7 day Follow Ups 12. For the month of June 2020, the Division has achieved 97.26% for 7 day and 94.44% (17/18) for

48hr CPA follow ups. There is a daily review of these patients and the priority is to contact them to ensure they are safe and action any follow up issues.

Bed Utilisation 13. For the month of June 2020 the Division reported a consistent score of three throughout the

month via the Escalation Management System (EMS).

14. The Executive report demonstrated a bed occupancy position of 82.13% as of the 28 June 2020.

15. A real time position for the Local Division based on reduced bed capacity for June equated to 92.21%.

16. Reduced bed capacity was as result of the introduction of social distancing guidance within the inpatient setting, which led to a loss of 35 beds (reduced to 33 on 27th June) from Adult Mental Health wards and none from the Complex Care or Specialist wards, the Division is currently operating at a reduced capacity of 78% (Adult Mental Health only).

17. The Division is working with the wider Trust and STP, in producing an estates options paper for

the future of inpatient accommodation with shared dormitories, this is also included in the Divisions service change review for Inpatient services.

Delayed Discharges 18. As of the 28 June 2020, there were 5 service users who met the criteria for a delayed discharge

this is a reduction of 4 from the previous month of May. The Division has continued to hold Delayed discharge conference calls and weekly RADAR meetings. The weekly delayed discharge meeting is attended by CSU, Local Authority colleagues and Modern Matrons.

Hospital Re-Admissions within 28 days - Adult Acute Only 19. For the month of June the Division reported a readmission rate of 9.68%, which is below the

target of 10.47%, the Division continues to review all of the individual cases. The Divisional response maintains the process where all service users discharged from hospital aim to be followed up within 48hrs by a face to face contact unless agreed otherwise by the MDT prior to discharge.

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Number of All Ligature Incidents 20. There has been a small reduction in reporting for June and all of the incidents during the

reporting period are recorded as low or no harm, with the majority of the incidents (31 of 58) recorded as no harm. They relate to a small number of highly complex service users, with one service user accounting for 20 of the total recorded incidents, who is now being supported at PICU. All self harm incidents are discussed and monitored by the weekly Divisional Safety Huddle and any further support identified.

21. A deep dive is currently being undertaken by the Centre for Perfect Care in relation to ligatures and a detailed report/presentation will be presented at the next Quality Committee.

Number of Restraints associated with Self-Harm Incidents 22. Reporting has remained stable within the division with six incidents in June which is within the

agreed Trust target. The incidents are all no or low harm and evenly split between Pine Admission Ward and Newton PICU.

Mental Health Liaison Response (1hr and 24hrs) 23. The Division missed the metrics agreed for both the 1hr (86.3%) and 24hr (90.82%) targets

during the month of June. The A&E attendances and ward liaison referrals have increased over the past few months. There continues to be COVID-19 restrictions and challenges which are impacting on service delivery. The service is working to ensure all referrals are responded to within the agreed KPI’s; however, the referral activity at times provides a challenge to service outcomes. This is monitored by team managers on a daily basis to ensure escalation is appropriate and timely. Lastly the Division is currently reviewing the Urgent Care model, which in turn will support services with compliance with metric targets.

Communications - All discharge communication from inpatient episodes are sent to General Practice within 24 hours from discharge Communications - Outpatients All clinic/outpatient correspondence/ letters sent to General Practice following the patient’s appointment, including discharge from service within 10 working days (excluding weekends and bank holidays) 24. In Q1 2020-21 communication from inpatient areas sent to the General Practice within 24 hours

from discharge was 52.20% and communication from outpatient clinics to General Practice within 10 working days was 53.10%, both below the target metric of 95%.

25. Services have highlighted issues with the e-discharge pilot, which would enable automated completion which was operational in our complex care inpatient areas which has now been withdrawn and has been escalated to the Provider and solutions are being sought. There has been no further progress with this reported.

26. This is a significant reduction from the previous quarter. Non-compliance has been identified from areas where a high number of administrative staff were shielding in line with COVID-19 guidance. Technology has now been purchased and delivered to allow these staff members to work from home. A high number of administrative long-term sickness absence continues alongside a number of vacancies. Sickness absences managed through the Trust’s policy are currently on hold and recruitment has recently restarted to fill vacant posts.

COVID-19 Impact on our Patients 27. During the month of June 2020 the Local Division has experienced one outbreak of COVID-19

within its inpatient wards. This resulted in one complex care ward temporarily closed to admissions/discharges. This area has been supported by Infection control throughout and re-opened in a timely and safe manner, after all staff and service users had been swabbed.

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COVID-19 Impact on Contacts 28. For the month of June 2020, the Local Division recorded 43558 attended contacts. With social

distancing measures now being in place and digital platforms being prioritised in some services, there has been a significant change in contact medium, with a continued high volume in telephone and online consultation.

Secure and Specialist Learning Disability Division - Steve Newton, Chief Operating Officer Divisional Waiting Times Update 29. The Division continues to have a weekly bed management meeting, a key element of this is to

review the waiting list for inpatient services. At present the only issue in terms of inpatients is Low Secure Learning Disability and Medium Secure Mental Health, both are long standing issues.

30. The Medium Secure Mental Health male waiting list is managed collaboratively with NHS England (NHSE) as alternative units are often agreed for patients, this waiting list pressure should ease when Rowan View opens. The waiting list pressure for Low Secure Learning Disability relates to the ongoing retraction of the service and commissioner requirement to reduce by a further five beds, again close collaborative review of the waiting list is in place with NHSE. Concerns regarding the length of some waiters have been escalated to NHSE, there is a regional and national pressure on Learning Disability beds. Discussions have commenced with NHSE regarding potential options to help support the pressure.

Bed Utilisation 31. The Division continues to operate at 92.87% capacity; this has been achieved with good bed

management, maintaining a focus on flow through services. Commissioners have thanked us for our approach and have shared our bed management model with other services as an area of good practice.

Ensure a ‘Barriers to Change Checklist’ is completed and regularly reviewed for all service users nursed in long term segregation 32. The trajectory target required for all service users nursed in long term segregation to have a

barriers to change checklist completed and regularly reviewed was 100% by the end of June 2020. The trajectory target for June month end was not achieved 84%. There were five service users’ Barrier to Change Checklist not reviewed within the set time frame of three months at time of audit. The appropriate care teams have been written to ensure the outstanding Barrier to Change Checklists are reviewed before the next audit.

Number of Physical Restraints associated with Self-Harm Incidents 33. The target for reduction in physical restraint associated with self-harm required no more than 39

incidents per month. The target was achieved during April and May but spiked up to 42 incidents in June. Four Specialist Learning Disability wards accounted for 98% of incidents in June. These issues have arisen primarily due to clinical acuity of a small number of service users. The impact of COVID-19 has increased anxiety within the service group which has been further exacerbated by not being able to receive visits from family members which is a protective factor. The division has developed a process to review individual cases within the tactical meeting and have developed a Standard Operating Procedure to follow for those cases agreed.

Number of T-Supine Physical Restraints – SpLD Only 34. During Q1 2020-21 there were 244 incidents of T-Supine physical restraint. Five service users

living in individualised packages of care with complex needs experienced 66% (162 incidents) of all incidents of ‘T’ supine physical restraint. The division has undertaken a clinical review of two

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service users who have experienced a large proportion of the incidents recorded during this time period and a quality improvement plan has been developed with the Multi-Disciplinary Team consisting of 1) Review of psychological formulations and Positive Behavioural Support Plans 2) In reach support and practice leadership from the senior clinical nurse for reducing restrictive practice to drive down incidents resulting in the use of T-supine physical restraint.

Operational and Performance Metrics 35. Many performance metrics remain on hold since April 2020, discussions are ongoing regarding

recovery and prioritising when they should recommence.

Community Division - Lee Taylor, Chief Operating Officer COVID-19 Impact on Contacts 36. In response to COVID-19, Community Division aligned each service into 3 categories of

prioritisation: • Category A – essential services • Category B – support services • Category C – wraparound services

37. Overall, there has been a reduction in the number of referrals to services within the Community

Division as a result of COVID-19 and the number of face to face contacts has also reduced however, there has also been some increases in activity within Category A essential Services which were supported through the movement of staff from Category B support services.

38. Work is underway within the Division to understand the following for each service:

• The historical demand profile showing the impact of COVID-19 and projections based on different recovery trajectories

• A view of current capacity and activity and the comparison against pre-COVID-19 levels as well as the future demand profiles

• Where necessary, analysis of the actions services can implement in order to bridge any gap in required capacity

• Trajectories based on the above relating to the impact of capacity and demand eg. waiting times

Divisional Waiting Times Update 39. As per the Matthew Wynne guidance Allied Health Professional Services during the COVID-19

outbreak were either suspended or reduced. As a result, there has been a general increase in the waiting times reported across Allied Health Professionals (AHP) with some of the individual services now breaching their respective targets.

40. At the end of February 2020, 8 of the 11 AHP waiting times were being achieved.

41. Whilst this deteriorated to just 4 of the 11 being achieved as at the end of April 2020, there was an improvement during May resulting in 6 of the 11 being achieved.

42. A robust, overarching action plan was developed and implemented across all AHP services to

manage the risk of patient harm which included the following: • All new referrals continue to be clinically triaged and those identified as urgent were

contacted and assessed appropriately • Non-urgent patients are added to the waiting list which is regularly validated and patients

waiting receive regular contact with the service • As a result, patient in the waiting list can be retriaged as urgent, discharged if no further

input is required, signposted elsewhere or offered e-consult/telephone treatment

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43. There have been no instances of any patient harm related to the increase in waiting times and

examples of cases that have been identified and managed through the above processes that have resulted in prevention of hospital admissions.

44. Digital technologies and telephone consultations have been utilised to replace face to face contacts during the outbreak period.

45. This has enabled some patients to be managed effectively from referral through to discharge in a

virtual manner and has resulted in the total number of patients waiting to reduce for all 11 individual AHP services.

46. As well as ensuring the mitigation of any risk of patient harm, the action plan also links into the Divisional Reset and Reshape Programme through which the individual recovery plans and associated trajectories of improvement are being developed and overseen. The first phase of these plans is for the services to re-commence seeing routine patients and this is planned for early July 2020.

Latest Reported Waiting Times Position as at end of May 2020 47. As discussed above the impact of COVID-19 has generally resulted in an increase in waiting

times however this has not been absolutely consistent across all the individual services.

48. Liverpool Dietetics Waiting times remain static and in line with the target.

49. Dietetics, Occupational Therapy and Podiatry waiting times in Sefton all remain within the target however have increased due to the impact of COVID-19.

50. Sefton Physiotherapy and Falls in Liverpool have both reduced during May and are now back within their respective targets.

51. The following services are those that have increased and are above target. Whilst the approach to improvement is consistent as detailed above, the specific details regarding the individual waiting lists are detailed below:

Speech and Language Therapy Waiting Times – Liverpool 52. As at the end of May 2020, the waiting time reported for the Liverpool Speech and Language

Therapy (SALT) Service increased for the fourth consecutive month to 22 weeks.

53. Waiting times had decreased down from a high of 21 weeks in September 2018 however more recent reductions in capacity due to unexpected turnover and loss of agency staff combined with an increase in demand led to waiting times remaining above the 8 week target.

54. The impact of COVID-19 has resulted in waiting times increasing further, significantly above the target.

Physiotherapy Waiting Times – Liverpool 55. As at the end of May 2020, the waiting time reported for the Liverpool Physiotherapy Service

decreased for the first time in three months however remained above the 8 week target at 10 weeks.

56. As described above, a full trajectory will be developed in line with the capacity and demand work to be carried out as part of the Divisional Reset Programme.

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57. This will take into account the impact of the temporary suspension of the service due to COVID-

19, the backlog of patients waiting and the capacity available to the service based on future social distancing considerations and any new models of service delivery.

Occupational Therapy Waiting Times – Liverpool 58. As at the end of May 2020, the waiting time reported for the Liverpool Occupational Therapy

Service increased for the third consecutive month to 15 weeks.

59. This is over double the pre-COVID-19 waiting time and remains significantly above the 8 week target.

60. As described above, a full trajectory will be developed which takes into account the impact of the temporary suspension of the service due to COVID-19, the backlog of patients waiting and the capacity available to the service based on future social distancing considerations and any new models of service delivery.

Podiatry Waiting Times – Liverpool 61. As at the end of May 2020, the waiting time reported for the Liverpool Podiatry Service increased

for the third consecutive month to 14 weeks.

62. Podiatry waiting times have been no higher than 5 weeks since June 2019 however they are now over three times the pre-COVID-19 waiting time significantly above the 8 week target.


Speech and Language Therapy Waiting Times – Sefton 64. Waiting times reported for the Sefton and Language Service have been higher than the 18 week

target since December 2019 due to capacity issues within the service however as at the end of May 2020, the waiting time had increased further to 24 weeks.


Pressure Ulcers – StEIS Reportable Deteriorations from Cat 2 to Cat 3 66. There was one StEIS reportable pressure ulcer which deteriorated from Cat 2 to Cat 3 whilst on

the caseload during June 2020. This is the second reported during 2020/21 and if continuing on the same trend the forecast would be that numbers remain static compared to the previous year.

67. Throughout the COVID-19 outbreak, the Community Division Governance and Quality Framework continued as normal to ensure scrutiny of the impact of the response on patient harm.

68. Service Line Safety Huddles and the Divisional Safety Huddle continued as normal along with the continuation of 72 Hour Reviews being completed 4 times each week.

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69. Work continues in line with the Pressure Ulcer Reduction Programme which has demonstrated a positive impact throughout 2019/20 and resulted in some significant improvements.

70. In total, there were 17 StEIS reportable Category 3 pressure ulcers during 2019/20 which was a 37% reduction compared to the previous year.

71. So far in 2020/21, there have been a total of two StEIS Reportable Category 3 pressure ulcers. If continuing on this trajectory, this would represent a further reduction of 33% compared to the previous year.

72. There was only one StEIS reportable Category 4 pressure ulcer during 2019/20 which was a significant 86% reduction compared to the previous year.

73. So far in 2020/21, there have been no StEIS reportable Category 4 pressure ulcers.

Falls per 1,000 Occupied Bed Days (Ward 35) 74. There has been an increase in the number of falls per occupied bed days on Ward 35 over the

last 2 months. There were 2 falls during May and 4 during June 2020 however all 6 of these did not result in any harm to the patient.

75. In order to respond to system pressures during Covid-19, admission criteria to Ward 35 has been expanded which has resulted in some patients being admitted that are at a higher risk of falls due to their physical and mental health conditions.

76. There has also been an impact on how quickly staff can respond to patients at risk of falling due to the way in which the bays on the ward are barrier nursed and the need for staff to wear PPE when entering and leaving each bay.

77. The Falls Risk Assessment Tool continues to be implemented for every patient on the ward as well a specific Falls Care Plan which has now been adopted across the wider Trust.

78. In addition a daily Falls Huddle is conducted to ensure that the risk of patients falling is mitigated as much as possible.

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COVID-19 Impact on our Capacity and Flow - Snapshot Position Target As at 03/05 As at 10/05 As at 17/05 As at 24/05 As at 31/05 As at 07/06 As at 14/06 As at 21/06 As at 28/06 As at 05/07 As at 12/07 As at 19/07

Bed Utilisation - Trust % 86.15% 86.33% 86.07% 85.28% 86.20% 87.39% 88.70% 88.17% 87.78% 88.29% 89.08% 89.43%Bed Utilisation - Local Division % 79.11% 80.88% 81.50% 79.31% 80.88% 81.82% 83.70% 81.82% 82.13% 83.02% 85.53% 86.52%Bed Utilisation - Secure & SpLD Division % 92.64% 92.40% 92.16% 92.64% 92.87% 93.11% 93.59% 93.11% 93.11% 92.64% 91.92% 92.02%Bed Utilisation - Community Division Ward 35 % 66.67% 47.62% 33.33% 28.57% 33.33% 57.14% 66.67% 85.71% 66.67% 80.95% 85.71% 80.95%No. of Service Users Delayed for Discharge - Local Division 12 month average: 36 10 11 11 9 9 5 5 7 5 5 4 3No. of Service Users Delayed for Discharge - Community Division Ward 35 12 month average: 23 1 1 1 0 0 0 0 0 1 3 2 1Number of Services Business as Usual following safe guidelines 88 89 87 87 88 88 87Number of Services Closed to Admissions/Referrals 1 1 2 2 1 1 1Number of Services Reduced 21 21 21 21 20 14 11Number of Services Remodelled 74 75 75 76 72 69 69Number of Services Suspended 25 23 24 23 21 19 18Number of Services Planning to Restart/ Commenced Restart 7 18 23

COVID-19 Impact on our Capacity and Flow - Weekly Target W/E 03/05 W/E 10/05 W/E 17/05 W/E 24/05 W/E 31/05 W/E 07/06 W/E 14/06 W/E 21/06 W/E 28/06 W/E 05/07 W/E 12/07 W/E 19/07No. of Discharges - Local Division Only (Adult Acute, Complex Care and PICU) - Total in Week 12 month average: 128 13 25 19 27 18 18 22 27 38 32 24 29No. of Discharges - Community Division Ward 35 - Total in Week 12 month average: 23 1 8 2 3 0 2 2 3 3 3 3 4

COVID-19 Impact on our Capacity and Flow - Monthly Target Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20

Hospital Re-admissions within 28 days - Local Division Adult Mental Health Services (excluding Rathbone Rehab) 10.47% 12 month average: 8.67% 4.31% 11.11% 3.03% 12.82% 9.73% 6.31% 7.84% 16.67% 19.23% 5.88% 9.68% 11.49% -

To-DateCare Programme Approach 7 day Follow Up (Cumulative In-Month) (Excludes patients who have not had 7 days since discharge for follow-up to be completed) - Local Division Only 95% 96.49% 96.61% 100.00% 97.18% 90.74% 98.39% 95.38% 97.20% 100.00% 100.00% 97.26% 96.55% To-

DateCare Programme Approach 48 Hour Follow Up (Cumulative In-Month) (Excludes patients who have not had 48 hours since discharge for follow-up to be completed) - Local Division Only 95% 100.00% 100.00% 100.00% 86.67% 100.00% 88.24% 100.00% 97.20% 100.00% 100.00% 94.44% 91.67% -

To-Date

Notes:1. The data for the CPA 7 day and 48 hour Follow Up is refreshed on a daily basis and is therefore subject to change. 2. The breakdown for Services Business as Usual following safe guidelines: 28 in Local, 14 in Community, 44 in Secure/ SpLD and 1 in Corporate.3. The breakdown for Services Closed to Admissions/Referrals: 1 in Local.4. The breakdown for Services Reduced: 1 in Local and 10 in Community.5. The breakdown for Services Remodelled: 32 in Local, 36 in Community and 1 in Corporate.6. The breakdown for Services Suspended: 5 in Local, 1 in Secure/SpLD and 12 in Community.7. The breakdown for Services Planning to Restart: 5 in Community.8. The breakdown for Services Restarted: 17 in Community and 1 in Local.

COVID-19 Impact on our Patients Target As at 03/05 As at 10/05 As at 17/05 As at 24/05 As at 31/05 As at 07/06 As at 14/06 As at 21/06 As at 28/06 As at 05/07 As at 12/07 As at 19/07Number of inpatients being isolated due to suspected COVID 19 as per national sitrep submission 2 0 1 3 1 1 3 1 1 2 1 0Number of inpatients being isolated confirmed as COVID 19 positive as per national sitrep submission 34 5 1 2 12 11 11 2 1 0 0 0

COVID-19 Impact on Equipment and Testing - Snapshot Position Target As at 03/05 As at 10/05 As at 17/05 As at 24/05 As at 31/05 As at 07/06 As at 14/06 As at 21/06 As at 28/06 As at 05/07 As at 12/07 As at 19/07Number of PPE Items due to run out in the next 7 days held in the central hub if no further deliveries are received 2 3 3 4 2 2 2 1 2 2 1 1Number of PPE Items due to run out in the next 7 days held in the central hub with a scheduled delivery date 0 0 0 0 0 0 0 0 0 0 0 0Number of PPE Items that have ran out of stock 0 0 0 0 0 0 0 0 0 0 0 0

COVID-19 Impact on Equipment and Testing - Weekly Target W/E 03/05 W/E 10/05 W/E 17/05 W/E 24/05 W/E 31/05 W/E 07/06 W/E 14/06 W/E 21/06 W/E 28/06 W/E 05/07 W/E 12/07 W/E 19/07

Number of Staff Swabbed for COVID-19 with a positive result 19 4 4 11 17 2 0 1 2 1 0 0Number of Staff Swabbed for COVID-19 with a negtive result 41 35 56 87 108 81 69 33 40 24 30 37Number of Staff Swabbed for COVID-19 with a result from the labatory that states the sample did not meet data quality standard 4 1 2 1 1 7 0 0 1 0 0 0

Number of Staff Not Swabbed - Family member swabbed 4 1 2 8 2 5 0 2 4 1 3 6

Notes:1. Breakdown of PPE Items are: Visors can be used as a substitute for Goggles2. IPC and Emergency Planning Informed for staff who have a positive COVID-19 result.

COVID-19 Impact on Capacity and Patient Flow

COVID-19 Impact on our Patients

COVID-19 Impact on Equipment and Testing

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Contacts Summary - April, May and June 2020 - Local, Secure and SpLD DivisionLocal Division - All Specialties (including Talk Liverpool)8% decrease in contacts in April compared to January to March average.11% increase in contacts in May compared to January to March average.16% increase in contacts in June compared to January to March average.

Jan to Mar monthly average

April May June Jan to Mar % of activity

April % of activity

May % of activity

June % of activity Key

Email 466 732 787 968 1% 2% 2% 2%Face To Face communication 24507 8335 9537 11221 65% 24% 23% 26%Other - Non Face-to-Face 4200 4447 6272 7100 11% 13% 15% 16%Short Message Service (Text) 216 388 406 318 1% 1% 1% 1%Talk Type for Person unable to speak 1 3 8 6 0% 0% 0% 0%Telemedicine/Video Consultation 72 963 1670 2113 0% 3% 4% 5%Telephone Conversation 8014 19452 22839 21832 21% 57% 55% 50%Local Division - All Specialties 37476 34320 41519 43558 100% 100% 100% 100%

Local Division - Addiction Services Local Division - Adult Mental Illness48% decrease in contacts in April compared to January to March average. 2% decrease in contacts in April compared to January to March average.15% decrease in contacts in May compared to January to March average. 6% increase in contacts in May compared to January to March average.1% decrease in attended contacts in June compared to January to March average. 17% increase in contacts in June compared to January to March average.



April % of activity

May % of activity

June % of activity


April May JuneJan to Mar

% of activity

April % of activity

May % of activity

June % of activity

Email 2 3 4 6 0% 0% 0% 0% Email 135 202 224 225 1% 1% 1% 1%Face To Face communication 2256 178 160 204 90% 14% 7% 8% Face To Face communication 12870 6367 6824 7892 71% 36% 35% 37%Other - Non Face-to-Face 63 159 291 237 2% 12% 14% 10% Other - Non Face-to-Face 1536 1937 2152 2398 8% 11% 11% 11%Short Message Service (Text) 0 1 1 4 0% 0% 0% 0% Short Message Service (Text) 203 357 376 274 1% 2% 2% 1%Talk Type for Person unable to speak 0 0 0 2 0% 0% 0% 0% Talk Type for Person unable to speak 1 1 6 3 0% 0% 0% 0%Telemedicine/Video Consultation 0 6 6 5 0% 0% 0% 0% Telemedicine/Video Consultation 22 369 586 699 0% 2% 3% 3%Telephone Conversation 197 963 1686 2036 8% 74% 78% 82% Telephone Conversation 3315 8466 9080 9699 18% 48% 47% 46%Addiction Services 2517 1310 2148 2494 100% 100% 100% 100% Adult Mental Illness 18083 17699 19248 21190 100% 100% 100% 100%

Local Division - Complex Care Local Division - Eating Disorders4% increase in contacts in April compared to January to March average. 3% increase in contacts in April compared to January to March average.53% increase in contacts in May compared to January to March average. No increase/ decrease in contacts in May compared to January to March average.28% increase in contacts in June compared to January to March average. 25% increase in contacts in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Email 319 516 541 727 4% 6% 5% 7% Email 0 0 1 0 0% 0% 0% 0%Face To Face communication 3464 865 1105 1411 45% 11% 9% 14% Face To Face communication 247 7 2 4 85% 2% 1% 1%Other - Non Face-to-Face 1341 1175 2157 2053 17% 15% 18% 21% Other - Non Face-to-Face 1 0 4 1 0% 0% 1% 0%Short Message Service (Text) 8 20 21 25 0% 0% 0% 0% Short Message Service (Text) 0 0 0 0 0% 0% 0% 0%Talk Type for Person unable to speak 0 1 1 0 0% 0% 0% 0% Talk Type for Person unable to speak 0 0 0 1 0% 0% 0% 0%Telemedicine/Video Consultation 7 122 156 223 0% 2% 1% 2% Telemedicine/Video Consultation 1 7 8 56 0% 2% 3% 15%Telephone Conversation 2536 5318 7798 5355 33% 66% 66% 55% Telephone Conversation 41 286 276 302 14% 95% 95% 83%Complex Care 7676 8017 11779 9794 100% 100% 100% 100% Eating Disorders 290 300 291 364 100% 100% 100% 100%

Local Division - Liaison Psychiatry Local Division - Perinatal Psychiatry60% decrease in contacts in April compared to January to March average. 2% increase in contacts in April compared to January to March average.21% decrease in contacts in May compared to January to March average. 2% increase in contacts in May compared to January to March average.9% decrease in contacts in June compared to January to March average. 2% increase in contacts in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Email 6 0 1 2 0% 0% 0% 0% Email 1 3 4 2 0% 1% 1% 1%Face To Face communication 1802 558 1172 1409 85% 66% 70% 73% Face To Face communication 214 61 40 34 62% 17% 11% 10%Other - Non Face-to-Face 140 81 163 170 7% 10% 10% 9% Other - Non Face-to-Face 26 8 25 23 8% 2% 7% 7%Short Message Service (Text) 0 0 0 0 0% 0% 0% 0% Short Message Service (Text) 0 0 1 2 0% 0% 0% 1%Talk Type for Person unable to speak 0 0 1 0 0% 0% 0% 0% Talk Type for Person unable to speak 0 0 0 0 0% 0% 0% 0%Telemedicine/Video Consultation 0 0 1 1 0% 0% 0% 0% Telemedicine/Video Consultation 1 2 14 12 0% 1% 4% 3%Telephone Conversation 165 204 330 338 8% 24% 20% 18% Telephone Conversation 101 277 267 279 29% 79% 76% 79%Liaison Psychiatry 2113 843 1668 1920 100% 100% 100% 100% Perinatal Psychiatry 344 351 351 352 100% 100% 100% 100%

Local Division - Psychotherapy Local Division - Specialist Brain Injury Rehab Inpatient32% decrease in contacts in April compared to January to March average. 8% decrease in contacts in April compared to January to March average.18% decrease in contacts in May compared to January to March average. 22% decrease in contacts in May compared to January to March average.18% decrease in contacts in June compared to January to March average. 17% decrease in contacts in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Email 0 0 0 0 0% 0% 0% 0% Email 0 0 0 0 0% 0% 0% 0%Face To Face communication 214 13 19 14 95% 8% 10% 8% Face To Face communication 290 239 208 248 86% 77% 79% 89%Other - Non Face-to-Face 3 6 3 10 1% 4% 2% 5% Other - Non Face-to-Face 37 64 39 23 11% 21% 15% 8%Short Message Service (Text) 0 0 0 1 0% 0% 0% 1% Short Message Service (Text) 0 0 0 0 0% 0% 0% 0%Talk Type for Person unable to speak 0 0 0 0 0% 0% 0% 0% Talk Type for Person unable to speak 0 0 0 0 0% 0% 0% 0%Telemedicine/Video Consultation 0 73 122 131 0% 48% 66% 71% Telemedicine/Video Consultation 0 0 0 1 0% 0% 0% 0%Telephone Conversation 8 61 40 28 4% 40% 22% 15% Telephone Conversation 10 7 16 6 3% 2% 6% 2%Psychotherapy 225 153 184 184 100% 100% 100% 100% Specialist Brain Injury Rehab 337 310 263 278 100% 100% 100% 100%

Local Division - Specialist Dietetics Local Division - Talk Liverpool (IAPTuS)17% decrease in contacts in April compared to January to March average. 9% decrease in contacts in April compared to January to March average.15% decrease in contacts in May compared to January to March average. 5% decrease in contacts in May compared to January to March average.17% increase in contacts in June compared to January to March average. 16% increase in contacts in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Email 3 8 10 5 1% 4% 5% 2% Email 0 0 2 1 0% 0% 0% 0%Face To Face communication 118 16 6 5 47% 8% 3% 2% Face To Face communication (Face to Face) 3031 31 1 0 54% 1% 0% 0%Other - Non Face-to-Face 119 93 101 161 47% 44% 47% 54% Other - Non Face-to-Face (cCBT, blank and other) 935 924 1337 2024 17% 18% 25% 30%Short Message Service (Text) 0 0 0 0 0% 0% 0% 0% Short Message Service (Text) (SMS) 4 10 7 12 0% 0% 0% 0%Talk Type for Person unable to speak 0 0 0 0 0% 0% 0% 0% Talk Type for Person unable to speak 0 1 0 0 0% 0% 0% 0%Telemedicine/Video Consultation 0 1 14 18 0% 0% 7% 6% Telemedicine/Video Consultation (Skype Consultation / 40 383 763 967 1% 7% 14% 14%Telephone Conversation 13 93 84 109 5% 44% 39% 37% Telephone Conversation (Telephone) 1628 3777 3262 3680 29% 74% 61% 55%Specialist Dietetics 254 211 215 298 100% 100% 100% 100% Talk Liverpool (IAPTus) 5638 5126 5372 6684 100% 100% 100% 100%

Secure & SpLD Division - Secure Secure & SpLD Division - SpLD19% increase in contacts in April compared to January to March average. 35% increase in contacts in April compared to January to March average.62% decrease in contacts in May compared to January to March average. 7% increase in contacts in May compared to January to March average.20% decrease in contacts in June compared to January to March average. 26% increase in contacts in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Email 0 0 0 0 0% 0% 0% 0% Email 94 193 171 220 6% 9% 10% 11%Face To Face communication 187 215 63 147 100% 96% 88% 97% Face To Face communication 845 165 185 230 51% 7% 10% 11%Other - Non Face-to-Face 0 4 4 0 0% 2% 6% 0% Other - Non Face-to-Face 265 530 365 362 16% 24% 21% 17%Short Message Service (Text) 0 0 0 0 0% 0% 0% 0% Short Message Service (Text) 4 7 6 16 0% 0% 0% 1%Talk Type for Person unable to speak 0 0 0 0 0% 0% 0% 0% Talk Type for Person unable to speak 0 0 0 0 0% 0% 0% 0%Telemedicine/Video Consultation 0 0 0 0 0% 0% 0% 0% Telemedicine/Video Consultation 0 21 39 121 0% 1% 2% 6%Telephone Conversation 0 4 5 4 0% 2% 7% 3% Telephone Conversation 446 1316 1011 1133 27% 59% 57% 54%Secure 188 223 72 151 100% 100% 100% 100% Secure 1655 2232 1777 2082 100% 100% 100% 100%

COVID-19 Impact on Contacts

Other - Non Face to Face Contacts = The majority of these contacts are professional to professional contacts i.e. correspondence and various IAPT therapies i.e. cCBT.

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Contacts Summary - April, May, June 2020 - Community DivisionCommunity Assessment Team ICRAS20% decrease in activity in April compared to January to March average. 10% increase in activity in April compared to January to March average.10% decrease in activity in May compared to January to March average. 8% increase in activity in May compared to January to March average.21% increase in activity in June compared to January to March average. 62% increase in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Face To Face communication 200 132 148 118 56% 46% 46% 27% Face To Face communication 3560 3875 3809 5717 100% 99% 99% 99%Other - Non Face-to-Face 7 0 0 0 2% 0% 0% 0% Group consultation 1 1 3 76 0% 0% 0% 1%Telephone Conversation 150 154 174 244 42% 54% 54% 56% Other - Non Face-to-Face 1 1 0 0 0% 0% 0% 0%Community Assessment Team 356 286 322 432 100% 100% 100% 100% Telephone Conversation 12 46 44 1 0% 1% 1% 0%

ICRAS 3575 3923 3856 5794 100% 100% 100% 100%

Emergency Response Team Palliative Care16% decrease in activity in April compared to January to March average. 20% increase in activity in April compared to January to March average.2% decrease in activity in May compared to January to March average. 14% increase in activity in May compared to January to March average.3% increase in activity in June compared to January to March average. 23% increase in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Telemedicine/Video Consultation 0 0 1 1 0% 0% 0% 0% Telemedicine/Video Consultation 0 2 2 0 0% 0% 0% 0%Face To Face communication 6233 4862 5767 6055 89% 82% 84% 84% Face To Face communication 643 583 662 727 46% 35% 42% 42%Group Consultation 0 0 1 0 0% 0% 0% 0% Group Consultation 19 13 15 0 1% 1% 1% 0%Other - Non Face-to-Face 7 8 6 6 0% 0% 0% 0% Other - Non Face-to-Face 6 17 21 27 0% 1% 1% 2%Telephone Conversation 776 1046 1122 1151 11% 18% 16% 16% Telephone Conversation 729 1063 892 965 52% 63% 56% 56%Emergency Response Team 7016 5916 6896 7213 100% 100% 100% 100% Palliative Care 1396 1678 1592 1719 100% 100% 100% 100%

Integrated Nursing Care Children Services (Service Suspended/Reduced)No increase/ decrease in activity in April compared to January to March average. 30% decrease in activity in April compared to January to March average.3% decrease in activity in May compared to January to March average. 22% decrease in activity in May compared to January to March average.4% increase in activity in June compared to January to March average. 48% decrease in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Consultation via SMS text message 1 11 9 9 0% 0% 0% 0% Consultation via SMS text message 438 625 677 477 2% 3% 3% 3%Telemedicine/Video Consultation 0 42 73 100 0% 0% 0% 0% Telemedicine/Video Consultation 0 67 193 258 0.0% 0% 1% 2%Face To Face communication 41563 39124 37521 41033 96% 90% 89% 91% Consultation via Typetalk relay service 0 4 10 4 0.0% 0.0% 0.0% 0.0%Group Consultation 2 8 3 0% 0% 0% 0% Face To Face communication 16320 2279 2387 1928 58% 12% 11% 13%Other - Non Face-to-Face 28 40 102 100 0% 0% 0% 0% Group Consultation 103 27 46 0% 0% 0% 0%Telephone Conversation 1800 4189 4245 3798 4% 10% 10% 8% Other - Non Face-to-Face 178 576 674 387 1% 3% 3% 3%Integrated Nursing Care 43393 43414 41953 45040 100% 100% 100% 100% Telephone Conversation 11001 15790 17907 11426 39% 82% 82% 79%

Children Services 28042 19368 21894 14480 100% 100% 100% 100%

Therapy Services (Service Suspended/Reduced) Urgent Care50% decrease in activity in April compared to January to March average. ``` 22% decrease in activity in April compared to January to March average.46% decrease in activity in May compared to January to March average. 20% decrease in activity in May compared to January to March average.23% decrease in activity in June compared to January to March average. 5% increase in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Consultation via SMS text message 31 22 40 31 0% 0% 0% 0% Consultation via SMS text message 0 0 0 1 0% 0% 0% 0%Telemedicine/Video Consultation 0 26 54 40 0.0% 0% 1% 0% Telemedicine/Video Consultation 0 0 1 0 0.0% 0% 0% 0%Consultation via Typetalk relay service 0 4 10 0 0.0% 0% 0% 0% Face To Face communication 1733 1247 1329 1684 86% 79% 83% 80%Face To Face communication 11226 3205 3571 5296 60% 35% 36% 37% Group Consultation 0 1 0 0 0% 0% 0% 0%Group Consultation 72 2 7 0% 0% 0% 0% Other - Non Face-to-Face 1 2 3 1 0% 0% 0% 0%Other - Non Face-to-Face 2504 884 1268 1793 13% 10% 13% 13% Telephone Conversation 274 324 267 415 14% 21% 17% 20%Telephone Conversation 4762 5075 5076 7069 26% 55% 51% 50% Urgent Care 2008 1574 1599 2101 100% 100% 100% 100%Therapy Services 18595 9214 10016 14229 100% 100% 100% 100%

Skin Service (Service Reduced) Bladder and Bowel (Service Reduced)32% decrease in activity in April compared to January to March average. 16% increase in activity in April compared to January to March average.10% decrease in activity in May compared to January to March average. 24% increase in activity in May compared to January to March average.3% decrease in activity in June compared to January to March average. 23% increase in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Consultation via SMS text message 0 0 1 0 0% 0% 0% 0% Consultation via SMS text message 1 0 2 1 0% 0% 0% 0%Telemedicine/Video Consultation 0 2 0 0 0.0% 1% 0% 0% Face To Face communication 193 53 59 97 16% 4% 4% 7%Face To Face communication 344 124 198 208 66% 35% 42% 41% Group Consultation 0 0 0 0 0% 0% 0% 0%Group Consultation 0 0 5 0 0% 0% 1% 0% Other - Non Face-to-Face 462 832 741 621 39% 61% 51% 43%Other - Non Face-to-Face 1 0 0 7 0% 0% 0% 1% Telephone Conversation 514 475 652 716 44% 35% 45% 50%Telephone Conversation 176 228 266 293 34% 64% 57% 58% Bladder and Bowel 1170 1360 1454 1435 100% 100% 100% 100%Skin Service 521 354 470 508 100% 100% 100% 100%

IV Therapy Children's Continence Service22% decrease in activity in April compared to January to March average. 23% increase in activity in April compared to January to March average.18% decrease in activity in May compared to January to March average. No increase/decrease in activity in May compared to January to March average.14% decrease in activity in June compared to January to March average. 17% increase in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Consultation via SMS text message 1 0 1 0% 0% 0% 0% Consultation via SMS text message 0 1 0 0 0% 0% 0% 0%Face To Face communication 471 387 352 394 79% 83% 72% 77% Face To Face communication 68 6 7 7 28% 2% 3% 2%Other - Non Face-to-Face 16 15 20 29 3% 3% 4% 6% Other - Non Face-to-Face 6 2 3 23 3% 1% 1% 8%Telephone Conversation 108 63 115 89 18% 14% 24% 17% Telephone Conversation 168 291 232 255 69% 97% 96% 89%IV Therapy 596 465 487 513 100% 100% 100% 100% Children's Continence Service 243 300 242 285 100% 100% 100% 100%

COVID-19 Impact on Contacts

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-17%Social Inclusion Team (Adults) Liverpool CEDAS Service (Service Reduced)6% increase in activity in April compared to January to March average. 13% decrease in activity in April compared to January to March average.47% decrease in activity in May compared to January to March average. 24% decrease in activity in May compared to January to March average.27% increase in activity in June compared to January to March average. 14% decrease in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Consultation via SMS text message 2 5 1 7 2% 4% 2% 5% Telemedicine/Video Consultation 0 0 7 0 0% 0% 1% 0%Face To Face communication 53 8 3 6 44% 6% 5% 4% Face To Face communication 363 150 180 232 40% 19% 26% 29%Other - Non Face-to-Face 1 6 1 0 1% 5% 2% 0% Other - Non Face-to-Face 84 5 2 11 9% 1% 0% 1%Telephone Conversation 65 109 59 141 54% 85% 92% 92% Telephone Conversation 470 639 504 547 51% 80% 73% 69%Social Inclusion Team (Adults) 121 128 64 154 100% 100% 100% 100% Liverpool CEDAS Service 917 794 693 790 100% 100% 100% 100%

Phlebotomy Service (Service Suspended) Rehab at Home Service (Service Suspended)17% decrease in activity in April compared to January to March average. 45% decrease in activity in April compared to January to March average.30% increase in activity in May compared to January to March average. 34% decrease in activity in May compared to January to March average.83% increase in activity in June compared to January to March average. 20% increase in activity in June compared to January to March average.



April % of activity

May % of activity

June % of activity



% of activity

April % of activity

May % of activity

June % of activity

Face To Face communication 7096 5854 9228 13055 99% 98% 99% 100% Face To Face communication 305 108 119 232 72% 46% 42% 45%Group consultation 0 0 1 0 0% 0% 0% 0% Group consultation 1 0 0 0 0% 0% 0% 0%Other - Non Face-to-Face 0 2 0 0 0% 0% 0% 0% Other - Non Face-to-Face 0 0 0 0 0% 0% 0% 0%Telephone Conversation 70 111 95 47 1% 2% 1% 0% Telephone Conversation 119 127 163 278 28% 54% 58% 55%Phlebotomy Service 7167 5967 9324 13102 100% 100% 100% 100% Rehab at Home Servivce 425 235 282 510 100% 100% 100% 100%

-20%

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Operational Performance and Quality Metrics - Trust Target Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20Number of All Ligature Incidents Year End - 62 94 147 144 103 48 66 113 97 78 87 71 96 46 76 74 39 - To-DateNumber of physical restraints associated with self-harm Year End - 47 64 47 61 26 29 25 37 22 42 61 49 29 29 27 48 21 - To-DateSuicide Level 1 Training 95% 90.00% 90.86% 89.90% 88.08% 88.39% 89.17% 90.52% 93.47% 93.61% 93.54% 93.78% 93.69% 93.55% 93.68% 93.99% Due August 2020Number of Suicides within an Inpatient Mental Health Bed (Local, Secure and SpLD) Zero 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 - To-DateTotal Number of Suicides (reported on STEIS) 12 month average: 2 3 7 0 3 0 2 2 1 0 1 2 1 1 0 0 0 - To-DateTotal Number of Attempted Suicides that did not result in death (reported on STEIS) 12 month average: 2 4 6 3 4 2 0 1 2 0 0 1 2 1 0 0 0 - To-Date

Operational Performance and Quality Metrics - Local Division Target Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20Liaison Response Times (all contacts) of 1 hour in Accident and Emergency (Cumulative In-Month) 90% 89.64% 89.17% 88.06% 90.09% 93.18% 92.92% 93.93% 94.70% 94.10% 95.28% 94.49% 95.32% 94.14% 91.48% 86.30% 90.83% - To-Date

Liaison Response Times (all contacts) of 24 hours on acute wards (Cumulative In-Month) 95% 90.41% 95.09% 91.76% 93.75% 91.79% 93.98% 93.61% 95.50% 97.05% 95.00% 95.45% 96.80% 97.13% 95.10% 90.82% 92.72% - To-Date

Physical Health Screenng for New Admissions 95% 86.96% 94.00% 87.10% 87.85% 84.55% 92.98% 96.97% 99.13% 99.10% 97.20% 96.97% 95.88% ####### 98.97% 96.36% Due August 2020% of Service Users on the Early Intervention in Psychosis Caseload with a diagnosis of First Episode of Psychosis and have a cluster of 10-14,16 and 17 with an Annual Physical Health Check completed. This includes all screening and intervention requirements.

Year End Target 90% 42.46% 46.52% 48.48% 49.03% 44.07% 49.64% 55.33% 51.49% 55.63% 51.79% 48.16% 43.67% 45.04% Due August 2020

% of Service Users on the Adult Community Mental Health Team Caseload for more than 12 months on CPA with a diagnosis of Psychosis and with a Cluster 10-14,16 and 17 with an Annual Physical Health Check completed. This includes all screening and intervention requirements.

Year End Target 75% 15.55% 20.23% 28.41% 35.54% 49.10% 50.35% 60.64% 67.41% 63.09% 57.99% 52.75% 42.34% Due August 2020

Gatekeeping Assessments 95% 98.96% 98.77% 93.02% 98.70% 98.86% 93.94% 98.73% ####### ####### 96.51% 96.15% 98.00% 98.80% 96.63% 100.00% Due August 2020Eating Disorder Service: Treatment commencing within 18 weeks of referral 95% 26.67% 19.48% 41.46% 52.00% 64.52% 54.26% 69.62% 74.49% 62.81% 66.35% 69.09% 58.27% 56.96% 48.70% 33.75% Due August 2020

Operational Performance and Quality Metrics - Secure and Specialist Learning Division Target Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20

Physical Health Screenng for New Admissions 95% ####### N/A 85.71% ####### N/A ####### ####### N/A ####### ####### ####### 100.00% ####### ####### 100.00% Due August 2019To reduce the amount of time (cumulative days) services users are nursed in long term segregation by 10% by March 2021 - Secure Only

15347 days by Mar 2021June Target: 16626 18356 18515 18273 18736 19552 19925 19818 20525 20385 21166 21540 17052 17104 15835 16105 Due August 2020

To reduce the number of service users who have been nursed in long term segregation for over 12 months by 20% by March 2020 - Secure Only

10 by March 2021June Target: 13 16 16 15 15 15 15 14 15 14 14 13 13 11 Due August 2020

To ensure a ‘Barriers to Change Checklist’ is completed and regularly reviewed for all service users nursed in long term segregation - Secure Only 100.00% 78.00% 80.00% 92.00% 96.00% 92.00% 78.00% 100% 100% 100% 94% 83% Not

Available 84% Due August 2020

To ensure every service user in long term segregation is provided the opportunity to access fresh air and exercise on a daily basis 100.00%

To ensure every service user nursed in long term segregation is provided the opportunity to have a monthly physical health check - Secure Only 100.00% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Due August 2020

To ensure every service user nursed in long term segregation has the opportunity to attend all physical health care appointments - Secure Only 100.00% 100% 100% 100% 88% 100% 97% 97% 100% 83% 100% 100% 100% 100% Due August 2020

To ensure every service user nursed in long term segregation for over a period of 12 months has a thorough independent MDT review 100% by March 2021 Due August 2020

To develop an e-learning training package on an introduction to the HOPE9S) Clinical Model of Care and 100% roll out across the division by October 2020 100% by October 2020 Due August 2020

Number of T-Supine Restraints - SpLD OnlyYear end Cumulative

Position: 10112020 Target TBC

100 192 296 352 392 449 500 538 595 668 718 765 68 158 244 Due August 2020

Operational Performance and Quality Metrics -Community Division Target Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20Pressure Ulcers Cat 2 to Cat 3 0 1 1 1 2 1 1 0 0 0 1 0 0 1 0 1 Due August 2020Pressure Ulcers Cat 3 to Cat 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Due August 2020Speech and Language Therapy Waiting Times - Liverpool Community 8 Weeks 12 12 11 10 9 9 11 10 10 10 12 14 17 22Fall Services Waiting Times - Liverpool Community 8 Weeks 9 9 7 7 8 8 8 9 11 12 9 9 10 6Physiotherapy Waiting Times - Liverpool Community 8 Weeks 6 8 8 9 8 8 7 9 9 9 8 9 11 10Occupational Therapy Waiting Times - Liverpool Community 8 Weeks 8 8 8 8 8 8 8 8 9 8 6 7 11 15Podiatry Waiting Times - Liverpool Community 8 Weeks 7 8 6 5 5 5 4 5 4 3 4 5 10 14Dietetics Waiting Times - Liverpool Community 8 Weeks 8 8 7 7 8 9 8 7 7 8 6 8 8 8Speech and Language Therapy Waiting Times - Sefton Community 18 Weeks 12 14 13 10 12 13 16 15 19 22 21 25 21 24Physiotherapy Waiting Times - Sefton Community 18 Weeks 20 20 18 17 18 20 17 16 16 17 15 16 20 18Occupational Therapy Waiting Times - Sefton Community 18 Weeks 18 16 16 14 16 13 12 11 9 9 12 14 15 18Podiatry Waiting Times - Sefton Community 18 Weeks 12 12 14 13 14 14 10 7 8 7 5 7 11 14Dietetics Waiting Times - Sefton Community 18 Weeks 14 19 18 13 9 10 8 8 8 11 7 10 12 15Falls: Number per 1,000 Occupied Bed Days 5.70 4.72 1.48 8.13 3.15 0 3.18 0 1.64 1.52 3.35 1.45 2.8 0.7 8.44 9.30 Due August 2020Medication Errors Resulting in Major Harm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Due August 2020Catheter Acquired Urine Tract Infections 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 0 Due August 2020

Operational Performance and Quality Metrics - Local Division (Quarterly) Target Q1 2019 Q2 2019 Q3 2019 Q4 2020 Q1 2020

IAPT: The number of people who have entered psychological therapies (at the end of the reporting quarter) as a proportion of prevalence 4.75% 3.74% 4.08% 4.11% 4.07% 1.87%

Falls Management: All adults who have had a fall within the last 12 months to be risk assessed using an appropriate tool (Inpatients Only) 98.0% 96.30% 95.24% 96.23% 93.48% 98.41%

Falls Management: Of the patients identified as at risk of falling to have a care plan in place 98.0% 69.23% 80.00% 78.00% 86.05% 100.00%

Communication - All discharge communication from inpatient episodes are sent to General Practice within 24 hours from discharge. 95.0% 84.80% 80.00% 90.70% 90.71% 52.20%

Communication - Outpatients All clinic/outpatient correspondence/ letters sent to General Practice following the patient’s appointment, including discharge from service within 10 working days (excluding weekends and bank holidays).

95.0% 49.13% 68.83% 62.72% 60.72% 53.10%

Notes:1. The data for the A&E liaison measures are refreshed on a daily basis and are therefore subject to change.2. Incidents data is refreshed on a daily basis and are therefore subject to change.

Reporting SuspendedReporting

Suspended

Reported One Month in Arrears

Operational Performance and Quality Metrics

Reporting SuspendedReporting

Suspended

New measure for 2020/21. To be reported on from August 2020.

New measure for 2020/21. To be reported on from August 2020.

New measure for 2020/21. To be reported on in October 2020

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Our People

Executive Lead: Amanda Oates

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Executive Summary – NHS Oversight Framework 2020/20 and Our People Accountable Director: Amanda Oates, Executive Director of Workforce Lost Capacity and Sickness Absence 1. Overall the available capacity in the Trust has reduced by 11.2% which relates to staff sickness

and staff who are self-isolating. This is a decreasing position to that reported in the previous month (at 12%). Staff sickness independent of staff that are self-isolating as at 30 June 2020 has improved by 0.6% with a rate of 7.08 % against a refreshed position of 7.64% at 31 May 2020.

2. Since April where were reported a sickness absence rate of 9.31% there has been a 2.2%

improvement. The current rate of 7.08% is the lowest reported sickness absence rate since August 2019 (7.02%).

3. Work is underway to gain a more in depth understanding as to the influencing factors for this reduction.

COVID-19 related Vulnerable People Risk Assessment and Enhanced Safety Assessment.

4. There is a national requirement via NHSI/E to report on the progress that the Trust is making in relation to undertaking risk assessments with an aim of having 100% complete by the end of July 2020.

5. The following table sets out the position as at 16th July 2020, which reflects the baseline position at 9th July 2020.

Total number of staff identified as BAME

Total number of Risk Assessments for vulnerable colleagues undertaken

Total number of Enhanced Safety Assessments undertaken

Total number who have completed both

% of risk assessments undertaken (of total number of staff identified as BAME)

As at 30.06.20

449 110 80 34 190 – 42%

As at 09.07.20

449 110 142 65 317 – 71%

6. It should be noted that on 14th July, a new direction has been provided from NHSI/E has

emerged which makes changes to the original scope of groups classified as vulnerable. The Trust’s vulnerable people’s risk assessment has been updated to reflect this new direction which is based on Faculty of Occupational Medicine guidance: • All colleagues over 60 • Colleagues with a BMI of >30 • Inclusion of bank staff into the risk assessment process • All male colleagues

7. These revisions to the criteria are in addition the requirements for pregnant workers and those with underlying health conditions to be risk assessed.

8. Challenge to the legitimacy of this revised criteria has been escalated to NHSI/E in relation to the groups deemed to be most “at risk” however the Trust will comply with the national requirements to undertake vulnerable risk assessments and/or enhanced safety assessments for the groups outlined above by 31 July 2020.

9. There has been acknowledgement from NHSI/E that they are anticipating to see a reduction in compliance figures previously presented (see table above) given the extended scope of risk assessments.

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10. At a national level, our approach and work is this area has been acknowledged. In order to ensure that all of our colleagues feel safe and supported, we have now decided to ask all colleagues to complete the enhanced safety assessment. We have built in the ability for colleagues to opt out if they do not wish to complete the assessment. We will be able to report on compliance figures at trust level.

Workforce Systems

11. Longer terms plans for the phased roll out and implementation of ESR Self Service from

September 2020 are being developed in conjunction with clinical divisions. The next stage of the process is to undertake a divisional readiness assessment to determine current usage of ESR functionality this is due to conclude at the end of August. ESR Self Service will support real time absence reporting across the Trust and is being considered in conjunction with the implementation of the NHSE/I Roster Levels of attainment programme which we were successful in gaining over £700k as part of a collaborative bid with North West Boroughs to roll our e-roster to 80% of our workforce.

12. A recommendation will be made to PIFC outlining the future proposal in relation to the planned pilot of Empactis Absence Manager.

13. From April-June 2020, to support the organisation’s response to COVID-19 the Workforce Systems Team achieved the following: • Development of new ELearning packages and revision of existing to support virtual

learning and social distancing (26k enrolments with 10k completions for interim packages).

• Supported new process to support fast track recruitment • ESR skype support • Skype calls for ID checks for smart cards; new way of working • Supported implementation of e-payslips and P60s • Workforce systems – use of bomgar increased

National Returners Scheme – Nursing and AHPs

14. We have contacted 78 possible nurse returners (through the national nurse return scheme), out of which eight have commenced in post, six in Fixed Term Posts and two on the bank. There is one still to confirm as the individual has arranged to visit the service prior to discussing any offer of employment. Additionally, we have contacted 18 Allied Health Professionals and Psychology Professionals Returners of which three having commenced. In total, four Returners have gone to Secure and SpLD Division, four to Community, two to Corporate and one to Local.

Students

15. Since the 27th April we have had three waves of deployment of student nurses totalling 167 that are being supported by the Practice Education Facilitators and Learning and Development teams who have been redeployed into clinical services as additional capacity. Recent announcement from HEE issued on 17th June 2020 suggested that student’s contracts could end on the 31st July so that they can return to programme. The Trust is currently in negotiation with the Universities to understand exact details as it remains unclear at the present time. The Trust has made its intentions clear and will continue to honour those students that have an employment contract until September however this will depend upon University return dates.

16. Allied Health Professionals students – currently twelve students have been offered contracts, all have started in the trust apart from one student who will start on 6th July.

17. There are seven Occupational Therapy students, three Physio students and three Dietetic students. Of these students, seven have already secured a permanent contract with the trust on completion of their programme this summer and will transition from their student contract to their band 5 contract over the next two months.

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18. The other five Allied Health Professionals students are on a band 3 contract until 31st July 2020.

Recruitment Activity and Time to Hire

19. We currently have 758 applicants within the recruitment process, this figure includes bank and volunteers. Of these 758 applicants, 122 of these are being processed via the fast track recruitment process. To support this additional demand staff were re-deployed into the service however due to some services commencing recovery or other work priorities leaving 1 re-deployed staff as well as 6 bank workers. The time to hire has decreased slightly from 51.1 days in May 2020 to 50.1 days against a target of 45 days.

20. From April to June 2020, to support the Trust’s response to COVID-19 the team:

• Managed increased recruitment activity levels • 780 new conditional offers processed – 46.34% increase compared to same quarter in

2019 • 586 starting letters/contracts issued – 50.25% increase compared to same quarter in

2019 • 576 start dates in the Trust – 31.80% increase compared to same quarter in 2019 • Reduction in Trust vacancy rate – from 8.6% this time last year to 3.9% • Developed and managed the Fast track process which resulted in 271 additional bank

staff being recruited

Additional Staffing 21. During April – June 2020 the additional staffing/roster team have:

• Filled 10,014 agency shifts • Filled 20,550 bank shifts • Received 15,057 calls

22. The above activity supported the following organisational response to COVID-19: • COVID-19 Home Swabbing workforce mobilisation • COVID-19 Pods workforce mobilisation • 98 Reports (data intelligence) to organisation • COVID-19 Antibody Support workforce mobilisation • 131 Students added to health roster in 3 days, responsive and enabled prompt additional

workforce capacity • 73 FMA’s supplied and mobilised across divisional areas • PPE Supplied to all Bank Staff during COVID-19 • Mapping and Set up of COVID-19 Absence within Health roster • Fast Track New Starters Input, Inducted and Skilled ready for services • 15 SKYPE training sessions for managers

Induction

23. A weekly condensed induction programme was introduced on 30 March, since this time 715 new starters have commenced employment with the Trust. The programme has been amended for Secure/SpLD and Local Divisions during July and August some sessions have been slightly extended.

Occupational Health and Wellbeing 24. Occupational Health and Wellbeing Team continue to provide support and guidance to

managers and staff on general health and COVID-19 related matters across a 7 day working week.

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25. The Occupational Health nurses are responsible for following up all COVID-19 swab results with staff members and providing appropriate advice to them and their managers to support their safe return to work. Referrals into the service as part of absence management initially dipped during the earlier parts of the pandemic and are now slowly risking again. The team also continues to ensure all recruitment based medicals including those that require fast tracking are completed in a timely manner (e.g. fast track screening for the domestic staff rapid response team).

26. Following a local risk assessment, the physiotherapists are now increasing their face to face interventions to better support staff with musculoskeletal problems to stay in / return to work. All necessary infection control measures will be applied in support of this work.

27. The mass antibody screening programme has now concluded. 68% of all staff (5262) opted to

have the test. Of the 4896 results currently available, 14% (704) were positive and 86% (4192) negative. In respect of BAME test results, 21% of these (64 of the 304 tests undertaken) were positive in comparison with 14% (640 out of 4592 results available) in the non-BAME workforce. In addition to the antibody testing, Vitamin D testing continues to be available on request for BAME colleagues over the age of 55. Results are given to the individual to enable them to share with their own GP for relevant advice/assessment.

28. The team is working with the IPC to develop a robust process to allow the OH nurses to pick up

the responsibility of the Track and Trace process within the trust for as and when staff are identified as being exposed to COVID-19. A business case to support the funding needed for additional nursing and admin resources has been submitted and the outcome of this is awaited.

29. The Occupational Health team is currently exploring the possibility of introducing a ‘Managers

Monday’ session with ring fenced times being set aside to allow managers to speak with a clinician to discuss staff health concerns and if a referral needs to be completed. It is hope this approach may help reduce unnecessary / inappropriate referrals moving forward.

30. The team continue to support the psychological sub cell for staff and its comprehensive

psychological support offer is now available in a promotional booklet so that all staff across the organisation including shielding staff can access this. We are also supporting external NHS organisations with their psychological support as part of our income generation work stream.

31. The team are currently working with organisational leads to ensure the delivery of the model

meets the needs of colleagues required to support staff throughout the recovery stage of the pandemic internally for our Mersey Care colleagues and also across the Cheshire and Merseyside footprint.

32. The staff hub continues to evolve and the team supports various initiatives and information

uploaded to the site. The team continues to coordinate care packages which are being distributed across the trust. Additional packages are now being pulled together for sharing with all colleagues across the trust who have been shielding.

33. The recently introduced ‘listening rooms’ pilot initiative has proven very successful and

continues to be rolled out across the Trust. Since its introduction, 6 weeks ago, a total of 135 colleagues have attend the ‘rooms’ of which two thirds have reported that the intervention supported them to cope and stay in work and prevented them from accessing counselling/psychotherapy services. Counselling continues to be delivered remotely to all staff wishing to access it and the local pilot of psychological interventions including CBT and EMDR is continuing.

34. The team has contributed to further updating the manager guidance to support vulnerable staff

in reference to the imminent changes in respect of shielding being paused from the end of July.

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COVID-19 Impact on our Workforce - (Snapshot Position) Target As at 26/04 As at 03/05 As at 10/05 As at 17/05 As at 24/05 As at 31/05 As at 07/06 As at 14/06 As at 21/06 As at 28/06 As at 05/07 As at 12/07 As at 19/07% of sickness episodes based on headcount (excluding bank staff) 14.45% 10.82% 10.54% 8.72% 7.23% 7.69% 7.85% 7.74% 7.30% 6.92% 7.06% 7.40% 6.84%Staffing Levels - Trust % 79.0% 84.4% 84.4% 86.7% 88.7% 88.2% 88.0% 88.4% 88.8% 89.0% 88.9% 88.7% 89.2%Staffing Levels - Local Division % 77.3% 82.0% 81.7% 85.1% 87.8% 87.1% 87.2% 87.2% 88.1% 89.6% 89.0% 88.7% 89.1%Staffing Levels - Secure & SpLD Division % 76.7% 85.2% 85.2% 87.0% 89.0% 87.6% 87.4% 87.7% 87.6% 86.5% 86.9% 86.9% 87.7%Staffing Levels - Community Division % 78.3% 84.0% 84.7% 86.5% 87.6% 87.8% 87.5% 88.2% 88.8% 88.9% 89.0% 89.1% 89.5%Staffing Levels - Corporate % 83.9% 86.0% 85.2% 87.7% 89.9% 89.7% 89.4% 89.5% 89.6% 90.0% 89.7% 89.0% 89.4%

Other Workforce Metrics Target Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

% Sickness - Single Oversight Framework Measure4.35%

12 month average: 7.24%

7.02% 7.28% 7.02% 7.50% 7.71% 8.14% 8.56% 8.01% 7.65% 8.90% 9.31% 7.64% 7.08%

Recruitment Time to Hire (days) 45 days 43.4 44.69 53.4 51.7 48.5 48.4 47.6 51.2 56.8 49.7 51.5 51.1 50.1Completion of Core Mandatory Training (Reported by Subject) 95% 97.08% 96.72% 96.94% 96.97% 97.05% 97.23% 96.51% 96.47% 96.59% 96.35% 96.41% 96.46% 96.73%Completion of Prevent Level 3 Training 95% by June 2020 77.11% 82.03% 84.87% 86.50% 88.22% 89.85% 90.40% 90.82% 90.76% 91.26%Completion of Role Specific Mandated Training (Reported by Subject) 90% by March 2020 87.56% 88.68% 88.76% 88.74% 89.20% 89.39% 88.76% 88.50% 89.34% 88.46% 88.13% 87.38% 86.29%

Information Governance (Window Attainment)95% by December

2020 - Trajectory to be confirmed for 2020

42.34% 52.40% 62.07% 71.31% 77.45% 82.86% 89.36% 93.03% 95.25% 95.07% 18.52% 33.70% 46.21%

Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Staff - From April 2020 includes All Clinical Divisions 90% 86.47% 91.88% 89.12% 91.28% 91.52% 91.11% 92.42% 90.26% 93.22% 85.43% 77.66% 86.50% 89.71%

Clinical Supervision completed in line with Trust Policy (every 8 weeks - Professional Staff Only - From April 2020 includes All Clinical Divisions 90% 88.27% 91.79% 89.55% 91.82% 92.01% 91.76% 93.04% 90.35% 93.59% 85.16% 78.79% 89.13% 91.77%

Clinical Supervision completed in line with Trust Policy (every 8 weeks) - All Clinical Staff (Community Division Only) 90% 49.66% 60.38% 63.95% 70.08% 74.69% 77.82% 80.09% 82.05% 85.78% 76.12%

Clinical Supervision completed in line with Trust Policy (every 8 weeks - Professional Staff Only (Community Division Only) 90% 54.69% 66.67% 69.88% 74.96% 78.36% 81.85% 85.18% 87.12% 90.20% 80.19%

COVID-19 Impact on the Workforce

Community Division now reported as part of Trust Position

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Our Resources

Executive Lead: Neil Smith

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Executive Summary – NHS Oversight Framework 2020 and Our Resources Accountable Director: Neil Smith, Executive Director of Finance COVID-19 and Digital Response - Asim Patel, Chief Information Officer

1. Digital solutions continue to be deployed and embedded as part of the Trust’s response to

COVID-19. Work initially focused around supporting colleagues to work from home in order to reduce footfall and support social distancing across our estate, and to support the clinical redeployment of staff.

2. Since mid-March over 2000 laptops, iPads and mobile phones have been sourced and configured for use in the Trust, and then deployed to colleagues across corporate and clinical areas.

3. Over 2000 staff per day are routinely connecting concurrently from home / outside of Trust premises to access Trust systems and resources. The network bandwidth and other infrastructure has been significantly upgraded to meet the additional demands and we are now seeing capacity not exceeding 50%. The number of IT service desk calls are returning back to pre COVID-19 levels which points towards increasing stability of the solutions deployed.

4. Skype for Business is now being used as the tool of choice for internal meetings and workforce collaboration. The team are now actively planning migration to Microsoft Teams which is a newer platform and will introduce additional collaboration capabilities.

5. The rollout of video consultation (“Attend Anywhere”) continues to be accelerated across the Trust and we now have 140 virtual clinics/waiting rooms that have been configured. We are currently seeing approximately 100 video consultation taking place every day and have had over 6000 video consultations since the deployment of the platform.

Finance - Rob Collins, Chief Finance Officer

6. The trust is reporting a breakeven position in month 3.

7. Nationally, all contracts continue to be paid as block during April – July with trusts being required

to record the additional cost of the COVID 19 response to support reimbursement. It has now been confirmed that this approach will continue for August with a strong indication that it will also continue through September. Further national guidance is still expected to be issued for the remainder of the year.

8. Robust process remains in place to track and monitor the national interim COVID 19 contract payment mechanism. 2020/21 budgets approved by the Board of Directors in March have been adjusted to reflect the impact of the contract mechanism through to 31st August 2020.

9. Financial controls remain in place to approve and track additional investments to support our response to COVID 19 and support full reimbursement from NHS E & I.

10. The cost due to COVID 19 to 30th June is £4.210m. This is an increase of £2.018m for June. This has been supported by the national block contract settlement funding (£0.017m) and assumed top up funding from NHS E & I (£4.193m).

11. A further £2.743m of resource has been redeployed across the trust to support the COVID 19 response, an increase of £0.636m in June. This has been supported by funding allocated to those suspended services in the base budget.

12. The top up funding of £4.193m will be subject to further review and audit as described in the NHS E & I guidance to all providers. The top up funding for month 1 and 2 has now been paid and the additional top up funding of £2.018m for June 2020 will be confirmed formally in August.

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13. NHS E & I has also asked all trusts to review their capital programme due to affordability issues nationally and within the region. The trusts revised capital plan included capital investment of £36.618m and disposals of £6.130m. This reflected a reduction of £3.100m capital investment and an additional £3.000m in disposals.

14. Capital expenditure to date is £3.450m. This is £0.781m above forecast due to the completion of schemes carried forward from 2019/20 and expenditure related to COVID 19.

15. The cash balance at the end of June was £79.434m, which is £40.089m above the draft plan of £39.345m. This is largely as a result of COVID 19 block payments being made a month in advance and receiving the £1.300m final 2019/20 PSF payment earlier than anticipated.

16. The agency spend to June was £3.156m. This reflects an increase of 26.3% against an agency spending cap of £2.498m.

COVID-19 and Impact on our Estates – Joanna Worswick, Strategic Transformation Programme Director

17. The Estates team have completed COVID-19 risk assessments of all communal areas across the

Trust. All clinical teams have been requested to complete a COVID-19 risk assessment of their individual environments.

18. 402 assessments have been received covering 97% of all teams and workplaces across the trust. Actions arising from these assessments have been logged and turned into work packages, for the relevant functions to complete to allow areas to be signed off as ‘COVDI-19 Secure’. As at the 19th July 31% of the 1038 actions have been completed.

19. Once the environmental checks are completed, the divisions take any decisions on resetting/restarting services through the appropriate governance processes. The aim of this work is to ensure the Trust is providing a safe working environment for staff and service users.

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COVID-19 and Digital Response - Weekly Target W/E 03/05 W/E 10/05 W/E 17/05 W/E 24/05 W/E 31/05 W/E 07/06 W/E 14/06 W/E 21/06 W/E 28/06 W/E 05/07 W/E 12/07 W/E 19/07Number of Agile devices set-up for deployment (inc Laptops, iPads and Smartphones) 01/03 - 01/04 - 437 200 114 96 203 79 84 101 85 77 68 88 66

Total number of Skype for Business Conferences 01/03 - 01/04 - 3,451 3799 3344 4048 4132 3289 4346 4337 4383 4080 4180 3968 4105Total number of Skype for Business Conference participants 01/03 - 01/04 - 12,340 16639 14099 16887 16410 12757 17308 17544 17628 16295 16324 15432 16063

COVID-19 and Digital Response - Weekly Average Target W/E 03/05 W/E 10/05 W/E 17/05 W/E 24/05 W/E 31/05 W/E 07/06 W/E 14/06 W/E 21/06 W/E 28/06 W/E 05/07 W/E 12/07 W/E 19/07Staff connected to the Trust network remotely (Home/Agile working) 250 on 01/03/2020 2050 1992 2598 2728 2079 2098 2410 2487 1880 1965 2077 2291

Network Bandwidth Capacity and Utilisation (Bandwidth upgraded from 200mb to 500mb on 9th March 2020, and 500mb to 1000mb on 5th April 2020)) 48.0% 29.6% 32.3% 34.3% 25.9% 31.3% 32.5% 32.5% 31.5% 28.9% 27.7% 27.7%

Total number of clinical video consultations 498 376 434 500 444 513 549 534 580 607 507 549

Notes:

2. Total number of clinical video consultations are subject to validation.

Our Resources Target Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20Use of Resource - NHS Improvement Rating 2019 /20 Year End Plan - 1 2 2 2 2 2 2 2 2 1Agency Spend - NHS Improvement Rating 2019/20 Year End Plan - 2 2 2 2 3 2 3 3 3 3Agency Spend (Cumulative) 3,755,000£ 4,960,000£ 6,144,000£ 7,358,000£ 8,310,000£ 9,410,000£ 10,624,000£ 11,687,000£ 12,711,000£ 1,011,000£ 1,978,000£ 3,156,000£ Agency Spend Vs Agency Ceiling % 12.70% 19.10% 23.00% 26.20% 24.70% 25.50% 27.60% 27.80% 27.20% 21.30% 18.70% 26.30%Total Turnover 128,346,000£ 160,745,000£ 193,612,000£ 226,266,000£ 259,118,000£ 290,823,000£ 324,205,000£ 358,232,000£ 397,004,000£ 34,053,000£ 68,443,792£ 107,375,549£ Surplus / Deficit 70,000£ 381,000£ 631,000£ 1,000,006£ 1,551,000£ 2,089,000£ 2,685,000£ 3,282,000£ 5,887,000£ -£ -£ -£ Cash 44,360,000£ 40,346,000£ 48,364,000£ 45,237,000£ 43,612,000£ 47,097,000£ 47,407,000£ 47,181,000£ 50,782,000£ 80,675,000£ 80,471,000£ 79,434,000£ Cumulative COVID-19 spend 962,000£ 1,370,003£ 2,577,000£ 4,281,583£ COVID-19 reimbursement 962,000£ 863,000£ 2,175,000£ 4,192,756£

COVID-19 and Our Estate Target / Baseline As at 14/06 As at 21/06 As at 28/06 As at 05/07 As at 12/07 As at 19/07Number of buildings assessed against the Covid-19 guidance: Communal areas (%) 100% by 22nd June 2020 81% 86% 100% 100% 100% 100%

Number of teams assessed against the Covid-19 guidance: Team assessments completed (%) 100% by 19th June 2020 40% 85% 95% 96% 97% 97%

COVID-19 and Our Estate Target / Baseline Jun-20

Number of remedial works or actions completed (%)

100% Completion of all Actions - Timescales to be

confirmed once all actions are identified.

12.86%

COVID-19 and Digital Response

Our Finances

COVID-19 and Our Estate

1. Network monitoring is continuing on a daily basis and current capacity is providing the bandwidth required for staff use. The planned upgrade to 10Gb has not yet happened and having been delayed with the 3rd party Nokia. This has been escalated within the supplier to seek swift resolution. Nokia are confident the upgrade will be fully completed by the end of July.

No Targets from April 2020 - August 2020 as per COVID-

19 Interim NHSi Arrangement

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Our Future

Executive Lead: Louise Edwards

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Our FutureOur Future - Louise Edwards, Director of Strategy

1. The review of the Trust’s long-term strategy informed the development of the Operational Plan for 2019/20 which was approved by the Board in March 2019. In summary, our long-term strategy is to continue to improve quality and safely reduce costs within our services and from this strong platform, develop more preventative, integrated community based services. We have agreed key performance indicators that will help us measure how well our strategy is being implemented. We have reviewed our Strategy in light of the COVID pandemic and are developing a Recovery Plan that consistent with our strategy to become more preventative and integrated in our approach, including giving people more control over their own health and working with partners to address challenges in our communities which require collective effort.

2. During the COVID-19 pandemic, Provider Alliances in Liverpool and Sefton have not met as usual, although work streams have continued where these have supported the COVID-19 response e.g. integrated care and 30-50,000 population level. Next steps for the Provider Alliances will form part of the system recovery planning.

3. The PROSPECT New Care Model partnership, consists of Mersey Care, North West Boroughs Healthcare NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, Elysium Healthcare and Cygnet Healthcare. Implementation of the standard clinical model was paused as services started to respond to the COVID-19 pandemic. Development of the electronic single point of access was however completed during this period and the pilot commenced with HMP Liverpool on 1st June 2020. The PROSPECT Management Team has continued to meet weekly to ensure flow across the secure pathway has been effective and to address any problems in a timely manner. In addition, PROSPECT has chaired meetings across the North west secure providers to explore mutual aid, share learning and consider future opportunities for closer working. The national Specialist Community Forensic Team pilot was paused at the outset of the pandemic and recruitment into the team was postponed for a number of weeks; recommencing at the end of May 2020.

4. In May 2019 NHS England (NHSE) announced the next steps in mainstreaming New Care Models and commenced a Lead Provider Collaborative (LPC) bidding process. NHSE has stated the ambition is to have 75% of the current New Care Models population covered by Lead Provider Collaborative arrangements by April 2020 and 100% by 2022/23. Mersey Care subsequently submitted a bid to be the Lead Provider for Cheshire and Merseyside in respect of low and medium secure mental health and learning disability and autism (LDA) services. Agreement has also been reached that there will be one LPC across the North West for LDA with Mersey Care will be the Lead Provider. On 25th March NHSE/I announced a pause in the LPC programme, until at least 1st October 2020, to allow providers to concentrate on the response to the pandemic. Recently NHSE/I has confirmed that the programme will recommence and fast track sites who are in a position to do so will go live on 1st October 2020, with those unable to achieve this date going live on 1st April 2021. Regular updates will be presented to Resources Committee and Trust Board of Directors.

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Safeguarding Adult and Children Annual Report 2019/2020

Accountable Director(s): Trish Bennett, Executive Director of Nursing & Operations

Report Author(s): Sandra O’Hear, Deputy Director of Nursing & Quality Lindsay Foy, Interim Head of Safeguarding


Our Services ☐ Integrate Services ☐ Improve population health ☒






sustainability ☐ Invest in digital technology ☐ Improve our estate ☐ Transform

Corporate Services

Our Future ☐ Develop Provider Alliances ☐






Purpose of Report: To allow members of the Board of Directors to: 1) gain assurance that the Trust has carried out it’s duties in relation

to Safeguarding Adults and Children for the period 1 April 2019 – 31 March 2020, or where unable to provide full assurance that the Trust is taking action to address the identified gaps.

2) Consider and raise awareness of the wide range of activities and responsibilities that fall under safeguarding duties, both statutory and non statutory.

Recommendation: The Board is asked to:

1) Consider the development, scope and nature of the work carried out by the Trust in relation to Safeguarding Adults and Children during 2019/20

2) Understand the impact of CoViD-19 on the delivery of safeguarding for Q4 1019/20

3) Note the priorities identified in relation to safeguarding for the period 2020/21, with due consideration of the need for working in a CoViD safe way.


Quality Assurance Committee 15/7/20 As above

Recommendations approved with request for further updates as below to September

Committee Further actions required: • Update in relation to the

impact of COVID once face-to-face consultations

restart;

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• Update around asylum children/families and

appropriate commissioning to the next Committee


Operational Performance ☐ Safeguarding is a statutory requirement of all NHS trusts and is monitored by both CQC and CCG’s in addition to internal governance processes Provider Licence Compliance ☒

Legal Requirements ☒ Resource Implications ☐

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☐ ☐ ☒


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Safeguarding Adult and Children Annual Report 2019/2020 PURPOSE 1. To allow members of the Committee to consider:

a) the development, scope and nature of the work carried out by the Trust in relation to Safeguarding Adults and Children during 2019/20

b) the impact of CoViD-19 on the delivery of safeguarding for Q4 1019/20 c) The priorities identified in relation to safeguarding for the period 2020/21,

with due consideration of the need for working in a CoViD safe way.

BACKGROUND 2. All NHS Trusts are required to report annually on their safeguarding activities

for adults and Children. The attached report has been compiled on behalf of the Trust’s Safeguarding Assurance Group, which is accountable to the Quality Assurance Committee.

3. MCFT continues to sub-contract to North West Boroughs NHSFT, South Sefton

services for Safeguarding.

4. During 2019/20, there has been a review of the management and leadership of safeguarding, resulting in some organisational change taking place, and a reorganisation of the staff team’s responsibilities, a closer alignment with the Trust’s Social Care team and a more integrated approach with the divisions.

ARRANGEMENTS FOR SAFEGUARDING AND KEY DUTIES 5. The Trust continues to promote that safeguarding is ‘Everybody’s Business’

and that concerns for Adults and Children are identified and responded to effectively and efficiently. It is fundamental to high quality health and social care.

6. The Care Act 2014 sets out the Local Authorities’ responsibility for protecting adults with care and support needs, from abuse or neglect for the first time in primary legislation. The significance of this Act should not be underestimated as it replaces much of the legislation and guidance that has governed adult social care since 1948. The Care Act has reformed the law relating to care and support for adults, the law relating to support for carers and has provided a legal basis for safeguarding adults from abuse or neglect.

7. The Children Act 2004 – Section 11 places a duty on key persons and bodies

to ensure that in discharging their functions they have regard to safeguarding and promote the welfare of children.

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8. The Trust is committed to continued work with partner agencies to ensure the principles are embedded across the organisation to keep those using services safeguarded, and to demonstrate robust accountability and assurance arrangements via internal processes and Board accountability, with support of Merseyside Safeguarding Adults Board (MSAB), Lancashire Safeguarding Adult Board (LSAB), Local Safeguarding Children Partnerships (LSCP’s) and external regulation (CQC). This report does not contain the detailed statistical information in relation to all multi-agency safeguarding activity. This is available within the individual Local Authority Safeguarding Adult and Children Boards.

9. The Trust continues to remain an “alerter” agency, alerting and referring

safeguarding adult and child issues and concerns to the relevant Local Authority who is the lead agency for co-ordinating investigations. Social workers in Community Division, out of hospital services are ‘Trusted Assessors’, acting in behalf of Liverpool City Council, for the completion of health assessments for Section 42 enquiries/investigations. Seconded mental health social workers, predominantly working in Community Mental Health Teams, and their managers, also have a responsibility to co-ordinate and manage safeguarding adult and children investigations. Secure and Specialist Learning Disability services have agreed policy and procedures with Local Authorities in areas with inpatient units.

10. Overarching statistical information in relation to all multi-agency safeguarding

adult and children activity is available within Local Safeguarding Adult and Children Board’s annual reports.

11. Key duties of the trust include

• Comply with all legal and statutory requirements as they apply to safeguarding children and adults including Children in Care (CIC) statutory requirements

• Demonstrate senior management commitment to the importance of safeguarding children and adults

• Ensure a clear statement of the agencies’ responsibilities towards children and adults

• Establish a clear line of accountability within the organisation to work on the safeguarding of and promoting the welfare of children and adults

• Provide appropriate staff training for all staff regarding safeguarding children/adults and children in care - specific to roles and responsibilities, with higher level training for those staff in direct contact with children, young people, adults and families

• Safe recruitment • Effective inter-agency working to safeguard and promote the welfare of

children and adults • Child and adult death review responsibilities • Information sharing

12. The Trust is represented at a Strategic level on the Local Safeguarding Adult

Board (LSAB) for Lancashire, and the Sefton Executive Children’s Board (LSCB), as well as the Merseyside Special Educational Needs and Disability

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(SEND) forum by the Deputy Director of Nursing and Strategic Lead for Safeguarding. The Youth Justice Board is also represented by Named Nurse for Children in Care.

13. The Head of Safeguarding or Named Leads attend sub-committees of each of the Boards and there is a high level of attendance and engagement in external activities by the Trust representatives.

TRUST RESPONSIBILTY & ACCOUNTABILITY ARRANGEMENTS

14. A clear statement of the Trust’s responsibilities is available to all staff The

Trust’s responsibilities are set out in the Safeguarding and Protection of Children Policy (ref. SD13), Safeguarding Adults from Abuse (ref.SD17), Children in Care and Child Contact (ref.HSS34) which are underpinned by LSCB/MSAB/LSAB policy and procedures.

a. In addition, the Safeguarding Team has established a dedicated safeguarding ‘SharePoint’ on the Trust web site to provide comprehensive guidance, further reading, resources and contact information for staff, service users and carers.

b. All service specifications have a statement stating all clinical services’

duties and responsibilities in relation to Safeguarding. c. Safeguarding supervision is both statutory and contractual within

Safeguarding Children and Children in Care services. The Safeguarding supervision policy has been reviewed and revised. From an adult safeguarding perspective, although safeguarding case supervision is offered on request within the divisions, a formal model needs to be developed.

d. The Trust has a Child Visiting Policy (Ref. SD 22) which ensures good

practice in facilitating child contact with in-patient services. High Secure Services have specific guidance regarding Child Visits as set out in the “Department of Health Directions” (HSC/1999/160) with policy and procedure for Safeguarding Adults (ref.HSS24). Medium and Low Services, have a specific Child Visiting Policy and Procedure, (Ref No.MSU 06); which should be read in conjunction with the Trust Child Visiting Policy.

e. The Trust has a young carer’s policy and procedure developed in

partnership with Barnardo’s Action with Young Carers, Liverpool City Council and Sefton Council (Ref SD 23).

15. Individual accountability sits with the following:

a. Trish Bennett For 19/20 the Executive Director for Nursing was the Executive Lead for this area at Board level and is accountable for all issues related to safeguarding.

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b. Sandra O’Hear, Deputy Director of Nursing and Strategic Lead for

Safeguarding is the Trust Strategic Safeguarding Lead reporting to the Executive Lead and Quality Assurance Committee (QAC) and is the Trust’s representative on Local Executive Safeguarding Adults Boards and the Liverpool Safeguarding Children’s Boards.

c. Angela Lacy, Head of Safeguarding has responsibility also for the

strategic and operational oversight of the Safeguarding agenda. Reporting to the Deputy Director of Nursing and Quality she also deputises on Local Executive Safeguarding Adults Boards and the Local Safeguarding Children’s Boards as required.

d. Nerys Edwards/Jane Hopkins are the Named Nurses for Safeguarding

Children, reporting to the Head of Safeguarding and are the Trust’s representatives on all Local Safeguarding Children’s Boards sub groups and Child Death Overview Panel (CDOP). Child exploitation (CE) and harmful practices sit within the remit of both of these roles.

e. Kerry Taylor, Named Nurse for Children in Care and Targeted Services

for Young People reporting to the Head of Safeguarding and holds responsibility to lead on all review health assessments (RHA) for this cohort of children and young people.

f. Leigh Tindsley is the Safeguarding Adult Lead Community

g. Crispin Evans Safeguarding Adult Lead Mental Health (covering for

Susan Harris-Hughes due to long term sickness) h. Chantelle Carey Safeguarding Lead Vulnerable Communities

i. Dr Steevart Named Doctor for Safeguarding Children and Adults,

reporting to the Executive Lead on all issues in relation to Safeguarding. j. Robert McLean is the Head of Forensic Social Care & Nominated Officer

for Safeguarding in the Secure Division’s High Secure Services, it is required by the “Directions” HSC1999/160 “Visits by children to Ashworth, Broadmoor and Rampton” to have a Nominated Officer. Robert represents High Secure Services and the Trust on the Sefton LSCB.

GOVERNANCE STRUCTURE

21. The Executive responsibility for Safeguarding within the Trust rests with the

Executive Director for Nursing/Executive Lead for Safeguarding.

22. The Deputy Director of Nursing and Strategic Lead for Safeguarding reports directly to the Executive Director / Executive Lead to provide the necessary assurances.

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GOVERNANCE ARRANGEMENTS

23. Quality Assurance Committee This sub-committee of the Trust Board has delegated responsibility for assuring the Board that clinical quality, patient safety and clinical effectiveness are appropriately delivered in the organisation. The Executive Director of Nursing and Operations has delegated responsibility from the Chief Executive for Safeguarding arrangements in the Trust.

24. Safeguarding Assurance Group (SAG) The Safeguarding Assurance Group (SAG) has been constituted to support the Accountable Executive in fulfilling their duties both in relation to Safeguarding Children and Adults. The full constitution of this group is described within its ratified terms of reference. The Safeguarding Assurance Group is chaired by the Deputy Director of Nursing & Quality on behalf of the Accountable Executive to provide assurance to the Trust Board via the Quality Assurance Committee that the Trust is effectively discharging its Safeguarding statutory responsibilities. In summary, the SAG has the following key functions:

a. Make recommendations to the Board on Safeguarding issues b. Assess and monitor compliance with Safeguarding/protection of children

and adults arrangements in the Trust c. Ensure the production, implementation and review of LSCP and LSAB

action plans emanating from Serious Case Reviews, Serious Adult Reviews, Domestic Homicide Reviews and internal SUIs (in the latter case wherever there is a safeguarding dimension)

d. Provide clinical practitioners and managers with appropriate policy direction and guidance for the safeguarding and protection of children and adults.

e. To consider the Annual Safeguarding Children report submitted by the Named Nurse for Safeguarding Children and Safeguarding Adult & Prevent Lead.

f. Consider reports, advice and other information provided by statutory agencies and ensure that an appropriate response is provided by the Trust.

g. Discuss and endorse the work plan of the Safeguarding Team and members of the Trust’s Safeguarding Operational Group obtaining assurance that the necessary resources are available to support their work.

h. Identify and report significant organisational risks relating to safeguarding that may affect achievement of the organisational strategic objectives and if required ensure these are captured in the Corporate Assurance Framework.

25. Safeguarding Operational Group

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a. bi-monthly meeting chaired by the Head of Safeguarding/Deputy Head of Safeguarding to ensure the implementation of actions agreed and monitored by the Safeguarding Assurance Group (SAG).

MONITORING AND ASSESSING COMPLIANCE 26. The Executive Director of Nursing and Operations has delegated the

responsibility for all relevant activity in relation to safeguarding adults and children to be coordinated via the Deputy Director of Nursing & Quality through the Named Nurses for Safeguarding Children/Children in Care and Safeguarding Adult Leads to the Accountable Executives, in order to effectively manage organisational risk and as a result produce the necessary reports for the Trust Board and other bodies.

27. The SAG will ensure that all areas where additional assurance is required or where control measures need to be tested are subject to routine audit and inspection. The Corporate Safeguarding Team will undertake programmes of work identified by the SAG as part of its annual programme.

REPORTING ARRANGEMENTS 28. The Executive Director of Nursing and Operations will report on an exception

basis to the Quality Assurance Committee and the Board any significant risks relating to Safeguarding highlighted by any member of the Safeguarding Assurance Group, or indeed any other employee or stakeholder concerned with the work of the Trust.

29. The SAG will formally report annually on its activities and in addition the minutes of the SAG will be formally tabled at the Quality Assurance Committee by the Executive Director of Nursing and Operations.

MULTI AGENCY RISK ASSESSMENT CONFERENCES (MARAC) 30. Attendance of Trust representatives at Liverpool MARAC has been consistent

at these meetings. Monthly meetings are held in Sefton, and Knowsley, and fortnightly meetings in Liverpool in which individual high risk cases of domestic violence are discussed by a city or borough wide group of agencies. Through swift and robust actions informed by shared information, MARACs aim to reduce and stop domestic violence in the lives of those individuals presented.

31. MARAC links within any organisation are seen as extremely valuable to the MARAC process in relation to the appropriate sharing of information and the interventions they agree to carry out in relation to children/adults and families. The Trust is now recognised as being fully engaged and represented at MARAC meetings throughout the boroughs.

32. MARAC is a fortnightly meeting lasting 1.5-2 days for Liverpool, 1 day every

fortnight for Sefton and Knowsley. The research prior to these meetings can take up to 2 days and then up to 2 days post meeting to share the information and add actions on to the clinical notes systems for all practitioners to see.

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PREVENT (CONTEST Government Strategy 2011)

33. The Prevent strategy, published by the government in 2011, is part of the overall counter-terrorism strategy, CONTEST. The aim of the Prevent strategy is to reduce the threat to the UK from terrorism by stopping people becoming terrorists or supporting terrorism. Prevent is one of the 4 key principles of the CONTEST strategy, which aims to stop people becoming terrorists or supporting terrorism.

34. The Health Service is a key partner in the Prevent strategy in line with all parts of the NHS, charitable organisations and private sector bodies which deliver health services to NHS patients. It refers to anyone (staff, patients or visitors).

PROCESS FOR DEALING WITH ALLEGATIONS OF ABUSE AGAINST STAFFAND NUMBERS OF SUBSTANIATED ALLEGATIONS 35. All allegations of abuse made against staff should be dealt with following the

relevant Trust Policy for Safeguarding Adults from Abuse (SD 17) and Safeguarding and Protection of Children (SD13), and the appropriate multi agency policy framework for Liverpool, Sefton, Knowsley or St Helens. This is incorporated into both Trust Policies

36. Additionally concerns regarding staff may be raised via the whistleblowing

policy, ‘Tell Joe’ email alert system or via the Trust’s appointed Speak up Guardian.

37. The responsibility for managing allegations against staff sits with the

Operational Managers of the staff member(s) involved and the Trust’ s Human Resources Department.

38. Where appropriate concerns will be reported externally i.e. to professional

regulatory bodies and the Human Resource Managers will consult and inform other Trust Managers where it is appropriate to do so.

39. Statistical information in relation to allegations against staff is maintained by the

HR department. A representative from this department sits on the safeguarding operational group to provide the relevant information sharing if the allegations are in relation to safeguarding concerns or incidents.

40. Additionally both of the Trust’s Deputy Directors of Nursing ( one of whom holds

the Strategic Lead for Safeguarding responsibility) sit on the Trust’s professional practice panel together with the Deputy Director of HR /designated deputy where any concerns regarding People in a Position of Trust (PiPoT) are discussed and overseen.

RECRUITMENT AND VETTING ARRANGEMENTS 41. In line with Government targets placing responsibilities on all agencies to

ensure that they have appropriate procedures in place, Mersey Care has made safer recruitment a high priority.

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42. The Trust’s Recruitment is undertaken in house by the Resourcing Team and

this process is fully compliant with NHS Guidance on Employment Checks. All new staff who meet the requirements for Disclosure and Barring (DBS) checks under the guidance is required to undertake the checks and be cleared prior to commencement in post.

43. The Trust adopted the practice of updating DBS checks for staff every 3 years all staff are now encouraged to join the DBS Update Service

44. The Safeguarding Adults: Roles and Competencies for Healthcare staff (2018)

– Intercollegiate guidance document has been reviewed and approved by NHS England.

ANALYSIS OF INCIDENTS AND ACTIVITY 45. The recording, tracking and monitoring of safeguarding activity across the Trust

has been done at a local level by divisions utilising the Trust’s various electronic incident management systems and patient record systems.

SAFEGUARDING ADULT REVIEWS AND DOMESTIC HOMICIDE REVIEWS 46. There has been involvement by the Trust safeguarding Team in one Local

Authority Safeguarding Adult Reviews (SAR’s) in the period April 2019 – March 2020 for Sefton Local Authority and two Safeguarding Adult Reviews (SAR’s) which came to fruition in 2019/2020 after commencement the previous financial year. One was for Liverpool and one was for Knowsley which was also a joint SAR/DHR. There has been 1 Domestic Homicide Review (DHR) in Liverpool involving Mersey Care service users during the period of April 2019 – March 2020.

SAFEGUARDING CHILDREN ACTIVITY 47. Mersey Care services have changed significantly with regards to the direct

involvement and engagement with Children and Children in Care. There are services within Mersey Care’s local and community divisions that have direct access and involvement with children, whereas within Secure and SpLD the contact with children would be as a result of the child’s involvement with adult service users. The Local Division contact with children are limited in nature and usually via the Criminal Justice Liaison or Early Interventions Teams. The Community Division contact is extensive, and includes School Nursing, Health Visitors and Walk –In Centres.

SAFEGUARDING CHILDREN SERVICE 48. Referrals - During 2019/2020 there has been a consistent number of

safeguarding children referrals throughout. (Fig 1) These are monitored by Named Nurse for Safeguarding Children and demonstrate engagement with Children’s Social Care Trust Wide. Further information in relation to the referrals is available and provided via monthly reporting arrangements. This

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allows for further clarification and oversight of the concerns identified and teams / staff roles initiating the referral. This is positive and demonstrates that safeguarding is integral to all services with referrals initiated from all teams across the trust. The concerns identified throughout the year also demonstrate that staff have a good understanding of safeguarding and what would contribute to making a safeguarding children referral. During this period there has also been on-going work in relation to the internal reporting of safeguarding concerns via Datix. There has been a particular focus on children’s Community Service reporting arrangements ensuring this is brought in line with the rest of the trust. This has allowed for more robust and accurate data to be reported on.

Fig 1

49. Engagement with Multi Agency Arrangements: Initial and Review Child

Protection Conferences a. During 2019/2020, there has been a targeted approach towards ensuring that

there is full engagement with the Child Protection agenda, and the improvements in attendance at initial CP conferences are clearly evidenced in the charts below

b. Staff involvement during both the Initial (Fig 2) and Review (Fig 3) Child Protection (CP) meetings shows a high level of engagement.

c. It has also been confirmed that on the occasions when attendance has not been possible a ‘report of involvement’ is shared prior to conference. During this annual period more robust mechanisms have been put in place to ensure invites for CP conference are sent to the Safeguarding Team as previously invites where going direct to practitioners. Consequently this has impacted positively on the accuracy of data collected for CP invites, and the oversight of attendance

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Fig 2

Fig 3

50. Multi Agency Safeguarding Hub (MASH) Requests and Responses - The MASH is focused on cases which are not clear cut and where further information via different agencies will affirm what level of assistance is needed. The purpose of the MASH is to gather intelligence and share information across different organisations to enable a more accurate assessment of risk and need to inform the most appropriate response. The aim is for the service to expand to deal with cases involving vulnerable adults and establishing links with wider safeguarding arrangements including violent extremism. During this period there has been improvements made integrating the wider Safeguarding Children’s Team within the MASH arrangements. This has brought about improvements in terms of cross cover and understanding MASH as part of wider safeguarding children work. The following charts display the

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volume of MASH requests from Sefton and Liverpool Local Authoritiesand good level of engagement with multi agency information sharing arrangements set out. Agency responses to MASH requests are monitored by CCG’s and for Sefton (Fig 4) and Liverpool (Fig 5) there is a high level of response by Mersey Care as illustrated below:

Fig 4

Fig 5 CHILDREN IN CARE/TARGETED SERVICES FOR YOUNG PEOPLE SERVICE 51. The number of Children in Care continues to rise steadily in Liverpool and

additionally the number of complex cases continues to increase. In 2015/16 there were 980 children in care to Liverpool; in June 2020 there are 1460 children in care to Liverpool. In addition to the number of Children in Care who

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Liverpool MASH

Requests

Responded to in Time

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come from Liverpool and remain in Liverpool, there are also other Children who require specialist input and oversight. These fall in to the following categories.

52. Profile of Children in Care Liverpool June 2020 Profile June 2020 Number Children in Care of Liverpool LA 1460 Children in Care of Liverpool LA placed outside of Borough 581 Children in Care of other Local Authorities placed in Liverpool 197 Lead Nurse & Specialist Nurse 16 – 18 age caseload 295 Unaccompanied Asylum Seeking Children (on 16 -18 caseload) 104

Children in Care Statutory Responsibilities

53. Under the Children Act 1989 and the Children Act 2004, Mersey Care has a duty to comply with requests from the local authority to provide timely and effective health services to Children in Care. The service for Children in Care (CIC) is set out within legislative framework and guidance, in particular Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children, 2015 (DfE/DH). This clearly sets out the duties and responsibilities of Clinical Commissioning Groups (CCG’s) in supporting Local Authorities in maintaining and improving the health outcomes of Children in Care (CIC). There are a number of Statutory responsibilities that apply to Health providers regarding Children in Care and Mersey Care hold the responsibility for reporting against these as part of the Key Performance Indicators (KPI’s). However, the service is co-dependent on partners to deliver on these KPI’s – this includes clinicians at Alder Hey and colleagues working in other LA areas where Liverpool children are residing. Because of the complications and reliance on other partners, the KPI’s for Children in Care are reasonable in terms of assurance, which is an improvement on the previous year

54. Initial Health Assessments (IHA’s). The Children in Care team are responsible for the overview and co-ordination of IHA’s in ensuring statutory timescales are met. The CIC team works in partnership with Alder Hey who are commissioned to complete the IHA. Achieving compliance requires multi-agency pathways that promote individuals and organisations to successfully manage specific elements. IHA’s are a challenging area as fragmentation within the pathway often creates delay and there is a reliance on all partners to complete set processes in a timely fashion. During 2019/20 372 IHA’s for children in care to Liverpool were processed by the CIC team;

• 237 of those met statutory timescales (63.71%)

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• 52 IHA’s for children in care to other authorities were processed by the CIC team

• 11 of those met statutory timescales (21.15%) ↓

• 35 IHA’s for children in care to Liverpool placed out of area were processed by the CIC team; 6 of those met statutory timescale (17.14%)

55. Statutory Review Health Assessments (RHA’s) Mersey Care has improved compliance with RHA’s during Q1, Q2 and Q3 of 2019/20. Key Performance Indicators for CiC health teams were suspended for Quarter 4 (2019/20). (It was accepted that standard quality assurance processes would be limited/stopped in order that completion of assessments and case reviews could be prioritised, and KPI’s due in Q1 are NOT expected to be completed). CiC & TSYP were be subject to a Case Review as per national directive detailed within the Covid 19 Community Response Annex issued on 19th March 2020.

56. The Children in Care team hold responsibility for the requesting of statutory Review Health Assessments from practitioners with caseload responsibility. For children placed in Liverpool this will be the Health Visitor, School Nurse or CIC Specialist Nurse. For children placed out of area this requires liaison with the receiving authority. The process involves a significant amount of support from the administrative team, who underpin the function of the team. Quality Assurance of RHA’s is undertaken by the Named/Lead Nurses for Children in Care. During 2019/20 940 RHA’s for children in care to Liverpool were processed by the CIC team

• 869 of those met statutory timescales (91.57%) ↑ • 557 RHA’s for children in care to Liverpool placed out of area were processed by

the CIC team; 410 of those met the statutory timescales (73.61%) ↔ • 188 RHA’s for children in care to other authorities in Liverpool were processed by

the CIC team • 174 of those met statutory timescales (92.55%) ↑

57. Children in Care Training Competencies

Training type Level Staff group(s) Children in Care

1 All staff including non-clinical managers and staff working in healthcare settings

Children in Care

2 Minimum level for all non-clinical and clinical staff who may have some contact with children, young people and/or

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Children in Care

3 All clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the health needs of a looked after child/young person or care leaver

Children in Care

4 Specialist medical, nursing and health professionals for looked after children, including Named professionals and Medical Advisors for Fostering and Adoption

Children in Care

5 Designated Professionals

58. Looked after children: Knowledge, skills and competence of healthcare staff, Intercollegiate Role Framework (March 2015) identifies five levels of competence, and gives examples of groups that fall within each of these. Level 3 training has been offered to practitioners who are eligible. This has been delivered by the Named and Lead Nurses for Children in Care. This ensures that staff that may come into contact with Children in Care or Care Experienced people will have been trained appropriately. Face to Face training has ceased from March 2019 due to sanctions of COVID -19. Merseycare has On line training packages available & LSCP on line training packages are available however Level 3 training on the Health Needs of Children in Care has ceased due to the sanctions of COVID-19. Any identified training need is currently escalated to Named Nurse for CIC and addressed in a bespoke way, whilst the service is developing e learning and specific packages for level 3.

59. Children in Care Performance concerns 2019/20 The performance level of the team remained under a high level of scrutiny last year both internally and externally, there has been an improved level of performance as evidenced via the 2019/20 actions and KPI monitoring processes.

Impact of CoViD -19 and interim plans 20/21

60. In response to COVID19 there have been required changes to service provision and some alteration of managing statutory assessments for the Children in Care team and delivery of the National Healthy Child Programme. This is in line with national guidance and is subject to change in response to emerging directives; current direction set out in the NHS Covid 19 Prioritisation of Community Services issued 19th March 2020

61. Risk assessments for CIC & TSYP were prioritised and completed and all CIC

and CYP with TSYP have been rag rated according to risk with control measures in place. Any contact with young people should where possible be

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virtual contact. Any face to face contact should be risk assessed for appropriate health need and COVID risk.

Ongoing challenges

62. Capturing the Voice of the Child at a time when relationships with parent’s, carers and young people has broken down has continued to be a challenge, and this will be an action to continue for 20/21

63. The IHA administrative function has continued to sit within Mersey care during 19/20, despite the lack of control or influence that the Trust has with Alder Hey practitioners. Moving forward, it has been agreed that the Children Administrative functions for IHA will be transferred to Alder Hey, this will provide opportunity to release administration capacity within the CIC health service and increase performance from Alder Hey as providers of IHA.

SAFEGUARDING ADULTS ACTIVITY (LIVERPOOL, KNOWSLEY & SOUTH SEFTON) Safeguarding Referrals by Month for Reporting Period 2019/2020

64. Adult Safeguarding referrals to Liverpool, Knowsley & South Sefton Local

Authorities have remained largely consistent over the previous reporting periods with no alarming spikes. This current reporting period 2019/20 has seen a slight increase of 29 on the 2018/19 reporting period which reported 646 Adult Safeguarding referrals. Previously Corporate referrals have been two or three a year. This increase that is documented above has been generated by the respective Life Rooms Services. Due to the nature of the Life Room service and service user contact in times of crisis it is expected that this number will continue to increase and will be monitored accordingly and reported on.

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar TotalLocal Division 25 18 30 28 17 23 24 26 19 27 13 20 270Specialist Learning Disabilities Division 1 0 0 0 0 0 0 0 0 1 0 0 2Secure Division 5 4 1 1 1 1 2 2 1 0 0 1 19Liverpool & South Sefton Community Division 35 28 32 39 20 33 30 32 31 29 36 26 371Corporate Services 0 3 2 0 0 0 2 3 2 0 0 1 13Total 66 53 65 68 38 57 58 63 53 57 49 48 675

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Referrals by Division

a) Local Division

Knowsley Safeguarding

Liverpool Safeguarding (Careline)

Other Local Authority

Sefton Safeguarding Total

Local Division 17 150 18 85 270 Total 17 150 18 85 270

b) Community Division


Liverpool Safeguarding (Careline)


Sefton Safeguarding Total

Liverpool & South Sefton Community Division 4 274 12 82 372 Total 4 274 12 82 372

01020304050607080

Safeguarding Referrals Local Division Financial Year 2019/2020


Liverpool Safeguarding(Careline)


Sefton Safeguarding

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65. The above charts show the Local Authority the Adult was referred to for Local Division and Community Divisions only. Referrals to Liverpool Local Authority have increased by 105 from 320 referrals in 2018/19 to 425 for the current reporting period 2019/20. Referrals to Sefton Local Authority have reduced by 119 from 286 referrals in the 2018/19 to 167 for the current reporting period 2019/20.

66. The highest reported Category of abuse requiring a Local Authority referral for

Local Division was under the category of Physical Abuse (patient on patient assaults) and this is consistent with previous reporting periods with a large proportion of these referrals generated by the In -Patient units with the Psychiatric Intensive Care Unit (PICU) generating 16 referrals and Older peoples Mental health and over 65 Organic Mental health wards (Irwell, Acorn and Oak Wards) generating 32 referrals collectively. The highest reported category of abuse requiring a Local Authority referral for the Community Division was under the category of Neglect (acts of omission) (141) and the vast majority of these were referred via the District Nursing teams who visit patients in both there own homes and residential Care Homes and cover large geographical areas.

67. Section 42 Enquiries - number where the safeguarding adult team have been requested to support Liverpool Local Authority social workers totals 56 for the reporting period of 1st April 2019 – 31st March 2020. The number of section 42 enquiries where the safeguarding adult team have been requested to support Sefton Local Authority social workers totals 4 for the reporting period of 1st

020406080

100120140160

Safeguarding Referrals Liverpool & South Sefton Community Division Financial Year 2019/2020

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April 2019– 31st March 2020. These were predominantly enquiries within the care home setting and also chronology’s of health professional’s notes, mainly district nurses if the section 42 enquiry relates to potential gaps in their care/

68. Safeguarding Adults Champions - A number of staff within the Community Division service areas have come forward to take on the role as Safeguarding Adults Champion. Champions meet each quarter and participate in update workshops covering relevant topics. In addition, a comprehensive quarterly newsletter is produced by the team for champions and the wider care economy.

SECURE DIVISION

69. The Directions require: - The Chief Executive must submit an annual report to the trust board at the end of each financial year providing details of— (a) the number of patients visited by children in that year; (b) any special arrangements put in place to ensure that safety of those children whilst visiting patients, together with the chief executive’s assessment of the appropriateness of such arrangements; and (c) the chief executive’s assessment of the continuing adequacy of the arrangements put in place by the hospital to ensure the safety of children whilst visiting patients.

70. It is a national standard to practice in accordance with the Children Act and Working Together to Safeguard Children March 2015. The child visiting suite or family room continues to provide an appropriate and child friendly environment for approved patient child contacts. The Named Nurse contributes to the training/supervision of staff who manage child contact; this is offered on a quarterly basis.

71. Quarterly Child Visiting Data within Secure Division

Service

Q1

Q2

Q3

Q4 Total

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

Low 0 2 0 1 2 3 1 2 1 0 1 0 13

Medium 6 3 6 4 6 5 6 7 9 8 9 0 69

High Secure 11 7 13 5 8 15 6 6 14 4 5 5 99

Grand Total 17 12 19 10 16 23 13 15 24 12 15 5 181

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Safeguarding Referrals within Secure Division The tables below provide information relating to the number of referrals made by the Secure Division Service for the period 2019/2020 by the specific categories of abuse reported.

72. Low Secure Services

73. There have been 12 Safeguarding Referrals from Low Secure Services between 01 April 2019 and 31 March 2020; Referrals have been made to the relevant Local Authority in respect of all

74. Medium Secure Services

75. There has been a total of 19 Safeguarding Referrals made in Medium Secure throughout April 2019 and March 2020. Of these 19 referrals, 7 relate to

1 2 3

2

1

2 1

Sexual Abuse OtherInappropriate

Behaviour

Other Physical Assault(Patient on

patient)

Financial

LSU Safeguarding Referrals by Category Q1 Q2 Q3 Q4

1 1 1 2

1

3 1 2

00.5

11.5

22.5

33.5

MSU Safeguarding Referrals by Category

Q4

Q3

Q2

Q1

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allegations against staff (captured in the separate table in page 10) with the remaining 12 classified in the table above.

High Secure Services

76. In High Secure Services a total of 86 Safeguarding Referrals were received in Quarter 1, Quarter 2, Quarter 3 and Quarter 4. Not all of the referrals met the threshold to be classified as Safeguarding and those which did not were regraded as Incidents and managed at ward level. Those Safeguarding Referrals which met the threshold were taken to the Safeguarding Strategy Meetings to discuss necessary actions and to capture outcomes. Out of the 86 Referrals received in High Secure Services, 66 met the threshold for discussion at Safeguarding Strategy Meeting, and the table below shows the categories of referrals made following discussion.

77. Complaints that come through to Safeguarding are investigated via the complaints procedure or if possible are resolved locally at ward level These complaints are not represented in the above graph. Patient on patient assaults

05

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Number of Safeguarding Referrals HSS

HSS Total Number ofReferrals

HSS Total Confirmed asSafeguarding

3 1 2 1 1 1 8 3

9 1

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PhysicalAbuse

Patient onPatientAssault

Other FinancialAbuse

Sexual Abuse

HSS Safeguarding Referrals by Category

Q4

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are noted and reviewed at Safeguarding Strategy Meetings along with any relevant care plans and police referrals to ensure adequate safeguards are in place.

78. Forensic Outreach Service

There are no reports of safeguarding concerns/referrals for Forensic Outreach Service for Quarter 1, Quarter 2 or Quarter 4. There was one Safeguarding Referral in Quarter 3.

79. Offender Health

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80. HMP Liverpool has seen a total of 59 Safeguarding Referrals in Quarter 1, Quarter 2, Quarter 3 and Quarter 4. There was 1 Safeguarding Referral for HMP Garth in Quarter 2 that is included in the above graph.

81. Safeguarding Outcomes for Secure A Safeguarding Strategy Meeting is convened within 5 working days for High Secure this is chaired by the Head of Forensic Social Care or deputy. Within medium and low secure referrals are made to the Local Authority. Safeguarding referrals to Local Authorities outside of Sefton Borough Council are made direct, without any strategy meeting held within HSS. This is when any person has been identified as being a possible subject of abuse and further investigation is needed by the persons host Local Authority.

82. The following chart provides information relating to Safeguarding Strategy

meetings and referrals. The outcome options for a child or adult are Community Mental Health Team, Local Authority Referral, Appropriate Agency, Police Referral, Complaint or Human Resources Investigation.

2 2 3 1 10

3 3 1 4

4

2 1 6

9

1 3

5

05

1015202530

Offender Health Safeguarding Referrals by Category

Q4

Q3

Q2

Q1

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SPECIALIST LEARNING DISABILITY DIVISION (Whalley) 83. Referrals

84. From 1st April 2019 to end of 31st March 2020 there have been a total number of 218 alerts raised into the Specialist Learning Disability Division Safeguarding Team. Of these 197 were deemed to not meet the safeguarding threshold and were managed in the following ways:

• Mediation was completed with good effect. • Managed via the police. • Managed as complaints via Trust processes.

25%

15%

7% 13%

40%

Safeguarding Outcomes for Secure Division

Strategy

Police

Complaints

Appropriate AgencyLA/CMHT

Adequate Safeguards

16 18

22 23

18 18

13

23

17 14

20

16

1 4 2 1 3 3 1 1 3 2

16 17 18 21

17 18

10

20

16 13

17 14

0

5

10

15

20

25

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Whalley Safeguarding Referrals

No. of Referrals into Safeguarding Safeguarding

Not Progressed as Safeguarding Linear (Safeguarding)

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85. In total there were 21 safeguarding reports which were generated across the Whalley site, meeting the threshold for referral to the local authority (Lancashire). Six referrals originated from the Enhanced Support Unit, nine from the Medium Support Unit and six from the Low Secure Unit.

A further breakdown of referrals by nature of abuse is captured in the graphs. Below indicating that physical abuse was the highest category of abuse across SpLD division totalling nine incidences

3

1

2

2

2

5

3

1

2

0 1 2 3 4 5 6

Neglect / Acts Of Omission

Sexual Abuse

Physical Abuse

Psychological Abuse

Sexual Abuse

Physical Abuse

Neglect / Acts Of Omission

Sexual Abuse

Physical Abuse

LSU

MSU

ESU

- Enh

ance

dSu

ppor

t Uni

t

19/20 - Types of Abuse Location - Whalley Site

4 1

63

88

23 2 16 9 2 4 6 0

102030405060708090

100

Whalley 19/20 Referrals - Nature of Abuse

Not Progressed as Safeguarding Safeguarding

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86. Source of Risk Of the nine instances in Medium Secure, the relationship of alleged perpertrator, four service user on service user allegations and five staff on service user allegations. Of the 6 instances in Low Secure, the relationship of alleged: 2 service user on service user allegations and 2 staff on service user allegations, 2 classed as other – one related to a service user at a new provider address, the other related to a new provider staff Of the six instances within the Enhanced Support Services, the relationship of alleged perpertrator was 1 service user on service user, 2 staff on service user. Three classed as other – one related to threats made by a flat mate at a discharge address, the other two related to external service providers. All allegations made implicating staff were referred to the Police and Local Authority as determined by the circumstances and context of the incident

87. Safeguarding Outcomes SpLD MSU

88. As detailed in the previous section, nine referrals are attributable to the MSU. However, at the time of writing this report just six investigations have been completed and an outcome provided. The remaining three external LCC safeguarding alerts remain subject to Section 42 enquiries and until these have been completed, it is not possible to provide a definitive outcome. Of the six outcome cases, four were substantiated, one was partially substantiated and one was unsubstantiated. None have been closed as inconclusive and therefore this does not appear on the above graph.

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89. As detailed in the previous section, six referrals are attributable to the LSU. However, at the time of writing this report just two investigations have been completed and an outcome provided. The remaining four external LCC safeguarding alerts remain subject to Section 42 enquiries and until these have been completed, it is not possible to provide a definitive outcome. Of the two which have an outcome, one was substantiated and the other one was partially substantiated. None have closed as inconclusive and therefore this does not appear on the above graph.

90. As detailed in the previous section, six referrals are attributable to the ESS. At the time of writing this report all six have been investigated and received an outcome. Of these three have been substantiated, one unsubstantiated and two found to be inconclusive.

STAFF TRAINING COMPLIANCE – End March 2020 for 2019/2020

1

0

1

2

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

Safeguarding Outcome - Enhanced Areas

Substantiated

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91. Local Division Level Target Compliance Level 1 90% 98.06% Level 2 90% 96.09% Level 3 90% 92.15%

92. Liverpool Community Division

Level Target Compliance Level 1 90% 98.01% Level 2 90% 92.07% Level 3 90% 95.50%

93. Secure Division


94. Specialist LD Division


95. PREVENT Trust wide

Level Target Compliance Preventing Radicalisation

90% 90.48%

96. Changes to safeguarding TRAINING delivery . Prior to Covid 19 pandemic level 3 training this has required staff to attend training on a face to face basis delivered by the Safeguarding Team, for Children and Adults. All face to face training has stopped, L3 Safeguarding Adults has moved, temporally to Skype training sessions. The challenge of delivering training during the past few months has led the service reviewing its delivery method. The Trust is in the process of adapting NWBH e-learning training packages to replace all face to face learning. The benefits are expected to be seen in compliance rates. THEMES AND LESSON LEARNED

SpLD Inpatient services

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97. As considered in previous annual safeguarding reports the proportion of external safeguarding alerts when compared against the overall number of safeguarding reports made within the service remains relatively low (11% of the total). Factors that appear to contribute to this are:

- Safeguarding is a daily consideration during senior managers safety huddles, which often raise matters for initial reporting and follow up by the social work/safeguarding team.

- Triaging of all safeguarding reports using the LSAB Guidance for raising safeguarding concerns, to ensure the appropriate level of response, to all reports and allegations of abuse.

- A long established, active review and reporting mechanism throughout the division which is centred on proactive safeguarding approaches and early intervention to areas of concern.

98. There have been repeated instances through the 2019/20 in which enhanced patient observation levels have not been maintained within both medium and low secure settings. A number of these have led to significant situations and/or of risks and instances of harm. This remains an area of concern, particularly so in connection with agency workers undertaking the role for supervising service users levels. The use of physical restraint is often a traumatic event for both service users and the staff involved. There have been repeated allegations (physical and sexual) made by a small number of service users following incidents. Routine and timely use of CCTV continues and is often used to respond to these concerns, providing a high level of assurance in connection with the direction of travel around safeguarding decision making.

99. Through the course of one particular safeguarding enquiry, which was initiated

following a whistleblowing report to the CQC, twelve restraints were reviewed in detail. This review revealed concerns in relation to staff competence and the techniques used for people with complex and challenging behaviours. Following this investigation a detailed, comprehensive review was also completed and action plans linked to the services provided to this person were developed.

100. The regular use of CCTV footage in SpLD inpatient services adds detail to

and/or provide assurance in connection with physical restraints has been effective throughout the service year 2019/20. The extensive review linked to the whistle-blowing reconfirms the efficacy of this resource within the context of secure services. Given this, commitments have been made regarding the use of body worn cameras, for staff involved in incidents. A trial of the body worn cameras has been undertaken within secure services. A further trial and the use of this resource are likely during this service year 2020/21.

101. The ongoing involvement of the Police, using the designated police officer for the Whalley learning disability service, has been particularly useful in early resolutions to Police/safeguarding matters including investigative and enquiry processes. This role has helped ensure that criminal justice responses, including prosecutions are proportionate and timely. The follow up of actions

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are often taken forward in conjunction with and complementing the actions of the forensic social work/ safeguarding team.

WHATS WORKING WELL 102. Information sharing - In addition to the LSAB/LSCP interagency working, the

Trust works closely with relevant partner agencies in relation to MAPPA (multi-agency public protection arrangements), MARGG (multi-agency response to gun & gang), MARAC (multi-agency risk assessment conference), MACE (multi-agency child exploitation), and CHANNEL Panel (multi-agency approach to safeguarding those at risk of radicalisation). Members of the Safeguarding Team are involved in all cases relating to individuals who pose a risk to children/adults, or who may be at risk of harm, abuse or neglect.

GOOD PRACTICE IDENTIFIED FOR THE YEAR 2019/2020 103. Safeguarding supervision offer has continued to strengthen to include group

supervision sessions offered to teams including Family Support Workers, Child Contact Staff, and Family Team: Drug and Alcohol services. Work is on-going to extend offer to wider teams. Safeguarding children supervision offer is now outlined within SD33: Clinical, Managerial, Safeguarding Supervision and Reflective Practice Policy which is currently being reviewed.

104. All polices related to the Safeguarding Team and services have been updated

105. Suicide Prevention Training (SERIOUS) for children and young people has been devised in conjunction with the Safeguarding team, CDOP, MYA, YOS and LSCB, launched September 2019.

106. Pro active approach to non compliance and staff who are due to become non

compliant with safeguarding training has seen a marked improvement across all divisions and at all levels.

107. Data collection mechanisms have greatly improved to allow for more accurate

data reporting

108. A review of standard operating procedures (SOPS) is continuing across the safeguarding service and aligned accordingly to meet the required outcomes of respective safeguarding remits.

PRIORITIES FOR THE YEAR 2019/2020

109. A number of key priorities have been identified for the year 2020/2021:

a. Implement Sign’s of Safety model across 0-19 services initially with a cascade plan for all frontline practitioners to adopt when working directly with children, young people and families.

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b. Implement ‘Neglect’ Strategy

c. Work closely with Sefton Council to agree safeguarding process to support

the opening of Rowan View

d. Continue to review and revise Safeguarding SharePoint site in line with new requirements and developments of services.

e. Continue to work with the main Local Safeguarding Adult/Children Boards and sub-committees to support the delivery of all safeguarding expectations in an

increasingly high profile area of practice. Continue to achieve excellent attendance at Local Safeguarding Boards & Sub Groups when invited.

f. Develop, implement and monitor any actions required to maintain compliance with the Care Quality Commission’s registration standards.

g. Develop performance framework in order to capture safeguarding activity at

operational levels to feed into service line reporting expectations of the Divisions.

h. Work collaboratively with Liverpool and Sefton CCG’s designated professionals in the implementation of the newly developed 2019/20 KPI framework.

i. Further develop collaborative approaches with the Social Care Leads to review, build upon and strengthen the remit and governance of the safeguarding service across the organisation.

j. Move to elearing approach for all training

k. Review electronic patient record systems across the safeguarding service.

l. Develop a Trust Wide Persons in Position of Trust (PiPoT) Policy in collaboration with the Trust’s HR colleagues and develop a reporting template to monitor and review allegations against staff.

CONSEQUENCES OF NOT TAKING ACTION The Trust is required to fulfil its statutory duties in respect of safeguarding issues. Failure to do so is not only a legal issue but would also lead to further scrutiny and inspection by our regulators

RECOMMENDATION The Committee is asked to:

a) Consider the development, scope and nature of the work carried out by the Trust in relation to Safeguarding Adults and Children during 2019/20

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b) Understand the impact of CoViD-19 on the delivery of safeguarding for Q4 1019/20

c) Note the priorities identified in relation to safeguarding for the period 2020/21, with due consideration of the need for working in a CoViD safe way

TRISH BENNETT EXECUTIVE DIRECTOR OF NURSING & OPERATIONS July 2020

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Report to: Board of Directors Meeting Date: 29th July 2020 This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

Nursing Revalidation Report

Accountable Director(s): Trish Bennett, Executive Director of Nursing & Operations Report Author(s): Jenny Hurst, Deputy Director of Nursing


Our Services ☒ Integrate Services ☐ Improve population health ☒






sustainability ☐ Invest in digital technology ☐ Improve our estate ☒ Transform

Corporate Services





STEEEP ☒ Safe ☐ Timely ☐ Effective ☐ Efficient ☐ Equitable ☐ Person-centred

CQC ☒ Safe ☐ Responsive ☐ Effective ☐ Caring ☐ Well-led

Purpose of Report: 1) The purpose of this report is to update the Board on the Trust’s approach to supporting registered nurses to meet the Nursing and Midwifery Council’s (NMC) revalidation requirements.

2) The report provides assurance on the robustness of our internal processes.

Recommendation: The Board is asked to: 1) Receive and note the content of this report. 2) Identify any further assurance required.


Quality Assurance Committee 15/07/2020 Nursing Revalidation Report Annual Update


Operational Performance ☐ Provider Licence Compliance ☐ Legal Requirements ☐ Resource Implications ☐



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EXECUTIVE SUMMARY

1. All registered nurse and nursing associates are required to renew their registration with the Nursing and Midwifery Council (NMC) every 12 months and to Revalidate every 3 years. Nurses and Nursing Associates can only practise if they have satisfied this requirement.

BACKGROUND

2. Revalidation replaced the previous system for post-registration which relied heavily on self-declaration to determine the registrant’s fitness to practice. The new process of revalidation contributes to the NMC`s core regulatory purpose aiming to deliver a proportionate, risk based and affordable system that provides greater public confidence in professionals regulated by the NMC.

3. Revalidation encourages a culture of sharing, reflection and improvement amongst nurses and midwives and is a continuous process that nurses and midwives have to engage with throughout their career. It allows nurses and midwives to demonstrate that they practice safely and effectively.

4. Our aim is to ensure that revalidation is not seen as a standalone additional

requirement for nurses but rather an integral part of everyday professional practice aligned with the NMC Code and the Trust values and behaviours.

5. From April 2016 every registered nurse, midwife and nursing associate is required to

provide evidence that they had met the following requirements.

• 450 practice hours or 900 if revalidating as both a nurse and midwife • 35 hours CPD including 20 hours participatory learning • Five pieces of practice related feedback • Five written reflective accounts • Reflective discussion • Health and character declaration • Professional indemnity arrangements • Confirmation from a third party

6. Following the introduction of revalidation in April 2016 the NMC published a range of

guidance and education materials to support nurses, their managers and employers.

7. For quality assurance purposes, each year, the NMC selects a sample of nurses and midwives to provide further information about their revalidation application. This process is known as 'verification'. If selected, the confirmer and registrant are required to complete an online form.

8. In our organisation there are 2384 nurses and 14 nursing associates in post each required to revalidate on a three yearly basis.

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9. Trust wide there were 4 reported lapses in Revalidation in 2019/20. This compares to 7 lapses in the previous year. Three nurses were downgraded to Band 3 whilst completing the Revalidation requirements and re-registering with the NMC. One has yet to revalidate due to long-term sickness absence. The Trust is assured that no nurses worked as a registered nurse whilst lapsed and necessary support was put in place.

10. Monitoring arrangements are in place and are detailed in the verification of statutory registration of staff policy (HR08). The transactional team undertake a monthly review of all registrations that are due to expire within that specified month by generating a report from the Electronic Staff Record system (ESR). This is forwarded to services for review and action.

11. Whilst Nurses have a personal and professional duty to ensure that they meet the

requirements of revalidation and must take responsibility for preparing their revalidation evidence, the Executive Nursing team takes a corporate lead on revalidation throughout the trust and is available to facilitate advice and support and acts as a point of contact to address any concerns.

12. The Trust’s Business Intelligence team are developing an automated revalidation

monitoring report. The development has been taking place in two stages as the current system over writes previous versions.

• The first stage has been completed which employs ESR information for all

nurses. The second stage which is being worked upon will capture historical data in order to report on compliance in a more seamless way this work has paused during the Covid-19 pandemic. The Trust’s Business Intelligence team are developing automated revalidation reporting. The development has required two distinct stages as the current national system over writes previous versions.

• The first stage, which has built 12 months of revalidation history, has now been completed. The second stage will be to assess this collected historical data and develop it into an, on demand, report available via the trusts BIT (Business Information Today) portal.

• It is estimated that this second stage will be completed by the end of September

2020.

COMPLIANCE AGAINST THE CQC’s DOMAINS 13. This paper provides assurance in respect of the following CQC Domain;

• Safe – Key line of enquiry (KLoEs) relating to S1.

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GAPS IN ASSURANCE / NEXT STEPS

14. There are no known gaps in assurance at present.

CONSEQUENCES OF NOT TAKING ACTION

15. None identified.

EQUALITY IMPACT ASSESSMENT

16. None identified.

RISKS

17. None identified

SIDE BY SIDE WITH SERVICE USERS / CARERS / STAFF 18. This paper does not involve significant change(s) to service delivery and as such no

engagement took place with service users, carers or staff.

TRISH BENNETT EXECUTIVE DIRECTOR OF NURSING & OPERATIONS

July 2020

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Report to: Board of Directors Meeting Date: 29 July 2020 This Report is provided: ☐ for a decision to note / for information ☐ as a consent item

Medical Revalidation Annual Report

Accountable Director(s): Dr Noir Thomas, Executive Medical Director & Responsible Officer 0151 471 2423

Report Author(s): Dr Noir Thomas, Executive Medical Director & Responsible Officer 0151 471 2423


Our Services ☐ Integrate Services ☐ Improve population health


Our People ☐ Become anemployer of choice ☐




sustainability ☐ Invest in digitaltechnology ☐ Improve our estate ☐ Transform

Corporate Services

Our Future ☐ Develop ProviderAlliances ☐


☐ Commercialise ourknowledge


STEEEP Safe ☐ Timely Effective ☐ Efficient ☐ Equitable ☐ Person-centred

CQC Safe ☐ Responsive Effective ☐ Caring ☐ Well-led

Purpose of Report: The purpose of this report is to inform the Board of the progress made in relation to medical appraisal and revalidation within Mersey Care and provide assurance that the expectations of the General Medical Council and NHS England are being fulfilled.

Recommendation: The Board of Directors is asked to: 1) Note the report and assurances2) Seek further assurance as required



Operational Performance ☐

Provider Licence Compliance ☐ Legal Requirements Resource Implications ☐

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☐ ☐

Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☐ If answered ‘YES’ to either question, please include a section in this report explaining why

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EXECUTIVE SUMMARY

1. Revalidation is the process by which licensed doctors are required to demonstrate ona regular basis that they are up to date and fit to practice. Revalidation aims to giveextra confidence to patients that their doctor is being regularly checked by theiremployer and the GMC.

2. Licensed doctors have to revalidate, usually every 5 years, by having annualappraisals with their employer, based on the GMC Good Medical Practice, the coreguidance for doctors.

3. Appraisal is a statutory process that enables doctors to have a formal and structuredopportunity to reflect on their work and to consider their forward development andhow their effectiveness might be improved. It is the key process by which doctors willprovide supporting information toward revalidation.

4. Appraisal will occur annually and requires submission of an electronic portfolio ofsupporting information mapped to the attributes defined by the GMC code of GoodMedical Practice.

5. This report provides assurance that doctors in Mersey Care are participatingsatisfactorily with medical appraisal and are being revalidated in line with GMCexpectations.

6. The Responsible Officer is appraised by an NHS England approved externalappraiser.

BACKGROUND

7. Medical Revalidation was launched in December 2012 to strengthen doctors’regulation, with the aim of improving the quality of care provided to patients,improving patient safety and increasing public trust and confidence in the medicalsystem. There are a number of statutory requirements underpinning this system,including the Responsible Officer role, the Designated Body, annual medicalappraisal, and 5-year revalidation cycle.

8. Mersey Care has in place a Responsible Officer, a medical lead for appraisal, and afull-time medical revalidation officer. This centralised leadership is fundamental toMersey Care’s performance in meeting regulations, assisting the medical workforcewith guidance and advice, and providing the organisation with annual appraisalreporting. The Responsible Officer function for all trainee doctors is devolved to thePostgraduate Dean, and therefore trainees are not included within our designatedbody.

9. The medical revalidation officer maintains a database of all doctors’ appraisal activity,which is updated and checked continuously. The list of prescribed connections (thelink between each doctor and the Responsible Officer) is confirmed each year beforethe appraisal cycle begins (which for most doctors is between September andFebruary).

10. Since the 2016/17 appraisal cycle, we have had new online appraisal software inplace (www.L2P.com) which securely stores all appraisal information for doctors,provides an up-to-date Responsible Officer dashboard and produces data for activity,including the Annual Organisational Audit. This software now allows for appraisal to

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be paperless and has reduced significantly the administrative burden on the revalidation officer. Built into the appraisal software are additional quality assurance measures and multisource feedback tools both for patients and colleagues.

11. The introduction of this software has been easy and effective and has hugelysimplified the process both for the revalidation team and for individual doctors.

COMPLIANCE AGAINST THE CQC’s DOMAINS – SAFE COMPLIANCE AGAINST THE CQC’s DOMAINS – WELL LED

12. The following report provides assurance predominantly across the safe and well ledCQC domains.

Mersey Care doctors:

13. For the 2019/20 appraisal cycle there were 100 doctors with a prescribed connectionto Mersey Care NHS Foundation Trust.

14. All General Practitioners working within the local community health division will beaccountable directly to a Responsible Officer within NHS England and are reportedseparately on a Prescribers’ List.

15. MCFT remains exempt from quarterly reporting on the appraisal process to NHSEngland given historical successes in attaining 100% compliance with medicalappraisals annually.

16. 96 doctors satisfactorily completed an appraisal within the 2019/20 cycle.

17. 4 doctors categorised as approved incomplete due to COVID suspension.

18. This information is usually collated within the Annual Organisational Audit (AOA)submitted by the trust in April of each year. An AOA has not been submitted for the2019/20 cycle due to the central suspension of the medical appraisal and revalidationprocess due to COVID-19.

19. 30 doctors have been recommended for revalidation over 2019/20 - this second yearof the 5-year revalidation cycle. A single deferral has been made on account ofinsufficient information, due to ongoing physical health concerns.

20. All doctors pending revalidation before October 2020 have been automaticallygranted a deferral by the GMC due to COVID-19.

Appraisers:

21. The Trust currently maintains a body of 37 appraisers in order that no appraiser isrequired to conduct more than three appraisals in any year. We are fortunate toretain our appraiser group, who undertake their work as SPA.

22. All medical appraisers have a job description, are required to complete an accreditedappraiser training course, confirm their competencies and attend appraiser refreshertraining every three years. Appraisers are also required to meet yearly to reviewprogress and update on developments.

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23. We are fortunate as a Trust to have ongoing support and interest from the medicalbody such that we now have 37 appraisers. This is our highest ever number oftrained appraisers, to include three appraisers from local sexual health services.

24. Positively, new appraisers from community health services have been readilyintegrated into our appraisal system such that sexual health doctors will nowappraise psychiatrists and vice versa.

25. High appraiser numbers have allowed us to reduce the burden individually and givenrise to opportunities in terms of sharing appraisers externally with otherorganisations, eg Royal Liverpool and Broadgreeen University NHSFT.

Quality Assurance:

26. Investing in simplified, electronic appraisal software has allowed us more time toimprove our quality assurance processes.

27. At the end of each appraisal, an appraisee is required to complete a feedbackquestionnaire on their appraiser’s performance. For the 2015/16 appraisal cycle, theresponse rate was 76%. For the 2017/18 cycle, we achieved a 97% response rateand, for 2018/19, a 100% response rate.

28. All questionnaires (anonymised) have been shared with the appraiser. The 2019/20response rate was 96%.

29. To ensure quality and consistency across appraisers, we have over the last threecycles used the audit tool provided by NHS England, the ASPAT (AppraisalSummary and PDP Audit Tool). The tool scores each appraiser’s documentationfrom a total of 50. For 2016/17, and again 2017/18, we adopted the new ASPAT(Appraisal Summary and PDP Audit Tool) devised by NHS England.

30. For both 2016/17 and 2017/18 appraisal cycles, we audited 100% of appraisaldocuments for quality. We did so using the ASPAT tool, with independent teams ofsenior appraisers, lay members and services users / carer representatives. Theaverage scores have increased from 2016/17 (34 out of 50) to 48 out of 50 in the2017/18 round.

31. This years quality assurance audit (2019/20) has not been completed due to COVID-19 suspension of process.

Other relevant matters:

32. No patient identifiable data or information governance breaches have been found inany appraisal portfolio.

33. Doctors are currently given links to Trust departments and intranet sites that provideclinical data to use as supporting information in their appraisal portfolio.

34. There were concerns raised with the National Clinical Advisory Service (NCAS) inrelation to one doctor. One doctor remains under investigation by the GMC. A seriesof GMC referrals against two other doctors have been closed with no further action.

35. There were 34 agency locums used in 2019/20, all having undergone pre-employment checks through the agencies and further CV scrutiny by a consultant

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prior to employment. Many of these doctors are brought in at short notice to ensure service continuity. In these instances, the locum agency is responsible for the appraisal and revalidation of its doctors.

36. The Trust policy for Revalidation and Medical Appraisal is now updated, and wasratified in November 2019.

INTERNAL AUDIT

37. The review of the consultants’ appraisal systems was conducted by MIAA inaccordance with the requirements of the 2018/19 internal audit plan, as approved bythe audit committee.

38. MIAA found a good system of internal control designed to meet the system objectivesand that controls were being applied consistently. The review noted substantialassurance and found that all consultants were up to date with appraisal requirementsin line with the Trust’s corporate policy. Reporting progress of consultant appraisalswas evident both operationally day to day and annually to the Trust Board.

39. MIAA identified two findings, one medium, one low risk:

a. Appraiser training records. (medium)Testing of a sample of training records identified that one appraiser training recordwas out of date. The appraiser in question had been unable to attend appropriatetraining, which is held in house every three years as per national requirements.

In future, appraiser training records will be reviewed and, if mandatory training isnot completed, additional training will be organised to ensure that we meetstandards and ensure consistent quality appraisals.

b. Completion and retention of appraisal documentation. (low)Reviewing a sample of appraisal documents, it was noted that some supportinginformation particularly around mandatory training was missing. This wasacknowledged as a problem associated with extracting data from the ESR trainingdatabase. This has since been rectified.

40. I confirm that both findings and recommendations have been addressed.

41. We have also agreed to an external audit of our appraisal and revalidationprocedures by an adjacent Trust in 2020/21, the results of which will be included innext year’s assurance report.

CONSEQUENCES OF NOT TAKING ACTION N/A

EQUALITY IMPACT N/A

RISKS N/A

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SIDE BY SIDE WITH SERVICE USERS / CARERS /

42. This paper does not involve significant change(s) to service delivery and as such noengagement took place with service users, carers or staff.

Dr N Thomas Executive Medical Director & Responsible Officer

22 June 2020

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Report to: Board Of Directors Meeting Date: 29 July 2020 This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

Annual Audit Letter

Accountable Director(s): Neil Smith, Director of Finance / Deputy Chief Executive Report Author(s): Grant Thornton


Our Services ☐ Integrate Services ☐ Improve population health ☐






sustainability ☐ Invest in digital technology ☐ Improve our estate ☐ Transform

Corporate Services





STEEEP ☐ Safe ☐ Timely ☐ Effective ☐ Efficient ☐ Equitable ☐ Person-centred

CQC ☐ Safe ☐ Responsive ☐ Effective ☐ Caring ☒ Well-led

Purpose of Report: To allow members of the Board of Directors to: 1) receive a copy of Grant Thornton’s Annual Audit Letter for the year

ending 31 March 2020. Recommendation: The Board of Directors is asked to:

1) note the contents of the Annual Audit Letter.



Operational Performance ☐ An Annual Audit Letter is required under the Code of Audit Practice Provider Licence Compliance ☒ Legal Requirements ☒ Resource Implications ☐



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EXECUTIVE SUMMARY

1. Please find attached a copy of the Annual Audit Letter for Mersey Care for the year ending 31 March prepared by the Trust’s external Auditor, Grant Thornton UK LLP

2. The report details the key findings arising from the work carried out at the Trust for the year ending 31 March 2020. It was shared by Grant Thornton with the Council of Governors at their meeting on 22 July 2020.

3. Grant Thornton gave an unqualified opinion on the Trust’s financial statements on 24 June 2020. This included a key matter in the report on the uncertainty over asset valuations as at 31 March 2020 given the pandemic. This does not affect our opinion that the statements give a true and fair view of the Trust’s financial position and its income and expenditure for the year.

4. Grant Thornton did not identify any matters which required them to exercise their additional statutory power

5. In preparing this report, Grant Thornton have followed the National Audit Office (NAO)’s Code of Audit Practice and Auditor Guidance Note (AGN) 07 – ‘Auditor Reporting’. The detailed findings from the audit work was reported to the Trust’s Audit Committee as those charged with governance in the Audit Findings Report on 12 June 2020.

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The Annual Audit Letterfor Mersey Care NHS Foundation TrustYear ended 31 March 2020

7 July 2020

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© 2020 Grant Thornton UK LLP | Annual Audit Letter | Mersey Care NHS Foundation Trust July 2020

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2

ContentsSection Page

1. Executive Summary 3

2. Audit of the Accounts 5

3. Value for Money conclusion 12

Appendices

A Reports issued and feesYour key Grant Thornton team members are:

Michael GreenKey Audit Partner

T: 0161 953 6382E: [email protected]

Naomi PoveyAudit ManagerT: 0161 953 6940

E: [email protected]

Stuart Richardson In Charge Auditor

T: 0161 214 6388E: [email protected]

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Executive SummaryPurpose

Our Annual Audit Letter (Letter) summarises the key findings arising from the work that we have carried out at Mersey Care NHS Foundation Trust ( the Trust) for the year ended 31 March 2020.

This Letter is intended to provide a commentary on the results of our work to the Trust and external stakeholders, and to highlight issues that we wish to draw to the attention of the public. In preparing this Letter, we have followed the National Audit Office (NAO)'s Code of Audit Practice and Auditor Guidance Note (AGN) 07 – 'Auditor Reporting'. We reported the detailed findings from our audit work to the Trust's Audit Committee as those charged with governance in our Audit Findings Report on 12 June 2020.

Respective responsibilities

We have carried out our audit in accordance with the NAO's Code of Audit Practice, which reflects the requirements of the National Health Service Act 2006 (the Act). Our key responsibilities are to:• give an opinion on the Trust’s financial statements (section two)

• assess the Trust's arrangements for securing economy, efficiency and effectiveness in its use of resources (the value for money conclusion) (section three).

In our audit of the Trust's financial statements, we comply with International Standards on Auditing (UK) (ISAs) and other guidance issued by the NAO.

Materiality We determined materiality for the audit of the Trust's financial statements to be £7,506,000, which is 1.88% of the Trust's gross revenue expenditure.

Financial Statements opinion We gave an unqualified opinion on the Trust's financial statements on 24 June 2020.

We included a key audit matter in our report on the uncertainty over asset valuations as at 31 March 2020 given the pandemic.This does not affect our opinion that the statements give a true and fair view of the Trust's financial position and its income and expenditure for the year.

NHS Group consolidation template (WGA)

We also reported on the consistency of the financial statements consolidation template provided to the National Audit Office with the audited financial statements. We concluded that these were consistent.

Use of statutory powers We did not identify any matters which required us to exercise our additional statutory powers.

Our work

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Executive Summary

Working with the Trust

Restrictions for non-essential travel has meant both Trust and audit teams have had to work remotely, adapting to the use of technology such as Microsoft Teams and Skype to support video conferencing and screensharing. This has enabled us to support assurance over completeness and accuracy of information provided to us by the Trust. We reported our audit findings to the Audit Committee at their virtual meeting by email in June.

We would like to record our appreciation for the assistance and co-operationprovided to us during our audit by the Trust's staff during these extraordinary times.

Grant Thornton UK LLPJuly 2020

Value for Money arrangements We were satisfied that the Trust put in place proper arrangements to ensure economy, efficiency and effectiveness in its use of resources. We reflected this in our audit report to the Directors of the Trust on 12 June 2020.

Quality Report Due to the Covid-19 pandemic, the Department of Health and Social Care suspended the requirement for the Trust’s Quality

Report to be certified.

Certificate We certified that we have completed the audit of the financial statements of Mersey Care NHS Foundation Trust in accordance with the requirements of the Code of Audit Practice on 24 June 2020.

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Audit of the Financial Statements

Our audit approach

Materiality

In our audit of the Trust's financial statements, we use the concept of materiality to determine the nature, timing and extent of our work, and in evaluating the results of our work. We define materiality as the size of the misstatement in the financial statements that would lead a reasonably knowledgeable person to change or influence their economic decisions.

We determined materiality for the audit of the Trust’s financial statements to be £7,506,000, which is 1.88% of the Trust’s gross revenue expenditure. We

used this benchmark as, in our view, users of the Trust's financial statements are most interested in where the Trust has spent its revenue in the year.

We also set a lower level of specific materiality of £5,000 for senior officer remuneration disclosure in the Remuneration Report.

We set a lower threshold of £300,000, above which we reported errors to the Audit Committee in our Audit Findings Report.

The scope of our audit

Our audit involves obtaining sufficient evidence about the amounts and disclosures in the financial statements to give reasonable assurance that they are free from material misstatement, whether caused by fraud or error. This includes assessing whether:• the accounting policies are appropriate, have been consistently applied and

adequately disclosed; • the significant accounting estimates made by management are reasonable; and• the overall presentation of the financial statements gives a true and fair view.

We also read the remainder of the Annual Report to check it is consistent with our understanding of the Trust and with the financial statements included in the Annual Report on which we gave our opinion.

We carry out our audit in accordance with ISAs (UK) and the NAO Code of Audit Practice. We believe that the audit evidence we have obtained is sufficient and appropriate to provide a basis for our opinion.

Our audit approach was based on a thorough understanding of the Trust's business and is risk based.

We identified key risks and set out overleaf the work we performed in response to these risks and the results of this work.

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Audit of the Financial StatementsKey Audit MattersThese are the risks which had the greatest impact on our overall strategy and where we focused more of our work.

Risks identified in our audit plan How we responded to the risk Findings and conclusions

Covid–19

The global outbreak of the Covid-19 virus pandemic has led to unprecedented uncertainty for all organisations, requiring urgent business continuity arrangements to be implemented. We expect current circumstances will have an impact on the production and audit of the financial statements for the year ended 31 March 2020, including and not limited to;

- Remote working arrangements and redeployment of staff to critical front line duties may impact on the quality and timing of the production of the financial statements, and the evidence we can obtain through physical observation

- Volatility of financial and property markets will increase the uncertainty of assumptions applied by management to asset valuation and receivable recovery estimates, and the reliability of evidence we can obtain to corroborate management estimates

- Financial uncertainty will require management to reconsider financial forecasts supporting their going concern assessment and whether material uncertainties for a period of at least 12 months from the anticipated date of approval of the audited financial statements have arisen; and

- Disclosures within the financial statements will require significant revision to reflect the unprecedented situation and its impact on the preparation of the financial statements as at 31 March 2020 in accordance with IAS1, particularly in relation to material uncertainties.

We therefore identified Covid-19 as a significant risk, which was one of the most significant assessed risks of material misstatement.

Our audit work included, but was not restricted to:

• Documenting and understanding the implications that Covid-19 pandemic has had on the Trust’s ability to prepare the financial

statements and updates to financial forecasts

• Liaison with other audit suppliers, regulators and government departments to co-ordinate practical cross sector responses to issues as and when they arise.

We have evaluated:

• the adequacy of the disclosures in the financial statements relating to the impact of the Covid-19 pandemic.

• whether sufficient audit evidence can be obtained in the absence of physical verification of assets through remote technology.

• whether sufficient audit evidence can be obtained to corroborate significant management estimates such as asset valuations and recovery of receivable balances.

• management’s assumptions that underpin the

revised financial forecasts and the impact on management’s going concern assessment.

We obtained sufficient audit assurance to conclude that:• The Trust’s disclosures are

in line with the DHSC guidance relating to the impact of the Covid-19 pandemic.

• Financial forecasts and the cashflow analysis of the Trust supports the ability for the Trust to prepare the accounts on a going concern basis.

• The Trust has appropriately disclosed the material uncertainty regarding the valuation of the Trust’s

property, plant and equipment which has been emphasised as a Key Audit matter in the Audit Report.

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Audit of the Financial StatementsKey Audit Matters - continuedThese are the risks which had the greatest impact on our overall strategy and where we focused more of our work.


Revenue recognition

Trusts are facing significant external pressure to restrain budgetoverspends and meet externally set financial targets, coupled withincreasing patient demand and costs pressures. In this environment,we have considered the rebuttable presumed risk under ISA (UK)240 that revenue may be misstated due to the improper recognitionof revenue.We have rebutted this presumed risk for the revenue streams of theTrust that are principally derived from contracts that are agreed inadvance at a fixed price. We have determined these to be incomefrom:• Block contract income element of patient care revenues.We have not deemed it appropriate to rebut this presumed risk for allother material streams of patient care income and other operatingrevenue.The block contracts include the rates for and level of patient careactivity to be undertaken by the Trust. The Trust recognised patientcare activity income during the year based on the completion ofthese activities. Patient care activities provided that are additional tothose incorporated in these contracts (e.g. contract variations) aresubject to verification and agreement by the commissioners and mayinclude estimates. As such, there is the risk that income isrecognised in the accounts for these additional services that is notsubsequently agreed to by the commissioners.We have therefore identified the occurrence and accuracy of theseincome streams of the Trust and the existence of associatedreceivable balances as a significant risk, which was one of the mostsignificant assessed risks of material misstatement and a key auditmatter.

Our audit work included, but was not restricted to::• Evaluating the Trust’s accounting policy for recognition

of income from patient care activities and other operating revenue for appropriateness and compliance with the DHSC Group Accounting Manual 2019/20 ;

• Updating our understanding of the Trust's system foraccounting for income from patient care activities andother operating revenue, and evaluated the design ofthe associated controls;

• Reviewing the DHSC mismatch report for unmatchedbalances over the NAO reporting threshold of £0.3m.There were three unmatched balances over £0.3mwhere the Trust was the Income Body and oneunmatched balance where the Trust was theExpenditure Body. We obtained explanations for all thebalances and in one case the Trust adjusted the balanceto correct the Expenditure Body. For the remainingbalances we have gained assurance that the balancesare correctly stated.

• Agreeing a sample of contract variations to signeddocumentation, invoices or other supporting evidence.

• Agreeing a sample of other operating revenue toinvoices and other supporting evidence.

Review of accounting policies and consideration of accounting systems and controls has not identified any significant issues to report. We have, as in the prior year, noted that income contracts with Informatics Merseyside were not signed.

Key observationsWe obtained sufficient audit evidence to conclude that:• The Trust’s accounting policy

for recognition of operating income complies with the DHSC Group Accounting Manual 2019-20 and has been properly applied.

• Revenue is not materially misstated.

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Audit of the Financial StatementsKey Audit Matters - continuedThese are the risks which had the greatest impact on our overall strategy and where we focused more of our work.


Valuation of land and buildingsThe Trust revalues it’s land and buildings on an annual basis to ensure the

carrying value is not materially different from current value at the financial statements date. This valuation represents a significant estimate by management in the financial statements.

Management engage the services of a qualified valuer, who is a Regulated Member of the Royal Institute of Chartered Surveyors (RICS), to estimate the current value of its land and buildings. The last full valuation was as at 31 March 2017.

For 2019-20, a desktop valuation has been undertaken. The valuation represents a significant accounting estimate by management in the financial statements, which is sensitive to changes in assumptions and market conditions.

The effects of the COVID-19 virus will affect the work carried out by the Trust’s valuer in a variety of ways. Inspecting properties could prove difficult

and access to evidential data, such as values of comparable assets may be less freely available. RICS Regulated Members have therefore been considering whether a material uncertainty declaration is now appropriate in their reports. Its purpose is to ensure that any client relying upon the valuation report understands that it has been prepared under extraordinary circumstances.

In their 2019/20 valuation report the Trust’s valuer, Cushman & Wakefield

included a material uncertainty and this was disclosed in note 1 to the financial statements.

We therefore identified valuation of land and buildings as a significant risk, which was one of the most significant assessed risks of material misstatement.

In responding to the identified risk we have:• Evaluated management’s processes and

assumptions for the calculation of the estimate, the instructions issued to the valuation experts and the scope of their work;

• Evaluated the competence, capabilities and objectivity of the valuation expert;

• Written to the valuers to confirm the basis on which the valuations were carried out;

• Challenged the information and assumptions used by the valuer to assess completeness and consistency with our understanding;

• Tested, on a sample basis, revaluations made during the year to ensure they have been input correctly into the Trust’s asset register; and

• Evaluated the assumptions made by management for any assets not revalued during the year end how management has satisfied themselves that these are not materially different to current value.

The Trust’s valuer prepared their valuations in

accordance with the RICS Valuation – Global Standards using the information that was available to them at the valuation date in deriving their estimates.

See overleaf

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Audit of the Financial StatementsKey Audit Matters - continued

These are the risks which had the greatest impact on our overall strategy and where we focused more of our work..


Valuation of land and buildings - continued The Trust’s accounting policy on valuation of property,

including land and buildings, is disclosed in note 1.8 to the financial statements and related disclosures are included in note 15.1

As, disclosed in note 1.8 to the financial statements, the valuation exercise was carried out in March 2020 with a valuation date of 31 March 2020. in applying the Royal Institute of Chartered Surveyors (RICS) Valuation Global Standards 2020 ('Red Book'), the valuer has declared a material valuation uncertainty' in their valuation report. This is on the basis of uncertainties in the markets caused by Covid-19. The values in the report have been used to inform the measurement of property assets at valuation in the financial statements. With the valuer having declared this material valuation uncertainty, the valuer has continued to exercise professional judgement in providing the valuation and believes this remains the best information available to the Trust.

Our audit work identified some inconsistencies between the floor areas of assets sampled from the valuation report and the records of the Trust, however this did result in a material error in the financial statements.

We obtained sufficient and appropriate audit assurance to conclude that:• the basis of the valuation of land and

buildings was appropriate• the assumptions and processes used

by management in determining the estimate of valuation of property were reasonable.

• the valuation of land and buildings disclosed in the financial statements is reasonable.

The uncertainties disclosed within the financial statements relating to the valuation of land and buildings as at 31 March 2020 were reported within the key audit matter section within our audit opinion.

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Audit of the Financial StatementsKey Audit Matters - continued

These are the risks which had the greatest impact on our overall strategy and where we focused more of our work..


Management override of controlsUnder ISA (UK) 240 there is a non-rebuttable presumed risk that the risk of management over-ride of controls is present in all entities. The Trust faces external pressures to meet agreed targets, and this could potentially place management under undue pressure in terms of how they report performance.

We therefore identified management over-ride of control, in particular journals, management estimates and transactions outside the course of business as a significant risk, which was one of the most significant assessed risks of material misstatement..

In responding to the identified risk we have:

• Evaluated the design effectiveness of management controls over journals;

• Analysed the journals listing and determine the criteria for selecting high risk unusual journals;

• Tested a sample of unusual journals made during the year and after the draft accounts stage for appropriateness and corroboration;

• Gained an understanding of the accounting estimates and critical judgements applied made by management and consider their reasonableness; and

• Evaluates the rationale for any changes in accounting policies, estimates or significant unusual transactions.

Our audit work in this area and in respect of the other areas identified above has, not identified any issues in respect of management override of controls.

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Audit of the Financial StatementsAudit opinionWe gave an unqualified opinion on the Trust’s financial statements on 24

June 2020.

Preparation of the financial statements

The Trust presented us with draft financial statements close to the revised national deadline and in accordance with pandemic lockdown restrictions that existed at the time, and provided a good set of working papers to support them. Whilst he finance team responded promptly to our queries remotely during the course of the audit, there was an increase in the number of queries raised on the working papers provided than in the previous year which resulted in a lengthier audit period and resulting additional fees

Issues arising from the audit of the financial statements

We reported the key issues arising from our audit for the significant risks identified as detailed previously on pages 5 to 10 to the Trust’s virtual Audit

Committee in June 2020. In addition to these key issues we also reported the adjustments made to the Trust’s financial statements for the following:

• The Trust had reclassified several assets to Assets Held for Sale due to the anticipated sale of them. Guidance on the valuation of such assets is that they should be held at the lower of carrying value or fair value less costs to sell. It was identified that the Trust has increased the value of two assets by a total of £1.3m on reclassification. The error was amended for with the result being a reduction in the surplus of £1.25m but no overall impact on the control total.

• The Trust had incorrectly classified income accruals in relation to matching expenditure which did not occur during 2019/20. The adjustment was made to reduce other operating income and operating expenses by £0.958m. This had no overall impact on the control total.

Annual Report, including the Annual Governance Statement We are also required to review the Trust's Annual Report, including the Annual Governance Statement. The Trust provided these on a timely basis with the draft financial statements with supporting evidence.

Whole of Government Accounts (WGA) We issued a group return to the National Audit Office in respect of Whole of Government Accounts, which did not identify any issues for the group auditor to consider.

Other statutory powers We are also required to refer certain matters to the Secretary of State under schedule 10 (6) of the National Health Service Act 2006. No other statutory powers were exercised.

Certificate of closure of the auditWe certified that we have completed the audit of the financial statements of Mersey Care NHS Foundation Trust in accordance with the requirements of the Code of Audit Practice on 24 June 2020.

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Value for Money conclusion

BackgroundWe carried out our review in accordance with the NAO Code of Audit Practice, following the guidance issued by the NAO in April 2020 which specified the criterion for auditors to evaluate:In all significant respects, the audited body takes properly informed decisions

and deploys resources to achieve planned and sustainable outcomes for

taxpayers and local people.

Key findingsOur first step in carrying out our work was to perform a risk assessment and identify the risks where we concentrated our work.

The risks we identified and the work we performed are set out overleaf.

Overall Value for Money conclusionWe are satisfied that in all significant respects the Trust put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2020.

We are satisfied that, in all significant respects, the Trust put in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources for the year ending 31 March 2020.

.

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Value for Money conclusionValue for Money Risks


Estates StrategyThe Trust has an extensive capital programme in place with the total value of capital investment forecast in 2019/20 of £54m. The Trust does have an agreed £60m capital financing facility in place, however the estates strategy will require further investment which will take the Trust beyond its borrowing limits. Where external funding is required for new strategic capital schemes post 2019/20, approval will be needed from the Cheshire and Merseyside Sustainability and Transformation Partnership (STP). The Trust needs to ensure that the operational and services strategies align with the estates strategy so that planned developments continue to be fit for purpose. .

Our review of the Trust’s arrangements for securing

economy, efficiency and effectiveness in its use of resources identified the following matters:• The Trust has an approved Estates Strategy in

place that is clearly linked to its operational and overall strategic plans.

• Progress on the capital investment has been monitored throughout the year and reported to the Performance, Investment and Finance Committee and the Board.

• The Trust is working closely with colleagues in Cheshire and Merseyside to enable consolidation of estate across the two Counties and to ensure that the Trust’s developments are reflected in

their capital planning..• The capital commitment in relation to the estates

strategy is included in the 2020/21 financial plan. The Trust has sufficient borrowing capacity to facilitate the capital build.

No issues have been identified that would suggest that the Trust does not have adequate arrangements in place for delivering economy, efficiency and effectiveness in the use of its resources.

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A. Reports issued and feesWe confirm below our final reports issued and fees charged for the audit and provision of non-audit services.

Fees

Planned£

Actual fees £

2018/19 fees£

Statutory audit 55,650 61,350 48,900

Review of Quality Report 5,700 - 5,700

Total fees 61,350 61,350 54,600

The additional fees included in the actual fees are as a results of the additional audit procedures performed due to Covid-19 pandemic.

Reports issued

Report Date issued

Audit Plan and addendum February and April 2020

Audit Findings Report June 2020

Annual Audit Letter July 2020

Fees for non-audit services

Service Fees £

Audit related services - None

Nil

Non- audit services

No non - audit services were carried out for the Trust as a result of the requirement to carry out a review of the quality report being removed.

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© 2020 Grant Thornton UK LLP. All rights reserved.

‘Grant Thornton’ refers to the brand under which the Grant Thornton member firms provide assurance, tax and advisory services to their clients and/or refers to one or more member firms, as the context requires.

Grant Thornton UK LLP is a member firm of Grant Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. GTIL and each member firm is a separate legal entity. Services are delivered by the member firms. GTIL does not provide services to clients. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions.

grantthornton.co.uk

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Report provided (check necessary boxes): Report to: Board of Directors To Note: ☒ For Assurance: ☒

Meeting Date: 29 July 2020

Minutes of Board of Directors Committees and of the Council of Governors (including Chairs’ Reports)

Page Name of Board Committee (Chair) Date of the Board Committee Meeting

Approved

Yes No

2 Audit Committee – via Email process (Mrs P Williams)

May 2020 ☐ ☒

10 Quality Assurance Committee (Mr Hales) 13 May 2020 ☐ ☒

23 Resources Committee (formerly Performance, Investment & Finance Committee) (Mr Williams)

19 June 2020 ☐ ☒

38 People Committee (Miss O’Dwyer) 19 June 2020 ☐ ☒

Recommendation: The Board is asked to note the contents of these Committee minutes and the accompanying reports from the respective Chairs.

This report was compiled by

Paula Murphy Corporate Governance Compliance Manager Tel: 0151 472 4042

July 2020

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CHAIR’S REPORT AND MINUTES FOR THE

Audit Committee

Date of Meeting: May 2020 Chair: Mrs P Williams

Summary of key issues from this meeting: This was a ‘Virtual by Email’ meeting in light of the COVID-19 outbreak. Any items deferred from the agenda due to pressures on teams, were included in the Committee action log to ensure continuity and an audit trail. The Audit Committee received an update in respect of: • The Trust’s consideration of recent developments and publications as identified by Grant

Thornton in their recent update report (April 2020). Emerging issues outlined had been issued to the relevant staff across the Trust who were charged with governance and actions taken were detailed in the report provided;

• The Trust’s Annual Accounts for the year ended 31 March 2020. Audited accounts would be presented for approval to the Audit Committee and Board of Directors in June 2020 with the final accounts being submitted to NHS Improvement midday on 25 June 2020;

• Tender Waivers in accordance with the Trust’s Standing Financial Instructions;

The Audit Committee discussed and noted the following: • An update on the national guidance for submission of the 2019/20 Annual Report and

Annual Accounts due to COVID-19; • The Internal Audit Annual Report and Head of Internal Audit Opinion, noting that the

report would assist the Board in the completion of its Annual Governance Statement (AGS), along with considerations of organisational performance, regulatory compliance, the wider operating environment and health and social care transformation;

The Audit Committee Approved the following: • The Anti-Fraud Annual Report which outlined the work plan delivered for 2019/20;

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Status of these minutes (check one box): Report to: Audit Committee

Draft for Approval: ☒

Formally Approved: ☐ Meeting Date: August 2020


Audit Committee Date: 20 May 2020 Time: Virtual by Email

Venue: Virtual by Email Meeting. Papers sent out on 19 May 2020 with responses requested by 27 May 2020.


Present (Papers Circulated To): Pam Williams Murray Freeman Gerry O’Keeffe

Non-Executive Director (Chair) Non-Executive Director Non-Executive Director

In Attendance(Papers Circulated To): Kevin Knowlson Trish Bennett Noir Thomas Neil Smith Gaynor Hales Aislinn O’Dwyer Nick Williams Rob Collins Steven Parker Gary Baines Kath Stott Michael Green Naomi Povey Clare Smallman Andy Meadows Sarah Jennings Paula Murphy

Service User / Carer Representative Executive Director of Nursing and Operations Interim Medical Director Executive Director of Finance / Deputy Chief Executive Non-Executive Director Non-Executive Director Non-Executive Director Chief Finance Officer Associate Director of IT Mersey Internal Audit Agency Mersey Internal Audit Agency Grant Thornton Grant Thornton Mersey Internal Audit Agency Trust Secretary Deputy Trust Secretary Corporate Governance Compliance Manager

Apologies Received:

ISSUES CONSIDERED 2020 In light of social distancing measures due to the COVID-19 outbreak, this meeting was a virtual meeting held by email. Members were asked to provide feedback/questions within one week from circulation of papers. All questions and the responses provided are included in the minutes of the meeting below.

Any items deferred from the agenda have been included in the action log to ensure continuity.

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A1 APOLOGIES FOR ABSENCE

1. The apologies for absence received were noted as detailed above.

A2 DECLARATIONS OF INTEREST

2. There were no declarations of interest.

A3 MINUTES OF THE PREVIOUS MEETING HELD ON 15 APRIL 2020

3. The minutes of the previous meeting were accepted as a true and accurate record.

4.


Recommendations approved by the Board, namely: • Approve the minutes of the previous meetings;


A4 AUDIT COMMITTEE ACTION LOG

5. Mrs Williams stated that the issues regarding clinical audit were included on the May 2020 agenda for the Quality Assurance Committee but were deferred until the July meeting, adding that this was an important area of concern and would not want to see this deferred again.

6. Dr Freeman agreed that focus needed to remain on clinical audit and also the Trust’s Mortality policy.

7. Mrs Williams asked the following question: There is a red item regarding the Protocol to Identify Service Users at Risk of Fraud Incidents. The audit of protocol is not reflected in MIAA 20/21 Plan. What is the proposal for addressing this issue?

8. Mr Baines provided the following response: This was not in the plan currently. I will liaise with Claire Smallman as the issue arose from a fraud investigation, to see if this will be picked up as part of the fraud plan 2020/21. Should this not be the case then I will discuss this with Mr Collins on Monday to revisit the plan in light of COVID-19 to review the topics in the plan to make sure they are still the correct areas to focus on and the timing of the work. I will discuss this issue with Mr Collins and if need be, build this into the plan, to ensure we do not lose sight of the issue. This will be picked up in 20/21, which we can do as an early priority.

9. The Committee noted the action log.

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10.


Recommendations approved by the Board, namely: • Note the action log.

Further actions required: • Ensure Clinical Audit issues are included on July

2020 QAC agenda; • Review MIAA 20/21 Plan in light of COVID-19 and

include an audit of protocol to identify service users at risk of fraud incidents;

A Meadows G Baines

July 2020 Jun 2020

On July 2020 QAC agenda By Jun 2020

A5 MATTERS ARISING

11. There were no matters arising.

B1 BOARD ASSURANCE FRAMEWORK

12. Deferred to a future meeting (tbc) – pressure on service.

B2 ANNUAL REPORT AND ANNUAL GOVERNANCE STATEMENT

13. Mr Meadows provided the Committee with an update on the national guidance for submission of the 2019/20 Annual Report and Annual Accounts due to COVID-19.

14. Mrs Williams stated that the Annual report was a good reminder of all the achievements in the past year and offered thanks to all.

15. Mrs Williams referred to paragraph 163 in the report, and asked that alternative wording be found to replace ‘drafted in’.

16. Mr O’Keeffe stated that he was happy to have a Zoom or email meeting in June 2020 to confirm the Annual Report.

17. Mr O’Keeffe asked that page 130 was amended to note he did attend the teleconference Board of Directors meeting on 25 March 2020.

18. Action Lead Timescale Status Recommendations approved by the Committee,

namely: • consider and comment on the draft Annual Report; • consider the proposal to ensure the approval of the

Annual Report by both this Committee and the Board of Directors.

Further actions required: • Use alternative wording to replace ‘drafted in’ in

paragraph 163 of the report; • Update page 130 to include GOK in attendance of

Mar-20 Board;

A Meadows A Meadows

May 2020 May 2020

By end May 2020 By end May 2020

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B3 MIAA MORTALITY REVIEW – MANAGEMENT RESPONSE AND ACTION PLAN


B4 MIAA REVIEW COMMUNITY SERVICES (CEDAS) – MANAGEMENT REVIEW AND ACTION PLAN


C1 INTERNAL AUDIT

a) Annual Report & Head of Internal Audit Opinion 2019-20

21. Mr Baines provided the Committee with the Head of Internal Audit Opinion which contributed to the assurances available to the Accountable Officer and the Board which in turn underpinned the Board’s own assessment of the effectiveness of the organisation’s system of internal control. The report would assist the Board in the completion of its Annual Governance Statement (AGS), along with considerations of organisational performance, regulatory compliance, the wider operating environment and health and social care transformation.

22. Mrs Williams referred to section 5, areas for Board attention and asked that this be cross referenced to the Annual Governance Statement to ensure all these were covered.

23. Mrs Williams noted the need to maintain overview of the internal audit work plan in

light of COVID-19.

24. Action Lead Timescale Status Recommendations approved by the Committee,

namely: • Note this annual report and consider and note the

Head of Internal Audit Opinion.

Further actions required: • Section 5 of the report, areas for Board attention,

ensure this is cross referenced to the AGS;

A Meadows

Jun 2020

By Jun 2020

C2 ANTI-FRAUD ANNUAL REPORT

25. Mrs Smallman provided the Committee with the Anti-Fraud Annual Report which outlined the work plan delivered for 2019/20. Work undertaken included:

a) The AFS has continued to either personally deliver activities, or provide support to the Trust, to ensure coverage against each of the NHS CFA Standards for Providers;

b) The AFS is to submit a self-assessment against the NHS CFA Standards for Providers which has resulted in an overall ‘GREEN’ rating. This will be submitted in line with the deadlines specified by the CFA 31/5/2020;

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c) The AFS has delivered a range of awareness presentations and activities across the organisation;

d) During the year the AFS has issued guidance and briefings on a number of fraud related topics to the Trust;

e) A series of information alerts and bulletins have been issued, and where appropriate action take to ensure that the Trusts were not exposed to potential fraud risks;

f) The AFS has ensured that National Fraud Initiative notifications were issued to staff as per the fair processing requirements;

g) Joint AFS/IA detection exercise was undertaken during the year; h) A range of advice and support was provided to the Trust; i) Assessments of fraud referrals were undertaken; j) A number of investigations have been progressed during the year one

progressing for consideration for prosecution.

26. Mrs Williams asked the following question: Regarding the amber standard on page 4, can this be checked to ensure it’s included on the risk register as required?

27. Mr Westhead provided the following response:

There has been some delay in getting the fraud risks finalised on the register due to Emergency planning commitments, however I am meeting with Claire Smallman from MIAA today to review and hope to get these signed of by the responsible Executive by the end of the month.

28. Mrs Smallman also responded:

I can now confirm that this has been included and I will be changing the rating from amber to green for the self-review submission.

29.


Recommendations approved by the Committee, namely: • Review and approve the Anti-Fraud Annual report for

2019/20.

Further actions required: • Ensure amber standard on page 4 is included on the

risk register as required;

N Thomas (F Westhead/ C Smallman)

May 2020

Completed.

D1 EXTERNAL AUDIT ISSUES / DEVELOPMENTS LOG

30. Mr Smith provided an update on the Trust’s consideration of recent developments and publications as identified by Grant Thornton in their recent update report (April 2020). The emerging issues and developments outlined within the report had been issued to the relevant staff across the trust, who were charged with governance, and action taken to date was detailed in Appendix A of the report.

31. Mr O’Keeffe welcomed the comprehensive responses.

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32.


Recommendations approved by the Committee, namely: • Note the contents of the report;

Further actions required: • None identified

E1 ANNUAL ACCOUNTS

33. Mr Smith provided the Committee with the Trust’s Annual Accounts for the year ended 31 March 2020. The draft accounts were subject to review by the Trust’s external auditors, Grant Thornton and the audited accounts would be presented for approval to the Audit Committee and Board of Directors in June 2020. The final accounts would be submitted to NHS Improvement midday on 25 June 2020.

34. Mr O’Keeffe welcomed the report and offered congratulations to all.

35.


Recommendations approved by the Committee, namely: • Note the draft accounts for the year ended 31 March 2020. • Note the ongoing review of the draft accounts by the trust’s

external auditors – Grant Thornton.


E2 TENDER WAIVERS

36. Mr Smith provided the Committee with an update on tender waivers in accordance with the Trust’s Standing Financial Instructions.

37. The report detailed one tender waiver application which had been approved during the reporting period January 2020 to March 2020 amounting to £35,116.00 + VAT, the supplier being A & AH Limited. This supplier was supporting the finance team in long term finance modelling for various projects such as the LSU Business Case, financial planning and latterly the potential acquisition of North West Boroughs Healthcare NHS Foundation Trust.

38.


Recommendations approved by the Committee, namely: • Note the contents of the report.


F1 ANY OTHER BUSINESS

39. There was no other business identified

F2 RISK REFLECTION

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40. The following issues were highlighted: a) Items deferred to future meeting to go on action log; b) Amber standard (item C2) to be included in risk register; c) Note need to maintain overview of internal audit work plan in light of COVID-19;

F3 MEETING REFLECTION

41. Mrs Williams asked that it be noted that from June 2020, all Audit Committees will be virtual meetings by Zoom.

42. There was no further business to discuss.


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Quality Assurance Committee

Date of Meeting: Wednesday 13 May 2020 Chair: Mrs Hales

Summary of key issues from this meeting: This was a ‘Virtual by Email’ meeting in light of the COVID-19 outbreak. Any items deferred from the agenda due to pressures on teams, were included in the Committee action log to ensure continuity and an audit trail. The Quality Assurance Committee received assurance in respect of: • Implications of COVID on quality of care, a briefing was circulated to the Committee

which allowed members to receive an update on COVID-19 development, responses, impact on services offered and actions taken within the Trust and the wider system. The update also included Infection Prevention and Control work/plans and next steps for recovery;

• Minutes and Chair’s reports for Sub-Committees;

The Quality Assurance Committee discussed and noted: • An overview of assurance on a range of patient safety issues, including issues of

concerns/good practice; • A summary of COVID-19 Trust performance from 27 April 2020 to 10 May 2020 against

key performance metrics; • An update on quarter 4 performance activity and feedback from the Clinical

Commissioning Group in relation to Safeguarding, including and update on Children in Care and actions;

• An overview of the Trust’s 2019 PLACE (Patient-Led Assessment of the Care Environment) including information detailing how performance compared nationally against other mental health and learning disability trusts along with steps that will be taken to address any identified issues;

• A detailed report which included the type and learning from complaints and concerns that had occurred during 2019/2020 in accordance with Care Quality Commission guidance;

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Draft for Approval: ☒ Report to: Quality Assurance Committee

Formally Approved: ☐ Meeting Date: July 2020

MINUTES OF THE MEETING OF THE Quality Assurance Committee

Date: Wednesday 13 May 2020 Time: Virtual

Venue: Virtual by Email Meeting. Papers sent out on 11 May 2020 with responses requested by 18 May 2020.


Present: Gaynor Hales Murray Freeman Aislinn O’Dwyer Trish Bennett Noir Thomas Amanda Oates

Non Executive Director (Chair) Non Executive Director Non Executive Director Executive Director of Nursing and Operations Medical Director Executive Director of Workforce

In Attendance: Joanne Bull Fran Cairns Elaine Darbyshire Beatrice Fraenkel Sandra O’Hear Gerry O’Keeffe Joe Rafferty Neil Smith Lee Taylor Nick Williams Pam Williams Steve Appleton Steve Bradbury Bridget Clancy Mandi Gregory Mel Higgins Jenny Hurst Dave Jones Chris Lyons Steve Morgan Kuben Naidoo Nicky Ore Asim Patel Zoe Prince Lynda Taylor Gayle Wells Frank Westhead Andy Meadows Paula Murphy

Associate Director of Patient Safety and Patient Experience Deputy Director of Therapies and Allied Health Professionals Executive Director of Corporate Governance and Communications Chairman Deputy Director of Nursing Non Executive Director Chief Executive Executive Director of Finance / Deputy CEO Chief Operating Officer & Director of Integration Non Executive Director Non Executive Director Deputy Chief Information Officer, Informatics and Performance Director Deputy Director of Improvement & Innovation Associate Director of Nursing and Patient Experience Chair of Staff Side Associate Medical Director Deputy Director of Nursing Deputy Chief Operating Officer, Community Division Director of Corporate Transformation Associate Director of Nursing Consultant Head of Clinical Governance Joint Chief Information Officer Associate Director of Nursing and Patient Experience Associate Director of Nursing and Patient Experience Strategic Head of Financial Management Trust Risk Manager Trust Secretary Corporate Governance Compliance Manager

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Apologies Received: ISSUES CONSIDERED 2020 In light of social distancing measures due to the COVID-19 outbreak, this meeting was a virtual meeting held by email. Members were asked to provide feedback/questions within one week from circulation of papers. All questions and the responses provided are included in the minutes of the meeting below.

Any items deferred from the agenda have been included in the action log to ensure continuity.


1. The apologies for absence received for this meeting were detailed above.


2. There were no declarations of interest.

A3 MINUTES OF THE PREVIOUS MEETING : 11 MARCH 2020

3. The minutes of the previous meeting held on 11 March 2020 were accepted as an accurate record.

4.


Recommendations approved by the Committee, namely: • Approve the minutes of the previous meeting.


A4 COMMITTEE ACTION LOG

5. The Committee reviewed and accepted the action log.

6.


Recommendations approved by the Committee, namely: • Note the action log;


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A5 MATTERS ARISING

a) Kirkup Independent Inquiry Update;

7. Deferred to a future meeting (tbc) - the Inquiry has been suspended due to the COVID-19 outbreak.

8. Following circulation of the Committee papers, Mrs Hales confirmed she had spoken to Mrs T Bennett as her overall concern was clarity with regards to the implications of COVID-19 on the quality of care. Mrs T Bennett provided a briefing (circulated via email on 15 May 2020) which allowed members of the Committee to receive an update on the COVID-19 development, responses, impact on services offered and actions taken within the Trust and the wider system. The briefing also included an update on Infection Prevention and Control work/plans and the planned next steps for recovery.

B1 CARE QUALITY COMMISSION ACTION PLAN UPDATE

9. Deferred to a future meeting (tbc) – pressure on service. B2 SAFETY REPORT

10. Dr Thomas provided an overview of assurance on a range of patient safety issues, including issues of concerns/good practice.

11. Miss O’Dwyer referred to paragraph 45 of the report noting she was pleased to note additional capacity had been identified to support the increase in requests with regard to inquest data.

12. The following questions/answers were received via email:

13. Miss O’Dwyer asked the following question:

a) Point 22. Is there a restart date for serious incident (SI) reviews?

14. Mrs Bull provided the following response: No date has been finalised yet to resume SI reviews. We maintain regular contact with the team at the CCG and maintain updates as required by the NHS Standard contract. The patient Safety Team had surplus monies in the legal budget so have purchased a service offered by Hill Dickinson Solicitors to assist with ‘RCAs’. They will be able to complete the timeline; undertake interviews and produce completed reports. This will enable us to restart the SI review process with involvement from clinicians without the administrative burden.

15. Miss O’Dwyer asked the following question: b) Point 34. Profile of patient harm - Can I clarify if this includes inpatients and

outpatients/community? As we move patients out of inpatient facilities, are we capturing harm taking place at home/other settings?

16. Mrs Bull provided the following response: Yes this includes the inpatient and community data in an aggregated format – below is the data for AMH services with highest rates of harm separating the community and inpatient services. Whilst harm rates for inpatient services do not appear to have

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increased this has to be countered with reduced bed occupancy so in relation to activity it is a relative increase. However, there is less people coming in to hospital and relying on community services so positive to note less incidents of serious harm during this pandemic period.

AMH Inpatient Highest Profile of Harm 2019 Q4

2020 Q4

Moderate Harm 19 17 • Deterioration of Physical Health 3 1 • Overdose 3 • Assault 3 1 • Cutting scratching or piercing 2 7 • Ligature 1 1 • Present on admission 1 • Fall from a Height 1 • Missing Patient Low Secure and PICU 1 • Unexpected Diarrhoea and or Vomiting 1 • Fall 1 2 • insertion or swallowing objects 1 1 • Fire or Burning 1 • Failure of Service Provision 1 • Seizure or Fit 1 • Coronavirus 1 • Medical/Clinical Emergency (Including physical injuries, cardio

pulmonary arrest, allergies, resuscitation incidents etc) 1

Severe Harm 1 3 • Cutting scratching or piercing 1 • Medical/Clinical Emergency (Including physical injuries, cardio


• Other self harm 1 • Delay in treatment 1

Death Caused by incident 2 • Missing Non-Secure Services 1 • Adult unexpected death 1

Grand Total 22 20

AMH Community Highest Profile of Harm 2019 Q4

2020 Q4

Death Caused by incident 11 7 • Adult unexpected death 11 7

Moderate Harm 5 3 • Overdose 2 2 • Seizure or Fit 1 • Found on Ground 1 • Medical/Clinical Emergency (Including physical injuries, cardio


• Burning or scalding 1

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AMH Community Highest Profile of Harm 2019 Q4

2020 Q4

Severe Harm 2 2 • ligature from a point 1 • Assault 1 • Other Accident / Injury 1 • Jumping from a height 1

Grand Total 18 12

17. Miss O’Dwyer made the following comment: c) Point 45. I’m pleased to note additional capacity has been identified to support

increase in inquests.

18. Miss O’Dwyer asked the following question: d) Point 47. What is the meaning/definition of “narrative” in relation to inquest

conclusions?

19. Mrs Bull provided the following response: There is no definitive list of conclusions available to a Coroner. The following re those most commonly used:

o natural causes (including fatal medical conditions); o accident or misadventure; o industrial disease; o dependence on drugs/non-dependent abuse of drugs; o attempted/self-induced abortion; o disasters subject to public inquiry; o lawful killing (such as deaths caused during acts of war, or self-defence); o unlawful killing; o suicide; o open verdict (where there is insufficient evidence for any other verdict). o The commencement of the provisions in the Coroners and Justice Act 2009

have added some further possible conclusions to this list: o alcohol/drug related death, and o road traffic collision.

20. Coroners or a jury may also deliver a 'narrative' conclusion which sets out the facts surrounding the death in more detail. This longer explanation will include the coroner's or jury's conclusions on the main issues arising in the surrounding circumstances of the death. The Coroner is also not bound by the list of suggested conclusions above; this means that as long as the Coroner can form a conclusion which is concise and indicates how the deceased came by their death, a narrative verdict is acceptable. The Coroner is unable to apportion any blame or civil or criminal liability of another individual (as defined by section 10(2) of the Coroners and Justice Act 2009).

21.


Recommendations approved by the Committee, namely: • Discuss the report; • Identify any new risks; • Identify an further assurances it required;


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B3 EXECUTIVE PERFORMANCE REPORT

22. Mr Patel provided a summary of COVID-19 Trust performance from 27 April 2020 to 10 May 2020 against key performance metrics.

23. Miss O’Dwyer referred to paragraph 44 of the report, stating it was good to see the number of ligature incidents had decreased as concerns were raised at the Resources Committee with regard to increasing numbers.

24. Mrs Hales asked the following question: Agency spend - could we break this down to understand what proportion is related to the impact of COVID19 including cover for staff sickness.

25. Mrs Oates provided the following response: The Trust has seen a large increase in request for agency staff due to COVID-19 during the month of April 2020 compared to March in Local Division and the SLD part of Secure/SLD Division for Health Care Assistants (HCA), Qualified Nurses in Community Division and FMA’s in Corporate Division.

26. The non COVID request have significantly reduced in Local Division in April compared to March for both HCA, however there were still a small number of requests for Qualified Nurses. Community have remained static with requests for Qualified Nurses as have SLD with requests for HCA’s.

27. Mrs Hales asked the following question: Are there any areas where as a result of high agency spend there was an impact on care quality due to lack of continuity.

28. Mrs Robinson provided the following response: Local Division: For local division, no safety issues have been escalated via our daily safety huddles to indicate any correlation between agency use and safety issues. We continue to monitor agency spend as part of our usual business activities. We are completing a desk top review of staffing following the changes to wards in line with our Covid-19 response (creation of admission wards and reduced beds in wards with dormitories). We have also undertaken some scoping work with recruitment and finance to forward plan to September when our current nursing students (working as either band 3 or band 4 staff in in-patient areas) will return to university or qualify as registered nurses to ensure we are ahead of the potential vacancy issues which impact on use of additional hours (bank and agency).

29. Mr Newton provided the following response: Secure Division: For Secure and SPLD, there has not been an increase in agency costs. We have in the main used our internal bank staff system which has been in operation for many years. The agency staff we do utilise are fairly static and well known to service and the service users, there has been no impact on quality

30. Mr Taylor provided the following response: Community Division: There is no correlation between quality of care being compromised in relation to use of agency in Integrated Community Nursing and Walk

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In Centre’s – there are no trends. Where agency staff are used we ensure there is a skill mix of regular staff to ensure continuity of care.

31.


Recommendations approved by the Committee, namely: • Note the assessment of performance against key

performance metrics.


C1 QUARTERLY SAFEGUARDING UPDATE (INCLUDING UPDATE ON CHILDREN IN CARE)

32. Mrs O’Hear provided an update on quarter 4 performance activity and feedback from the Clinical Commissioning Groups, noting the removal of the performance improvement notice along with an update regarding Children in Care and related actions.

33. The following comments/questions and answers were provided via email:

34. Mrs Hales asked the following question: Well done for the increase in the training figures. How assured are we that during this time of heightened risk we are making sure every contact counts and that we know the added risks associated with lockdown.

35. Mrs O’Hear provided the following response: We are assessing the risk by reviewing referrals regularly to see if any trends are emerging. Due to restrictions, we are aware that there is not the same level of contact taking place and therefore safeguarding alerts may not be raised due to lack of witnesses/reduced professional footfall. The safeguarding practitioners are therefore reaching out and making contact with services proactively, in order to do a ‘temperature check’ regarding potential concerns in the system.

36. For our higher risk service users a RAG rating has been introduced and this, together with agreeing a Single Point of Contact (from a multi-agency pool) is assisting with making the contacts count. Where contact cannot be made, there is an agreed escalations system.

37. There is however an awareness that safeguarding concerns may not be brought to the surface until lockdown begins to ease, this is a concern that has been raised nationally and all agencies are anticipating a spike when restrictions are lessened. Whilst the situation continues, there is advice and guidance being pushed out to all professionals who are acting as Single points of contact , not only about how to make contacts meaningful , but also advice regarding how to make enquiries (using professional curiosity approach) in more creative ways given the specific lockdown situation at the minute.

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38. Miss O’Dwyer asked the following question: Point 10 - when you do anticipate this system partner meeting to take place? Page 6 Referrals - no local authority data. Should we be worried about this?

39. Mrs O’Hear provided the following response: In response to point 10, the current situation was actually helping to force some of the integration working forward. I anticipate that this meeting will not take place until quarter 2 now, but that some of the work will have moved forward.

40. Regarding referrals, I am expecting data will be available at the end of Q1, not a significant concern at this stage due to other measures to check safeguarding concerns are being acted upon, but it will remain under review.

41.


Recommendations approved by the Committee, namely: • Comment on any additional information or assurance

required in relation to performance activity.


C2 MEDICAL DEVICES REPORT (OUTSTANDING ACTION FROM TRANSITION SUB-COMMITTEE)

42. Deferred to a future meeting (July 2020) – pressure on service.

C3 PLACE (Patient-Led Assessment of the Care Environment) OUTCOMES AND ACTION PLAN

43. Mrs Darbyshire provided an overview of the Trust’s 2019 PLACE including information detailing how performance compared nationally against other mental health and learning disability trusts along with steps that will be taken to address any identified issues.

44. The following comments/questions/responses were provided via email: 45. Mrs Hales asked the following question:

Cannot work out why Secure appears red without figures in appendix C on maintenance tracker. Please clarify.

46. Mrs Darbyshire/ Mrs McGee provided the following response: Apologies for the missing data, this is unfortunately an oversight. On 15 May 2020 an amended paper was circulated to the Committee which included the cleanliness data for the Secure Division (appendix C).

47. Miss O’Dwyer welcomed the good, detailed report.

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48.


Recommendations approved by the Committee, namely: • Note the content of the report; • Note that there are plans in place to address the

areas requiring improvement;


C4 CLINICAL AUDIT UPDATE AND 2020/21 PROGRAMME


C5 ANNUAL COMPLAINTS AND CONCERNS REPORT 2019 /2020

50. Dr Thomas provided a detailed report including the type and learning from complaints and concerns that had occurred during 2019/2020 in accordance with Care Quality Commission guidance.

51. Mrs Hales asked the following question: Concerning to see the number of complaints with regards to attitude and care of treatment by District Nurses which is at 38%. How is value based appraisal being evaluated?

52. Dr Thomas/ Mrs Ore provided the following response: The DN is the largest staff group within the division – this is also where we would anticipate to see most complaints based on the size of the service and also the complexity of their caseloads. As part of the divisions PE work plan to support improvement we worked with Healthwatch and undertook a postal survey this evidenced the below:

a) The work with regards to the District Nursing postal survey has now been

completed. In August 2019, following a recommendation from the Patient Experience Committee, Mersey Care, supported by Healthwatch teams in Liverpool and Sefton, conducted a survey of District Nursing patients. All District Nursing teams in Liverpool and Sefton were requested to participate. The aim of the Survey was to get a snapshot of opinion from District Nurse patients. To find out what they thought about the service provided to them by their District Nurses.

b) Patients were given the option to return completed questionnaires via their District Nurse or in a Freepost envelope.

c) 57 completed questionnaires were returned. Key Findings were:

54 (95%) reported that they had been informed about what the District Nursing service provides;

57 (100%) reported that District Nurses introduce themselves; 56 (98%) reported that they feel involved in decisions about their care; 55 (96%) reported that the care they had received from the District Nurses

had been effective; 56 (98%) reported that they are informed when District Nurses are next going

to visit;

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57 (100%) reported that they knew how to contact the District Nurses if they needed them;

50 (88%) reported that they knew who to contact if they had any concerns about the District Nursing service

53. Recommendations – Overall the feedback received about the District Nursing service

was positive. The following recommendations have been implemented: a) Results of the survey shared with staff in the service; b) Raise more awareness amongst patients about how to raise a concern or make a

complaint. This forms part of the divisional PE work plan.

54. We are aware of the highest category being staff attitude and care and treatment, we monitor and review this monthly through the divisional PE meeting – we have undertaken a deep dive in the ICN service line to review this further – on review it was identified a significant volume of these complaints related to End of Life care where situations can be increasingly emotive – to support this we have implemented a palliative care patient experience

Palliative Care Patient Experience

55. The Friends and Family test is not appropriate for the Palliative Care Service, therefore

a Patient Experience Survey was developed and implemented to seek the views of service users to monitor and improve the performance of the palliative care service. The survey took pace during Q2 and Q3 2019-20.

56. Summary: a) 14 surveys were completed in total; all surveys were completed in Sefton. b) Of the 14 surveys completed, 9 were completed by a carer or family member and

5 were completed by the patient. c) 100% response rate for all questions. d) 100% of patients/family would extremely recommend the Palliative Care Service. e) Only positive comments were made regarding the Palliative Care Service.

57. This was then implemented across the division – currently paused due to COVID 19.

We also identified that in End of Life complaints they are not being addressed at PALS level and moving straight to complaint stage – we are actively working with CSD to support this and also waiting as a division to trail the PALS 2 process in the division.

58. Miss O’Dwyer asked the following questions:

a) Point 21. How do our numbers of referrals to Ombudsman, compare with other Mental Health/Community Trusts?

b) Pt 38 Concern regarding capacity of clinicians to investigate complaints. This has

also previously been identified as a matter of concern, regarding clinicians being available to conduct mortality reviews. When might this be resolved?

59. Dr Thomas/ Mrs Ore provided the following response:

Point 21. The complaints Lead has contacted several Trusts and had two responses below as follows: a) Greater Manchester Mental Health Trust had 17 complaints referred to the

Ombudsman. b) Lancashire Care NHS Trust had 11 complaints referred to the Ombudsman.

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60. Point 38, just to clarify the difficulties are not with the availability of clinicians

undertaking mortality reviews.

61. The Trust has a separate Mortality and Incident Team who undertake the mortality reviews. This issue only relates to clinical complaints where it is felt more appropriate for a clinician to investigate issues for example around diagnosis or medication. There are plans in future to implement a PALS plus process whereby the clinicians involved are able to review there own clinical complaints and provide a full response involving the complainant. The statutory NHS Complaints Regulations state that all complaints should be responded to within 6 months and can be extended in exceptional circumstances. On reviewing the data, all complaints were closed within 6 months.

62. Miss O’Dwyer welcomed the detailed Annual Report stating it was good to see progress across al Divisions.

63.


Recommendations approved by the Committee, namely: • Note the contents of the report; • Clarify that the actions taken by the divisions and

complaints department to manage complaints are acceptable;

• Request further assurances as required;


C6 WINTER PLAN UPDATE


C7 WALK IN CENTRE UPDATE


C8 UPDATED CLINICAL STRATEGY


C9 NURSING REVALIDATION ANNUAL REPORT


C10 MONTHLY RISKS REPORT

68. Deferred to a future meeting (tbc) – pressure on service. Team is heavily engaged in incident management. The Board Assurance Framework will still be provided to the Board of Directors to ensure oversight until further notice.

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D1 SUB-COMMITTEE MINUTES & CHAIR’S REPORTS:

a) Infection Prevention and Control; b) Mental Health Act Managers; c) Mortality Review Group;

69. In relation to D1a – Infection Prevention and Control, minutes and chair’s report the following questions/responses were provided via email:

70. Mrs Hales asked the following question: I understand these are the minutes from February but I would have expected for this meeting to see something referring to issues with PPE and the potential impact this could have on care quality and how we are assured of patient and staff safety. Mrs Hurst provided the following response:

71. There is a process whereby we monitor PPE: • There is a central hub and each division has a PPE hub to ensure that there is a

supply within all teams . There is a daily sitrep of PPE which gives a summary of days / weeks supply that the Trust has of essential PPE;

• Two documents were circulated post meeting, showing the PPE process with escalation and the daily sitrep.

72. Miss O’Dwyer asked the following question: IPC Minutes suggests “Sarah Rafferty” is put on Risk Register. Please can you clarify what exactly has gone on the Risk Register?

73. Mrs Hurst provided the following response: The risk is the lack designated antimicrobial pharmacist in line with health and social care act. This caused a delay in the quarterly audit of safe antibiotic prescribing in line with national guidance reports to being presented at the IPCC. The new structure for pharmacy includes this dedicate pharmacy post and currently Sarah has identified a pharmacist to complete this role while the structure recruited to within for pharmacy.

74.


Recommendations approved by the Committee, namely: • Note the sub-committee minutes;


E1 RISK REFLECTION

75. No items raised.

E2 ISSUES FOR CONSIDERATION OF AUDIT AND/OR OTHER COMMITTEES

76. No issues were identified.

E3 ANY OTHER BUSINESS


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Resources Committee

Date of Meeting: Friday 19 June 2020 Chair: Mr N Williams

Summary of key issues from this meeting: The Resources Committee received and noted: • The Deputy Chief Executive provided an update on key issues of interest arising since

the previous meeting, including: a) The challenges of COVID-19 were likely to continue for many months/years to

come and balancing management of the incident whilst planning for future was a key challenge;

b) A recovery group has been set up to ensure the Trust comes out of the immediate pandemic safely;

c) Recovery plans will be coordinated by the Group and presented to the Board; d) A review of the Trust’s Strategy to manage the move from emergency planning

into a ‘living with COVID-19’ future; e) Assessment of resource implications of our plans and setting out the relevant

workforce, estate, digital and financial consequences; f) Those who can, will continue to work from home for the foreseeable future; g) Work continued to develop system bandwidth and accessibility so services can

continue to work remotely alongside new ways of working; h) Work will continued with the Board and relevant committees in development and

delivery of these plans; i) Work also continues in relation to the aspiration to acquire North West Boroughs

with the Strategic Outline Case to NHSI being submitted in the forthcoming days. • A summary of discussions held at the People Committee in relation to the items below

which had been transferred to the new Committee: a) Agency Spend b) Medical Productivity c) Pharmacy Rotas & Expenditure

• The Committee received a verbal update with regard to progress of the Recovery Coordination Group, noting that plans had been brought forward/fast tracked, including the digital response to COVID;

• An update on the current status of the strategic case for the acquisition of North West Boroughs (NWB), noting that the Strategic case had not been approved at NWB May 2020 Board, however an updated case will be presented and then go through due diligence;

• An update regarding PROSPECT, noting the Centre has suspended the process, however now wish to advance quickly;

• The Digital Board minutes and chair’s report;

The Resources Committee received and discussed: • An update on the monthly Risk Report (BAF), including the following:

a) 14 strategic risks identified by the Board, of which 13 were noted as being impacted in some way by Covid-19.

b) 14 Strategically significant divisional risks with a score of 15 or above. • 2 Liverpool and South Sefton Community Division Risks with 1 noted as having

a potential impact from Covid-19. • 7 Local Division Risks, of which 6 are noted as being impacted by Covid-19. • 2 Secure and Specialist LD Division risks of which 1 is noted as Covid related.

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• 3 Corporate Risks, with all 3 noted as being impacted by Covid-19. c) 1 Strategically significant programme risk with a score of 15 plus, impacted by

Covid-19. Of the current fourteen strategic risks identified by the Board for 2020/21), two had been raised due to Covid-19 and two reduced.

• The latest Executive Performance Report including arrangements for future performance reporting. The Committee received a summary of COVID-19 performance, as below:

a) 7 day follow up stood at 100% for April and May 2020, which was a significant achievement;

b) Readmission rates for March/April 2020 were the highest in the 12 month period. Unable to say if this was linked with COVID. The agile nature of the Division saw actions taken to address this increase and in June 2020 readmission had reduced to 7%;

c) IAPT recovery rates dropped to 33% in April 2020, with a slight increase in May 2020. This was a focus area and work was underway to get recovery rates on a sustainable footing;

d) Cardio Metabolic Assessments – inpatient admissions. 100% of all new admissions had the assessment and the Trust had continuously met this target for the past 7 months;

e) A reduction in physical health checks was evident in response to COVID due to some transfer of staff and infection prevention. These checks had been suspended and prioritised for people as appropriate. Discussions were taking place regarding how to safely reinstate checks;

f) As expected, waiting times and AHP services had increased. National guidance stated that these services should only see urgent, priority cases. All services do accept patients onto their caseload with regular tele-triage and weekly tele-checks. Patients who no longer need this service were being discharged;

g) Over the last 2-3mths, 3000 video consultations had taken place. This was a really good piece of work and clinical engagement. Work with divisions continued in order to maintain this momentum;

h) In relation to sickness absence, this was headed in the right direction with the best figures over the last 7 months. Potentially, increased flexible working may be having a positive impact;

• An update on the financial performance along with key financial risks for the Trust as below:

d) The in month position of breakeven; e) The increase in cost due to COVID-19 to May is £2.577m. This had been

supported by the national block contract settlement funding (0.354m) and assumed top up funding from NHS E & I (£2.175m). This is an increase of £1.312m for May 2020 COVID costs;

f) The top up funding for COVID-19 in April has been confirmed; g) The most significant financial cost pressures to May are consistent with those

identified in the 2020/21 financial plan and have been mitigated in the breakeven position. Those cost pressures relate to:

i. Medical cost management ii. Corporate cost management

h) The revised capital plan submitted to NHSI&E had capital investment of £36.618m with disposals of £6.1m, a reduction of £3.1m capital investment and an additional £3.0m in disposals;

i) The cash balance at the end of May was £80.471m, which is £43.925m above the plan of £36.546m. This is largely as a result of COVID 19 block payments being made a month in advance.

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The Resources Committee approved: • In relation to Hartley Hospital, the Committee approved usage of the £400k FF&E budget

underspend and £40k from the remaining project contingency along with additional funding of £152,513 to enable phase 2 of Hartley Hospital, new build, to be completed. The Committee also approved release of £102,675 should the risks materialise to complete Hartley Hospital;

• Disposal of 141 Rufford Road by public auction at or above the recommended reserve price, along with an update of the latest position in respect of the ongoing disposal process and the proposals for the surplus properties in Lancashire;

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Draft for Approval: ☒ Report to: Resources Committee

Formally Approved: ☐ Meeting Date: 21 August 2020


Resources Committee Date: Friday 19 June 2020 Time: 13:30

Venue: Held via Video Conference.


Present: Nick Williams Aislinn O’Dwyer Gerry O’Keeffe Amanda Oates* Elaine Darbyshire* Neil Smith*

Non Executive Director (Meeting Chair) Non Executive Director Non Executive Director Executive Director of Workforce Executive Director of Communications and Corporate Governance Executive Director of Finance / Deputy CEO (*in line with the terms of reference, indicates the Executive Directors who would have voted during the meeting if a vote had been required)

In Attendance:

Louise Edwards Asim Patel Noir Thomas Andy Meadows Sarah Jennings Paula Murphy

Director of Strategy Chief Information Officer Executive Medical Director Trust Secretary Deputy Trust Secretary Corporate Governance Compliance Manager

Apologies Received: Trish Bennett

Executive Director of Nursing and Operations

ISSUES CONSIDERED 2020 In light of social distancing measures due to the COVID-19 outbreak, this meeting was held via Video Conference.


1. The apologies for absence received for this meeting were detailed above.


2. There were no declarations of interest. A3 MINUTES OF THE MEETING HELD ON 24 APRIL 2020

3. The minutes of the previous meeting were accepted as an accurate record.

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4. Mr Williams commented that the meeting by email worked very well although discussion was missing and responses were concise.

8.


Recommendations approved by the Committee, namely: • Approve the minutes of the previous meeting;


A4 ACTION LOG

5. The action log was received and noted.

9.


Recommendations approved by the Committee, namely: • Note the action log;


A5 DEPUTY CHIEF EXECUTIVE’S REPORT

10. Mr Smith provided an update on key issues of interest arising since the previous meeting, including:

j) The challenges of COVID-19 were likely to continue for many months/years to come and balancing management of the incident whilst planning for future was a key challenge;

k) A recovery group has been set up to ensure the Trust comes out of the immediate pandemic safely;

l) Recovery plans will be coordinated by the Group and presented to the Board; m) A review of the Trust’s Strategy to manage the move from emergency planning

into a ‘living with COVID-19’ future; n) Assessment of resource implications of our plans and setting out the relevant

workforce, estate, digital and financial consequences; o) Those who can, will continue to work from home for the foreseeable future; p) Work continued to develop system bandwidth and accessibility so services can

continue to work remotely alongside new ways of working; q) Work will continued with the Board and relevant committees in development

and delivery of these plans; r) Work also continues in relation to the aspiration to acquire North West

Boroughs with the Strategic Outline Case to NHSI being submitted in the forthcoming days.

11. Mr O’Keeffe sought clarity in relation to the timeline for returning to the ‘new normal’ in respect of operational delivery. Mr Smith confirmed that this would be dependant on the individual services; some could be as soon as weeks. Some services were governed nationally, i.e., dental and school nursing and therefore the re-opening of these services would be determined nationally. Reinstatement of services would also be determined by the Executive Director of Nursing & Operations and the Medical

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Director’s perspectives on what was considered most essential and services would only reopen when it was safe to do so. A lot of work had been undertaken and services had worked together to develop plans, including resource implications of addressing the backlog of cases. Working with services had also provided a good, shared understanding of what estates changes were required including the strategic goal of improving the estate/services. Timescales would be provided to the Board members at their learning session on 24 June 2020, but it was important to note that this was an operational issue.

12. Mrs Darbyshire stated that it was important to embrace the learning from COVID-19, including the opportunities digital had provided and could provide going forward. All programmes will be brought together to permit a view of productivity gains.

13. Mr Williams referred to the Government rating of the pandemic which had been

reduced. Mr Smith stated that there was still potential for a second spike despite social distancing restrictions being relaxed. Mrs Edwards added that preparations were being made for a potential second wave in autumn and it was expected that the Level 4 Incident would continue for another 6-8 months. Mr Meadows agreed but stated that the Trust were led to believe this position would continue until the end of the financial year and that today’s announcement that the country was moving from Level 4 to Level 3 did not impact the current command and control approach being taken by NHS organisations.

14. Mrs Darbyshire highlighted the challenge in opposing the public perception while the

Trust remained under the directive of a Level 4 major incident.

15.


Recommendations approved by the Committee, namely: • Note the update


A6 MONTHLY RISK REPORT (BAF)

16. Dr Thomas presented the risk report which provided assurance that the strategically significant risks were being actively managed and highlighted the following:

17. The current BAF consisted of: d) 14 strategic risks identified by the Board, of which 13 are noted as been impacted

in some way by Covid-19. e) 14 Strategically significant divisional risks with a score of 15 or above.

• 2 Liverpool and South Sefton Community Division Risks with 1 noted as having a potential impact from Covid-19.

• 7 Local Division Risks, of which 6 are noted as being impacted by Covid-19. • 2 Secure and Specialist LD Division risks of which 1 is noted as Covid related. • 3 Corporate Risks, with all 3 noted as being impacted by Covid-19.

f) 1 Strategically significant programme risk with a score of 15 plus, impacted by Covid-19.

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18. Of the current fourteen strategic risks identified by the Board for 2020/21 (Table 1 - Appendix A of the report), two had been raised due to Covid-19 and two reduced. Full details were included in the report. As a caveat, Dr Thomas confirmed that Mersey Internal Audit Agency (MIAA) had reviewed the risk reporting with particular reference to COVID related risks and had provided a series of recommendations. Moving forward we would have a high level assurance checklist, based on a RAG-rated self assessment, included as appendix to the Board Assurance Framework.

19. Emerging risks (5) were all COVID related and there was a need to develop a new risk

in relation to BAME staff and patients.

20. Mr O’Keeffe welcomed the good, easy to read report. Referring to the register at the back of the report, Mr O’Keeffe highlighted 2 risks with the highest rating which had been unexpected, specifically a potential fire risk and the risk of slippage in the Maghull build. The slippage in the Maghull build was relatable in the current circumstances; however the fire risk required further action. Mrs Darbyshire confirmed that the Trust had systematically reviewed the fire risk and mitigations were in place, therefore it was suspected that this was a scoring issue and a review would be undertaken. In relation to the Maghull build, this was not very far behind and was being monitored.

21. Mr Williams agreed with Mr O’Keeffe’s comments and stated that calibration across risks/risk scoring was required, including re-educating staff in relation to scoring.

22. Mrs Darbyshire confirmed that a fire in Scott House, Rochdale had been an arson attack and this was being followed up with the police.

23.


Recommendations approved by the Committee, namely: • Confirm that the risks are being identified and

managed appropriately. • Identify any risks that need to be escalated as part of

the Board Assurance Framework.

Further actions required: • Fire risk to be reviewed/scoring reviewed;

E Darbyshire

Jul-20

By Jul-20

A7 COMMITTEE’S TERMS OF REFERENCE

24. This item was deferred to the next meeting.

25.


Further actions required: • Committee ToR deferred to the August 2020

Committee.

A Meadows

Aug-2020

On Aug-2020 Agenda

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B1 COVID-19 EXECUTIVE PERFORMANCE REPORT AND ARRANGEMENTS FOR FUTURE EXECUTIVE PERFORMANCE REPORTING

26. In order to reduce the burden on the team producing this report, it was agreed that a revised paper, focussing solely on COVID-19 would be provided to the Committee.

27. In March 2020, the report to Committee was suspended to enable focus on key metrics and provide information in relation to the immediate response to COVID-19. The report had evolved over the weeks and this was now a weekly report. Over the coming weeks, Mr Patel confirmed he would converse with Committee chairs to agree on a final monthly report; however it was anticipated the format of the report would be similar to the one provided to this Committee and split into chapters.

28. Mr Patel provided a summary of COVID-19 Trust performance to week ending 7 June 2020 against key performance metrics, highlighting the following:

a) 7 day follow up stood at 100% for April and May 2020, which was a significant achievement;

b) Readmission rates for March/April 2020 were the highest in the 12 month period. Unable to say if this was linked with COVID. The agile nature of the Division saw actions taken to address this increase and in June 2020 readmission had reduced to 7%;

c) IAPT recovery rates dropped to 33% in April 2020, with a slight increase in May 2020. This was a focus area and work was underway to get recovery rates on a sustainable footing;

d) Cardio Metabolic Assessments – inpatient admissions. 100% of all new admissions had the assessment and the Trust had continuously met this target for the past 7 months;

e) A reduction in physical health checks was evident in response to COVID due to some transfer of staff and infection prevention. These checks had been suspended and prioritised for people as appropriate. Discussions were taking place regarding how to safely reinstate checks;

f) As expected, waiting times and AHP services had increased. National guidance stated that these services should only see urgent, priority cases. All services do accept patients onto their caseload with regular tele-triage and weekly tele-checks. Patients who no longer need this service were being discharged;

g) Over the last 2-3mths, 3000 video consultations had taken place. This was a really good piece of work and clinical engagement. Work with divisions continued in order to maintain this momentum;

h) In relation to sickness absence, this was headed in the right direction with the best figures over the last 7 months. Potentially, increased flexible working may be having a positive impact;

29. Mr O’Keeffe welcomed the progress evident in the report. In relation to the People Metrics, it was good to see the improvement and an observation of why this may be the case would be interesting. In relation to digital consultation, this was less than 5% of our consultations and Mr O’Keeffe queried if these were the only ones that could be undertaken digitally. Mr Patel confirmed that there was not sufficient detail available at this time and that this was the number of contacts made by video. The next step

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would be to review the data and structures to ensure we do not lose the benefit of video contact and patient feedback to date was in the main positive. Mr O’Keeffe stated that it would be good to see the positives and negatives and a solid case study would be beneficial. Dr Thomas concurred with Mr O’Keeffe, noting the significant opportunity to make efficiency gains. Early adopters in various teams were propping up the figures currently and some service needed further prompting and encouragement to move people to virtual assessments where appropriate.

30. In response to Mr O’Keeffe, Mr Patel confirmed that the Trust were still measured by the National Oversight Framework with a rating given to organisations. Since the commencement of the COVID-19 outbreak, some of that flow of information for national benchmarking had been suspended, however this was beginning to be resumed. New metrics had been introduced around culture and people and the Trust were performing well with the exception of BME aspiration positions. Discussions had taken place with the Executive Director of Workforce and this would be a key focus for the newly established People Committee.

31. Mr Smith confirmed that the Trust were not being measured against the national

resources metrics at this time and it was assumed all NHS organisations would break-even and their financial risk rating had been suspended.

32. Mr O’Keeffe referred to category 3 and 4 ulcers, noting the Trust had gone 12 months

without an incident, welcoming this fantastic achievement.

33. Mr O’Keeffe referred to the ligature performance which showed no evidence of improvement. Following discussion, it was agreed that an assurance report would be provided to the Quality Committee for further scrutiny.

34. Mr Williams highlighted the National Oversight Framework metric in relation to the

number of clients in settled accommodation, asking if that included care homes. Mr Patel agreed to review this and provide a response outside of the meeting.

35. In response to Mr Williams, Mr Patel confirmed that greyed out cells indicated that data

was not available or services had been switched off. In addition, some reporting had been suspended. Mr Patel agreed to review the coding to ensure this was clearer going forward.

36. Discussion followed in relation to reporting to the various committees and the different

requirements of each committee. Subsequently, it was agreed that the chairs of the Quality, Resources and People Committees would meet with Mr Patel and Mr Meadows along with appropriate Executive Directors to discuss reporting requirements for each committee going forward.

37. Mr Patel left the meeting at this point.

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38.


Recommendations approved by the Committee, namely: • Note the assessment of performance against key

performance metrics;

Further actions required: • Assurance report in relation to ligatures /action plan

to be provided to the Quality Committee for scrutiny; • Confirm if number of clients in settled accommodation

includes care homes; • Review coding/greyed out cells and clarify what this

indicates; • Chairs of QC/RC/PC along with appropriate

Executive Directors and Mr Patel/Mr Meadows to meet to discuss reporting requirements for each committee going forward;

T Bennett A Patel A Patel A Meadows

Jul-20 Aug-20 Aug-20 Jul-20

Included on Jul-20 QC agenda

Aug-20 In next report (Augl-20) Jul-20

C1 FINANCIAL PERFORMANCE REPORT

39. Mr Smith provided an update on the financial performance at month 2, 2020/21 along with the key financial risks for the Trust.

40. The report highlighted the following:

a) The in month position of breakeven; b) The increase in cost due to COVID-19 to May is £2.577m. This had been

supported by the national block contract settlement funding (0.354m) and assumed top up funding from NHS E & I (£2.175m). This is an increase of £1.312m for May 2020 COVID costs;

c) The top up funding for COVID-19 in April has been confirmed; d) The most significant financial cost pressures to May are consistent with those

identified in the 2020/21 financial plan and have been mitigated in the breakeven position. Those cost pressures relate to: iii. Medical cost management iv. Corporate cost management

e) The revised capital plan submitted to NHSI&E had capital investment of £36.618m with disposals of £6.1m, a reduction of £3.1m capital investment and an additional £3.0m in disposals;

f) The cash balance at the end of May was £80.471m, which is £43.925m above the plan of £36.546m. This is largely as a result of COVID 19 block payments being made a month in advance.

41. Mr Williams welcomed the comprehensive report.

42. In response to Mr O’Keeffe, Mr Smith confirmed that in light of COVID-19, financial plans would be reviewed; however the Trust had been informed that all COVID related costs would be funded. The Trust were currently in a good, stable position and had a good understanding of where spikes would be and had put a reserve aside. Once events stabilised, plans would be reviewed/refreshed with priorities being revised.

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43. Mr Williams referred to the true costs of COVID which appeared to be £5m a month

and queried whether the Trust were able to subsidise this extra activity and when we reopen services, how would this position be reconciled. Mr Smith confirmed that all funds for COVID would be reimbursed and the Committee then discussed the finance impact of COVID and plans for reimbursement of funds and financial plans should a second spike occur.

44.


Recommendations approved by the Committee, namely: • Note the key financial indicators at month 2, 2020/21; • Note the key financial risks for the Trust;


C2 HARTLEY HOSPITAL – REQUEST FOR ADDITIONAL FUNDS

45. Mrs Darbyshire provided a project status and financial update report in order to inform

the Committee why additional monies were required.

46. Phase 2 of the works commenced on 6 January 2020 which included asbestos surveys/removal, demolition of the old Boothroyd Unit, creation of a car park, refurbishment of the boundary wall and the completion of the landscaping. The intrusive asbestos surveys showed a far greater level of asbestos than anticipated and they had identified an underground duct and concrete asbestos, left in situ when the old Southport General Hospital was demolished.

47. The impact of COVID-10 delaying the asbestos removal, additional asbestos being

exposed and trust variations/changes had led to increased project costs.

48. Mr Williams noted that table 2 in the report summarised this well.

49. Mrs Darbyshire also referred to ongoing issues with doors in the building consistently not working and the Trust were pushing back on the builders to address this. A solution was being sought and the Trust were going down a legal route and a further update would be provided to the Committee. In response to Mr O’Keeffe, Mrs Darbyshire confirmed that if the issue was not resolved legally, the cost of the doors could be another potential £250k.

50. Mr Williams queried how much remained in the contingency. Mrs Darbyshire agreed

to check and report back to the Committee.

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51.


Recommendations approved by the Committee, namely: • Note the content of the report. • Approve the usage of the £400k FF&E budget

underspend and £40,000 from the remaining project contingency

• Approve the additional funding of £152,513 to enable phase 2 of Hartley Hospital, new build, to be completed.

• To approve the release of £102,675 if the risks materialise to complete Hartley Hospital.

Further actions required: • Confirm funds remaining in the contingency;

E Darbyshire

Aug-20

Aug-20

C3 UPDATE ON DISPOSALS

52. Mrs Darbyshire provided an update on the ongoing actions asking the Committee to discuss and agree proposals for the next steps concerning the disposal of the surplus properties.

53. Mrs Darbyshire confirmed the project has progressed consistently with disposals as per the report in relation to the agreed properties, specifically, Queen Mary Terrace, Bridge Terrace and adjacent land parcels, Gisburn Lodge and adjacent land interests and Scott House. The report also set out the next steps for the remaining houses at Whalley and sought approval for the disposal of 141 Rufford Road, Southport.

54. In response to a question from Mr O’Keeffe, Mr Smith confirmed that in relation to the

Whalley site/Lancashire Care’s interest, a resolution was awaited from the Department of Health. This will hinge on planning permission support for the Low Secure Unit. The Trust were seeking £20m to pay off the loan and we can then transfer the site to Lancashire Care.

55. Mrs Darbyshire confirmed that work in relation to Rowen View was some 4-5 weeks

behind due to the impact of COVID.

56.


Recommendations approved by the Committee, namely: • Note the latest position in respect of the ongoing

disposal process and the proposals for the surplus properties in Lancashire.

• Agree to the disposal of 141 Rufford Road by public auction at or above the recommended reserve price.


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D PEOPLE COMMITTEE REPORTS – FOR INFORMATION

• Agency Spend • Medical Productivity • Pharmacy Rotas & Expenditure

57. Mr O’Keeffe confirmed that full discussion had taken place in the People Committee

held earlier today (19 June 2020) in relation to the 3 papers listed above.

58. Mr O’Keeffe summarised, stating that agency costs and medical costs were not the major part of costs and the Trust spends more in nursing and AHPs and other agency. The team were taking away an action to undertake more detailed work and would be providing an update to the People Committee.

59. In relation to Medical Productivity, Dr Thomas continued to work on recruitment and

was working with Mrs Oates to develop a recruitment and retention plan.

60. In relation to Pharmacy Rotas and Expenditure, the People Committee will continue to monitor this.

61. Mr Williams stated he was happy that in depth discussion occurred in the People

Committee.

62. In response to a question from Mr Williams, Mr Smith confirmed that the Trust had factored in £300k overspend at year end. Agency costs for medical staffing were lower than usual due to the ability to utilise COVID funds. Sufficient monies were set aside to cover the £300k.

E1 RECOVERY COORDINATION GROUP UPDATE

63. Mr Smith stated that the Recovery Coordination Group had reviewed how the COVID response aligned to Trust plans.

64. At this stage, it was not possible to provide detailed costs; however the Trust had reacted really well and changed our estate to meet need during this time. Plans had been brought forward and fast tracked and a full discussion will take place in the Board meeting, including the digital response to COVID.

65.


Recommendations approved by the Committee, namely: • Note the verbal update.


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E2 NORTH WEST BOROUGHS ACQUISITION UPDATE

66. Mr Smith provided an update on the current status of the strategic case for the

acquisition of North West Boroughs (NWB) by Mersey Care, stating that NWB had not approved the Strategic case at their May 2020 Board meeting. In light of this, the Strategic case had been updated, mainly presentational, and the updated case will go through due diligence. The Joint Transaction Board had approved the revamped format.

67. The CEO of NWB has assured Mersey Care that the updated case will go through their Board and Mersey Care will need to approve this again.

68.


Recommendations approved by the Committee, namely: • Note the status update provided.


E3 PROSPECT UPDATE

69. Mr Meadows stated that the Centre had suspended the process; however now wish the Trust to be one of the Trusts to advance quickly. A decision was expected in early July and then due diligence would be undertaken. After this, a further update would be provided to the Committee.

70. Mr Smith expressed concern that the resource element would not be resolved within that timeframe.

71.


Recommendations approved by the Committee, namely: • Note the content of the report.


F1 DIGITAL BOARD MINUTES (Consent Item)

72.


Recommendations approved by the Committee, namely: • Note the report provided.

Further actions required:

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• None identified

G2 RISK REFLECTION

73. Mr O’Keeffe highlighted the potential risk of all three Board Committees duplicating / not covering everything. Mr Williams agreed. Mr Meadows confirmed that this will be addressed by the action already agreed earlier in the meeting, in relation to the meeting of Chairs/Executive Directors which Mr Meadows will facilitate in the coming weeks.

74. Mr Williams referred to the financial risk/forecast risk in respect of COVID-19 and second peak in infection rates expected later in 2020, stating that if the Trust were building up concurrent costs and the monies promised were not provided, there was potential for significant deficit, therefore this needed to be included on the risk register. Mr Smith stated that there was a future risk should these funds not be underwritten by the Government. Mr Smith confirmed he has asked the finance team to analyse by service, the nature of the costs and whether they were recurrent and there would be a need to respond, potentially with exit strategies.

75.



G3 ISSUES FOR CONSIDERATION BY AUDIT AND / OR OTHER

COMMITTEES

76. There were no issues raised. G3 ANY OTHER BUSINESS

77. No other items of business were discussed.


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CHAIR’S REPORT AND MINUTES FOR THE People Committee

Date of Meeting: Friday 19 June 2020 Chair: Miss A O’Dwyer

Summary of key issues from this meeting: The People Committee received and noted: • An update on the revised governance arrangements for Equality and Inclusion along with

an update in relation to the Workforce Race Equality Scheme (WRES) and Workforce Disability Equality Scheme (WDES);

The People Committee received / discussed: • Plans for items to be included on the annual cycle/future agendas. A timeline was being

developed and a Draft Annual Cycle of Business would be provided to the August 2020 meeting for approval;

• An update on the current performance against agency price caps, including: a) Clarity on the requirements in relation to agency expenditure ceilings; b) Assurance of the Trust’s bank and agency booking processes; c) Detailed oversight of where agency usage was occurring within the Trust;

• An update on medical productivity highlighting: a) A trajectory for 2020-21 costs against the plan; b) An overview of a revised workforce plan proposed to mitigate escalating

overspend within the medical budget. • An update on the integration of the Community and central Corporate Division’s

medicines management teams, including the medicines management action plan and details of the work and progress which had taken place;

• A presentation/verbal update on actions taken in relation to BAME colleagues which covered:

a) COVID-19 Research for BAME b) COVID-19 and our Workforce c) What we have done so far d) What we are planning e) Public Health England’s Disparities in the risk and outcomes of COVID-19 link f) Enhanced safety assessment for BAME staff & others g) Risk flow chart h) Public Health England’s suggestions to be considered by the Board i) 5 Ambitions for BAME networks j) Roger Kline – After the Speeches what now for NHS staff race discrimination –

suggestions k) Revised Governance Process Equality & Inclusion l) Confronting Inequality Head on

The People Committee approved: • The Operational Workforce Group Terms of Reference, subject to finalising the

membership/attendees;

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Draft for Approval: ☒ Report to: People Committee

Formally Approved: ☐ Meeting Date: 21 August 2020


People Committee – held via Video Conference Date: Friday 19 June 2020 Time: 10am-12noon

Venue: Video Conference


Present: Aislinn O’Dwyer Gerry O’Keeffe Amanda Oates Noir Thomas

Non Executive Director (Chair) Non Executive Director Executive Director of Workforce (Lead Director of the Committee) Executive Medical Director

In Attendance: Clare Almond Jo Davidson Lynn Lowe Gayle Wells Andy Meadows Sarah Jennings Paula Murphy

Associate Director of Workforce Associate Director of Workforce Associate Director of Workforce Strategic Head of Financial Management Trust Secretary Deputy Trust Secretary Corporate Governance Compliance Manager

Apologies Received:

ISSUES CONSIDERED 2020 A1 APOLOGIES FOR ABSENCE

1. There were no apologies for absence.


2. No declarations of interest were made.

B1 AGENDA AND ANNUAL CYCLE OF BUSINESS FOR PEOPLE COMMITTEE

3. A discussion took place to identify items to be included on agendas and the cycle of business going forward for this new committee. Mrs Oates stated that work had begun to map out a timeline.

4. A short discussion took place regarding the dates of future meetings and Miss O’Dwyer noted the importance of ensuring that the Committee took place ahead of the Board to ensure timings of items were correct and allowing time for consideration/amendment of reports ahead of presentation to the Board. It was

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agreed to keep the People Committee on the morning of each Resources Committee held every other month.

5. Miss Jennings stated that an Annual Cycle of Business was currently being drafted for this new Committee and this will include a review of timings for items to go to the Board to ensure this was appropriate. The draft cycle will be shared with HR initially and then presented to the August People Committee for approval.

6.


Recommendations approved by the Board, namely: • Note the discussion.

Further actions required: • Draft Annual Cycle of Business to be presented to the

August 2020 People Committee for approval.

S Jennings

Aug-20

On Aug-20 People Committee Agenda

C1 AGENCY SPEND

7. Mrs Oates provided an update on the current performance against agency price caps. The report provided:

a) Clarity on the requirements in relation to agency expenditure ceilings; b) Assurance of the Trust’s bank and agency booking processes; c) Detailed oversight of where agency usage was occurring within the Trust;

8. Mrs Oates stated that the Trust were still above the agency cap, however there had

been a reduction on last month. The medical transformation plan was the most significant action which should dramatically reduce agency uptake and it was anticipated that an improvement would be evident by summer.

9. There had been less use of agency in May 2020, mainly in light of some services being closed due to COVID-19 and staff being redeployed as well as our own staff covering additional hours.

10. Mrs Oates confirmed that a deep dive into non clinical aspects of roles was planned as potentially this would help make a difference in terms of being over cap. There were real variations in Divisions and Mrs Oates confirmed that she had been asking all HR colleagues to work with Divisions to address and begin to scenario plan. In addition Mrs Oates noted that should we get a second wave of the COVID virus and have no student nurses, this would impact agency usage further.

11. Mrs Oates advised that the Trust were aiming to address medical recruitment or how

clinicians were operating and this would potentially have the biggest impact.

12. Mr O’Keeffe stated that the forecast appeared to be a straight line forecast, i.e., no plan to really make a difference and it appeared that the Trust expected to spend a consistent amount throughout the year on agency. Mrs Oates accepted that the forecast was not ideal and further work would be undertaken to liaise with finance colleagues to address this, including a review of the cap in a more proportionate way going forward. Mrs Wells agreed, acknowledging the fair challenge, adding that the cap was internally generated target with no stretch in the target, therefore this can be

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reviewed. Mr O’Keeffe welcomed this, stating that the Trust need to review and make plans if this is to improve going forward.

13. Miss O’Dwyer asked if the Trust were permitting staff to assist other trusts at the

expense of our agency costs. Mrs Oates confirmed that this was not the case. Those services had closed down and the staff would not have the appropriate skills to support our other services

14. Miss O’Dwyer queried what new services were commissioned within Local Division

(paragraph 16 of the report). Mrs Oates confirmed that those services were Criminal Liaison services and Crisis Resolution Home Treatment (CRHT).

15. Miss O’Dwyer referred to paragraph 47 of the report and stated that this referred to

Mersey Care being a provider who required support by regulators and asked at what point would that support commence. Mrs Oates confirmed that it was unlikely this would be the case for Mersey Care as targets had been paused and the Trust permitted to spend as needed at this time and Mersey Care had been impacted less than other Trusts due to the mobilisation of our student nurses.

16. Mr O’Keeffe stated that it may be helpful to pull out the IM costs as a separate entity

and referred to paragraph 29 regarding COVID related requests, adding that this would likely be the case for some time and sought clarity in relation to table 4 in the report. Mrs Oates agreed to address both these points in the next report.

17. Mrs Fraenkel joined the meeting at this point. 18.


Recommendations approved by the Board, namely: Consider the contents of the report and approve the recommendations. • To undertake a look back at agency usage by division

and medicals services for 2018/19 and 2019/20 to assess the impact of agency spend and the risks associated.

• Continue with the medical recovery plan and review the medical transformation plan against this when it is finalised.

• Local Division to continue with their work on their agency usage reduction plan.

Further actions required: • Review internal agency ceilings and then forecast

and plan aligned with these; • Presentation of COVID aspect differently and

separate the IM costs in the report;

A Oates (G Wells) A Oates

Aug-20 Aug-20

Aug-20 report to the Ctte

Aug-20 report to the Ctte

C2 MEDICAL PRODUCTIVITY

19. Dr Thomas provided an update on medical productivity highlighting:

a) A trajectory for 2020-21 costs against the plan; b) An overview of a revised workforce plan proposed to mitigate escalating

overspend within the medical budget.

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20. Dr Thomas noted that substantive vacancies currently stood at a total of 18.21 whole time equivalent consultant vacancies. A workforce plan pre-COVID had looked at various solutions including reviewing other disciplines.

21. Plans in terms of using senior nursing staff to undertake some work that consultants had been doing has been paused due to COVID impact. Some redeployment of senior nurses has prevented us from pursuing this. Additional work had been taken on by some of our doctors who are now very stretched. Recruitment will continue in July.

22. Dr Thomas confirmed that medical supplies were sufficient should there be a second wave and agency cover was working differently, particularly in community services where there was the biggest deficit of consultants. Overall COVID had impacted plans for workforce which will now require a further review.

23. Mr O’Keeffe thanked Dr Thomas for the report and stated that in the previous year there had been a number of instances where it was thought that recruitments had taken place and the candidates subsequently moved elsewhere and asked if there was any intelligence as to why this had occurred. Dr Thomas stated that physician Associates in particular had been keen and enthusiastic at the time, however two moved to Manchester as they lived in Manchester. Historically there had been some disparity in our recruitment and retention offer with competitors however we do now match this. Some intelligence was evident to suggest that our case load, complexity and deprivation discourages uptake. In reality it was very difficult to compete.

24. Mr O’Keeffe stated that it was good that we now match what our neighbours offer in terms of R&R offers, however perhaps we should now be thinking of paying a premium. Dr Thomas agreed that the Trust needed to offer more, however over the years the Trust had offered recruitment and retention packages for certain areas/posts and this has resulted in an inequity across the Trust. Attempts have been made to address this, however doctors are frustrated by the inequity and it was evident that the Trust needed to develop a standard equity and a more structured approach. Mrs Oates stated that there was a need to engage consultants to seek their suggestions to address the problem. Mr O’Keeffe asked Dr Thomas and Mrs Oates to review and report back.

25. Miss O’Dwyer sought clarity around the role of SAS doctors. Dr Thomas stated that there was one recruitment pending in July. Traditionally, SAS doctors were middle grade, senior, 9am-5pm working doctors. The Trust had advertised staff grade jobs with additional on-call payments and some interest was evident in this.

26. Miss O’Dwyer asked if the Trust were exploring what could be done within the training programme to expose these staff to community work and supporting them further in order to try and retain and ‘grow our own’. Dr Thomas stated that this was a point of difficulty and there was a need to review our senior trainees and understand how to make this an attractive prospect. The issues could potentially be linked to the morale of doctors working in this area.

27. In response to Miss O’Dwyer, Dr Thomas agreed to share feedback from the engagement session with the Committee.

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28. Miss O’Dwyer noted that contracts were a work in progress; however a significant amount of work had been undertaken. It was challenging to understand the crux of the issues and Miss O’Dwyer offered thanks to all those involved in this work.

29.


Recommendations approved by the Board, namely: • Note progress against the original 5 year plan to

address mitigation; and

Further actions required: • Dr Thomas and Mrs Oates to liaise to address

inequity issue/potential solution; • Share feedback from the engagement session with

the Committee (Dr Thomas to notify when this will be available / add to agenda);

N Thomas / A Oates N Thomas

Aug-20 TBC

Update to Aug-20 PC TBC

C3 PHARMACY ROTAS & EXPENDITURE

30. Dr Thomas provided an update on the integration of the Community and central Corporate Division’s medicines management teams including the medicines management action plan and details of the work and progress which had taken place.

31. Mr O’Keeffe welcomed the report, adding that he would appreciate a more objective view of what we are doing and why and sought clarity on definitions of actions in the report. As part of the redesign, Mr O’Keeffe asked for very clear objectives of what we wanted this to look like going forward. Dr Thomas welcomed the feedback, confirming that this information was available, however had not been included in this report. A reiteration would be provided to the next meeting including a transformation plan.

32. Miss O’Dwyer acknowledged how busy Mrs Rafferty was currently in light of the COVID impact and thanked Dr Thomas and Mrs Rafferty for the report.

33.


Recommendations approved by the Board, namely: • note agreed next steps to be taken; • agree a timescale for update papers, taking into

consideration the current Covid-19 situation.

Further actions required: • Future reports to include transformation plan and

progress gains;

N Thomas

Aug-20

Include in Aug-20 update

C4 OPERATIONAL WORKFORCE GROUP TERMS OF REFERENCE

34. Mrs Oates provided the proposed terms of reference for the Operational Workforce Group which will report to the People Committee and sought approval. Further work on the membership/attendees of the Group will be finalised once the terms of reference (and membership) of the 6 supporting sub-groups have been confirmed.

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35. The Committee discussed some changes to be made and gave Mr Meadows delegated authority to make amendments to the Terms of Reference, specifically to the membership.

36.


Recommendations approved by the Board, namely: • to consider and approve, subject to Amanda Oates

finalising the membership / attendees, the terms of reference for the Operational Workforce Group


C5 DISPROPORTIONATE IMPACT RE COVID FOR BAME COLLEAGUES

37. Mrs Oates provided a presentation which provided members with an update on actions taken in relation to BAME colleagues.

38. The presentation covered:

• COVID-19 Research for BAME • COVID-19 and our Workforce • What we have done so far • What we are planning • Public Health England’s Disparities in the risk and outcomes of COVID-19 link • Enhanced safety assessment for BAME staff & others • Risk flow chart • Public Health England’s suggestions to be considered by the Board • 5 Ambitions for BAME networks o Roger Kline – After the Speeches what now for NHS staff race discrimination –

suggestions o Revised Governance Process Equality & Inclusion o Confronting Inequality Head on

39. Mrs Fraenkel acknowledged Mrs Oates passion and hard work on this subject.

40. Mrs Fraenkel requested that in relation to metrics and data quoted, the Trust should

articulate the caveats on data, i.e., data only shows what we know to date. This was a significantly neglected issue nationally and the issue must be addressed from the Board down. Mrs Fraenkel and Mrs Oates agreed to discuss how this can be achieved outside of the meeting.

41. Mrs Fraenkel highlighted that the Trust were appointing a new Non Executive Director

and the participation of Governors was also required in this recruitment. It was important to ensure that as a Trust we are progressing and growing and this should be built in to the Chairman’s appraisal/Board appraisals. Mrs Oates confirmed that Governors will be included in this development.

42. Miss Jennings clarified that the appraisal process is approved by Governors.

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43. Mrs Oates stated that a number of BAME psychologists had formed a group to make suggestions for improvement and it was proposed that the Board undertake some action learning sets. Mrs Fraenkel welcomed this idea.

44. Mr O’Keeffe welcomed the presentation and offered thanks to the team.

45.


Recommendations approved by the Board, namely: • Note the presentation.

Further actions required: • Mrs Fraenkel and Mrs Oates to discuss Board

inclusion/participation outside of meeting; • Mrs Oates and Mrs Fraenkel to discuss the Board

undertaking Action Learning Sets in relation to BAME;

A Oates / B Fraenkel A Oates / B Fraenkel

Aug-20 Aug-20

By Aug-20 Ctte Aug-20

C6 EQUALITY AND INCLUSION STRATEGY (IMPACT ON GOVERNANCE ARRANGEMENTS)

46. Mrs Oates provided an update on the revised governance arrangements for Equality and Inclusion along with an update in relation to the Workforce Race Equality Scheme (WRES) and Workforce Disability Equality Scheme (WDES). Plans to refresh the Equality & Inclusion Strategy were also included in the update.

47. Mrs Oates confirmed that a paper will be provided to the August 2020 People Committee and then to the Board for sign-off.

48. In reply to Miss O’Dwyer, Mrs Oates confirmed that the strategy will be refreshed and provided to the October 2020 Committee. National plans were anticipated sometime in September/October 2020 and these will be reflected in the Strategy.

49.


Recommendations approved by the Board, namely: • Note the contents of this paper • Note the revised governance arrangements for

Equality and Inclusion • Approve the approach proposed in relation to the

refresh of the Trust’s Equality and Inclusion Strategy • Note the actions taken to date in relation to our

BAME colleagues resulting from the COVID-19 incident

Further actions required: • WRES and WDES data to be presented to the

Committee in Aug-20 and then the Board in Sep-20

• Equality and Inclusion Strategy to be presented to the October Committee;

A Oates A Oates

Aug-20 Oct-20

Aug-20 PC agenda and Sep-20 Board agenda Oct-20 PC agenda

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D1 ANY OTHER BUSINESS

50. There was no further business.

D2 RISK REFLECTION

• Mrs Oates would review BAME risks for staff, while Dr Thomas would consider BAME risks from a patient perspective;

51.


Further actions required: • Mrs Oates to review BAME risks from staff

perspective; • Dr Thomas to review BAME risks from patient

perspective;

A Oates N Thomas

Aug-20 Aug-20

By Aug-20 By Aug-20

D3 MEETING REFLECTION

52. Miss O’Dwyer reflected that having less paperwork for the meeting permitted more time for discussion and therefore asked that paperwork was kept to a minimum (max 50 pages) going forward to allow appropriate time for scrutiny.

53. The Committee recommended escalation of risks to BAME patients (re COVID) to the Quality Committee.

54.


Further actions required: • Escalate risks to BAME patients re COVID to the

Quality Committee through the Risk Report;

A Oates (A Meadows)

Jul-20

Jul-20



END OF REPORT

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