public meeting of the trust board 1.30pm, thursday, 2 … · 2017-01-31 · public meeting of the...

PUBLIC MEETING OF THE TRUST BOARD

1.30pm, Thursday, 2nd February 2017

Conference Room 1, Trafalgar House, King Street, Dudley AGENDA

Culture and Conduct Protocol

We are a values-led Board. We place quality of care and safeguarding the needs of our patients at the heart of everything we do. We work consciously as a team to support and constructively challenge each other in the best

interests of service users, their carers and families. We champion the interests of staff and acknowledge that they are working well in challenging times. We seek to ensure value for money at all times through efficient use of our

resources in the delivery of services and achievement of standards. We welcome the rigour of debate with fellow Board members, drawing upon a range of different experiences and perspectives and applying the Nolan principles of

Selflessness, Integrity, Objectivity, Accountability, Openness, Honesty and Leadership.

ITEM Purpose Board Lead Format Timings

1. EBE Reflection Assurance Mr Axcell Presentation 1.30pm

2. Apologies Mr Reid Oral

3. Declarations of Interest For Board members to declare any relevant interests in items on the agenda

Mr Reid Oral

4.

Minutes of the Previous Meeting To approve the minutes of the Board meeting held on 5th January 2017

Approval Mr Reid Enc 1

5. Matters Arising/Action Schedule Continuity Mr Reid Enc 2

6. Summary Report of Confidential session of Trust Board held on 5th January 2017 Information Mr Reid Enc 3

7.

Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)

Information

Mr Axcell

Enc 4 1.55pm

8. QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

8.1 Trust Integrated and Contract Performance Dashboard (Month 9)

Assurance

Mr Davies Enc 5 2.00pm

8.1.1 a b c

Quality Quality and Safety Committee Chairs Report Quality & Safety Committee Minutes from meeting held on 11th January 2017 Quality Report

Assurance Assurance Assurance

Dr Murphy Dr Murphy Ms Musson

Enc 6 Enc 7 Enc 8

2.05pm


8.1.2 a b c d

Finance & Performance Finance & Performance Committee Chairs Report Finance & Performance Committee Minutes from meeting held on 19th December 2016 Finance Report Cost Improvement Programme (CIP) Progress Report

Assurance Assurance Assurance Assurance

Mr Rana Mr Rana Mr Davies Mr Davies

Enc 9 Enc 10 Enc 11 Enc 12

2.25pm

8.1.3 a b

Workforce Workforce Committee Chair’s Report Workforce Performance Report

Assurance / Approval Assurance

Ms Clymer Mrs Williams

Enc 13 Enc 14

2.50pm

8.2 Medical Directors’ Report

Assurance Dr Gingell /Dr Weaver

Enc 15 3.10pm

8.3 Director of Operations and Nursing Report

Assurance Ms Musson/Ms Ingram

Enc 16 3.20pm

8.4 Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Assurance Ms Musson Enc 17 3.30pm

9. STRATEGIC DEVELOPMENT & DIRECTION

9.1 MERIT Vanguard Overview Report Assurance Mr Axcell Enc 18 3.40pm

9.2 Board Assurance Framework – Quarter 3 Review Assurance Mr Axcell Enc 19 3.50pm

9.3 High Level Operational Risk Register Assurance Ms Musson Enc 20 3.55pm

9.4 Annual Plan 2016/17 Quarter 3 update Assurance Mr Axcell Enc 21 4.00pm

10. LEADERSHIP, CULTURE & WORKFORCE

10.1 Communications and Engagement Report – Quarter 3 2016/17

Assurance Mr Axcell Enc 22 4.10pm

11. FOR ASSURANCE

11.1 MExT Chair’s Report from 24th January 2017 Assurance/ Information

Mr Axcell Enc 23 4.20pm

12. ANY OTHER BUSINESS

13. QUESTIONS FROM MEMBERS OF THE PUBLIC

Questions from members of the public pertaining to agenda items.

Oral

4.25pm

14. DATE AND TIME OF THE NEXT MEETING


1.00pm on Thursday 2nd March 2017 in The Board Room, Canalside, Bloxwich

Enc 1 MINUTES OF THE TRUST BOARD MEETING OF

DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUST

Held at 1.00pm on Thursday 5th January 2017 The Board Room, Canalside, Bloxwich

PUBLIC SESSION Present Mr B Reid Chair Mr M Axcell Chief Executive Officer Ms O Clymer Non-Executive Director Mrs G Cooper Non-Executive Director Mr R Davies Interim Director of Finance, Performance and IM&T Dr K Gingell Joint Medical Director Ms M Ingram Acting Director of Operations Dr S Murphy Non-Executive Director (from minute 179.2) Ms R Musson Acting Director of Nursing Mr P Rana Non-Executive Director Mr H Turner Associate Non-Executive Director Dr M Weaver Joint Medical Director Mrs A Williams Acting Director of People In Attendance Mr P Lewis-Grundy Company Secretary Mrs L Wix Corporate Governance Support Officer (minutes) ITEM ACTION 173. APOLOGIES & WELCOME

There were no apologies for absence.

174. DECLARATIONS OF INTEREST

Members were asked to disclose any interest they may have, direct or indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. No interests were declared in addition to those already recorded on the Register of Interests.

175. MINUTES OF THE PREVIOUS MEETING

To approve the minutes of the meeting held on 8th December 2016.

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RESOLVED: That the minutes of the meeting held on 8th December 2016 be approved and signed by the Chair.

176. MATTERS ARISING/ACTION SCHEDULE 176.1 176.2 176.3 176.4 176.5 176.6

An update on outstanding items on the Action Schedule was provided. Minute 125.1 Quality & Safety Committee Chair’s Report Mr Davies confirmed that he would provide an update on the patient record procurement exercise to the Board in private by reason of it being commercially confidential Minute 126 Medical Directors’ Report Dr Gingell confirmed that the SUI reporting process had been refreshed and a report would be submitted to the Board in February 2017. Minute 157 Quality Improvement Priorities and CQUIN Quarterly Report Mr Davies advised that there were two CQUINs that may not reach their target and further detail was included in the Improving health and wellbeing of NHS Staff The Trust had come very close to achievement of this CQUIN and would have reached the target had 40 additional individuals had the flu vaccination, although there had been a significant improvement on the uptake figures on previous years The likely cost implication was £67,000 although there were on-going discussions with the CCG with the potential to reduce this figure. Physical Health Care Ms Musson advised that this related to the level of compliance to a clinical audit being undertaken nationally which had been delayed until February 2017 and the Trust had to demonstrate it had reached the required standard. Whilst there was confidence that the standard would be achieved, there was a potential cost implication to the Trust of £20,000. Mr Davies confirmed that both of the above figures were incorporated in the forecast outturn. He confirmed that the Finance & Performance Committee would receive the forecast outturn of CQUINs at the January meeting. Minute 145 Patient Story Following a request from the Chair for an update on the

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patient story, Mr Axcell confirmed that a meeting had been held to discuss the patient story reporting process Suggested improvements to the process included clinical colleagues providing updates and actions taken as a result of the issues raised by patient stories “on the day”. The proposed improvements would be reviewed by the Quality & Safety Committee, although it was noted that the Board had previously agreed the process and protocols for receiving patient stories and these would remain unchanged. RESOLVED: That the matters arising and the assurance given where those actions have been completed be noted.

177. SUMMARY REPORT OF THE CONFIDENTIAL SESSION OF TRUST BOARD HELD ON 8th DECEMBER 2016

Members noted the content of the confidential summary of the meeting held on 8th December 2016. RESOLVED: That the Board received the report for information.

178. CHIEF EXECUTIVE OFFICER’S OVERVIEW

Mr Axcell provided an update on the following: Transforming Care Together

The work streams had concluded their work and Service on a Page outlines of the potential benefits (clinical and non-clinical) of the Transforming Care Together Partnership had been presented to all three Trust’s boards for review.

MERIT and Dudley CCG Vanguard

Mr Axcell confirmed that the MERIT and Dudley CCG Vanguard had had their funding for 2017/18 confirmed in December as £4.4m per annum for the Dudley Multi Specialty Community Provider and £1.8m per annum for MERIT. The IT development proposals for sharing records across MERIT partners had been signed off enabling greater co-ordination of care across Trust boundaries which would be helpful particularly in relation to crisis care.

Walsall CCG Healthy Walsall Partnership Board

The health and social care organisations across the Walsall Borough continued to work closely on a shared agenda to improve outcomes and integration of services. Mr Axcell advised that greater collaborative working across Walsall had been discussed at a recent meeting with providers and

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four of the confederation of GPs.

Freedom to Speak Up

The Trust had signed up to the Freedom to Speak Up campaign as part of on-going work to encourage a more open culture. A Freedom to Speak Up guardian had been appointed and would take up the post in January 2017, with the post holder leading on Freedom to Speak Up as well as staff Engagement.

Single Oversight Framework (SOF)

Following the publication of the draft Segmentation of Trusts and Foundation Trust’s, NHS Improvement had published its first formal segmentation based on the first month working under the SOF. This segmentation is based on performance data and other information gathered after the SOF came into place on 1 October 2016. Mr Axcell confirmed that the Trust had been placed in Segment 2 of 4, 1 being providers with maximum autonomy, 4 being providers in special measures.

Mr Axcell commended all those involved in the recent significantly challenging round of negotiations, advising that their efforts were greatly appreciated and had resulted in the Trust signing the contract within the prescribed deadline of 23rd December 2016. The Chair requested that Dr Gingell take the lead in relation to the learning, candour and accountability review referred to under Item 2 of the National Policies and Strategies. Dr Gingell advised that as the action indicated the Mortality Review Group would discuss the review, including the Serious Untoward Incident process, and report to the Board ACTION: The Mortality Review Group to discuss the Learning, Candour and Accountability Review and review the process for investigating SI’s and patient deaths incorporating the recommendations from the CQC review and report back to Board in March. RESOLVED: That the Board:

• Noted the report for information and the actions contained therein.

Dr Gingell

QUALITY, SAFETY, EFFICIENCY & EFFECTIVENESS

179 Trust Integrated performance Dashboard (Month 8) Mr Davies summarised the main points advising that the

finance, performance and workforce reports included greater

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detail on the items referred to.

RESOLVED:

That the Board noted the content of the report.

179.1 Mental Health Act Scrutiny Committee Chair’s Report

In presenting the report, Mrs Cooper referred to:

• The committee’s meeting with the ALM’s (associated lay members)

• Mental Health Act Quality Dashboard • Quarterly AMHP Activity and Audit Report • CQC Action Plan • Internal Audit reports • CQUIN Avoidable Mental Health Act admissions and

Care Plans update

Mrs Cooper confirmed that the Committee had received the two internal audit reports and had raised concerns at the limited assurance received following the Mental Capacity Act (MCA) and Deprivation of Liberty (DOLs) audit. Care Records and Least Restrictive Practice had been given moderate assurance. She did however confirm that action plans were in place and these would be monitored by both the Mental Health Act Scrutiny Committee and the Audit Committee.

Mrs Cooper advised that there were no significant risks contained within the Committee’s Risk Register that needed escalating to the Board.

RESOLVED:

That the Board received the report for information and assurance.

Dr Murphy joined the meeting.

179.2 Quality & Safety Committee Minutes from the meeting held on 9th November 2016.

RESOLVED:

That the Board received the minutes for information and assurance.

179.3 Quality & Safety Committee Chair’s Report

Dr Murphy introduced his Chair’s report referring specifically to:

Complaints response times

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Dr Murphy advised that there had been an improvement in complaint response times and consideration was being given to shortening the 40 day completion target for complaints.

Dementia care mapping

The Committee had received a presentation on the implementation of the Dementia Care Mapping in Older Adult Services that was being adopted by the Trust and this would impact positively on patient assessments.

Clent Ward Refurbishment

Dr Murphy advised that the refurbishment planning process had now put enough emphasis on preparing for the potential impact on their day to day working. Mr Axcell advised that the Board had initially approved the refurbishment of bedroom and bathroom areas and subsequently had given approval for the work to be extended to include the communal and corridor areas and the extended works had in part caused some of the issues when the works had started.

In response to the Chair and Ms Clymer, Mr Davies advised that the Head of Estates would be managing the construction works and whilst there was no overall project manager the Acting Head of Service for Inpatients would have greater involvement going forward. Mr Axcell provided assurance that lessons learnt had resulted in the development of a robust project and business case management process.

Fire Safety Management Risk

Dr Murphy advised that this item had been on the agenda for three months and he had not anticipated the extent of the challenges related to putting Trust wide fire safety policies and plans in place and he hoped to provide further assurance on progress in his Chair’s report to the Board in February. Mr Axcell fully supported Dr Murphy’s synopsis advising that differing views on the number fire Marshalls had been presented to the Committee and the Head of Estates had been charged with providing substantive information and assurance to the Committee at the meeting in January. The Chair advised that having been appraised of the issue the necessary action should be expedited for the Board to be assured that the Trust was fully compliant with fire standards and therefore fulfilling its statutory responsibility.

Out of hours incident analysis.

The Committee had concluded that there was a clear pattern of incidents occurring during week day evenings, aligned to higher numbers of agency staff on duty during the evening. The Committee would continue to monitor trends going

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forward.

CQC Unannounced Visit update

Mr Axcell advised that following the unannounced re-inspection in November, further unannounced visits had taken place in Older Adults during the same month. It was expected that the CQC Triangulation Board would consider the re-inspection report in January and the final CQC report would be submitted to the Trust in early February. The Chair queried whether there was any evidence that the areas that had been re-inspected had improved, in response Mr Axcell anticipated that the significant improvements in CAMHS would be reflected in an improved rating for that service . Two areas of concern remained which were the levels of improvement in record keeping and serious incident reviews.

Mr Axcell advised that Quality & Safety Committee had received a report on the two Trusts that had recently been rated as “outstanding” by the CQC which would be analysed by the Trust to consider areas of best practice that could be adopted by this Trust.

RESOLVED:

That the Board accepted the report for assurance about the exercise of delegated authority by the Quality and Safety Committee.

179.4 Quality Report

Mrs Musson presented the Quality report which included reference to:

• The Trust’s Incidents & Serious Incidents in month • Individual Operational Service Line Reports • Safety Alert Broadcasts (SABs) • Benchmarking • Safety Thermometer Reports • Safeguarding Performance Framework

There had been four serious incidents, although none invoked a duty of candour and there were no key exceptions to report. The Chair queried how the report would highlight to the Board any areas of concern. Ms Musson confirmed that this would be clear from the reporting on trends and the Trust was periodically reviewed against peer groups and was not an outlier in any areas. Operationally, the introduction of daily incident reporting to Executive Directors would also highlight areas of concern that needed urgent resolution.

Mr Turner drew attention to the increase in incidents over the preceding period and that only Dudley data was included. Dr Murphy stated that the increase in incidents would be

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reviewed by the Quality & Safety Committee. Mrs Musson confirmed that she would review the structure of the data included in future reports.

ACTION. Quality & Safety Committee to review the increase in incidents.

RESOLVED:

That the Board received the report for information and assurance.

179.5 Finance & Performance Committee Chair’s Report

Mr Rana presented his report and made reference to the key items discussed:

• Performance • Data Quality Improvement Plan (DQIP) • Payment by Results (PbR) • Finance • Workforce • Review of Risk Register • Estates & Capital Planning Minutes

With reference to the agency spend the Committee had concluded that whilst an action plan was in place it was unlikely that that any significant improvements could be made before the year end that would impact positively on the year-end and it was therefore expected that the £4.05m agency cap would be exceeded. Mr Axcell advised that the overspend was aligned with the 14.5% vacancy rate and reiterated that the agency cap was unlikely to be achieved , although this would continue to be managed going forward. and continuing actions to reduce agency spend were in place. Mr Axcell confirmed that non-compliance with the agency cap would not result in financial sanctions.

The Chair queried which staff group had the greatest number of vacancies and was advised that it was mainly Band 5 nurses in acute inpatient areas. Ms Musson stated that an on-going active recruitment process was in place, although the local difficulties in recruiting to these posts reflected the national position. The Trust was mitigating this by encouraging staff to join the internal bank and by undertaking a review of the staffing establishment

RESOLVED: That the Board received the report for assurance and information and noted the content.

179.6 Finance & Performance Committee Minutes from the meeting held on 28th November 2016.

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RESOLVED:


179.7 Audit Committee Chair’s Report

In presenting his report, Mr Lancaster advised that there were two areas to bring to the Board’s attention related to Estates and IT development. He confirmed that he had requested that a report on the issues in Estates be reported to the Trust Board in February.

Mr Lancaster advised that whilst IT development was not specifically an issue for the Audit Committee he wished to make the Board aware and there was a need to take a decision on the procurement of an electronic patient record system as a priority to support the improvements required in patient records identified through the CQC report even though that decision may be superseded by the outcome of partnership working.

Referring to the compliance with the Fit & Proper Persons Regulations Report, Mr Davies advised that the policy had been reviewed by the Quality and Safety Committee and an audit of personnel files was undertaken by the Company Secretary on a bi-annual basis with a subsequent report being received by the Nominations and Remuneration Committee for assurance.

Ms Clymer queried how audit recommendations were monitored to which Mr Davies provided assurance that these were input on the outstanding recommendations tracker administered by the Trust’s internal auditors and progress reported to each meeting of the Committee.

RESOLVED:

That the Board received the report for assurance and information and noted the content.

179.8 Audit Committee Minutes from the meeting held on 12th December 2016

RESOLVED:


179.9 Finance Report

Mr Davies referred to the key points within the report:

• I&E was on plan and driven by £0.5m under spend on

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pay. • CIPs were on plan although some elements were

non-recurrent and this would have an impact on the 2016/18 financial year.

• The forecast outturn of £1.7m would be achieved • Capital spend was low although the two major

schemes on Halesview and Clent Ward which were underway would have an impact .

• The Trust was negotiating with NHSI related to the transfer of £1.1m of the budget for the capital programme from 2016/17 to 2017/18 due to delays in the decision on the clinical record IT development.

RESOLVED: That the Board received the report for assurance and noted the content.

179.10 Contract Performance Report Mr Davies presented the report advising that there were 3

non-compliant KPIs.

• KPI 9 - Percentage of patients who are provided with a copy of their care plan

• KPI 16 – The proportion of users with a valid KD10 diagnosis recorded

• KPI 18 – The proportion of patients within cluster review periods

These had been discussed during the Finance & Performance Committee and the Chair of that Committee had consistently challenged the Trust to take relevant actions to ensure compliance.

The Chair stated that non-compliance with KPI 9 was of concern given that care plans had been an issue raised by the CQC following their unannounced visit. Mr Rana advised that the Board had focussed on this previously and improvements had been realised, however, it appeared that there had been some slippage in both areas once the Board had focussed attention on other areas.

The Chair queried the actions that were being taken to address the KPI 16 and Dr Weaver confirmed that whilst there remained some IT related issues and a lack of administrative support, he had met with the Clinical Directors and had advised them that appropriate action had to be taken to ensure that the KPI was compliant. The Chair sought assurance that actions taken would impact positively on the KPI.

Action: Assure the Board that actions taken have improved the Trust compliance of performance against

Dr Weaver

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KPI 16.

RESOLVED:

That the Board received the report for assurance and noted the content.

179.11 Performance Report

Mr Davies presented the headlines through the Quality and Safety, Efficiency and Resources Domains, referring specifically to the following:

Care Plans

Completion of care plans in older adults continued to be an issue. Ms Clymer queried whether the Care plans were being completed and not recorded and Mr Davies confirmed that they were not being completed. Mr Rana confirmed that the Finance & Performance continued to focus on care plans, and in particular the impact on patients when care plans were not completed. Ms Clymer stated that compliance was a requirement of the Care Act 2014.

Workforce

There were workforce issues in the community, recovery and older adults service lines.

Mr Axcell referred to th lack of benchmarking“ included against some targets within the report advising that these would be replaced by either target or benchmarking in future reports. He advised that the Performance Dashboard Report provided an overview to the more detailed finance, quality and workforce elements of integrated performance reporting to Board and as such would be incorporated into the the overarching Integrated Performance Report at future meetings of the Board to

Dr Murphy queried how the improvements in sickness rates had been achieved. Ms Williams advised that in some instances managers were not completing the end date of periods of sickness and following a data this information had been included and this had impacted positively on sickness rates. There were still issues within the community service line and these were in the process of being addressed with progress being monitored by the Workforce Committee.

RESOLVED: That the Board received the report for assurance and noted the content.

179.12 CIP PMO Report

Mr Davies advised that there were 28 projects for the current

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year two of which had been closed and 14 have delivered. A further three schemes had delivered and these are:

• CIP019-16 PMO Efficiencies CIP021-16 Performance and IM&T Establishment

Changes CIP028-16 Procurement and Tendering

CIP scheme CIP028-16 Procurement and Tendering delivered savings from the assets valuation.

He confirmed that £2.5m of CIPs would be delivered in the current financial year, although £700k would be non-recurrent.

In response to the Chair requesting a focus on the preparation of the CIP 2017-18 in future reporting to Board, Mr Davies advised that the forthcoming financial year would be challenging and taking into account non-delivery of QIPP and CIP this year would result in a cost reduction of £3.8m for 2017/18. The Executive Team had met and had identified £2.8m of CIPs for 2017/18. Mr Axcell confirmed that the draft CIP schemes would be explored in more detail at the Board Development Session on 16th January 2017.


179.13 Workforce Committee Report

Mrs Williams confirmed that the Committee was working well and that going forward the Committee would be a Board Sub-committee and chaired by Ms Clymer, with a report on January’s meeting being submitted to the Board in February 2017. She confirmed that the DBS update service was being rolled out with a programme in place to ensure staff were signed up to the updated service by the end of the financial year. Under the service, periodic checks would be undertaken instead of the full DBS with a positive cost implication for the Trust. Ms Williams drew attention to the Health & Well-being events being held on 9th and 31st January and encouraged members to attend. Whilst the Trust had not met the Health & Wellbeing of NHS Staff CQUIN target, the Committee had noted that there had been a significant improvement on last year’s take up.

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179.14 Workforce Performance Report

Ms Williams presented the report and referring to the key messages she advised that: There were 164 Full Time Equivalent (FTE) contracted vacancies across the Trust with a reduction in the vacancy rate to 14.5% in Month 8. There were 95 FTE posts being recruited to at various stages of the process. The 12 Month Turnover rate had increased slightly to 11.62% and this was average when compared to other mental health organisations. The rolling 12 month sickness rate had decreased in Month 8 to 4.59% which was within the Trusts target for the first time during the last 12 months. In month sickness had also decreased to 3.89% in Month 8, and therefore the Trust was demonstrating a lower absence rate than the Trust target for 6 months. Compliance against the appraisal target had decreased slightly from 80.0% to 79.1%, and is still below Trust target of 85%. There were 183 employees in the Trust that haven't had an appraisal recorded in the last 12 months. Mandatory Training Mandatory Training compliance had increased significantly 89.3% in Month 8 and remained just below the target of 90% agreed at MEXT for all mandatory training (IG remains at 95%). New reports were being distributed to service leads to assist with what training individuals need to undertake over the remainder of 2016/17 in order to remain compliant. All staff had been written to informing them that their Mandatory training must have been compliant by 1st December 2016 in order to qualify for an additional ½ day annual leave. Mr Turner referred to the significant variance in the number of reported vacancies and the advertised posts and Ms Williams advised that not all the posts included in the report as vacant were being actively recruited to. Further analysis would be included in future reports to the Board.. A significant amount of work was being undertaken devolve the recruitment process and empower services having more input into the process, including the recruitment to Band 5 nursing posts.

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Mr Turner stated that sickness rates had a cost implication of £1.5m for the Trust and queried the action being taken to address this. Mr Axcell confirmed that sickness rates were continually under review and highlighted that in some cases long term sickness and maternity absences were not covered by agency but managed internally by team members taking on additional duties. Mr Axcell confirmed to the Chair that the Trust had been listed in the HSJ Best Place to Work awards in 2015/16 and staff survey results had been benchmarked the previous year and the benchmarking exercise would be repeated for the 2016/17 results. RESOLVED: That the Board noted the updates on key current workforce agenda items

179.15 Freedom to Speak Up and Raising Concerns - Update

Ms Williams confirmed that, as mentioned in the Chief Executive’s report, a Staff Engagement Lead/Freedom to Speak Up Guardian (FSUG) had been appointed and had taken up post on 4th January 2017. The Staff Engagement Lead/FSUG would be pivotal in ensuring that staff were encouraged and supported to raise concerns, and to continue to develop an organisational culture of transparency and learning, although this was a cultural issue.

The Chair queried whether the concerns raised by staff had been via the electronic reporting system, and if this was the case it had not been made apparent in the report. Dr Murphy advised the Chair that the Quality & Safety Committee had reviewed an alternative recommended electronic reporting system utilised by other NHS Trusts and that the systems utilised by those Trusts that had been rated as “outstanding” by the CQC would also be reviewed. He agreed with Ms Williams that a cultural change was needed in the organisation to improve the reporting of staff concerns. Mr Axcell advised that tone of the key initial roles of the FTSU guardian would be supporting managers to positively receive and address concerns raised by staff at an early stage.

Ms Williams confirmed that the Leadership and Management programme for the Trust’s people managers would begin in April 2017. Referring to the Trust’s Value’s and Behaviour’s, Ms Williams advised that there had been an improvement in staff awareness of the Trust’s values.

RESOLVED: That the Board noted progress and received the report

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for information and assurance.

180. Medical Directors’ Report In presenting the Medical Directors report, Dr Weaver

referred to:

• GMC • Doctors under investigation • Royal College of Psychiatrists

He advised that two consultant appointments had been made and accepted in Dudley CRHT and Older Adults.

Mortality Report

There had been two unexpected deaths, both of which were being progressed to a formal investigation.

Mr Axcell received a positive response to his query related to whether a review was conducted if a patient died of natural causes following transfer from the Trust to acute services.


181. Research & Development Update Report

Dr Gingell confirmed that this was a major research project led solely by psychotherapists. It was generally agreed that organisations involved in Research & Development provided better services for patients. The Trust had received Clinical Research Network (CRN) funding in advance of achievement of the accrual target. She advised Dr Murphy that studies may have commercial potential, there was funding for portfolio studies and R&D impacted positively on staff retention and service provision. RESOLVED: That the Board received the report for assurance and information and noted the content.

182. Director of Nursing and Operations Report

Mrs Musson made reference to:

ERostering The E-Rostering system had been rolled out across all inpatient wards and was in the final stages of roll out across all other services. There continued to be substantive work to embed the system into the culture and operations of the Trust.

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In addition the Bank and Agency module of the system had been implemented. The Chair sought assurance that the system was being utilised appropriately and whether it had the potential to address any long standing local practices which did not support the effective rotas for staff to support service delivery. Ms Musson confirmed this to be the case advising that the system was now linked to pay roll and the Safer Staffing module was in the process of being implemented providing further assurance with the granular information being reported and reviewed by the Workforce Committee. Dr Murphy stated he would welcome feedback on the cost benefits realisation for E-Rostering to ensure that the investment had been worthwhile. Section 75 partnership agreements Ms Ingram provided an overview of the historical nature of the agreements, advising that two local authorities had legally delegated the Trust to provide mental health social care services under Section 75 of the Mental Health Act with social workers seconded into teams within the Trust. An extension for a further 12 months was currently in negotiation, and the Trust was reviewing whether responsibility for services in Walsall could be fulfilled given the reduction in income in that area. Winter Plan and Associated Reporting Requirements Ms Ingram that the Trust was reporting Level 2, Moderate pressure to the Department of Health under the recently introduced reporting process. RESOLVED: That the Board received the report for assurance and information and noted the content.

183. Enhancing Quality through Safer Staffing Levels – Monthly Exception Report

Mrs Musson advised that there were no areas of concern she wished to raise and no exceptions although there had been increased acuity on one ward.

Mr Turner requested, and it was agreed, that the data would be presented by ward and include the percentage of agency staff on each shift in future reports.

ACTION: Include data for each ward and percentage of staff on each shift in future reports.

Ms Musson

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RESOLVED:

The Board noted the monthly data return submitted, providing details of planned and actual staffing at ward level.

184. STRATEGIC DEVELOPMENT & DIRECTION

184.1 Business Plan 2017/18-2018/19

Mr Axcell presented the Trust’s Annual Plan for 2017/18 and confirmed that the formal submission had been made to the NHS Improvement on 23rd December 2016. He advised that the following the discussion at the Board Development session on 19 December 2016 the Trust had agreed its stretch target for 2017/18 and also for 2018/19, although the latter was subject to the outcome of decisions related to the Multi-speciality Community Provider (MCP) and Transforming Care Together (TCT) proposals.

He confirmed that the contract for 2017-2019 with Dudley and Walsall CCG’s had been signed within the appropriate timeframe.

RESOLVED:

The Board adopted the Trust’s Business Plan 2017/18 and 2018/19 and stretch targets for 2017/18 and 2018/19 with the caveats outlined in the minute above and noted that that the plan had been submitted to NHS Improvement by the required deadline of 23 December 2016.

184.2 High Level Operational Risk Register

Ms Ingram introduced the report advising that there were currently 11 risks, there were no new risks and a recommendation that the risk related to the instability of pay roll be downgraded to Amber following the transfer to The Royal Wolverhampton NHS Trust.

With regard to the Fire safety management risk, Dr Murphy requested that the gaps in assurance noted by the Quality & Safety Committee related to the unknown number of Fire Marshalls be included in the “Further Comments” column of the Risk Register.

ACTION: Include the “unknown number of Fire Marshalls” in the “Further Comments” column of the Risk register

RESOLVED: That the Board received the report for assurance and information subject to the additional future reporting

Ms Ingram

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requirements and noted the content of the report.

185. FOR ASSURANCE

185.1 MExT Chair’s report from 20th December 2016

Mr Axcell presented the report advising that the following items had been discussed:

• TCT and Dudley MCP • Business Cases • Apprenticeship Levy • Communications Update • Contracting Update • E-Rostering • Trust Business

RESOLVED: That the Board noted the content of the report for information and assurance.

186. ANY OTHER BUSINESS

There were no items of any other business.

187. DATE AND TIME OF NEXT MEETING

The next Trust Board meeting would take place at 1.00pm on Thursday, 2nd February 2017, Conference Room 1, Trafalgar House, King Street, Dudley

Meeting closed at 15.22pm Signature……………………………………………………….. Date……………. Mr B Reid, on behalf of the Dudley and Walsall Mental Health Partnership NHS Trust Board

Page 18 of 18

Enc 2 MATTERS ARISING FROM PUBLIC MEETINGS

RAG Actoin Outstanding Completion date in the future Action Completed

Item No. Date Added Action Responsibility Due Date Update

126 & 176.2

3 November 2016 & 5 January 2017

Medical Directors’ Report Review current SUI reporting process and take a decision on future reporting protocols.

Dr Weaver/Dr Gingell March

2017

Dr Gingell confirmed that the SUI reporting process is being examined in a detailed manner and through a series of meetings, and a report will be submitted to the Board in March following presentation at February’s Q&S

179.10 5 January 2017

Contract Performance Report Assure the Board that actions taken have improved the Trust compliance of performance against KPI 16.

Dr Weaver

March 2017

183 5 January 2017

Enhancing Quality through Safer Staffing Levels Include data for each ward and percentage of staff on each shift in future reports.

Mrs Musson March

2017

184.2 5 January 2017

High Level Operational Risk Register Include the “unknown number of Fire Marshalls” in the “Further Comments” column of the Risk register

Ms Ingram March

2017

149 8 December 2016

SED Report The Quality & Safety Committee to review the structure and reporting of the SED report to both the Quality & Safety

Mrs Bytheway/Mrs Musson

March 2017

1


Committee and Trust Board.

145 8 December 2016

Patient Story Investigate the issues raised by the patient’s story and report back to the Board in March.

Dr Gingell/Ms Musson

March 2017

178 5 January 2017

Chief Executive’s Overview The Mortality Review Group to discuss the Learning, Candour and Accountability Review and review the process for investigating SI’s and patient deaths incorporating the recommendations from the CQC review and report back to Board in March.

Dr Gingell

March 2017

63.1 184.1 & 4.9TB

1 July 2015 2 March 2016 6 April 2016

Quality Implications should be included more prominently on Board and Committee reports and that quality impact assessments should have greater visibility within the report.

Mr Lewis-Grundy

April 2017

Discussions are on-going with the Head of Nursing, Quality & Innovation with implementation at the beginning of the 2017/18 financial year.

125.1 3 November 2016

Quality & Safety Committee Chair’s Report Provide an up to date position report to members in relation to the Patient Record procurement exercise via Email.

Mr Davies January

2017

A verbal update will be provided in the private session of the Trust Board meeting. Completed Closed.

157 & 176.3

8 December 2016 & 5 January 2017

Quality Improvement Priorities and CQUIN Quarterly Report Include the potential risks related to

Mr Davies January

2017

Mr Davies advised that two CQUINs may not reach their target – Improving Health & Wellbeing of NHS Staff and Physical Health

2


CQUINs in the forecasted financial position.

Care. Completed. Closed.

129.4 3 November 2016

High Level Operational Risk Register Identify the risks that will be managed through the Workforce Committee and the actions to mitigate the risks to their residual score.

Ms Ingram/Ms Williams February

2017

The Work Force Committee Risk Register is a standing agenda item and the risks would be managed by the Committee. Completed. Closed.

3

Board meeting date: 2 February 2017

Agenda Item number: 6 Enclosure: 3

Report Title:

Summary of Confidential session of Trust Board held on 5 January 2017

Accountable Director:

Ben Reid, Chair

Author (name & title):

Paul Lewis-Grundy, Company Secretary

Purpose of the report: Best practice in corporate governance requires that business

considered in private session is reported into the public session as soon as possible. Given the arrangement of the Board meetings, the earliest opportunity is at the public session of the following month. This report outlines the business considered in private at the meeting of the Board held on 5 January 2017.

Action required from the Board Decision / Approval

Gain assurance

Discussion

Information

What other Trust Committee or Group has considered the key elements of this report?

Committee: None

Date reviewed: N/A

Key points or recommendations from Committee:

Strategic Objective(s) to which this paper relates:

High quality services

Inclusive partnerships

Leadership culture

Responsible workforce

Supporting strategies

Effective/efficient resources

The CQC domains that this report relates to are:

Please give brief details:

Caring

Best practice in corporate governance requires that business considered in private session is reported into the public session. Responsive

Effective Well-led Safe Enc 3 Summary of confidential session 5 January 2017 (Final)5 January 2017 (Final) Page 1 of 2

Title Summary of Confidential session of Trust Board held on 5th

January 2017. Introduction This report outlines the business considered at the meeting of the Board held in private on 5th January 2017. Summary of key points, issues and risks The Board discussed the following reports / issues:

• Sustainability Options - Transforming Care Together (TCT) Partnership Outline Business Case

• Service Development & Growth Progress Report • Director of Operations and Nursing Report • Refurbishment of wards at Bushey Fields Hospital

Board approved a revised Business Case to include the refurbishment of the communal areas and corridors as well as the bedroom and bathrooms on Clent Ward.

• On Board visits

Recommendation

The Board is invited to note the business transacted in the private session held on 5 January 2017.

Board action required The Board is asked to receive this report for information.

Enc 3 Summary of confidential session 5 January 2017 (Final)5 January 2017 (Final) Page 2 of 2


Agenda Item number: 7 Enclosure: 4

Report Title: Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)

Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary Purpose of the report: This report summarises recent reports, publications and information,

which are of relevance or interest to the Trust. It sets out the key points of each item and identifies the officer accountable for any action required and appraising the Board where appropriate.

Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: None

Date reviewed: N/A Key points or recommendations from Committee:

N/A




Leadership culture

Accountable workforce





Caring The report provides information regarding latest news and relevant strategic developments that may impact all 5 CREWS domains. Responsive

Effective

Well-led

Safe

Enc 4 Chief Executive's Overview Report Page 1 of 6

Report Title: Chief Executive Officer’s Overview (including written summary of strategic publications and headlines)

Introduction This report provides a summary of internal news from the Chief Executive and recently announced legislation, publications and information that is of interest and relevance to the Board. It identifies the Trust officer accountable for any action the Trust may be required to take and for appraising the Board where appropriate.

Summary of key points, issues and risks CHIEF EXECUTIVE UPDATE Transforming Care Together – Our partnership with Black Country Partnership NHS Foundation Trust and Birmingham Community Healthcare NHS Foundation Trust continues to progress. The work streams will now be asked to expand their membership and provide more detail on the recommendations previously made. Action: To note. MERIT and Dudley CCG Vanguard – The MERIT vanguard is in the process of agreeing a shared approach to Bed Management and was visited by the National Director for New Models of Care Samantha Jones. Dudley CCG Vanguard – the model of care development continues apace. The tender for the services within the scope of the Multi-Specialty Community Provider is due to commence in March subject to gateway reviews by NHS England. Action: To note. Walsall CCG Healthy Walsall Partnership Board – The Walsall Partnership Board has not met in January Action: To note. Strategic Planning Workshop – In January the Trust held a workshop for all managers across the Trust to discuss strategic plans, contracts, efficiency and 17/18 plan priorities. The workshop was well attended with good contribution and discussion. The feedback will now be used to shape our priorities, approach and another event is planned for February Action: To note. NATIONAL POLICIES & STRATEGIES The following national strategies and policies have recently been issued. They are potentially relevant to the future strategic, planning and operational management of the Trust and the implications should be taken into account. Each document has been considered with the respective executive directors.


This summary is not intended to incorporate all national publications, for instance those issued by National Patient Safety Agency, National Institute for Clinical Excellence or every operational directive issued by Department of Health which should be considered within the Trust by the appropriate department and necessary action taken. 1. National Tariff Payment System for 2017/18 and 2018/19

Published by: NHS England Date Published: 22 December 2016

Following a period of consultation, NHS Improvement and NHS England have published the National tariff payment system for 2017/18 and 2018/19. This package of materials contains the prices and payment rules for commissioners and providers to use for the period April 2017 to March 2019. By running for two years the national tariff aims to give providers and commissioners of NHS-funded services time to restore financial balance and support all organisations to develop and deliver ambitious longer term plans for their local health economies. Action: To assess and implement as part of the 2017/18 and 2018/19 contract negotiations. Web-link: https://improvement.nhs.uk/uploads/documents/2017-2019_national_tariff_payment_system.pdf Executive Director: Director of Finance, Performance and IM&T Board Committee: Finance and Performance Committee 2. Consultation Launch on 5 service specifications for Child and Adolescent Mental Health

Services Published by: NHS England Date Published: December 2016

NHS England has launched a consultation on five service specifications for Child and Adolescent Mental Health Services (CAMHs) Tier 4. These specifications have been developed with the support of lead clinicians and patient and public representatives, ensuring the views of stakeholders have informed development. NHS England is undertaking a formal 90 day public consultation, with plans to host a series of webinars and face to face events in early 2017. The closing date for responses is 28 February 2017. Action: We are in the process of studying the consultation document and will respond taking into account opinions of clinicians and Service Line Managers. Web-link: https://www.engage.england.nhs.uk/consultation/camhs/ Executive Director: Medical Director Board Committee: Quality & Safety Committee 3. 5 Year Forward View for Mental Health: Government Response

Published by: Department of Health Date Published: 9 January 2017

This report sets out the government’s response to the work of the Mental Health Taskforce. The taskforce report to NHS England, the Five Year Forward View for Mental Health, is an independent and far-reaching overview of what modern mental health services should be. The government will accept the taskforce report’s recommendations in full. This report provides full responses to each of the 58 recommendations made to government.


https://improvement.nhs.uk/uploads/documents/2017-2019_national_tariff_payment_system.pdf

https://www.engage.england.nhs.uk/consultation/camhs/

All of the recommendations, whether for NHS England or for government, will be taken forward. Action: Ensure recommendation are incorporated into strategic planning and priorities. Web-link: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582120/FYFV_mental_health__government_response.pdf Executive Director: Chief Executive Board Committee: Trust Board 4. Patient Experience Headlines Tool

Published by: NHS Improvement Date Published: January 2017

NHS Improvement have developed a tool in partnership with trusts to enable access to key sources of published patient experience measures all in one place – friends and family, ambulance survey, A&E survey, community mental health survey, maternity survey, PLACE, CQC inspection ratings and more. Users can get a sense of how an organisation is doing compared to others with similar characteristics. Action: To be developed as part of SED reporting. Web-link: https://tableau.monitor.gov.uk/t/Public/views/PatientExperienceHeadlinesTool/CoverPage?%3Atoolbar=top&%3AisGuestRedirectFromVizportal=y&%3Aembed=y&%3AusingOldHashUrl=true Executive Director: Chief Executive Board Committee: Quality & Safety Committee 5. NHS terms and conditions for procuring goods and services

Published by: Department of Health Updated On: 13 January 2017

The NHS terms and conditions are for the use of NHS bodies procuring goods and services from commercial organisations. This Guidance is intended to support NHS bodies when preparing terms and conditions for inclusion in tender documents and when drawing together contracts for the purchase of goods and services. They were updated in January 2017 to reflect changes in the Public Contract Regulations 2015. Action: To review; paper currently being prepared for Finance & Performance Committee. Web-link: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582539/1_Guidance_goods___services.pdf Executive Director: Interim Director of Finance, Performance & IM&T Board Committee: Finance & Performance Committee 6. Taking Revalidation Forward – Improving the process of relicensing for doctors

Published by: GMC Date Published: January 2017

Revalidation has been in place for four years and nearly all licensed doctors have been through the process. Sir Keith’s overall impression is that revalidation has settled in well and is progressing as expected thanks to the medical profession and those leading revalidation both nationally and locally. Enc 4 Chief Executive's Overview Report Page 4 of 6

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582120/FYFV_mental_health__government_response.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582120/FYFV_mental_health__government_response.pdf

https://tableau.monitor.gov.uk/t/Public/views/PatientExperienceHeadlinesTool/CoverPage?%3Atoolbar=top&%3AisGuestRedirectFromVizportal=y&%3Aembed=y&%3AusingOldHashUrl=true

https://tableau.monitor.gov.uk/t/Public/views/PatientExperienceHeadlinesTool/CoverPage?%3Atoolbar=top&%3AisGuestRedirectFromVizportal=y&%3Aembed=y&%3AusingOldHashUrl=true

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582539/1_Guidance_goods___services.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582539/1_Guidance_goods___services.pdf

The report found that there have been significant benefits:

• Revalidation has ensured that annual whole practice appraisal is now taking place. • Regular supported reflection, including feedback from patients and colleagues, is starting to drive

change in doctors' practice. • Revalidation has strengthened clinical governance within healthcare organisations, helping them

to identify poorly performing doctors, and support improvement. The report concludes that the principles of revalidation are sound but that more can be done locally to support doctors to meet requirements. There are a number of recommendations as to how the GMC, healthcare organisations, and health departments can work together to improve aspects of revalidation for the benefit of both doctors and patients. The report includes a number of recommendations aimed at healthcare organisations and their boards including the need for boards to know about any learning from revalidation, how local processes are developing, and to challenge how revalidation is helping to improve safety and confidence. Action: Noted. Any changes to our current processes will be discussed at consultant away days and through the medical management system by the Responsible Officer, one of the Joint Medical Directors Web-link: http://www.gmc-uk.org/Taking_revalidation_forward___Improving_the_process_of_relicensing_for_doctors.pdf_68683704.pdf Executive Director: Joint Medical Directors Board Committee: Workforce Committee 7. Suicide Prevention; third annual report

Published by: Department of Health Date Published: 9 January 2017

The third progress report of the cross-government suicide prevention strategy details the activity that has taken place across England to reduce deaths by suicide in the year ending March 2016. The report updates the 2012 strategy in 5 main areas:

• expanding the strategy to include self-harm prevention in its own right • every local area to produce a multi-agency suicide prevention plan • improving suicide bereavement support in order to develop support services • better targeting of suicide prevention and help seeking in high risk groups • improve data at both the national and local levels

These updates will help to meet the recommendations of the Five Year Forward View for Mental Health relevant to suicide prevention: to reduce the number of suicides by 10% by the year ending March 2021 and for every local area to have a multi-agency suicide prevention plan in place by the end of 2017. Action: To note. Web-link: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582117/Suicide_report_2016_A.pdf Executive Director: Joint Medical Directors Board Committee: Quality & Safety Committee


http://www.gmc-uk.org/Taking_revalidation_forward___Improving_the_process_of_relicensing_for_doctors.pdf_68683704.pdf

http://www.gmc-uk.org/Taking_revalidation_forward___Improving_the_process_of_relicensing_for_doctors.pdf_68683704.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/582117/Suicide_report_2016_A.pdf

Recommendation It is recommended that the Board: • Considers and discuss the information contained within this report, and note for assurance the

actions identified throughout the report. Board action required The Board is asked to:

• Note the information and actions contained within the report. • Identify any further specific action required and agreed timeframe for completion.



Agenda Item number: 8.1

Enclosure: 5

Report Title:

Trust Integrated and Contract Performance Dashboard (Month 9)


Rupert Davies – Interim Director of Finance and Performance


Makhan Singh (Principal Consultant, Information & Performance)

Purpose of the report:

To update the Board on all aspects of Trust performance at month 9 of 2016/17

• Quality and Safety • Service User Experience • Efficiency • Resources • NHS Improvement


Decision / Approval

Gain assurance

Discussion

Information


Committee: • Quality and Safety Committee considered elements from

within the Quality and Safety domain, and the Service User Experience domain.

• Finance and Performance Committee considered elements from the Efficiency, Resource and Quality and Safety Domains

Date reviewed • N/A





Leadership culture




Enc 5 Integrated Contract & Performance Dashboard Month 9 Page 1 of 5

What impact or implications does this report have on any of the following:


Caring

The report provides an update on the performance in relation to Quality and Safety, Service User Experience, Efficiency and Resources Responsive

Effective Well-led Safe


Title Trust Integrated and Contract Performance Dashboard Month 9

Introduction

• This paper presents the Trust’s performance at the end of month nine 2016/17 financial year.

• The 2016/17 Integrated Dashboard at appendix 1 allows comparison and triangulation across

Quality and Safety, Service User Experience, Efficiency, and Resources to give a comprehensive picture of the performance of the Trust.

• The 2016/17 Integrated Dashboard also includes performance, and exception commentary, by service line, so that the Board is better able to see achievements as well as any adverse performance within the overall aggregate level.

• The Trust performance against targets within its contacts with its two main CCG’s is included at Appendix 2.

Summary of key points, issues and risks

• Following a review of the KPI’s where no target was agreed, or the RAG rating was set to N/A, the Trust has now introduced in the month 9 report a set of thresholds based on the approach to use the 12 monthly average performance. The Contract Performance report has a number of KPIs where the target is only applicable to one CCG and there is no Trust wide target, and therefore performance is only reported against the applicable CCG. For these KPI, the report is showing the performance and the trend information a shade of grey where it is not reported.

Quality and Safety Domain • In December, the Trust reported 335 incidents and increase of 1.2% on the figure for November

2016. Of the reported incidents 209 were Patient Safety Incidents, but none of these incidents were considered for Duty of Candour Criteria.

• The incident numbers for Acute & Access Services have shown an increase since the previous month but remains below the 12 month average. In Older Adults the number of incidents has decreased since the previous month and is now below the 12 month average. In both areas there has been an increase in the number of incidents relating to Disruptive / Aggressive Behaviour. Further commentary in relation to themes, trends and hotspots can be found within each of the Service line reports

• The Trust reported one Serious Incident during December under the Community service line relating to a patient who died following an overdose, further details about which are included in the separate Quality Report.

• CPA Performance at Month nine where the threshold is set at 95%: Copies of Care Plan - 95.23%; CPA Formal Reviews – 96.77%.

• During December there were 7 alerts received from the Central Alert System. 6 Alerts required no action taking, 1 alert required circulating for information

Efficiency Domain • Activity against contract (NHS Activity) – NHS contracted activity remains above the target as at

month nine. In December, the Trust is reporting 261,989 units of activity against a target of 245,028. Activity against contract is above target for all service lines.


• The Trust’s Cost Improvement Target for the year is £2,500k and schemes have been

developed for the year equating to £2,663k. A recent review of schemes has reduced the total down to £2,587k, which is still more than the required target for the year. At Month 09 £1,743k worth of CIP schemes have been transacted and delivered however there are several schemes (OA Day Hospital and OA Establishment Review for example), totalling £119.7k that have yet to be devolved down to service lines. Income budgets also reflect £703k of CIP targets in relation Acute Wrekin beds and OA Dementia beds and this is non-recurrently being supported year to date by over-performance on both the Walsall contract and within NCA’s. Delivery of the full CIP target is key in achieving the financial plan for the year. Following the introduction of the Single Oversight Framework (SOF) the previous four metrics of Liquidity, Capital Serving, I&E Margin and I&E Variance form Plan that had previously been reported up to and including September 2016, have now been re-modelled. As from October 2016 the Trust is now required to report on five metrics as follows:

(i) Capital Service; (ii) Liquidity; (iii) I&E Margin; (iv) Distance from Financial Plan; (v) Agency spend (new)

• The SOF has also adjusted the scoring matrix from the previously reported top score of 4 (and a worst score of 1) to a revised top score of 1 (down to a worst score of 4). This change can be clearly seen between the reported scores in September and October. Based on the agreed ‘Agency Cap’ ceiling of £4.05m for the financial year this equates to an overall target of 8.20% of the Trust’s annual pay costs. Current position to date is reflecting an adverse position to plan of 13.91% .

• Vacancies – There are currently 176 FTE contracted vacancies across the Trust increasing the vacancy rate to 15.4% in Month 9 from 14.5% during Month 8. There are 96 FTE posts that are currently being recruited to at various stages of the process. The budgeted WTE increased by 12.8 FTE, between Month 8 & Month 9. The increase in vacant WTE can be attributed to this movement.

• Turnover – The 12 Month Turnover rate has decreased from 11.62% to 11.27%. When comparing the Turnover (exc Jr Medics) rate of the trust against other Mental Health organisations in the NHS, it was found that the trust can be considered average in terms of % Turnover.

• Sickness Absence The rolling 12 month sickness rate has decreased in Month 9 to 4.43% from 4.59% in Month 8, this is within the Trusts target and the first time this has been achieved during the last 12 months. It is the 3rd consecutive monthly fall and an improvement of 0.5% since Feb-16

• In month sickness has decreased from 3.89% in Month 8 to 3.62% in Month 9, this means 7 of the last 12 months have had a lower absence rate than that of the Trust target.

• Appraisal – Compliance has decreased from 79.06% to 77.61%, this is still below Trust target of 85% but showing a positive trend in recent months. There are 193 employees in the Trust that haven't had an appraisal recorded in the last 12 months, an improvement of the 258 reported in Month 4.

• Mandatory Training - Mandatory Training compliance has increased slightly from 89.26% in Month 8 to 89.73% in Month 9 and remains just below the target of 90% agreed at MEXT for all mandatory training (IG remains at 95%). As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake over the remainder of 16/17 in order to remain compliant.Sickness - Trust Sickness in November 2016 is 3.89%, compared to 3.91% as reported in October 2016.

• The overall Continuity of Service risk rating for the month remains green. • The overall Financial Sustainability risk rating for the month remains green. • Our overall Governance risk rating for the month is green with a score of 0.


Further detail

• Please see appended the Integrated and Contract Performance Dashboard and underpinning reports for finance, quality and workforce.

Recommendation

• It is recommended that the Board note the performance of the Trust as at month nine and

debate accordingly. Board action required

• Debate the content of the reports accordingly.


Integrated Performance Dashboard (Month 9)

Agenda Item 8.1: Appendix 1

Indicator Period Target Actual RAG Trend Indicator Period Target Actual RAG Trend

CQC Compliance YTD 0 0 G Bed Occupancy (Inc Leave) Monthly 94% 90.50% A

7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 95.49% G Bed Occupancy (Exc Leave) Monthly 80% 76.80% A

Home Treatment Episodes by CRHT (Walsall CCG only) Monthly 51 63 G Activity Against Contract (NHS Activity) YTD 63,786 66,495 G

Delayed Transfers of Care (all reasons) Monthly <7.5% 0.60% G

Never Events YTD 0 0 G

Incidents Monthly N/A 184 N/A Indicator Period Target Actual RAG Trend

Serious Incidents Monthly N/A 0 N/A Income Against Plan (£000) YTD £15,776 £15,796 G

Falls Resulting in Severe Injury/Death Monthly 0 0 G Performance against Budget (£000) YTD B/Even £53k R

Grade 3 or 4 Pressure Ulcers (whilst in our care)Monthly 0 0 G

Cumulative Agency Spend as a % of Total Employee Benefits

YTD 8.20% 22.02% N/A

MRSA Bacteraemia Monthly 0 0 G Turnover - Rolling 12 Month Jan 16 - Dec 16 8-14% 9.45% G

CRHT Gate Keeping of Inpatient Admissions YTD 95% 100.00% G Sickness - in Month Monthly 4.68% 3.18% G

Mixed Gender Breaches (Wards) Monthly 0 0 G Sickness - Rolling 12 Month Jan 16 - Dec 16 4.68% 4.18% G

PDR's % in Date (Data in ESR) Monthly 85% 68.05% R

Mandatory Training (Aggregated) Monthly 90% 86.06% A

Indicator Period Target Actual RAG Trend

New Complaints Monthly N/A 2 N/A

New Concerns Monthly N/A 7 N/A

% Complaints/Concerns regarding Care/Treatment Monthly <80% 56.00% G

Complaints Upheld/Partially Upheld (YTD) Monthly <75% 75.00% G

Compliments (Month) Monthly N/A 7 N/A

Response Breaches YTD <30% 54.05% N/A

Efficiency

Acute & Access Services Performance Dashboard 2016/17 Month 9

Quality and Safety

Resources

Service User Experience

Service Line Summary • This service line has overspent by £53k to Month 9. Ward staffing is £300k

overspent year-to-date, but is offset to a large extent by various non-ward vacancy savings (psychology and management posts), and non pay savings.

• Acute Services sickness in-month has remained consistent, 3.16% in month eight to 3.18% in month nine and continues to achieve the 4.68% Target. 12 month sickness has decreased from 4.49% in month eight to 4.18% in month nine and therefore is achieving the 4.68% Target.

• Appraisal performance has slightly increased from 67.24% in month eight to 68.05% in month nine and the service remains below the 85% target. New reports are in development which will be sent to managers to facilitate planning of appraisals during 2016/17.

• Performance for Mandatory Training has slightly increased from 85.71% in month eight to 86.06% in month nine and still remain below the 90% Target. 3


CQC Compliance YTD 0 0 G Activity Against Contract (NHS Activity) YTD 55,883 61,624 G

7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 95.49% G

CPA - Review in 12 months YTD 95% 96.86% G

CPA – Copies of Care Plans YTD 95% 96.32% G Indicator Period Target Actual RAG Trend

Never Events YTD 0 0 G Income Against Plan (£000) YTD £7,433 £7,214 A

Incidents Monthly N/A 6 N/A Performance against Budget (£000) YTD B/Even £122k G

Serious IncidentsMonthly N/A 0 N/A


YTD 8.20% 0.19% N/A

Falls Resulting in Severe Injury/Death Monthly 0 0 G Turnover - Rolling 12 Month Jan 16 - Dec 16 8-14% 3.42% R

Grade 3 or 4 Pressure Ulcers (whilst in our care) Monthly 0 0 G Sickness - in Month Monthly 4.68% 3.99% G

MRSA Bacteraemia Monthly 0 0 G Sickness - Rolling 12 Month Jan 16 - Dec 16 4.68% 5.54% G

PDR's % in Date (Data in ESR) Monthly 85% 69.91% R



Friends and Family Test - % of Promoters (CQUIN) Monthly N/A 68.00% N/A




Complaints Upheld/Partially Upheld YTD <75% 70.00% G



Efficiency

Community & Recovery Performance Dashboard 2016/17 Month 9

Quality and Safety

Resources


Service Line Summary • Community & Recovery Services position at Month 9 is £122k underspent

(a reduction of £2k in the month). This is driven by agency backfill in Walsall CRS, the formation of the Community Rehabilitation team and draw down of monies aligned with Employment Support. This is offset by continued vacancy slippage across the CRS Teams and Criminal Justice MH Team. The forecast improvement is a reflection of this continued net gain from vacancies being unfilled.

• Sickness – this service has seen a decrease in month nine to 3.99%, 4.79% reported in month eight.

• Appraisals – this service has decreased in performance to 69.91% in month nine (74.55% reported in November). New reports are in development which will be sent to managers to facilitate planning of appraisals during 2016/17.

• Mandatory training performance has remained consistent, 85.92% in December compared to 86.07% in November.

4


CQC Compliance YTD 0 0 G Activity Against Contract (NHS Activity) YTD 77,425 80,806 G

7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 95.49% G IAPT - people receiving Psychological Therapies Monthly 787 396 A

CPA - Review in 12 months YTD 95% 96.86% G IAPT - people who have successfully completed treatment (Dudley) Monthly 50% 43.17% A

CPA – Copies of Care Plans YTD 95% 96.32% G IAPT - people who have successfully completed treatment (Walsall) Monthly 50% 46.81% A

Never Events YTD 0 0 G

Incidents Monthly N/A 29 N/A

Serious Incidents Monthly N/A 1 N/A Indicator Period Target Actual RAG Trend

Falls Resulting in Severe Injury/Death Monthly 0 0 G Income Against Plan (£000) YTD £11,934 £11,941 G

Grade 3 or 4 Pressure Ulcers (whilst in our care) Monthly 0 0 G Performance against Budget (£000) YTD B/Even £232k G

MRSA BacteraemiaMonthly 0 0 G


YTD 8.20% 12.24% N/A

Turnover - Rolling 12 Month Jan 16 - Dec 16 8-14% 8.06% G

Sickness - in Month Monthly 4.68% 2.81% G

Indicator Period Target Actual RAG Trend Sickness - Rolling 12 Month Jan 16 - Dec 16 4.68% 4.40% G

Friends and Family Test - % of Promoters (CQUIN) Monthly N/A 33.00% N/A PDR's % in Date (Data in ESR) Monthly 85% 84.52% A

New Complaints Monthly N/A 2 N/A Mandatory Training (Aggregated) Monthly 90% 92.92% G



Complaints Upheld/Partially Upheld YTD <75% 80.00% A



Early Intervention Performance Dashboard 2016/17 Month 9

Quality and Safety Efficiency


Resources

Service Line Summary • IAPT Project team is in place to review and take action on the needs of delivering an IAPT

service, where the Trust needed to increase the target for IAPT KPI’s during the year in order to meet the end of year target that now only applies to IAPT and can only be met by IAPT recognised staff and IAPT therapies for depression and anxiety only. The thresholds are extremely difficult for an element of the service to meet compared with the previous position where the service met their KPI’s and also measured against the prevalence for depression and anxiety in the local communities. There is a robust communication campaign on going to encourage more people to access the service.

• The Early Intervention service line is underspent by £232k at Month 9 (an improvement of £143k in the month). The driver in month for the improvement is from our negotiations with Dudley CCG which we have now concluded and no claw back will be taken re: Dudley CAMHS slippage. Inroads have been made by the CAMHS team to address the over-establishment found in both localities. Additional monies are expected from our main CCGs for Waiting List Initiatives for CAMHS. The forecast improvement is a reflection of the net gain from these monies offset by some increased usage within Walsall PC re: IAPT.

• Early Intervention sickness has seen a decrease to 2.81% in month nine (3.91% in month eight). There has been a slight decrease in the 12 month sickness and this service is now performing in line with the 4.68% threshold reporting at 4.40%. Performance for appraisals remain consistent at 84.52% in month nine. Mandatory training remains consistent , 92.92% in month nine.

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CQC Compliance YTD 0 0 G Bed Occupancy (Inc Leave) Monthly 76% 78.00% G

7 Day Follow Up on Inpatient Discharges (YTD) YTD 95% 95.49% G Bed Occupancy (Exc Leave) Monthly 70% 69.30% A

CPA - Review in 12 months YTD 95% 97.14% G Activity Against Contract (NHS Activity) YTD 36,272 38,338 G

CPA – Copies of Care Plans YTD 95% 92.76% A

Delayed Transfers of Care (all reasons) Monthly <7.5% 0.00% G

Never Events YTD 0 0 G Indicator Period Target Actual RAG Trend

Incidents Monthly N/A 106 N/A Income Against Plan (£000) YTD £8,887 £8,616 A

Serious Incidents Monthly N/A 0 N/A Performance against Budget (£000) YTD B/Even £145k R

Falls Resulting in Severe Injury/DeathMonthly 0 0 G


YTD 8.20% 18.55% N/A

Grade 3 or 4 Pressure Ulcers (whilst in our care) Monthly 0 0 G Turnover - Rolling 12 Month Jan 16 - Dec 16 8-14% 12.38% G

MRSA Bacteraemia Monthly 0 0 G Sickness - in Month Monthly 4.68% 3.68% G

CRHT Gate Keeping of Inpatient Admissions YTD 95% 100.00% G Sickness - Rolling 12 Month Jan 16 - Dec 16 4.68% 4.64% G

Mixed Gender Breaches (Wards) Monthly 0 0 G PDR's % in Date (Data in ESR) Monthly 85% 73.86% R



Friends and Family Test - % of Promoters (CQUIN) Monthly N/A 81.00% N/A




Complaints Upheld/Partially Upheld YTD <75% 78.00% A



Older Adults Performance Dashboard 2016/17 Month 9

Quality and Safety Efficiency

Resources


Service Line Summary • Copies of Care Plan is below the 95% threshold at 92.76% at Month 9 and

Head of Service and Team Managers are reviewing the reported exceptions with the clinical.

• This service line has overspent by £145k to Month 9. Ward staffing is £335k overspent year-to-date, but is offset to some extent by various non-ward vacancy savings (psychology and community posts).

• Older Adults sickness has slightly increased from 3.09% in month eight to 3.68% in month nine. The 12 month sickness has decreased from 4.78% in month eight to 4.64% in month nine.

• Performance in appraisals has remained consistent from 74.84% in month eight to 73.86% in month nine and the service remains below the 85% target.

• Mandatory training has seen an increase in performance to 86.46% in month nine but remains below the 90% target (84.80% reported in month eight).

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1 1 1

Contract Performance Dashboard (Month 9)

Agenda Item 8.1: Appendix 2

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Part 1 – Contractual Quality Requirements – Trust and CCGs (In month performance and monthly trends)

KPI No KPI Detail and Target Trust Dudley CCG Walsall CCGTrust Monthly

TrendDudley CCG

TrendWalsall CCG

Trend

1Percentage of Service Users on incomplete RTT pathways (yet to start treatment) waiting no more than 18 weeks from Referral. (Target: Above 92%)

92.50% 100.00% 95.45%

2Care Programme Approach (CPA): The percentage of Service Users under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care. (Target: Above 95%)

95.49% 92.73% 100.00%

3Completion of a valid NHS Number field in mental health and acute commissioning data sets submitted via SUS (Target: Above 99%)

99.81% 99.89% 99.97%

4Completion of Mental Health Minimum Data Set ethnicity coding for all detained and informal Service Users. (Target: Above 90%)

91.81% 92.25% 91.81%

5Completion of IAPT Minimum Data Set outcome data for all appropriate Service Users. (Target: Above 90%)

100.00% 93.48%

6 Delayed Transfer of Care (All Reasons). (Target: Below 7.5%) 2.52% 0.00% 4.26%

7aIAPT - Proportion of people who complete treatment who are moving to recovery. (Target Dudley: Above 50%)

43.17%

7bIAPT - Proportion of people who complete treatment who are moving to recovery. (Target Walsall: Above 50%)

46.81%

8aIAPT - number of people who receive psychological therapies. (Target Dudley: 5108 pa; 426 per month)

228

8bIAPT - number of people who receive psychological therapies. (Target Walsall: 4328 pa; 361 per month)

168

9 Percentage of patients who are provided a copy of their care plan. Target: Above 95%) 95.25% 95.18% 95.67%

10 Number of home treatment episodes by crisis teams. (Target Walsall only: 608 pa; 51 per month) 63

11Percentage of people experiencing a first episode of psychosis will be treated with a NICE approved care package within two weeks of referral. (Target: Above 50%)

88.89% 100.00% 85.71%

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Part 1 – Contractual Quality Requirements – Trust and CCGs (In month performance and monthly trends)

KPI No KPI Detail and Target Trust Dudley CCG Walsall CCGTrust Monthly

TrendDudley CCG

TrendWalsall CCG

Trend

12The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 75%)

97.56% 96.17% 98.83%

13The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment against the number of people who enter treatment in the reporting period. (Target: Above 95%)

99.51% 99.52% 99.42%

14The proportion of users on CPA who have had a review within the last 12 months. (Target: Above 95%)

96.77% 96.57% 97.03%

15The proportion of users on CPA with a crisis plan in place. (Target: Walsall Only: Q1 - no target; Q2 - 75%; Q3 - 85%; Q4 - 95%)

95.00%

16The proportion of users with a valid ICD10 diagnosis code recorded. (Target: (Dudley: M1 - 75%; M2 - 80%; M3 - 85%; Q2 and Q3 - 90%; Q4 - 95%);(Walsall - TBC))

90.06% 73.02%

17 Proportion of in-scope patients assigned to a cluster. (Target: Above 95%) 96.40% 96.00% 97.40%

18Proportion of patients within cluster review periods. (Target: (Dudley Q1 - 70%; Q2 - 80%; Q3 - 90%; Q4 - 95%); (Walsall Q1 - 70%; Q2 - 76.5%; Q3 - 83%; Q4 - 90%))

71.46% 72.88%

19 Sleeping Accommodation Breach 0 0 0

20 Duty of Candour --- --- ---

21 Zero tolerance RTT waits over 52 weeks for incomplete pathways 0 0 0

22 IAPT DNA Rate (Target Walsall Only: Below 13.1%) 10.16%

23Memory Assessment Service - Face to face initial assessment to be made within 20 days (Target Walsall Only: Above 95%)

100.00%

24Dudley and Walsall Recovery Outcome Measure - Number of CPA patients assessed using DWROM (Target Dudley Only: Q1 - 65%; Q2 - 75%; M7 - 78% ; Q3 - 85%; Q4 - 95%)

87.74%


Agenda Item number: 8.1.1a

Enclosure: 6

Report Title:

Quality and Safety Committee Chair’s Report

Committee:

Quality and Safety Committee

Author:

Simon Murphy – Non Executive Director Rosie Musson – Acting Director of Nursing


Gain assurance

Discussion

Information

Introduction The Quality and Safety Committee met on the 11th of January 2017. Summary of key points, issues and risks Trust’s Criteria for Admissions from a risk to self and others due to aggressive and disruptive behavior The Committee received a presentation which highlighted a case study of a service user who was of high risk of violence and aggression. The presentation raised concerns relating to

• Inconsistencies in timely access and acceptance criteria to Psychiatric Intensive Care (PICU) wards resulting in service users being admitted to open wards. This has resulted in increased risks for both service users and staff.

• The complexities of creating a simple and consistent framework for flagging patients who are assessed as dangerous

• The need to introduce an evidence based risk assessment that would give a more consistent approach to assessing dangerousness

The Committee received information that the case presented was not isolated and actions were agreed to reduce risks to staff and ensure service users were getting timely access to PICUs.

• To look at best practice relating to the management of violence and aggression towards staff and to ensure staff well being

• To improve multi agency risk assessments and mitigation plans for high risk service users

• For discussions to be taken with partners to enable more effective risk management • To be raised through the MERIT work stream • Task and Finish group to ensure there are processes in place for high risk service

users to have robust risk management plans supported by robust risk assessments. Quality and Safety Report The Quality and safety report has now been amended to provide a summary included in the Integrated and Contract Performance Dashboard report to enable the Board to have a clearer picture of issues and trends. The Board will receive the new format in February 2017.

Enc 6 Q&S Committee Chair's Report for Trust Board - Feb 16 Page 1 of 2

Update on works around Anti-Ligature Assessments The Committee received assurance on the work relating to anti ligature assessments and mitigation plans. The Committee was satisfied with the assurance provided and agreed to receive updates by exception above and beyond the annual Anti-Ligature Report. Fire Mitigation Plan The Chair explained that initially it was hoped that the Committee would receive a formal report on the Fire Risk Mitigation Plan but this had been delayed. It was agreed that the formal report would be presented to the Committee in February. In the meantime the Committee received a verbal update which included detailed discussions about the current gaps in assurance and what actions needed to be taken. Mr Axcell explained that an outline Fire Action Plan report would be provided to the Trust Board in February for assurance. A separate report is included on the Agenda for the Private meeting of the Trust Board. Bed Occupancy Levels and Environmental Benchmark within Older Adults and Adult Services The Committee reviewed a benchmarking report relating to bed occupancy levels within Older Adults and Adult Services. It was agreed that the information in the report could be best utilised through the ongoing work being undertaken on bed usage. Expert by Experience report The Committee received the report for assurance and acknowledged the excellent ongoing work being undertaken by EBEs. CQC Action Plan Update The Committee received assurance on the progress made against the CQC action plan. The Committee was informed that following the success of the internal supportive visits future visits have now been planned for the forthcoming year. Progress against Equality and Diversity Delivery System The Committee received a report on the positive progress made against the Equality and Diversity delivery system. Board Assurance Framework The Chair advised that due to the late circulation of the Board Assurance Framework it was proposed that the report be sent to the Board in February with an explanation that due to exceptional circumstances this item was not discussed at the Quality and Safety Committee. It was suggested that the Board review the report. The Committee agreed this proposal. Mr Axcell explained that Executives would be reviewing the report prior to the Board Meeting. Recommendation and requests for direction The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Quality and Safety Committee.

Enc 6 Q&S Committee Chair's Report for Trust Board - Feb 16 Page 2 of 2

QUALITY AND SAFETY COMMITTEE MINUTES OF MEETING HELD ON 14 DECEMBER 2016 WHITEHAVEN MEETING ROOM, DOROTHY PATTISON HOSPITAL START TIME: 9.00 AM Present Dr Simon Murphy Non-Executive Director (Chair) Mr Mark Axcell Chief Executive Dr Andrew Campbell Chief Pharmacist Mrs Debbie Cooper Vulnerable Adults and Children’s Lead Dr Ananta Dave Clinical Director for Quality and Safety Mrs Olive Hewitt Clinical Quality Improvement Manager Ms Marsha Ingram Director of People and Corporate

Development/Deputy CEO Mr Tom Jinks Patient Safety and Compliance Manager Mrs Rosie Musson Interim Director of Nursing Mrs Ashi Williams Associate Director of People In Attendance Mrs Julie Adams Service Experience Lead Mr Phil Clark Interim Head of Estates Ms Jo Marshall Consultant OT - Older Adults & DCM Lead (Item 6) Mr Neil Tong Patient Safety Facilitator Mr Andy Simpson Expert by Experience (Item 18) Mr Graeme Welsh Patient Safety Analyst Mrs Winsome Tyrell-Haye Senior Administrator (Note Taker) Apologies Mr Liam Dolan Associate Director of Operations Dr Kate Gingell Joint Medical Director Mr Harry Turner Non-Executive Director Ms Wendy Pugh Director of Nursing, Operations and Estates Dr Mark Weaver Joint Medical Director

219 WELCOME AND APOLOGIES

Apologies for absence were noted as above.

220 DECLARATION OF INTERESTS

Members were asked to disclose any interest they may have, direct or

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indirect, in any of the items being considered during the course of the meeting and to note that those members declaring an interest would not be allowed to participate in the consideration, discussion or vote on any issue relating to that item. No interests were declared.

221

MINUTES OF THE PREVIOUS MEETING

The Minutes of the meeting held on 9 November 2016 were agreed as an accurate record.

222

MATTERS ARISING ACTION SHEET

The Chair asked whether there were any actions from the Minutes which were not included in the Matters Arising schedule. No further actions were raised.

Action updates were noted as follows:

223

Item 113 – RM and OH to discuss with Chair future deep dives for the Committee from Clinical audit Forward Plan. Mrs Musson advised that both she and Mrs Hewitt met with the Chair to discuss the Forward Audit Plan for Deep Dives. The Deep Dives will be cross referenced with the Commissioner’s Annual Reporting Cycle and will be shared with the Committee in January. It was agreed this action could be closed.

223.1 Item 127.10 – Response Time to Breaches. Mrs Adams advised that following a meeting with Ms Ingram, Mr Axcell and SED it has been agreed that with effect from February 2017 there will be a single point of allocation of investigating officers, SED to liaise with Governance on this and a “Please Explain” meeting will take place with the Chief Executive should investigators not meet the 25 working days deadline. Plans will be made to increase the number of officers and get them trained if required and Exec Comms will receive a weekly report on breaches. It was agreed that this action could be closed. The Chair requested that the update be included in the Committee’s report to the Board. Actions: Mrs Musson: Update on Response Time Breaches to be included in Committee’s report to Board. Mrs Adams: Progress Report on Response Time to Breaches to be

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brought back to the Committee in June.

223.2 Item 128 – Feedback from Board - Assurance on actions taken from previous Patient Story – Mrs Musson gave assurance that the actions are being reviewed with the Medical Director and an oral update would be provided to the Committee in February.

223.3 Item 142 – Workforce to ascertain progress on training to enable gym sessions. The Chair explained that Mrs Williams had sent an e-mail requesting that this be brought back in the New Year. The Committee agreed this.

223.4 Item 156.2 – Update on discussions at the Triangulation Group regarding combining outcomes and lessons learned from Embedding Lessons and Complaints. Mrs Adams explained that an update would be brought back to the Committee in January as the last Triangulation Meeting was postponed.

223.5 Item 159 – Bloxwich Improvement Plan – The Committee agreed to close this action as it was an Agenda Item and written updates had been provided on the separate actions. Action closed.

223.6 Item 163.1 – Committee to be updated on the outcome of the meeting with HR and medical colleagues to discuss the shortage of consultant cover. The Chair explained that an e-mail had been received from Dr Weaver which gave assurance that the issue relates to a particular consultant and was not about the shortage of consultant cover. The issue has been resolved, cover has been provided and there is sufficient locum cover for the consultant’s team. Action closed.

223.7 Item 191 – Mr Tong to follow up with Estates the action for the Clinical Room identified at Cross Street to be brought up to specification. Mr Tong advised that he is awaiting feedback from Estates. An update will be brought back to the Committee in January.

223.8 Item 191.1 – Mr Tong to look at the issue around safety on a public highway at the Elms and suggestion for letter to be sent to the local authority. Mr Tong explained that he had spoken to staff at the Elms since the Local Security Management Specialist undertook some work at the site and made contact with the School. Improvements have been made to the parking, however, the risk will be held on the Risk Register to monitor the situation. The Chair asked whether the Trust had received confirmation in writing regarding the improvements to the parking. Mr Tong advised that there is an audit trail of e-mails which he will add to the incident reporting system. It was agreed that the action for this Committee could be closed. Action closed.

223.9 Item 191.2 – EI Risk Register. Mr Tong advised that a meeting has been arranged with Anne-Marie Care to look at this and an update will be brought back to the Committee in January.

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223.10 Item 193 – Communication and letter to be sent to the Water Management Group to thank them for their efforts in turning the situation around. Action complete.

223.11 Item 196 – Anti-Ligature Report. Agenda Item. Action closed.

223.12 Item 197 – Task and Finish Group to be established to review recommendations to identify the standards for Dual Diagnosis. Discussion was had regarding this and it was agreed that Dr Weaver and Mrs Musson should identify champions and update the Committee in February 2017. Action: Dr Weaver and Mrs Musson to identify Dual Diagnosis champions and update the Committee in February.

223.13 Item 200 - EBE’s Report – Mrs Bytheway to look at the issues raised by Mr Stocks. Written update had been received confirming that the electronic expenses had been implemented and use of nhs.net accounts for EBEs is being looked at. The Distress Tolerance Group is being investigated through a formal complaint. Action closed.

233.14 Item 204 – Service Experience Quarterly Report - Mrs Bytheway to check that the benchmarking data on Slides 13 and 9 are correct. Written update had been received confirming that the data was correct. Action closed.

223.15 Item 205 – Quality Improvement Priorities & CQUIN Report. Mrs Musson confirmed that the issue of the Trust awaiting formal feedback regarding its plan for 1A of the Health and Wellbeing CQUIN would be included in the quarterly report to Commissioners and also raised verbally. Action closed.

223.16 The Chair asked whether members had any issues with the Forward Plan Reports Schedule. Mrs Musson advised that as the next meeting was due to take place early January, members should inform her and Mrs Tyrell-Haye if they had any issues in meeting the January deadline for reports before the Christmas holidays. Following discussion it was agreed that the reports on “Outcome of the Audit from the Working Group for patients being admitted across the localities” and the “Spotlight Session on Children and Young People Suicide and Self Harm” would be deferred to the February meeting. This will be reflected on the Forward Plan.

223.17 The Committee agreed that the actions completed could be removed from the action log.

224 FEEDBACK FROM BOARD / Q&S COMMITTEE REPORT FROM PREVIOUS MEETING

The Chair gave an oral update as follows: • The Board discussed Response Time to Breaches.

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• A Patient Story was presented to the Board which drew attention to some issues on Clent Ward and issues with integrating agency staff at particular times in service user’s care on the Wards.

• The Board received the full SED Report. Board has requested that a summary report be submitted in future, highlighting what the issues are, what the Board should be looking at and benchmarking data.

• Agency spend and overspend was discussed. • The Chairman of the Trust had requested that the structure and

contents of the DONs report be reviewed to include more information about the Trust’s nurses.

SPOTLIGHT SESSION

225 Dementia Care Mapping Ms J Marshall joined the meeting

Mrs Musson gave an introductory overview of the work undertaken by Ms Marshall around Dementia Care Mapping. Ms Marshall took the Committee through the presentation and highlighted the process for Dementia Care Mapping, Observation, Data Collation and Data Analysis. The Committee noted the progress which had been made to date and that 6 mappers had been trained. The data analysis themes showed that there were no significant differences between Dudley and Walsall, no immediate risks had been identified and the impact of other quality priorities such as “My name is” has had a positive effect. In response to a query from the Chair related to the capturing of the data, Mrs Musson advised that there are proposals to look at how IT can support audit in the coming year. A suggestion was made for I-Pads to be used to collect the data. Mrs Cooper made reference to agency and bank staff and asked whether staffing is looked at when Dementia Care Mapping is taking place. Ms Marshall gave assurance that this does take place, differences in approaches from bank and agency staff have been noted, but positive and good person centred care has also been observed and this has been feedback to staff and the agencies. The Chair asked Ms Marshall if there was one improvement that she would like to make in relation to Dementia Care Mapping what would that be? Mrs Marshall explained that she would like to see more mappers in the Trust. There was discussion regarding the possibility of the Trust having more mappers, however, it was acknowledged that there may be an issue in releasing staff for the training. Mrs Marshall agreed to look at how other Trusts undertook this. The Committee acknowledged that the Trust has driven the process for Dementia Care Mapping and there are opportunities around partnership working. The Committee noted that Commissioners are aware of the work

5

being undertaken and have asked for a presentation. In response to a query from Ms Ingram related to how the aggregated data for a ward is used, Ms Marshall explained that action themes are developed and this does impact on the wards. The Committee noted that this kind of activity would be suitable for nursing staff to use as a case base discussion to encourage reflective practice and could be embedded as part of Training and Development. The Committee recommended the commitment to continue using Dementia Care Mapping as a Quality Improvement Tool. The Committee thanked Ms Marshall for a very informative presentation. Ms Marshall left the meeting.

QUALITY AND SAFETY

226 Quality and Safety Report

Mr Welsh took the Committee through the report for November and highlighted the following:

• 4 serious incidents had been reported. • There were no cases for Duty of Candour • 9 Safety Alert Broadcasts had been received.

Acute and Access Service – There was a slight decrease in the number of incidents when compared to the previous month and these remain below the 12 month average. The highest incident reported category was Disruptive / Aggressive Behaviour. The Committee noted the spike in attempted suicides. It was agreed that Mr Welsh would explore this and provide feedback. Action: Mr Welsh to explore the spike in attempted suicides and provide an update in January. Older Adults – There was a slight increase in the number of incidents when compared to the previous month. Disruptive Aggressive Behaviour and Patient Accident were the highest reporting categories. It was clarified that the disruptive/aggressive behaviour incidents were low level incidents. Targeted training is being undertaken in Dudley to ensure that the same cohort of staff are reporting incidents as in Walsall and this may result in an increase in reporting. Mrs Musson stated that there may be some correlation in the number of incidents from long stay service users and activity and that this may need to be looked at.

6

Action: Patient Safety Team to look at number of incidents from long stay service users and activity on the wards to see if there is any correlation and inform the Committee by exception. Early Intervention Services – The Trust continues to review the incidents reported by iCAMHs. There was a decrease in the number of incidents reported for the Early Intervention Service Line. The Committee noted that there had been a peak in incidents reported from ICAMHs. Patient Safety are to review the incidents over a period of time to identify incidents reported for patients who are currently under services against incidents reported for patients who have a deliberate self-harm assessment if they are admitted to the General Hospital. Action: Patient Safety to review iCAMHs incidents over a period of time to identify incidents reported for patients who are currently under services against incidents reported for patients who have a deliberate self-harm assessment if they are admitted to the General Hospital. Community & Recovery Service – There has been an increase in the number of incidents reported this month. Mr Welsh reported that there were 4 serious incidents during the month and investigations are still ongoing. It was noted that the outcome and recommendations from the investigations would be discussed at the Embedding Lessons Group. The Committee discussed the proposal to review the Serious Incidents Process following the CQC report, it was noted that Mrs Musson and Dr Weaver will be leading on this with the Patient Safety Team. Action: Mrs Musson/Dr Weaver: Update on the review of the Serious Incidents Process to be provided in February. Ms Ingram informed the Committee that at the recent Execs to Execs Meeting with Dudley CCG they advised that they were keen to participate in a system review of how providers can work together regarding Serious Incidents. Mrs D Cooper gave assurance that this process has commenced as she had worked on some serious incidents with Dudley Group. In response to a query from Mrs Adams related to when will the new reporting structure for data input for incidents, complaints and safeguarding commence, Ms Ingram advised that a Working Group will be set up to support services and the new reporting structure will commence in the new financial year. Members were asked to be aware of the limitations around reporting until the new system is in place. Mr Tong reported that 9 alerts had been issued, 5 required no action, 3 required action and has subsequently been completed and 1 is being assessed for relevance.

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Safeguarding – Mrs D Cooper reported on the Month 7 Training data and advised that some of the Training Compliance have moved into the red because the target for the Trust’s compliance against this commissioner contracted indicator had increased. Narrative around this will be added to the report for Board. Mrs D Cooper explained that a report would be presented to the Mental Health Act Scrutiny Committee regarding the DoL’s activity because systems have changed. The Committee noted the Safeguarding Children and Adults data and that there were no exceptions to report. Mrs D Cooper advised the Committee that a Serious Case Review is due to be published next week. Originally, the Trust was not asked to provide information for this, but later received a request. The information has been provided and has been signed off by the Chair of the Safeguarding Board and the Serious Case Review Sub Group. The Trust’s Communications Department have been informed of this. The Committee received the report for information and assurance.

227 Quality and Safety High Level Risks

Mr Tong took the Committee through the report and explained that there are currently 10 red operational risks. Mr Tong explained that following the recommendation from this Committee to downgrade Risk 285 “Risks around water management systems at Dorothy Pattison Hospital, Bushey Fields and Bloxwich Hospitals, this was approved by Trust Board. The Chair explained that the Board agreed to downgrade the risk to amber as the Trust continues to monitor the risk. The Water Management Group will be informed of the Board’s decision. Mr Tong explained that it is proposed to close Risk 326 in relation to payroll activity as whilst this risk is not reportable to this Committee it had been highlighted in previous reports and has now been recommended to be downgraded. Mr Tong advised the Committee of a new risk in relation to how the planned refurbishment of Clent Ward had been carried out and the unforeseen impact that this potentially may have. Whilst this is not a red risk it was felt prudent to bring this to the Committee’s attention. It was noted that discussions would take place at Finance and Performance Committee regarding this. It was agreed that this risk should be included in the Committee’s report to Board. Action: Risk in relation to Clent Ward refurbishment to be included in the Committee’s report to Board.

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The Chair referred to the Fire Safety Management Risk and asked if the Committee was happy for the item on Fire Risk Mitigation Plan to be deferred to January as he was expecting the information at this meeting but it had not been possible. The list of Fire Marshall names which the Committee requested had not been received. The Chair stated that the Board should be informed of this via the Committee’s report and that the Fire Safety Management risk should be amended to include “Fire Marshalls”. The Committee were informed that discussions had taken place at Health and Safety Committee regarding Health and Safety Advisors and Fire Marshalls. The Trust’s contractors will be providing a list of Advisors and Fire Marshalls which will be shared with Mrs Musson. The Committee noted the Intelligent Monitoring Report. The Committee approved the Quality and Safety Risk Register and noted the actions taken to date in managing these.

228 Interim Director of Nursing Update

Mrs Musson gave an oral update as follows: • From a nursing point of view, Infection Prevention Control will be a

priority next year and how we are performing against the Code of Practice on the prevention and control of infections and related guidance.

• A pilot scheme on Observation Levels in Mental Health will be taking place and there is an opportunity for the Trust to be involved in this.

229 Fire Risk Mitigation Plan Mr Phil Clark joined the meeting

The Chair updated Mr Clark on the discussion that took place regarding the Fire Risk Mitigation Plan and Fire Marshalls. Mr Clark advised the Committee that there is a shortage of Fire Marshalls and currently there were 23 Fire Marshalls who require re-training and an additional 25 Fire Marshalls are required across the organisation. Mr Clark was asked to share the list of Fire Marshalls with Ms Ingram and Mrs Musson detailing the sites, how many Fire Marshalls are required for each site and the names of the Fire Marshalls currently in place. It was agreed that the completed list would then be shared with the Heads of Service so that the positions could be filled and training needs addressed. Action: Mr Clark to provide Ms Ingram and Mrs Musson with a list of Fire Marshalls and include details of the sites, how many are required for each site and the names of those currently in place. Mr Clark to include in the Fire Mitigation Plan suggestions for how the Plan will be sustained.

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The Chair requested that the update be included in the Committee’s report to Board. Action: Update on the Fire Mitigation Plan to be included in the Chair’s Report to Board. The Fire Mitigation Plan to be brought back to the Committee in January.

230 Risk Assessment in relation to Door Sensors

Mr Tong took the Committee through the report and explained that following an incident in April 2016, it was suggested that it may be possible to build into the planned refurbishment of Clent Ward and possibly future wards, door top pressure sensors. Consideration was given to installing an after-market door top product alarm. The device had previously been installed at Dorothy Pattison Hospital but proved to be unreliable, and had created potential fire hazards by compromising the safety of the doors. However, it has since transpired that there is a product in the research and development phase. Assurance was given that there are current controls in terms of the risk and this includes Ligature Point Risk Assessments being undertaken on all inpatient areas. Detailed discussions took place regarding this issue and it was highlighted that there is a national debate taking place within Mental Health Trusts regarding this and although the outcome is inconclusive it is felt that the evidence does not give assurance that the door top sensors will make an impact. The Committee agreed that Board should be informed that in view of the national debate and the fact that the risk of an incident involving the top of doors was low, the Committee’s recommendation is that at this stage the Trust should not retrofit all the doors with technology which may have adverse consequences. The Interim Head of Estates is liaising with the manufacturer regarding a more efficient product. Action: Board to be informed of the Committee’s recommendation that at this stage the Trust should not retrofit all the doors with technology which may have adverse consequences. The Committee received the report for discussion and information.

231 Self-Harm Incident (SI 2016/24671) Report

Mr Jinks presented the report and advised the Committee on the outcome and learning from this incident. The Committee agreed that further work was required around the timeline

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and that a risk assessment of the patient history should be formulated. Action: Patient Safety Team to formulate a risk assessment of the patient’s history and provide an update to the Committee in February. The Committee received the report for discussion and information.

232 West Midlands Quality Review Frailty Plan

The Committee noted that the West Midlands Quality Review Frailty Plan has been deferred to January.

233 “Out of Hours” Incident Analysis

Mr Tong explained that a previous report to this Committee in relation to “out of hours incidents” noted a possible spike in incidents regarding disruptive aggressive behaviour on two wards during August occurring on a weekday evening between 18:00 hours and 23:00 hours. Further work was requested by the Committee on this issue using a larger dataset to identify any commonality trends in relation to these issues. Mr Tong updated the Committee on the trends identified and explained that it was apparent that there were more incidents on a weekday evening on the two wards than for other wards and that less than 1% of these incidents were of moderate harm or higher and are classified as either low harm or no harm. Mr Tong explained that the report would be reviewed at the Inpatient Service Line Quality Meeting in January with Ward Managers and Senior Clinical Leads. A full analysis of 2016/17 incident data will be completed as part of the review of annual incident data at the end of the financial year. Discussions took place regarding the timeframe of when incidents occurred and the availability of activities during the evening. It was agreed that the Service Line Quality Groups should review the trends and see what can be done to improve this from a staff, patient, EBEs and Engagement Champions point of view and that a Ward Review should be undertaken which includes a drill down around handover and whether the incidents took place on the ward or out of the hospital setting. Actions: Mr Tong: Service Line Quality Groups to review the trends related to “out of hours incidents” and see what can be done to improve this from a staff, patient, EBEs and Engagement Champions point of view. Mrs Cooper: Ward Review to be undertaken which includes a drill down around handover and whether “out of hours incidents” occurred on the ward or out of the hospital setting.

11

The Chair requested that this be included in the report to Board. The Committee received the report for information, discussion and approval and noted the trends outlined in the data.

234 Mortality Report Q1 & Q2 2016/17

Mr Tong took the Committee through the report and highlighted the following:

• 69 deaths were reported during Quarters 1 and 2. 13 were listed as expected deaths, 41 as a natural death/natural cases and 12 as unexpected deaths and 3 deaths (due to the Trust’s contact with these service users being historic) were listed as unknown.

• There was a 72.4% higher reporting rate in Walsall than Dudley. Discussions had taken place regarding this at the Mortality Review Group and it is thought that the “Fusion System” and Memory Clinic in Walsall may be attributable to this.

• The figures were comparable between male and female mortality and were predominantly “White British”.

Discussions took place regarding the difference in figures across the Boroughs and ways of addressing this. Mr Tong advised that the Mortality Review Group, via informatics, are currently in the process of exploring the ability for the NHS Spine to feed mortality information into OASIS. Mr Jinks advised that Dr Dave delivered a presentation on Suicide Prevention at the Dudley Clinical Quality Review Meeting and they were keen for us to work together in relation to Suicide Prevention and perhaps there may be an opportunity to explore this further to include Mortality. The Chair asked that given the context of what the CQC had claimed in a report covered by the national media, and what happened at Southern Health, is the Committee clear that the Trust processes do clearly identify unexpected death. Mr Tong advised that there is an issue where death is of natural causes but the death is unexpected. Assurance was given that the decisions within the categorisation are arrived at through discussion with the Mortality Group but there are some where we continue to get information sent through because toxicology can sometimes take up to 16 weeks and further information is then sought. In response to a query from Dr Dave related to when a death occurs is this communicated to the CCG, Mr Jinks advised that this is done if the Trust is unsure and it is a serious incident. The Coroners produces a “Death List” of all deaths that occur and there was a process for sending the list of deaths to the PCT but we are unsure if this has changed given the information governance guidelines for CCGs. Discussion was had regarding the 12 Unexpected Deaths. It was agreed that the Committee should review the CQC Guidance on what the

12

requirements are and then decide the process for reviewing these. The Committee noted Appendix 2 which related to DWMH Deaths and Mortality Review Process applicable to ALL deaths and Appendix 3 which related to the Mortality Review Tool and was agreed by the Mortality Review Group. This item to be included in the Committee’s report to Board. The Committee received the report for information and discussion.

235 Bloxwich Improvement and Assurance Plan

Mr Jinks explained that the report provides an update in relation to the actions that are being implemented following a safeguarding investigation and concerns raised. Walsall CCG had undertaken an unannounced visit and a further follow up visit. A recent report has been received from the CCG and has been circulated to the Committee. The Older Adult Inpatient and Day Service Lead has reviewed the report against the Improvement Plan and feels that all the areas raised are covered in the Improvement Plan. The Committee noted that the majority of actions have been completed and the Patient Safety Team continues to monitor the incident reports. Mr Jinks suggested that the Committee recommend to the Board that in terms of monitoring around this we de-escalate back to business as usual. Mrs D Cooper reported that she attended the wards and the environmental changes have been made, it is proposed that the amber action will now turn green as all the equipment have been signed off. Mrs D Cooper further updated the Committee on the feedback which had been received from the CCG and CQC regarding the observation levels. Mrs D Cooper reported that there are some challenges around the Dementia Training Plan and work is being done around the PDR levels. Mr Axcell raised a query regarding the action around the concerns relating to current staffing establishment. Ms Ingram updated the Committee on the vacancies and explained that there are concerns about underlying staffing for Bloxwich and that a review of the establishment in light of the cohort of patients need to take place. The Chair asked what would be done about this issue. Mrs Musson explained that the Trust has an obligation every six months to review its nursing establishment as part of Safer Staffing and that this would be undertaken in that context and is scheduled to take place in January. In response to a query from the Chair related to the anonymous allegations received in relation to a patient safeguarding concerns, Mrs Musson

13

explained that the actions for that investigation have been incorporated into a larger Assurance Plan. The Committee received the report for assurance.

236 Summary of external/peer reviews assessments – Ambleside Ward This item was discussed after Item 21

Mrs D Cooper presented the report and explained that the responsive visit highlighted that there needed to be improvements made in relation to the systems and processes relating to the locking of bedroom doors and for Child visiting procedures on Ambleside Ward. The CQC subsequently formally issued two regulation notifications in relation to these areas, which the Trust is required to submit a formal response to. The report is an update in relation to the actions that are being implemented and was discussed at the CQC Steering Group. The Committee received the report for information.

EXPERIENCE AND EFFECTIVENESS

237 EBEs Report Mr A Simpson joined the meeting

This item was discussed after Item 15. Mr Simpson explained that Walsall Commissioners were invited to attend the Mental Health Forum to hear how successful the Criminal Justice Liaison and Street Triage are but they were not represented at the meeting. Mr Simpson explained that due to funding the Street Triage service in Walsall will be withdrawn. Mr Simpson has contacted the Local MP regarding this and Ms Cross and Mr Simpson are to meet with the MP to discuss this further. The Chair advised that there is a report which looks at comparison of our Trust against Northumberland Tyne and Wear Trust and their Police Force and Commissioners have praised the Street Triage because it has made a difference. Mr Tong explained that in a recent Coroner’s Report for another Trust elsewhere in the Country our local Street Triage was cited as an excellent example of good practice. Mr Axcell advised that he had written to the Chief Executive of Walsall CCG and sent him a copy of the slide which was presented at the meeting regarding the Street Triage. The Committee noted the EBEs report, which highlighted good practice and concerns arising from their visit to Bushey Fields, Bloxwich and Dorothy

14

Pattison Hospitals and their involvement in Corporate Activity. The Chair asked what was being done in terms of the issues around the buildings and environment if there was anything that could be done to improve the 136 suite. Mrs Musson explained that in terms of the cleanliness of areas this will feed back into the PLACE lite process. The Committee noted the Service Users request for Sky TV. Mr Simpson explained that there was not a lot of activity on the wards in the evenings for service users. Mrs Cooper informed the Committee that the EBEs will be involved with the Clent Refurbishment from a patient feedback point of view and this will be included in future reports. The Committee thanked Mr Simpson and his EBEs colleagues for their valuable work and for the quality, range and depth of the work covered. The Committee received the report for information, discussion and assurance. Mr Simpson left the meeting.

REGULATION AND COMPLIANCE

237 CQC Action Plan Update This item was discussed after Item 17

Mr Jinks updated the Committee on the action plan and advised that good progress had been made against the actions and that from assurance received, the Trust is confident that the amber actions are being managed on an ongoing basis. The CQC Steering Group will continue to meet until the end of March. The Trust is awating the CQC Report following its inspection. The Committee received the report for information and assurance.

238 CQC Comparator Report

The Chair stated that this report was an excellent piece of work and that Mr Shakeel should be thanked for pulling this together. Mr Jinks took the Committee through the report which provided a comparison of CQC outcomes for Trusts that have received a rating of “Outstanding” and triangulated the themes. Discussions took place regarding the report and The Chair asked what the Trust would do with the information. Mr Axcell explained that there was a theme about empowerment and decision making at the right level and where the other Trusts have been outstanding it showed that the right people at the

15

right level had the scope and authority to ensure that CREWS is carried out. It was agreed at the CQC Steering Group that Dr Weaver and Mr Jinks would lead on detailed discussions at the January meeting regarding what the Trust’s Action Plan would look like if we aspired to achieve outstanding. It was also noted that the report would be discussed at the Board Development Day. The Committee agreed that communication and innovation were key for those Trusts that stood out. The Committee received the report for information and discussion.

239 Performance Report Mr M Singh joined the meeting

This report was discussed after Item 16 Mr Singh presented the report and referred specifically to CPA Copies of Care Plan and explained that in Month 7 the Trust was above the 95% threshold, however, there was an underperformance of CPA Formal Review. Mr Singh updated the Committee on the Month 8 position. It was noted that where teams are underperforming on Copies of Care Plans this will be documented in the Month 8 report. Ms Ingram asked whether there was a system in place for notifying Heads of Services when the targets are underperforming. Mr Singh gave assurance that fortnightly reminders are sent out to Heads of Service. Mr Axcell explained that there are a number of KPIs on the Integrated Performance Dashboard where the targets are not applicable and all teams should work together to show what they are and this should be done by February Board. Mr Singh explained that there had been good engagement from operational colleagues around data recording of sickness and the rate had decreased. The Committee received the report for information.

240 Walsall Quality Schedule – Patient Safety/Adult Safeguarding/Children Safeguarding

Mr Jinks informed the Committee of the proposed reporting requirements for Patient Safety and Adult & Children Safeguarding and explained that discussions had taken place with Walsall CCG regarding the reporting schedules but are yet to take place with Dudley CCG. Mr Jinks and Mrs Cooper updated the Committee on the levels of requirement.

16

Mrs Musson explained that the Committee would need to have sight of the Dudley reporting schedule. The Committee supported the Reporting Schedules for Quality, Adult Safeguarding & Children Safeguarding.

241 Progress against Equality and Diversity Delivery System

The Committee agreed to defer this item to the next meeting due to the absence of Mrs A Williams and Mr P Singh. Action: Report on Progress against Equality and Diversity Delivery System to be deferred to the next meeting. Mr Jinks explained that the report is due to be presented at the December Clinical Quality Review Meeting. The Committee discussed this and agreed that the report could be sent to the Commissioners in draft form with an explanation that detailed discussions have not taken place at the Quality and Safety Committee. Action: Report to be sent to the Commissioners in draft form with an explanation that discussions have not taken place at Q&S Committee.

COMMITTEE BUSINESS, REPORTING & PLANNING

Sub-Group Exception Reporting / Minutes

242 Policy and Procedures Focus Group

Mr Tong reported that at the Policy and Procedures Focus Group Meeting held on 1st December 2016, the Group agreed to re-ratify the following policies which had minor amendments: • Pseudonymisation Policy • Internet Access Policy • Confidentiality and Data Protection Policy • Closed Circuit Television (CCTV) Policy • Access Control Procedure • Email Policy

The Group recommended the following policies to the Quality and Safety Committee for ratification: • Medical Revalidation Policy • Transfer and Discharge (external and internal) Policy • Incident, Near Miss and Serious Incident reporting Policy The Committee agreed the ratification of the policies and the suggestion that a summary of the key points from each policy should be included in the

17

Wednesday Wire and Team Brief. The Committee received the report for discussion and approval.

243 Medicines Management Committee

The Committee noted the exception points raised in the report. Mr Campbell advised that an audit on Safe and Secure Handling of Medicines for Community sites was undertaken and the outcome of this was that the lowest standards are 90%. Generally standards were maintained and there were no immediate cause for concern. The Committee received the report for information.

244

AGREEMENT OF NEXT QUALITY AND SAFETY AGENDA • Monthly Reports • Bi-Monthly Spotlight on Risk • Report on Bed Occupancy Levels & Environmental Benchmark with

Older Adults and Adults Services • Fire Risk Mitigation Plan • West Midlands Quality Review Frailty Plan • Commissioner’s Requirements • Benchmarking against findings from CQC Report • Quality Improvement Plan

ANY OTHER BUSINESS

245 Safeguarding Annual Report

Mrs D Cooper informed the Committee that the Safeguarding Annual Report was due in October but was deferred due to the CQC visit. Mrs D Cooper asked the Committee whether 12 or 18 months data should be included in the next report. It was agreed that discussions should take place with the Company Secretary regarding this. Action: Mrs D Cooper to discuss with the Company Secretary the period of data required for the Safeguarding Annual Report which was deferred in October.

246 AGREEMENT OF ITEMS FOR COMMITTEE’S REPORT TO THE BOARD

The items for the Committee’s report to Board were highlighted in the meeting.

247 DATE AND TIME OF NEXT MEETING

Wednesday, 11 January 2017, 9.00 am – 12.30 pm, Board Room, Canalside

18

House, Walsall Document Details

Author Winsome Tyrell-Haye Department Governance Organisation Dudley and Walsall Mental Health Partnership NHS Trust Document Type Minutes Document Title Quality and Safety Committee Minutes Version 2.0 Date of Creation 14 December 2016

19

Quality Report

Trust Board: 2 February 2017

Agenda item: 8.1.1c Enclosure: 8

Section 1 Summary of Trust Incidents and

Serious Incidents

1 SIs*

Incid

en

ts b

y C

au

se

Serv

ice

Lin

es

Section 1 Quality & Safety Exception

Summary of Trust Incidents and Serious Incidents 01/12/2016 to 31/12/20116

Report for January 2017

335 INCIDENTS

REPORTED

62.39% of incidents were Patient Safety

Incidents (209 of 335 incidents)

Cause Group No.

Incidents

Disruptive / Aggressive Behaviour: Top Causes

1 Behavioural - Aggressive 51 incidents 2 Physical Assault - Pt On Staff 23 incidents

0 Never Events

97 SIRS** DiDsisruptive / Aggressive Behaviour

CCCliiin cccal Care, Assessment And MHA

146 3

51

Behavioural - Disruptive 14 incidents

Service Line

No.

Incidents

Ser

Pat

Serious Harming Behaviour 42

Patient Accident 37 Clinical Care, Assessment And MHA: Top Causes

1 Clinical - Treatment / Care Related 29 incidents Acute 184

Older 106

E.I. 29

Other 9

Comm & Rec 6

Unclassified 1

Ac Access, Admission, Transfer 14

Medication 10

Consent, Communication And 8

Health & Safety 7

Security 7

Documentation 4

Equipment 4

Fire Incident 3

Infection Control Incident 2

2 Death - Natural Causes/Expected 6 incidents

3 Agency Staff Usage - (Please Provide Details) 4 incidents

Serious Harming Behaviour: Top Causes

1 Self Harm - Cut 10 incidents

2 Self Harm - Self Injury 10 incidents

3 Self Harm - Medication Overdose 7 incidents

Patient Accident: Top Causes

1 Fall - Observed Fall Mobilising Alone 5 incidents

2 Fall - Unobserved Fall Mobilising Alone 5 incidents

3 Patient Accident - Cuts / Skin Tear 5 incidents

335 Total Incidents Reported

Access, Admission, Transfer Discharge: Top Causes

1 Absconded (Sectioned Patient) 3 incidents

2 Attempted To Leave Ward Without Permission 3 incidents

3

Both of the recorded deaths are under investigation. One of the deaths is included in Sec 3. The other will be included in next months report as this has occured over the month end.

* SI: Serious Incidents ** SIRS: Security Incidents Reporting System

Appendix 1 - Incidents and Serious

Incidents by Commissioning Locality

Quality and Safety Report

January 2017

AP1 - Graph to show total Trust Incidents, broken down by service locality

250

200

150

100

50

0

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

2016

Dudley

Walsall

AP2 - Graph to show total Trust Incidents, broken down by serviceline showing locality only.

140

120

100

80

60

40

20

0


2016

Walsall

Acute

E.I.

Older

Comm & Rec

100

80

60

40

20

0


2016

Dudley

Acute

E.I.

Older

Comm & Rec

AP3 - Graph to show total Serious Incidents, broken down by locality.

7

6

5

4

3

2

1

0


2016

Dudley

Walsall

Section 2 Individual Operational Service line Reports

Inpatient Wal Dud Dud Dud Wal

CR

HT

PLT

Oth

er

F F mix M M

Am

ble

sid

e

Kin

ver

Wre

kin

Cle

nt

Lan

gdal

e Totals

24 16 4 17 27 1 0 1 90 7 3 0 3 9 1 0 0 23 5 3 0 1 3 0 0 0 12 2 0 1 3 4 0 0 0 10 3 3 1 1 2 0 0 0 10 7 7 2 9 9 0 0 1 35

16 0 1 0 3 3 1 1 25 8 0 0 0 0 0 0 0 8 4 0 0 0 1 0 0 0 5 2 0 1 0 1 0 0 0 4 2 0 0 0 1 3 1 1 8 8 3 1 2 10 1 0 0 25 5 2 1 2 4 0 0 0 14 3 1 0 0 6 1 0 0 11 5 0 1 1 3 0 1 0 11 0 0 0 1 1 0 0 0 2 1 0 0 0 1 0 0 0 2 4 0 1 0 1 0 1 0 7 2 2 0 3 0 1 0 0 8 2 2 1 1 0 0 0 0 6 0 4 0 1 0 0 0 0 5 2 0 0 0 0 1 1 0 4 0 1 0 1 1 0 0 0 3 1 0 0 1 0 1 0 0 3 0 0 0 0 1 0 1 0 2 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0

60 29 8 27 45 8 5 2 184

Table 2.1.1 - Total Acute & Access incidents by Cause Group and showing a position on the previous months figures

Incident Cause Group

Trend analysis 12 mth ●High

●Low

Cu

rren

t M

on

th

Pre

vio

us

mo

nth

Disruptive / Aggressive Behaviour 90 58

Top

61.5% of

Group

Behavioural - Aggressive

Destructive / Damage To Property

Physical Assault - Pt On Staff

Behavioural - Disruptive

23 18 12 4 10 9 10 5

14 Other incident causes 35 22 Serious Harming Behaviour 25 28

Top 64% of

Group

Self Harm - Self Injury

Self Harm - Cut

Self Harm - Ligature

8 5 5 1 4 3

5 Other Incident causes 8 19 Clinical - Treatment / Care Related 25 16 56% Clinical - Treatment / Care Related 14 5

5 Other Incident causes 11 11 Access, Admission, Transfer Discharge 11 14

45% Absconded (Sectioned Patient)

Attempted To Leave Without Permission 2 1

2 1 4 Other incident causes 7 12

Patient Accident

Medication

Consent, Communication And Confidentiality

Security

Fire Incident

Health & Safety

Equipment

Infection Control Incident

Documentation

Skin Integrity

8 4 6 0 5 1 4 3 3 2 4 4 2 3 1 1 1 1 0 0

Grand Total 184 145

Be

d O

ccu

pan

cy

Section 2 - Service Line Reports

2.1 - Acute & Access Service

Quality and Safety Report January 2017

Chart 2.1.1 - Total Acute & Access incident numbers received by the Trust during the last 12 months

210

190

170

150

130

110

100%

95%

90%

85%

80%

75%

Acute and Access Services Mean + 2S.D. Acute Bed Occupancy

Commentary

12 Monthly Average

Mean - 2S.D.

The monthly (mean) average for incidents relating to Acute & Access Services (calculated using data from the last 12 months) is 168.50

• Chart 2.1.1 shows the incident numbers for Acute & Access Services have shown an increase since the previous month and has risen above the 12 month average.

• Chart 2.1.1 also offers a comparison of the bed occupancy for acute inpatient services

during this period.

•Table 2.1.1 - shows the total number of incidents broken down by cause group, and highlights some of the incident categories with most activity and provides a further break down to the incident causes. Below, further information regarding some of the hotspots.

• There has been an increase in the number of incidents relating to Disruptive / Aggressive Behaviour. There are several patients on both Ambelside and Langdale who have been involved in a high number of the incidents shown on table 2.1.1. • One patient has been involved in 7 of the 16 incidents of Self harm on Ambleside ward. As part of the patients presentation this patient has been banging their head against the wall and harming with cigarettes, some requiring hospital treatment. A specialist placement is being sought and there is a case conference in early January to discuss this patient's future.

Inpatient Wal Wal Dud Dud

Oth

er O

A

Func Org Func Org

Ced

ars

Lin

den

Ho

lyro

od

Mal

vern

Totals

10 29 6 9 0 54 5 15 4 4 0 28 3 7 0 3 0 13 0 2 1 0 0 3 1 1 0 1 0 3 1 4 1 1 0 7 5 4 3 16 0 28 1 2 0 2 0 5 0 0 1 4 0 5 2 1 0 2 0 5 0 0 0 3 0 3 2 1 2 5 0 10 1 3 3 3 7 17 1 3 3 3 1 11 0 0 0 0 6 6 0 0 0 0 0 0 2 0 0 0 0 2 0 0 0 0 1 1 1 0 0 0 0 1 1 0 0 0 0 1 0 0 0 1 0 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

20 36 12 29 9 106

69

%

79%

Cu

rren

t M

on

th

Pre

vio

us

mo

nth

Be

d O

ccu

pan

cy

Section 2 - Service Line Reports

2.2 Older Adults Service Line

Quality and Safety Report January 2017

Table 2.2.1 - Total Older Adults incidents by Cause Group and showing a position on the previous months

Trend analysis

12 mth

Chart 2.2.1 - Total Older Adults incident numbers during the last 12 months

160

140

120

100

90%

80%

70%

60% 50%


Disruptive / Aggressive Behaviour

●High

●Low

80

60

40

54 41 20

40%

30%

20%

10% Behavioural - Aggressive

Physical Assault - Pt On Staff

Physical Assault - Pt On Pt

Behavioural - Disruptive 7 Other Incident causes

28 19

13 11

3 3

3 3 7 5

0

Older

12 Monthly Average

0%

Mean + 2S.D.

Patient Accident

Fall - Observed Fall Mobilising Alone

28 34

5 3

Mean - 2S.D. Older Adults exc Leave

Fall - Unobserved Fall Mobilising Alone

Patient Accident - Cuts / Skin Tear

Controlled / Lowered To Ground With Support

3 Other Incident causes

Clinical Care, Assessment And MHA

Clinical - Treatment / Care Related 45%

Death - Natural Causes/Expected

4 Other Incident causes

Medication

Serious Harming Behaviour

Access, Admission, Transfer Discharge


Documentation

Security

Consent, Communication And Confidentiality

Health & Safety

Equipment

Skin Integrity

Fire Incident

Grand Total

5 2

5 4

3 5

10 20

17 25

11 8

6 11

0 6

2 0

1 1

1 1

1 1

1 1

1 2

0 3

0 2

0 1

0 3

0 0

106 115

Commentary

The monthly (mean) average for incidents relating to Older Adults Services (calculated using data from the last 12 months) is 111 Chart 2.2.1 shows the number of incidents has decreased since the previous month and is now just below the 12 month average. Table 2.2.1 shows the total number of incidents broken down by cause group.

• From the hotspot map, Linden ward have reported a high number of incidents related to Disruptive /

Aggressive Behaviour. This appears to be in relation to a few patients. • One patient remains with the Trust (126 days) and is awaiting a bed in a care home, the family have

requested a specific care home however no beds are available. This patient continues to be involved in high numbers of low level, low harm aggression, full care plan in place.

• There has been an increase in the number incidents relating to the category of Patient accident for Malvern Ward. There is one specific patient linked to 6 incidents, as part of this patients illness they believe that they should be in an acute Hospital and they are placing themselves or being found on the floor with no harm or injury. There are no further trends in this category.


January 2017 Section 2 - Service Line Reports

60

50

40

30

20

2.3 Early Intervention Service line

Table 2.3.2 - Total Early Intervention incidents by Cause Group and showing a position on the previous months figures


Current

Month

Early Intervention

Previous month

Last 12

months

Chart 2.3.1 - Total Early Intervention incident numbers during the last 12 months

Serious Harming Behaviour 14 27

10

0

Disruptive / Aggressive Behaviour 2 6 Clinical Care, Assessment And MHA 7 4 Consent, Communication And Confidentiality 2 1 Security 0 1 Health & Safety 2 3 Equipment 0 2 Medication 1 0 Access, Admission, Transfer Discharge 2 2 Documentation 0 1 Patient Accident 0 3 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Fire Incident 0 0 Skin Integrity 0 0 Infection Control Incident 0 0 E.I. 1 2 Monthly Avera ge

Grand Total 30 50

Commentary

The monthly (mean) average for incidents relating to E.I. Services (calculated using data from the last 12 months) is 29.17 Chart 2.3.1 shows this month has seen a decrease in the number of incidents for the Early Intervention Service line, with 50 incidents reported for the month. • Table 2.3.2 shows the total number of incidents broken down by Cause Group.

Exceptions/Trends

The review of incidents reported by iCAMHs continues with a higher numbers of deliberate self harm incidents reported for the last 6 months.

All other incidents show no themes or trends.


January 2017 Section 2 - Service Line Reports

Community & Recovery


Current

Month Previous

month Last 12

months

Serious Harming Behaviour 2 3 Disruptive / Aggressive Behaviour 0 2 Clinical Care, Assessment And MHA 1 3 Consent, Communication And Confidentiality 0 1 Security 0 2 Health & Safety 0 0 Equipment 0 0 Medication 1 0 Access, Admission, Transfer Discharge 0 1 Documentation 1 2 Patient Accident 1 0 Fire Incident 0 0 Skin Integrity 0 0 Infection Control Incident 0 0

Grand Total 6 14

2.4 Community & Recovery Service line

Table 2.4.2 - Total Community & Recovery incidents by Cause Group and showing a position on the previous months figures

Chart 2.4.1 - Total Community & Recovery incident numbers during the last 12 months

18

16

14

12

10

8

6

4

2

0

Community & Recovery Service 12 Monthly Average

Commentary

The monthly (mean) average for incidents relating to Community & Recovery (calculated using data from the last 12 months, and as a combination of the previous individual Services) is 9.92 Chart 2.4.1 shows the incident figures which have increase when compared to the previous month. • Table 2.4.2 shows the total number of incidents broken down by cause group.

Exceptions/Trends

The have been no trends or significant incidents relating to this service.

Section 3 Serious Incidents

Section 3.1 - Serious Incidents Quality and Safety Report

January 2017

Table 3.1 - List of Serious Incident raised during the month of December 2016

SI Number Date of Incident Service Line Incident Description

Level of

Risk

DoC

applicable

Level of response Current status

2016/32619 13/12/2016 Comm & Rec Completed Suicide - Medication Overdose Moderate No Clinical Review Ongoing

Chart 3.2 - Total number of Serious Incidents during the last 12 months Chart 3.1 - Summary of the Serious Incident types during the last 12 months

12 2% 2% 2% 2% 10

8 5%

6

4

2

0

46%

Serious Harming Behaviour

Access, Admission, Transfer Discharge

Clinical Care, Assessment And MHA

Disruptive / Aggressive Behaviour

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 41% Fire Incident


Serious Incidents

Trust Average

Mean + S.D.

Mean - S.D.

Patient Accident

Commentary Incident Summary

The monthly (mean) average for serious incidents across the Trust (calculated using data from the last 12 months) is 4.00

Table 3.1 Shows a list of the serious incident logged on STEIS during the previous month, this includes details of the service line and nature of the incident • There was one Serious Incident raised during the month of

December 2016. This is listed at the side of the page along with an update of the previous Serious Incidents logged in November 2016.

Chart 3.2 shows that the number of Serious Incidents are consistent across the year on a monthly basis.

Chart 3.1 illustrates the types of the Serious Incidents that have been reported over the previous 12 months.

December Serious Incident(s)

2016/32619 - The patient had passed away at hospital due to taking an overdose of paracetamol tablets. The patient was last seen by the Psychological Therapies Hub in August 2016, however, was discharged due to disengagement following four DNA's. A review is due to take place in January 2017.

November Update: 2016/30859 - The patient had taken their life by Asphyxiation. The patient had previously been seen by the Trust’s Psychiatric Liaison Team a week prior to their death and was discharged from the service. The patient was due to be followed up by the Primary Care Mental Health Team. A review took place following the incident and it was identfied that there were no failings in our care or service provided, a timeline was sent to the Coroner's who were in agreement and closed the case.

2016/30156 - The patient had taken their life by hanging. The patient was open to CMHT from February 2016 and was discharged in May 2016. The patient was last seen by their care co-ordinator in late October and there were no significant risks or changes identfied. A review is due to take place in January to review the care provided for the patient.

2016/28752 - Patient who was histroically known to the service but discharged back to GP had been arrested and charged with attempted murder. The Trust reviewed the patient's care and access to service and established a number of low risk actions not directly affecting the outcome of the investigation, these actions are currently being implemented. The Trust has requested a downgrade from the CCG.

2016/28743 - Patient known to our E.I. team took an overdose and was admitted to the Acute Hospital - ITU for treatment. The patient is reported to have recovered well and is engaging well with the service. A review took place and it was agreed that there were no failings identified in our care or service provided to the patient, therefore, a downgrade has also been requested.

Section 4 National Guidance:

Safety Alert Broadcasts (SAB's)

Type of Alert

Number of Alerts in December

Action not Required

Assessing Relevance

Action Required

Circulated for Information

MDA 2 2 0 0 0 MHRA 1 1 0 0 0 CMO 1 0 0 0 1 DDL 0 0 0 0 0 EFN 3 3 0 0 0 DH – EFA 0 0 0 0 0 DH 0 0 0 0 0 SDA 0 0 0 0 0 NHS – PSA 0 0 0 0 0 Total 7 6 0 0 1

Section 4 – Safety Alerts


January 2017

Table 4.1 – Summary of Alerts received during December 2016

• During December 2016 there were 7 alerts issued via the Central Alerting System, of these 7 alerts:

o 6 Alerts required no action taking. o 1 alert required circulating for information.

• The table below (4.2) outlines a summary of the alerts

issues and any action taken.

Table 4.2 –Alerts issued during December via the Central Alerting System Alert Number

Alert Date

Description of Alert

Status

Notes / action taken / assurance

MDA/2016/022 13-Dec-

2016 Heater-cooler devices used in cardiac surgery – risk of infection with Mycobacterium species.

Updated advice from manufacturers on device management for systems known or suspected to be contaminated with Mycobacterium chimaera.

Action Not Required

The Trust does not conduct cardiac surgery. As such no action was required in relation to this particular alert

EFN/2016/61 14-Dec- 2016

High Voltage Hazard Alert - Suspension of Operational Practice (SOP) - CG Power Systems - 11 kV/200 kVA Pole Mounted Transformers

Action Not Required

The Trusts authorising officer acknowledged receipt of the alert and that no action was required by the Trust

EL(16)A/17 14-Dec- 2016

Drug alert class 4 caution in use; Medreich; amoxicillin sugar free suspension 250mg/5l and 125mg/5l; pl 21880/0124 and pl 21880/0123 Medreich has provided handling instructions following several complaints that the child-resistant caps are difficult to open. The complaints follow the introduction of a new child-resistant cap with a red tamper-evident ring earlier this year. A very small number of caps have an incompatibility between the cap and the bottle.

Action Not Required

The Trust has not been supplied with any of this particular medication.

CEM/CMO/20 16/005

19-Dec- 2016

Influenza Season 2016/17: Use of Antiviral Medicines With surveillance data indicating an increase in influenza cases in the community. GPs and other prescribers working in primary care may now prescribe antiviral medicines for the prophylaxis and treatment of influenza at NHS expense. This is in accordance with NICE guidance, and Schedule 2 to the National Health Service (General Medical Services Contracts) (Prescription of drugs etc) Regulations 2004),

Circulated for information

This alert was circulated for information as per the requirements of the alert

EFN/2016/62 21-Dec- 2016

High Voltage Hazard Alert - AEI - JB921 Class QA471 - Circuit Breaker Action Not Required


MDA/2016/023 22-Dec- 2016

Alaris® syringe pumps (all models) – risk of uncontrolled bolus of medicine with non-recommended syringes Action Not Required

The Trust does not use any of these devices. As such no action was required in relation to this particular alert

EFN/2016/63 22-Dec- 2016

High Voltage Hazard Alert - Dangerous Incident Notification (DIN) - Hawker Siddeley Switchgear Ltd - URV12 - Circuit Breaker

Action Not Required


Section 1 Safeguarding Training Compliance

Safeguarding Training Complaince Safeguarding Performance Framework

for December 2016

Training Data Month 8 (November)

DWMH Dudley Walsall Corporate / Pan Trust Compliance Target Compliant Required Compliant % Compliant Required Compliant % Compliant Required Compliant % Compliant Required Compliant %

compliance compliance compliance compliance Safeguarding Induction 100% 13 13 100% 4 4 100% 7 7 100% 2 2 100% Safeguarding Adults Lvl 1 85% 248 263 94% 73 78 94% 65 70 93% 110 115 96% Safeguarding Adults Lvl 2 85% 614 702 87% 243 284 86% 257 292 88% 114 126 90% Safeguarding Adults Lvl 3 85% 431 497 87% 160 192 83% 194 215 90% 77 90 86% Safeguarding Adults Lvl 4 85% 3 4 75% 0 0 - 0 0 - 3 4 75% Safeguarding Children Lvl 1 85% 247 263 94% 72 78 92% 65 70 93% 110 115 96% Safeguarding Children Lvl 2 85% 613 702 87% 246 284 87% 255 292 87% 112 126 89% Safeguarding Children Lvl 3 85% 422 497 85% 160 192 83% 185 215 86% 77 90 86% Safeguarding Children Lvl 4 85% 4 5 80% 0 0 - 0 0 - 4 5 80% Mental Capacity Act 85% 586 712 82% 242 289 84% 252 309 82% 92 114 81% PREVENT 90% 615 710 87% 246 288 85% 275 310 89% 94 112 84%

Domestic abuse & Violence 40% 306 662 46% 118 271 44% 137 288 48% 51 103 50%

Exceptions / Commentary This section shows the latest Training requirement and compliance levels as set out in the new Comissioner Contract, related to Safeguarding and Vulnerable Adults. Within the contract there are agreed trajectory requirements.

There is work ongoing with ESR to ensure the new training in relation to Domestic Abuse & Violence is captured and recorded accurately.

Adult Safeguard Training - Childrens Safeguarding Training - Q1 - Scoping exercise to identify numbers and training levels required Compliance as detailed in the table above. Q2 - 80% Q2 - 80% Q3 - 85% Q3 - 85% Q4 - 90% Q4 - 90%

Mental Capacity Act (MCA) and Deprivation Of Liberty (DOL’s) Prevent Domestic Abuse Q1 80% Q1 75% Q1 20%

Q2 80% Q2 80% Q2 30% Q3 85% Q3 90% Q3 40% Q4 90% Q4 95% Q4 50%

Section 2 Deprivation of Liberty (DoL's)

& Domestic Violence

Active DoL's NHS

Dudley NHS

Walsall

Old

er

Linden 9

Cedars 3

Holyrood 10

Malvern 6 Acute Langdale 1

Total 16 13

2016 Grand

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

NHS Dudley 1 0 0 3 0 3 4 4 6 1 5 2 29

DOL's Applied For 0 0 0 1 0 1 3 2 1 1 5 2 16

DOL's Closed 1 0 0 2 0 2 1 2 5 0 0 0 13

NHS Walsall 4 5 2 4 8 2 5 7 5 6 7 1 56

DOL's Applied For 0 0 0 0 0 0 1 0 2 4 5 1 13

DOL's Closed 4 5 2 4 8 2 4 7 3 2 2 0 43

Grand Total 5 5 2 7 8 5 9 11 11 7 12 3 85

Dudley Walsall

Open To

Mental

Health

Referred

into

MARAC

Open To

Mental

Health

Referred

into

MARAC

MARAC 40 1 20 1

Safeguarding Cases Internally reported as

Domestic Abuse

Dec-16

Alert Only 15

Referral 7

Safeguarding Performance Framework for December 2016

Section 2 - DoL's and Domestic Violence

2.1 Deprivation Of Liberties (DOL's) - This shows the total number of active cases of DOL's,

broken down by Locality

2.2 Domestic Abuse

Total number of cases of Domestic Violence for the current

month, these include cases reported within the Trust and

Externally notified by MARAC (Multi-Agency Risk Assessment

Conference)

Commentary Table 2.1 This table shows the activity in relation to cases of Deprivation Of Liberties (DOL's). This information is broken down by locality and shows the current number of Active cases, and activity for the last 12 months. There are currently 29 active cases of DoL's across the Trust

Further information relating to Older Adults, health related legal restrictions / provisions (Ward breakdown provided above).

Table 2.2

• Dudley - 16 patients

• Walsall - 13 patients

Domestic abuse cases are reported as separate figures to display the prevalence within the service. Case figures are also shown for MARAC (multi agency risk assessment conference), these figures demonstrate how many cases are heard at MARAC where the victim, perpetrator or children are open cases to mental health. • The first table provides information on Cases reported Externally of the Trust which are then checked to see if these

Patients are open to Dudley and Walsall Mental Health. • The second table provides information on Domestic Abuse cases which have been reported internally into our Trust

Section 3 Safeguarding Children

& Vulnerable Adults

Dudley Walsall Grand

Total Referral Alert Only Referral Alert Only

Child Safeguarding Case 8 17 4 1 30

Patient considered High Risk 0 0 0 0 0 Position of Trust Internal 0 0 0 0 0 Position of Trust External 0 0 0 0 0 Under 18 Admission 0 0 0 0 0 Under 18 Death 0 0 0 0 0 FGM 0 0 0 0 0 Serious Case Review (Child) 0 0 0 0 0 Grand Total 8 17 4 1 30

3.1 Safeguarding Children Safeguarding Performance Framework

for December 2016

Graph 3.1 - This graph provides information relating to the last 12 months and shows a breakdown of Safeguarding cases which are just for alert only and those which have been progressed to be continued under Safeguarding

Table 3.1 -This shows that the number of Safeguarding cases broken down by case type and showing the locality . This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency.

Table 3.1.1 This table provides information in relation to Looked after Children (LAC), who have been referred or in receipt of our services. Serious Case Reviews (SCR) - The Trust is currently involved in 3 Serious Case Reviews. In the Walsall Borough there is 1 case, which the Trust has provided input, The final report for this case is now out for review. In Dudley there are 2 cases . 1 case involves a child perpetrator and 2x child victims all of whom have been known to CAMHs. The other case is now complete and we are awaiting sight of the final report. The outcome requires the trust to produce evidence of action taken over the past 2 years to ensure systems are in place to flag and respond Safeguarding concerns effectively with the Police.

Table 3.1 Total number of Safeguarding Children cases for the current month

Graph 3.1 - Total number of Safeguarding Children incidents reported during the last 12 months

Table 3.1.1 Looked after Children (LAC) Total number of cases of Looked after Children

35

30

25

20

15

10

5

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

2016

Alerts Referral

Dudley Walsall

Grand

Total Number of Looked after

Children Number of Looked after

Children Total 109 135 244

3.2 Vulnerable Adults

Safeguarding Performance Framework

for December 2016

Graph 3.2 -This graph provides information relating to the last 12 months and shows a breakdown of Vulnerable Adults Cases which are just for alert only and those which have been progressed to be continued under Safeguarding.

Table 3.2 This shows that the number of Vulnerable Adults cases broken down by case type and showing the locality. This also shows information on whether the case is for alert only or if it has been referred for further investigation to another agency .

There is 1 PREVENT case which has been reported by the Trust, this case is being overseen and monitored by the Safeguarding team along with Multi agency professionals.

Serious Case Review - There is one SCR in walsall, this case is ongoing and both Victim and Perpetrator are previously know to the Trust. Domestic Homicide Review (DHR) - There is one case in Dudley which is ongoing

Table 3.2 - Total number of Vulnerable Adults incidents for the current month

Graph 3.2 Total number of Vulnerable Adults incidents reported during the Last 12 Months

Dudley Walsall Grand

Referral Alert Only Referral Alert Only Total

Adult

Patient Considered High Risk

Position Of Trust Internal

Position Of Trust External

Prevent Case

Serious Case Review (Adult)

DHR

FGM

Grand Total

18 28 26 59 131

0 0 3 5 8

0 0 0 0 0

0 0 1 1 2

0 0 2 1 3

0 0 0 0 0

0 0 0 0 0

0 0 0 0 0

18 28 32 66 144

100

50

0


2016

Alerts Referral



Enclosure: 9

Report Title:

Finance and Performance Committee Chair Report

Committee:

Finance and Performance Committee (F&P)


Pawiter Rana – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Key issues & risks The Finance and Performance Committee met on the 23rd January and considered the Finance, Performance information and HR position for December (Month 09). The committee reviewed the following items of business: Performance Several reports were tabled including:

• Monthly Performance report • Inpatient Services report • Delayed Transfer of Care report • 2017/18 KPI update • CQUINs update

The reports tabled were accepted and the following areas were noted:

• KPIs – still under-performance against 5 of the agreed 26 KPI’s, namely ‘cluster review periods’ and ‘IAPT’. Discussion took place around assurances regarding data quality and also around the consistency of processes in place, as some areas are performing well against cluster reviews whilst others are not.

• Cancellations – overall still above Trust target of 15% - currently 19%. • Inpatient ALOS – benchmarking is showing the Trust is at the lower quartile, although it

has been identified that our overall bed capacity of 181 beds might be overstated and is therefore reducing our actual occupancy levels. Agreed for this to be reviewed.

• KPIs – for 2017/18 there are 8 new KPI’s identified. It was noted that whilst some KPI’s (such as percentage of clients offered a copy of care plan) are no longer being specifically monitored by one of our two main commissioners, the Trust will continue to record and report on these for its own internal monitoring.

Enc 9 FandP Chairs report Feb Board MeetingPage 1 of 3

• CQUINs – there are currently two schemes at financial risk at this time – Health &

Wellbeing (flu vaccinations) and Physical Healthcare (IAPT). In terms of flu vaccinations the Trust may well receive part payment from Walsall commissioners due to having negotiated a more favorable achievement threshold.

PbR Update Unclustered activity had seen a rise in December and was reflective of a growing trend over the last few months following a period earlier in the year of good performance. The main driver is in relation to ‘admitted’ activity. Concern was raised that parts of the clustering data was reflecting staff members within the medical group who have since left the Trust – agreed to review data quality and update. Finance Report & Income Report The finance report was presented. The financial position to the end of December 2016 showed a £1,340k surplus which was £74k ahead of the plan to date (based on the planned annual surplus of £1,700k). Current forecast positions within the service lines, supported by Trust-wide Reserves are on track to achieve the required annual surplus. In December Contracted Income continued to show an adverse variance of £418k (£438k in Month 08). This has been driven by the inclusion of the projected claw-back of QIPP monies by Walsall CCG, with a Full Year Effect of £728k. Following a meeting with the respective CEO’s and Finance Directors, a settlement has now been reached which will mean Walsall CCG will pay £335k in relation to these QIPP schemes in 2016/17. It was noted that the previously reported under-performance against CQUINs is also reflected in the current financial position. Agency spend was discussed in light of the NHSI agency cap of £4.05m. The position year to date as of month 09 is reporting an overspend of £311k and a projection for year-end of circa £500k above the required target. CIPs were discussed and it was noted that there was currently a £46k gap in achievement in year but this is improving (noting recent movements within the Medical CIP that will deliver the full target by year end). There still, however, remains a £1m recurrent gap moving into next financial year. Reference Costs The report highlighted that the Trusts RCI had moved from the previously reported position of 82 in 14/15 to the higher score of 91 in 15/16. This change had been driven by reduced activity in Dudley along with a data cleanse of non-admitted data.


Deloitte’s Report on Dudley MCP Financial Impact The report presented highlight 3 scenarios whereby the loss of Dudley activity would significantly impact on the financial sustainability of the Trust, ranging from a shift in 17/18 from a surplus financial position to a deficit position of between £3m to £6m (and a 5-year deficit of around £23m). Workforce Report The latest report was discussed which reflected an deteriorating position in terms of vacancies (15.4% in Month 09 compared to 14.5% in Month 08) which was due mainly to an increase in budgeted wte. Sickness and mandatory training have improved slightly in month whilst appraisals have taken a slight downturn. The committee agreed that a further push on appraisals was needed. Review of Risk Register A report on the risk register was reviewed and amendments to the key risks detailed on the register were discussed and agreed. A watching brief on CQUIN performance was also suggested going forward. BAF A report of SR2 financial sustainability was tabled and discussed. The content was noted and accepted. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups:

• MEXT • Audit Committee • Governance & Quality Committee • CARM • CQR

Recommendations and requests for direction The Trust Board is asked to:- Accept this report for assurance about the exercise of delegated authority by the Finance and Performance Committee Endorse the decisions and recommendations made by the Finance and Performance Committee.



Agenda Item number: 8.1.2b

Enclosure: 10

FINANCE & PERFORMANCE COMMITTEE MEETING

Minutes of a Meeting Held on

19th December 2016

Conference Room 1, Trafalgar House, Dudley

START TIME 13:00 HOURS

Present: Pawiter Rana Non Executive Director (Chair) John Lancaster Non Executive Director Mark Axcell Chief Executive Officer Dr Kate Gingell Joint Medical Director Rupert Davies Interim Director of Finance Rosie Musson Interim Director of Nursing In Attendance: Jacky O’Sullivan Clinical Development Director/Acting Associate Director of

Operations Makhan Singh Principal Consultant, Information & Performance Paul Chamberlain Head of Financial Planning Ashi Williams Interim Director of People Dan Howard Head of IM&T Steve Byng PbR Lead (Agenda Item only) Emma Jackson Note Taker Apologies: Dr Mark Weaver Joint Medical Director Wendy Pugh Director of Operations, Nursing & Estates Marsha Ingram Interim Director of Operations Mark Banks Deputy Director of Finance Liam Dolan Associate Director of Operations ACTION 74. Apologies For Absence

74.1 Apologies noted as above.

Enc 10 FPC Minutes_Final_19.12.16 Page 1 of 8

75. Minutes of Previous Meeting held on 28 November 2016

75.1 The minutes of the previous meeting held on 28 November 2016 were agreed as an accurate record.

76. Matters Arising

76.1 76.2 76.3 76.4

The completed and closed matters were discussed and an update was provided on those actions where appropriate: Minute 55.5 Matters Arising – Any Other Business Mr Rana acknowledged that the action to share Fujitsu Rapid Assessment process remained outstanding. Action to be brought forward to January. Minute 68 – PbR Update – Month 7 Dr Gingell confirmed that her PA was in the process of setting up a meeting to take forward the issues relating to cluster review performance. Action to be brought forward to February. Minute 11.62 – CQUIN Update – Month 10 It was noted that the Committee required a regular update with regards to performance against CQUINs and likely forecast outturn. Mr Axcell requested that a paper be brought to the Committee in January 17. Minute 98.2.1 Data Systems and Clinical Review It was noted that the Replacement Clinical System Business Case had not been scheduled on the Committee agenda today and therefore this action was not green/completed/closed as indicated on the actions sheet. It was agreed that a business case or an alternative paper (dependant on outcome of TCT discussions) would be brought to the Committee in February. Action to be brought forward to February.

Mr Parker

77. PERFORMANCE

77.1 Performance Report – Month 8

Mr Singh talked through the key messages as reflected on page 5 of the report noting a positive position with regards to NHS contracted activity and KPI compliance, with the exception of one KPI relating to the proportion of patients within a cluster review period. Mr Rana questioned the reason for an underperformance against the percentage of patients provided with a copy of their care plan (Dudley). In response, Mr Singh acknowledged that this same question had been raised and discussed at previous Committee meetings. Mr Singh continued to explain that he did work with colleagues, had met with Mr Nick Stephens in addition to


discussions having taken place at CARM around the need for actions to be undertaken in a timely manner. Mr Davies acknowledged that the Trust was on the cusp of achieving target, following which Mr Davies asked if the membership of CARM was deemed appropriate. Mr Howard acknowledged that CARM needed to challenge individuals more, in addition to work needing to take place with teams to eliminate any red rag ratings. Mr Rana highlighted that the issue impacted on the Trusts service users and therefore needed to be addressed. Mr Rana added that the challenge raised at the Committee today needed to be replicated at other relevant committee’s/meetings. Mr Lancaster questioned why the target against this particular KPI was not set at 100%. Mr Singh commented that 100% would be achievable. However, thresholds were set via Commissioners, based on a number of different reasons for example, not all patients wished to receive a copy of their care plan. Mr Axcell added that there would always be a group of patients whereby the Trust could not provide a copy of their care plan. The question raised via Mr Axcell was “what are the factors preventing individuals from providing a copy of a patients care plan”? What were the real issues? Mr Axcell acknowledged that some teams were frequently below the 95% target – therefore, what was needed/what did the Trust need to put in place for these teams to achieve target, without the Trust having to monitor their performance? Mrs Musson echoed Mr Axcell’s comment that the root causes needed to be identified and addressed. It was agreed that operational teams would present a report to the Committee in February, identifying the drivers for underperformance re; care plan indicators and actions to address. Mr Rana noted compliance against the Memory Assessment Service KPI, requesting that a “well done” message was relayed to the team, on behalf of the Committee. As discussed previously, Mr Rana commented that the underperformance against the KPI relating to the proportion of patients within cluster review periods, needed to be addressed. Dr Gingell provided assurance that a meeting would be held, as agreed, to look at the process and the issues, following which feedback would be provided to the Committee in February. Mr Axcell requested that a 2017/18 KPI update be added to January’s agenda. Mr Axcell felt it was important for the Committee to understand what KPIs the Trust were signed up to next year and how ready the Trust would be as at end March 16. The Committee discussed and noted the contents of the report.

Mr Singh Mr Singh Mr Singh

77.2 PbR Update

Mr Byng attended the meeting to provide an update around


progress with the monitoring un-clustered activity and clustered caseload performance. Mr Byng highlighted two concerns, the first relating to inpatient clustering which had increased in month and secondly, cluster reviews. With regards to inpatient clustering, Mr Byng advised that training needs were being reviewed, acknowledging the importance of ensuring individuals were clear of the process and expectations. Upon questioning, Mr Byng advised that the issue related to the use of Oasis on ward areas. Mr Howard commented that he was not aware of any system issues and offered his support to address any system issues. In relation to cluster reviews, Mr Byng advised that he had met with a number of teams and Clinical Directors, outcomes of which would feed into the action agreed at the previous meeting to look at the process/issues and actions to address (item number 68). In response to Dr Gingell, Mr Axcell advised that he expected this action to be clinically led, acknowledging that operational input would be necessary. Dr Gingell was keen to understand how Mr Byng was working with teams i.e. EAS, CRS, questioning if there was a different action plan for teams. Dr Gingell highlighted that focus should not be placed on individual doctors only. Mr Byng confirmed that based on the team examples provided by Dr Gingell, the patient would show in two lists, resulting in the cluster review position potentially looking worse than it actually was. Dr Gingell highlighted that this was why the data needed interrogating. The Committee discussed and noted the contents of the report.

78. FINANCE

78.1 Finance Report – Month 8

In the absence of Mr Banks, Mr Chamberlain talked through the key messages as reflected on page 3 of the report, highlighting a Month 8 surplus of £1,069k, a favourable variance against plan of £16k year to date. The following points were raised and noted:-

• Mr Axcell commented that whilst the Trust was on target, individuals needed to be mindful that any remaining monies from this year would contribute to the financial challenges next year.

• Pressure inpatient areas included Ambleside and Bloxwich with £60k spend, in month (above forecast) due to a significant number of patients requiring observation.

• The agency position was difficult to manage. Whilst the Trust was one of the better performing Trusts, the Trust was now starting to move away from the agency cap. The


reasons for this were linked to activity on specific wards.

• Mr Davies advised the Committee that whilst the Trust had provided three clear water tests, continued testing was being recommended.

• In relation to the forecast position that had been debated at the previous committee meeting, Mr Axcell noted that the areas under discussion had improved since last month which was positive. However, Mr Axcell required assurance that the forecast position was robust and would remain stable. Mr Chamberlain commented that he did not expect the forecast position to change vastly, and should the position change, the change would be favourable.

• The Trust continued to report very limited capital spend. Mr Davies advised that works at Hill House and Halesview had now commenced. In addition, contractors were now on site at Bushey Fields Hospital to commence the bathroom and bedrooms refurbishment, due to be completed at the end of March 17. In relation to Electronic Patient Records, Mr Davies informed the Committee that he had been liaising with NHSi with regards to slipping the capital budget by £1m this year, to put into next year.

• The CIP position had not changed since Month 7. In response to Mr Axcell, Mrs O’Sullivan commented that Mr Andrew Smith should be actioning admin review full transaction. Mr Rana questioned how many red rated schemes would not deliver. Mrs O’Sullivan confirmed that all schemes had a plan in place to deliver in year, either recurrent or non recurrently.

The Committee discussed and noted the contents of the report.

78.2 Income and Activity Report – Month 8

Report not provided.

78.3 Deloitte High Level Market Assessment

Mr Davies apologised that the incorrect agenda item had been scheduled on the agenda, in addition to the report title on the front sheet of the report being incorrect (Dudley MCP as opposed to High Level Market Assessment). MR Davies advised that the Deloitte report relating to Dudley MCP would be brought to the Committee in January. Mr Davies talked the Committee through the report, highlighting the key message that there were not sufficient opportunities in the external marketplace, to allow the Trust to grow out of financial difficulty through income growth. However, Mr Davies felt it would be worthwhile for the Trust to pursue the 7 service development income opportunities as identified within the report. Mrs O’Sullivan acknowledged that these services were topical at the current time, whilst advising that the services currently existed

Mr Davies


in part. In terms of service development maturity, Mr Rana questioned if the views of the Trust matched with the views of Deloitte. Mr Davies advised that he agreed, in general, with the views of Deloitte, with the exception of Rehabilitation Services which he felt Deloitte had under-marked. The Committee agreed to put time and effort in, over the next 12 month period, to pursue the income generation opportunities. Dr Gingell highlighted the need for Board commitment, and the appetite to go out “at risk”. Mrs O’Sullivan added that the set up of services was also key. In response to Dr Gingell, Mr Axcell commented that if no supporting evidence was provided, the Trust would not support the initiative. Mr Axcell added that he would expect a business case, clinically led, to be brought to MExT with the supporting evidence. Dr Gingell highlighted that resource could be an issue. Mr Axcell asked that this was raised should that be the case. A question was raised with regards to CAMHs Tier 2 and why this had been listed as an opportunity given the Trust was already delivering a CAMHs Tier 2 service. Dr Gingell was of the view that that a CAMHs Tier 4 service would have been a more suitable opportunity for the Trust to pursue. Mr Davies to provide a progress update to the Committee in March.

Mr Davies

79. WORKFORCE

79.1 Workforce Report – Month 8

Ms Williams talked the Committee through the Workforce Report for Month 8, noting the following points:-

• The Trust’s vacancy rate had reduced to 14.5% in Month 8 compared to 15.5% in Month 7.

• The 12 month turnover rate had increased slightly from 11.5% to 11.62%. Mr Rana was keen to understand what preventative action the Trust was taking to lower its turn-over rate and suggested this being considered at the Workforce Committee.

• The Trust was reporting a rolling 12 month sickness rate of 4.59% in Month 8; this was the first occasion whereby the Trust was within target range.

• The Trust would be writing in January to all staff who did not have an appraisal recorded in the last 12 month period, to remind individuals that an appraisal was a mutual obligation between the individual and their respective manager.

• Managers needed to ensure they were pushing mandatory training. Mrs Williams advised that the Trust was looking at ways to ensure compliance moving forward, for example, using performance management as a tool.


• In relation to recruitment, Mr Axcell questioned what

progress had been made against the action previously agreed relating to vacancies, being led by Ms Ingram. Whilst Mrs Williams could recall the meeting taking place, Mrs Williams could not recall the outcome of the discussions. Mr Chamberlain noted that it had been agreed that a monthly reconciliation between the workforce system and the financial management system would be reinstated.

• In relation to the Employee Relations Dashboard and grievance, Mrs Williams confirmed to Mr Rana that the figure of 153 referred to the average number of days to fully investigate and close a grievance. Mr Rana questioned if the data was correct with regards to closed grievances given the report was illustrating no closed grievances since January 16. Mrs Williams agreed to review the accuracy of this data.

• Mr Axcell was pleased to note that some of the workforce indicators were starting to move in the right direction. However, it was important that the Trust did not become complacent.

Mrs Williams

80. Risk Register

Mr Davies talked the Committee members through the risk register, discussing each of the four risks in detail. The following outcomes were agreed:- 1. Risk FINAN 1 to be refined and reworded to capture the

following risks:- - MCP, funding for Mental Health and QIPP. - Long term financial viability for DWMH.

2. Risk HR002. Financial risk limited. However, significant

impact on service provision. - To make the LA aware of the impact on service provision. - To liaise with the originator of risk to review wording to

ensure the emphasis of the risk focused upon service implications, rather than the more limited financial implications.

- Progress update to be provided at the Committee meeting re; S75 negotiations.

- Impact with regards to quality reduction to be raised via CARM.

3. Risk 314. To remain on risk register.

- Risk ID number to correlate between the risk register and table 1.1 moving forward.

4. Risk 326. To be removed from the risk register with

immediate effect.

Mr Davies Mr Davies Mr Davies Ms Ingram Mr Davies Ms Jackson Mr Davies


Mrs Musson suggested Mr Davies looking at adding CQUIN to the risk register. It was agreed that the estates risk would be raised at the next Estates and Capital Planning Group meeting, prior to being brought back to the F&P Committee.

Mr Davies Mr Davies

81. Any Other Business

81.1 No items of any other business were noted.

81.2 Minutes of the Estates and Capital Planning Group Meeting held on 23rd November 16

Mr Davies briefed Committee members of the content of the minutes, whilst acknowledging the need for more operational support. Given the minutes were not included within the meeting papers, it was agreed that the minutes would be circulated to Committee members. Committee members were asked to review and feedback any comments to Mr Davies.

Miss Jackson All

82. Date and Time of Next Meeting

82.1 Monday 23rd January 2017, 14:00pm to 17:00pm, Board Room, Canalside House, Walsall.

Document Details

Author Emma Jackson Department Corporate Organisation Dudley & Walsall Mental Health Partnership Trust Version Final V1.0 Document Title Final Minutes 191216 Date of Creation 20 December 2016


Finance Report

1

Trust Board date: 2 February 2017

Agenda Item: 8.1.2c Enclosure: 11

2

2016/17 DWMHPT Finance Report Month 09 Page

• Key Messages: Current Performance 3

• Single Oversight Framework (NHS Improvement) 4

• Overall Summary and RAG Assessment 4-5

• Trust Summary Income & Expenditure Statement: Functional Analysis 6-9

• Cost Improvement Programme 10

• Capital Programme 11

• Single Oversight Framework (NHS Improvement) 12

• Agency Cap / Agency Spend by Staff Group / Reported Shift Breaches (weekly) 13-15

• Cash Flow Statement 16

• Payables Performance & Aged Debt 17

• Statement of Financial Position (Balance Sheet) 18

Key Messages : Current Performance

3

Financial Position £1,340k surplus YTD £74k Favourable variance

• The Trust has delivered a Month 09 surplus of £1,340k.

• This represents a favourable variance against plan of £74k Year to Date YTD (based on a planned surplus for the year of £1.7m).

Expenditure – Pay £738k Favourable variance

• Pay expenditure is £738k in surplus against budget YTD, which is being driven by surpluses within Community and Corporate Ops.

• Bank & Agency spend equates to £518k in month (split £370k for Agency and £148k for Bank), which is down on the Month 08 spend of £555k.

• Agency spend is behind plan by £311k in relation to the overall £4.05m Agency target for the year (actual spend of £3,517k against £3,206k plan to date). There is now a risk that the Agency Cap Target will be exceeded by year end.

Expenditure – Non Pay

£239k Adverse variance

• Non-Pay expenditure is £239k in deficit against budget YTD.

• Reserves are over committed by £508k reflecting the impact of un-devolved CIP yet to be allocated down to service lines, non pay items such as water testing and IT expenditure as well as provisions made against NHS Prop Co charges and CQUIN under-delivery clawback.

Income & Activity– 2016/17 outturn

£424k Adverse variance (incl £418k contract activity under-performance)

• The Trustwide Activity position at Month 09 is reflecting an under-performance of £418k and is explained as:

• Dudley CCG is now on block and so has no in-month impact

• Walsall CCG has over-performed against its ‘cap and collar by £375k but has been deflated by £363k in relation to the potential impact of QIPP funding being removed (FYE impact of £728k).

• Other smaller CCG contracts in total (such as Birmingham and Worcester) are under-performing by £37k

• NCAs have over-performed against plan by £198k

• The activity in the Detox beds at Bushey Fields has under recovered by £64k

• The Net position is an over-performance of £109k, however, after taking account of the impact of the CIP target that has been applied to activity, being £527k , overall performance is £418k behind plan.

• Bed days for Acute and Older Adults in Dudley continue to be low in comparison to contracted levels.

• Non-contracted Income such as SLA’s and Education Income is ahead of plan and is supporting the current under-performance in contracted income mentioned above, giving an overall adverse income position for the year to date of £424k.

CIP plans delivered for 2016/17

Potential risk of £1.010m as at Month 09

• The Trust’s Cost Improvement Target for the year is £2,500k and schemes have been developed for the year equating to £2,587k.

• At Month 09 there are currently £1.010m worth of schemes that pose a recurrent pressure in terms of delivery going forward. Of these schemes the two Income CIPs of £703k (relating to Acute Wrekin beds and OA Dementia beds) are being covered on a non-recurrent basis through activity over-performance.

Expenditure - Capital

£272k spend YTD

• The Capital Programme has been agreed at £2,748k for the year.

• Despite minimal spend during the first three quarters of the year several schemes including works at Bushey Fields and across IT services are now coming on stream.

• It has been requested with NHSI that several of the schemes be carried over into 2017/18 as part of a revised plan.

Overall Summary and RAG Assessment

4

Commentary

Revenue Position • The plan for the year currently reflects a planned surplus position

of £1.7m.

• The Trust is reporting a surplus of £1,340k as at Month 09 which is £74k ahead of plan.

• Total Income after taking account of the impact of the applied CIP (£703k FYE) is reflecting an under-performance of £418k, coupled with other SLA and Educational income giving a total under-recovery of £424k on income.

• Income is also currently reflecting the anticipated impact of Walsall CCG QIPP claw back (£728k FYE).

CIP 2016/17 Delivery • The Trust has a declared plan of £2,500k for 2016/17 and has

updated schemes in place totalling £2,587k.

• There is an indication of risks to several schemes in terms of delivery on a recurrent basis

Budgetary Reserves • Trust wide reserves are reflecting a balance of £473k for the

year, and are over-committed by £508k at Month 09 – this is due primarily to un-devolved CIP schemes, commitments to support partnership working, one-off non-pay costs around water management and IT and provisions for NHS Prop Co and CQUIN under-delivery claw back.

Statement of Comprehensive Income - Financial Position to 31st December 2016 Annual In Month Year To Date Plan Plan Actual Variance Plan Actual Variance

Income £000 £000 £000 £000 £000 £000 £000 Revenue From Activities Revenue-NHS Clinical 61,178 5,104 5,215 111 45,895 45,796 (98) Revenue-Non NHS Clinical 817 77 44 (33) 603 284 (319) Total Revenue From Activities 61,995 5,180 5,259 78 46,498 46,080 (417) Other Operating Revenue Revenue-Employee Benefits 464 39 50 11 348 464 116 Revenue-Education & Training 1,562 154 131 (23) 1,188 1,194 6 Revenue NHS Non-Clinical 979 73 61 (12) 759 686 (73) Other Revenue 556 46 40 (6) 417 366 (51) Total Other Operating Revenue 3,561 313 282 (30) 2,712 2,711 (2) Total Revenue 65,556 5,492 5,541 48 49,211 48,790 (420) Expenditure Pay (49,728) (4,136) (3,887) 249 (37,245) (36,222) 1,023 Non Pay (11,101) (928) (890) 38 (8,351) (8,493) (142) Trustwide Reserves (473) (2) (405) (403) (435) (943) (508) Total Operating Expenditure (61,302) (5,066) (5,182) (116) (46,030) (45,657) 370 EBITDA 4,254 426 358 (68) 3,181 3,133 (49) Depreciation (1,473) (123) (63) 59 (1,105) (1,045) 59 Amortisation (256) (21) (54) (33) (192) (224) (33) Net Operating Surplus 2,525 282 241 (42) 1,884 1,864 (23) PDC (865) (72) 29 101 (649) (548) 101 Interest Receivable 40 3 2 (1) 30 25 (5) P/L Disposal 0 0 0 0 0 0 0 Net Surplus /(Deficit) 1,700 213 272 58 1,264 1,340 74

Technical Adj - Impairment 0 0 0 0 (16,475) (16,475)

Technical Surplus 1,700 213 272 58 1,264 (15,135) (16,401)

Overall Summary and RAG Assessment Continued

5

2,587

2,555

2,500

0 1,000 2,000 3,000

Identified Schemes(FYE)

Identified Schemes(PYE)

CIP Target as perNHS Improvement

£'000

CIP 2016/17

700

1,700

1,340

0

250

500

750

1,000

1,250

1,500

1,750

£'00

0

Run Rate 2016/17

CumulativePlanned RunRate (Surplus)

Cumulative'Stretch'Revised RunRate

Actual RunRate

2,748

272 0

500

1,000

1,500

2,000

2,500

3,000

£'00

0

Capital Programme 2016/17

CumulativePlannedSpend

CumulativeActualSpend

12,00012,50013,00013,50014,00014,50015,00015,50016,00016,500

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17

£'00

0

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17Revised Plan 12,740 12,802 12,846 12,926 13,010 13,325 13,384 13,505 13,384 13,257 13,084 13,450

Original Plan 12,745 12,812 12,861 12,890 12,924 12,908 12,916 12,986 12,815 12,638 12,414 12,450

Actual 13,374 13,578 14,068 14,325 15,060 15,087 15,671 16,115 16,304

Forecast vs Actual Cash Balance 2016/17

Trust Summary Income & Expenditure Statement Including Functional Analysis

Commentary

• The Trust is showing a £418k under-performance position against contracted activity levels. This is due to reporting the potential impact of claw back of QIPP monies from Walsall commissioners (£728k Full Year Effect (FYE)) which is offsetting the benefit of the £500k FYE ‘cap and collar’ over-performance. Coupled with this we also have the impact of £527k relating to the CIP target for 2016/17.

• Corporate areas are currently reflecting a surplus position which is due to surpluses within Governance, MCA DOLs and Liaison & Diversion.

• Central Reserves are reflecting the impact of CIP schemes that have yet to be devolved down to service lines, as well as one-off costs around water management and IT as well as NHS Prop Co and CQUIN claw back provisions.

• Acute and Older Adult Services are £43k in surplus, but are being impacted by overspends within to Inpatient areas (including Bank and Agency).

• Community areas are also in surplus due to additional funding received during the year that has yet to be fully utilised due to slippage on recruitment.

• The Trust is presently reporting a surplus position for the month and for the year to date is £74k ahead of the trajectory to deliver the £1.7m planned surplus at year end.

• The Trust is still forecasting a breakeven variance position against the £1.7m surplus plan. This is despite the shortfall against Income for the year and can be seen as underspends against service lines such as Corporate, Community and Medical offsetting pressures against AOA and Trustwide Reserves.

Annual Plan In Month Year to Date FOT M09

2016/17 Plan Actual Var Plan Actual Var Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

NHS Revenue-Activities 61,678 5,146 5,241 95 46,270 45,921 (348) (480) Revenue from LAs 286 24 15 (9) 214 144 (70) (100) Total Revenue from Activities 61,964 5,169 5,256 86 46,484 46,066 (418) (580) Corporate Functions Corporate Departments (12,310) (1,024) (979) 45 (9,266) (8,861) 405 212 Central Reserves (473) (2) (405) (403) (435) (943) (508) (203) Total Corporate Functions (12,783) (1,026) (1,384) (358) (9,701) (9,804) (103) 9 Operational Services Total Acute & Older Adults (18,540) (1,559) (1,522) 37 (13,894) (13,851) 43 (103) Total Community Services (14,566) (1,197) (1,039) 157 (10,986) (10,576) 410 353 Medical Services (11,821) (963) (953) 9 (8,722) (8,702) 20 125 Total Operational Services (44,927) (3,718) (3,515) 204 (33,602) (33,129) 473 375 Total Expenditure (57,710) (4,744) (4,899) (155) (43,303) (42,933) 370 384 Sub Total 4,254 425 357 (68) 3,181 3,132 (49) (196) Interest Receivable 40 3 2 (1) 30 25 (5) (4) PDC Dividend (865) (72) 29 101 (649) (548) 101 150 Depreciation (1,729) (144) (117) 27 (1,296) (1,270) 27 50 Net Surplus/(Deficit) 1,700 212 271 58 1,266 1,340 74 0

6

Trust Income Statement – Income

7

Commentary

• The Trust is now operating on a block contract with Dudley CCG and Walsall CCG, with the exception of C&V for Inpatients, CRS and EAS in Walsall.

• Neighbouring CCG’s remain on block contracts with the exception of Birmingham CCG’s where there is a cost per case arrangement in place for Inpatient activity that exceeds the agreed plan.

• The position at the moment still reflects the potential claw-back aligned to QIPP from Walsall CCG (£728k impact FYE)

• In terms of the impact on the year end forecast this QIPP element has been scaled back by 50%.

• Walsall activity is currently over-performing against Inpatients, CRS and EAS, however, the contract includes a ‘cap and collar’ arrangement of £500k a year which limits the impact of any over/under-performance to £43k per month. Thus the chargeable activity for Month 09 is only £375k, despite out-performing this cap (true over-performance is £1,756k).

• Dudley contract is under-performing at Month 09 by £90k on the traditional currency method – this is due to low Inpatient activity within Older Adults and Acute of £120k and Primary Care of £120k, offset by over-performance on CAMHs. However, as we are on a block arrangement there is no adverse financial impact in year.

• NCA’s reflect an over-performance of £198k to date.

• In patient detox service at Bushey Fields is currently £64k adrift against the expected activity levels to date.

• CIP of £703k has been applied to activity which means a required over-performance of £59k each month in order to deliver the target.

• Overall the Trust is £418k under-performing at Month 09 against it’s contracted income.


2016/17 Plan Actual Variance Plan Actual Variance Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Revenue From NHS Activities Dudley CCG 28,370 2,365 2,365 0 21,285 21,285 0 0 Walsall CCG 27,256 2,273 2,426 152 20,437 20,449 12 80 NHS Walsall 0 0 0 0 0 0 0 0

Sandwell & West Birmingham CCG 2,043 170 170 0 1,532 1,532 0 0 Wolverhampton CCG 289 24 24 0 217 224 7 0

Birmingham Cross City CCG 543 45 35 (10) 407 339 (69) (90) Birmingham South Central CCG 27 2 2 0 20 36 16 20

South East Staffs & Seisdon CCG 128 11 11 0 96 96 0 0 Stafford & Surrounds & E Staffs CCGs 8 1 1 0 6 7 1 0

Cannock Chase CCG 101 8 8 0 75 76 0 0 Total Staffs CCGs 237 20 20 0 177 179 1 0

Redditch & Bromsgrove CCG 17 1 2 0 12 14 2 0 Wyre Forrest CCG 33 3 3 (0) 25 28 3 0

NHS South Worcester CCG 2 0 0 0 1 3 2 0 Total Worcester CCGs 51 4 4 0 39 45 7 0

NCA - Adult Neuro 34 6 18 12 34 79 45 43 Income - DoH 500 42 42 0 375 375 0 0

Income Generation CIP 703 59 0 (59) 527 0 (527) (703) NCAs 242 20 19 (1) 181 340 159 170

CAMHs Deaf 1,384 115 115 0 1,038 1,038 0 0 Total NHS Revenue-Activities 61,678 5,146 5,241 95 46,270 45,921 (348) (480)

Revenue - Local Authorities

Walsall MBC 0 0 0 (0) 0 0 (0) 0 Dudley MBC 102 9 9 0 77 77 0 0

Sandwell MBC 0 0 0 0 0 0 0 0 Wolverhampton MBC 0 0 0 0 0 0 0 0

Stafford MBC 0 0 0 0 0 0 0 0 Detox Beds 183 15 7 (9) 138 73 (64) (90) Dudley CRI 0 0 0 0 0 0 0 0

NCA - Other HC 0 0 (0) (0) 0 (6) (6) (10) Total Revenue from LAs 286 24 15 (9) 214 144 (70) (100)

Total Revenue from Activies 61,964 5,169 5,256 86 46,484 46,066 (418) (580)

Trust Income & Expenditure Statement - Corporate Functions

8

Commentary

• Chief Executive – Vacancy slippage continues against the new Liaison and Diversion service and CSD department which continues to support the function which has anticipated overspends generated by CEO/PA/Non Exec areas. The position has improved as the call off of the Emergency Planning funds is smaller than expected. The reduction to agency in the PA Team and the Emergency Planning cost 2016-17 have resulted in the improvement to the forecast.

• Corp orate Affairs – Non-recurrent slippage against Business Development is

currently offsetting the impact of the Community Development Workers reductions in funding from commissioners along with anticipated overspend generated by trust legal costs. Cost Pressure of 0.8 B5/1.00 MA on SED.

• Corporate HR has remained static in the month along with the forecast that

had been adjusted last month for the improvement on the LDA income improvement. Some additional costs are expected as part of this income.

• Corporate Medical – One CD post still remains unfilled which is offsetting

some non-recurrent effects within Pharmacy and Admin. • Corporate Estates –Water Maintenance costs now stand at 200k of costs up

to M09. Expecting further costs for this including remedial works relating to the Hospital sites but these to be at a much slower rate. The other contributing factor is for the premium of using Agency within the service both in Management and operational support. The forecast overall has improved in the month to reflect the verbal assessment that had been provided by the Head Of Service.

• Corporate Operations – Vacancy slippage throughout the function is offset by

Cost pressures from CQC requirement costs (42k), the accelerated use of MCA DOLS monies (3k) and unexpected income reduction for Psychology trainees (3k). The forecast has improved by 47k in the month to reflect the reduced expenditure from additional Psychology support and redundancy/retirement costs.

• Corporate Finance – Various cost pressures remain including Finance

memberships, Asset revaluation, offset by non-committed budget and slippage against the DoF post 8k. Forecast had previously not incorporated the cost pressure of the Quality Accounts.

• Corporate IT – Saving on EPR due to postponement of the system until next

year. This will release 71k of costs from the forecast. The service will be recruiting to the Head of Information role currently filled by agency staff member.

Annual

Plan In Month Year to Date FOT M09

2016/17 Plan Actual Var Plan Actual Var Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Corporate Functions

Chief Executive (864) (72) (41) 30 (649) (464) 185 203 Corporate Affairs (509) (42) (47) (6) (384) (403) (19) (67)

Corporate Human Resources & Dev. & People (1,278) (106) (108) (2) (960) (905) 55 33

Corporate Medical (1,125) (94) (92) 2 (842) (837) 6 10 Corporate Estates (1,306) (109) (127) (18) (979) (1,071) (92) (146)

Corporate Operations (3,570) (295) (317) (22) (2,684) (2,447) 237 204 Corporate Finance (1,145) (97) (101) (4) (880) (913) (33) (56)

Corporate Performance & IT (2,514) (209) (145) 63 (1,888) (1,821) 66 31 Total Corporate Functions (12,310) (1,024) (979) 45 (9,266) (8,861) 405 212

Trust Income & Expenditure Statement - Operational Services

9

Commentary

• The Acute & Older Adult service Year To Date (YTD) position has improved by £36k in November, of which £20k relates to a planned business rates rebate. There was an overspend of £35k on inpatient staffing (£13k Acute, £21k Older Adults (OA)), which was exceeded by various management, psychology, HT/Access and OA Community vacancy savings. The forecast overspend has increased since last month, due to decision to bring in 5.00 whole time equivalent (wte) extra agency workers for CRHT throughout Quarter 4.

• The medical service forecast outturn has improved from

breakeven to an expected £125k underspend, due to a reduction in various forecast costs (e.g. three agency locums have recently been replaced by Trust-paid locums), and because few new staffing situations have arisen towards year end, releasing some uncommitted staffing contingency towards the Trust surplus.

• Community & Recovery Services results have deteriorated by

(2k) in month to 122k favourable. The impact of Community Rehabilitation (£11k), Agency usage in Walsall CRS South (5k), Walsall Employment Support (8k) are offset by vacancy slippage within other Community areas. The forecast has improved due to further vacancy slippage anticipated within the teams.

• Community Management – Head of Service post still vacant. Monies currently covering cost pressure on B7 Nurse (0.46wte). Old year accruals have been moved here for vacated buildings which we anticipate will be used.

• EI – The overall position has improved in month by 143k to 232k. The negotiation with Dudley CCG Re: CAMHS slippage has now been resolved and this is the benefit being shown within the position. The CAMHS teams in particular have made some inroads into over establishments within the two localities.


2016/17 Plan Actual Variance Plan Actual Variance Var £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Operational Services

Acute and Older Adults

Acute Access (3,513) (296) (283) 12 (2,666) (2,560) 106 41 Management and Administration (997) (83) (60) 23 (747) (526) 221 278

Acute Services (5,614) (471) (483) (12) (4,202) (4,361) (159) (232) Acute Estates (1,593) (139) (127) 12 (1,175) (1,155) 19 24 Older Adults (6,823) (570) (568) 2 (5,104) (5,249) (145) (214)

Total Acute & Older Adults (18,540) (1,559) (1,522) 37 (13,894) (13,851) 43 (103)

Community Services

Community Estates (512) (43) (28) 15 (384) (380) 4 9 Management and Administration (159) (11) (10) 1 (126) (73) 53 23 Community Services & Recovery (5,017) (416) (418) (2) (3,768) (3,646) 122 120

Early Intervention (8,877) (727) (584) 143 (6,708) (6,476) 232 201 Recovery Services 0 0 0 0 0 0 0 0

Total Community Services (14,566) (1,197) (1,039) 157 (10,986) (10,576) 410 353

Medical Services (11,821) (963) (953) 9 (8,722) (8,702) 20 125

Total Operating Services (44,927) (3,718) (3,515) 204 (33,602) (33,129) 473 375

10

Cost Improvement Programme

Commentary

• Target for 2016/17 = £2,500k.

• Trust had identified schemes for the year which could deliver £2,664k Full Year Effect (FYE), but two schemes have been re-assessed (CIP005 and CIP009) and have been reduced by £69.6k and £7.2k respectively, thus giving a revised scheme values of £2,587k.

• As at month 09 £2,467k of the schemes had been devolved to appropriate budget areas and £120k were being managed centrally in reserves.

• Of those devolved schemes £1,743k have been transacted to date.

• At this stage there are several schemes still at risk of non-delivery on a recurrent basis. These have been highlighted in the table opposite under the ‘At Risk’ column and currently equate to £1,010k of risk.

• Of these, schemes CIP003 and CIP005 (relating to Income) are being covered non-recurrently through the over-performance within the Walsall Contract and NCA Income.

• CIP001 (Postage) is due to be closed as no further savings are expected.

• CIP010 (Medics) has recurrently part achieved due to savings on the LDA training contract. Additional benefits have been scoped and now actioned, but there still remains a recurrent risk of full delivery

Annual Schemes Schemes Transacted to Date

(against original scheme)

Likely Achieveme

nt

Cost Improvement Programmes (by POD) Ref Plan Devolved Held

Centrally Recurrently Non-Rec Variance (incl.

mitigations) At Risk Current

RAG £ £ £ £ £ £ Recurrently

Estates - Postage CIP001 10,000 0 10,000 0 0 10,000 0 -10,000 Acute - Phlebotomy CIP002 12,000 12,000 0 12,000 0 0 12,000 - Acute - Wrekin Option 4 CIP003 400,000 400,000 0 0 0 400,000 400,000 -400,000 Community - Walsall CRS CIP004 111,810 93,175 18,635 123,032 0 -11,222 123,032 - Community - Employment Support CIP005 0 0 0 0 0 0 0 - OA - Dementia Beds CIP006 303,000 303,000 0 0 0 303,000 303,000 -303,000 OA - Day Hosp Reconfiguration CIP007 40,800 7,934 32,866 7,934 0 32,866 7,934 -32,866 OA - Establishment Review CIP008 77,500 38,242 39,258 38,242 0 39,258 38,242 -39,258 EIA - Developments CIP009 172,480 172,480 0 116,509 0 55,971 116,509 -55,971 Medics - Establishment Review CIP010 350,000 350,000 0 190,843 151,138 8,019 350,000 -168,863 CEO - Admin Review CIP011 10,734 10,734 0 10,734 0 0 10,734 - CEO - Emergency Planning CIP012 10,000 10,000 0 10,000 0 0 10,000 - CEO - Office Furniture CIP013 5,000 5,000 0 5,000 0 0 5,000 - W&D - Library CIP014 1,531 1,531 0 1,531 0 0 1,531 - W&D - NonPay CIP015 8,000 8,000 0 8,000 0 0 8,000 - Corp Dev - NonPay CIP016 10,000 10,000 0 10,000 0 0 10,000 - W&D - Payroll CIP017 24,000 12,000 12,000 0 12,000 12,000 12,000 - Finance - Pay & NonPay CIP018 38,500 31,540 6,960 31,540 12,500 -5,540 44,040 - CEO - PMO CIP019 33,583 33,583 0 33,583 0 0 33,583 - IM&T - Subject Access CIP020 2,400 2,400 0 2,400 0 0 2,400 - IM&T - Establishment Review CIP021 40,659 40,659 0 40,659 0 0 40,659 - Corporate - NI Savings CIP022 90,000 90,000 0 90,000 0 0 90,000 - Corporate - Savings (NP Inflation) CIP023 125,000 125,000 0 125,000 0 0 125,000 - Corporate - Incremental Drift CIP024 350,000 350,000 0 350,000 0 0 350,000 - Corporate - Reduction in Trust Surplus CIP025 250,000 250,000 0 250,000 0 0 250,000 - Psych Liaison - efficiences from Corporate savings CIP026 24,636 24,636 0 24,636 0 0 24,636 - MH Urgent Care - efficiences from Corporate savings CIP027 35,499 35,499 0 35,499 0 0 35,499 - Procurement CIP028 50,000 50,000 0 50,000 0 0 50,000 - Total CIPs 2,587,132 2,467,413 119,719 1,567,142 175,638 844,352 2,453,799 -1,009,958 Annual Target 16/17 2,500,000 2,500,000 Excess of Schemes Above Plan 87,132 -46,201

Capital Programme

11

Commentary

• Proposed Capital Funding for 2016/17 has been amended at Month 9 to reflect the delay in the purchase of the Trust’s Electronic Patient Record System.

• Capital expenditure remains minimal Year To Date but a number of the large Estate’s schemes are now starting to get underway.

12

Commentary

• The Single Oversight Framework is designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’. The Framework doesn't give a performance assessment in its own right.

• The Framework will help NHSI identify NHS providers' potential support needs across five themes: - quality of care - finance and use of resources - operational performance - strategic change - leadership and improvement capability

• NHSI will segment individual trusts according to the level of support each trust needs. NHSI can then signpost, offer or

mandate tailored support as appropriate.

• Scoring a ‘4’ on any finance metric will mean the overall rating is at least a ‘3’, triggering a concern.

• Current month position and forecast position for the Trust by year end is giving a maximum rating of 1.

Single Oversight Framework – Trust Performance

M08 M09 Forecast Outturn

subcode Plan Actual Plan Actual Plan Actual

Liquidity Ratio Days 373 61 68 60 70 57 67 Liquidity Ratio Metric 374 1 1 1 1 1 1 Capital Servicing Capacity 377 5 5 5 6 5 6 Capital Servicing Capacity Metric 378 1 1 1 1 1 1

I&E Margin 425 0.02 0.02 0.03 0.03 0.03 0.03 I&E Margin Rating 430 1 1 1 1 1 1 Distance from Plan 435 0 0 0 Distance from Plan Rating 440 2 1 2

Agency Metric 460 1 2 2 2 1 2

Overall Use of Resources 520 1 1 1 1 1 1

NHS Improvement – Agency Expenditure Cap 16/17

Commentary

• For 2016/17 the Trust has been tasked with working within an overall agency expenditure cap of £4.05m for the year, which represents a circa. 35% reduction on the actual spend in 2015/16.

• The planned spend across the year has been profiled in line with the workforce plan based on increasing recruitment of substantive staff and the use of bank staff to offset the previously required use of agency staff. At Month 09 the Trust is £311k behind plan in terms of anticipated agency spend (£3,517k spend against £3,206k plan).

• With the planned spend/target now running at circa £285k per month the Trust will need to tighten controls further in order to ensure the current spending levels of circa £370k per month are reduced. If this level of spend could not be reduced then the Trust is likely to exceed the NHSI Agency Cap by circa £500k at year end.

Agency Analysis (TFR 3) 2016-17

ACTUALS (£000's) Expenditure In Month as at Agency Staffing Mth 1 Mth 2 Mth 3 Mth 4 Mth 5 Mth 6 Mth 7 Mth 8 Mth 9 Mth 10 Mth 11 Mth 12

Qualified Nursing £114 £144 £128 £107 £113 £106 £72 £107 £112 £0 £0 £0 Medical £101 £95 £107 £86 £76 £88 £85 £128 £97 £0 £0 £0 Other (Incl. Admin, Estates, HCA's , AHP's) £255 £283 £195 £154 £141 £134 £159 £167 £161 £0 £0 £0

Total Agency Staffing £470 £523 £430 £347 £330 £329 £316 £402 £370 £0 £0 £0

Total Employee Benefits Total Staffing Costs (Substantive + Agency + Bank) £4,058 £4,237 £3,991 £4,057 £4,083 £4,103 £4,081 £4,182 £3,947 £0 £0 £0

Agency £ as % of Total Staffing (incl Agency) £ 11.59% 12.34% 10.76% 8.54% 8.09% 8.01% 7.74% 9.62% 9.38%

Cumulative Position 11.59% 11.97% 11.58% 10.83% 10.28% 9.90% 9.59% 9.59% 9.57%

of which, relate to 'pilot' schemes (backfill agency costs circa):

MH Urgent Care Centre £12 £12 £12 £12 £12 £12 £12 £12 £12 Street Triage £10 £10 £10 £10 £10 £10 £10 £10 £10 CAMHs Tier 3+ £25 £27 £26 £23 £11 -£42 £0 -£2 £70

£47 £49 £48 £45 £33 -£20 £22 £20 £92

PLAN (£000's) Expenditure In Month as at Agency Staffing Mth 1 Mth 2 Mth 3 Mth 4 Mth 5 Mth 6 Mth 7 Mth 8 Mth 9 Mth 10 Mth 11 Mth 12

Qualified Nursing £160 £155 £150 £145 £140 £105 £105 £105 £105 £105 £105 £105 Medical £90 £90 £90 £90 £90 £90 £90 £90 £88 £88 £87 £87 Other (Incl. Admin, Estates, HCA's , AHP's) £257 £243 £180 £96 £96 £89 £89 £89 £89 £89 £89 £89

Total Agency Staffing £507 £488 £420 £331 £326 £284 £284 £284 £282 £282 £281 £281

Total Employee Benefits Total Staffing Costs (Substantive + Agency + Bank) £4,122 £4,160 £4,173 £4,136 £4,135 £4,125 £4,125 £4,124 £4,123 £4,126 £4,119 £4,122

Agency £ as % of Total Staffing (incl Agency) £ 12.30% 11.73% 10.06% 8.00% 7.88% 6.88% 6.88% 6.89% 6.84% 6.83% 6.82% 6.82%

Cumulative Position 12.30% 12.01% 11.36% 10.52% 10.00% 9.48% 9.11% 8.83% 8.61% 8.44% 8.29% 8.17%

13

Agency Spend by Staff Group

Commentary

• As of Month 09 the current spending on Agency staffing equates to £3,517k, which when compared to the phased plan of the £4.05m target (£3,206k Year To Date), means the Trust is behind plan by £311k.

• Previously we had seen a levelling out of spend during the last several months (around £330k) but we have seen a peak of spending over the last two months (M08 spend of £402k and current M09 of £370k).

• This month spending on Other staff has risen the most.

• The monthly target in place now over the remaining half of the year is set at £284k which is around £100k lower than the average level of spending.

• If we were to maintain our average level of spending of around £390k from now until year end this would result in an end of year spend of circa.£500k above the required plan.

• This will be a significant challenge for the Trust.

In Mth (£000) YTD (£000) Plan Act Variance Plan Act Variance

Agency Staffing Qualified Nursing £105 £112 -£7 £1,170 £1,005 £165 Medical £90 £97 -£7 £808 £863 -£55 Other (Incl. Admin, Estates, HCA's , AHP's) £89 £161 -£72 £1,228 £1,649 -£421

£284 £370 -£86 £3,206 £3,517 -£311

Other' represented by: Unqualified Nursing £62 £679 note 1 Admin & Clerical / Maint & Works £54 £489 note 2 Scientific & Technical £44 £481 note 3

£161 £1,649

note 1 note 2 note 3 Malvern £26.1 Estates £129.6 Walsall CAMHs £82.4 Wrekin £26.6 E-Rostering £84.9 Pharmacy £4.8 Clent £40.0 IM&T £61.6 Dudley CAMHs £117.9 Kinver £50.8 DPH / BF Med Secs £61.7 Dudley Primary Care £169.2 Langdale £88.9 HR £42.5 Walsall Primary Care £23.7 Cedars £66.8 PA's Exec Office £21.0 PT Hub £8.8 Linden £131.1 Various (incl. £87.6 OA Malvern / OT / £57.5 Ambleside £127.4 Primary Care / Mgmt Holyrood £109.0 CAMHs / SED) Adult In-Pats £16.0 Dudley Primary Care £12.7

£679.4 £488.9 £480.3

all the above relate to Psychology

staff with the exception of Pharmacy

14

Agency – Reported Shift Breaches to NHSI (weekly)

Commentary

• The above graph represents the reported shift breaches, both in terms of agency staff who are not on an approved framework agreement and /or who are charging hourly prices above the mandated agency cap rates.

• Reporting is reflective of staff groups as per TFIMS headings – Medics do not appear on this analysis as they are covered under StaffFlow which ensures that agencies used and rates paid are in line with the mandated agency rules.

0

5

10

15

20

25

30

3504

-Apr

11-A

pr

18-A

pr

25-A

pr

02-M

ay

09-M

ay

16-M

ay

23-M

ay

30-M

ay

06-Ju

n

13-Ju

n

20-Ju

n

27-Ju

n

04-Ju

l

11-Ju

l

18-Ju

l

25-Ju

l

01-A

ug

08-A

ug

15-A

ug

22-A

ug

29-A

ug

05-S

ep

12-S

ep

19-S

ep

26-S

ep

03-O

ct

10-O

ct

17-O

ct

24-O

ct

31-O

ct

07-N

ov

14-N

ov

21-N

ov

28-N

ov

05-D

ec

12-D

ec

19-D

ec

26-D

ec

No

of S

hift

s

04-Apr

11-Apr

18-Apr

25-Apr

02-May

09-May

16-May

23-May

30-May

06-Jun

13-Jun

20-Jun

27-Jun

04-Jul

11-Jul

18-Jul

25-Jul

01-Aug

08-Aug

15-Aug

22-Aug

29-Aug

05-Sep

12-Sep

19-Sep

26-Sep

03-Oct

10-Oct

17-Oct

24-Oct

31-Oct

07-Nov

14-Nov

21-Nov

28-Nov

05-Dec

12-Dec

19-Dec

26-Dec

Nursing (Framework + Price) 18 20 20 20 20 16 16 11 13 12 14 16 14 12 12 18 17 17 8 15 17 16 15 16 12 12 12 12 13 15 9 14 15 0 0 0 0 0 0

Nursing (Price) 18 20 22 23 23 5 4 12 9 8 5 6 17 9 8 12 13 13 3 3 2 7 6 2 0 6 6 5 5 6 6 0 0 15 14 18 20 18 16

ST&T / AHPs (Price) 0 0 0 0 0 24 20 24 11 10 16 15 3 10 11 24 19 19 25 20 10 8 15 6 13 17 15 8 8 17 12 18 10 13 13 13 13 13 12

Admin & Estates (Price) 24 23 21 22 21 30 23 3 9 9 8 10 10 9 10 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

HCA (Framework + Price) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 0 3 3 3 3 3 3 3 3 3 3 3 3

No of Shift Breaches by Week/Staff Group

15

Cash Flow Statement

16

Commentary

Cash Flow • The Trust has made an operating deficit of £14,612k in

2016/17 and received cash of £1,270k in respect of depreciation and amortisation

• The Trust has transacted £16,474k of net impairments in 2016/17 as a result of the MEA alternative site valuation

• Trade and Other Receivables have increased over the period (a negative impact on cash)

• Trade and Other Payables have increased over the period (a positive impact on cash)

• The Trust has received £25k of interest, and spent £594k on capital (£330k on reducing capital payables from the 2015/16 year end and £264k on 2016/17 capital expenditure). Total capital expenditure in cash terms was less than the cash received for depreciation and amortisation (a positive impact on cash)

• The impact of all these movements was to increase the Trust’s cash balance Year To Date by £2,010k.

Payables Performance & Aged Debt

17

Commentary on Payables

Better Payment Practice Code • The Trust has not achieved the required target for Non-NHS invoices by number in the current month.

NHS invoices have achieved in both indices as have Non-NHS invoices by value in the month.

• In terms of Year To Date all areas with the exception of NHS invoices by value still remain outside of the 95% threshold, albeit marginally for NHS invoices by number.

• Performance in April was impacted by the decision to hold payments at the end of March to ensure the Trusts cash balance remained within External Financing Limits at the year end.

Commentary on Aged Debt

Aged Debt Profile by Value • 53.7% of debt was aged 90 days or older at the end of December (this figure was 16.6% at the

end of the previous month).

• Debt between 91-120 days (totalling £399k) relates in the main to:

• Walsall CCG £368.7k re monthly SLA

• Debt over 120 days old (totalling £203k) relates in the main to:

• Walsall CCG – MCA DOLs £76.2k and Eating Disorders £40.0k

• Various CCGs re NCAs of £32.8k

• Walsall MBC £16.1k re salary recharges

• Dudley MBC £30.2k re MCA DOLs

• Dudley CCG £7.2k

Better Payment Practice Code

Agreed Tolerances Transactions by Number Value Non-NHS <75% 75% - 95% >95% Qtr 1 82.76% 90.20% Qtr 2 78.63% 92.86% Mth 07 85.70% 94.08% Mth 08 87.07% 93.44% Mth 09 93.61% 98.04% Non-NHS YTD 83.31% 92.50% NHS <75% 75% - 95% >95% Qtr 1 92.45% 90.28% Qtr 2 96.77% 97.19% Mth 07 100.00% 100.00% Mth 08 88.64% 95.56% Mth 09 100.00% 100.00% NHS YTD 94.68% 95.10%

12.9% 13.2%

20.2% 35.5%

18.1%

Aged Debt as of December 2016

Current 31-60 days 61-90 days 91-120 days 120+ days

Debt Profile and Value Current 31-60 days 61-90 days 91-120 days 121+ days Total £000 £000 £000 £000 £000 £000 £145 £149 £227 £399 £203 £1,122

Aged Debt

Value % of Total

Agreed

Tolerances £000

Debt

Over 91 days >20% 10% - 20% <10% £602 53.7%

Over 120 days >10% 5% - 10% <5% £203 18.1%

Statement of Financial Position

18

Commentary

Non Current Assets • Amortisation and depreciation exceeds capital expenditure

for the year decreasing the value of the Trust’s Non-Current Assets in the year

• In addition, the impact of the MEA land and building asset impairment has decreased the value of the Trust’s Property, Plant and Equipment assets by a further £19,645k

• Final outturn against capital schemes is reviewed later in this report

Current Assets • Receivables have increased by £273k in 2016/17

• Cash is £2,011k higher than the balance at 31 March 2016

• An analysis of cash flows can be seen elsewhere in this report

Current Liabilities • Payables have increased by £60k in the financial year

• There has been a decrease in provisions in the year of £111k

Tax Payers’ Equity

• The Current Year I&E figure represents the net effect of the surplus for the year to date of £1,340k and the MEA land and building asset impairment of £16,475k

• This is £116k ahead of the revised plan for Month 9 2016/17


Agenda Item number: 6.1.2e

Enclosure: 12

Report Title:

Cost Improvement Programme (CIP) Progress Report – January 2017


Rupert Davies, Interim Director of Finance, Performance, IM&T and Estates


Jacky O’Sullivan, Clinical Development Director/Acting Associate Director of Operations

Purpose of the report: To present to the Board a summary of the current status of the Cost

Improvement Programme for 2016/17. Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee: MExT

Date reviewed: 24th January 2017 Key points or recommendations from Committee:




Leadership culture






Caring

Plans use evidence based practice to ensure improvements in quality, outcomes and patient experience.

Responsive

Plans are developed to ensure responsiveness to service user needs.

Effective

Plans represent best value to ensure CIP plans are met through efficiency and effectiveness

Well-led

All transformational and service development plans have a project team approach to both development and implementation.

Safe

All plans are assessed for the need for a Quality Impact Assessment and where indicated a full assessment including risks and mitigations is undertaken and monitored.

CIP ideas brainstormed and scoped by Management Executive Team (MExT) and wider

Yes

Idea developed and presented to MExT MExT approve/reject

No Idea archived

Project Overview Document (POD) developed & submitted to MExT for approval & sign off –

including QIA, EIA, PIA & risks

Implementation Stage

Final QIA and risks presented to MExT for project closure

Summary of schemes including Quality Impact Assessment (QIA) & risks submitted to Trust Board

Review of all strategic themes by Trust Board to agree which proceed further within these

parameters: • High Quality Services • Inclusive Partnerships • Supporting Strategies • Effective & Efficient Resources • Leadership Culture • Responsible Workforce

QIA & risks on delivered projects presented to MExT for sign off including Director of Nursing & Medical Directors

All projects – complete POD Completed PODs & QIA signed off by Director of Nursing and Medical Directors and MExT

Final QIA and risks presented to Trust Board for final sign off

Idea archived No

Title Cost Improvement Programme (CIP) Progress Report – January 2017

Introduction The purpose of this report is to present to the Board a summary of the current status of the Cost Improvement Programme for 2016/17. Summary of key points, issues and risks 1.0 CIP 2016/17 £

• Target for 2016/17 2,500,000 • Projects in total (full year effect) 2,577,132 • Variance 77,132

The majority of CIP targets are devolved down to team budgets so any slippage is managed at team level. A full list of projects can be found in appendix 2 and 3. There are also 3 schemes that will deliver savings non-recurrently; these are listed in appendix 4. There are 28 projects for the current year. 2 have been closed and 17 have delivered, these are listed in appendix 2. A further scheme (CIP011-16 CEO Led Admin Review) has delivered and was presented for closure to MExT on 24 January 2017 which was approved (appendix 1). The scheme did not deliver the CIP target as planned, the scheme delivered savings from the Disaster Recovery budget. The scheme identified impact pre implementation but as the original scheme was not progressed, post implementation there is no impact and the RAG is green. There are no open risks and no KPIs linked to the scheme. It can be seen in appendix 3 that there are 6 schemes with an overall project status of red. The projects are: - Acute Services – Wrekin Ward Beds Older Adults Inpatient beds (Dementia) Redesign of Day Opportunities Older Adults Establishment Review Early Intervention Service Line Developments Medical Services Establishment Review

Acute Services – Wrekin Ward Beds (value £400,000) The project is RAG rated red due to the finance. The scheme is being met non recurrently from NCA activity. The CIP Board reviewed the finances against this scheme in January and potentially £200k could be classed as recurrent. This scheme will carry over into 2017/18. Older Adults Inpatient beds (Dementia) (value £303,000) The scheme has identified red risks, and the finance is RAG rated red. The scheme is being progressed however it may not generate further income, discussions remain in progress with DGoH. The scheme is being covered non recurrently. Enc 12 CIP Progress report January v1 Page 3 of 10

Redesign of Day Opportunities (value £40,800) The project is RAG rated red due to the finance. The Walsall element has delivered and the scheme will carry over into 2017/18 and the will be delivered via the Dudley Older Adults Service transformation. Older Adults Establishment Review (value £77,500) The scheme is subject to the same issues as the scheme above. The scheme will carry over into 2017/18 and the remaining CIP will be delivered via the Dudley Older Adults Service transformation. Early Intervention Service Line Developments (value £172,480) The finance is RAG rated red as the scheme has not met the CIP target. £117k has been met. There is further investment for this service line which will be reviewed for potential contribution to this target; therefore the scheme will carry over into 2017/18. Medical Services Establishment Review (value £350,000) The project is RAG rated red due to the finance. £200k savings have been identified recurrently, and £149k non recurrently. The scheme will carry over into 2017/18. The CIP Board will be monitoring and tracking the progress of these red rated schemes to report risks, and mitigations to MExT and the Board. The RAG rating for the forecast year end position is as follows: - RED Will not achieve full target AMBER Will not deliver full target until 17/18 GREEN Will achieve FYE by March 17 Further detail (if required) Appendix 1, 2, 3 and 4 contain further details of the schemes. Recommendation Trust Board members are asked to note the contents of this report and receive it for information and assurance. Board action required No action is required.

Enc 12 CIP Progress report January v1 Page 4 of 10

Appendix 1 – Project Closure Summary Table Division / Type Ref Project Title QIA Initial

Assessment Score

QIA Review Assessment

Score

Outstanding Risks KPIs

Corporate / Transformational

CIP011-16 CEO Led Admin Review

A G 2 closed risks: 1. Work load on other departments 2. Full role review and agreement

across admin teams

No KPIs identified


Appendix 2 – 2016/17 CIP schemes Closed / Delivered Projects Division / Type Ref Project Title Value (£) Status

Operations / Transformational CIP001-16

Postage 0 Closed

Operations / Transformational CIP002-16 Phlebotomy 12,000 Delivered

Operations / Transformational CIP005-16 Employment Support Services Review

0 Closed

Corporate / Transactional CIP012-16 Healthcare Emergency Planning

10,000 Delivered

Corporate / Transactional CIP013-16 Office Furniture

5,000 Delivered

Corporate / Transactional CIP014-16 Library Services

1,531 Delivered

Corporate / Transactional CIP015-16 People & Workforce Development Non Pay

8,000 Delivered

Corporate / Transactional CIP016-16 Corporate Development Non Pay Savings

10,000 Delivered

Corporate / Transactional

CIP018-16 Finance Department – Pay and Non Pay Savings

38,500 Delivered

Corporate / Transactional CIP019-16 PMO Efficiencies

33,583 Delivered

Corporate / Transformational CIP020-16 Subject Access Requests

2,400 Delivered

Corporate / Transformational CIP021-16 Performance and IM&T Establishment Changes

40,659 Delivered

Corporate / Transactional CIP022-16 Planned National Insurance Savings

90,000 Delivered

Corporate / Transactional CIP023-16 Corporate Savings

125,000 Delivered

Corporate / Transactional CIP024-16 Incremental Drift

350,000 Delivered

Corporate / Transactional CIP025-16 Reduction in Planned Surplus

250,000 Delivered

Corporate / Transactional CIP026-16 Psychiatric Liaison Productivity Efficiencies from Corporate Savings

24,636 Delivered

Corporate / Transactional CIP027-16 MH Urgent Care Productivity Efficiencies from Corporate Savings

35,499 Delivered

Corporate / Transactional CIP028-16 Procurement and Tendering

50,000 Delivered


Appendix 3 – 2016/17 CIP schemes Active Projects

Operations Scheme Executive

Lead Links to

other projects

Value £

Overall Project Status Pl

an

Fina

nce

Ris

ks

QIA

EI

A

PIA

KPIs Implementation Month

Mon

th 9

RA

G

Mon

th 9

Fi

nanc

ial

Posi

tion

(FYE

) Fo

reca

st Y

ear

End

RA

G

Fore

cast

Yea

r En

d Po

sitio

n

Acute Services Wrekin Ward

The project is an income generation scheme that aims to provide 5 acute beds on Wrekin ward to another commissioner / provider. The scheme is expected to meet the target non recurrently from over performance on NCA and other contracts, and not from the original plan.

Wendy Pugh

None 400,000 R A R A A

No

impa

ct

No

impa

ct

1. 28 days readmission 2. The Average Length of

Stay 3. 7 day follow up 4. Bed Occupancy 5. Activity against

Contract 6. Delayed transfers of

care

R 400,000 (NR)

R 400,000 (NR)

Walsall CRS Activity & Staff Establishment

The project is about implementing the findings from the Meridian review and therefore reducing activity and associated workforce. The scheme has delivered and is under review.

Wendy Pugh

None 111,180 G G G G G

No

impa

ct

No

impa

ct

N/A

November 16 G 123,032 G 123,032

Older Adults Inpatient Beds (Dementia)

This project is an income generation scheme to utilise existing capacity in the Dementia Wards to accommodate those patients that have a diagnosis of Dementia who are medically fit for discharge and are Delayed Transfers of Care from WMH/RHH. The scheme is being progressed but may not generate further income, discussions remain ongoing with DGoH. The target is being met non recurrently from over performance on NCA and other contracts, and not from the original plan.


Operations Scheme Executive

Lead Links to

other projects

Value £


an

Fina

nce

Ris

ks

QIA

EI

A

PIA

KPIs Implementation Month

Mon

th 9

RA

G

Mon

th 9

Fi

nanc

ial

Posi

tion

(FYE

) Fo

reca

st Y

ear

End

RA

G

Fore

cast

Yea

r En

d Po

sitio

n

Wendy Pugh

None 303,000 R A R R R

No

impa

ct

No

impa

ct N/A R 303,000

(NR) R 303,000

(NR)

Redesign of Day Opportunities

This project relates to commissioner intentions to redesign Older Adult Day Services. Savings will be realised from transport.

Wendy Pugh

None 40,800 R A R R R

No

impa

ct

No

impa

ct N/A

December 16 R 7,934 R 7,934

Older Adults Establishment Review

The project is about implementing the findings from the Meridian review and therefore reducing activity and associated workforce. This links to the work for the scheme above.

Wendy Pugh


No

impa

ct

No

impa

ct N/A December 16 R 38,242 R 38,242

Early Intervention Service Line Interventions

This project relates to increased efficiency and productivity in the Early Intervention Service line and associated corporate services by providing a number of new service developments within existing overheads. The scheme will carry over into 2017/18 as it will not meet the target.

Wendy Pugh


No

impa

ct

No

impa

ct N/A April 16 G 116,509 R 119,000


Medical Scheme Executive

Lead Links to

other projects

Value £


an

Fina

nce

Ris

ks

QIA

EIA

PI

A KPIs Implementation

Month

Mon

th 9

RA

G

Mon

th 9

Fi

nanc

ial

Posi

tion

(FYE

)

Fore

cast

Yea

r En

d R

AG

Fo

reca

st Y

ear

End

Posi

tion

Medical Services – Establishment Review

The scheme is about identifying savings from Pharmacy, the DGoH contract and underspend. The scheme will carry over into 2017/18.

Mark Weaver /

Kate Gingell

None 350,000 R A A R A

No

impa

ct

No

impa

ct N/A December 16 R 350,000

(R & NR) R 350,000

(R & NR)

Corporate Scheme Executive

Lead Links to

other projects

Value £


an

Fina

nce

Ris

ks

QIA

EIA

PI

A KPIs Implementation

Month

Mon

th 9

RA

G

Mon

th 9

Fi

nanc

ial

Posi

tion

(FYE

) Fo

reca

st Y

ear

End

RA

G

Fore

cast

Yea

r En

d Po

sitio

n

Payroll This project delivers a more efficient payroll service through economies of scale and removal of the SBS contract. The original plan will not be progressed as recurrent savings will not be realised in this financial year. The PYE target has been met non recurrently and the scheme will carry over to the next financial year.

Marsha Ingram

None 24,000 A A A G A

No

impa

ct 9 N/A

September 16 A 12,000 (NR)

A 12,000 (NR)

Key: QIA = Quality Impact Assessment EIA = Equality Impact Assessment PIA = Privacy Impact Assessment KPIs = Key Performance Indicators NR = Non Recurrent R = Recurrent


Appendix 4 – 2016/17 Non Recurrent CIP schemes Division Type Project Title Exec Lead Project Lead Value (£) Delivery

Corporate Transactional Band 7 reduction Rupert Davies Mark Banks 12,500 Available

Corporate Transactional Liaison & Diversion Productivity Efficiencies from Corporate Savings

Mark Axcell Jacky O’Sullivan 61,113 Available

Operations Transactional School Link Pilot Productivity Efficiencies from Corporate Savings

Wendy Pugh Anne Marie Carey 4,500 Available




Enclosure: 13

Report Title:

Workforce Committee Chair’s Report

Committee:

Workforce Committee

Author:

Olivia Clymer – Non Executive Director


Decision / Approval

Gain assurance

Discussion

Information

Introduction The Workforce Committee met on the 24 January 2017 for the first time as a Board Committee, where they considered and discussed key topics around the Trust’s Workforce Summary of key points, issues and risks Terms of Reference The Committee reviewed the Terms of Reference in light of it becoming a Board Committee, and subject to a number of agreed amendments and formatting consistent with other Board Committee’s the Terms of Reference were recommended to Board. The amendments, including formatting were made and the revised version circulated to Committee members for comment and is appended to the report for Board approval. Any further comments received will be reported verbally at the meeting. Workforce Performance Report The Committee reviewed the Workforce Performance Report at month 9. It is good to note that the rolling 12 month sickness rate has decreased in Month 9 to 4.43% from 4.59% in Month 8. It is the 3rd consecutive monthly fall and is within the Trust target. There was a more detailed breakdown of vacancies and recruitment following the discussion at Board last month and this is included in the Workforce Performance Report to Board for assurance. A new software solution to manage recruitment is embedding, the committee heard that this had been positive to date, a base line will be taken in March and action will be taken to ensure a rolling advert for bands 3 and 5 nurses. The picture of appraisals across the Trust is mixed, some teams performing well, others lagging behind. There will be a more concerted effort across the Trust to improve the number

Enc 13 WorkforceCommitteeChairsReport Page 1 of 8

of staff with appraisals in the coming months and a draft letter to those staff who had not had an appraisal within the last 12 months was shared with the Committee. The Committee received a separate detailed report on compliance against Mandatory Training competencies. Mandatory Training compliance has increased slightly from 89.3% in Month 8 to 89.7% in Month 9 but remains just below the target of 90%. It has been agreed to restrict the availability of one of the competencies to online e-learning as a pilot from April 2017 to review whether this addresses concerns about releasing staff to undertake classroom based training. Apprenticeship Levy The Committee received a useful paper detailing distribution of apprenticeship, where they can add value for the organisation as a whole and ensure that the Levy is met. Older Adults Sickness Analysis The Committee received a detailed presentation from the Head of Service regarding sickness in the Older Adults service, which generated good debate. Sickness levels have improved in the service but recording by managers across the Trust is still variable and not consistently in line with policy. It was agreed that the sickness policy would be revised for the next meeting, with HR and Heads of Service working together. It also generated a detailed discussion on the nature of sick leave and what could be done proactively to reduce this, for example more bespoke manual handling training where there were higher incidences of sickness for muscular skeletal reasons. Workforce Risk Register and Board Assurance Framework

The Committee received an early iteration of a stand-alone risk register for the Workforce Committee which would be developed and discussed the Board Assurance Framework Strategic Risk regarding the recruitment and retention of staff. With the exception of bring forward the deadline of a review of the implementation on the new electronic recruitment system, the Committee were assurance that the risk was being appropriately managed.

The Committee also received the following:

• An update on the Health and Wellbeing events for staff. • An audit on occupational health activity, which generated good discussion about the

nature of any future service contract. • The Physician’s Associate Programme. • The November Midlands and East Agency Report. • A letter from Health Education England launching its policy underpins its aim to enable

all NHS professionals to have access to healthcare library and knowledge services. • Immigration Act Action Plan. • Safer Staffing Levels Report, also included on the Agenda for Board. • Progresses in implementing the DBS update service focusing initially on staff that

required enhanced checks.


A report on the Trust leavers analysis was deferred for further work to aggregate the key issues for the Committee. Interfaces with other Committees The business that was discussed by the committee interfaces with the following Committees/Groups: • MExT • CARM / CQRM • Finance & Performance Committee • Health & Wellbeing Group Recommendation and requests for direction The Trust Board is asked to: Accept this report for assurance about the exercise of delegated authority by the Workforce Committee Approve the Terms of Reference for the Workforce Committee appended to this report.


Appendix

DUDLEY AND WALSALL MENTAL HEALTH NHS PARTNERSHIP TRUST

WORKFORCE COMMITTEE

The Board recognises that high standards of governance throughout the Trust are essential for the delivery of the identified strategic objectives, the safety of its services the quality of service user and carer experience and the long term protection of stakeholder interests. Good governance emanates

from the Board but pervades the entire organisation, being reflected in its operating practices, policies and procedures. This responsibility encompasses clinical, financial and organisational aspects of governance and enables key risks to be identified and managed, in both operational and strategic

terms.

This committee will therefore ensure that: The Trust has established a sound framework of clinical governance comprising those processes,

systems and controls that enable NHS organisations to demonstrate accountability for continuously improving the quality of services and safeguarding high standards of care. That arrangements are in place to support staff to deliver safe and quality patient care. That consultation and involvement by service users, carers and stakeholders effectively informs continuous improvement. That clinical governance, clinical/operational risk management and safeguarding systems and processes are

operating effectively, provide robust information and comply with statutory and regulatory guidance, standards and reporting requirements. That learning from feedback is embedded throughout the

organisation. That all aspects of information governance relating to clinical and patient information are in place to meet IG Toolkit standards.

TERMS OF REFERENCE

1. Authority 1.1 The Workforce Committee is constituted as a standing committee of the Trust's board of

directors. Its constitution and terms of reference shall be as set out below, subject to amendment at future board of directors meetings.

1.2 The Workforce Committee is authorised by the Board of directors to instruct professional

advisors and request the attendance of individuals and authorities from outside the Trust with relevant experience and expertise if it considers this necessary for or expedient to the exercise of its functions.

1.3 The Workforce Committee is authorised to obtain such internal information as is

necessary and expedient to the fulfilment of its functions. 2. Purpose: 2.1 To enable the Board to obtain assurance that there is a coordinated strategic response

to the workforce needs of the organisation and ensure the delivery of the Trusts strategic objectives in relation to “People” and ensure that there is an appropriate response to the strategic workforce risks and performance against workforce key performance indicators


3. Membership: 3.1 The membership of the Workforce committee shall consist of:

A minimum of 2 Non-Executive or Associate Non-Executive Directors who will act as the Chair or Vice Chair

Chief Executive Director of People and Corporate Development Director of Nursing, Operations and Estates Director of Finance, Performance & IM&T Joint Medical Director

3.2 The Workforce Committee will be deemed quorate when 4 members are present

including at least one Non-Executive / Associate Non-Executive Director and one Executive Director.

3.3 The Chair will be appointed by the Trust Board. 3.4 For the avoidance of doubt, Trust employees who serve as members of the Workforce

Committee do not do so to represent or advocate for their respective department, division or service area but to act in the interests of the Trust as a whole and as part of the Trust-wide governance structure.

3.5 Core members may nominate an appropriate deputy to attend the committee on their

behalf. However, it is expected that any nominated deputy will be fully briefed and have the necessary authority to participate fully in the debate and any subsequent decisions arising.

3.6 Additional members or associates may be co-opted to attend the Committee as

necessary. 4. Attendance 4.1 The following participants are required to attend meetings of the Workforce Committee:

Associate Director of Operations Associate Director of People and Workforce Development Heads of Service Senior Workforce Development Manager Senior HR Business Partner ESR Systems Manager Senior Finance Manager Communications Manager Equality and Diversity Manager Professional Leads Head of Nursing Head of Social Care Contracting Manager


4.2 Other people may be invited to attend on an ad hoc basis. 4.3 Administrative support to the Committee will be provided and maintain minutes/actions

of the meetings. 4.4 Other than as set out in paragraphs 4.1 to 4.3, only members of the Workforce

Committee are entitled to be present at its meetings. 4.5 Members listed at paragraph 3.1 and attendees listed at paragraph 4.1 are,

respectively, required to attend at least 75% of the meetings held annually. 5. Frequency 5.1 Meetings shall be held monthly and will be subject to review after the first 6 months. 6. Duties 6.1 To develop a Workforce Strategy and Implementation Plan. 6.2 To support the coordination of the various streams of strategic workforce activity and to

monitor progress specifically in the following areas: Human Resources Management Temporary resourcing Workforce Planning Education and Learning Organisational Development Staff Engagement Equality, Diversity and Human Rights

6.3 To provide a forum for Service Line strategic workforce issues to be considered.

6.4 To consider national and local workforce developments and influence the organisation’s

response

6.5 To ensure strategic workforce planning and development is embedded in the organisation and appropriate workforce planning and assurance systems are in place.

6.6 To have an oversight of national and regional LDAs and delivery of education.

6.7 To ensure Trust meets Regulatory / mandatory workforce requirements

6.8 To support the Trust’s Library knowledge services

6.9 To support the Trust’s Organisational and Leadership Development 6.10 To receive reports and review progress in relation to HR Management, Temporary

Staffing, Recruitment Workforce Planning, Education and Learning Development, Organisational Development, Staff Engagement, Equality, Diversity and Human Rights.


6.11 To oversee the Trust’s vacancy reduction plans

6.12 To oversee the Trust’s approach to managing temporary labour and Agency usage

6.13 To monitor compliance in respect of CQC KLOE the Workforce Race Equality Standard (WRES), Staff Engagement and other Workforce Standards

6.14 To receive reports and review progress of Service Line and Professional group updates strategic workforce activity, plans and issues.

6.15 To review Trust wide and service level performance against workforce KPI’s, and ensure an appropriate response.

6.16 To monitor workforce risks and the Board Assurance Framework as it relates to the

Terms of Reference of the Committee

6.17 To receive the annual Staff Survey and agree and monitor any resulting action plan to address the outcomes from the staff survey.

6.17 To oversee Staff Health and Wellbeing performance

7. Minutes and Reporting 7.1 A summary report agreed with the Chair of the Committee will be presented to the Trust

Board following each meeting of the Committee. 7.2 The Chair of the Committee shall draw to the attention of the Board any issues that

require disclosure to the full Board, or require executive action. 7.3 The minutes of all meetings of the Workforce Committee shall formally be recorded and

the ratified minutes submitted, together with recommendations where appropriate to the board of directors.

7.4 The Company Secretary will act as secretary to the Committee and will provide advice

and ensure administrative support. The duties of the secretary in this regard include but are not limited to: • Agreement of the agenda with the chair of the Committee and attendees together

with the collation of connected papers. • Taking the minutes and keeping a record of matters arising and issues to be carried

forward. • Advising the Workforce Committee as appropriate.

7.5 The Health and Wellbeing Group will report to the Workforce Committee and the

effectiveness of this Group will be monitored by the Workforce Committee. 7.6 The Health and Wellbeing Group will submit its minutes to the Workforce Committee

and will report on progress on a monthly, quarterly or annual basis as appropriate. Key


issues will be reported by exception. The Terms of reference of the Health and Wellbeing Group will be subject to Workforce Committee approval on an annual basis.

8. Review 8.1 These terms of reference will be formally reviewed by the Committee at least annually.

Any proposed amendments to the Terms of Reference will be approved by the Trust Board

8.2 The Workforce Committee will undertake an assessment of its overall effectiveness and

compliance with these terms of reference at least annually. This review process will be in the form of a self-assessment and will include the development of the following year’s reporting cycle. The terms of reference will be formally reviewed by the committee as part of this assessment.

APPROVED BY THE BOARD OF DIRECTORS ON XX XXXX XX



Agenda Item number: 8.1.3b Enclosure: 14

Trust Board Workforce Report 2016/17 Month 9 Page

• Key Messages • Workforce Dashboard • Recruitment • Turnover • Sickness • Appraisal • Mandatory Training

3 5

6-7 8

9-10 11 12

2

Vacancies – There are currently 176 FTE contracted vacancies across the Trust increasing the vacancy rate to 15.4% in Month 9 from 14.5% during Month 8. There are 96 FTE posts that are currently being recruited to at various stages of the process. The budgeted WTE increased by 12.8 FTE, between Month 8 & Month 9. The increase in vacant WTE can be attributed to this movement. The TRAC recruitment system is currently being implemented which gives increased control and oversight to recruiting managers and allows the Trust to performance manage against recruitment KPIs. Refreshed service recruitment plans are also being developed via the Workforce Committee. Turnover – The 12 Month Turnover rate has decreased from 11.62% to 11.27%. The Trust’s turnover percentage rate (excluding Junior Medics), is average when comparing the Turnover rate of other Mental Health organisations in the NHS.

3

Sickness Absence – The rolling 12 month sickness rate has decreased in Month 9 to 4.43% from 4.59% in Month 8, this is within the Trusts target and is the 3rd consecutive monthly fall and an improvement of 0.5% since February 2016. In month sickness has decreased from 3.89% in Month 8 to 3.62% in Month 9, this means 7 of the last 12 months have had a lower absence rate than that of the Trust target. Appraisal – Compliance has decreased from 79.1% to 77.6%, this is still below Trust target of 85% but showing a positive trend in recent months. There are 193 employees in the Trust that haven't had an appraisal recorded in the last 12 months, an improvement of the 258 reported in Month 4. These staff are being written to in January 2017. Weekly reports are now being produced in order to support managers in highlighting with low compliance and future requirements. Mandatory Training - Mandatory Training compliance has increased slightly from 89.3% in Month 8 to 89.7% in Month 9 and remains just below the target of 90% agreed at MEXT for all mandatory training (IG remains at 95%). As with the Appraisal, new reports are being distributed to Service leads to assist with what training individuals need to undertake over the remainder of 16/17 in order to remain compliant.

4

445 Dudley and Walsall Mental Health Partnership NHS Trust

Staff in PostTarget Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

Headcount 1005 1015 1008 1012 1018 1018 1021 1023 1036 1055 1059 1059Funded Establishment 1093.6 1096.5 1094.6 1067.5 1082.9 1113.9 1129.4 1134.1 1141.5 1138.9 1128.9 1142.6Staff in Post FTE (Contracted) 918.7 925.1 919.4 920.2 927.6 926.3 928.3 933.1 944.0 962.1 965.3 966.2WTE Variance 174.9 171.3 175.2 147.3 155.3 187.6 201.1 201.0 197.5 176.8 163.6 176.4Vacancy % 10.0% 16.0% 15.6% 16.0% 13.8% 14.3% 16.8% 17.8% 17.7% 17.3% 15.5% 14.5% 15.4%Worked FTE (Substantive) 918.3 920.9 926.7 915.2 920.2 927.2 929.8 932.8 952.0 954.6 966.0 964.5Worked FTE (Temp) 166.7 187.5 188.8 193.0 67.2 174.3 138.7 146.1 145.7 135.6 139.7 147.4Worked FTE (Total) 1,085.0 1,108.5 1,115.5 1,108.2 987.4 1,101.4 1,068.5 1,078.8 1,097.7 1,090.2 1,105.6 1,111.9Turnover % (12 Months) 8-14% 15.06% 15.10% 15.53% 14.86% 14.96% 12.47% 12.12% 11.74% 10.71% 11.47% 11.62% 11.27%

Pay SpendTarget Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

Funded £ £4.32m £4.45m £4.28m £4.06m £4.25m £4.14m £4.30m £4.17m £4.16m £3.91m £4.18m £4.16mSubstantive Spend £ £3.32m £3.59m £3.46m £3.47m £3.56m £3.44m £3.58m £3.61m £3.64m £3.60m £3.63m £3.45mTemp Spend £ £0.78m £0.66m £0.76m £0.60m £0.68m £0.54m £0.48m £0.47m £0.46m £0.48m £0.56m £0.52mTotal Pay Spend £ £4.11m £4.25m £4.22m £4.06m £4.24m £3.98m £4.06m £4.08m £4.10m £4.08m £4.18m £3.96mVaraince - Budget to Actual £ £216K £194K £67K £K £11K £160K £245K £86K £58K -£173K £K £200K

AbsenceTarget Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

Sickness % (Month) 4.68% 4.77% 5.18% 4.33% 4.40% 4.57% 4.39% 4.83% 4.85% 5.03% 3.91% 3.89% 3.62%Sickness Days Lost FTE (Month) 1,357 1,382 1,240 1,210 1,311 1,218 1,392 1,394 1,424 1,154 1,123 1,085No of Sickness Episodes (Month) 168 168 166 144 163 144 162 141 175 163 174 168Cost of Sickness (Month) £125K £125K £104K £104K £131K £127K £116K £122K £130K £95K £85K £82KMaternity % (Month) 1.84% 1.77% 1.87% 1.71% 1.53% 1.63% 1.62% 1.50% 1.45% 1.64% 1.61% 1.85%Sickness % (12 Months) 4.68% 4.84% 4.92% 4.87% 4.81% 4.80% 4.82% 4.82% 4.82% 4.88% 4.73% 4.59% 4.43%Long Term Sickness % (12 Months) 67.1% 67.4% 68.5% 67.3% 68.1% 68.7% 66.9% 68.9% 69.6% 68.3% 68.0% 66.3%Cost of Sickness (12 Months) £1,368K £1,407K £1,391K £1,386K £1,420K £1,454K £1,423K £1,430K £1,457K £1,418K £1,359K £1,303K

DevelopmentTarget Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

Appriasals Completed 685 644 619 600 606 606 638 649 626 694 691 669Appraisals Outstanding 163 221 251 268 269 262 258 218 223 174 183 193Appraisals Required 848 865 870 868 875 868 896 867 849 868 874 862Appraisal % 85% 80.8% 74.5% 71.1% 69.1% 69.3% 69.8% 71.2% 74.9% 73.7% 80.0% 79.1% 77.6%Mandatory Training % 90% 78.9% 77.9% 80.5% 81.7% 81.9% 81.4% 84.2% 84.1% 83.8% 85.4% 89.3% 89.7%Essential Skil ls Training % 90% 78.0% 78.0% 80.7% 83.0% 83.6% 57.6% 59.5% 60.1% 61.3% 62.1% 64.6% 65.6%

Dec-16

5

Staff GroupNo of

advertsWTE

AdvertisedAdvert views Applications

Application to advert view rate

Applications per WTE

Avg no of days

advertisedAdditional Clinical Services 1 1.4 1375 85 6.2% 60.7 4.0Additional Professional Scientific & Technical 2 3.0 1644 4 0.2% 1.3 36.0Administrative & Clerical 4 3.8 4450 172 3.9% 45.3 10.5Nursing & Midwifery Registered 7 8.8 3122 50 1.6% 5.7 21.4Total 14 17.0 10591 311 2.9% 18.3 19.1

The table above shows the number of adverts published on NHS jobs in November and the associated WTE by Staff Group. Both Qualified Nursing and Clinical Psychologist roles had the lowest number of applications per Whole Time Equivalent (WTE) advertised (when more than 1 WTE is advertised) with an average of 4 for this period. This can be seen as an indicator of the lack of supply of Qualified Nursing staff across the region/nationally. Whereas Admin & Clerical and unregistered clinical support roles attract the highest number of applicants. Band 5 nursing recruitment are included within the above figures.

6

The table below details the vacancy position by Service as at the end of December 2016. There are 176 Full Time Equivalent (FTE) contracted vacancies across the Trust, which has reduced from 201 FTE in Aug-16. There are 96 FTE vacancies in the current Recruitment Pipeline. Therefore there are 74 FTE posts that are not currently being recruited to.

Service Funded FTE Contracted

FTE Contracted

VacsActing In Acting Out Rot In Rot Out Sec In Sec Out

Change of Hours

Known Leavers

Total Adj Adj FTE Adj Vacs NREC Posts REC Vacs Recruitmen

t Pipeline

Outstanding REC

Vacancies 445 Dudley and Walsall Mental Health Partnership NHS Trust 1142.6 966.2 176.4 -6.0 7.0 7.6 -8.0 -15.7 17.3 10.6 -8.6 4.2 970.4 170.2 50.9 119.3 96.2 73.9

445 ACU Acute Services Level 3 155.9 123.7 32.2 0.0 0.0 1.0 -1.4 -0.6 3.6 0.9 -1.8 1.7 125.4 30.5 0.0 30.5 21.0 9.5

445 ACC Access Services Level 3 82.7 63.6 19.1 -1.0 1.0 0.0 0.0 -6.8 7.8 1.6 -0.8 1.8 65.4 17.3 10.0 7.3 5.0 12.3

445 AOMGT Acute & Older Adults Management Level 3 28.4 23.2 5.1 0.0 0.0 0.0 0.0 -1.0 0.0 0.3 0.0 -0.8 22.5 5.9 0.0 5.9 0.0 5.9

445 CAF Corporate Affairs Level 3 10.7 12.5 -1.8 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.4 12.9 -2.2 0.8 -2.9 1.0 -3.2

445 CDP Corporate Development and People Level 3 6.0 6.0 0.0 -1.0 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 6.0 0.0 0.0 0.0 0.0 0.0

445 CHX Chief Executive Level 3 39.2 26.1 13.1 0.0 0.0 0.0 0.0 -2.0 0.0 0.0 0.0 -2.0 24.1 15.1 28.4 -13.3 12.0 3.1

445 COM Community Services Level 3 123.6 118.2 5.3 -1.0 1.0 0.0 -1.0 0.0 1.0 0.0 0.0 0.0 118.2 5.3 0.0 5.3 5.1 0.3

445 EIN Early Intervention Level 3 224.8 198.2 26.5 0.0 0.0 0.0 0.0 -1.0 0.0 0.2 0.0 -0.8 197.4 27.3 8.1 19.2 18.6 8.7

445 FIN Finance Level 3 41.0 38.2 2.9 0.0 0.0 0.0 0.0 0.0 0.0 -0.2 0.0 -0.2 38.0 3.1 0.5 2.6 3.0 0.1

445 HR Human Resources Level 3 17.8 17.8 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 17.8 0.0 0.0 0.0 1.6 -1.6

445 MED Medical Level 3 134.5 108.7 25.8 -1.0 1.0 1.0 0.0 1.7 0.9 4.7 0.0 8.3 117.0 17.5 0.0 17.5 6.7 10.8

445 OAS Older Adults Level 3 186.3 157.1 29.1 -1.0 1.0 5.6 -5.6 -2.0 4.0 1.6 -6.0 -2.4 154.7 31.5 1.0 30.5 16.3 15.2

445 OPS Operations Level 3 102.8 85.8 17.1 -1.0 2.0 0.0 0.0 -4.0 0.0 1.2 0.0 -1.8 83.9 18.9 2.1 16.8 5.9 13.0

Grand Total 1142.6 966.2 176.4 -6.0 7.0 7.6 -8.0 -15.7 17.3 10.6 -8.6 4.2 970.4 170.2 50.9 119.3 96.2 73.9

7

12 Month Turnover has decreased slightly to 11.3% in Month 9. This is within the Trusts targeted range and could be considered a good indicator that the Trust in general retains its staff.

15.1% 15.1% 15.5%14.9% 15.0%

12.5% 12.1% 11.7%10.7%

11.5% 11.6% 11.3%

5.0%

7.0%

9.0%

11.0%

13.0%

15.0%

17.0%

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

DWMH Turnover % by Month

Target Range Turnover %

ServiceStarters FTE

(Month)Leavers FTE

(Month)Turnover %(12 Months)

445 ACC Access Services Level 3 0.0 0.8 6.9%445 ACU Acute Services Level 3 2.0 1.0 10.9%445 AOMGT Acute & Older Adults Management Level 3 0.0 0.0 4.4%445 CAF Corporate Affairs Level 3 0.0 0.0 14.5%445 CDP Corporate Development and People Level 3 0.0 0.0 0.0%445 CHX Chief Executive Level 3 0.0 0.0 38.9%445 COM Community Services Level 3 1.0 0.0 3.4%445 EIN Early Intervention Level 3 1.6 1.3 8.1%445 FIN Finance Level 3 0.0 0.0 12.5%445 HR Human Resources Level 3 1.4 0.0 31.1%445 MED Medical Level 3 1.8 0.0 13.2%445 OAS Older Adults Level 3 0.0 2.0 12.4%445 OPS Operations Level 3 0.0 0.8 20.1%445 Dudley and Walsall Mental Health Partnership NHS Trust 7.8 5.9 11.3%

8

The rolling 12 month sickness rate has decreased in Month 9 to 4.43% from 4.59% in Month 7. This is within the trusts target 4.68% and the third consecutive month that sickness rate has improved. In month sickness has decreased from 3.89% in Month 8 to 3.62% in Month 9.

4.77%

5.18%

4.33% 4.40%4.57%

4.39%

4.83% 4.85%5.03%

3.81% 3.89%

3.62%

3.00%

3.50%

4.00%

4.50%

5.00%

5.50%

Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16

Sickness Absence % v Trust Target

Target Sickness % Sickness % 12mth

445 ACC Access Services Level 3 3.57% 2.41%

Service Nov-16 Dec-16Sickness %

(12 Months)4.10%

445 ACU Acute Services Level 3 2.94% 3.58% 4.22%

445 CAF Corporate Affairs Level 3 0.75% 0.00% 0.41%445 AOMGT Acute & Older Adults Management Level 3 4.45% 5.89% 5.04%

445 CHX Chief Executive Level 3 15.70% 13.85% 7.29%445 CDP Corporate Development and People Level 3 0.00% 0.54% 1.65%

445 HR Human Resources Level 3 6.82% 0.73% 1.66%

445 COM Community Services Level 3 4.79% 3.99% 5.54%445 EIN Early Intervention Level 3445 FIN Finance Level 3

3.91%0.44%

2.81%1.56%

4.40%2.43%

445 Dudley and Walsall Mental Health Partnership NHS Trust 3.89% 3.62% 4.43%

445 MED Medical Level 3 3.61% 4.88% 4.07%445 OAS Older Adults Level 3 3.09% 3.68% 4.64%

5.25% 3.69% 5.20%445 OPS Operations Level 39

Long term sickness accounts for 66% of sickness for the rolling 12 month period to December 2016. The number of open Long Term sickness cases is 23 in Month 9. The top 3 reasons for sickness based on FTE days lost for Month 9 were: 1. Anxiety/Stress – 246 2. Gastrointestinal problems - 137 3. Cold, Cough, Flu - Influenza -

136

1.0% 1.4% 1.8% 1.6% 1.4% 1.5% 2.0% 1.5%

2.93% 2.70% 2.44%3.92%

3.05% 2.55%2.66%

2.93%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

445 CorporateLevel 2

445 ACC AccessServices Level 3

445 ACU AcuteServices Level 3

445 COMCommunity

Services Level 3

445 EIN EarlyIntervention

Level 3

445 MEDMedical Level 3

445 OAS OlderAdults Level 3

445 Dudley andWalsall Mental

HealthPartnership NHS

Trust

Short Term/Long Term Sickness % (Rolling 12 Months)

ST% LT%

Add ProfScientific and

Technic

AdditionalClinicalServices

Administrativeand Clerical

Allied HealthProfessionals

Estates andAncillary

Medical andDental

Nursing andMidwiferyRegistered

DWMH

Nov-16 2.26% 5.08% 3.39% 6.54% 13.22% 1.07% 3.71% 3.89%Dec-16 0.65% 4.33% 4.19% 0.55% 10.11% 2.21% 3.69% 3.62%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%Sickness Absence Comparison by Staff Group

10

Appraisal compliance is tracking at 79.1% at the end of Nov-16. This is still below Trust target and a slight decrease on the previous month but is still the 4th highest result in the last 12 months. There are 183 employees in the Trust that haven't had an appraisal recorded in the last 12 months.

83.2%79.7%

76.1%71.1%

76.4% 74.5%69.8% 71.2%

74.9% 73.7%

80.0% 79.1%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

Appraisal % v Trust Target

Target Appraisal %

ServiceAppraisals Required

445 ACC Access Services Level 3 66445 ACU Acute Services Level 3 108445 AOMGT Acute & Older Adults Management Level 3 24445 CAF Corporate Affairs Level 3 11445 CDP Corporate Development and People Level 3 5445 CHX Chief Executive Level 3 13445 COM Community Services Level 3 110445 EIN Early Intervention Level 3 170445 FIN Finance Level 3 32445 HR Human Resources Level 3 11445 MED Medical Level 3 88445 OAS Older Adults Level 3 155445 OPS Operations Level 3 81445 Dudley and Walsall Mental Health Partnership NHS Trust 874

76.8% 74.1%

84.1%96.9% 93.8%

100.0% 100.0%

Oct-16 Nov-16

47.7% 54.5%

+/-

88.1%

100.0%100.0%

100.0%100.0%

77.3% 75.0%

80.0% 79.1%

90.8% 94.3%72.7% 74.8%

90.5% 87.5%81.8% 90.9%

80.0% 74.5%

11

445 Dudley and Walsall Mental Health Partnership NHS Trust

Training Compliance

Competence Target Completed Required % +/- Completed Required % +/-Mandatory Training 90% 7224 8093 89.3% 7308 8144 89.7%

kMandatory Training

Competence Target Completed Required % +/- Completed Required % +/-Equality, Diversity and Human Rights 90% 902 989 91.2% 919 997 92.2%Fire Safety 90% 875 989 88.5% 893 997 89.6%Health and Safety 90% 896 989 90.6% 916 997 91.9%Infection Control (Clinical) 90% 583 688 84.7% 602 692 87.0%Infection Control (Non Clinical) 90% 276 302 91.4% 278 306 90.8%Information Governance 95% 903 989 91.3% 881 997 88.4%Moving and Handling (Foundation) 90% 911 989 92.1% 923 997 92.6%Moving and Handling (Patient Handling) 90% 156 228 68.4% 161 227 70.9%Safeguarding Adults Level 1 90% 248 263 94.3% 253 268 94.4%Safeguarding Adults Level 2 90% 614 702 87.5% 618 699 88.4%Safeguarding Children Level 1 90% 247 263 93.9% 249 268 92.9%Safeguarding Children Level 2 90% 613 702 87.3% 615 699 88.0%

Dec-16

Nov-16 Dec-16

Nov-16 Dec-16

12



Enclosure: 15

Report Title:

Medical Directors’ Report


Dr Gingell and Dr Weaver, Joint Medical Directors


Dr Gingell and Dr Weaver, Joint Medical Directors

Purpose of the report: To update the Board on matters pertaining to the joint medical

directors’ portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


N/A

Strategic Objective(s) to which this paper relates: High quality

services


Leadership culture






Caring Responsive Effective Well-led Safe

Enc 15 MD Board Briefing Paper Page 1 of 7

Title Medical Directors’ Report

National and Regulatory guidance We have continued to implement the junior doctors’ contract with current trainees transferring to the new contract in February, as well as new trainees entering the specialty and starting their first job with the Trust. A great deal of work has been undertaken to ensure the smooth implementation with regular meetings between Trust management, the Postgraduate Department who have developed the new rotas and job plans and the HR department. There are quality improvements anticipated through the moving of the Walsall on call to a residential rota, and simplified planning of emergency rotas during the day time. We will be monitoring the implementation to ensure any difficulties are addressed immediately. The Guardian of Safe Working will be providing quarterly updates to the LNC and the Board, and will be attached as a supplementary report to this report in May. Recent Publications and Hot Topics RE: Building Capacity, Psychiatry Leadership in Perinatal Mental Health Services A priority under the Five Year Forward View for Mental Health is that by 2020/21, at least 30,000 more women in all areas of England will be able to access treatment closer to home when they need it. This includes developing and sustaining the right range of evidence-based specialist community services and inpatient care. Reflecting this commitment, NHS England in partnership with Health Education England commissioned The Royal College of Psychiatrists to manage and deliver the Building Capacity, Psychiatry Leadership in Perinatal Mental Health Services project. This project plans to administer bursaries to backfill 10 consultant level psychiatrist posts for one year while individual psychiatrists engage in training in the sub-specialty of Perinatal Psychiatry. This training programme will develop clinical, leadership and teaching skills to enable the participants to establish and lead Perinatal Mental Health services in their respective localities. As a result of the information, consultants were canvassed within DWMHPT, and following conversations with our local specialist in-patient consultant, one consultant put in an application with support from the Trust management and the CCG. We are delighted to inform the Board that the application was successful and therefore one outcome will be better services for all women who suffer mental health difficulties during pregnancy and during the postnatal period throughout the Black Country. Local Matters Regular updates on Medical Revalidation are included in the Medical Directors report. In the last 180 days 7 doctors were under notice for revalidation submission. There were 5 successful recommendations and 2 deferrals. Mortality Report Mortality Data for December 2016 There are 13 cases applicable for inclusion within this month’s figures which are outlined within the table below. Information in respect to these cases has been collected from the Safeguard


Reporting system and the Informatics and Performance Department. The information from each electronic system complements the other and through cross referencing within other clinical information on OASIS, information from the coroner’s office and information from partner agencies, are aligned via the agreement of the Trusts mortality review group with one of the 4 following definitions: Natural deaths - ones from a recognisably incurable condition. Expected death - one where prognostic features have been identified leading to a reasonable expectation of death within an identified timescale Unexpected death - one occurs at a time that is sooner than may reasonably have been predicted from a non-natural cause or where the cause in unknown Preventable death - one that should not have occurred given current medical knowledge and technology’ It is the intention that “preventable deaths” are reported to the Trust Board via this report as and when they are identified. There are 2 incidents which are being investigated as Serious Incidents and 1 incident which the Mortality Review Group has agreed would be applicable for further review via the Trusts Mortality Review Tool, copy template appended to the report, for which the completed documents will be reviewed by Mortality Review Group, these are as follows: Mortality Review Tool

• 56 year old male patient open to CRS North (Dudley) – Cause of death confirmed as; 1a) Pneumonia 2) Triple vessel coronary atheroma

Serious Incident Investigation • 47 year old Male, with a recent referral to EAS, was last seen by the Trusts

Psychological Therapies Hub in August 2016 – Cause of death confirmed as; 1 a. Multi organ failure, 1b. Paracetamol overdose, 1c. Alcohol dependency syndrome, 2. Depression.

• 49 year old Male open to outpatients is thought to have taken an overdose. Exact cause of death is still to be confirmed with the Coroner’s Office as they are awaiting toxicology.

There are 13 cases falling inside the scope of this report and can be summarised as follows:

Age Team Diagnosis Summary Definition 80 CMHTOA

Walsall Mild depressive episode

80 year old gentleman passed away of natural causes, wife was with him when he passed away in his care home. Patients last face to face contact with the Trust was with OA CMHT Walsall in May 2016. Cause of death confirmed by patients GP Cause of death listed as: Vascular Dementia

Natural death

86 Memory Service Walsall

None given Memory Assessment Nurse saw the details that this patient has passed away on the FUSION system. The last face to face contact with Trust services was in September 2016 Cause of death confirmed following correspondence with Walsall Manor Hospital staff Cause of death listed as: Pneumonia.

Natural death


Dementia in Alzheimer’s disease, atypical or mixed

Patient passed away at Walsall Manor Hospital on 14/12/16. The patients last face to face contact with Trust Services was in October Cause of death confirmed following correspondence with Walsall Manor Hospital staff Cause of death listed as: 1a) Sepsis 1b) Pancreatic abscess 2)Old age and frailty

Natural death


Age Team Diagnosis Summary Definition 49 Adult

outpatients Recurrent depressive disorder, current episode mod

Incident form noted that: Patient contacted Crisis team, outpatients and colleague and medic from our South Team to get an earlier outpatient appointment. His mother rang to get an earlier outpatient appointment as he was getting verbally abusive to her, he was delusional and desperate. An appointment was sought and a cancellation was identified for the Wednesday 4th January at 9.30am. Outpatients confirmed there was nothing on Tuesday. Staff rang patients mobile at around 13.22 and got no reply so rang back his mother as staff had her contact details. She stated that it was too late and that he had killed himself. Cause of death is still to be confirmed however a non-specific tablet bottle was found next to the patient. The coroner is currently awaiting toxicology Incident logged as a Serious Incident 2017/98 Patient’s last face to face contact with Trust Services was in November 2016 via the Trusts Medical Outpatients.

Unexpected death


None given Patient passed away in hospital Cause of death confirmed with Cause of death listed by Walsall Manor Hospital as: 1a) Bronchopneumonia 1b) Frailty of age and immobility Patients last face to face contact with Trust Services was in September 2016

Natural death

96 CMHTOP Dudley

None given Informed by Finance that this person died 20/12/16 Was seen once by secondary mental health services for a review in April 2016 and had no open referrals. Cause of death confirmed by Coroner’s Office Cause of death listed as 1a) Dementia 1b) Hypertension 1c) Asthma

Natural death

79 CMHTOA Walsall

Mixed anxiety and depressive disorder

Passed away peacefully at the Manor hospital due to pneumonia. The death was expected. Patient was last seen on the 20/12/2016. Cause of death was listed as: 1a) Respiratory failure 1b) Secondary to community acquired pneumonia

Expected death

47 EAS Dudley Recurrent depressive disorder, unspecified

Notified by the District Coroner that a patient known to our service has died. Previously open to our PT hub (last seen August 2016), recent referral to EAS. Cause of death confirmed with Coroners Office Cause of death listed as: 1 a. Multi organ failure 1b. Paracetamol Overdose 1c. Alcohol dependency syndrome 2. Depression. Incident logged as a serious incident 2016/32619

Unexpected death

84 Memory service

None given Saw details on Fusion that patient had passed away. Cause of death confirmed by GP Cause of death listed as: Suspected malignancy. Patient was last seen face to face by the Trusts Memory Service in November 2016

Natural death

57 Primary Care Mental Health and Talking Therapies Service (Walsall)

None given Patient’s husband arrived at Kingshill to advise that she had passed away on December 25th. Advised likely natural causes Patient was not open to secondary care as patients only contact with Trust services is through the Walsall Primary Care and Talking Therapies Team Still awaiting cause of death.

Unexpected death (suspected natural causes but not yet confirmed).

86 CMHTOP Dudley

Vascular dementia, unspecified

Patient died of Vascular Dementia and Parkinson’s Disease. Cause of death confirmed by patients GP Patient was last seen by Trust Services in June 2016

Natural death

91 CMHTOP Dudley

Dementia in alzheimer's disease with late onset

Patient was receiving care in Broadway Halls Residential Home Cause of death confirmed by patients GP Cause of death listed as Chest Infection/Pneumonia

Natural death


Age Team Diagnosis Summary Definition 56 CRS Dudley

north Paranoid schizophrenia complete remission

Sister of patient telephoned to inform Care Coordinator that the patient had been found deceased in his flat on Saturday. Sister said that he had been with her on Friday displaying flu like symptoms and had been quite unwell. His sister stated she believed there were no suspicious circumstances however due to the sudden nature of the death this had been reported to the coroner. The cause of death was listed as: 1a) Pneumonia 2) Triple vessel coronary atheroma A mortality review tool is being completed to ascertain further information in relation to this patients physical health

Natural death

Recommendation This report is to be received for information only as there are no recommendations to put forward currently.


Appendix MORTALITY REVIEW TOOL The below mortality review tool has been designed with the agreement of the Trusts Mortality Review Group and is designed to gather information on those deaths which are known by the Trust or have been reported to the Trust involving its service users and former service users. It is the aim of this tool to provide the Trust a better understanding of the organisations mortality rates and the underlying causes, contributory factors and reasons. MORTALITY REVIEW TOOL Section 1 – Patient details 1.1 Patient Forename: 1.2 Patient Surname: 1.3 Incident number 1.4 Patient NHS Number: 1.5 Patient Date of Birth: 1.6 Patient Date of Death: 1.7 Patient Home Address:

1.8 Patient Home Postcode: Section 2 – Initial screening questions 2.1 Was the patient a current

patient of the Trust or one which had been

recently discharged from services

Current Patient ☐ Recently Discharged ☐ If discharged, what was the discharge date

2.1 What team(s) was the patient open to at the

time of death: (If recently discharged

please mark as N/A)

2.2 Please give details of the patients MH diagnosis

2.3 What was the medical cause of death / likely

medical cause of death:

2.4

Objectively, was this death expected:

Yes ☐ No ☐


If yes, please move to question 2.5, If no, please move to Section 4 2.5 Please give details as to

why this death was felt to be expected (e.g. patient

was suffering with terminal illness)

Review tool is now

complete as this death was expected, please

move to section 6

Section 3 – Additional questions 3.1 Was this patient currently

taking medication: (If Yes Please detail)

Yes ☐ No ☐

3.2 When the patient last presented to services,

were there any concerns above and beyond the

patient’s normal presentation (both

physically and mentally). If yes please briefly

detail.

Yes ☐ No ☐

3.3 Has the patient recently missed or DNA’d an

appointment If yes, please give details

Yes ☐ No ☐

3.4 Were there other providers involved in the individuals care If yes, please give details

Yes ☐ No ☐

Section 4 4.1 Completed By 4.2 Date




Enclosure: 16

Report Title:

Director of Operations and Nursing Report


Rosie Musson – Acting Director of Nursing Marsha Ingram – Acting Director of Operations


Rosie Musson – Acting Director of Nursing Marsha Ingram – Acting Director of Operations

Purpose of the report: To update the Board on matters pertaining to the Director of

Operations and Director of Nursing portfolio that are of relevance and interest to the Board. This will include, but is not limited to, strategic implications of national and regulatory guidance and publications, together with local matters including risk and governance issues.


Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A Key points or recommendations from Committee:

N/A




Leadership culture






Caring The items in this report potential impact on all of the domains. Responsive

Effective Well-led Safe

Enc 16 DoNs Report - Public TB 2 2 177 Page 1 of 4

Title Director of Operations and Nursing Report Nurse Revalidation Update National Picture The Nursing and Midwifery Council (NMC) has published year 1 Quarter 2 data for national revalidation (covering July - September 2016). The Trust awaits more up to date information This shows that since revalidation commenced on 1 April 2016, that a total of 110,000 nurses and midwives have successfully revalidated In Quarter 2 94% of all nurses expected to revalidate nationally did so and of this 80% were in England. The NMC say categorically that this figure is in line with expectation and that early retirement or nurses leaving the profession due to revalidation has not been increased significantly. Just to give a balanced view however a survey commissioned by the Independent Nurse found that 20% of their respondents in a survey of 508 nurses had considered early retirement or knew of colleagues who had said they would exit the profession rather than go through the revalidation process. Issues around revalidation preparedness seem to be linked to place of work with some nurses who work in isolation without support feeling more vulnerable and in the same survey 60% of respondents felt that their employers were not adequately prepared for the support required by their staff. This is borne out in anecdotal discussions with colleagues across the Birmingham and Black Country areas where revalidation support and opportunities for development does seem to vary. Trust Picture Local data sourced from ESR shows:

• No red NMC flags • 112 nurses will need to revalidate during 2017 • 126 nurses revalidated during 2016 calendar year

Nurses are taking up development opportunities both in terms of the annual Nurse Development programme and bespoke Nurse Development programmes for Band 5 and 6 nurses. An even more comprehensive programme has been planned for the year April 2017 - March 2018 with new sessions being developed with our Development Associates and popular session being rolled over for another year. This will be published on the Nurse Development webpage with hard copies available for teams in February 2017 with staff able to book on sessions from April 2017. New sessions include: Clinical disengagement, Self- harm, Crossroads - where CAHMS meet Adult Mental Health, Introduction to the development of mindfulness-based therapies in clinical practice, Learning Disability Awareness and the roll-over of popular sessions like Compassion Focused Therapy and Nurse Revalidation, the code and portfolio building Enc 16 DoNs Report - Public TB 2 2 177 Page 2 of 4

Data will soon be available reviewing uptake of the programme for 2016/2017 and an example of session evaluation summaries CQC Report - Learning, Candour and Accountability The CQC have published a report into how use to identify, investigate and learn from the death of a person using their services. The investigation involved visits to 12 community and acute Trusts, and discussions with 100 families. The Trust has reviewed the report and has undertaken a benchmarking exercise against the recommendations which will initially be submitted to the Mortality Review Group in March. Local Matters Fire Alarm Issues – Bushey Fields Hospital The Trust has recently invoked it business continuity procedures following the failure of the fire alarm system on Wrekin Ward at Bushey Fields hospital in Dudley. Following the routine maintenance procedures it became clear that the fire alarm ‘panel’ on the ward was not working. The clinical team put in place all relevant mitigations overnight and the following day, patients on the ward were decanted to other beds within the Trusts. Whilst mitigating more fully the risks in Wrekin ward, this resulted in significant bed pressures in the rest of the Trust. Over the subsequent few days, business continuity measures remained in place, until the ward was ready to repatriate patients. This increased the trust’s reported OPAL escalation level from 2 to 3, due to the additional pressure on services during this period. The team will be reviewing the incident to ascertain whether there are any lessons to be learned to help improved management of future incidents. Service Transformation The operational teams have been closely involved in the planning and management of a range of service transformation projects, some of which relate to internal Trust improvement and efficiency agendas and some of which relate to commissioner led QIPP programmes. Further detail will be provided to the Board under separate agenda items relating to CIP and service transformation. However, the impact of these programmes of work upon service delivery is significant. Strategic Planning Workshop On 12 January 2017, the Trust’s senior operational managers and clinicians attended a half-day session on strategic planning. The session, led by the Chief Executive, gave an over view of the strategic national and local challenges faced by the Trust, along with interactive sessions focused on agreeing priorities for the next 12 months. The session was extremely well attended and received positive feedback – it in planned to repeat the session at the end of February to take forward these important discussions. Enc 16 DoNs Report - Public TB 2 2 177 Page 3 of 4

Recommendation As a result of the above the Board is asked to receive the update from the DONs portfolio. Board action required As Recommended.

Enc 16 DoNs Report - Public TB 2 2 177 Page 4 of 4


Agenda Item number:

Enclosure:

Report Title:

Enhancing Quality through Safer Staffing Levels - Monthly Exception Report

Accountable Director: Rosie Musson – Acting Director of Nursing


Rosie Musson – Acting Director of Nursing Makhan Singh – Principal Consultant, Informatics and Performance

Purpose of the report:

This report aims to provide the Trust Board with: 1. The summary report of planned and actual staffing which has been

submitted to NHS Choices as part of a national staffing return 2. Exception reporting regarding variances provided by Heads of Service 3. Trend analysis reporting monthly average fill rate


Decision / Approval

Gain assurance

Discussion

Information


Committee: Workforce Committee

Date reviewed: 24 January 2017 Key points or recommendations from Committee:

The report was contextualised against the inpatient staffing establishment review which is reviewing demand against establishment, from which recommendations will be made. Work is also underway to integrate safer staffing data into the integrated performance dashboard to improve triangulation. The consistent percentage of agency care staff nurse hours was highlighted and linked to the work relating to recruitment and improvements to internal bank.




Leadership culture






Caring Responsive Ensuring staffing levels are responsive to meeting patient need Effective Well-led Safe Ensuring staffing levels are adequate to deliver safe care

Enc 17 TB Safer Staffing Levels on Wards Page 1 of 9

Title Enhancing Quality through Safer Staffing Levels Monthly Exception Report

Introduction There is now a requirement post publication of the Francis Report 2013 and following the publication of Hard Truths that Trusts fulfill key commitments regarding publishing staffing data. This report aims to provide the Trust Board with: • the summary report of planned and actual staffing which has been submitted to NHS Choices as

part of a national staffing return and is available on the Trust’s website. • exception reporting for variances • trend analysis monthly average fill rate • bank and agency actual hours analysis v’s substantive hours

All Trusts are required to submit data, by ward, which shows planned against actual staff fill rates for inpatient wards. This is provided by total hours for both day and night shifts. The data is broken down by registered nurse and care staff. Trust Boards are asked to receive this published data monthly. The Board will be informed by exception of those wards where staffing fell short, the reasons for the gap, the impact and the actions taken to address this gap. There has currently been no agreement on RAG rate for this data for shortfalls, or oversupply of staffing nationally, although further guidance on this tolerance is expected. However the report has used a rating based on the provisional Information Centre range thresholds which were used to identify outliers from the first submission in May 2014. Summary of key points, issues and risks This information is collected manually and further systems have been introduced to improve data quality and reduce the risk of double counting bank and agency staff. It is anticipated that from April 2017 the information will be collated directly from the Electronic Rostering system, Across the inpatient areas the overall fill rates are 100.04%, with 100.12% for registered staff and 99.99% for care staff. Typically where our care staff rates exceed the planned numbers significantly, this is due to temporary staff being used to support patient observations or changes in skill mix. There are no exceptions to report relating to incidents The Board is asked to note that the first e-rostering continues to be implemented and is making good progress line with the agreed project plan.


Recommendation To note and discuss the monthly data return submitted providing details of planned and actual staffing at ward level. Data represents December 2016 and a monthly trend analysis for a 12 month period. To note:

• The work underway to enable more detailed analysis of staffing data and the current complexities.

• The introduction of e-rostering and the safer staffing framework Board action required The Board of Directors is asked to:

• To note and discuss the monthly data return submitted, providing details of planned and actual staffing at ward level. Data represents December 2016 and a 12 month trend analysis.


1. Nursing and healthcare staffing fill rates December 2016 The data submission was made on 12th January 2017 of December data. The following table provides a summary of the planned verses actual staffing levels on the inpatient wards.

Planned Actual Planned Actual Planned Actual Planned Actual

Cedars 945 925 1980 1957.5 462.25 451.5 1204 1214.75 97.9% 98.9% 97.7% 100.9%Linden 945.0 925.0 1980.0 1957.5 462.3 451.5 1204.0 1214.8 97.9% 98.9% 97.7% 100.9%Ambleside 1140 1125 2332.5 2332.5 612.75 612.75 1623.25 1623.5 98.7% 100.0% 100.0% 100.0%Langdale 957 949.5 1405.5 1413 655.75 655.75 774 774 99.2% 100.5% 100.0% 100.0%Clent 947.75 947.75 1507.5 1507.5 333.25 333.25 1225.5 1225.5 100.0% 100.0% 100.0% 100.0%Kinver 1020 1020 1147.5 1147.5 333.25 333.25 990 990 100.0% 100.0% 100.0% 100.0%Wrekin 975.0 972.6 824.0 794.0 333.3 451.5 548.3 569.8 99.7% 96.4% 135.5% 103.9%Holyrood 817.5 817.5 1892.0 1892.0 333.3 333.3 1494.3 1494.3 100.0% 100.0% 100.0% 100.0%Malvern 1035.0 1028.5 1272.2 1294.0 505.3 495.5 992.8 993.8 99.4% 101.7% 98.1% 100.1%Grand Total 8782.3 8710.8 14341.2 14295.5 4031.3 4118.3 10056.0 10100.3 99.2% 99.7% 102.2% 100.4%

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

RMN Care Staff RMN Care Staff Average fill rate - registered

nurses/midwives (%)

Day Night Day Night

Lowest range – less than 80% Highest range – greater than 150%

Low range – greater than 80% but less than 90%

High range – greater than 120% but less than 150%

Greater than 90% but less than 120%

Across the inpatient areas the overall fill rates are 100.04%, with 100.12% for registered staff and 99.99% for care staff. The overfill result is as expected, as most of the inpatient wards do not have planned staff levels built into their rotas for increased levels of patient observation and complexity. Typically where our care staff rates exceed the planned numbers significantly, this is due to temporary staff being used to support patient observations.


2. Exception Report on Variance – December 2016 For December 2016, the Trust has no exceptions to report to the Trust Board in relation to safer staffing returns. 3. Trend Analysis average fill rate The following table shows a monthly trend of the total average fill rates planned verses actual for the Trust. It shows the improvement in the data quality and significant understanding of the capturing of planned hours of working.


4. Registered Nurse Hours – Substantive v’s Temporary Staff fill rates

The below table shows percentage of hours in 2016/17 split by bank hours, agency hours and substantive hours for all registered nurses.


Further analysis of registered nurse hours by ward for December month is presented in the below table:


5. Care Staff Nurse Hours – Substantive v’s Temporary Staff fill rates

The below table shows percentage of hours in 2016/17 split by bank hours, agency hours and substantive hours for all care staff.


Further analysis of registered nurse hours by ward for December month is presented in the below table:




Enclosure: 18

Report Title:

MERIT Vanguard Overview Report


Mark Axcell – Chief Executive


Mark Axcell – Chief Executive

Purpose of the report: The attached updates the Board on progress with the MERIT

Vanguard. Action required from the Board Decision / Approval

Gain assurance

Discussion

Information


Committee: N/A

Date reviewed: N/A


The Board is asked to note progress with the MERIT Vanguard.


services


Leadership culture






Caring

The MERIT Vanguard aims effect all CQC domains

Responsive Effective Well-led Safe

Enc 18 MERIT Vanguard Overview Report Page 1 of 22

Title MERIT Vanguard Overview Report Introduction MERIT alliance is an equal partnership between four trusts:

• Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) • Black Country Partnership NHS Foundation Trust (BCPFT) • Coventry and Warwickshire Partnership NHS Trust (CWPT) • Dudley and Walsall Mental Health Partnership NHS Trust (DWMHT)

The programme consist of two clinical workstreams (Crisis Care; and Recovery Culture) and five enabling workstreams (Information Technology; Workforce; Quality Governance; Equality & Diversity; and Research & Innovation). The report outlines the draft milestones and budget for 2017/18 with a high level programme plan and detailed activity. The initial dashboard of the national metrics is included which will form part of the evaluation of the outcomes. Summary of key points, issues and risks The Crisis Care workstream is developing a crisis care blueprint for a replicable clinical model that delivers the Crisis Care Concordat and a shared clear and efficient process for bed management which provides optimum bed utilisation and flexibility across the West Midlands. The Recovery workstream is exploring different models of recovery and share best practice and service user feedback with the aims of preventing relapse/readmission back to secondary care, being more responsive to the local communities and actively working to facilitate recovery and improved quality of life. The focus of the enabling workstreams are to support the delivery of the clinical workstream priorities and utilise additional opportunities from four Trusts working in collaboration. The MERIT Value Proposition (Business Case) outlined the high level short, medium and long term objectives for the MERIT Vanguard Programme for the two clinical workstreams, Crisis Care and Recovery. The programme budget and risks are outlined in sections 4 and 5 of the report. A detailed list of the originally planned actions for 2016/17, the achievements against the plans and the planned milestones for 2017/18 for each workstream is appended to the report. Recommendation That the board receive this quarterly update on progress with the MERIT vanguard Board action required To receive the report for assurance.


MERIT Vanguard Trust Board Report January 2017

1. Purpose The purpose of the report is to provide a consistent update to each partner member’s Board of Directors on the achievements and plans for the MERIT Vanguard Programme following the confirmation of funding for 2017/18.

The report outlines what was planned and delivered in 2016/17. It describes the draft milestones and budget for 2017/18 with a high level programme plan and detailed activity. The initial dashboard of the national metrics is included which will form part of the evaluation of the outcomes.

2. Background MERIT alliance is an equal partnership between four trusts:

• Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT) • Black Country Partnership NHS Foundation Trust (BCPFT) • Coventry and Warwickshire Partnership NHS Trust (CWPT) • Dudley and Walsall Mental Health Partnership NHS Trust (DWMHT)

MERIT is part of the acute care collaborate cohort and the only Mental Health specific Vanguard across the New Care Models Programme. The programme consist of two clinical workstreams (Crisis Care; and Recovery Culture) and five enabling workstreams (Information Technology; Workforce; Quality Governance; Equality & Diversity; and Research & Innovation)

2.1 The Crisis Care workstream is developing a crisis care blueprint for a replicable clinical model that delivers the Crisis Care Concordat and a shared clear and efficient process for bed management which provides optimum bed utilisation and flexibility across the West Midlands. The workstream priorities are:

• Shared bed management process across the West Midlands • Seamless crisis care pathway and improved after crisis care. • Improve quality of crisis assessment • Shared records • Agreed standards

2.2 The Recovery workstream is exploring different models of recovery and share best practice and service user feedback with the aims of preventing relapse/readmission back to secondary care, being more responsive to the local communities and actively working to facilitate recovery and improved quality of life. The workstream priorities are:

• Community co-production and collaboration model • Support service users back into employment • Developing proactive recovery practices across all our mental health services

2.3 The focus of the enabling workstreams are to support the delivery of the clinical workstream priorities and utilise additional opportunities from four Trusts working in collaboration. The Workforce workstream are developing a joint workforce planning collaboration to enable quicker and more effective


response to national and local staffing issues, including recruitment, retention and development and introduction of new roles. There is a focus on delivering joint training programmes, and benefits from collaborative working on flexible staffing to support the development of a highly skilled critical mass of staff which reduces agency usage.

3. MERIT Delivery for 2016/17 and planned milestones for 2017/18

The MERIT Value Proposition (Business Case) outlined the high level short, medium and long term objectives for the MERIT Vanguard Programme for the two clinical workstreams listed below:

3.1 Crisis Care Short-term (1 year)

Milestones Progress Shared access to clinical information/care records

Development of proposals for shared records which aims to have completed a pilot by March 2017

Shared approach to bed management with care closer to home

Proposed Memorandum of Understanding (MOU) for bed management expected to be finalised in February 2017

Agreed criteria for inpatient treatment at admission

At a high level this is outlined in the draft MOU. Standard Operating Procedure (SOP) to be developed in 2017/18.

Joint operational policy and collaborative plan for bed management

MOU expected to be developed in Year 1 with clear co-ordination of bed management. Detailed Joint operational policy to be developed in 2017/18

All service users have an agreed, person centred, crisis plan

High level outlined in draft MOU. Standard Operating Procedure (SOP) to be developed in 2017/18.

Care pathways developed using evidence based practice which has been evaluated

Current Crisis Care pathways mapped across the Vanguard. Validation under way.

Workshops held with police, ambulance, social care, A&E, to agree care pathway

Crisis Care workshops held with key stakeholders.

Equality analysis completed Equality analysis complete All organisations working to the same crisis care clinical model (adapted for local variation where relevant)

Year 1 will describe the current pathways establish quick win areas. Year 2 will be perceptive phase creating consistency across the collaboration.

Medium-term (2-3 years)

• A consistent 24 hours, 7 days, age inclusive, rapid response Liaison Psychiatry (RAID) model in place • An agreed 24/7 rapid response liaison and support to the acute hospitals • Shared clinical information/care records in place • Technology developed for use by users to assist clinicians assess risk • Central IT system to enable identification of available bed resources across the region. • 24/7 psychiatry bed management operational framework in place, again across the alliance.

Long-term (4+ years)

• A national model for crisis and emergency psychiatric care.


3.2 Recovery Culture

Short-term (1 year)

Milestones Progress Baseline pre-existing recovery services and practices in the alliance

Baseline of services underway and expected completion date is March 2017

Research evidence based models of recovery

Logic Model developed with Research and Innovation workstream

Workshops held with stakeholders to agree a service model

Workshop held with key stakeholders

Framework for recovery culture agreed between the alliance and across communities, linking with communities in a new supportive way.

Framework of recovery culture developed through Mental Health First Aid, ReQol (quality of life indicators) and community engagement.

Medium-term (2-3 years)

• The workforce, users and carers recognise and understand what is involved in changing culture • Complete implementation of the new service model for recovery.

Long-term (4+ years)

• New recovery practices established as the changed culture is underpinned by structural changes in commissioning and pathways

• Previous service users are living with recovery, their lives are integrated into their community and their choices are not limited by environment but possibly by illness.

3.3 2017/18 Milestones The high level milestones for 2017/18 are included in the plan below. Appendix 1 includes a detailed list of the originally planned actions for 2016/17, achievements against the plans and the planned milestones for 2017/18 for each workstream.


4. Programme Budget

NHS England have been impressed with the collaboration across MERIT partner to date, which has resulted in the award of continued investment of £1.75m in 2017/18 to deliver the programme activity set out in the value proposition. The programme will need to demonstrate a strong return on investment and delivery of outcomes in 2017/18 to be successful in further funding from Sustainability and Transformation Planning (STP) areas moving into 2018/19.

The 2017/18 budget for the programme is set out below:

Workstream/Project Description Lead 2017/18 (£)

Prog

ram

me

Backfill of staff time Directors of Finance 992,196 Less: local contribution to backfill Directors of Finance (509,696) Project management Directors of Finance 266,344 Admin Directors of Finance 55,000 Workforce lead Tracey Cotterill 27,000 Comms lead Ian McAndrew 40,000 Intelligence hub Sandra Betney 22,656

Wor

kstr

eam

s

IT general allocation Carl Beet 15,000 IT development posts Carl Beet 139,500 Shared patient record Carl Beet 340,000 Bed management system Carl Beet/George Tadros 60,000 Crisis care general allocation George Tadros 15,000 Recovery general allocation Anne Crawford-Doherty 15,000 Workforce general allocation Julia Cross 20,000 Bespoke training packages Directors of Finance 34,000 Research posts R&I Workstream 60,000 Research general allocation R&I Workstream 15,000 Quality governance general allocation Lisa Cummins 20,000 Equality and Diversity general allocation Paul Singh 15,000

Enga

ge-

men

t

Service user and carer engagement Shakeel Sabir 30,000 Staff events Shakeel Sabir 38,000 Communication/marketing - advertising, marketing, website, external events

Louise Butler 40,000

Total 1,750,000

Additional funding will be confirmed in February 2017 to support evaluation of the programme. This will consist of quantitative (national metrics) and qualitative (e.g. patient experience, and assessment of collaborative working). A first draft of the dashboard is included in appendix 2, which will be developed in more detail in collaboration with Business Intelligence colleagues across all partner organisations.

5. Risk

Risk is monitored on a monthly basis by the MERIT Steering group, and highlights the usual risks associated with a transformational programme delivered through partnership around engagement and leadership. Appendix 3 shows the risk register, as reported to the January 2017 Steering Group, which will be updated for the position agreed during that meeting.

Although future funding was identified as a high level risk the confirmation of funding for 2017/18 means that this is likely to focus more on future funding and the expectation to deliver a return on investment. Vanguards were expected to deliver improvements in quality and efficiency which can be replicated nationally, and this pressure is likely to increase in line with any worsening of the national financial position.

Given the complexity within the strategic landscape another key risk for MERIT will be to maintain momentum as a priority given the conflicting demands on resources. This is not only a risk given competing agenda for individual provider partner organisations, but also for other stakeholders, particularly commissioners and will again put pressure on MERIT to deliver demonstrable improvements to quality and finances.


Appendix 1

1 Crisis Care and Information Technology

16/17 expected Delivered 16/17 Planned 17/18 Original Plan What has been delivered What is planned Electronic Shared Health Record • Agree scope of

future state and requirements

• Gap Analysis • Baseline

assessment of current clinical arrangements

• Define clinical need moving forward across the MERIT pathways

• Identification of gaps

• Define required resources

• Develop best practice guidance for ICT systems and integration

• Support requirements

• ICT Project integration / knowledge share

• Training requirements TBC

• Material etc reviewed and established

• Communications plan

• Showcased proposed ESHR model to CCIO, technical and data leads, clinicians across all 4 Trusts

• Develop Electronic Shared Patient Record Specification

• Agree minimum dataset to be shared. Phase 1 Demographics and Clinician Data, Phase 2 sharing with third sector

• Coventry and Warwick agreed to host proof of concept

• Intersystem submitted their proposal - delivery against allocated budget

• MERIT ICT Group agreed Intersystem Proposal

• Development of PID and Business Case for Board approval

• 4 Trusts to confirm way forward (in view of finances/resources with MERIT funding)

• Equality & Diversity Impact Assessment completed

• Procurement route established; route to market compliant; framework agreed

• Proposal agreed by 3 out of 4 Trusts (services, at cost, agreed payment structure)

• Training requirements outlined within supplier proposal

• Communications plan developed

• Develop Data Sharing Agreement with IG involvement

• Supplier Roll Out: • Application build • User Interface configuration • Production of test plans and scripts • Agreed back loading of data • ISC to build out HealthShare Application software • ISC to build out DEV, test and live environments • ESHR link to Bed Management System • Milestone 3 - Application software build • Configure and application build • Build and Configure Application in DEV • Implement 4 interfaces • Migrate code to test environment • Implement 4 interfaces • Migrate code to Prod environment • Implement 4 interfaces • Milestone 4 - Environment Configuration

Complete - Preparation for go live - stage 3 • Testing • ISC to carry out Integration testing • MERIT to conduct testing • Milestone 5 - testing complete - Go live - Stage 4 • Training Approach approved • MERIT to carry out training • Go live • Go live cutover • Implementation and control health check

submitted to PMB • Implementation and control health check

approved • Milestone 6 - Full go live - Project complete -

Solution Review - Stage 5 • Monitor data quality • Assess user satisfaction • Resolve outstanding issues • Data dictionary to be developed • Training team review - Review skill set / capacity • Review standardise training material • Development of shared project library • Development of shared procurement initiatives • Shared ICT information and training • Developed mechanism to capture patient

feedback • Review of cost reductions and efficiencies • Dependant on funding allocated enhance the ESHR

functionality to include additional modules within the HealthShare system


Bed Management 16/17 expected Delivered 16/17 Planned 17/18 • Understand the current

process for accessing inpatient beds across the 4 trusts

• What staff are involved • What information is required

to make a decision • How and when discharge

planning occurs • Record the use and occupancy

of leave beds • Review the Panel

process/DToC • Review the bed management

systems used : • -District General hospitals • - Private sectors • - OATS • - Specialised Commissioning • (in terms of what information

is required and how the use of theses beds are monitored, ICT system)

• Understand the step up step down process with NHSE specialised commissioning and private sector providers

• Review Information sharing protocol re shared clinical records

• Review Contractual/ funding implications with CCGs

• Development of workshop sessions to involve various stakeholders/investors/Universities/staff and clinicians involved in the infrastructure.

• In receipt of all 4 bed management operational policies

• All 4 bed managers and clinicians worked collaboratively to produce a joint draft bed management policy

• MOU and SOP produced for finalisation at COSG February 2017

• In the process of reviewing and agreeing capacity and threshold for sharing beds – all 4 Trusts bed usage data received – to be agreed at Steering Group

• Mapped four trusts admissions/OOA admissions/ discharges/DToC

• Review of Bed Management co-ordination • Lessons learnt form first phase of bed

management implementation • Agreed criteria for inpatient treatment

admission and discharge • A single coordinated bed management

structure across the region providing 24/7 bed management function.

• Review 3-6 months from initiation to provide a platform for further integration of the local management teams

• Review and monitor cost savings plan to ensure 50% reduction in out of area placements by 2018/2019 saving 2.1m is on target - review against value proposition

• Develop an agreement and strategy to evaluate Co-ordinated Bed Management system

• Review bed management system with General Hospitals, Private Sectors, OATS

• Review contractual / funding implications with CCGs

• Development of Centralised Bed Management functionality

• Review and agree standardised risk assessment tool for threshold and criteria - electronic tool to feed into ICT

• Develop 24/7 psychiatry bed management joint operational framework

• Bed Management System development and testing

• Design and proof of concept review • ESHR link to Bed Management System • Pilot Review

Crisis Pathway: 16/17 expected Delivered 16/17 Planned 17/18 • Scoping of crisis services across

MERIT • Creation of crisis pathways • Validation of crisis pathways • Include crisis pathways on MERIT

website with input from service users

• Identification of any gaps in services

• Scoped crisis services across MERIT

• Creation of crisis pathways

• Validation of pathways has commenced

• Develop standards around different stages of critical pathway

• Analysis of pathways • Develop aligned pathways • Implementation of aligned

pathways • Interactive website • Website launch, marketing


Training Competencies: 16/17 expected Delivered 16/17 Planned 17/18 • Scope training

competencies (nationally and regionally)

• Literacy search • Map

competencies against crisis pathways

• Scoped training competencies (nationally and regionally)

• Completed literacy search

• Following the agreement of the bed management policy, provide awareness training for staff

• Shared clinical record training • Identification of core skills for crisis staff • Review structure of teams with job roles, skills and

competencies • Map interventions required on pathways • Business case to be developed for e-learning packages • Share training across MERIT for cross fertilisation • Shadowing sessions • Create unified care plan • Training for Street Triage staff


2 Recovery Culture

16/17 expected Delivered 16/17 Planned 17/18 • Baseline pre-

existing recovery services and practices in the alliance (VP)

• Research evidence based models of recovery (VP)

• Workshops held with stakeholders to agree a service model (VP)

• Framework for recovery culture agreed between the alliance and across communities, linking with communities in a new supportive way (VP)

• Research component completed (recovery service models & outcome measures/ literature search finalised)

• Recovery practices implementation groups & governance structures embedded within the four trusts

• Engagement with stakeholders and embedding Recovery Practices into future commissioning plans

• Refocus framework sign off and co-production roll out initiated across 4 Trusts (including a review of assessment/ care plan paperwork)

• Sign off of ReQol model / measure across all 4 Trusts

• ReQol baseline plan agreed • Communities literature search

initiated • IPS Event & Review Completed • Mental Health First Aid model and

training.

• Refocus framework and plans signed off; rolled out and embedded across Trusts

• ReQol rolled out across Trusts and embedded in governance measures (policies and reporting dashboards)

• Robust Organisational Development and Training Plans agreed and rolled out

• Community Connections model confirmed & roll out plan agreed across 4 Trusts

• Mental Health/ Stigma reduction strategy developed in collaboration with E&D work stream (including wider roll out of MHFA)

• Support & alignment of targets to wider WMCA, STP’s


3 Workforce

16/17 expected Delivered 16/17 Planned 17/18 • Staff moving

between the four trusts will have a statutory and mandatory training passport, so that staff do not have to repeat statutory and mandatory training (VP)

• Reduce spend on agency/ bank staff by 20% Scoping of the workforce issues

• Exploration of shared bank arrangements

• Shared training elements across the four trusts

• Joint recruitment campaign operating across the four trusts

• Reduced vacancy rates

• Joint approach to apprenticeships

• Identify gaps in workforce competencies in recovery and how these can be filled

• Review training and competency frameworks for both crisis and recovery work streams.

• Joint recruitment event • Review of apprentice approaches across

the 4 Trusts • Passport of training is in place but not all

training is recorded in ESR and this is dependent on the applicant sharing their previous employment history. This will be reviewed and developed further.

• Achieved Statement of intent to share e- learning packages subject to review of costs and licensing agreements.

• Trusts are required to reduce expenditure as a result of the agency targets and have made savings to date but not as a result of the MERIT plans as yet

• Survey of new appointees has been completed. The initial findings have been circulated from the CSU, but this requires further analysis.

• Review of bank working practices and recording with Allocate

• Discussions are ongoing with Allocate regarding the option to create a software solution called CloudStaff, enabling the 3 /4 organizations to access staff across a virtual bank once all home bank options have been exhausted. A formal proposal has been received from Allocate.

• Review joint recruitment campaigns • Gap analysis for employment support –

not sure what this means but if it means closing skills gaps then we need the baseline in place and then assess against staff in post. This is a huge piece of work.

• Review approaches so we develop the job roles and supporting skill set and provides the additional training to support/ inputs for behavioural change.

• Complete options appraisal of shared bank with a view to implementing a joint, flexible staffing bank (VP)

• Confirm Cloud staff element for bank working

• Increase the number of existing staff undertaking Bank across the MERIT

• Ensure sections of the workforce have an ability to work on all sites across the Alliance (VP)

• Confirm statutory and mandatory training passport arrangements, so that staff do not have to repeat statutory and mandatory training (VP) - Implement one set of essential/fundaments training across the MERIT.

• We will also focus on confirming competency frameworks for crisis and recovery work streams

• Roll out of e-learning approaches across the MERIT

• Consistent recruitment campaigns across 4 Trusts – as above we need to assess the options for this including the benefits of doing this as location is a key driver for appointments.


4 Quality Governance

16/17 expected Delivered 16/17 Planned 17/18 • Systematic approach via quality

assurance framework to support Vanguard clinical priorities work-streams

• Joint working agreement associated quality assurance requirements to support Vanguard

• Consistent quality standards / measures – this is now likely to move into 17/18.

• Dedicated review team / resource • Shared approaches and tools to

use for inspections • Development of associated

PROMs – this is now likely to move into 17/18.

• Joint working agreement for cross Trust mock inspections

• A Safety and Quality Governance Framework has been developed and agreed. This will be finalised in 16/17.

• Circa 80 people to be trained by end of 16/17 to form part of the review teams across the Vanguard.

• A shared tool and standard approach has been agreed.

• A Standard Operating Procedure (SOP) is under development and will be completed in 16/17 that details how the cross Trust mock inspections will work.

• Confirmed data metrics • Software development to

support shared governance approach

• Aligned quality assurance policies and strategy aligned to external factors e.g. commissioner requirements

• Software development to support shared inspection approach, reduce inefficiencies

• Development of associated PROMs

• Consistent quality standards / measures


5 Research and Innovation

16/17 expected Delivered 16/17 Planned 17/18 • Evidence syntheses

(scoping review followed by realist systematic review) in support of each of the clinical work streams, to help shape their content.

• Detailed (and fully costed) evaluation plans for each of the three clinical work streams.

• Consensus meetings of key stakeholders to review evidence and refine final service models in for each of the clinical work streams.

• Scoping reviews for Crisis Care and Recovery work-streams completed.

• Systematic reviews to be completed in 16/17 for both Crisis Care and Recovery work-streams.

• The Evaluation element is now being undertaken by a third party, i.e. Mental Health Strategies (MHS).

• Stakeholder meetings to review evidence and refine model have taken place. Further input is envisaged to refine the service models for Crisis Care and Recovery work-streams. Service models are expected to be finalised in 16/17.

• Engagement events including stakeholder seminars and workshops.

• Update systematic reviews at regular intervals, and undertake planned interim analyses (following pre-defined schedule).

• Specify and support delivery of searchable data system for patient information and routine clinical outcomes data, covering all four Trusts, capable of supporting the clinical work stream evaluations as well as audit and other research.

• Complete evaluations of the clinical work streams. This will be carried out by MHS.

• Disseminate programme findings, including results of evidence syntheses (reviews) and completed work stream evaluations.

• Peer review publications for Crisis Care and Recovery.


6 Equality and Diversity

16/17 expected Delivered 16/17 Planned 17/18 • Develop a

standardised Equality Analysis Framework

• Provide support / guidance and scrutiny of EQIA’s

• Conduct a baseline assessment and gap analysis on Equality in each Trust

• Co-production and collaboration with all workstreams to embed EDHR

• Shared Strategic Objectives and Action Plans to address health inequalities and access issues

• Developed a standardised Equality Analysis Framework

• Provided support / guidance and scrutiny of EQIA’s

• Conducted a baseline assessment and gap analysis on Equality in each Trust

• Co-production and collaboration with all workstreams to embed EDHR

• Shared Strategic Objectives and Action Plans to address health inequalities and access issues

• Created a Single EqIA Tool and Guidance

• EqIA Workshops held with Workstream Leads

• EDI Workstream membership extended to External groups representing protected characteristic including LGBT Network, EBE representation

• MERIT EDI Workstream achieved NHS Employers Partners Programme 2016/17 (Only Vanguard)

• Developed a Community Engagement Sub-Group in partnership with the Recovery Workstream (Community Connections)

• Delivering a Training programme “Forward Thinking Leadership” in partnership with HEE/ Leadership Academy West Midlands – focusing on Inclusion and elements of WRES (Workforce workstream)

• Align the workstream work programme with EDS2 and WRES

• Stakeholder engagement events across the region

• Continue to address gaps identified in year 1 and set key priorities

• Develop EDHR training packages for all Trusts to deliver

• Shared Best practice case studies • Develop corporate social responsibility

with business across Merit • Increased number of staff trained in

Mental Health First Aid • Develop Time To Change to reduce

stigma in the local communities • Income generate to improve patient

quality of care • Support the development of and

review and sign off EqIA across the Merit workstreams

• In collaboration with the workforce workstream recruitment videos to support WRES

• Map out health inequalities and access issues across the demographic areas including evaluating interpreting and translation services

• Develop equality, diversity and inclusion strategy training for staff working across Merit

• Share good examples for work completed across Merit whereby funding has been found that improves patient care in EDS2 workshops

• Develop a mental health first aid strategy


Appendix 2


Appendix 3


Meeting date: 2 February 2017

Agenda Item number: 9.2 Enclosure: 19

Report Title:

Board Assurance Framework (BAF) – Quarter 3 2016/17

Accountable Director: Mark Axcell, Chief Executive Author (name & title): Paul Lewis-Grundy, Company Secretary Purpose of the report: To present the Board Assurance for discussion and provide

assurance to Board that the risks are being appropriately managed.


Gain assurance

Discussion

Information


Committee: Finance & Performance Committee and Workforce Committee Date reviewed: 23 January 2017 and 24 January 2017


The Finance & Performance Committee was assured that Strategic Risk 2 was being appropriately managed. The Workforce Committee was assured that Strategic Risk 4 was being appropriately managed subject to bringing forward the assessment of the impact of the newly implement recruitment system.




Leadership culture






Caring

The Board Assurance Framework covers all of the CQC domains.


Enc 19 BAF2016-17-Q3 Page 1 of 5

Title Board Assurance Framework (BAF) – Quarter 2 2016/17 Introduction The Board Assurance Framework for 2016/17 has been reviewed and revised through discussion at Board Development Sessions in March and June 2016. The risks included in the Board Assurance Framework have been agreed through the Board Development Sessions as those strategic risks to the delivery of the Trusts overarching priorities. Within the reporting process the Committees of the Board have a significant role in monitoring the strategic risks within their Terms of Reference to ensure that they are being managed effectively and provide assurance through that work to the Board. Summary of key points, issues and risks Through the discussions at the Board Development Sessions the reporting template has been revised to include a more comprehensive summary of the issues around the reported risk which encompass:

• Initial and mitigated risk score • The origins of the risk • Impact on CQC domains and risk consequences • Risk Controls and reporting Mechanisms • The positive assurances received • The Gaps in Control and Assurance mechanisms and any actions to address those

gaps The initial and mitigated risk scores have been calculated using the matrix in the Trusts Risk Management Strategy. The Assurance Framework at Quarter three has been comprehensively reviewed and prepared in collective discussion with the Executive team and discussed at the Finance and Performance and Workforce Committees respectively. The Finance and Performance Committee at its meeting on 23 January 2017 reviewed Strategic Risk 2 – Financial Sustainability. The Committee through the discussion at the meeting remained assured that the risk was being appropriately managed. Following the recommendation in November 2016 that with the establishment of the Workforce Committee as a Board Committee from January 2017, SR4 – Ability to Recruit and Retain Staff become the responsibility of the Workforce Committee, the Committee at its meeting on 24 January 2017 reviewed Strategic Risk 4 – Ability to Recruit and Retain Staff. Through the discussion at the meeting the Committee suggested that the deadline for the review of the newly implemented recruitment system to provide assurance that it had reduced the time to recruit be brought forward to April 2017, although remained assured that the risk was being appropriately managed. The review of the BAF at quarter 3 was not in time for the Quality and Safety Committee when it met on 11 January 2017. With the agreement of the Chair of that Committee Strategic Risk 3 Enc 19 BAF2016-17-Q3 Page 2 of 5

– Failure to Achieve Quality of Care and Strategic Risk 5 - Management, Maintenance and Strategy for the Estate are presented as reviewed by the Executive team for discussion by the Board. The BAF and the Operational Risk Register The BAF and the operational risk register should be aligned such that the high red rated operational risks inform the development of the BAF at the start of the financial year, and therefore the Board will see the high level red rated risk reflected in the origins of and gaps in either the control or assurance of the Strategic risks in the BAF. Further detail The Board Assurance Framework at Quarter 3 is appended to the report. The tables below outline the movements in the Strategic risks in Quarter 3: SR1 – Sustainability of the Organisation Control Mechanisms The strength of the Research and Development

Strategy as a control mechanism has increased to green following the receipt of the annual report by the Quality & Safety Committee and Trust Board.

Reporting Mechanisms The frequency of the meeting of the CIP Programme Board has been revised to 4 weekly in accordance with the changes made following the internal audit diagnostic review, although the strength of that reporting mechanism remains unchanged until assurance is received that the changes to the Board are effective.

Gap in Control / Negative Assurance The action associated with the standardisation of the project management approach across the Trust has been updated to reflect that the approach is bring trailed for service developments in quarter 4 and rolled out across the Trust in quarter 1 2017/18 The deadline for the understanding of the MCP model and process has been revised to March 2017. The action in connection with the Project Management approach and monitoring / management of CIP’s has been updated to an assessment of the implementation of the internal audit diagnostic review recommendations with a deadline of July 2017

Assured Level Q2

Assured Level Q3

Assured Level Q4

Trend

12 12 On the basis of the review at quarter three it is not proposed to alter the current risk and rating against this risk. Enc 19 BAF2016-17-Q3 Page 3 of 5

SR2 – Financial Sustainability Control Mechanisms Following an independent assessment of the

Trust’s growth opportunities, the control mechanism of a growth strategy has been removed.

Positive Assurance Additional positive assurance has been received that the contracts with the Trusts two main commissioners have been agreed and signed and the Board has received a Forecast Outturn report demonstrating that the Trust will remain in surplus at the year end.

Reporting Mechanisms Following the internal audit diagnostic review the frequency of the CIP Programme Board has been revised to align with the Committee reporting structure and now meets 4 weekly.

Gap in Control / Negative Assurance The recommendations from the internal audit diagnostic review of the PMO / CIP Process have been implemented – a planned review will provide assurance on the effectiveness of the recommendations

Assured Level Q2

Assured Level Q3

Assured Level Q4

Trend

12 12 On the basis of the review at quarter three it is not proposed to alter the current risk and rating against this risk. SR3 - Achieving quality of care Positive Assurance Additional positive assurance in terms of the

Whistleblowing / Freedom to Speak up Policy being approved and quarterly updates being reported to Board. Appointment of an Engagement / Freedom to Speak Up Lead.

Assured Level Q2

Assured Level Q3

Assured Level Q4

Trend

12 12 On the basis of the review at quarter three it is not proposed to alter the current risk and rating against this risk. SR4 – Ability to recruit and retain staff Reporting Mechanisms The Workforce Committee has been established

as an operational Committee which meets for the first time as a Board Committee on 24 January 2017

Gap in Control / Negative Assurance Where resources have permitted, the recommendations of the internal audit of the recruitment process have been implemented and the TRAC recruitment system implemented. The strength of the recruitment process as a control to mitigate this risk remains amber until the scheduled evaluation of the TRAC recruitment system.


The date for the Development of Service Recruitment Plans with services has been amended back to April 2017

Assured Level Q2

Assured Level Q3

Assured Level Q4

Trend in Assured Level

12 12 On the basis of the review at quarter three it is not proposed to alter the current risk and rating against this risk. SR5 - Management, Maintenance and Strategy for the Estate Positive Assurance Additional positive assurance received regarding

the normalisation of water monitoring in the Trust.

Assured Level Q2

Assured Level Q3

Assured Level Q4

Trend in Assured Level

12 12 On the basis of the review at quarter three it is not proposed to alter the current risk and rating against this risk. Recommendation

• That the Board be assured that the Strategic Risks that form the BAF are being managed appropriately.

Committee action required The Board is asked to:

• Review the Board Assurance Framework at quarter 3


Enc 19 BAF2016-17-Q3-FinalDraft Page 1 of 1

Dudley & Walsall Mental Health Partnership NHS Trust

ASSURANCE FRAMEWORK

QUARTER 3 - 2016/17


Ref. Strategic Risk Executive Director Board Committee Meeting Date

SR1 Sustainability of the Organisation Chief Executive Board 02-Feb-17

SR2 Financial Sustainability Director of Finance Finance & Performance Committee 23-Jan-17

SR3 Achieving quality of careDirector of Nursing and OperationsJoint Medical Director

Quality & Safety Committee 11-Jan-17

SR4 Ability to recruit and retain staff Director of People and Corporate Development Workforce Committee 24-Jan-17

SR5 Management, Maintenance and Strategy for the Estate Director of Nursing, Operations and Estates Quality & Safety Committee 11-Jan-17

All Overall Assurance Company Secretary Audit Committee 20-Mar-17

All Overall Assurance Company Secretary Trust Board 02-Feb-17

Dudley & Walsall Mental Health Partnership NHS Trust

ASSURANCE FRAMEWORK

CONTENTS


REFQ2 REFQ3

Q4 A1

A2A3

REF A4A5

A6

A7A8A9A10A11A12A13A14A15A16A17A18

REF RAG A19O1 Red A20O2 AmberO3 AmberO4O5O6O7 REF DEADLINEO8O9O10

REF RAG REF FREQUENCY RAG

DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP NHS TRUSTBoard Assurance Framework 2016/17

STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 5 x 3 = 15CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4 x 3 = 12What is the strategic risk to be controlled?

Trend in Assured

Level

Partnership Report Trust Board

EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence

be located?

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Annual Plan Approved Trust Board

STRATEGIC RISK

SR1 Sustainability of the Organisation Chief Executive Board Amber

POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / Meeting

Approved Memorandum of Understanding for MERIT and TCT Partnership and Dudley MCP Trust Board

Transform Services to improve the patient Experience and the quality of services

What are the key potential consequences (up to 4) of the risk? Approved Budget for 2016/17 Trust Board

PC1 There would be a gap in the provision of services to patients that would have implications across the whole of the local and regional health economy.

TDA IDM reports show level 4 escalation (5 is best) IDM

PC3CQC Inspection Report CQC Website

Sign off of the 2015/16 accounts and 2015/16 annual report as a "going concern" Audit Committee

Become the preferred provider of prevention and recovery services for mental health and wellbeing within Black County and beyond

Sign off of the 2016/17 CIP plans and quality impact assessments Trust Board

PC2Agreed Contracts with the Trust's two main Commissioners Trust Board

Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CREWS domains QGAF / BGAF review under the Well-Led Framework Board Development / Trust BoardAll Domains PC4

CIP/PMO & PMO/Business Growth Reports Trust BoardService Development Business Cases MExTResearch and Development Annual Report Q&S Committee & Trust Board

Potential or actual origins that have led to the risk… IMPACT LEVEL

ORIGINTrust’s ability to influence, pick up and respond to local and national external drivers for change

What are the most significant origins (up to 10) which could or have led to the risk?Red

AmberGreen

GAP ACTION PLAN

G1 Implementation of the Annual Plan Action Plan Plan is in place with quarterly milestones and reporting ro Board

Ability to influence the commissioning of services that allow the Trust to be the preferred provider of Mental Health / well being services Obstacles to innovation, growth and development opportunities The GAPS IN CONTROL / NEGATIVE ASSURANCES are…

What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?

Strength

What are the key controls (up to 10) that are in place to mitigate these risks?

RedAmberGreen

What are the key reporting mechanisms (up to 10) that will provide assurances that the key controls are effective? (E) = External assurance.

RedAmberGreen

G3

Mar-17

G2 Benefits Realisation through Partnership Working Partnership Workstream Scoping and delivery of workstream actions Nov-17The risks are CONTROLLED by… Strength The REPORTING mechanisms are…

Standardised project management approach across the Trust

Project Management theough Sharepoint is being rolled out across the Trust, it is being trailed for service development projects in quarter 4 2016/17 and for all projects in the first quarter 2017/18

Jun-17

CONTROL REPORTING MECHANISMG4 Understanding challenges in Walsall to improve

partership Board to Board and combined leadership meetings Mar-17Green

C2 MERIT Vanguard Partnership Green R2 Management Executive Team Meetings Monthly

C1 CIP Service Development PMO Green R1 Trust Board (and Board Development) Monthly

Programme management approach to the ownership, monitoring and management of CIPs through the PMO

Assessment of Implementation of the Internal Audit Diagnostic Review Recommendations Jul-17

Green

GreenG5 Understanding MCP model and requirements of the

procurement processDiscussing with partners and CCG to ensure full understanding of the model and process Mar-17

C4 Healthy Walsall Partnership Amber R4 Board Sub Committees Generally Monthly

4 weekly Amber

G6

C3 Transforming Care Together (TCT) Partnership Green R3 CIP Programme Board

C6 Financial & Annual Business Planning Process Green R6 NHSI IDM (e)

C5 Dudley MCP Vangaurd Partnership Red R5 Workforce Committee

Monthly Green

G8Green

AmberG7

Monthly

C8 Business Growth PMO Amber R8 Healthy Walsall Partnethip Board (e) Monthly / 6 weekly

C7 Research and Development Strategy Green R7 MERIT & TCT Partnership Boards (e) Monthly / 6 weekly

GreenG9

C10 R10G10

C9 Sustainabilty and Transformation Plan Amber R9


REFQ2 REFQ3Q4

A2REF A3

A4A5A6A7A8A9

A10A11A12A13A14A15A16A17

REF RAG A18O1 Amber A19O2 AmberO3 RedO4 AmberO5 Red O6 AmberO7 Red REF DEADLINEO8O9O10


G9

G8

Strength

RedAmberGreen

G3 Programme management approach to the ownership, monitoring and management of CIPs through the PMO

Assessment of Implementation of the Internal Audit Diagnostic Review Recommendations

Green

GreenG7

G4

Operation of tariff requires internal efficienciesDifficult Contract Negotations with CCG's inluding CCG QIPPsContracts are predomianely block therefore overactivity not paid for

Agency Use Escalation and Monitoring Process


RedAmberGreen


CCG Contract Review Meetings (e)

MonthlyMonthly Returns to NHS I & NHS I IDM (e)

Monthly

C5 STP Cost Improvement Programme Amber R5 Trust Board

C3

CONTROL REPORTING MECHANISM

C1

C9 R9 CIP Programme Board 4 weekly

C8

G10C10 R10 PMO fortnighly meeting - review

schemes

R8

2 weekly Green

Amber

Amber

Monthly

C6 Green

G5

Green

R6 Internal and External Audit (e) Ad-hoc Green

C7 R7

C4 Partnership Working Amber R4 Audit Committee Regular

C2

Amber

Monthly Green

G6

Programme management approach to the ownership, monitoring and management of CIPs through the PMO Amber R3 Finance and Performance

Committee

Green

Reserves / Provisions to offset financial risk Green R2 Management Executive Team Meetings Monthly

Annual Financial Plan including budget monitoring and management Amber R1 Quarterly Performance Reviews quarterly

Jul-17

Challenge to deliver annual CIP target GAP ACTION PLAN

G1 CIP delivery for 16/17 - impact of QIPP schemes on CIP projects 3 schemes slippage Older Adults business case being developed

The GAPS IN CONTROL / NEGATIVE ASSURANCES are…National context - Proposed financial settlement from 2017/18

What are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?Vacancy rate higher than target and high level of Reliance on Agency Staff to cover vacancies

Feb-17

G2 CIP Delivery for 16/17 schemes slippage Alternative proposals, discussions with Commissioners monitored through PMO Mar-17The risks are CONTROLLED by… Strength The REPORTING mechanisms are…


AmberGreen

Size of the Trust and place in the local health economy / regional health economy


ORIGIN

Trust BoardWell Led Domain PC4

Financial Outturn Forecast including impact of CIP / QIPP & CQUINs Trust Board


What are the key potential consequences (up to 4) of the risk? Annual internal audit of the CIP Process Audit Committee

PC1 Loss of organisational control

Ad hoc reporting to F&P and Board Finance & Performance Cttee / Board

PC3Inability to maintain safe and effective local services

Monthly Returns to NHS Improvement NHS Improvement Portal

Financial System Audit - internal audit plan approved Audit Committee


Managemant and Committee Reports monthly - Strong cash position Finance & Performance Committee / MExT / Board

PC2 Negative financial impact on local health economyDevelopment of Financial information for partnerships and STP Board Development

Develop the organisational culture and capabilities to support high quality service deliveryIMPACT ON CQC CREWS domains Contracts with two main Commissioners signed


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) @ 16/2 Red: 5 x 4 = 20CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Red: 4 x 3 = 12What is the strategic risk to be controlled?

STRATEGIC RISKEXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence

be located?

Trend in Assured

Level

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Sign off of the 2016/17 CIP plans and quality impact assessments Trust Board

SR 2 Financial Sustainability Director of Finance Finance & Performance Committee Amber

POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / Meeting

Audit CommitteeYear end Audit process - sign off of accounts and audit letter giving good assurance on some of the key financial systemsA1


REFQ2 REFQ3Q4 A1

A2

A3

REF A4A5A6

A7

A8A9

A12A13A14 Trust BoardA15 Quality & Safety CommitteeA16 Trust Board

REF RAG A17O1 Red A18O2 RedO3 AmberO4 RedO5 AmberO6 RedO7 Amber REF DEADLINEO8 RedO9 RedO10 AmberO11 Amber


IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Quality and Safety Cttee Chairs reportQuality and Safety Reports to Quality & Safety Committee and Trust Board Q&S Committee / Trust Board

STRATEGIC RISKEVIDENCE

What is the report received that provided that assurance? Board / Committee / MeetingQuality Account presented and approved by Trust Board Trust Board

SR 3 Achieving quality of careDirector of Nursing and

OperationsJoint Medical Director

Quality & Safety Committee AmberPOSITIVE ASSURANCE

Annual Report on Infection, Prevention and Control Trust Board

Trend in Assured

Level


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) Red: 5 x 4 = 20 CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Amber: 4 x 3 = 12What is the strategic risk to be controlled?

EXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?


PC2Not a provider of choice and negative impact on likelihood of GPs promoting the Trust

Patients health and well being at risk Reduction in patient referrals and related income

PC3Increase in patient complaints and poor patient experience with a poor net promoter scoreIMPACT ON CQC CREWS domains

Transform Services to improve the Patient Experience and Quality of Services

What are the key potential consequences (up to 4) of the risk?

PC1

AllDomains PC4 Non compliance with our regulatory requirements and commissioner contracts, potentially resulting in greater external regulation no longer being Safer Staffing Report

Royal College of Pschiatrists Centre for Quality Improvement (CCQI) Accreditations (Reported through the Quality Account)A10 Trust Board

Recruitment of Clinical Staff Whilstleblowing Policy approved and quarterly Freedom to Speak Up Report Trust Board

Trust BoardNursing Strategy Trust Board


Medical Directors Report to Board / Nursing Director report to BoardAnnual Report on Research and DevelopmentStaff Survey Results What are the most significant origins hich could or have led to the risk?

Small Bank serviceWhat are the remaining key gaps (up to 10) in the controls or negative assurances despite the stated controls and positive assurances in place?Continuous need to deliver Cost Improvements

Increasing emphasis on working with our Partners GAP ACTION PLAN

West Midlands Quality Review OutcomesPatient Experience Feedback

ORIGIN Staff Friends and Family Results Trust Board

Higher turnover of StaffWorking torwards the national Agency Staffing Cap The GAPS IN CONTROL / NEGATIVE ASSURANCES are…Clinical Supervision

Mar-17

Mar-17

The risks are CONTROLLED by… Strength The REPORTING mechanisms are… Strength

CQC Inspection outcome and recommendationsG1 Delivery of the Priority Activities 2016/17 Action Plan with Quarterly Milestones agreeed and Monitored

Quarterly

G2 Delivery of the Quality Priorities Implement Actions to deliver quality Priorities 2016/17

G3

Lack of capacity appropriately skilled managers and clinicians


Green

What are the key controls that are in place to mitigate these risks?Red

AmberGreen

What are the key reporting mechanisms that will provide assurances that the key controls are effective? (E) = External assurance.

RedAmberGreen

C1 Agreement of Priority Activities in the Annual Plan 2016-17 Green R1 Quality & Safety Committee Monthly

C2 Quality Impact Assessment carried out for all CIP schemes Green R2Sub Committees and groups reporting to Quality & Safety Committee

Monthly

Green

Green

Monthly GreenC3 Quality Improvement Strategy & Quality Priorities for 2016/17 Green R3 Trust Board

C4

C6 OnBoard Walkabouts Amber R6

C5 Effective process in place for staff to raise concerns and whistleblow that are regularly reviewed Amber R5 Quartely Performance Reviews GreenQuarterly

6 weekly Green

CQC Action Plan Amber R4 Finance & Performance Committee Monthly

C7 Nurse Revalidation Green R7

C10 Clinical Audit Green R10

Medical Revalidation Green R9

C8 Experts by Experience Visit Feedback and Reviews

C11 Service Development Quality Impact Assessmment Red R11

Green R8

Annual Green

CLRN - Clinical Research Network Midlands (e) Monthly

C13

C9 Internal Audit reports (e) Ad hoc Green

CCG CQRM meetings (e) Monthly Green

6 monthly

6 monthly

Green

Green

Green

GMC PEST training survey feedback (e) West Midland Deanery Feedback on Foundation

Mortality Review Group

Essential skills training clinical role specific Health Education England - Workforce Return (e)

CQC reports and visits (e)

R15

R16

CQC Meetings & Progress Updates (e)

Monthly / Quarterley

Green

Monthly IDM (e) Monthly Green

Ad hoc Green

External stakeholder visits (e) Ad hoc Green

R12

C14 Postgraduate training scheme under West Midlands School of Psychiatry with training placements for junior medical

Green R14

C12 Research and Development Green

R13Green

Mar-17

Quality Improvement Strategy not fully implemented Implement the Quality Improvement Strategy in accordance with plans by achieving 2016/17 deliverables and milestones Mar-17

QIA on negative quality impact

Project Management through Sharepoint is being rolled out across the Trust, it is being trailed for service development projects in quarter 4 2016/17 and for all projects in the first quarter 2017/18

CQC Action Plan Approved and update reports to Quality & Safety Committee Trust Board / Quality & Safety CtteeQ&S CommitteeQuality Priorities 2016/7 approved

Quality & Safety CommitteeClinical Audit PlanTrust BoardAnnual Medical Revalidation Report to Board Nurse Revalidation Report

Board DevelopmentCIP POD (includes QIA)

Trust BoardQuality Improvement Strategy 2016/2020 approved

Jun-17

G5 Rolling out availability of esential skills trainig to all front facing clinalposts

Profiling of staff and breaking down of clinical and essential skills in the next stage of the roll out. Profiling for Medical workforce oustanding after which the revised matrix will be built into the Mandatory Training Policy

Mar-17

G6 CQC Inspection - Requitres Improvement Implemention of the CQC Action Plan

G4


REFQ2 REFQ3Q4 A1

A2A3

REF A4A5A6

A7

A8A9

A10A11A12A13A14A15A16A17A18

REF RAG A19O1 Red A20O2 AmberO3 AmberO4 RedO5 AmberO6O7 REF DEADLINEO8O9

O10


Develop Plans with Services Apr-17

Evaluation of the implementation of the revised recruitment process Apr-17

EXECUTIVE DIRECTOR BOARD COMMITTEE What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be located?

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Implementation of Staff Engagement Programme / Report to Board Trust Board

STRATEGIC RISKEVIDENCE

What is the report received that provided that assurance? Board / Committee / MeetingRegular workforce report to Trust Board Trust Board

SR 4 Ability to recruit and retain staff Director of People and Corporate Development Workforce Committee Amber

POSITIVE ASSURANCE

Regular workforce report to Finance & Performance Committee


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) Red: 5 x 4 = 20CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) Red 4 x 3 = 12What is the strategic risk to be controlled?

Trend in Assured

Level

Finance & Performance Committee


CQC Report Trust Board

PC2 Increased use of agency staff with negative impact on quality and cost of care including lack of continuity of care

Internal Audit Report on Staff Engagement Audit Committee

Develop the organisational culture and capabilities to support high quality service delivery

Delivery of poor care (with potential high incidents and complaints)

Quality Report (reporting of incidents) Trust Board

PC3 Impact on capability to deliver activity to contractService Experience Reports Trust Board

Safer Staffing Report Trust Board

IMPACT ON CQC CREWS domains Use of Temporary Labour monitoring report Finance & Performance Committee


What are the key potential consequences (up to 4) of the risk? Outcome of Staf Survey Results Trust Board

PC1

Caring Responsive and Safe Domains PC4Negative impact of remaining staff on job satisfaction and morale

Lack of suitable candidates



AmberGreen

ORIGIN

Competition from other local and larger TrustsCarrying larger than target vacancy rate The GAPS IN CONTROL / NEGATIVE ASSURANCES are…Staff morale, motivation and resilience in an ever changing environment National Shortage of staff in certain disciplines


GAP ACTION PLAN

G2 Service Recruitment PlansThe risks are CONTROLLED by… Strength The REPORTING mechanisms are… Strength

G1 Effectivess of Recruitment Process

CONTROL REPORTING MECHANISMG4

Green


RedAmberGreen


RedAmberGreen

G3

C1 Recruitment plans in place for all higher risk areas Amber R1 Trust Board Monthly

C2 Close liaison with the University Green R2 Finance & Performance Committee Monthly

Green

AmberG4

Monthly Amber

G5

C3 Leadership Development Programme Amber R3 Workforce Committee

C4 Staff Engagement Programme and Staff Survey Action Plan Green R4 Staff Partnership Panel Monthly

C6 Recruitment Process Amber R6 Internal audit reports (e)

C5 Use of temporary Labour (Monitoring Process) Green R5 Staff survey (e) GreenG6

Annually

Ad hoc Green

G8

R8

C7 R7

C9 R9

C8

C10 R10G10

G9


REFQ2 REFQ3Q4 A1

A2

A3REF A4

A5A6A7

A8

A9

A10

A11A12

PC5 A13

A14A15A16A17A18

REF RAG A19

O1 Amber A20

O2 AmberO3 AmberO4O5O6O7 REF DEADLINEO8O9O10


Health & Safety Executive Visit and Report on the Trust's management of the water supply


STRATEGIC RISKS INITIAL RISK SCORE (Impact x Likelihood = Total) 4 x 5 = 20CURRENT ASSURED

LEVEL

These are the POSITIVE ASSURANCES actually received…CURRENT RISK SCORE (Impact x Likelihood = Total) 4 x 3 = 12What is the strategic risk to be controlled?

Trend in Assured

Level

Independent Engineer for Water Management Presentation to Board - Assurance around the implications of the water management issues Trust Board

EXECUTIVE DIRECTOR OWNER BOARD COMMITTEE OWNER What are the key actual positive assurances received through reporting (up to 20) that a control has remained effective and where can the evidence be

located?

IMPACT ON CORPORATE OBJECTIVES (up to top 3) POTENTIAL CONSEQUENCES OF THE RISK Annual Report from Independent Engineer Quality &Safety Committee

STRATEGIC RISK

SR 5Management, Maintenance and Strategy for the Estate

Director of Nursing, Operations and Estates Quality & Safety Committee Amber

POSITIVE ASSURANCE EVIDENCE What is the report received that provided that assurance? Board / Committee / MeetingPLACE Survey outcomes and action plan approved MExT / Capital Planning


What are the key potential consequences ( of the risk? Independent Risk Assessments Water Management Group

PC1 Impact on the quality and safety of the care that the Trust is able to provide its patients

Trust Board

PC3 Failure meet specific needs of Trust's client GroupTrust Board

DON's report to Board Trust BoardEstates Compliance Matrix Quality &Safety Committee

PC2 Potential restriction on the services the Trust could deliver and it capacity resulting in failing to comply with its contractual obligations with Commissioners

Estates Gap analysis completed Quality &Safety Committee

IMPACT ON CQC CREWS domains Infection Prevention and Control Sub Committee Exeception Report and risk report the normalisation of water monitoring in the Trust Quality & Safety Committee

Bushey Fields Refurbishment Plan approved

Safe, Effectiveness Domain PC4 Failure achieve outcome 6 facests survey

Failure to comply with legal compoants Fire, water electricity and health and safety


ORIGINRecommendations from Previous Independent Reports on the trust's Estate not being acted upon through changing priorities and demands on personal


AmberGreen

GAP ACTION PLAN

G1 Estates Strategy Review being undertaken

Water Management Issues in 2015/16, ongoing across all hospital sitesLimitations of Bloxwich Hospital for our client group served The GAPS IN CONTROL / NEGATIVE ASSURANCES are…


Strength


RedAmberGreen


RedAmberGreen

G3

Apr-17

G2 Fire Safety Management within the Trust

Risk assessments in place and reviewed formally as per annual plan to be completed.Fire compartmentation assessments to be completed and reviewed.

Mar-17The risks are CONTROLLED by… Strength The REPORTING mechanisms are…

Electrical Safety across all Trust Sites (non HV) Develop action plan around developing accurate drawings and schematics to aid understating of system connections. Mar-17


G4 Ventilation Systems and the management of ventilation systems

Authroising Engineer to be appointedA full appraisal of assets is to be completed (December 2016)Policy to be written along with procedural guidance (December 2016)

Mar-17Green

C2 PLACE Survey R2 Finance & Performance Committee Monthly

C1 Estates Review Red R1 Trust Board Monthly

Green

Green

Green

G5 Gas Safety across the Trust Policy, procedure and documentation to be standardizedAudit of Gas safety certificate to ensure compliance Mar-17

C4 Approved Business Case Process R4Water Management Group (inc appointed microbiologist and independent engineer (e)

Monthly

Monthly Green

G6

C3 Capital Programme overseen by Estates and Capital Planning R3 Estates and Capital Planning

GroupGreen

Green

C6 Independent Risk Assessments for 3 hospital sites Green R6 ERIC Returns published through HSCIC website (e)

C5 Annual Ligature Assessment Review R5

Stakeholder Conference Calls / Meetings with exteral stakeholds inc HSE and Public Health England

Green

Annual Amber

G8 Green

GreenG7

Ad Hoc

C8 Authorising Engineer in place for Electrical Safety Green R8 CQRM's (e) Monthly

C7 Appointed Independent Engineer for Water Management Green R7 Monthly IDM (e) Monthly

GreenG9

C10 R10G10

C9 R9

Trust Board date: 2 February 2017


Report Title: High Level Operational Risk Register

Accountable Director: Rosie Musson (Acting Director of Nursing)

Author (name & title): Neil Tong (Patient Safety Facilitator)

Purpose of the report: • The purpose of this report is to provide the Trust Board with the Red Risks for the period ending 25 January 2017 and in doing so provides the committee with information on: o Any new red risks being escalated to the High Level

Operational Risk Register o Any red risks being downgraded from the High Level

Operational Risk Register. o Any updates to red risks currently held on the Trust

High Level Operational Risk Register.

Action required from the Committee

Decision / Approval

Gain assurance

Discussion

Information


Committee: Quality and Safety Committee Finance and Performance Committee Workforce Committee

Date reviewed: Quality and Safety Committee 11/01/2017 Finance and Performance Committee 23/01/2017 Workforce Committee 24/01/2017


The risks enclosed within this risk register were approved by Quality and Safety Committee, Finance and Performance Committee and Workforce Committee in line with their delegated responsibilities.




Leadership culture




Enc 20 High Level Operatoinal Risk RegisterPage 1 of 13



Caring Some of the risks held on the register have the ability to directly or indirectly impact upon the care/services offered

Responsive The Trust Wide Risk Register Provides a representation of the Trusts “Red Risks” and the responses to managing/action planning these risks; some (due to the nature of the risk) provide a response to a short term or long term issue

Effective Some of the risks held on the Trust Wide Risk Register impact upon the future viability / effectiveness of the Trusts operations.

Risk FINAN 1 specifically relates to the long term outlook in relation to CIP

Well-led Some risks held on operational risk registers Pertain to issues around service redesign and may have impacts upon leadership and staffing issues

Safe The appropriate management of risk is central to the provision of a quality, safe service. In particular CQC Outcome 16 – Assessing and monitoring the quality of service provision


Title High Level Operational Risk Register Introduction

It is the purpose of this report is to provide the Trust Board with the Red Operational risks held across the Trusts Risk Registers (for the period 25th January 2017) and in doing so provides Trust Board with information on:

• Any new red risks being escalated to the High Level Operational Risk Register. • Any red risks being downgraded from the High Level Operational Risk Register Any

updates to red risks currently held on the High Level Operational Risk Register. There are currently 11 risks being presented as part of this report. This is being done in line with the Trusts risk management strategy and further details of these are included within table 1.1. As noted at Trust Board Last Month risk 326 in relation to payroll activity has been downgraded via agreement at Trust Board last month and has hence been removed from this report Due to realignment of roles and responsibilities at board level, the risks held on this risk register have been realigned based upon these new reporting lines. Via discussion at F&P committee the following changes have been proposed to the risk register this month:

• Risk FINAN 1 has been re-worded to the following: Inability to meet CIP targets, funding for Mental Health, QIPP (and in longer term the Dudley MCP) have the potential to impact upon the long term financial viability for DWMH. Issues Include: * CIP and QIPP requirements from existing baselines * Reduction in investment by Local Authorities * In longer term, the Dudley MCP plans can be expected to require ongoing efficiencies through internal CIPs * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward (Risk related to long term challenges around CIP and not "In Year Position")

• Risk HR002 has been reworded: Reduction in Local Authority Funding for Mental Health Social Care Workforce. This has the potential to impact on service delivery and on the viability of the S75 agreements and has the potential to place operational pressures on clinical teams and operational viability of some service

Summary of key points, issues and risks There are 9 risks included within this report which are applicable for presentation to the Trust Board. A summary of these risks are detailed within table 1.1. The full details of these risks are articulated in appendix 1.1.


Table 1.1. – Summary of risks

Risk ID

Risk Description

Impacts Opaerationally (and updates)

Status of risk

FINAN 1 Inability to meet CIP targets, funding for Mental Health, QIPP (and in longer term the Dudley MCP) have the potential to impact upon the long term financial viability for DWMH. Issues Include: * CIP and QIPP requirements from existing baselines * Reduction in investment by Local Authorities * In longer term, the Dudley MCP plans can be expected to require on-going efficiencies through internal CIPs * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward (Risk related to long term challenges around CIP and not "In Year Position")

Source – Financially driven risk with quality implications. Existing risk already reported to Quality and Safety Committee

Addition information / update Risk has been updated by the Acting Director of Finance to include information in relation to MCP and QIPP requirements.

=

HR 002 Reduction in Local Authority Funding for Mental Health Social Care Workforce. This has the potential to impact on service delivery and on the viability of the S75 agreements and has the potential to place operational pressures on clinical teams and operational viability of some services

Source – Risk to quality of service driven by a reduction in local authority funding. Existing risk already reported to Quality and Safety Committee

Addition information / update Risk has been updated to include impact on service provision and additional required actions

=

314 A complex interface between electronic and paper clinical records presents challenges to staff when assessing and caring for patients across inpatient and community services. This may lead to an inconsistent approach being taken to clinical risk management, having implications upon continuity of patient care planning and risk management.

Source – Major project already enacted by the Trust to replace existing clinical system. CQC assessment highlighted that interface between electronic and paper system is a clinical risk and as such interim measures are being put in place to mitigate the risk along with long term measures (the replacement of OASIS)

Addition information / update A review of patient’s notes as part of internal program of supportive visits has indicated that most inpatient areas are now recording directly onto OASIS, however there were some issues noted with staff updating paper copies in some areas.

=

315 An inconsistent approach is being taken to the management of clinical risk management and care plan development was identified by the CQC. This is likely to have implications upon continuity of patient care planning and risk management.

Source – CQC visit highlighted that this is a recurrent issue

Addition information Trust has purchased a license agreement for writing person centered care plans. The standards are supported by the CCA and NHS improvement.

There were a number of inconsistencies noted in respect to ensuring Clinical Risk Assessments are updated systematically and that care plans are patient focused

=


Risk ID

Risk Description


Status of risk

317 Some staff may not be receiving a regular appraisal of their performance in their role or always may not always receive appropriate ongoing or periodic supervision. Where this is occurring the Trust cannot always evidence this due to a lack of central monitoring mechanism for supervision.

This can therefore result in the provider not ensuring staff are suitably skilled enough to ensure that they can meet people's care and treatment needs.

Source – CQC highlighted that this was a risk to the Trust

Addition information Quarterly “pulse check” of supervision to check how many staff within given areas have received supervision is being completed.

Supervision has also been added to the “Walkabout” checklists.

Potential electronic solutions to centrally recording supervision is still being explored, with existing systems such as ESR and E-rostering system being scoped for suitability.

=

319 It is noted through the CQCs Feb 16 assessment that there is inconsistent use of blanket restrictions which were sometimes not in accordance with the MHA code of practice and that this, allied with the failure to make patients aware of their rights may lead to dissatisfaction with service, de-facto detention and failure to adhere the MHA Code of Practice.

Source – CQC highlighted that this was a risk to the Trust and recent CQC MHA visits have also highlighted that this is a recurrent issue

Addition information Least restrictive practice information is held on the Intranet, with Ward Managers asked to cascade a training package.

Training has commenced, awaiting confirmation that training has been delivered across all wards.

Inconsistencies in relation to the use of blanket restrictions has also been noted as part of recent CQC MHA reviews

=

320 The Trust has a lack of clearly defined processes and policies in respect to the use of personal alarms, the provision of call alarms which allied to an additional need for personal safety training for staff has the ability to impact upon the health and safety of both staff and patients, especially when staff are working on their own.

Source – The Trusts CQC visit highlighted this as a risk to the Trust.

Addition information There were a number of issues identified by the CQC in relation to lone working and staff safety, of both a site specific nature and also throughout the Trust. In addition to this, issues were identified regarding the provision of call alarms

Teams have now completed the development of local protocols for the use of alarms, however further longer term work is still ongoing.

=


Further detail (if required)

Further details of the risks are outlined in appendix 1 Recommendation It is recommended that the Trust Board approve the enclosed copy of the High Level Operational Risk Register Action required To approve the risks included within this report and note the action taken to date in managing these.

Risk ID

Risk Description


Status of risk

322 The Trusts assessment by the CQC noted that there may be a lack of evidence to support that calls within the Trusts Crisis team are responded to in a timely manner

Source – The Trusts CQC visit highlighted this as a risk to the Trust.

Addition information As noted a new crisis call log has been established and a standard for incident reporting has been agreed

Whilst no incident forms have been entered in relation to this issue since the CQC visit, there is at this stage audit results to indicate the number of calls which are being returned and the average response time for these.

Audit results to be processed before risk can be downgraded.

=

EF002 Fires Safety Management within the Trust and lack of assurances in respect to certain arrangement regarding fire safety

Source – Gap analysis of assurances undertaken within estates. Issue escalated via Estates Risk Register

Addition information At this present time there are noted gaps in assurance especially in relation to fire Compartmentation assessments which will need completing. Risk has previously been discussed via the Estates Risk Register at Quality and Safety Committee. Further information is to be brought back to Quality and Safety Committee in December in relation to this particular risk

=


Risk ID

Risk Description Source of Risk

Date Principle Owner

Other Contributors

Initial Score

Current Controls Current Score

Further Actions Required (including target date)

Residual Score

Sources Of Assurance

Date of Review Further Comments

FINAN 1

Inability to meet CIP targets, funding for Mental Health, QIPP (and in longer term the Dudley MCP) have the potential to impact upon the long term financial viability for DWMH. Issues Include: * CIP and QIPP requirements from existing baselines * Reduction in investment by Local Authorities * In longer term, the Dudley MCP plans can be expected to require on-going efficiencies through internal CIPs * Efficiency of 4 percent has been experienced for a number of years and will be experienced going forward (Risk related to long term challenges around CIP and not "In Year Position")

Finance Projections / Data

28/02

/2011

Rupert Davies

Mark Axcell

Finance Department

5 x 4 = 20

Red

Detailed development of cost improvement programme

Approach to CIP has been agreed at Finance Committee

PMO Board established

Level of CIP has been communicated to operational teams

Arrangements for monitoring programme of CIP now in place

CIP targets being met through agreed disestablishment

Continue to manage locum medical costs as agreed through F&P

Quality Impact Assessment for all 2014/15 and 2015/16 and 2016/17 schemes all updated

Finance team integrated into the process

Active partner of the Mental Health Programme Board main forum for commissioner liaison.

Sensitivity analysis built into current plans

Trust approach to mitigation. Remodelled efficiency plan

Reporting arrangements to board enhanced to provide more detail on schemes as well as quality impact assessments

Monitoring of bank, agency and locums now forms part of finance report and discussion at both F and P and MExT

5 x 3 = 15

Red

Trust Board to consider new communication on CIP through team brief, building on previous communications, to ensure that the message is well understood regarding the scale of the challenge

Work required to ensure PODs and reporting framework is linked effectively into completed Quality Impact Assessments (Ongoing process).

Review of report from revised PODs and reporting framework accordingly

Expressions of interest for an external partner in developing CIP plans for 2017/18, 2018/19 and 2019/20

5 x 1 = 5

Green

Various Finance and Performance reports

Reports to Board

Reports to F&P Committee including individual action plans on pressure areas.

Reports to MEXT

Reviews by external assessors including TDA, HDD and Monitor

Internal audit reports around CIP giving further assurance

External benchmarking of plans

14

/12/20

16

Risk has been updated by the Acting Director of Finance to include information in relation to MCP and QIPP requirements.

Enc 20 High Level Operatoinal Risk Register Page 7 of 13

Risk ID



Other Contributors

Initial Score



Residual Score



HR 002

Reduction in Local Authority Funding for Mental Health Social Care Workforce. This has the potential to impact on service delivery and on the viability of the S75 agreements and has the potential to place operational pressures on clinical teams and operational viability of some services

Feedback From Stakeholders/ Partners

30

/05/20

12

Marsha Ingram

Rosie Musson

Hassan Omar

4 x 4 = 16

Red

Section 75 agreements provide formal platform as the basis for any further negotiations in funding and resource changes

Joint approach agreed with Walsall MBC regarding implementation of funding reductions.

Risk Assessments on loss of posts has been completed

Regular discussions being held at Partnership Operations Group.

Additional short term capacity has been commissioned

4 x 4 = 16

Red

Discussions ongoing at POG (Monthly)

4 x 2 = 8

Amber

Reports to MEXT

Updates to Board

14

/12/20

16

Risk has been updated to include impact on service provision and additional required actions


Risk ID



Other Contributors

Initial Score



Residual Score



314 A complex interface between electronic and paper clinical records presents challenges to staff when assessing and caring for patients across inpatient and community services. This may lead to an inconsistent approach being taken to clinical risk management, having implications upon continuity of patient care planning and risk management.

Feb 2016 CQC Visit

19/05

/2016

Rupert Davies

Dan Howard

David Crook

IM&T Team

4 x 4 = 16

Red

Review of risk assessment templates has been completed in line with CPA requirements to ensure that staff practice is in line with best practice

Training needs analysis has been looked at across the Trust to ensure that inpatient staff can update electronic risk assessments on OASIS

Consultation with over 60 clinical and clinical admin staff to develop the business case and specification for the new clinical system has been undertaken

Suppliers have submitted responses to the Invitation to Tender (ITT)

Inpatient are being trained to update FACE risk assessments on the OASIS system, to ensure that community staff are aware of risks which may have emerged during the patients inpatient stay

Reference Site Visits have occur

System Demonstrations undertaken

4 x 4 = 16

Red

Identification of preferred supplier (December 2016)

Full business case approved and contract signed (February 2017)

Roll out of new clinical system commences (September 2017)

4 x 1 = 4

Green

Reports to MExT

Reports to IG IM&T committee

14

/12/20

16

The project to replace OASIS is on schedule and we are now moving into the procurement phase, following national approval of our Outline Business Case by NHS Improvement.

There were a number of issues raised in respect to the interface between paper and electronic records within the Trust. As such inpatient staff have recommenced updating FACE risk assessments.


Risk ID



Other Contributors

Initial Score



Residual Score



315 An inconsistent approach is being taken to the management of clinical risk management and care plan development was identified by the CQC. This is likely to have implications upon continuity of patient care planning and risk management.

Feb 2016 CQC Visit

19/05

/2016

Rosie Musson

Marsha Ingram

Mark Weaver

Kate Gingell

Patient Safety and Compliance Team

Bob Yardley

4 x 4 = 16

Red

Review of risk assessment templates has been completed in line with CPA requirements

Training needs analysis has been looked at across the Trust

Spot check of care inpatient care plans have been undertaken

Outcome of spot checks in relation to risk assessments has been presented to MHASC

4 x 4 = 16

Red

Regular spot checks of risk assessments to be completed (ongong)

Outcome of spot checks in relation to risk assessments has been presented to MHASC. Targeted work is ongoing where care plans are not patient focused and contain recovery based goals

4 x 1 = 4

Green

Reports to MHASC

Clinical Audit outcomes

14

/12/20

16

Trust has purchased a license agreement for writing person centered care plans. The standards are supported by the CCA and NHS improvement.

There were a number of inconsistencies noted in respect to ensuring Clinical Risk Assessments are updated systematically and that care plans are patient focused

317 Some staff may not be receiving a regular appraisal of their performance in their role or always may not always receive appropriate ongoing or periodic supervision. Where this is occurring the the Trust cannot always evidence this due to a lack of central monitoring mechanism for supervision.

This can therefore result in the provider not ensuring staff are suitably skilled enough to ensure that they can meet people's care and treatment needs.

Feb 2016 CQC Visit

19/05

/2016

Ashi Williams

Mark Axcell

Marsha Ingram

Learning and Development Team

Patient Safety and Compliance Team

Quality Team

4 x 4 = 16

Red

Supervision policy has been reviewed and now contains the recording requirements

Audit tool to review current levels of compliance against supervision has been developed

Appraisal updates and appraisal rates are presented to MExT on an ongoing

Appraisal data is provided to ward managers, with compliance data being presented to Trust board

Communications strategy has been developed and implemented in respect to clinical supervision.

4 x 4 = 16

Red

Spot check audits to be undertaken to review the content and the quality of supervision (ongoing basis)

An options appraisal was presented to the Trusts CQC steering group and a short term (Excel Based solution was agreed). Further work is ongoing to look at an electronic solution to this.

4 x 1 = 4

Green

Reports to Trust Board

Reports to MExT

Spot check audit results

14

/12/20

16

Quarterly “pulse check” of supervision to check how many staff within given areas have received supervision is being completed.

Supervision has also been added to the “Walkabout” checklists.

Potential electronic solutions to centrally recording supervision is still being explored, with existing systems such as ESR and E-rostering system being scoped for suitability.


Risk ID



Other Contributors

Initial Score



Residual Score



319 It is noted through the CQCs Feb 16 assessment that there is inconsistent use of blanket restrictions which were sometimes not in accordance with the MHA code of practice and that this, allied with the failure to make patients aware of their rights may lead to dissatisfaction with service, de-facto detention and failure to adhere the MHA Code of Practice.

Feb 2016 CQC Visit

19/05

/2016

Rosie Musson

Marsha Ingram

Mark Weaver

Kate Gingell

Nageena Bibi

Least Restrictive Practice Group

4 x 4 = 16

Red

Communication has been issued to staff in relation to Least Restrictive Policies and Procedures

Immediate review undertaken of all informal patients and their rights

Communications have been issued in relation to the rights of informal patients

Standardised poster and leaflet has been agreed and printed for all inpatient areas in respect to informal patients (and leave arrangements)

Audit of patient has been completed to determine level of compliance with policy

Audit of “rights of patients” has been carried out to determine levels of compliance against standards,

4 x 4 = 16

Red

Least Restrictive Practice Training has commenced across all inpatient wards and all staff groups (Ongoing, with regular refreshers)

An action plan from internal audits has been developed. Further actions therefore to be implemented as a result of this, these are scheduled for sign off by audit committee in (December 2016)

4 x 1 = 4

Green

MHA Scrutiny Committee Mins / Papers

Clinical Audit and Effectiveness Committee

14

/12/20

16

Two internal audits have been completed. One was in relation to the implementation of the Search Policy.

This audit was conducted by CW Audit and did not provide the Trust with full assurances in respect to this area

In addition an audit has been conducted in relation to Mental Capacity and patient rights. This provided the Trust with only limited assurances.

As such an action plan is being developed for both of these in relation to the recommendations from CW audit and id due to presented to Audit committee in December 2016


Risk ID



Other Contributors

Initial Score



Residual Score



320 The Trust has a lack of clearly defined processes and policies in respect to the use of personal alarms, the provision of call alarms which allied to an additional need for personal safety training for staff has the ability to impact upon the health and safety of both staff and patients, especially when staff are working on their own.

Feb 2016 CQC Visit

19/05

/2016

Rupert Davies

Estates Department

Health and Safety Officer

Team manager

Compliance and Safety Team

4 x 4 = 16

Red

Communication has been issued to team managers regarding the use of personal alarms with a request to develop an individual local protocol.

Agile working policy has been developed which highlights roles and responsibilities in respect to the use of mobile devices when lone working

Lone working policy has been re-communicated communicated to staff.

Provision of call alarms at Anchor Meadow and poplars has been reviewed

Review of all trust premises to be completed and assessed against agreed standards for alarm systems (completed)

A TNA has been completed in respect to identifying what staff require personal safety training, including a review of the content of such training

4 x 4 = 16

Red

Funding requirements are to be identified / highlighted via Estates and Capital Planning (Jan 2017)

A six monthly review of Trust alarms to be completed (January 2017)

Report into training compliance around personal safety training to be presented to Quality and Safety Committee

Provision of call alarms at Anchor Meadow and poplars has been reviewed

4 x 1 = 4

Green

Completion of local protocols

Audit results

Estates and Capital Planning Papers

14

/12/20

16

There were a number of issues identified by the CQC in relation to lone working and staff safety, of both a site specific nature and also throughout the Trust.

In addition to this, issues were identified regarding the provision of call alarms.

322 The Trusts assessment by the CQC noted that there may be a lack of evidence to support that calls within the Trusts Crisis team are responded to in a timely manner

Feb 2016 CQC Visit

19/05

/2016

Marsha Ingram

Rosie Musson

Crisis Team

5 x 3 = 15

Red

A new crisis call log has been developed

A standard has been agreed that if a call is not returned within the hour an incident form will be submitted

Processes have been communicated to staff

5 x 3 = 15

Red

Audit into compliance is to has been completed however an assessment of the risk is to be completed.

Report into compliance to be presented to Clinical Audit and Effectiveness Committee

5 x 1 = 5

Green

Incident figures

Clinical Audit Results

14

/12/20

16

As noted a new crisis call log has been established and a standard for incident reporting has been agreed

Whilst no incident forms have been entered in relation to this issue since the CQC visit, there is at this stage audit results to indicate the number of calls which are being returned and the average response time for these.

Audit results to be processed before risk can be downgraded.


Risk ID



Other Contributors

Initial Score



Residual Score



EF002 Fires Safety Management within the Trust

Review of Existing Assurance Mechanis ms

19/05

/2016

Rupert Davies

Fire Safety Advisors (STK)

5 x 4 = 20

Red

All sites maintained by the Trust have a specific Fire Risk Assessments in Place.

PPMs are in place as required by HTMs

All mattresses are 5 and or 7 Crib rated.

Mandatory training is in place.

5 x 4 = 20

Red

Trust Target to ensure fire safety training compliance at 90%

Risk assessments in place and reviewed formally as per annual plan to be completed – (December 2016)

Fire compartmentation assessments to be completed and reviewed – (December 2016)

Responsible Persons training to include director responsible for Estates

5 x 2 = 10

Amber

STK Fire Manager

Fire compartmentation assessments

Fire Risk assessments

Training figures

14

/12/20

16

Gap analysis with budget costs undertaken cost pressure identified and agreed at Mext.

At this present time there are noted gaps in assurance especially in relation to fire Compartmentation assessments which will need completing.




Enclosure: 21

Report Title:

Annual Plan 2016/17 Quarter 3 update


Mark Axcell, Chief Executive Officer


Mary Bytheway, Interim Associate Director Corporate Development

Purpose of the report: Board to note progress in delivery against the Trust’s stated

Annual Priorities for 2016/17 at the end of Quarter 3. Action required from the Board

Decision / Approval

Gain assurance

Discussion

Information


Committee:

Date reviewed: Key points or recommendations from Committee:




Leadership culture






Caring

Some of the objectives on our annual plan directly or indirectly impact upon the quality of care and the service experience.

Responsive

The annual plan reviews ensure that good progress is being made against its key objectives and that slippage and risks are known and managed.

Effective

The quarterly review of the Trust’s annual plan priorities provides the Board with insight and assurance that allows them to effectively monitor performance against its key objectives and supports decision making that can impact upon longer term strategic aims.

Well-led Safe

Enc 21 Annual Plan Trust Q3 Page 1 of 5

Title 2016/17 Annual Plan Q3 update report Introduction The Trust submitted its Annual Plan to NHS Improvement in June 2016 and shared a summary version with staff and the wider public. This document contains details of the Trust’s Annual Plan Priorities for 2016/17 aligned with the Trust’s corporate objectives as set out in the Trust’s five year plan (strategy on a page). Each quarter we review progress against the priority activities defined in the plan. Summary of key points, issues and risks Of the 54 priority activities, 43 (80%) are currently blue or green rated – meaning they have been delivered or are on track to be delivered. All of the remaining 11 have mitigation plans in place. Further detail (if required) Further detail is included in the appended report. Recommendation The Board is asked to receive the paper for assurance and discussion. Board action required There are no actions for the Board.


2016/17 ANNUAL PLAN Q3 PROGRESS REPORT Summary of progress against our priority activities (PAs) aligned to strategic themes The table below shows progress against our priority activities at Q3. Of the 54 PAs, 11 are currently rated as amber or red (compared to 7 last quarter). The exception report below describes the current status of these 7 and the mitigating actions / rational in place to redress. The increasing intensity of partnership activity (STP, TCT, MERIT and MCP) is having an impact on some PAs, however we are ensuring that what we do through our partnerships is supportive where possible of our annual plan priorities and doesn’t create duplication or conflict. Figure 1 Q3 progress summary (Q2 in brackets)

Strategic Theme Blue Green Amber Red TOTAL

High quality services (HQS) 2 (1) 8 (9) 1 (4) 3 (0) 14

Inclusive partnerships (IP) 2 (0) 8 (11) 0 (0) 1 (0) 11

Leadership culture (LC) 1 (1) 4 (5) 0 (0) 2 (1) 7

Responsible workforce (RW) 5 (4) 2 (4) 0 (0) 1 (0) 8

Supporting strategies (SS) 0 (0) 5 (5) 1 (1) 0 (0) 6

Efficient and effective resources (EER) 2 (2) 4 (5) 2 (1) 0 (0) 8

TOTAL 12 (8) 31 (39) 4 (6) 7 (1) 54

KEY: Complete On track to complete

in year Off track but plans to rectify in year

Work continuing with full implementation expected in 2017/18


Exception report

The table below describes the current position and mitigating actions in place to address those PAs that are currently off track (red or amber).

Ref Priority activity Update Mitigation

AMBERS

HQ8 Extend our seven day services

OAMH Walsall now has an initial weekend presence for only known OA CMHT patients with future development expected by May 2017.

In Dudley, there will be OAMH home treatment expected by July 2017.

Agreed to carry this priority into 2017/18 for older adults in line with commissioner priorities and align with work on-going in MERIT adult services work stream.

SS6

Enhance the publication of Trust performance data that is concise and accessible

Work has commenced to review the Integrated Performance Dashboard. A number of individual performance reports (such as S75) have been improved to aid clarity and further improvements to include KPIs are planned for Q4.

Business Intelligence (BI) hub is further integrated in performance review meetings and further engagement sessions are planned for Q4 to improve utilisation and ownership within the service lines.

We are in the process of agreeing how we might make more accessible our performance dashboard and other KPIs for the general public as well as potential employees etc.

EER3 Achieve our 2016/17 Cost Improvement Plans

28 projects in place in year – 19 of these projects have fully delivered on a recurrent basis, four projects are part delivered recurrently (and will be carried over into 17/18 for completion) and two projects are being supported on a non-recurrent basis. One project has been closed as not achievable. Three projects have not delivered in year - these will also carry over into 2017/18.

Regular reviews by the CIP programme, reports to MEXT and escalation to Execs is in place to drive the delivery and closure of all schemes in 16/17. We are now commencing 17/18 plans and will consider any that may carry forward at Q3.

EER6

Roll-out e-Rostering including links to ESR and safer staffing acuity tool for wards

The roll out of the safer staffing acuity tool “SafeCare” was postponed as more work was required on developing an effective acuity tool before implementation.

Agreed to carry forward into 2017/8.

RED

HQ4 Moving forward with our Older Adults Pathway development

Therapy and Liaison Community Service is now fully functioning working with third sector and linking with OACMHT.

Recruitment of band 6 Community Mental Health Nurses for the Enhanced OACMHT has been unable to fill all vacancies, however the OACMHT is now providing some weekend cover but not yet out of hours.

Plan being negotiated around medical cover and recruitment commenced for the

Agreed to carry forward into 2017/18 from a local transformation perspective and align to wider Black Country review as part of TCT clinical work streams.


community based Nurse Practitioners for GP practices, posts being banded 20/1/2017.

Dudley – project meetings continue, agreement from CCG on revised finances and home treatment model for OAMH being included within existing service.

HQ5

Review the role and functioning of outpatient clinics so that they provide high quality and safe services to an appropriate cohort of patients

Review of outpatient clinics is being proposed.

Agreed to carry forward into 2017/18 from a local transformation perspective and align to wider Black Country review as part of TCT clinical work streams.

HQ13

Develop a robust approach to how we develop and manage patient information

Further progress has been made to ensure we will be able to implement the Accessible Information Standard. Improvements have been made to ensure information is available in different languages.

In Q4 we plan to make further improvements such as information being available in braille.

In 2018, the revised General Data Protection Regulations (GDPR) will supersede the current Data Protection Act 1998 – our plan for compliance will be agreed and communicated in Q4 and the plan will be implemented in 2017/18.

IP11 Improve GP access to information

We are beginning to scope a new GP portal utilising existing and new information available through our website. Extensive involvement in partnership communications strategies has meant that this priority has been delayed and will be picked up in 2017/18.

Agreed to be carried forward into 2017/18.

LC4

Succession planning and approach to Talent Management

Scoped as part of PA LC5 and included in programme of future Leadership and Management development. Trust now hosting National Graduate Trainees and senior staff part of NHS Leadership Academy Director and Aspiring Director programmes.

To be considered through joint partnership working in TCT 2017/18.

LC5

Invest in our next leadership development programme to improve leadership effectiveness to meet future challenges

Leadership development programme out to procurement to identify partner. To be launched Q4 2016/17 and Q1 2017/18.

Agreed to be carried forward into 2017/18.

RW2

Develop and support staff competencies, skilling up to support flexible workforce models

Job shadowing process/guidance agreed. Vacancy reduction group reviewing rotations to support staff development opportunities (2017/18). Training needs analysis undertaken for staff groups

To be considered through joint partnership working in TCT 2017/18.




Enclosure: 22

Report Title:

Communications and Engagement Report – Quarter 3 2016/17


Mark Axcell, Chief Executive Officer


Mary Bytheway, Associate Director Corporate Development

Purpose of the report: To inform the Board on progress against communications and

engagement work plan.


Gain assurance

Discussion

Information


Committee: MExT

Date reviewed: 24th January 2017


None


services


Leadership culture






Caring The report provides information on how the Trust plans to engage and communicate with stakeholders and build strong relationships that will support its role as a responsive, effective and well-led organisation. It describes progress against our plans to develop the tools and target the messages that are appropriate for our diverse stakeholder groups.


Enc 22 Trust Board Communications report Q3 2016-17 Page 1 of 9

Title Communications and Engagement Report – Quarter 3 2016/17

Introduction This is the quarterly communications and engagement report that updates progress against the Communications and Engagement Strategy 2015 -19. Summary of key points, issues and risks In Quarter 3 a number of communications and engagement activities took place, these included: Partnership Communications Activity We are present at all partnership communications meetings and are involved in shaping future stakeholder engagement events and activities as well as approving internal and external communications and updates. Staff flu vaccinations Throughout the flu season, we prepared a variety of messages to staff regarding the flu virus itself, Occupational Health’s flu clinic dates and prize draw incentives. The intranet page was updated with FAQs, myths and facts and staff case studies. We have discussed ways in which we can improve this campaign next year with the Health and Wellbeing Committee. We also sought feedback on how we can improve the campaign next year and will inform the Health and Wellbeing Committee. Staff health and wellbeing days We provided communications support for the health and wellbeing days that have been organised at Dorothy Pattison and Bushey Fields Hospitals in line with the Trust’s health and wellbeing CQUIN. Support included the creation of posters, payslip attachments and intranet, Wednesday Wire and Team Brief news items. Human Resources are gathering feedback on the events and we will look at any comments relating to the communications in due course. Recruitment We are working on promoting the Trust as a place to work and reducing the number of band 5 vacancies. We have plans to attend an RCN event in March along with other recruitment events aimed at nurses. A short film will be developed to support this recruitment campaign via social media and our website and alongside this, we are working closely with HR to produce a new starter handbook. Marketing Dudley and Walsall Talking Therapy services We have been continuing to work on a marketing campaign to promote the online self-referral routes for both Dudley and Walsall Talking Therapy services in order to meet CCG targets.


The latest development in this campaign is the Black Country Free Radio advertising campaign which will launch on Monday 23 January 2017 and run for three weeks. An mp3 file of the advert will be circulated when received. Campaigns We are also supporting the communications and engagement of the following campaigns:

• Smoking cessation – working with the committee to offer communications support • Employment services – promoting both Dudley and Walsall services. Alongside this we

will be running a marketing campaign to launch the Building Better Opportunities EU / National Lottery funded employment project. Our Trust employment services won funding to deliver employment support to people with mental illness across Dudley, Walsall and Wolverhampton

Other areas of work

• Regular internal communications to support the CQC action plan and preparation for re-inspection

• Support operations projects such as Clent refurbishment • Supporting trust health and wellbeing strategy • Recruitment communications – working with Vacancy Reduction Group to boost

applications to roles and promote the Trust positively as a place to work In Quarter 4, 2016/17 we will be focusing on:

• Continuing to support strategic partnerships. In quarter 3 we are expecting more information around TCT partnership future direction which will require a lot of communications support moving forward

• Start to work on the internal communications review • Continuing with the Dudley / Walsall Talking Therapy campaign promotion including bus

advertising in November • Recognising Success awards ceremony planning for 2017/18 • Recovery Stories – David Stocks is working on this in conjunction with communications.

We are looking at a booklet and potentially a film or flipogram to highlight the stories • Launching the social media strategy

Further detail (if required) Appendix 1: Updated communications and engagement action plan Q3 16/17 Appendix 2: Communications and engagement dashboard Q3, 2016 Appendix 3: Summary of press coverage Q3, 2016 Recommendation The Board is asked to receive the report and further appendices for information and discussion. Board action required There are no actions for Board.


Communications activity

Strategic objective Milestones Timescale Status

Develop our Trust Prospectus - Carried over from 15/16

• Ensuring that there is good awareness of the MH services available in the Trust and in the community

• Manage and enhance our reputation as a high performing aspirant FT

• Research other Trust prospectuses • Draft and agree content for

prospectus • Liaise with designers • Printed prospectus delivered and e-

version added to website • Ensure key individuals are given a

supply of prospectuses

On hold This has been postponed pending partnership work within TCT and as part of our STP

Design and publish e-version of recovery stories including artwork and poetry Carried over from 15/16

• Raising awareness of MH and tackling stigma

Design and publish booklet of recovery stories including artwork and poetry

On-going David Stocks leading work – to link in with MERIT work stream

Review social media policy for staff Carried over from 15/16

• Provide a range of engagement opportunities at all levels across the Trust

• Revise policy following consultation with staff and other trust comparison

• Submit to governance department • Launch social media policy to staff

June 2016 Approved promotion of policy highlighted in Social Media Strategy

Conduct a stakeholder survey on engagement effectiveness

• Identify and analyse our current and future stakeholders

• Managing stakeholder expectations

• Draft questions and agree format • Create survey • Identify stakeholders to target • Send survey • Analyse results and report back

January 2017

To review approach in line with partnership communications strategies

Refresh Board stakeholder Engagement Plan



• Refresh stakeholder engagement plan and submit to Trust Board for approval

September/October 2016

To review approach in line with partnership communications strategies

Appendix 1: Updated communications and Engagement action plan 16/17


Meet/engage with key stakeholder groups to understand what they want/need to know (GPs and MPs)



• This will follow on from stakeholder engagement survey.

• Identify MPs / GPs to set up meetings with to discuss what they want/need to know

June 2016 – Dec 2017

Updated service guides online

Use social media to share mental health stories with stakeholders

• Raising awareness of MH and tackling stigma

• Ensuring that there is good awareness of the MH services available in the Trust and in the community

• Manage and enhance our reputation as a high performing aspirant FT

• Ongoing use of social media to raise awareness of our Trust’s work and case studies

On-going See draft Social Media Strategy

Develop intranet to encourage further engagement and interaction

• Continuous development of communication tools and resources


• A review of the Exchange based on feedback from focus groups / engagement champions and statistics

• Regular programme of ensuring team / service information is kept up to date

• Work with Dudley IT to make those changes

By March 2017 Forms part of internal communications review

Conduct media training for Trust Board members


• Arrange for media training session as part of a future Board Development day

TBC Have obtained quotes awaiting feedback

Develop engagement session for Governors to support their engagement with members



• Prepare presentation to governors focusing on ways in which they can engage with members

25 October 2016 Working with Company Secretary to agree programme of activities for our new Ambassadors


Participate in national and local awareness events



• Support national and local health initiatives where relevant to include:

- Mental Health Awareness Week

- Dementia Awareness Week - World Mental Health Day - Men’s Health Awareness

Week - World Suicide Prevention Day - National Stress Awareness

Day

On-going On-going

Develop member e-bulletin



• Create member e-bulletin highlighting trust updates and events in-between issues of One in 4 magazine

Quarterly Next bulletin due February

Develop a social media strategy

• Having a clear communication and engagement delivery plan that is targeted, bespoke and inclusive

• A strategy that will highlight how we will build upon and develop our social media activities

August 2016 See draft Social Media Strategy

Develop a brand identity / corporate style guide

• Having a clear communication and engagement delivery plan that is targeted, bespoke and inclusive

• Launch guide to staff to ensure consistency across the organisation

September 2016 Awaiting feedback from national NHS brand guidelines as this might affect our logo

Undertake an internal communications review with recommendations to further develop our approach

• Encouraging feedback from all stakeholders

• Evaluation of communication and engagement activities

• Review current internal communications channels

• Look at best practice / good examples from other areas • Develop proposals to enhance

September / October 2016

On-going


Introduce an annual members survey to ensure membership engagement is effective

• Encouraging feedback from all stakeholders

• Evaluation of communication and engagement activities

• Draft survey questions to review membership engagement

• Send to members to complete • Review and feedback

March 2017 Under review


Communications and Engagement Dashboard Quarter 3, 2016/17 Activity Q1 Q2 Q3 Q4 Press releases 8 9 6 Press coverage 23 44 22 Media enquiries 2 3 1 Twitter followers 1,104 1,193 1,291 WellMind downloads 20,534 22,636 30,803 WellMind rating (app store)

3.5 / 5 3.5 / 5 3.5 / 5

New members 207 13 6 Lost members 135 13 9 Total public members 7430 7430 7427

Top 3 page hits quarter 3 Website

Walsall Talking Therapies Service (20,323) Dudley Talking Therapy Service (47,872) Contact Us (5,035)

The Exchange Oasis Introduction Page (27,855) Phone Book Search (51,467) ESR Introduction Page (9,385)

Top 3 downloads quarter 3 Website

Seven eyed model (2,122) Service Guide for Walsall GPs (861) Systems Training for Emotional Predictability and Problem Solving (758)

The Exchange

Sickness Absence Policy (230) Medicines Management Policy (263) Annual Leave Policy and Procedure (177)

Membership total

0

1000

2000

3000

4000

5000

6000

7000

8000

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Series1


Press coverage summary quarter 3, 2016/17

Oct 16 Nov-16 Dec-16 Press releases 2 4 0 Press coverage 12 7 3

Value £4,391.50 £4,258.20 £1,788.92 Reach 192,557 87,530 39,014

£4,391.10 £4,258.20

£1,788.92

0.00

500.00

1,000.00

1,500.00

2,000.00

2,500.00

3,000.00

3,500.00

4,000.00

4,500.00

5,000.00

October November December

Value over time 2016




Report Title:

MExT Committee Chair’s Report

Committee:

MExT meeting held 24th January 2017


Mark Axcell – Chief Executive Paul Lewis-Grundy Company Secretary


Decision / Approval

Gain assurance

Discussion

Information

Key issues and Risks Chair’s Report The Chair’s Report included updates on the following:

• Dudley Multi-Specialty Community Provider(MCP) • Walsall Multi-Specialty Community Provider (MCP) • Transforming Care Together (TCT)

The Committee received a number of business cases for consideration. MExT received updates on

• Quality Improvement priorities and CQUINs • Implementation of changes to the Junior Doctors Contract • CQC Action Plan • Finance position at month 9 • Cost Improvement Plan • Estates • Outpatient/discharge information • Project Management Governance to strengthen the process in light of the internal audit

diagnostic review of the PMO / CIP Process • Workforce • Trust and Service Line Performance • Apprenticeship Levy Funding, which was also considered at the Workforce Committee • Partnerships/Clinical Development/Growth Update

MExT Chair’s Report (Final) Page 1 of 2

Interfaces with other Committees The business that was discussed by MExT interfaces with the following Committees/Groups:

• Audit Committee • Quality & Safety Committee • Finance & Performance Committee • Workforce Committee • Trust Board

Recommendations and requests for direction The Board is asked to receive this report from MExT for information and assurance.

MExT Chair’s Report (Final) Page 2 of 2

public meeting of the trust board 1.30pm, thursday, 2 … · 2017-01-31 · public meeting of the...

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