vision: working to improve lives part one: …...2018/04/25 · board of directors meeting 25 april...

Board of Directors Meeting 25 April 2018 FINAL

Meeting of the Board of Directors held in Public at 10:00

Wednesday 25 April 2018

TR1, The Lodge, Lodge Approach, Wickford SS11 7XX

Vision: Working to Improve Lives

PART ONE: MEETING HELD IN PUBLIC

AGENDA

1 APOLOGIES FOR ABSENCE CL Verbal Noting

2 DECLARATIONS OF INTEREST SS Verbal Noting

PRESENTATION: DELAYED TRANSFERS OF CARE

Alex Green, Director for Local Delivery – West Essex

Stephane Rea – Associate Director Dementia & Frailty Services West Essex Community Mental Health Services

Phil Wing – Head of Integrated Services

Jenny Able – Princes Alexander Hospital Trust

Lynne Jacobs – Essex County Council

3 MINUTES OF THE PREVIOUS MEETING HELD ON 28 March 2018

SS Attached Approval

4 ACTION LOG AND MATTERS ARISING SS Attached Noting

5 QUALITY AND OPERATIONAL PERFORMANCE

(a) Board of Directors Quality & Performance Scorecard

SM Attached Approval

6 ASSURANCE, RISK AND SYSTEMS OF INTERNAL CONTROL

(a) Board Assurance Framework NL Attached Approval

(b) Standing Committees:

(i) Finance & Performance (ii) Quality

AD AS

Attached Attached

Noting Noting

7 STRATEGIC INITIATIVES

(a) National and Local Systems Update (inc NE Alliance Update)

SM Verbal Noting

Board of Directors Meeting 25 April 2018 FINAL

(b) Service Transformation Update AB Verbal Noting

(c) Education and Training Update Report MK/NH Attached Noting

(d) Medicines Optimisation Strategy MK Attached Approval

8 REGULATION AND COMPLIANCE

(a) CQC Inspections Update SM Verbal Noting

(b) Potential Ligature Risk Assessment and Mitigation Processes Update

NL Attached Noting

(c) Duty of Candour Update NH Attached Noting

(d) Chair and Chief Executive: Division of Responsibilities

SS Attached Approval

(e) Board Governance Update NL Attached Noting

9 OTHER REPORTS

(a) Use of Corporate Seal SM Attached Noting

(b) Correspondence circulated to Board members since the last meeting

SS Verbal Noting

(c) New risks identified that require adding to the Risk Register or any items that need removing

All Verbal Noting

10 ANY OTHER BUSINESS All Verbal Noting

11 DATE AND TIME OF NEXT MEETING

Wednesday 30 May 2018 at The Lodge, Lodge Approach, Wickford SS11 7XX

12 QUESTION THE DIRECTORS SESSION

There will be a 15 minute session for members of the public to ask questions of the Board of Directors

13 DATE AND TIME OF FUTURE MEETINGS (NB: all meetings will be held at The Lodge commencing at 10:00)

27 June 2018

25 July 2018

26 September 2018

31 October 2018

28 November 2018

Professor Sheila Salmon Chair

ESSEX PARTNERSHIP UNIVERSITY NHS FT

Minutes of the Board of Directors Meeting held in Public Held on Wednesday 28 March 2018

At The Lodge, Lodge Approach, Wickford SS11 7XX

Attendees: Prof Sheila Salmon (SS) Chair of Trust Sally Morris (SM) Chief Executive Andy Brogan (AB) Executive Director Mental Health & Deputy CEO Alison Davis (AD) Non-Executive Director Natalie Hammond (NH) Executive Nurse Dr Milind Karale (MK) Executive Medical Director Nigel Leonard (NL) Executive Director Corporate Governance & Strategy Mark Madden (MM) Executive Chief Finance Director Malcolm McCann (MMc) Executive Director Community Health Services & Partnerships Mary-Ann Munford (MAM) Non-Executive Director Amanda Sherlock (AS) Non-Executive Director Nicci Statham (NS) Non-Executive Director (from agenda item 2) Nigel Turner (NT) Non-Executive Director In Attendance: Brian Arney (BA) Public Governor Roy Birch (RB) Public Governor Keith Bobbin (KB) Public Governor Charlie Bosher (CB) Quality Health David Bowater (DB) Appointed Governor Naresh Chenani (NC) NHS Improvement Jo Debenham (JD) Head of Employee Engagement, EPUT Finola Devaney (FD) NHS Improvement Pippa Ecclestone (PE) Public Governor John Jones (JJ) Public Governor Cathy Lilley (CL) Trust Secretary (minute taker) Pam Madison (PM) Staff Governor Poppy Miller (PM) Public Governor Astrid Pollard (AP) Principal Guardian (F2SU), EPUT Sam Rakusen (SR) Public Governor Cathy Trevaldwyn (CTre) Member of the public James Watson (JWn) Accounts Assistant, EPUT Clive White (CW) Public Governor Judith Woolley (JWy) Public Governor SS welcomed Governors, staff and members of the public to the meeting as well as Naresh Chenani, Deputy Regional Director and Fiona Devaney, Senior Clinical Manager from NHS Improvement. SS advised that due to the severe weather conditions, the February Board meeting was cancelled and acknowledged that there would be carry forward of several reports to this meeting. She pointed out that due to timebound decision requirements, a Part 2 Board meeting was held on 7 March 2018. 022/18 APOLOGIES FOR ABSENCE Apologies for absence were received from: Janet Wood (JWd) Vice-Chair

Signed ………………………………………….… Date …………………………………. In the Chair Page 1 of 14


023/18 DECLARATIONS OF INTEREST There were no declarations of interest. 024/18 PRESENTATION: STAFF SURVEY RESULTS The Board received a presentation from Charles Bosher from Quality Health on the Trust’s staff survey results for 2017, and discussed and noted the content. The Board was overall pleased with the encouraging results that acted as a temperature gauge for the Trust particularly following the merger and establishment of the new Trust but acknowledged that there were areas for improvement that would be taken forward by the Trust’s Staff Experience Team and as part of the organisational development programme. SS advised that she had commissioned an external benchmarking evaluation of the Board with external stakeholders that would also help to inform the Trust’s strategic direction. An update report would be provided to the Board. On behalf of the Board, SS thanked CB for the interesting and informative presentation. 025/18 MINUTES OF PREVIOUS MEETING

Subject to the following amendment, the minutes of the extraordinary Board of Directors meeting held on Wednesday 31 January 2017 were agreed as a correct record:

• Page 5 008/18 (vi) Charitable Funds Committee: to read … and advised that of the 39 bids received … 17 were approved/part approved totalling £50,524.

026/18 ACTION LOG AND MATTERS ARISING The Board noted and agreed the changes to the timeframe for actions 113/17 and 012/18. 027/18 QUALITY & OPERATIONAL PERFORMANCE SCORECARD SM reminded the Board that the Board of Directors Scorecard presents a high level summary of performance against quality priorities, safer staffing levels, financial targets and NHSI key operational performance metrics and also confirms quality/ performance hotspots (variance against target/ambition) agreed by the Finance & Performance Committee as well as identifying trends. The Scorecard identifies the key issues that are being considered by the standing Committees of the Board; the intention was therefore not to undertake further in depth scrutiny at the Board meeting. SM advised that due to the cancellation of the February 2018 Board meeting, the scorecards for both February and March 2018 had been circulated. She would, however, provide an update on the March scorecard. SM drew the Board’s attention to:

• Eight hotspots at the end of February 2018 two of which (staff turnover rate and cardio-metabolic assessment) relate to the NHS Improvement (NHSI) Single Oversight Framework quality of care metrics; however, there is currently no target set in the SOF for vacancy and turnover rates, and cardio-metabolic assessment;



assurance was provided that where performance is under target, action was being taken and being overseen and monitored by the relevant Board standing committee

• The revised benchmark figures following the publication of the Mental Health Benchmark report 2017 and the CHS Benchmark report 2017 that identified there has been a change to the benchmark for vacancies that reflects the recruitment issues experienced by all Trusts

• The inclusion of safer staffing as a hotspot as a result of CQC identifying this as a potential risk; assurance was provided that monitoring was being undertaken at a granular level and processes have been put in place to manage staff requirements

• The technical issues in relation to the trainer tracker used by the Trust which was having an impact on the staff training, appraisal and supervision data. Assurance has been provided by the operational directors that the required level of training was being received by staff

• The inpatient capacity which reflects the intense pressure within the system. In response to a question by AS on the hotspots which were also quality priorities, assurance was provided that work was being undertaken to address the data issues in relation to cardio-metabolic assessments, physical health and early warning systems and the Trust was also working with other organisations with similar challenges. MAM commented that the fill rate for registered nursing staff was lower than target although there was 100% occupancy. SM explained that the fill rate requirements was monitored through the twice daily sit rep calls and including the use of moving unregistered staff and the matron on units as appropriate to meet requirements. Discussions took place on the pressures in the system that were affecting the achievement of some KPIs and how the service transformation initiatives would contribute over a period of time to integration and the service flow. In response to a question by MAM on the psychiatric readmissions hotspot MK acknowledged that there were pressures on the units and highlighted the importance of the Home Treatment Teams. MM provided an update on the Trust’s financial position as at the end of month 11. He confirmed that the Trust was reporting an operating deficit of £4,583k which was a favourable variance of £978k against the current internal plan of £5,561k. The forecast at year end is expected to be £972k below revised plan largely due to changes in provisions and final agreements with CCGs in relation to the return of funding which has not been accounted for in month 11. He advised that the Trust is expected to receive an incentive bonus if it is ahead of its control total; this would also improve the year-end balance. MM pointed out that there remained challenges with agency costs; the Trust was not expected to meet the ceiling set by NHSI with expected costs reaching £16.7m compared to the £16.4m target. He advised that the cash balance remained healthy although the Trust was still in dispute with NHS Property Services; the Trust had made payments on account. The Board received and noted the report. 028/18 BOARD ASSURANCE FRAMEWORK (BAF) NL presented the full BAF and full Corporate Risk Register (CRR) as at 23 March 2018 which identifies the potential risks to achieving the Trust’s objectives for 2017/18. He reminded the Board that the BAF provides a comprehensive method for the effective management of the potential risks that may prevent achievement of the key strategic and corporate objectives agreed by the Board.



There were 17 potential risks identified on the BAF as at 23 March 2018 with 15 action plans developed to mitigate risks and two risks did not require action plans. These plans are reviewed each month by Executive Directors to ensure that action is contributing to risk mitigation and are subject to planned review each quarter. In addition the Board’s standing committees had responsibility for oversight and scrutiny of allocated risks, and have received the action plans. NL advised that the Executive Operational Sub-Committee (EOSC) had recommended removal of risk R5 – if the level of additional funding agreed with commissioners is not sufficient and/or model required by SW CCGs does not meet RCP criteria for NICE compliant service, the Trust may not be able to achieve the NHS Improvement (NHSI) early intervention in psychosis service access target – as the action plan for the south had been completed and the action plan for the north becomes an issue rather than a risk for 2018/19. In addition, EOSC had also recommended the removal of the risk in relation to Corporate Objective 5 (embed a robust mortality review process) as the reporting and monitoring system had become ‘business as usual’. NL pointed out that the risks that are open as at 31 March 2018 would be carried forward to the appropriate risk register for 2018/19 subject to approval of the Trust’s corporate objectives. The Board was reminded that Board Directors had received training at its development session on 22 March 2018 on the assurance framework which following audit had received a full assurance rating. He advised that the Board had agreed to pilot in shadow form an approach to risk appetite for the BAF. An update will be provided in Q2 following evaluation. The Board:

1 Received and discussed the report 2 Reviewed the potential risks identified in the BAF 2017/18 (as detailed in table

1) and approved the reduction to the risk score for R29 and the removal of R5 from the BAF

3 Reviewed the potential risks identified in the CRR 2017/18 (as detailed in table 3) and approved the removal of the risk in relation to the reporting and monitoring system for the mortality review process

4 Agreed the carry forward of all potential risks still open as at 31 March 2018 into the 2018/19 BAF

5 Did not identify any further risks for escalation to the risk registers. 029/18 STANDING COMMITTEES ASSURANCE REPORT (i) Finance & Performance Committee As chair of the Finance & Performance Committee, AD presented the report of the meeting held on 22 March 2018 and provided assurance that the performance - operational, financial and governance - were subject to appropriate and robust scrutiny; in addition, that the risks that may affect the achievement of the Trust’s objectives and impact on quality were being managed effectively. AD pointed out that some of the discussions held at the Committee have been covered under previous agenda items but drew the Board’s attention to the discussions on the Trust’s Engagement Strategy and six underpinning frameworks, in particular that work was being undertaken on the development of KPIs which would be monitored through the Finance & Performance Committee. She also highlighted the introduction of cultural performance indicators; EPUT is the first Trust to measure this.



The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action taken. (ii) Quality Committee As chair of the Quality Committee meeting on 15 March 2018, AS took the opportunity of thanking Executive Directors and Trust officers for the huge amount of work undertaken by the Quality Committee during 2017/18 in particular the focus on harmonisation following the merger to ensure the safety and quality of services. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action taken.

(iii) Audit Committee On behalf of JW, the chair of the Audit Committee, MAM presented the report of the meeting held on 8 March 2018. She highlighted the discussions on the internal audit progress report in relation to estates management focusing on fire safety where nil assurance had been provided. The Committee received assurance that measures are in place to address the concerns arising from this report. MAM advised that as part of the Committee’s effectiveness review, there was a proposed minor change to its terms of reference in relation to 3.7. She also confirmed that no new risks had been identified. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action taken.

(iv) Investment & Planning Committee On behalf of JW, the chair of the Investment & Planning Committee, AD presented the report of the meeting held on 7 March 2018 and also took the opportunity of thanking Committee members for their contribution during 2017/18. She drew the Board’s attention to the discussions on the development of the corporate objectives for 20181/9 acknowledging the significant amount of work undertaken to ensure clarity and that the objectives were understandable and concise. AD also pointed out that the Committee had received assurance on the disaggregation of Bedfordshire community mental health services that would be effective from 1 April 2018. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action taken. (v) Mental Health & Safeguarding Committee As chair of the Mental Health & Safeguarding Committee, MAM presented the report of the meeting held on 20 March 2018 and acknowledged the significant progress with the development and understanding of the roles and responsibilities of this Committee. She highlighted the discussions as part of the Committee’s effectiveness review and advised that recommendations would be made as to the future of the committee which would be included in the overall analysis and recommendations to be presented to the Board. MAM also confirmed that full assurance had been received in relation to all actions in relation to the safeguarding function and compliance with the Mental Health Act requirements. She also confirmed that no new risks had been identified. The Board received and noted the report, and confirmed acceptance of assurance provided in respect of action taken.



030/18 NATIONAL AND LOCAL SYSTEMS UPDATE SM provided a verbal update report on the progress of the four STPs that the Trust is involved in: Mid & South Essex (Success Regime); Hertfordshire & West Essex; Bedfordshire, Luton & Milton Keynes (BLMK); and North East Essex & Suffolk. With regards to Essex Mid & South, SM advised that the main focus has been on the consultation of the merger of the three acute hospitals which was due to close on 31 March 2018. She confirmed that the Trust had also responded to the consultation supporting the direction of travel as detailed in the consultation document. SM also reported that the membership of the main STP Programme Board had been reviewed and would now include all provider organisations. Discussions had also taken place regarding the potential governance arrangements, the terms of reference for the Board, the possible establishment of an Executive Group, the required infrastructure and the financial contribution arrangements. SS also advised that she had met with the independent clinical chair, Dr Anita Donley recently who had been involved in establishing a Chairs Advisory Group with the inaugural meeting on 12 April 2018. MMc provided an overview of the progress with the Thurrock ICS, a sub-system of the Essex Mid & South STP. A similar approach was currently being considered by South East Essex (Southend, Castle Point and Rochford). The aim was to formalise the structure which was based on the current informal working arrangements. AB reported on the progress with North East Essex & Suffolk STP that was working towards establishing two Integrated Care Systems (ICS). A Senior Responsible Officer (SRO) and clinical lead had been appointed for mental health – both from EPUT. The intention was to set up alliances across North East Essex and Suffolk with a coalition of members from commissioners and providers. SS and JWd are actively involved in this STP. MMc advised that the Bedford Luton & Milton Keynes (BLMK) STP continued to progress towards becoming an ICS. The Trust would however not be involved in future following the transfer of Bedfordshire community services to East London Foundation NHS FT. MMc provided an update on the good system-working with the West Essex & Herts STP that was potentially working towards two ICSs as part of the third wave. He explained the current thinking regarding mental health services but pointed out that the direction of travel had not been agreed. An integrated service alliance model with four partners working potentially as one organisation was being developed in the West MM reported on recent guidance from the centre on control totals which states that an organisation can only sit in one STP as a provider except in exceptional circumstances. This will have implications on the Trust. AS enquired, as a resident in West Essex, whether there would be more active public engagement in future strategy development. MMc agreed he would raise this with the CCG. The Board received and noted the verbal report. Action:

1 Feedback regarding public engagement in West Essex on future strategy development to be given to West Essex CCG (MMc).



030/18 CORPORATE OBJECTIVES NL presented the report on the final draft corporate objectives for 2018/19 that had been developed following engagement with staff, service users and partners. He reminded the Board that the development and finalisation had also taken place through Board development sessions, a NED/ED task and finish group, the EOSC and Investment & Planning Committee. The 11 objectives are aligned to the Trust’s strategies and include proxy measures where identified; an associated work and action plan will be developed following approval. Following a question by MAM, NL agreed that the Freedom to Speak Up initiative should be included as a proxy measure in relation to corporate objective 5 engage with our workforce to embed an open and learning culture. In addition, under corporate objective 8 the proxy measure in relation to patient reported outcomes/improvement would be made more explicit. In response to a question from ML regarding the transformation of services, NL confirmed that this work was being led by AB and the implementation of the initial plans would be undertaken by the Investment & Planning Committee and subsequently the Finance & Performance Committee would monitor performance. SS also pointed out that a detailed progress report would be presented at the April Board meeting. AB offered to provide an update to ML outside of the meeting recognising that the detail of the service transformation programme had been presented at the Board development session in October, prior to ML joining the Trust. Discussions took place regarding the alignment of the service transformation programme with the STPs’ direction of travel and the complexity of working within three STPs. The Board:

1 Received and discussed the report 2 Subject to some additions/strengthening of the proxy measures, the corporate

objectives for 2018/19 were approved. 031/18 COMMERCIAL STRATEGY NL presented the Commercial Strategy report. He explained that due to the state of variability and flux currently in the system, this was an interim position and the Commercial Strategy for the Trust would be fully refreshed and re-presented in September 2018 taking account of the Board’s strategic discussions which will be taking place over the next few months. The Trust’s commercial vision is to be an innovative organisation that delivers compassionate and safe patient care through a well-led and motivated workforce, ensuring that services are competitive, risk assessed and contribute to the Trust overheads to support the corporate infrastructure. However, although some of the identified external challenges provide an opportunity to transform and improve the design and delivery of Trust services, the constrained financial environment and commissioner affordability are key risks. The Board discussed the Commercial Strategy and challenges facing the Trust. Members were keen that the Strategy reflected the speed and pace required to enable flexibility and nimbleness, as well as the opportunity for staff to share ideas. An emphasis on innovative thinking and thinking outside the box should also be included as well as property and assets



rationalisation and return on investment. The Board recognised however the complexities in relation to estates. SS explained that a programme for Board strategic discussions was being developed and this would include discussions on the Estates and Commercial Strategies. The Board:

1 Received and discussed the report 2 Approved the Commercial Strategy 2018-2020.

Action:

1 Refreshed Commercial Strategy to be presented in September 2018 (NL). 032/18 CHILDREN, YOUNG PEOPLE AND FAMILIES FRAMEWORK The Board received the updated Children, Young People and Families Framework 2018-2021 from MMc; this is one of the underpinning frameworks for the Trust’s Quality Strategy. The Framework sets out the priorities for the delivery of children’s services within the Trust including both community and mental health services, and includes the vision for the future delivery of integrated evidenced based children’s services as well as how services will be delivered and measurable outcomes. The Board approved the Framework, acknowledging the significant work that had been undertaken in its development. The Board:

1 Received and discussed the report 2 Approved the Children, Young People and Families Framework 2018-2021.

033/18 CQC INSPECTIONS UPDATE SM reminded the Board that the CQC would be undertaking its comprehensive inspection of the Trust for the two weeks commencing 30 April 2018. In addition, the CQC would be undertaking a separate mental health inspection. She confirmed that the Trust had submitted all Provider Information Requests (PIR) on time and that CQC was now triangulating this information together with information from other sources. The task and finish group continued to meet in preparation for the inspection and regular updates and support sessions were being provided to staff. The Board, staff and Governors would continue to be updated on preparations for the inspection. The Board received and discussed the report. 034/18 LEARNING FROM DEATHS: MORTALITY REVIEW MK presented the learning from deaths mortality review reports for Q2 and Q3, and reminded the Board that the Q2 report would have been presented at the February meeting which had been cancelled due to the severe weather conditions. The report had however been published on the Trust’s website together with all February Board meeting papers. MK advised that discussions were taking place on how mortality review and data reporting can be incorporated into ‘business as usual’ processes moving away from a standalone



project approach which has been the focus to date. He pointed out, however, that mortality review processes and associated data/information were still in their formative stages both nationally and within the Trust, and that there was a range of varied approaches being undertaken. The Board noted that the Q2 report which included data for deaths occurring in Q1 went beyond the minimum national requirements which is to report on inpatient deaths as it also includes other deaths that the Board had agreed should be within scope for mortality review, i.e. deaths occurring in the community of service users with a recorded learning disability and deaths of service users occurring in the community meeting serious incident criteria. The data is therefore not comparable with other Trusts. The data was however being used locally to monitor the review of mortality and to assist in the ultimate aim of learning from deaths and improving the quality of services. For Q2 the Trust had 55 deaths “in scope” for mortality review in Q2 (there were 59 deaths “in scope” for mortality review in Q1). 23 of the deaths were inpatient deaths, all of which have been confirmed as due to natural causes. Assurance was provided that all deaths “in scope” have either been fully reviewed/investigated (47 deaths) in accordance with processes in place at the time of the death or are in the process of having the review/ investigation concluded (8 deaths). For Q3, the Trust had 61 deaths “in scope” for mortality review in Q3. 23 of the deaths in Q3 were inpatient deaths, 22 of which have been confirmed as due to natural causes. Assurance was provided that all deaths “in scope” have either been fully reviewed/investigated (15 deaths) in accordance with processes in place at the time of the death or are in the process of having the review/investigation concluded (46 deaths). AS provided further assurance that the Trust was taking proactive action to learn from deaths and detailed discussions were held at the Quality Committee. The Board recognised the significant amount of work required to prepare the learning from deaths mortality review report and discussions took place on the future format and content with a recommendation that the key data in the report could be summarised as a matrix. The Board received and discussed the report. Action:

1 Consideration to be given to the future presentation of information and report format (MK).

035/18 SAFEWORKING OF JUNIOR DOCTORS The Board received the assurance report from MK that doctors in training are safely rostered and that their working hours are compliant with the terms and conditions of service, and that there were no exception reports for the period 1 November 2017 to 31 January 2018. Assurance was provided that there are robust monitoring processes in place. The Board received and discussed the report. 036/18 ESTABLISHMENT REVIEW NH presented the report that detailed the recommended establishment reviews undertaken across all 49 wards within the Trust that determined the baseline establishment budgets. She



outlined the background to the review which was based on the National Quality board’s publication Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time: safe, sustainable and productive staffing and provided an overview of the establishment review process undertaken including the factors taken into consideration when conducting the review. NH highlighted that there was currently a mixture of 3 shift and 2 shift systems across the wards with different shift times; the proposal is for the majority of wards to implement 12.5 hour shifts to support consistency across EPUT services as detailed in the pre-circulated report. She provided assurance that the aim was to strengthen services with additional arrangements for site cover. An update with regards to the establishment at Wood Lea would be provided once finalised. The Board

1 Received and discussed the report 2 Approved the establishments as detailed in the report

Action:

1 Update on Wood Lea establishment to be provided following review (NH). 037/18 FREEDOM TO SPEAK UP ANNUAL REPORT SS welcomed Astrid Pollard (AP) to the meeting in her role as Principal Guardian for the Freedom to Speak Up (F2SU) initiative. NL presented the annual report for the Trust’s F2SU service. He reminded the Board that during the year there had been two Principal Guardians – Suzanne Deighton from April – November 2017 and AP who was elected from 1 December 2017. The report included a summary of the visit by the National Guardian, Dr Henrietta Hughes, to the Trust who was impressed with the Trust’s progress to date and for the innovative and varied channels available to staff to raise concerns. An overview of the activity and progress to date as well as the contacts made, concerns raised and actions taken, emerging themes, challenges/barriers and successes was also included in the report. AD advised that as Senior Independent Director she had met and would continue to meet with AP on a quarterly basis. NS queried if there was any correlation between the staff survey results and the use of the F2SU service. NL agreed to consider how the F2SU data could be fed into the organisational development and culture work being undertaken at the Trust. The Board agreed that a presentation on the F2SU service would be given by AP at a future meeting. The Board received and discussed the report. Action:

1 F2SU Service presentation to be arranged for a future Board meeting (NL/CL) 2 Inclusion of F2SU service outcomes/analysis to be included in the Trust’s

organisational development and culture programme.



038/18 BOARD GOVERNANCE UPDATE CL presented the Board Governance Update and highlighted the impact of the purdah period on the Trust as local government elections were due to be held in May 2018. Purdah will commence on 28 March 2018. An update was provided on the progress with the Board of Directors Committees effectiveness review and assurance was provided that to date there are no major concerns or issues raised, and that there has been positive validation of the work of all Committees from both members and non-members. CL also presented the current Register of Interests for Board Directors. The Board received and discussed the report. 039/18 VIEWS OF MEMBERS AND GOVERNORS REPORT SS presented the report that outlined the approach the Trust takes in ensuring that the views of Governors and members are communicated to the Board as a whole that demonstrated how the Trust encourages quality engagement with stakeholders and regularly consults and involves Governors, members, patients and the local community through various routes. CL explained that the report focuses on those opportunities for engagement and gathering views that are directly related to the role of the Council of Governors. She shared some of the wide-ranging engagement mechanisms for Governors and members. The Board received and noted the report. 040/18 USE OF CORPORATE SEAL The Board noted that the seal had been used on nine occasions since the last meeting in January 2018. MM pointed out that the sale of 32 Thoroughgood Road, Clacton on Sea CO15 6DD had fallen through. The Board received and noted the report. 041/18 CORRESPONDENCE CIRCULATED TO BOARD MEMBERS SINCE THE LAST MEETING SS confirmed that due to the cancellation of the February Board meeting (parts 1 and 2), in order to meet deadlines the following Chair’s action had been taken; she provided assurance that all Board Directors were provided with the opportunity to comment via email before Chair’s action was taken):

• BAF: approve the risk scores recommended by EOSC for R25 and R29 and the removal or risk R28

• Granting of NEP Charity Funds to SEPT Charity: - Approve the grant of £86,632.32 by NEP general charitable fund to SEPT

general charitable funds plus any transactional movements that arise by the grant date of not more than £10k

- Approve the delegation of authority to financial trustee and CEO or Deputy CEO to agree and sign the final letter that accompanies the grant.



SS also advised that the following correspondence had been circulated to Board members since the meeting in January 2018: • Emails regarding the BBC File on Four programme about the Trust • Letter re NHSE and NHSI: working closer together.

042/18 NEW RISKS IDENTIFIED THAT REQUIRE ADDING TO OR REMOVED

FROM THE TRUST RISK REGISTER The Board noted no new risks had been identified. 043/18 ANY OTHER BUSINESS (i) Media SM provided a statement following the recent media interest in the Trust including the BBC Radio 4 File on Four programme broadcast on 20 March 2018 (full statement is attached at appendix 1). (ii) ARU Medical School SS took the opportunity of acknowledging the landmark achievement of Anglia Ruskin University in becoming the first University to host a medical school in Essex with publicly funded places allocated to the new medical school. She advised that ARU would be providing students with a mix of experiences in urban and rural environments in collaboration with five NHS hospitals, GPs and the Trust. Students will be taught by visiting clinicians from NHS Trusts and general practice as well as the University’s own staff. MK agreed to present a paper at the next Board meeting on the potential impact to the Trust and how this aligns with and supports the Trust’s recruitment and training of doctors. Action:

1 Education and Training Update report to be presented at April Board meeting to include the impact of the establishment of the ARU Medical School on the Trust’s training of doctors (MK).

(iii) Annual Quality Awards SM commented on the Trust’s Annual Quality Awards that were held on 21 March 2018. She stated that it was a fabulous opportunity to share our successes and learn from other parts of the organisation. Directors were impressed with the number of high calibre projects and staff who were put forward to shortlist. (iv) Bedfordshire Community Services SM reminded the Board that Bedfordshire Community Services would be transferring to ELFT with effect from 1 April 2018. She took the opportunity of thanking Bedfordshire Community Health Services staff for their support over the years to our patients, carer and the community healthcare services in Bedfordshire. The Board was provided with assurance that there were no issues with the disaggregation of these services which were expected to be transferred safely and on time. 044/18 DATE AND TIME OF NEXT MEETING The next meeting of the Board of Directors will be held on Wednesday 25 April 2018 at 10:30 at The Lodge, Lodge Approach, Wickford SS11 7XX.



045/18 QUESTION THE DIRECTORS’ SESSION Questions from attendees, members, public and staff are detailed in Appendix 1. SS closed the meeting by asking AS to summarise how the Board had demonstrated through its deliberations and reports the Trust’s vision and values. AS explained that the presentation on the staff survey demonstrated the Trust’s approach to openness, and there was a richness displayed in relation to openness and compassion values with the questions asked by Board members and the conversations on the papers particularly the F2SU service and learning from deaths mortality review. 046/18 EPUT EXCELLENCE AWARDS: STAFF RECOGNITION SCHEME SS and SM were delighted to present Our People Award certificates to:

• Individual - Susan Beeharry, Support Worker, Grangegwaters Ward, Basildon MHU - Jo Debenham, Head of Engagement, The Lodge, Wickford - Susan Inglis, Community Psychiatric Nurse, Street Triage Team, Force Control

Room Essex Police HQ - Paul Keeling, MH Services Management, Acute Adult Inpatient Service & Clinical

Manager/Matron at Derwent Centre, Harlow - Clare MacAlpine, Palliative Nurse, Rayleigh/Hullbridge - David Powell, Clinical Nurse Specialist, NHS Veterans Mental Health Intervention

& Liaison Service Midlands & East of England - Ashley Ryan, Nurse on Beech Ward, Epping Hospital - Jacqui Schon, MH Services Management, Senior Occupational Therapist, The

Lodge, Wickford - Richard Weidner, Community Psychiatric Nurse & Clinical Lead, Rochford

Hospital - Bradley Willis, Secure Service Management Unit Manager Palliative Care, Byron

Court, Billericay.

• Team - AMHP Hub Coordinators, Linden Centre: Debbie Griffiths Ian Bartram

- Serious Incident Team/Support Service, the Lodge, Wickford: James Hixon Tracey Palmer

- IAPT Therapy for You, Pride House Laindon: Comfort Boaitey Sue Brown.

The meeting closed at 13:15.



Appendix 1: Governors/Public/Members Query Tracker (Item 045/18)

Governor / Member / Public

Query Assurance provided by the Trust

JJ Since 1 April 2017 how many suicides of inpatients have there been under EPUT?

NH confirmed there has been one inpatient death which occurred whilst the individual was on leave from the ward which the coroner has confirmed is suicide. The verdict from another coroner’s inquest was awaited

JJ How many suicides under EPUT have there been of those who have been inpatients but have died within 1 month of discharge?

NH confirmed that there had been two occurrences

RB Referring to the Children, Young People and Families Framework queried the transitional arrangements between children and adult care

SM explained that children’s MHS emotional wellbeing services ae provided by NELFT. Whilst the Trust has CAMHS inpatient services the transitional arrangements would take place from CHS. The Trust is currently working on transition protocols with NELFT for the safe transfer of services.

CT Referring to the File on Four radio programme, queried the safeguards in place for those patients who appeared on the programme who were under EPUT care

SS explained that the Trust has requested the names of the patients involved but had not been provided with this information. She provided assurance that appropriate safeguards would be put in place if the names are advised

PE Pre-sent questions in relation to inappropriate out of area placements reported in the performance, finance and quality reports for Jan and Feb 2018

SM explained that a more detailed report would be sent to PE outside of the meeting

PE Asked if there are any ‘bed-spaces/bedrooms in inpatient units which have outstanding anti-ligature work to be completed

SM confirmed that a programme of the removal of ligature points was in place but acknowledged that ligature risks changed frequently and this presented challenges. An update report on ligatures is due to be presented to the April Board

CW As a Governor of the Trust had pre-sent a question asking for assurance that the Board was openly considering the issues raised by the File on Four radio programme broadcast on 20 March. He confirmed that he had received full assurance following the briefing statement provided by SM

RB Queried the current staff vacancy rate SM confirmed this was just under 14% CT Queried the delay in the paying out of charitable funds MM agreed to check this


Board of Directors Meeting 28 March 2018 Minute 043/18 (i) Media – Appendix 1

CEO Statement: Media Interest As a Trust we are required to abide by strict confidentiality rules and are not allowed to comment on individual cases, nor may we confirm or correct information, even if it has been said publically by a patient or relative, as doing so may involve us breaching their confidentiality. We have taken every opportunity to provide firm public assurances that concerns raised with us are taken very seriously and reported as safeguarding incidents and to the police, as appropriate. If an allegation is related to someone employed by an agency or contractor, we would report it to their employer to be investigated. Someone against whom an allegation of sexual misconduct is made, for example, would be removed from the situation during the investigation and full support would be provided to the patient. We have asked the BBC repeatedly to provide us, in confidence, with the details they hold so that we can ensure the allegations raised have been, or are, fully investigated and appropriate safeguarding is in place. Unfortunately, they’ve not provided them so far. They have confirmed, however, that they will ask their sources to contact us directly and we sincerely hope the individuals concerned will do so. Despite the lack of detail about the allegations, the Trust has taken a number of actions. We have launched a formal investigation into the allegations of illicit substances on our inpatient wards and asked anyone with any information to contact the investigation lead directly. We have increased security at Basildon mental health unit and had extra patrols by the sniffer dogs. All staff have been reminded about all the ways in which they can raise any concerns with us, anonymously if they wish, and been urged to continue to support patients and relatives to do so too. We have increased even further the visibility of our directors and clinical managers on inpatient wards and are planning more awareness-raising and training for staff on specific issues raised in the programme. It was impossible to assess accurately the content or impact of the BBC programme before broadcast and we were concerned about patients or relatives listening who may be distressed by it, so we set up a helpline to call after the programme. The number has been well advertised and calls are answered by clinicians So far we’ve had seven calls, but we’ll keep it going until after Easter at least. I hope this provides you and any others who may have concerns, with assurance that the Trust has taken the issues raised in the BBC programme seriously and that we are taking prompt and appropriate action to address them.

Page 1 – 280318

Agenda Item 4 Board of Directors Part 1 Meeting

25 April 2018

Board of Directors Meeting Part 1 25 April 2018: Action Log Page 1 of 2


Board of Directors Meeting Action Log (following Part 1 meeting held on 28 March 2018)

Lead Initials Lead Initials Lead Initials

Andy Brogan AB Malcolm McCann MMc Amanda Sherlock AS

Alison Davis AD Mark Madden MM Janet Wood JW

Natalie Hammond NH Sally Morris SM

Milind Karale MK Mary-Ann Munford MAM

Nigel Leonard NL Sheila Salmon SS Cathy Lilley CL

Minutes

Ref

Action Owner Dead- line

Outcome Status

Comp

/ Open

RAG rating

Nov 147/17

Performance Report: F&P Committee to consider how significant improvements in performance can be recognised and celebrated in reports

SM April 18 All Committees to include this in the Assurance report to the Board. Chairs of Committees to e-mail the team/individuals and when relevant invite the teams/individuals to present their work to the Committee. This could then lead to inviting the teams/individuals to submit quality improvements/quality award applications.

Open

Sept 113/17

Board of Directors Meetings 2018/19: Schedule of business to be presented

CL April May 18

Due to the changes in the timeframe for reviewing the Board meetings framework, recommendation this is presented at May meeting as a standalone document to support the business of the Board

Open

Jan 012/18

Service Transformation: progress update to be presented at March Board meeting

AB April 18 Agenda item April meeting Open

Sept 107/17

Ligature Audit: updates to be provided at Jan and April 2018 Board meetings

NL April 18 Agenda item April meeting Open

Requires immediate attention /overdue for action

New action or required next meeting

Action Completed

Future Actions

Agenda Item 4 Board of Directors Part 1 Meeting

25 April 2018

Board of Directors Meeting Part 1 25 April 2018: Action Log Page 2 of 2

Minutes

Ref

Action Owner Dead- line

Outcome Status

Comp

/ Open

RAG rating

Mar 043/18(ii)

ARU Medical School: Education and Training report to include the impact of the establishment of the ARU Medical School on the Trust’s training of doctors

MK April 18 Agenda item April meeting Open

Mar 045/18

Q&As: MM to check the delay in the release of charitable funds following a query by Cathy Trevaldwyn in relation to the mosaic project at one of the Trust’s units

MM April 18 Verbal update to be provided at April meeting Open

Mar 037/18

F2SU/OD: inclusion of F2SU service outcomes/analysis to be included in the Trust’s OD and culture programme

NL May 18 Open

Mar 036/18

Establishment Review: update on Wood Lea establishment to be provided following review

NH May 18 Open

Mar 029/18

STPs: feedback regarding increased public engagement in West Essex on future strategy development to be given to West Essex CCG

MMc May 18 Open

Mar 034/18

Learning from Deaths Mortality Review: consideration to be given to the future presentation of information and report format

MK June 18 Open

Jan 008/18(ii)

Quality Committee: Update on Quality Academy to presented at a future Board meeting

NH June 18 Open

Mar 037/18

F2SU: presentation by Principal Guardian (Astrid Pollard) at July Board meeting

NL July 18 Open

Mar 031/18

Commercial Strategy: refreshed strategy to be presented in September 2018

NL Sept 18 Open


Page 1 of 3

Agenda Item No: 5a

SUMMARY REPORT

BOARD OF DIRECTORS PART 1

25 April 2018

Report Title: Quality and Performance Scorecards

Executive/Non-Executive Lead: Sally Morris Chief Executive Officer

Report Author(s): Jan Leonard Director of ITT

Report discussed previously at: Executive Operational Steering Committee – 16.04.2018 Finance and Performance Committee – 19.04.2018

Level of Assurance: Level 1

Level 2 Level 3

Purpose of the Report

The Board of Directors Scorecards present a high level summary of performance against quality priorities, safer staffing levels, financial targets and NHSI key operational performance metrics and confirms quality/ performance “hotspots” agreed by the Finance and Performance Committee. The scorecards are provided to the Board of Directors to draw attention to the key issues that are being considered by the standing committees of the Board. The content has been considered by those committees and it is not the intention that further in depth scrutiny is required at the Board meeting.

Approval

Discussion

Information

Recommendations/Action Required

The Board of Directors is asked to:

1 Note the contents of the report 2 Request further information and/ or action by Standing Committees of the Board as

necessary

Summary of Key Issues

The Finance & Performance (FPC) (as a standing committee of the Board of Directors) have considered the full Trust performance report, from which the content of the score cards is summarised, in respect of performance against target in the month of March 2018. Seven hotspots (variance against target/ambition) have been identified as at the end of March 2018 and are summarised in the Hot Spot Score Card. Data to support rates of Training, Appraisal and Supervision are currently undergoing internal validation and are not available at time of writing this report. Two of the hotspots (Staff Turnover rate and Cardio-Metabolic Assessment ) reported relate to NHSI Single Oversight Framework metrics. EPUT safer staffing has been identified as a potential risk by the CQC and this has been added as a hot spot for the Trust.


Page 2 of 3

Two hotspots have been identified in Single Oversight Framework Score Card (Cardio-Metabolic Assessment and Incident Reporting Rates, it should be noted these are expected to improve following internal validation) Five hotspots identified in Quality Account Score Card. One hotspot identified in Finance Score Card. Where performance is under target, action is being taken and is being overseen and monitored by standing committees of the Board of Directors.

Relationship to Trust Strategic Objectives

SP 1: Continuously improve patient safety, experience and outcomes

SP 2: Attract, develop, enable and retain high performers

SP 3: Achieve top 25% performance

SP 4: Co-design and co-produce service improvement plans

Which of the Trust Values are Being Delivered

1: Open

2: Compassionate

3: Empowering

Relationship to the Board Assurance Framework (BAF)

Are any existing risks in the BAF affected? Yes

If yes, insert relevant risk R1 CQC R5 EIP R6 Learning from incidents R8 NHSI SOF R12 Restraints R16 Vacancies R19 Agency spend

Do you recommend a new entry to the BAF is made as a result of this report?

No

Corporate Impact Assessment or Board Statements for Trust: Assurance(s) against:

Impact on CQC Regulation Standards, Commissioning Contracts, new Trust Annual Plan & Objectives

Data quality issues

Involvement of Service Users/Healthwatch

Communication and consultation with stakeholders required

Service impact/health improvement gains

Financial implications: Capital £

Revenue £ Non Recurrent £

Governance implications

Impact on patient safety/quality

Impact on equality and diversity

Equality Impact Assessment (EIA) Completed? YES/NO If YES, EIA Score


Page 3 of 3

Acronyms/Terms Used in the Report

CCG Clinical Commissioning Group OT Outturn

CEO Chief Executive Officer PbR Payment by Results

CQC Care Quality Commission RAG Red-Amber-Green

EOSC Executive Operational Steering Committee

RTT Referral to Treatment

IAPT Improving Access to Psychological Therapies

WTE Whole Time Equivalent

NHSI NHS improvement YTD Year To Date

Supporting Documents and/or Further Reading

Scorecards attached

Lead

Name Sally Morris Job Title Chief Executive

of 4

HOTSPOTS AMBITION POSITION TRENDTREND

PERFORMANCE KEY

NARRATIVE

Proportion of people on CPA having a review within 12

months will meet the 95% target

At the end of March the percentage who received a

review is 94.0%

Above threshold = good performance

The following areas are below target: • Mid Essex: 92.8% • West Essex: 93.5% • North Essex OOA / Unknown: 87.8% • Thurrock : 89.6% • South Essex OOA / Unknown: 68.9%

The Trust will maintain an overall 12 month rolling

turnover rate of less than 10%

At the end of March the Trust turnover rate was 16.1%.

Turnover is an NHSI Single Oversight Framework metric

Below threshold = good performance

Six directorates were above 14.0%: • Operations (SE Specialist ):14.6% • Corporate Governance : 14.5% • CHS Essex Children: 14.0% • Operations (North MH):22.4% • Operations (CHS WE):17.3% • Workforce, Development and Training: 14.4%

The Trust will maintain an overall monthly vacancy rate of

less than 10%

At the end of March the Trust vacancy rate was 13.4% and

the registered nurses vacancy rate was 14.5%.


Areas with the highest vacancy rates are: : • Operations (CHS WE): 13.7% • Specialist MH : 16.9% • North Essex Primary Care : 100% • Corporate Governance : 15.4% • CHS Essex Children: 12.4% • Workforce, Development and Training: 24.6% • Finance & Resources : 18.4% • Operations (North MH): 16.9%

Board of Directors Scorecard – Hotspots Month 12 – March 2018

Staff Turnover, & Vacancy Rate

CPA Reviews within 12 Months

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

TrustwideVacancy Rate

RegisteredNursing

Target

0%

5%

10%

15%

20%

25%

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Turnover

Threshold

0%10%20%30%40%50%60%70%80%90%

100%110%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Mar

EPUT

Target

of 4


PERFORMANCE KEY

NARRATIVE

The Trust will achieve 0 price cap breaches

In MarchNorth had 171 and

South had 96, a total of 267

Agency Shift Price Cap breaches

Achieve threshold = good performance

There were 267 Price Cap breaches reported in March– 96 in South Essex and 171 in North Essex.The same service areas continue to breach price caps. These are Compliance and Assurance, Urgent Care, Medical Staffing West, Adult Mental Health Illness, Psychiatry Services, Forensic Psychiatry, Geriatric Medicine, Medical Prison and GP Practice. However, the Trust are aware of these breaches and the reasons for them and we are doing all we can to support reducing in these areas.

It must be noted that week 46 breach data, specifically for North was not sent to NHSI. The data was not received on time to be able to send, however it has now become apparent that this information can be sent retrospectively (4 weeks after). Any delays or failure to send data should then not occur again.

The Trust will maintain overall staff appraisal and supervision

rates of 90%

The Trust will maintain a staff training rate of over 85%

with the exception of Inpt Fire, TASI and Safeguarding training

which will be maintained at 90%

Data subject to internal validation

Data subject to internal validation

Staff Training, Appraisal and Supervision

Agency Breaches

0

100

200

300

400

500

600

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

Agency Shift PriceCap Breaches

Threshold

of 4


PERFORMANCE KEY

NARRATIVE

Ensure that cardio metabolic assessment and treatment for

people with psychosis is delivered routinely in

a) Inpatient areas - target 90%

b) EIP services - target 90%c) Community MHS (people on

CPA) - target 65%

• North : Inpatients & Community 79%, EIP 6%• South : Inpatients &

Community 58%, EIP 78%

The CQUIN submission shows that the % of patients with CMA and treatment , as defined as % complete Lester Tool indicator, is

• North : Inpatients & Community 79%, EIP 6%• South : Inpatients & Community 58%, EIP 78%

Above threshold = good performance

The Single Oversight Framework specification confirms that this is an annual Board declaration and that the data source used will be the internal MH provider sample submitted to national audits ( NCAP audit for Inpatients and Community , EPIN audit for EIP ) for the CQUIN.

The Trust will achieve national average Length Of Stay ( LOS ) of

33 days for Adult MH on discharge

In March Adult MH LOS on discharge was 38 days (

excluding MHAU ) ( 28 days including MHAU )

• North : Inpatients & Community 79%, EIP 6%

Below threshold = below performance

In March the average Adult LOS was: • MH North : 37 days • MH South : 40 days ( 22 days including MHAU )

The Trust will achieve national average Length Of Stay ( LOS ) of 82 days for Older People MH on

discharge

In March Older People MH LOS on discharge was 105 days,

and Older People MH current inpatients was 93 days

• South : Inpatients & Community 58%, EIP 78%


In March, both North and South OP services were above threshold on discharge: • MH North: 104 days • MH South: 91 daysNorth Essex ( 105 days ) was above threshold for current inpatients : Topaz Ward : 289 days Bernard Ward : 111 days Ruby : 110 daysTwo wards in South Essex were above the threshold for current inpatients: Maple : 86 days Meadowview : 86 days

Cardio Metabolic Assessment

Inpatient Capacity (MH)

0

20

40

60

80

100

120

140

160

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

ALOS (OPMH) onDischargeALOS (OPMH) CurrentInpatientsThreshold

0

10

20

30

40

50

60

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

Adult MHondischarge

Threshold(Adult MHondischarge)

of 4


PERFORMANCE KEY

NARRATIVE

The Trust will fill >90% of expected day and night time registered and unregistered

shifts.

See Board of Directors Scorecard - Month 12 - Safer StaffingSafer Staffing

PROJECT AMBITION TARGET CURRENT MONTH POSITION

Board of Directors Scorecard- Quality Priorities Month 12- March 2018

To reduce the number of Pressure Ulcers, Avoidable Falls,

Medication Omissions and Restrictive Practice

Unexpected Deaths

During Q1, the Trust will establish a baseline for the new organisation for each of the areas identified ( see list left )and standardise processes and reporting where differences exist.

At the end of Q1 when the baseline across EPUT has been established, the Trust will establish appropriate reduction targets for the remainder of the year.

The Trust will monitor performance in each of the above categories during Q2 – Q4 and will have achieved an appropriate reduction against the new organisational baseline established in Q1 for:

● The number of avoidable grade 3 and 4 pressure ulcers acquired in our care ● The number of avoidable falls that result in moderate or severe harm ● The number of omitted doses within services

● The number of prone restraints

The Trust will achieve above 95% harm free care from the “Safety Thermometer” every month throughout the year.

Avoidable PU – 11 for year Avoidable falls - 7 for year Baseline review undertaken - - (Omitted doses 290 for Q2. Prone Restraint – 122 for Q1 = 488 for year) 2016/17 data for falls, pressure ulcers and unexpected deaths. Unexpected deaths - 53 for year

10% reduction across all workstreams

Avoidable Pressure Ulcers : 5 to date Avoidable Falls : 4 to date Omitted Doses: 107 in Oct, 61 in Nov, 56 in Dec = 224 for Q3 compared to target of 261 ( 10% reduction on 290 baseline ). Jan 68, Feb 43, 36 in March= 147 for Q4, which has achieved the target reduction.. Prone Restraints : 104 in Q3 compared to target of 110 ( 10% reduction on 122 baseline). There were 41 prone restraints in February, and a total of 98 in Q4, which has achieved the target reduction Unexpected Deaths : 84 ( 2017/18 ) vs baseline of 53

The Trust has consistently achieved or surpassed 95% harm free care from the “Safety Thermometer” every month throughout the year.

During Q1 the Trust will review the different suicide prevention training packages in place across the Trust and establish the organizational baseline for staff having completed suicide prevention training.

At the end of Q1, the Trust will agree the training approach going forward and appropriate trajectories for completion of agreed suicide prevention training across the Trust.

The Trust will monitor training completion during Q2 – Q4 and will have achieved the agreed completion rate by the end of Q4.

Decision made by ET to take forward Connecting for People training

Trajectory agreed : 60% of targeted clinical staff to be trained in either STORM or Connecting with People training by March 2018 ( Adult inpatient & Crisis teams). STORM training ceased in Oct 2017 with CwP adopted Trust wide.

Two CWP courses provided each month (84 delegates trained, 45 of whom were in the target group e.g. adult inpatient, CAHMS, Community and Crisis Services. Target group WTE 428, figures obtained Jan 2018). The majority of other attendees not in the target group were from community mental health services and older adult. In total, 252 individuals have received some form of suicide prevention training since 2015. Percentage WTE of target teams (who have received training since 2015 either STORM or Connecting with People N.B. STORM no longer provided) currently 50%. * Consideration currently be given to employing dedicated trainers and mandating training. * Consideration also needed as to how to increase attendance by target group. * Consideration to be given to a review of training records to ensure data is current and reflects those still employed by the Trust.

Patient Safety- Continued Reduction in Harm

Project 1

Project 2


Physical Health of Mental Health Patients and early warning

systems for deteriorating Patients

To develop and implement revised standards for record keeping and achieve an improvement in the

quality of record keeping between Q1 and Q4

During Q1 the Trust will review the physical health monitoring tools in place across the Trust, standardise and deliver training on the agreed tool.

During Q2, the Trust will undertake an audit of physical health and early warning systems for deteriorating patients and agree appropriate outcome measures to achieve by the end of Q4.

At the end of Q4, the Trust will review performance against the agreed outcome measures.

Review undertaken and MEWs adopted across mental health inpatient areas. Training being taken forward through mandatory EES (Enhanced Emergency Skills training)

Audit completed and results shared with Quality committee – remains a BAF risk.

MEWS audit completed. Paper presented to the March Quality Committee - remains a BAF risk.

The Trust will consistently achieve the following targets in terms of patients with psychosis receiving a cardio metabolic assessment from Q1: Inpatients 90% Early Intervention in Psychosis patients 90% Community patients on CPA 65%

The Trust will consider how to implement a sustainable process which ensures that all patients with psychosis receive a cardio metabolic assessment and will set stretch targets for the remainder of the year at the end of Q1.

The Service Improvement team is currently working with relevant internal and external stakeholders to ensure that the trust is working towards achieving the relevant assessments going into year 2 of the CMA CQUIN. The CQUIN submission shows that the % of patients with CMA and treatment , as defined as % complete Lester Tool indicator, is North : Inpatients & Community 79% , EIP 6% South : Inpatients & Community 58%, EIP 78%, When these CQUIN submissions for the North are compared to data extracted from the patients electronic record ( Inpatients 99%, EIP 83%, Community 75% ), a discrepancy arises with the EIS data. However in the South the electronic data in the patients records is not sufficiently robust to support a comparison. Data is collected on eform 3.2-010CP and the following CMA rates demonstrate the level of uptake of this form, rather than the rates of CMA. Inpatients : 6.0% EIP : 62.9%

Cardio metabolic assessments are currently undertaken. Stretch targets to be determined.

Project 3

During Q1, the Trust will undertake a record keeping baseline audit and develop and launch revised standards for record keeping.

At the end of Q1, the Trust will agree appropriate improvement targets to be achieved by Q4 against the established baseline.

The Trust will undertake a further record keeping audit in Q4 and will have achieved a percentage improvement in the quality of record keeping.

Five record audits undertaken across CAMHS & LD, Mother& Baby, Secure Services, MH Adult Wards and MHOP wards

Inpatient collated results: CAMHS – 85% Mother and Baby – 98% Secure – 95% MH adults- 88% MH OP – 89% Target for inpatients – to achieve 90%

Re-audit undertaken. The Trust has partially achieved the priority as two of the five areas exceeded the 90% target.

Clinical Effectiveness- Record Keeping and Care Planning

Project 4

AMBITION TARGET CURRENT MONTH POSITION

To ensure that all patients identified as on an “End Of Life” care pathway have a personalised care

plan in place

To develop and implement organisational systems to deliver

the National Quality Board’s “ Learning from Deaths” Guidance issued in March 2017.

During Q1, the Trust will undertake an audit of the number of patients identified as on an “end of life” pathway who have a personalised care plan in place.

During Q4, the Trust will undertake another audit of the number of patients identified as on an “end of life” pathway who have a personalised care plan in place and will have achieved an increase in the number.

Audit completed in CHS. Now agreed to include MHS - audit standards developed and audit undertaken and results shared with end of life group.

The Trust has achieved this target. Audit in Q2 identified that the overall number of people who are at end of life ith care plans in place was 75%. In Q4 this number was 77%.

Project 5

Clinical Effectiveness- Record Keeping and Care Planning Clinical Effectiveness- mortality review

By September 2017, the Trust will have developed and approved an updated Mortality Review Policy in line with the “Learning from Deaths” national guidance.

From Q3 onwards, the Trust will report mortality information on a quarterly (and annual) basis in line with the requirements of the “Learning from Deaths” national guidance (data to be published will be from April 2017 onwards). This will include the total number of the Trust’s in-patient deaths and those deaths that the Trust has subjected to case record review; of the deaths subjected to review, an estimate of how many deaths were judged more likely than not to have been due to problems in care; and learning points.

At the end of Q4, the Trust will undertake an audit of implementation of the Policy to assess whether processes have been embedded and are operating effectively.

The Mortality Review Policy was approved and is available from EPUT’s website

A report was presented to the Board Of Directors in accordance with national requirements. EPUT has published three Learning from Deaths reports. The Trust has established processes for reviewing deaths in scope The Trust has had a review of deaths in the elderly and a review of LD deaths.

The policy on Mortality Review and Learning from Deaths was approved by the Board of Directors in September 2017, to be implemented from October 2017. The Trust will undertake an audit on compliance with the policy after 12 months of its implementation at the end of quarter three.

Project 6


To achieve high quality family and carer engagement and involvement after the death of an

inpatient or the death in a community setting which is classified as a “serious incident” in line with national guidance on learning from deaths.

Clinical Effectiveness- Record Keeping and Care Planning Patient Experience- Family and Carer involvement in mortality review

By September 2017, the Trust will have developed a Family and Carer Engagement and Involvement Policy which will include how families and carers are involved after the death of a patient who died in in-patient services or the death of a patient in a community setting which is classified as a “serious incident”.

By September 2017, the Trust will design appropriate mechanisms of seeking feedback from families and carers in terms of their engagement and involvement following the death of a patient in in-patient services or the death of a patient in a community setting which is classified as a “serious incident”.

The outcomes of the Q3 - Q4 audit will be assessed and actions agreed that could be taken to achieve improvement for on-going monitoring.

The Family / Carer Involvement Protocol was approved by Executive Team in September 2017.

As a result of the protocol being approved an implementation action plan has been drawn up which was approved by the Mortality Review Sub-Committee. This includes the design of questions to obtain feedback from families and carers on their involvement and engagement. Regular monitoring will take place at the Group. The Family and Carers protocol has been agreed by the Trust. Feedback questions have been implemented and we are awaiting sufficient responses to enable meaningful analysis.

Analysis of responses to questions was undertaken in Q4 and will be reported to the Sub-Committee in April 2018 with details of actions to be taken if required.

The Trust will implement these mechanisms and undertake an audit through Q3 – 4 to establish the position in terms of the effectiveness of engagement and involvement, aiming to achieve a target of 100% of families / carers of patients whose death was in in-patient services or classified as a serious incident indicating that they were satisfied with their engagement and involvement after the death.

Audit undertaken

Project 7

HOTSPOTS METRIC FREQUENCY TARGET TREND NOTES

Staff Sickness Monthly/QuarterlyTBC

Local target =<4.5%

In March the EPUT sickness rate was 2.2%

The only directorate above the 4.5% target in March was:Operations CHS Essex Children : 11.0%

Staff TurnoverMonthly/ Quarterly

Benchmark TBC

TBC

Local target 10%

In March the EPUT turnover rate rate was 16.1%

Most areas were above the target. The highest rates were in: • Operations (CHS WE) : 17.3% • Operations (CHS Essex Children ) : 14.0% • Operations (North MH) : 22.4% • Corporate Governance : 14.5% • Operations (SE Specialist) : 14.6% • Workforce, Development and Training : 14.4%

Executive Team TurnoverMonthly/ Quarterly

Benchmark TBC

TBC

Local target 10%

For March, the Executive Team Turnover was 0.0%.

Executive Team Turnover excludes NEDs and administrative staff

NHS Staff Survey Annual TBC

2017 Results :

7 Key Findings – Worse than Average23 Key Findings – Average2 Key Findings – Better than Average

Proportion of Temporary Staff Quarterly TBC

Proportion of temporary staff for March:North MH : 5.4%South MH : 9.8%CHS : 6.1%

Board of Directors Scorecard - SINGLE OVERSIGHT FRAMEWORKORGANISATIONAL HEALTH INDICATORS - March 2018

Executive Team

Turnover

Staff Sickness

Staff Turnover

0%

5%

10%

15%

20%

25%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Mar

ET Turnover

Target

0%

2%

4%

6%

8%

10%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Mar

% Temorary Staff

NHS Staff Survey

0%

1%

2%

3%

4%

5%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Mar

Trust Total

Target

0%2%4%6%8%

10%12%14%16%18%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Mar

Turnover

Target

Worse than Average

Average

Better than Average

Board of Directors Scorecard - Month 12 - March 2018Finance

AMBITION POSITION TREND NARRATIVE

NHS Improvement's metric of financial risk

For 2017/18 the Trust is assessed against the Use of Resources Rating, good performance is indicated by a rating of 1. The forecast risk rating at Month 12 remains at 3, in line with our plan.

The Risk rating for Month 12 will be confirmed when the draft annual accounts submission is made.

Operating Income and Expenditure

The Trust's Continuing Operating performance at Month 12 is a deficit of £4,785k which exludes the additional STF income allocation from 16/17 of £389k and forecast STF Incentive of £2,495k for 2017/18.

The delegated expenditure position is broadly in line with forecast out-turn at Month 11 (actual spend of £312.86m for Month 12 against a Month 11 forecast of £312.71m).

Planned improvement in productivity and efficiency

The total recurrent CIP target for the 2017/18 financial year is £11,980k and as at Month 12 a total £13,002k CIP schemes have been identified. £12,217 have been implemented and actioned in the ledger.

Control of Agency Costs

At Month 12 the Trust expenditure is £2,635k above the year to date internal target. The expenditure in month was £1,828k, which is an increase on the M11 spend of £1,243k. Largely due to winter pressures, Community and Mental Health investment schemes and a catchup of shifts booked on the system after year end.

Cash Balances

At the end of Month 12 (March 2018) the Cash balance is £60,027k against the plan of £53,962k. This favourable variance is predominantly as a result of receipts being higher than planned, and the net impact of capital under spends of £2,686k, creditors higher than forecast by £760k and an improvement in the deficit position.

RATING

Financial Risk Rating / Use of Resources

Cost Improvement Programmes

Cash Balance

Agency Costs

0

1

2

3

4 Financial Risk Rating - Use of Resources

Overall UORRatingPlanned UORRating

0% 20% 40% 60% 80% 100%

Corporate & Non Delegated

Community

MH & Specialist

Medical

Dir of Nursing

CIP Progress

Actioned

To be actioned

0

5000

10000

15000

20000

1 2 3 4 5 6 7 8 9 10 11 12

£000

Month

Agency - Cumulative Plan vs Expenditure

YTD Plan

YTD Actual

Year to Date Operating

Deficit

-7000-6000-5000-4000-3000-2000-1000

01000

Year to Date Surplus/(Deficit) Vs Plan

EPUT RevisedPlanned Year to DateSurplus/(Deficit)

010000200003000040000500006000070000

1 2 3 4 5 6 7 8 9 10 11 12

£(00

0's)

Month

Cash balance - Actual vs Forecast

Actual

Registered Staff Day Time

We will achieve >90% of expected day time

shifts filled.

TREND STAFF / SHIFT AMBITION LATEST POSITION TREND PERFORMANCE KEY NARRATIVE

Board of Directors Scorecard – Month 12 – March 2018 Safer Staffing

Registered Staff Night Time

Unregistered Staff Day Time

We will achieve >90% of expected day time

shifts filled.

We will achieve >90% of expected night time

shifts filled.

97% of expected Unregistered Nurse day time shifts were filled.

97% of expected Registered Nurse night time shifts were filled.

Breakdown: North Essex: 96.7% South Essex: 96.9%

95% of expected Registered Nurse day time shifts were filled.

Above target = good performance



Breakdown: North Essex: 97.4% South Essex: 96.8% Hotspot as 1 South ward below target in March (please see scorecards below)

Breakdown: North Essex: 93.6% South Essex: 96.0% Hotspot as 3 North and 4 South wards below target in March (please see scorecards below)

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

All Trust(EPUT)2017/18North MH

South MH

Target

70.0%

80.0%

90.0%

100.0%

110.0%

120.0%

130.0%

140.0%

150.0%

Ap…

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

All Trust2017/18

North MH

South MH

Target

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Apr

May Jun Jul

Aug

Sep

Oct

Nov De

c

Jan

Feb

Mar

All Trust2017/18

NorthMH

SouthMH

Target

Page 1 of 4

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Apr…

Jun

Aug

Oct

Dec Feb

All Trust2017/18

Target

NorthEssex MH2016/17

It should be noted that EPUT safer staffing has been identified as a potential risk by the CQC. A Task and Finish Group has been established to look at better ways of reporting safer staffing. New weekly reports have been developed and it has been agreed that the intranet will be the main source of data. Data for Bryan Roycroft is not included, as this closed in December 2017 Recruitment is ongoing across the Trust and site managers are being utilised to support wards alongside the ward managers and matrons to ensure the wards are safe as discussed through the monitoring at the twice daily teleconference calls and SitRep. This information is also being triangulated with the Quality Dashboard and CQC compliance information.

Unregistered Staff Night Time

We will achieve >90% of expected night time shifts filled.

101% of expected Unregistered Nurse night time shifts were filled.

TREND STAFF / SHIFT AMBITION LATEST POSITION TREND PERFORMANCE KEY NARRATIVE

Breakdown: North Essex: 100.4% South Essex: 101.5%


70.0%

90.0%

110.0%

130.0%

150.0%

170.0%

Apr

May Jun

Jul

Aug

Sep

Oct

Nov

Dec Jan

Feb

Mar

All Trust2017/18

North MH

South MH

Target

Page 2 of 4

North Essex Safer Staffing Scorecard

Page 3 of 4

South Essex Safer Staffing Scorecard

Page 4 of 4


Agenda Item No: 6a

SUMMARY REPORT

BOARD OF DIRECTORS PART 1 25 April 2018

Report Title: Board Assurance Framework 2018-19

Executive/Non-Executive Lead: Nigel Leonard Executive Director of Corporate Governance and Strategy

Report Author(s): Susan Barry Head of Assurance

Report discussed previously at: Executive Operational Sub-Committee

Level of Assurance: Level 1 Level 2 Level 3

Purpose of the Report This report presents the Board of Directors with a summary of the first Board Assurance Framework (BAF) for 2018/19 as at the 19 April 2018.

Approval

Discussion

Information

Recommendations/Action Required The Board of Directors is recommended to: 1. Note the development of the Board Assurance Framework for 2018/19; including the receipt

of positive assurance from the Trust’s Internal auditors (Appendix 1) 2. Agree the impact assessment/rating of 2018/19 Corporate Objectives (and allocation to BAF

or CRR as set out in section 2.3) 3. Confirm the risks identified as at April 2018 (in Table 1), the proposed risk scores and the

action being taken to mitigate them 4. Consider and agree the new risks for 2018/19 (Section 5) for escalation to the BAF 5. Identify any further risks for escalation to the BAF or risk registers.


• Substantial Assurance opinion received from Mazars in respect of risk management arrangements (Appendix 1)

• Impact rating of the Trust’s Corporate Objectives has identified 8 out of 11 have significant impact on the Trust’s strategy if not achieved and these therefore form the basis of the BAF 2018/19

• 3 risks are closed off the 2017/18 Board Assurance Framework • 14 risks are carried forward to the 2018/19 BAF (Table 1) • BAF action plans in respect of risks carried forward are currently being reviewed. • 7 new risks are proposed for 2018/19 (Section 5) • The Corporate Risk Register is being reviewed and updated for 2018/19 • Directorate Risk Registers are being transferred to the new 2018/19 template • Tailored coaching cards have been circulated to Service Management Teams

Page 1 of 2


Relationship to Trust Strategic Priorities SP 1: Continuously improve patient safety, experience and outcomes SP 2: Attract, develop, enable and retain high performers SP 3: Achieve top 25% performance SP 4: Co-design and co-produce service improvement plans

Which of the Trust Values are Being Delivered 1: Open 2: Compassionate 3: Empowering

Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? All If yes, insert relevant risk See report Do you recommend a new entry to the BAF is made as a result of this report? Yes see report

Corporate Impact Assessment or Board Statements for Trust: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, new Trust Annual Plan & Objectives

Data quality issues Involvement of Service Users/Healthwatch Communication and consultation with stakeholders required Service impact/health improvement gains Financial implications:

Capital £ Revenue £

Non Recurrent £

Governance implications Impact on patient safety/quality Impact on equality and diversity Equality Impact Assessment (EIA) Completed? YES/NO If YES, EIA Score

Acronyms/Terms Used in the Report NICE National Institute for Health and

Care Excellence EOSC Executive Operational Sub Committee

CQC Care Quality Commission CCG Clinical Commissioning Group SOP Standard operating procedure NHSI NHS Improvement KPI Key performance initiative LOC Learning and oversight committee OD Organisational development BOD Board of Directors NHS NHS England LOS Length of stay NCI NHS Centre for Involvement NHSD NHS Digital LSMS Local Security Management

Specialist ECG Electro cardiograph

BAF Board Assurance Framework CRR Corporate Risk Register

Supporting Documents and/or Further Reading Appendix 1 Mazars Internal Audit Report

Lead

Nigel Leonard Executive Director of Corporate Governance and Strategy

Page 2 of 2

1

Agenda item 6a Board of Directors

25 April 2018

EPUT

BOARD ASSURANCE FRAMEWORK 2018/2019 AS AT APRIL 2018

1.0 PURPOSE OF THE REPORT

This report presents the Board of Directors with a summary of the first Board Assurance Framework (BAF) for 2018/19 as at the 19 April 2018.

2.0 BOARD ASSURANCE FRAMEWORK DEVELOPMENT

2.1 Assurance on current arrangements In order to assess the robustness of the trust’s risk management and assurance arrangements and to determine any improvement required going forward, Mazars, the Trust’s internal auditors reviewed the systems of internal control in place during March 2018. The final report of their findings was issued in March 2018 giving an opinion of ‘substantial assurance’ on the arrangements in place. No recommendations for action/improvement were made. The report is attached at Appendix 1. 2.2 Actions that support development of 2018/19 BAF The BAF provides a comprehensive method for the effective management of the potential risks that may prevent achievement of the key aims agreed by the Board of Directors. In order to present the first BAF for 2018/19, the following action has been taken:

Development and approval of the Corporate Objectives for the Trust for 2018/19 (including detailed consideration by a Board Task & Finish Group)

The impact of not achieving any Corporate Objective on the Trust’s Strategy was assessed in order to identify those risks with the most significant impact which should be included on and managed via the BAF or Corporate Risk Register (CRR)

The Board of Directors reviewed potential risks that had not been closed as at the end of March 2018 and agreed carry forward relevant to the strategy for 2018/19

New potential risks associated with achievement of the 2018/19 objectives have been identified During 2017/18, detailed consideration was given to the introduction of risk appetite into the Trust’s risk management arrangements to further enhance the systems that have been established. A proposal for implementation during 2018/19 has been agreed by the Board of Directors that will be implemented in shadow form first (via Board Development Sessions) to fully test the concept and have more detailed discussion prior to a final decision being made regarding roll-out. 2.3 Outcome of impact rating of the Corporate Objectives 2018/19 In line with the approved EPUT Risk Management and Assurance Framework the Board, at its Development Session in March, considered the impact assessment of all Corporate Objectives in order to define those risks to be escalated to the BAF or CRR. Any Corporate Objective that was assessed to have a HIGH (amber) or EXTREME (red) impact if not achieved forms the basis of the BAF and associated potential risks will be monitored by the Board of Directors. Any Corporate Objective assessed as having a MEDIUM (yellow) or LOW (green) impact if not achieved forms the basis of the CRR and associated risks will be monitored by the EOSC.

2

It is therefore proposed that the objectives that have the greatest impact on the Trust’s strategy if not achieved are:

Provide services that are compliant with our regulators

Deliver the Trust’s quality priorities

Have an estate that is fit for purpose

Complete planned ligature works

Engage with our workforce to embed an open and learning culture

Achieve contract targets

Have a highly trained workforce

Improve patient experience

Deliver the Trust’s financial plan for 2018/19

Participate as a partner in the STPs

Transform services Potential risks to achieving these objectives will be recorded on the BAF during 2018/19. The remaining three Corporate Objectives will form the basis of the CRR. 2.4 Risks closed as at 31 March 2018 The following risks were closed as at year end:

If the level of additional funding agreed with commissioners is not sufficient and/or model required by SW CCGs does not meet RCP criteria for a NICE compliant service the Trust may not be able to achieve the NHSI early intervention in psychosis service access target

If the disaggregation of Bedfordshire Community Services is not planned and delivered adequately, continuity of patient care, quality of services and financial sustainability could be impacted during transition and in future periods

If adequate preparatory action is not taken in 17/18 the ability to implement a new mental health clinical model in 2018/19 could be jeopardised

3.0 INITIAL BOARD ASSURANCE FRAMEWORK SUMMARY

The full Board Assurance Framework will be presented for Q1 in June 2018. Table 1 presents current risks, carried forward from 2017/18 Table 1 – BAF 2018/19 Summary of Risks carried forward from 2017/18 Note: Risk coding has changed from April 2018 (former risk reference in brackets). New wording included for Strategic and Corporate Objectives as agreed for 2018/19

Code Real Risk Exec Lead

Overview Update Risk scoring status (Consequence x Likelihood)

Action Plan Overview & Scrutiny/ Date

Strategic Objective 1: Continuously improve patient safety, experience and outcomes

Corporate Objective 1: Provide services that are compliant with our regulators

BAF1 (R1)

If services fall short of the standards required to remain compliant with the Health and Social Care Act there is the potential for CQC enforcement action

NL Enable East has commenced with checks against the CQC focused inspection action plans

Support sessions are now being delivered at key location sites linked to the Communications Plan

Current risk scoring 5 x 4 = 20

Risk scoring is unchanged

Quality Committee 15 March 18

3




or in extreme cases closure of services.

Analysis of information submitted as part of the CQC provider information request is still in progress

BAF2 (R4)

If the Trust fails to have consistent good governance arrangements in place this could impact upon care quality and the ability to achieve a GOOD CQC rating.

NL Internal audits undertaken in March resulted in substantial assurance for Board Assurance and Risk Management, and no recommendations for the Corporate Governance Statement. An opinion for the latter was not given due to the timing of the audit in relation to the self-certification process

A comprehensive Board Development Session took place in March covering risk appetite in relation to the impact on Trust Strategy if corporate objectives are not achieved



Finance and Perfor-mance Committee 22 March

BAF 3 (R24)

If the Trust is not adequately prepared it could be subject to a cyber-attack that compromises clinical or corporate IT systems

MM The new cyber security team is now in place and work has begun on bringing Trust systems up-to-date, which will include the deployment of software patches, ensuring anti-virus (and other security related tools) are installed and up-to-date and advising on changes to Trust policies

The new team will minimize the risk by endeavouring to ensure all systems are protected against the latest cyber threats and the Trust complies with NHS Digital and best practice recommendations

Current Risk Score 5 x 3 = 15



BAF 4 (R26)

If fire safety systems and processes are not suitable and sufficient there is a potential risk of injury or death to patients, staff and visitors, and that enforcement action could be taken by the Fire Authority in the form or restrictions, forced closure of premises, fines, and prosecution/ custodial sentencing

MM A number of actions have turned green this month, however there are still a number of actions in progress and some overdue

Funding has been approved and instruction to proceed with remaining Fire Risk Assessments has been issued to contractor to be completed by end April

Evacuation aids to be delivered to sites by end April. Initial training completed with ongoing training provided in mandatory training sessions

Current Risk Score 5 x 4 = 20

Risk scoring unchanged


4




for ‘Responsible’ persons

Fire training strategy has been approved and implemented with effect from 1

st April. Compliance

statistics are expected to be low initially but additional training provision will be provided where required

BAF 5 (R14)

If the Trust has vacancy rates in excess of benchmark target of 10%, particularly in in-patient environments, the quality of patient care could be impacted as a result of requiring temporary staffing.

NL An e-app around benefits and rewards is being developed for introduction in 2018/19

Benefits are now available through staff ESR portal on the Total Rewards System

Meetings are taking place with Managers that have high vacancy rates to offer additional support and recruitment plans being developed

Social media advertising and Open Days.

Retention Action Plan in place


Risk scoring recommended to increase to 4 x 4 = 16


Corporate Objective 2: Deliver the Trust’s quality priorities

BAF 6 (R6)

If learning from incidents is not embedded quality and patient safety may not be maintained or improved.

NH The timeline has been extended to July 2018 for receipt of the feedback and findings from the NCI relating to independent reviews




BAF 7 (R7)

If the Trust fails to provide strong clinical leadership to support staff and promote learning this will impact upon the quality of patient care and the reduction of serious incidents

NH Always event pathways now in place

A paper was presented to EOSC 10 April on developing a future Quality Improvement Strategy Model

Quality Improvement Hubs are now in place across Forensic services




BAF 8 (R11)

If the Trust does not have systems in place to monitor and provide assurance that it complies with its own Seclusion and Long Term Segregation policy and procedures the trust may breach the Mental Health Act.

AB An update on the seclusion policy implementation plan is reported to Clinical Governance and Quality Committee



Mental Health Act and Safe-guarding Committee 20 March

BAF 9 (R12)

If action being taken is not having an impact on the number of restraints

AB Action plan to be reviewed and revised to reflect “No Force First” ambition identified as a Quality

Current risk scoring 4 x 4 =



5




(particularly prone restraint) the Trust will need to consider whether there are gaps in plans in place.

Priority dor 18/19

16

Corporate Objective 3: Have an estate that is fit for purpose

No risks carried forward

Corporate Objective 4: Complete planned ligature works

BAF 10 (R3)

If the Trust fails to provide high quality services from premises that are safe, then the risk related to ligatures is not minimised and this may impact on the safety of patients in inpatient services.

NL/ MM/AB

Priority environmental actions completed with exception of DTA installation across south Essex estate (planned for completion in Q1)

Tool revised, tested and roll out started

Policy will be approved by end of April 2018

Ligature awareness training launched in April 2018

Risk assessments of community and A&E locations underway




Strategic Objective 2: Attract, develop, enable and retain high performers

Corporate Objective 7: Have a highly trained workforce


Strategic Objective 3: Achieve top 25% performance

Corporate Objective 6: Achieve contract targets


Corporate Objective 9: Deliver the Trust’s financial plan for 2018/19

BAF 11 (R16)

If in-patient activity levels exceed funded (commissioned) capacity, the Trust will not be able to meet its statutory financial duties.

AB Out of area activity reduced in Q4 compared to Q3.

It is anticipated that the new assessment unit in north Essex will open in May 2018

A new risk is suggested around bed capacity (quality of service), see table 3




BAF 12 (R19)

If the assumed reduction in agency spend is only partially achieved this may impact on the financial position of the Trust.

NL Work is continuing with Managers to identify reasons for high agency spend where they are not already part of the agency usage top 20 action plans.

Some revised dates have been added for some of the newer actions relating to cross-checking of information with finance invoicing, work with managers on long-term agency use, and areas not placing agency shifts on




6




temporary staffing systems

Further actions completed include the identification of all long-term agency workers; liaison with management and agency workers/agencies to move over to bank or other relevant employment status; and setting up a system to identify long-term agency workers going forward

BAF 13 (R23)

If services are unable to identify efficiencies through CIPs then the organisation will not be financial sustainable.

MM Draft CIP targets allocated to Directors

Draft CIP schedules produced

QIAs still outstanding Currently a £1m gap

between CIPs allocated and financial gap.

Final CIP target will be available after and year end accounts completed final contracts

March 18 risk scoring 4 x 2 = 8

Risk scoring recommended to increase to reflect Month 1 of new financial year 4 x 4 = 16


Strategic Objective 4: Co-design and co-produce service improvement plans

Corporate Objective 10: Participate as a partner in the STPs

BAF 14 (R25)

There is a potential risk to EPUT’s sustainability in light of developments taking place in STPs and particularly the creation of Integrated Care Systems, Integrated Care Alliances or Organisations

MMc The Board agreed on a corporate objective 10 as iterated above

There is no certainty at present as the way forward has not been set out by the STPs

The Trust may need to prepare for conflict either as a sovereign organisation or as a partner




Table 2 - BAF Risks scoring by month from April 18 to March 19 Note arrows indicate movement from March 2018 not from April 2017

Initial

Risk (17/18)

Apr 2018

May 2018

Jun 2018

Jul 2018

Aug 2018

Sep 2018

Oct 2018

Nov 2018

Dec 2018

Jan 2019

Feb 2019

Mar 2019

BAF1 (R1) 20 20↔

BAF2 (R4) 12 12↔

BAF3 (R24) 12 15↔

BAF4 (R26) 15 20↔

BAF5 (R14) 12 16↑

BAF6 (R6) 12 12↔

BAF7 (R7) 12 12↔

BAF8 (R11) 12 12↔

BAF9 (R12) 16 16↔

BAF10 (R3) 12 20↔

7

Initial Risk (17/18)

Apr 2018

May 2018

Jun 2018

Jul 2018

Aug 2018

Sep 2018

Oct 2018

Nov 2018

Dec 2018

Jan 2019

Feb 2019

Mar 2019

BAF11 (R16) 12 12↔

BAF12 (R19) 12 16↔

BAF13 (R23) 16 16↑

BAF14 (R25) 12 9↓

4.0 BAF Action Plans

In the light of this being the first report for 2018/19 together with the changes detailed and suggested above all existing action plans for risks carried forward are currently being reviewed to reflect the position as at April 2018.

5.0 New Potential Risks for Escalation to BAF/CRR

The Board is asked to consider and agree the following potential risks (and scores) for escalation to the BAF 2018/19: 5.1 Strategic Objective 1: Continuously improve patient safety, experience and outcomes


BAF Risk: If the HSE investigations into the actions taken by former NEP in respect of patient safety identify failings in the systems in place prior to merger this could result in prosecutions and/or fines being imposed on EPUT impacting on financial sustainability and reputation. C5 x L3 =15

5.2 Strategic Objective 1: Continuously improve patient safety, experience and outcomes

Corporate Objective 3: Have an estate that is fit for purpose

BAF Risk: If the Trust does not take account of current and emerging guidance relating to dormitory accommodation, single sex accommodation, and the size of wards, then this could impact on privacy and dignity, patient safety and quality and compliance with CQC standards. C4 x L3 =12

5.3 Strategic Objective 2: Attract, develop, enable and retain high performers

Corporate Objective 7: Have a highly trained workforce

BAF Risk: If the Trust does not resolve recording of training issues then mandatory training may be affected impacting on compliance, service delivery and contractual obligations. C4 x L2 = 8

5.4 Strategic Objective 3: Achieve Top 25% Performance

Corporate Objective 9: Deliver the Trust’s Financial Plan for 2018/19

BAF Risk (suggested by Finance and Performance Committee March 18): If the 2018/19 pay award is not fully funded via the tariff inflator in the contract with Commissioners then there will be a cost pressure on budgets impacting on financial sustainability C4 x L3 = 12



BAF Risk: If there is insufficient adult mental health bed capacity this may lead to continued bed occupancy levels above 85% and high numbers of out of area placements which may impact on the quality and effectiveness of service delivered C4 x L3 = 12

5.6 Strategic Objective 4: Co-design and co-produce service improvement plans

Corporate Objective 11: Transform Services

BAF Risk If the Trust does not implement the Transforming Services agenda in mental health in line with the milestones agreed for year 2 then patients may not receive the best care impacting on service delivery, contracting, reputation and financial sustainability. C5 x L3= 15

8



BAF Risk: (suggested by Finance and performance Committee April 18) If in-patient shifts are not filled consistently to a minimum of 90% on every ward, patient care, staff morale and compliance with CQC regulations could be adversely impacted. C5 x L3= 15

6.0 Continued Development of Risk Management and Assurance Arrangements

A review of the Corporate Risk Register is taking place in order to develop the 2018/19 version. This includes updating the Corporate Objectives specific to the CRR, which will be:

Engage with our workforce to embed an open and learning culture

Improve patient experience

Transform services The full Corporate Risk Register will be presented for Q1 in June 2018. Directorate Risk Registers are currently being transferred to the new 2018/19 risk register template with a revised coding system and rewording where appropriate. This is being carried out in conjunction with the regular review process through senior managers and Service Management Teams.

Tailored coaching cards have been developed for each Service Management Team and circulated with agenda papers. At the Board Development Session in March 2018, it was suggested that to reflect the importance of the consideration of risks to the organisation that any Agenda items relating to the Board Assurance Framework and Risk Registers should be moved to a priority point on the Agenda of the Board, EOSC, Standing Committees, and Service Management Teams. A revised guide will be issued to enable completion of Board and Committee cover sheets for 2018/19. At the Finance and Performance Committee 19 April 2018, it was agreed that quality and performance “hotspots” should also be considered as potential risks and reflected on the appropriate risk register going forward. All hotspots relating to March 2018 performance were reviewed at the committee meeting. An additional BAF risk relating to shift fill rates was recommended (see 5.7 above) as a result.

Recommendations

The Board of Directors is recommended to: 1. Note the development of the Board Assurance Framework for 2018/19; including the receipt of positive

assurance from the Trust’s Internal auditors (Appendix 1) 2. Agree the impact assessment/rating of 2018/19 Corporate Objectives (and allocation to BAF or CRR

as set out in section 2.3) 3. Confirm the risks identified as at April 2018 (in Table 1), the proposed risk scores and the action being

taken to mitigate them 4. Consider and agree the new risks for 2018/19 (Section 5) for escalation to the BAF 5. Identify any further risks for escalation to the BAF or risk registers.

Prepared by: Susan Barry, Head of Assurance On behalf of:

Nigel Leonard, Executive Director of Corporate Governance & Strategy

Report to:

Final Internal Audit Report Board Assurance Framework and Risk Management March 2018

Priority 1 Recommendations 0

Priority 2 Recommendations Priority 3 Recommendations

0 0

Essex Partnership University NHS Foundation Trust

2

Introduction ........................................................................................................................................ 3

Background ....................................................................................................................................... 3

Key Findings ..................................................................................................................................... 4

Opinion and Direction of Travel ..................................................................................................... 5

Detailed Findings .............................................................................................................................. 6

Recommendations ........................................................................................................................... 9

Appendix 1 – Summary of Terms of Reference ........................................................................ 10

Appendix 2 – Definitions of Assurance ....................................................................................... 11

Appendix 3 – Staff Consulted ....................................................................................................... 12

Appendix 4 – Audit Timetable and KPIs ..................................................................................... 13

Appendix 5 – Satisfaction Survey ................................................................................................ 14

Appendix 6 – Statement of Responsibility .................................................................................. 16

Status of our reports

This report (“Report”) was prepared on the basis of the limitations set out in Appendix 6 by Mazars LLP at the request of Essex Partnership University NHS Foundation Trust (the Trust / EPUT).and terms for the preparation and scope of the Report have been agreed with them. The matters raised in this Report are only those which came to our attention during our internal audit work. Whilst every care has been taken to ensure that the information provided in this Report is as accurate as possible, Internal Audit have only been able to base findings on the information and documentation provided and consequently no complete guarantee can be given that this Report is necessarily a comprehensive statement of all the weaknesses that exist, or of all the improvements that may be required.

Contents


3

This internal audit forms part of the agreement between Mazars LLP and Essex Partnership University NHS Foundation Trust (the Trust / EPUT). The report details the results of the internal audit of the Board Assurance Framework and Risk Management and has been undertaken in accordance with the approved Internal Audit Plan for 2017/18 (“Plan”). The audit has been included in the Plan due to the related risk that, without an embedded assurance framework, the organisation may not meet its objectives. There is also the possibility that risks may not be identified and managed effectively. This audit work is a core component which contributes to our annual Head of Internal Audit Opinion. Our audit approach and a summary of the work undertaken are provided in the Summary of Terms of Reference in Appendix 1.

Note: the findings within this report should also be read in conjunction with the separate audit report

produced in respect of the Corporate Governance Statement 2017-18.

The Chief Executive of the Trust has a statutory responsibility as the Accountable Officer to prepare an Annual Governance Statement (AGS). NHS organisations are required to support their AGS through a Board Assurance Framework (BAF).

The BAF is a statutory requirement. It incorporates a register of the highest risks faced by the Trust in meeting its principal objectives; this aims to provide the Trust with a simple but comprehensive method of describing the organisation’s objectives, identifying the key risks to their achievement and

the gaps in assurances on which the Board relies in agreeing action plans.

Risk management is a framework for the systematic identification, assessment, treatment and management of risks. Its purpose is to prevent or minimise the possibility of recurrence of risks and their associated consequences.

The Trust should have a Risk Management Framework which documents the Trust’s approach to the

management of risk and implementation of a system, which aims to enable informed management decisions in the identification, assessment, treatment and monitoring of risk. The Risk Management Framework should support the achievement of its principal objectives by minimising the risks that threaten them.

Introduction

Background


4

Areas of good practice / compliance identified during this audit.

Based on our audit testing:

A reporting structure has been created which details how reporting is to be carried out within the Trust's governance structure;

The merged Trust has established a BAF which sets out its key risks and how these are to be managed. A Corporate Risk Register (CRR) is also in place;

The BAF and CRR are aligned to the Trust’s corporate and strategic objectives;

The BAF and CRR are reviewed by the Executive Operational Sub Committee (EOSC) and Board on a monthly and quarterly basis respectively. Our review of the meeting minutes of both the EOSC and the Board in 2017 up to January 2018 verified this;

Directorate Risk Registers (DRR) are maintained by each Directorate and linked to Trust objectives / Care Quality Commission (CQC) outcomes - this facilitates an inherent escalation process of risk from an operational to a corporate level as required;

The Trust has adopted a new process for review of the DRR with these to be reviewed at meetings of the EOSC monthly, on a rotational basis. This commenced in January 2018 and was evidenced in our review of the EOSC minutes for this meeting;

Documented governance structures have been created for the Directorates within the Trust to help provide clear lines of responsibility in respect of risk management;

The Trust has developed a Risk Management and Assurance Framework document which has been reported to and signed-off by the Trust Board;

Job descriptions created for key officers within the Trust state specific responsibilities for risk management;

Training is provided to the Trust Board in identifying and managing risk at Board Development sessions (sessions evidenced March 2017, June, July and December 2017);

Details of the risk management process are included in the Risk Management and Assurance Framework and the process for escalation of risks between Service Management Teams, the EOSC, Board Standing Committees and the Board of Directors is clearly detailed;

All DRRs are updated locally by the Directorate Senior Management Team (SMT) meetings as confirmed from reviewing the last three minutes of SMT meeting for five directorates;

The Head of Assurance meets with Executive Directors and/or their direct reports/Associate Directors to monitor and discuss risks on a monthly basis (to help embed a risk management culture); and

A report is presented to the Health Safety and Security Committee (HSSC) on risk management at its monthly meetings, as confirmed from our review of HSSC minutes in November 2017, December 2017 and January 2018.

Issues identified as a result of our work.

No issues have been identified from our testing during this audit.

Key Findings


5

We categorise our opinions according to the assessment of the controls in place and the level of compliance with those controls.

Rationale Supporting Award of Opinion

The audit work carried out by Internal Audit (the scope of which is detailed in Appendix 1) indicated that: There are sound systems of internal controls designed of achieve the Trust’s objectives. The control procedures tested are being consistently applied.

Direction of Travel

This is the first audit of this area at EPUT but the Direction of Travel is unchanged since the last audit report in 2016/17 (conducted for SEPT).

Opinion and Direction of Travel


6

Assurance Framework

A Committee reporting structure has been created that provides a map of how reporting is to be provided to the Board and its sub committees on risk management and assurance throughout the financial year.

The Trust maintains a BAF and a CRR which contains the extreme and high level risks faced by the Trist in achieving its strategic and corporate objectives. A Lead Executive Director has been allocated to each risk and information has been provided within these about the mitigating controls, target completion dates (for any controls yet to be in place), and any gaps in controls and assurance for each risk.

Information is also included about the scoring of each risk and the direction of risk scores i.e. whether scores are improving, deteriorating or remaining the same.

Reports on the BAF are presented to the EOSC throughout the year. A summary report on the BAF is also presented to the Board on a monthly basis by the Executive Director of Corporate Governance and Strategy. The reports presented throughout the period to January 2018 were reviewed and it was confirmed that these included a review of risks and the progress made in managing risks.

Examination of the CRR as at January 2018 identified that similar information to that included in the BAF was included in the CRR (see further in the reporting section).

We identified, through walkthrough with the Head of Assurance that action plans have been developed to address the risks on the BAF and these are monitored quarterly by the four Trust Standing Committees i.e. Quality, Finance and Performance, Mental Health and Safeguarding and Investment.

The last three quarterly reports, together with minutes, were made available for each sub-committee. Each report included a summary section which provided an overview of the risks and the status of the actions being managed by that committee. A more detailed section was then included which provided further information on each action and the progress made in completing them.

Risk Management Strategy, Policy and Procedures

A Risk Management and Assurance Framework document has been developed for the Trust. The Framework came into effect in April 2017 and is due to be reviewed again in April 2018. The Framework describes the Trust’s approach to the management of risk and the implementation of a system which enables informed management decisions in the identification, assessment, treatment and monitoring of risk (covering the tools referred to above re the BAF, CRR, DRR etc.). It reflects NHS Improvement’s Well-Led Framework, Code of Governance and Department of Health requirements and guidance. The Framework makes reference to the Trust’s Policies and Procedures and how these help to provide assurance over risk management.

The roles, responsibilities, and accountability arrangements for managing risk have been defined within the Risk Management Framework, including the key officers and committees (covering duties of operational staff up to the Chief Executive).

Detailed Findings

A Risk Management and Assurance Framework has been developed

The Trust has in place a Board Assurance Framework and a Corporate Risk Register (CRR) which are regularly reviewed.


7

In addition, job descriptions have been created for the Executive Directors and other officers, with responsibilities for risk management included therein. This was confirmed from reviewing the job descriptions for the Executive Director of Finance and Resources, Executive Director of Corporate Governance, the Executive Nurse as well as for the Director of Compliance and Assurance and the Head of Assurance.

DRRs are maintained by each of the Trust’s Directorates and are linked to the Trust objectives and CQC quality outcomes. The latest available DRR for all seven Directorates (Excel format) were made available and our review identified that the DRRs were in a similar format to the BAF and CRR, with information provided about the risk sources, assumptions made, risk scores, mitigating actions, target dates for completion of actions, gaps in controls and assurances and information about when each risk was last reviewed.

The DRRs are presented to SMT meetings monthly (for review), which we confirmed through our examination of the last three sets of minutes for a sample of five directorates i.e. the Medical, Clinical Governance, Community Health, Mental Health and Health Safety and Security Committee (HSSC) Directorates.

Discussions with the Head of Assurance identified that DRRs are also submitted to EOSC meetings, at a rate of one per month, as part of the monthly reporting process (see further details in the Reporting section below). The intention of this is to help enable consistency of risk assessment across localised areas and therefore better inform any required escalation of risks to a corporate level (if required).

Training

Training on risk management is provided to the Trust Board members at Board Development Sessions. Papers for the Board Development Session held in March 2017 (just prior to the merger) were made available to us. This session was part of an extraordinary Board meeting and was presented by the Executive Director of Corporate Governance. It included training on the corporate objectives and the vision of the Trust as well as the risks facing their achievement. The risks on the risk registers of the former SEPT and NEP, and how these would form the basis for the EPUT BAF/CRR, were discussed at this meeting. It was confirmed that further Board Development sessions were held in June, July and December 2017 to discuss various areas of risk management including risk appetite and how to formulate appropriate actions for the management of risks.

The Board is scheduled to receive its next training on risk management in March 2018.

Attendance records were also provided in relation to the Board Development sessions and we confirmed that the Executive Directors were in attendance at these sessions.

Discussions with the Head of Assurance identified that staff training is reported to and monitored at the HSSC. Examination of the HSSC minutes in November 2017, December 2017 and January 2018 identified that mandatory training was discussed at each meeting. There is no specific training module on corporate risk management but managers are required to ensure that their staff attend appropriate risk related training, that risk assessments are carried out, and actively promote the upward reporting of all incidents and near misses. At the time of finalising this audit report, the Head of Assurance further advised that a coaching card has been developed on risk registers and presented to the Senior Leadership Team on 14 March 2018. A module on risk registers is to be incorporated into the Health and Safety for Managers Training.

Risk Registers, including links to the Assurance Framework

The Trust operates an escalation process depending on the level of risk identified, that determines whether risks can be managed at Directorate (local) level i.e. low and moderate risks, or need to be escalated to Trust level (BAF/CRR).

A process is in place for the escalation of risks depending on the level/category of risk

Training is provided to Board members at Board Development Sessions.


8

Details of the risk management process is included within the Risk Management and Assurance Framework, including a detailed flowchart that shows the relationship between risk assessment and escalation between SMTs, the EOSC, the Board Standing Committees and the Board of Directors. Risks rated at 10 or above are considered for escalation to the Corporate Risk Register or BAF by the EOSC.

Discussions with the Head of Assurance identified that further work will be undertaken during the year to review risks on existing DRRs from both the North and South localities and to ensure that a consistent approach is being taken to risk scoring and escalation.

Risk Management Structure and Framework

The Risk Management and Assurance Framework documents the process for developing, maintaining and monitoring risk registers including the BAF, CRR and DRRs. It provides guidance for staff involved in the process regarding the categorisation of risk and the monitoring arrangements related to each type of register.

The Head of Assurance discusses the DRRs with the Executive Directors on a monthly basis. Minutes are not taken at these meetings but any discussions are annotated on a printed copy of each Directorate's DRR and used to make changes to the next iteration of the document. Emails exchanged between the Head of Assurance and Executive Directors discussing directorate risks and calendar invites of planned meetings were made available as evidence of these meetings.

We identified from reviewing the BAF, CRR and DRRs that controls to mitigate the causes of all risks included on these registers have been defined and are linked to the Trust’s strategic and corporate objectives for 2017/18. Gaps in assurance and the actions to mitigate these gaps have also been detailed.

Reporting Framework

Discussions with the Head of Assurance identified that a rolling programme of DRRs are presented to each EOSC meetings (except quarterly meetings). We identified from the minutes of the EOSC in January 2018 that the Medical DRR prepared by the Executive Lead and Medical Director was presented. This was the first DRR presented to the EOSC.

The BAF and CRR are reported into the EOSC on a monthly basis. On a quarterly basis the full BAF and CRR are reported, together with the BAF action plans as identified in area one (Assurance Framework) above.

Examination of the minutes of the EOSC in December 2017 identified that the BAF and CRR were presented in full (quarterly presentation).

We confirmed that the Trust Board received a summary report on the BAF at its monthly meetings during the year. The Board also

received the full BAF at its last quarterly meeting in January 2018.

A Risk Management report is presented to the HSSC at its meetings. The purpose of this report is to provide the HSSC with an update in relation to the monitoring and management of risks within the Trust. We confirmed that the HSSC received this report at its last three meetings in November and December 2017 and January 2018, and it was also on the agenda for the February 2018 HSSC meeting.

Acknowledgement

We would like to thank the management and staff involved in the internal audit work for their co-operation and assistance during the audit.

The Head of Assurance discusses the DRRs with the Executive Directors on a monthly basis

There is a reporting framework which includes reporting to the HSSC, SMTs, EOSC and Trust Board on a regular basis.


9

No recommendations have been raised. Adequacy and Effectiveness Assessments

Adequacy and Effectiveness Assessments

Please note that adequacy and effectiveness are not connected. The adequacy assessment is made prior to the control effectiveness being tested.

The controls may be adequate but not operating effectively, or they may be partly adequate / inadequate and yet those that are in place may be operating effectively.

In general, partly adequate / inadequate controls can be considered to be of greater significance than when adequate controls are in place but not operating fully effectively - i.e. control gaps are a bigger issue than controls not being fully complied with.

Adequacy Effectiveness

G Existing controls are adequate to manage the risks in this area

Operation of existing controls is effective

A Existing controls are partly adequate to manage the risks in this area

Operation of existing controls is partly effective

R Existing controls are inadequate to manage the risks in this area

Operation of existing controls is ineffective

Area of Scope Adequacy of Controls

Effectiveness of Controls

Recommendations Priority

1 2 3

Assurance Framework G G

0 0 0

Risk Management Strategy, Policy and Procedures

G G

0 0 0

Training

G G

0 0 0

Risk Registers, including links to the Assurance Framework

G G 0 0 0

Risk Management Structure and Framework

G G

0 0 0

Reporting Framework G G

0 0 0

Recommendations


10

Audit Objectives

The audit was designed to assess whether management have implemented adequate and effective controls relating to the Board Assurance Framework and Risk Management.

Audit Approach and Methodology

The audit approach was developed with reference to the Internal Audit Manual and by an assessment of risks and management controls operating within each area of the scope.

The following procedures were adopted:

Identification of the role and objectives of each area; Identification of risks within the systems, and controls in existence to allow the control objectives to

be achieved; Evaluation and testing of controls within the systems though visits to locations where records are

kept; Interview of staff involved in systems at the locations visited; and Inspection/Review of relevant records including policies and procedures.

From these procedures, where we have identified weaknesses in the systems of control, we have produced specific proposals to improve the control environment and have drawn an overall conclusion on the design and operation of the system.

Areas Covered

Audit work was undertaken to establish the following:

Systems and processes for embedding and maintaining the assurance framework, including governance structures, monitoring and reporting are in place;

The risk management arrangements form part of the Trust's strategy, and policy and procedures are embedded within the Trust;

Staff receive a level of training appropriate to their individual responsibilities relating to the assurance framework and risk management and a record is made of all training received;

There is an ongoing review process for the corporate risk register, to identify and address all risks that the Trust is exposed to, and that this process has been formally embedded in regular and routine management processes;

The appropriateness of the present risk management structure as a framework, including the directorate risk registers devised and maintained, is effective in practice; and

A reporting framework to monitor risks and risk management is established and is working effectively.

Appendix 1 – Summary of Terms of Reference


11

Assurance Gradings

We have four categories by which we classify internal audit assurance over the processes we examine, and these are defined as follows:

Recommendation Gradings

In order to assist management in using our internal audit reports, we categorise our recommendations according to their level of priority as follows:

Appendix 2 – Definitions of Assurance


12

Staff Consulted

Susan Barry

Faye Swanson

Cathy Lilley

Head of Assurance

Director of Compliance and Assurance

Trust Secretary

Draft Report Distribution

Susan Barry

Faye Swanson

Head of Assurance

Director of Compliance and Assurance

Audit Team

Graeme Clarke

Stuart Coogan

Sammy Olugboji

Key contact for this audit will be:

Stuart Coogan

[email protected]

07887 954584

Director

Engagement Manager

Audit Manager (Auditor)

Final Report Distribution

All of the above

Nigel Leonard - Executive Director of Corporate Governance

Appendix 3 – Staff Consulted


13

Dates Target KPI Days Taken

Planning meeting 13/12/2017

Fieldwork start 08/02/2018

Fieldwork completion 05/03/2018

Exit meeting 05/03/2018

Draft report issued to the CCG 20/03/2018 15 Days 11 Days

Management response received 21/03/2018 15 Days 1 Day

Percentage of recommendations accepted N/A

Appendix 4 – Audit Timetable and KPIs


14

Audit:

Board Assurance Framework and Risk Management

Guidance

For us to continuously improve our internal audit and risk management services, it is vital to obtain feedback from you on various aspects of the service. Please answer the following questions and mark your score using the scale below. If you have any other comments on our service please note these on the second page.

Scale

5 Very Good

4 Good

3 Satisfactory

2 Poor

1 Very Poor

Please ensure that if you score 2 or 1 you supply us with details to help us to improve our service.

Score

Very

Goo

d 5

Goo

d 4

Satis

fact

ory

3

Poor

2

Very

Poo

r 1

Team

Did the team demonstrate knowledge and understanding of the area being audited and the current issues?

☐ ☐ ☐ ☐ ☐

Did the team present a professional manner in their dealings with you? ☐ ☐ ☐ ☐ ☐ Communications

Did the team communicate in a clear manner? ☐ ☐ ☐ ☐ ☐

Were you given sufficient time before the audit commenced to review and provide input to the scope and objectives of the audit?

☐ ☐ ☐ ☐ ☐

Was the team responsive to verbal, telephone or written requests? ☐ ☐ ☐ ☐ ☐ Deliverables

Appendix 5 – Satisfaction Survey


15

Score

Very

Goo

d 5

Goo

d 4

Satis

fact

ory

3

Poor

2

Very

Poo

r 1

Did you agree with the validity of the points made in the report and the recommendations? ☐ ☐ ☐ ☐ ☐ Did you agree with the priority rating given to the recommendations made in the report? ☐ ☐ ☐ ☐ ☐ Were the audit report and recommendations communicated in a clear manner? ☐ ☐ ☐ ☐ ☐ Were you given adequate notification of the audit? ☐ ☐ ☐ ☐ ☐

Was the report issued on a timely basis? ☐ ☐ ☐ ☐ ☐ Value

Do you feel you were the appropriate person to be involved in the audit? If not who do you think should have been involved?

☐ ☐ ☐ ☐ ☐ Do you think the audit achieved its purpose? If not what would you have changed? ☐ ☐ ☐ ☐ ☐ Did you feel confident about the audit process or do you think some additional training would be of benefit?

☐ ☐ ☐ ☐ ☐ Other comments


16

We take responsibility to Essex Partnership University NHS Foundation Trust for this report which is prepared on the basis of the limitations set out below.

The responsibility for designing and maintaining a sound system of internal control and the prevention and detection of fraud and other irregularities rests with management, with internal audit providing a service to management to enable them to achieve this objective. Specifically, we assess the adequacy and effectiveness of the system of internal control arrangements implemented by management and perform sample testing on those controls in the period under review with a view to providing an opinion on the extent to which risks in this area are managed.

We plan our work in order to ensure that we have a reasonable expectation of detecting significant control weaknesses. However, our procedures alone should not be relied upon to identify all strengths and weaknesses in internal controls, nor relied upon to identify any circumstances of fraud or irregularity. Even sound systems of internal control can only provide reasonable and not absolute assurance and may not be proof against collusive fraud.

The matters raised in this report are only those which came to our attention during the course of our work and are not necessarily a comprehensive statement of all the weaknesses that exist or all improvements that might be made. Recommendations for improvements should be assessed by you for their full impact before they are implemented. The performance of our work is not and should not be taken as a substitute for management’s responsibilities for the application of sound management

practices.

This report is confidential and must not be disclosed to any third party or reproduced in whole or in part without our prior written consent. To the fullest extent permitted by law Mazars LLP accepts no responsibility and disclaims all liability to any third party who purports to use or rely for any reason whatsoever on the Report, its contents, conclusions, any extract, reinterpretation amendment and/or modification by any third party is entirely at their own risk.

Registered office: Tower Bridge House, St Katharine’s Way, London E1W 1DD, United Kingdom.

Registered in England and Wales No 0C308299

Appendix 6 – Statement of Responsibility

ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST

Agenda Item No: 6b(i)

SUMMARY REPORT

BOARD OF DIRECTORS PART I

25th April 2018

Report Title:

Finance & Performance Committee Assurance Report

Executive/Non-Executive Lead:

Alison Davis Chair of the Finance and Performance Committee Sally Morris Chief Executive Officer

Report Author(s): Janette Leonard Director of ITT, Business Analysis and Reporting

Report discussed previously at:

Level of Assurance:

Level 1 Level 2 Level 3


This report provides:

Assurance to the Board of Directors that the Finance and Performance Committee (FPC) is discharging its terms of reference and delegated responsibilities effectively, and that the risks that may affect the achievement of the Trust’s objective and impact on quality are being managed effectively.

Approval

Discussion

Information



1 Note the contents of the report 2 Confirm acceptance of assurance provided 3 Request any further information or action.


The Committee considered the following key issues: 2.Quality and Performance Report The committee noted that there were 7 hotspots and 8 emerging risks 3.Financial Position March 2018

The Trust’s draft continuing operating position at Month 12 is a deficit of £4,785k (excluding additional 16/17 and 17/18 incentive income STF income and technical adjustments) which is an improvement of £1,850k against the Trust’s plan.

Total income is £2,563k above plan and total expenditure is £1,094k above plan at Month 12.

This position provisional, and will be finalised following the year end Audit of the accounts.


4.Sub Committee Reports The committee received 3 sets of the Executive Operational Sub Committee part one minutes for noting: • 14 March 2018 • 20 March 2018 • 27 March 2018 5.Approval of Policies/Policy Harmonisation Report Update The following policy was approved by the Committee: • 18 Week Referral to Treatment Policy and Procedure Approval Policy Harmonisation Report for EPUT – Update The Director of Governance and Assurance updated the Committee on the current position with the Policy Harmonisation project. The position as at 13th April 2018 shows: 159 policies/guidelines have been ratified and implemented for Trust wide use (out of 187) 9 policies/guidelines are currently going through approval / ratification processes by end of April 2018. • (2 high risk, 5 medium risk and 2 low risk) 14 policies / guidelines are still outstanding • (5 high risk, 6 medium risk and 3 low risk) 5 policies have been given extensions to end of Q1 • (4 high risk, 1 medium risk and 0 low risk) The Committee noted the position as at the 13th April 2018. 6.Draft Audit Plan Update The Chief Finance Officer informed the committee that the draft Internal Audit Plan 2018/19 was presented to the Executive Operational Committee on the 10 April to discuss and recommend to the Audit Committee for approval. At the meeting held on the 10 April the Executive Operational Committee reviewed the proposed timetable over the next 3 years and subject to the following changes which have been incorporated within the attached revised report recommended that the draft Internal Audit Plan for 2018/19 is presented to the Audit Committee for approval. Key changes are:

Bank & Agency has moved to Year 1 and Rostering to Year 2

There was a review previously in the Plan titled ‘Risk Maturity and Corporate Governance’ at 25 days however this has been changed to cover Risk Maturity only and the days reduced to 15.

The spare 10 days have been allocated to a review around handovers where retiring Safeguarding and Senior MHA staff pass over responsibilities to new staff.

7.Workforce Transformation Update The Executive Director of Governance and Strategy updated the Committee on the current position with the Workforce transformation Plan and informed the committee that the Workforce Transformation Group had identified a list of key issues and actions had been


made in respect of these. The committee was pleased to note the reduction in sickness absence and the actions identified in the assurance report. 8.Annual Governance Development Plan including Risk Management Framework Update The Director of Compliance and Assurance updated the Committee on progress and provided revised action plans to support the progress. Listed below are the key areas to focus on: • Good progress has been made post-merger in establishing robust governance

arrangements in line with the priorities agreed by the FPC. • A “substantial assurance” opinion was issued by Mazars in respect of the Trust’s Risk Management and assurance arrangements. Slippage in progressing the Risk Management and Assurance Framework Implementation Plan reported earlier in the year has been recovered • The action plan to ensure implementation of recommendations made by Grant Thornton

has been largely delivered • The action plan to strengthen compliance with the CQC/NHSI Well Led Framework was

also nearly completed The Director of Compliance and Assurance also suggested that the Performance Hotspots should be aligned to the Board Assurance Framework (BAF) and that this should be discussed as part of the presentation of the performance report to the Executive Operational Committee. The Committee discussed the plans and requested that a task and finish group meet to discuss the areas identified and report back to the next meeting.

9.NHSI Self Certification

The Director of Compliance & Assurance provided a self-assessment of the current position to facilitate these discussions this included evidence of compliance, identification of any gaps, and a suggested confirmed/not confirmed statement based on the evidence and gaps.

The Committee considered and discussed in detail the evidence that supports positive assurance and potential gaps. It was agreed that further discussion was required outside of this meeting in order to reach agreement on the final recommendations to be considered at the main meeting.

10.Code of Governance Review

To support this the Trust’s Annual Report must include a statement as to how the Trust applies the Code and also confirm that the Trust ‘complies’ with the provisions, or if not, provide an explanation as to why it has departed from the Code.

The review process to establish compliance was in two stages:

• Self-assessment: A comprehensive review against of each Code provision

• Internal independent assessment: Council of Governors Governance Committee reviewed with invited NEDs the self-identified sample provisions across all five sections of the Code scrutinising the evidence and enabling NEDs to directly answer any queries.


Based on both the self-assessment and assurance from the Governance Committee, there is strong evidence that the Trust is compliant with all provisions in the Code with the exception of:

• Code Provision B.1.2: At least half the Board, excluding the Chairperson, should comprise NEDs determined by the Board to be independent

The Committee supported the Trusts compliance with the Code provisions with the exception statement in relation to provision B.1.2.

11.Patient Experience Framework

The Patient Experience Framework forms part of the Trust’s Engagement Strategy. The Engagement Strategy details a number of pledges to achieve the overall vision of ‘working to improve lives’. This framework seeks to show how the Trust will meet its pledges and detail how progress will be monitored. It will be continuously reviewed to ensure that it keeps up with the changing healthcare agenda and any changes in the population the Trust serves.

The Executive Director of Governance and Strategy presented the key service user engagement objectives and how we will measure the effectiveness of our actions and the associated action plan.

The Committee agreed supported the content of the action plan supporting the Framework with minor amendments.

12.Information Assurance Framework

The Director of IT, Business Analysis and Reporting informed the Committee that the information assurance framework has been developed in response to a KPMG recommendation following their last Governance review of the Trust.

The document presented helps to identify any potential gaps in data confidence and potentially define the internal audit program for data quality. It is not expected that all indicators will have full data confidence at any one time.

The Committee agreed that the Information Assurance Framework supported and gave assurance that data quality for key indicators was being routinely monitored across the Trust.

13.Merger Benefits Realisation Update

The Executive Director of Governance and Strategy updated the Committee on the current position. A draft paper has been written and discussed at the Executive Operational Sub Committee. The draft paper will be presented to the Board in April.

14.Cyber Security Update

The Director of IT, Business Analysis and Reporting informed the Committee that NHS Improvement (NHSI) has requested a position statement and sign off by Trust Board against the 10 cyber security control areas by the 11th May 2018. An assessment has taken place against each of the 10 controls.

The paper provided the committee with the current position against the 10 controls. EPUT is required to provide a return against fixed statements provided by NHSI in order to gauge our readiness position in response to cyberattacks.

The Committee was assured with the content of the current position against each of the 10 controls and supported submission back to NHSI.


15.Any risks or Issues Identified

There was one issue raised:

The Director of Compliance and Assurance asked that the action to align Performance Hotspots to the BAF be identified as a current issue until the new process is implemented to address this shortfall.

16.Any Other Business

The CEO reminded the Committee that at a recent Board meeting a suggestion had been made that Committees should also focus on positive aspects of their work.

As a result of these discussions the following was agreed:

• To add an agenda item to recognise improvements in performance to all Committee meetings

• To ensure that this is included in the assurance report to the Board

• Chairs of the Committees to email the team/individuals to invite/present their work at the Committees

• Invite staff to submit these quality improvements forward to the Quality Academy for a potential QI award.

Relationship to Trust Strategic Priorities



SP 3: Achieve 25% performance



1: Open

2: Compassionate

3: Empowering


Are any existing risks in the BAF affected?

If yes, insert relevant risk

Do you recommend a new entry to the BAF is made as a result of this report? NO



Data quality issues













None

Lead

Alison Davis Chair of Finance & Performance Committee

Agenda Item 6b(i)

Board of Directors Meeting Part 1 25th April 2018


FINANCE AND PERFORMANCE COMMITTEE ASSURANCE REPORT

1.0 Purpose of Report

This report is provided by the Chair of the Finance and Performance Committee to provide assurance to Board members that the performance operational, financial and governance as at Month 12, March 2018 were subject to appropriate and robust scrutiny. The Finance and Performance Committee (FPC) is constituted as a standing committee of the Board of Directors. The Board of Directors has delegated responsibility to this committee for the oversight and monitoring of the Trust’s financial, operational and organisational performance in accordance with the relevant legislation, national guidance, the Code of Governance and current best practice from 1 April 2017. The Committee is required to ensure that risks associated with the performance and governance arrangements of the Trust are brought to the attention of the Board of Directors and/or to provide assurance that these are being managed appropriately by the Executive Directors. The minutes of the meeting held on the 28th February 2018 were agreed as an accurate record.

2.0 Quality and Performance Report

The Chief Executive presented the committee with a summary of performance as at month 12, 2017/18 of the Essex Partnership NHS University Foundation Trust. Quality and performance headlines for March 2018 are listed below. The Chief Executive reported that the Trust had identified 7 hotspots and 8 emerging risks in month 12. The hotspots and emerging risks identified are monitored through various task and finish groups across the Trust and reported back to ET on a monthly basis. Below is a list of those hotspots and emerging risks: Hotspots 7 hotspots have been identified as a result of reviewing performance relating to March 2018 against agreed targets of which 2 are NHSI Key Indicators Single Oversight Framework (SOF). .

• Safer Staffing • Cardio Metabolic Assessment (SOF) • Proportion on CPA having a formal review within 12 months • Inpatient MH Capacity • Vacancy and Turnover Rates -Training/Supervision/Appraisals data is currently under

review and should be available as a verbal update to the Trust Board. (SOF) • Agency Breaches • Staff Survey The CEO informed the Committee that the Trust set itself a local target of 10% and to date has been unable to achieve this. The issues around vacancies are NHS wide and as a result of this the new benchmark has now been set at 17% for Mental Health Services and 8.3% for Community Health Services. This change reflects the issues all organisations are having with recruitment.


The CPA reviews currently include the number of patients currently on a standalone medical caseload being managed in outpatients, investigations show that these patients should have been changed to Non-CPA when transferred to the outpatient caseload and as a result the Medical Director has agreed that these patients records should be amended accordingly and the responsible Consultant informed. This administrative change will take place and the figures will be re-run as a result. The Medical Director informed the committee of the issues surrounding the collection of Cardio Metabolic Assessments and gave assurance that this area would be given a priority for improvement.

Emerging Risks 8 risks have been identified as a result of reviewing performance relating to March 2018 against agreed targets

• Incident Reporting Rate • No/Low Harm MH • Complaints • Patient FFT • Clients on Section 117 • Annual Physical Health Checks • Staff FFT • Discharge Summaries

It should be noted that all of the above emerging risks are being managed under various task and finish groups led by Senior Managers responsible for the performance in these areas. The committee noted the content of the report and were assured that both Hotspots and Emerging risks were being managed across the organisation.

3.0 Financial Performance Report

The Trust’s continuing operating position at Month 12 is a deficit of £4,785k (excluding £389k of 16/17 STF additional income, STF 17/18 incentive income of £2,495k and any technical adjustments) which is an improvement of £1,850k against the Trust’s plan. Total income is £2,563k above the revised plan at Month 12 (Month 11 adverse variance of £98k). Other non-patient related income favourable variance is largely due to N3 COIN and Estates and Facilities income. Total expenditure is £1,094k higher than the revised plan at Month 12. Cost Improvement Programme The total recurrent CIP target for the 2017/18 financial year was £11,980k which included £1,015k carried forward from the 2016/17 programme. As at Month 12 there was a total of £13,002k CIP schemes identified, meaning there is an overachievement of £1,022k against the planned target. Capital Plan at Month 12 As at the end of month 12, the Trust has spent £7,250k against a revised planned spend of £9,936k. The above variance is mainly as a result of slippages in some project completions such as the Derwent Centre works and the CQC works; final expenditure on some projects being lower than expected; and a final review of all capital expenditures leading to exclusions of any cost


that is determined to be revenue rather than capital expenditure, in line with the Trust’s capitalisation policy. Cash As at the end of the financial year, the cash is more than forecast by £6,465k. This is relates to the improved financial position, final capital underspend and movements on working capital balances. Use of Resources Rating

Until all year-end adjustments are complete, the risk rating may be subject to change, it is currently forecast to be a 2 before overrides, changing to a 3 after overrides in line with plan.

4.0 Sub-Committee Reports

The committee received 3 sets of the Executive Operational Sub Committee part one minutes for noting:

14 March 2018

20 March 2018

27 March 2018

5.0 Approval of Policies/ Policy Harmonisation Report for EPUT - Update

The Director of Governance and Assurance asked the committee to approve the following policy on the understanding that they had already been signed off by the Executive Operational Committee.

• 18 Week Referral to Treatment Policy and Procedure Approval

The Committee agreed to approve the above policy. Policy Harmonisation Report for EPUT – Update The Director of Governance and Assurance updated the Committee on the current position with the Policy Harmonisation project. The position as at 13th April 2018 shows: 159 policies/guidelines have been ratified and implemented for Trust wide use (out of 187) 9 policies/guidelines are currently going through approval / ratification processes by end of April 2018.

• (2 high risk, 5 medium risk and 2 low risk) 14 policies / guidelines are still outstanding

• (5 high risk, 6 medium risk and 3 low risk) 5 policies have been given extensions to end of Q1

• (4 high risk, 1 medium risk and 0 low risk) The Committee noted the position as at the 13th April 2018.


6.0 Draft Internal Audit Plan

The Chief Finance Offer informed the committee that the draft Internal Audit Plan 2018/19 was presented to the Executive Operational Committee on the 10 April to discuss and recommend to the Audit Committee for approval. At the meeting held on the 10 April the Executive Operational Committee reviewed the proposed timetable over the next 3 years and subject to the following changes which have been incorporated within the attached revised report recommended that the draft Internal Audit Plan for 2018/19 is presented to the Audit Committee for approval. Key changes are:

Bank & Agency has moved to Year 1 and Rostering to Year 2

There was a review previously in the Plan titled ‘Risk Maturity and Corporate Governance’ at 25 days however this has been changed to cover Risk Maturity only and the days reduced to 15.

The spare 10 days have been allocated to a review around handovers where retiring Safeguarding and Senior MHA staff pass over responsibilities to new staff.

7.0 Workforce Transformation Update

The Executive Director of Governance and Strategy updated the Committee on the current position with the Workforce transformation Plan. The following were identified as key issues by the Workforce Transformation Group and actions have been made in respect of these:

Vacancy rates continue to be identified as a hotspot area and targeted work is being undertaken and monitored via recruitment and retention project group. An improvement in Trust vacancy rates is reported for month 11 now being reported as 12.9% reduction from 14%. The Trust is targeting the Clacton clinical services and plans are in place to take forward proactive recruitment for this area, including a recruitment day and engagement with student nurses.

Turnover rates have been identified as a hotspot area and targeted work is being undertaken and monitored via recruitment and retention project group. The turnover rate has seen a minor increase for month 11 reported as 16.1%

Sickness rates are below Trust KPI, and continue to improve. Month 11 reported the lowest sickness absence rates for whole financial year as 3.6%. Targeted work is being taken forward via sickness Task and Finish groups for teams who breach national sickness targets and Trust KPI. No directorates are reporting Trust KPI breach this month which is a positive shift from previous months.

Agency usage continues to drop month on month and NHSi have complimented the Trust on the steps taken to reduce agency spend and usage and the temporary project post implemented to support operational services in delivering this.

E-Rostering was discussed and recognised as a key long term solution to support the reduction in agency usage.

The committee was pleased to note the reduction in sickness absence and the actions identified in the assurance report.

8.0 Annual Governance Development Plan including Risk Management Framework Update

The Governance Development Plan (GDP) 2017/18 encompasses the full range of governance arrangements that EPUT needs to have in place. The GDP and associated action plans take account of recommendations/issues raised pre-merger and carried forward to EPUT


The Director of Compliance updated the Committee on progress and provided revised action plans to support the progress. Listed below are the key areas to focus on:

Good progress has been made post-merger in establishing robust governance arrangements in line with the priorities agreed by the FPC.

A “substantial assurance” opinion was issued by Mazars in respect of the Trust’s Risk Management and assurance arrangements. Slippage in progressing the Risk Management and Assurance Framework Implementation Plan reported earlier in the year has been recovered

The action plan to ensure implementation of recommendations made by Grant Thornton has been largely delivered

The action plan to strengthen compliance with the CQC/NHSI Well Led Framework was also nearly completed

Any action that is outstanding will be carried forward into the GDP for 2018/19. There are no significant risks associated with actions that have not been completed. The GDP 2018/19 will now be developed for presentation to the committee for approval. The Director of Compliance also suggested that the Performance Hotspots should be aligned to the Board Assurance Framework (BAF) and that this should be discussed as part of the presentation of the performance report to the Executive Operational Committee. The Committee discussed the plans and requested that a task and finish group meet to discuss the areas identified and report back to the next meeting.

9.0 NHSI Self Certification

The Director of Compliance & Assurance informed the Committee that the self-certification is required by the end of May 2018. The committee was asked to take this opportunity to consider compliance with the Corporate Governance Statement requirements prior to finalisation next month. The Director of Compliance & Assurance provided a self-assessment of the current position to facilitate these discussions this included evidence of compliance, identification of any gaps, and a suggested confirmed/not confirmed statement based on the evidence and gaps. The Committee considered and discussed in detail the evidence that supports positive assurance and potential gaps. It was agreed that further discussion was required outside of this meeting in order to reach agreement on the final recommendations to be considered at the main meeting.

10.0 Code of Governance Review

The Executive Director of Governance and Strategy described the purpose of the Code is to provide guidance to help Trusts deliver effective and quality corporate governance, contribute to better organisational performance and ultimately discharge their duties in the best interests of patients. To support this the Trust’s Annual Report must include a statement as to how the Trust applies the Code and also confirm that the Trust ‘complies’ with the provisions, or if not, provide an explanation as to why it has departed from the Code. NHSI has clearly stated that satisfactory engagement between the Board, Council of Governors, members and patients is crucial to the effectiveness of the Trust’s corporate governance approach. In particular, Directors and Governors both have a responsibility for ensuring that ‘comply/explain’ remains an effective alternative to a rules-based system.


The review process to establish compliance was in two stages:

• Self-assessment: A comprehensive review against of each Code provision • Internal independent assessment: Council of Governors Governance Committee

reviewed with invited NEDs the self-identified sample provisions across all five sections of the Code scrutinising the evidence and enabling NEDs to directly answer any queries.

Based on both the self-assessment and assurance from the Governance Committee, there is strong evidence that the Trust is compliant with all provisions in the Code with the exception of:

• Code Provision B.1.2: At least half the Board, excluding the Chairperson, should comprise NEDs determined by the Board to be independent

Explanation: There have been timing issues with the appointment of the NEDs

and Chair due to the regulatory governance requirements of establishing a new Trust following an FT to FT merger. In summary, the appointments of NEDs to the permanent Board could not commence until the establishment of the new Council of Governors which in turn could not take place until the establishment of the new Trust on 1 April 2017. Although the permanent Chair of the Trust had been identified and had confirmed acceptance of the offer of appointment effective 1 November 2018 due to previous commitments, for the month of October 2017 there were only six NEDs in place with the Vice-Chair acting up as the Chair of the Trust. To maintain Board balance, the CEO agreed with the EDs that one ED would withdraw his/her voting rights on the Board for October. It should be noted that there were no requirements for a vote at Board during this period. There are now eight NEDs in post (including the Chair of the Trust) with no vacancies.

The Committee was asked to provide an update and assurance on the Trust’s compliance with the Code provisions to the Board of Directors and agree that the exception statement in relation to provision B.1.2 be included in the Trust’s Annual Report for 2017/18. The Committee supported the Trusts compliance with the Code provisions with the exception statement in relation to provision B.1.2. Although the Trust was compliant the review identified a small number of further recommendations to enhance current practice. The committee agreed to that the new Governance Task and Finish Group should review these recommendations.

11.0 Patient Experience Framework

The Patient Experience Framework forms part of the Trust’s Engagement Strategy. The Framework is a key document that draws together the Trust’s approach and priorities in relation to patients and service user experiences promoting a shared culture, new vision, new values and motivation to deliver corporate and team objectives. The Engagement Strategy details a number of pledges to achieve the overall vision of ‘working to improve lives’. This framework seeks to show how the Trust will meet its pledges and detail how progress will be monitored. It will be continuously reviewed to ensure that it keeps up with the changing healthcare agenda and any changes in the population the Trust serves. The Executive Director of Governance and Strategy presented the key service user engagement objectives and how we will measure the effectiveness of our actions and the associated action plan.


EPUT recognises that every interaction we have is an engagement opportunity, and an opportunity to live our values. Therefore the aim of the Patient Experience framework is to:

engage with and involve our patients, carers, families, workforce and partners;

co-produce and co-design our services and plans with people with lived experiences;

to have a culture of openness where we use data and robust governance arrangements to improve our performance and identify areas for celebration and improvement;

Support the elimination of discrimination within the Trust for our patients and carers ensuring that everyone has fair access to services.

The framework draws together customer service and service user engagement to ensure there is a focus and objectives set aligned to the overall experience of all those who come into contact with EPUT’s services. The framework supports the overall Engagement Strategy in relation to patients, carers and also the voluntary sector and the public. It is not a standalone document and fits in with the other frameworks (Communications, HR and Workforce, Carers, Membership and Organisational Development) enabling the aims and objectives of the strategy to be fulfilled. The Committee agreed supported the content of the action plan supporting the Framework with minor amendments.

12.0 Information Assurance Framework

The Director of IT, Business Analysis and Reporting informed the Committee that the information assurance framework has been developed in response to a KPMG recommendation following their last Governance review of the Trust and the recommendation that an information assurance framework be developed against all key performance indicators to review the current levels of assurance in place around the accuracy of data used to report against the KPI. The document presented helps to identify any potential gaps in data confidence and potentially define internal audit programmes for data quality. It is not expected that all indicators will have full data confidence at any one time. For 2018/19 the information assurance framework has been revised to focus on the changes that were made to the Single Oversight Framework published November 2017. Each indicator from the Single Oversight Framework has been reviewed and mapping of assurance available undertaken. Current assurance shows data confidence as:

High for 7 Indicators (High – Operational, internal and independent assurance in place)

Medium for 14 Indicators (Medium – assurance has found some gaps / two out of three assurances in place)

Low for 1 Indicators (Low - assurance has found significant gaps / only 1 level of assurance in place)

The only indicator with low data confidence is Cardio Metabolic Assessment and Treatment and currently audit results are used to determine compliance against the national indicator. The Committee agreed that the Information Assurance Framework supported and gave assurance that data quality for key indicators was being routinely monitored across the Trust.


13.0 Merger Benefits Realisation Update

The Executive Director of Governance and Strategy updated the Committee on the current position. A draft paper has been written and discussed at the Executive Operational Sub Committee. The draft paper will be presented to the Board in April.

14.0. Cyber Security Update

The Director of IT, Business Analysis and Reporting informed the Committee that NHS Improvement (NHSI) has requested a position statement and sign off by Trust Board against the 10 cyber security control areas by the 11th May 2018. An assessment has taken place against each of the 10 controls and they are listed below:

Senior level responsibility

Completing the Information Governance toolkit v14.1

Preparing for the introduction of the General Data Protection Regulation in May 2018

Training staff

Acting on CareCERT advisories

The EPUT Cyber Security team have signed up for CareCert Collect.

Business continuity planning

Reporting incidents

Unsupported systems

On-site cyber and data security assessments

Checking Supplier Certification The paper provided the committee with the current position against the 10 controls. EPUT is required to provide a return against fixed statements provided by NHSI in order to gauge our readiness position in response to cyberattacks. The Committee were assured with the content of the current position against each of the 10 controls and supported submission back to NHSI.

15. Any risks or Issues Identified

There was one issue raised: The Director of Compliance asked that the action to align Performance Hotspots to the BAF be identified as a current issue until the new process is implemented to address this shortfall.

16. Any Other Business

The Chief Executive Officer reminded the Committee that at a recent Board meeting a suggestion had been made that Committees should also focus on positive aspects of their work. As a result of these discussions the following was agreed:

To add an agenda item to recognise improvements in performance to all Committee meetings

To ensure that this is included in the assurance report to the Board

Chairs of the Committees to email the team/individuals to invite/present their work at the Committees

Invite staff to submit these quality improvements forward to the Quality Academy for a potential QI award


Report prepared by: Janette Leonard Director of ITT, Business Analysis and Reporting On behalf of:

Alison Davis Chair of the Finance and Performance Committee


Board of Directors 28 February 2018 Page 1 of 3

Agenda Item No: 6b(ii)

SUMMARY REPORT


25 April 2018

Report Title: Board of Directors Quality Committee Assurance Report

Executive/Non-Executive Lead: Amanda Sherlock, NED and Chair of Committee

Report Author(s): Sarah Browne, Deputy Director of Nursing




This report provides assurance to the Board that the Quality Committee is discharging its terms of reference and delegated responsibilities effectively, and that the risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively.

Approval

Discussion

Information


The Board of Directors is asked to: 1 note the contents of the report 2 confirm acceptance of assurance given in respect of risks and actions identified 3 request further action/information as required.


At its meeting on 12 April 2018 the Quality Committee:

Received a report covering a case study within Health visiting where professional curiosity identified some potential risks to a patient and their child and appropriate .

Received External Bodies Report

Received draft internal audit plan

Received update report Received report on Quality committee workplan review and approved workplan for 2018/19.

Approved Infection Control and Clinical Audit Annual Reports.

Received CQC report covering registration and work being undertaken in preparation or CQC inspection.

Approved six policies and procedures

Received assurance reports from eight of its sub-committees

Did not identify any new risks for escalation to the BAF or CRR

Identified the following issues to be raised with other standing Committees:

Management of Trust Intellectual Property Policy to be referred to the Executive Team to ensure it encompasses the whole organisation and did not focus solely on research and development.

Cancelled Patient and Carers Subcommittee – although this is a known issue, the Committee were concerned that a meeting had not been held since November 2017.

Importance of attendance at Committees / Subcommittees.

Over use of local urine analysis testing and over prescription of antibiotics.

Concern around delays in response to complaints and no evidence of agreed extension for response.

Feedback comments regarding internal audit programme to Audit Committee









1: Open

2: Compassionate

3: Empowering



R1 If services fall short of the standards required to remain compliant with the Health and Social Care Act there is the potential for CQC enforcement action or in extreme cases closure of services. R3 If the Trust fails to provide high quality services from premises that are safe, then the risk related to ligatures is not minimised and this may impact on the safety of patients in inpatient services. R6 If learning from incidents is not embedded quality and patient safety may not be maintained or improved. R7 If the Trust fails to provide strong clinical leadership to support staff and promote learning this will impact upon the quality of patient care and the reduction of serious incidents R12 If action being taken is not having an impact on the number of restraints (particularly prone restraint) the Trust will need to consider whether there are gaps in plans in place. R24 If the Trust is not adequately prepared it could be subject to a cyber-attack that compromises clinical or corporate IT systems

Do you recommend a new entry to the BAF is made as a result of this report? No



Data quality issues









Equality Impact Assessment (EIA) Completed? NO If YES, EIA Score


BAF Board Assurance Framework CQC Care Quality Commission

GDPR General Data Protection Regulation CRR Corporate Risk Register

MPEC Multi-Professional Education Committee DPA Data Protection Act

DSE Display Screen Equipment




Main report

Lead

Amanda Sherlock Non-Executive Director Chair of the Quality Committee


Board of Directors Part 1 25 April 2018 Page 1 of 3

Agenda Item 6b(ii) Board of Directors Meeting Part 1

25 April 2018

BOARD OF DIRECTORS QUALITY COMMITTEE ASSURANCE REPORT

1 Purpose of Report

This report is provided to the Board of Directors by the Chair of the Board of Directors Quality Committee. As an integral part of the Trust’s agreed assurance system, the report is designed to provide assurance to the Board that:

risks that may affect the achievement of the Trust’s objectives and impact on quality are being managed effectively. This is an integral part of the Trust’s agreed assurance system

the Committee is discharging its terms of reference and delegated responsibilities effectively.

2 Executive Summary

2.1 Minutes of previous meeting The minutes of the Quality Committee meeting held on 15 March 2018 were approved at the meeting on 12 April 2018. These are available in full to Board members via the Trust Secretary Office. Representatives from NHS Improvement were also in attendance. 2.2 Summary of discussions and issues identified as well as assurances provided at the meeting held on 15 March 2018: 2.2.1 Patient Story: The Committee was presented with a patient story covering a case

study within the health visitor service with a positive professional outcome. Due to professional curiosity of the health visitor in regards to a new patient being seen, potential risks were identified and appropriate actions taken to safeguard the patient and their child.

2.2.2 Quality Priority: Medication Omissions. The report covered the work undertaken in relation to the Sign Up For Safety Campaign work stream aligned to our Quality Strategy in regards to the work around medication omissions. The Committee was informed of the two main areas of focus covering reducing the number of omitted doses (or blank boxes on forms regarded as omitted doses) and working with clients refusing medication. The report confirmed that a full year of EPUT data is now available which identifies 123 omitted doses within Community Health Services and 723 within Mental Health and Learning Disability services. The Committee was informed that Community Health Services reporting remains reasonably static however staff are continuously encouraged to report any incidences of omitted doses. Mental Health had historically been the biggest concern however significant improvement has been seen and assurance was given to the Committee that this issue is taken seriously at ward level.

2.2.3 Internal Audit Plan: The draft internal audit plan was shared to give members an

opportunity to review and comment on the proposed plan. 2.2.4 Infection Prevention and Control Annual Report: The Committee received and

approved the report.

2.2.5 Clinical Audit Annual Report: The Committee received and approved the report.



2.2.6 CQC Compliance Report: The report provided the Committee with the updates on current registration status, update on the action plans developed as a result of CQC inspections and the work in progress for the planned CQC inspection commencing 30 April 2018.

2.2.7 External Bodies Report: The report provided the Committee with the Royal College

of Psychiatrists Quality Improvement Review completed for Wood Lead Clinic in January 2018.

2.2.8 Policies and Procedures: The following were approved:

Research and Development

The Spiritual and Pastoral Care

CCTV

Assured Safe Catering

Corporate Health and Safety

Cleaning

2.2.9 Sub-Committees Assurance Reports:

Clinical Governance and Quality Sub-Committee: An update on previously reported hotspots was provided. Three new hotspots were reported covering review of De-fib requirements within clinic areas in north of the Trust, capacity within the Clinical Audit Department to support the programme going forward and the Training Tracker. Assurance was provided that mitigating actions were being taken forward.

Health, Safety and Security Sub-Committee: An update on previously reported hotspots was provided. Two new hotspots were reported covering HSE request for documentation and poor attendance from operational staff with updates on actions being taken forward.

Mortality Review Sub-Committee. Assurance given that work is being undertaken regarding mortality framework with majority of processes now in place. No new hotspots were identified although capacity was highlighted with the ongoing work going forward.

Patient and Carer Sub-Committee. Report presented informed the Committee that a meeting had not been held since November 2017, but relevant reports are being submitted to other meetings and reports requiring decision/approval are being submitted to the Executive Team. An update was given on previously reported hotspot.

Learning Oversight Sub-Committee. An update on previously reported hotspots was provided. Two new hotspots were reported covering triangulation of data and inappropriate referrals across clinical services. Assurance was provided that mitigating actions were being taken forward.

Executive Physical Healthcare Sub-Committee. An update on previously reported hotspots was provided. No new hotspots were identified.

Equality and Diversity Sub-Committee. An update was given in regards work being undertaken. Now new hotspots identified.

Information Governance Sub-Committee. An update was provided in regards to submission of the IG Toolkit and an update of the external audit undertaken.

2.3 Risks/hotspots: The Committee did not:

Identify any risks for escalation to the BAF or CRR The Committee identified the following issues to be raised with other standing Committees:



Management of Trust Intellectual Property Policy to be referred to the Executive Team to ensure it encompasses the whole organisation and did not focus solely on research and development.

Cancelled Patient and Carers Subcommittee – although this is a known issue, the Committee were concerned that a meeting had not been held since November 2017.

Importance of attendance at Committees / Subcommittees.

Over use of local urine analysis testing and over prescription of antibiotics.

Concern around delays in response to complaints and no evidence of agreed extension for response.

The Committee identified the following recommendations to the Audit Committee linked to the internal audit programme.

Feedback comments regarding internal audit programme to Audit Committee

3 Action Required


1 Note the contents of this report 2 Confirm acceptance of assurance given in respect of risks and action identified 3 Request further action/information as required.

Report prepared by Sarah Browne Deputy Director of Nursing/DIPC On behalf of: Amanda Sherlock Non-Executive Director Chair of the Quality Committee 25 April 2018


Page 1 of 2

Agenda Item No: 7c

SUMMARY REPORT

TRUST BOARD 25 April 2018

Report Title: EDUCATION SUMMARY Executive/Non-Executive Lead: MILIND KARALE/ANDY BROGAN Report Author(s): Anthea Hockly, Abdul Raoof Report discussed previously at: Level of Assurance: Level 1 Level 2 Level 3 Purpose of the Report This report provides an update on the main issues in non-medical and medical education that have been considered over the past six months.

Approval Discussion Information X

Recommendations/Action Required The Board of Directors is asked to:

1 Note the contents of the report .

Summary of Key Issues ion

This report gives a summary of some of the key education and training initiatives that have taken place over the past six months. This includes a brief summary on:

Apprenticeships Leadership Programmes CPD Workforce Planning Health Education England Quality Performance Reviews Mandatory Training Undergraduatae and postgraduate medical education Course developments Joint initiatives with HEE

Relationship to Trust Strategic Priorities SP 1: Continuously improve patient safety, experience and outcomes SP 2: Attract, develop, enable and retain high performers x SP 3: Achieve top 25% performance SP 4: Co-design and co-produce service improvement plans Which of the Trust Values are Being Delivered 1: Open 2: Compassionate 3: Empowering x Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? If yes, insert relevant risk Do you recommend a new entry to the BAF is made as a result of this report? N


Page 2 of 2


x

Data quality issues Involvement of Service Users/Healthwatch Communication and consultation with stakeholders required Service impact/health improvement gains Financial implications: Potential net cost of programmes


Non Recurrent £

Governance implications Impact on patient safety/quality Impact on equality and diversity Equality Impact Assessment (EIA) Completed? YES/NO If YES, EIA Score Acronyms/Terms Used in the Report SFA Skills Funding Agency HEE Health Education England LWAB Local Workforce Action Board Supporting Documents and/or Further Reading Lead

Dr Milind Karale Medical Director


Trust Board Page 1 of 4

Agenda Item 7cBoard of Directors

Date: 25 April 2018 EDUCATION REPORT

1 Purpose of Report The purpose of this report is to inform the Trust Board of the main initiatives in no-medical and medical education and training that have taken place over the past six months. The education and training in the organization in the Trust is monitored by the Quality Committee which received bi-monthly reports from the Multi-Professional Education Committee.

2 Non-Medical Education . 2.1 Apprenticeships The initial procurement rounds have now been finalised and contracts are in place for the following courses:

Level 2 & 3 Health and Social Care – End Point Assessment

Customer Services

Level 2, 3 & 4 Business Administration

Associate Practitioner (Year 2)

Top up Nursing Degree (Mental Health and Adult) The Trust can use other apprenticeship courses but these are unlikely to be in large numbers and a formal procurement process is not required for those courses. The Trust has over £900k in the Levy fund and have committed about £200k to Associate Practitioners and HCAs and a further £250k will be required for the top-up cohort starting in October. 2.2 Continued Professional Development – Contracts The Trust has not been advised of 2018/19 funding by Health Education England and is proceeding on the basis that the NMET ( non-medical education training) funding is likely to be similar to the funding received in 2017/28. The Essex contracts for 2017/18 at Anglia Ruskin University and Essex University were fully utilised and the Trust had to put extra funding in to cover the courses required. The Hertfordshire and Bedfordshire contracts were underspend. These contracts were drawn up after consultation with staff on training requirements. The underspent was due to staff failing to apply for the courses and for certain courses not being offered by these Universities. The Trust is awaiting further information from the universities which is likely to influence the ‘end of year’ position.



2.3 Leadership Courses The Essex Leadership Group has approved funding for another cohort of the Integrated Leadership Course. Each provider in Essex will have three places allocated. This course is aimed at Band 7s upwards and aims to deliver skills in strategic planning and decision making. The group are also supporting additional cohorts of the Mary Seacole course. This course is aimed at Band 5/6 upwards and aims to give a broad overview of leadership skills. EPUT uses this course as a progression step from the in-house Management Development Programme. 2.4 Workforce Planning – Stepping Forward The Trust sits across the 3 STPs in Essex and each STP area has been requested to submit a plan to Health Education England to demonstrate how the STP will meet the expansion targets set out in the Mental Health Five Year Forward View – Stepping Forward. Work was undertaken with service leads from across the Trust to explore how EPUT will plan to meet these targets. The plans submitted are in line with the clinical transformation plans that are in development and the Trust Recruitment and Retention plan. It was made clear in the submission that any expansion of the overall workforce numbers would require additional funding. As the funding situation is unclear, it is our working assumption that expansion in the targeted areas will need to be accompanied by new ways of working or workforce reductions in other areas. Some aspects of the plan are dependent upon new ways of working, including the delivery of apprenticeship programmes which have not yet been approved (e.g. Psychological Well-being Practitioner). Work will continue on producing an implementation plan and achieving the targets set out in the Trust’s Recruitment and Retention plan. The workforce development element of the Recruitment and Retention plan involves targets for the recruitment of students and improving the experience of newly qualified staff through the development of a preceptor pathway and additional resources. 2.5 Quality Assurance for the Deanery The Multi-Professional Deanery has changed its quality assessment process to a risk based system. Each organisation is asked to self-assess and report just the top ten risks – or any risk which scores higher than 12 on the risk scoring. Workforce Development consulted with our partner education providers to discuss how we could improve the student experience. Although, no high level risks were identified, some areas for improvement include improving access to IT systems for students and working to improve the recruitment levels. The action plan following the risk assessment is now in development. 2.6 Mandatory Training The Trust has been working to merge the training systems that existed in NEPT and SEPT. As an interim measure, a training tracker has been created for the Trust. This



has highlighted some of the difficulties involved in aligning various systems within the Trust. 3.1 Undergraduate Medical Education Based on the excellent feedback from medical students placed in NEP and SEPT during 2016-17, UEA (University of East Anglia) requested the Trust to increase the number placements for Norwich Medical School (NMS) students. We have increased the number from 12 to 18 for 2017-18. The provision of suitable accommodation is one of the limiting factors in further increasing the number students. The Trust is also mindful to retain adequate capacity for students from the new Anglia Ruskin Medical School opening this year Trust was actively involved in the development of the ARU Medical School. 3.2 Physician Associate Students There has been an expansion in placements offered to the Physician Associate students from Anglia Ruskin University. The Trust provided placements for a total of 25 students in 2017/18 as compared to 12 students in 2016-17. 3.3 Recruitment Initiatives The Trust has actively engaged in multiple recruitment initiatives targeting A level students, medical students and Foundation Year doctors. The Trust offers job shadowing placements and clinical attachments for local and overseas students. The Trust has received positive feedback from overseas doctors and the Royal College of Psychiatrists from its contribution to the Medical Training Initiative. In line with our commitment to make EPUT the desired destination for trainees we have improved facilities for trainees in all localities based on feedback from Junior Doctors Forum 3.4 Joint initiatives with HEE (Health Education England) Trust has been successful in our bids to continue running Simulation Training, MRCPsych Course and other one of events under the CCDF (Central Curriculum Delivery Fund) 3.5 Development of new courses and income generation The NHS Midlands & East Mental Health Act Approval Panel has approved EPUT proposal to start Section12 and AC (Approved Clinician) Refresher courses. EPUT is the first NHS Trust in Eastern region to receive such an approval. This initiative is likely to generate some revenue by offering training places to external delegates

3. Medical Education



4 Action Required The Trust Board is asked to note the contents of the report and seek assurance that Trust continues to meet its commitment to education and training.

Report prepared by Anthea Hockly Head of Workforce Development and Training Abdul Raoof Director of Medical Education


Page 1 of 2

Agenda Item No: 7d

SUMMARY REPORT

Trust Board of Directors

25 April 2018

Report Title: Medicines Optimisation Strategy

Executive/Non-Executive Lead: Milind Karale, Executive Medical Director

Report Author(s): Hilary Scott, Chief Pharmacist

Report discussed previously at: Medicines Management Groups (Mental Health and Community Health Services) Executive Operational Sub-Committee Investment and Planning Committee



The purpose of this report is to present the interim Medicines Optimisation Strategy to the Trust Board of Directors for approval.

Approval

Discussion

Information


Members of the Trust Board of Directors are asked to:

1. Ratify the strategy.


The Medicines Optimisation Strategy primarily supports the delivery of strategic objectives 1 and 3. Medicines management is the term that has historically been used when referring to managing people’s medicines. It has primarily been led by pharmacy teams and relates to the way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes to patient care. Medicines management focuses on improving systems and processes, and is central to the provision of quality healthcare. Medicines optimisation builds on the systems and processes of medicines management, but has a focus on getting the best outcomes for patients from their medicines. It is about ensuring that the right patients get the right choice of medicines, at the right time. By focusing on patients and their experiences, the goal is to help patients to:

improve their outcomes

take their medicines correctly

avoid taking unnecessary medicines

reduce wastage of medicines

improve medicines safety. Ultimately medicines optimisation can help encourage patients to take ownership of their treatment. Robust medicines management is an important enabler of medicines optimisation. NHS England is due to publish a Mental Health Medicines Optimisation Strategy, and the Lord Carter review of Mental Health and Community Services is also due to be released in 2018. It is anticipated that these documents will be have an impact on EPUT’s Medicines Optimisation Strategy. Therefore this document sets out the Trust’s interim position, the finalised Strategy for the Trust will be developed and fully refreshed post the publication of these documents.


Page 2 of 2







1: Open

2: Compassionate

3: Empowering







Data quality issues




Financial implications




Equality Impact Assessment (EIA) Completed? No If YES, EIA Score No



Lead

Milind Karale Executive Medical Director

MEDICINES OPTIMISATION

STRATEGY

2018-2020

Medicines optimisation is a vital agenda, not an agenda added on to something else we are trying to do; this is absolutely central to it.

Sir David Nicholson, Chief Executive, NHS

Royal Pharmaceutical Society Conference, 10th September 2012

2

BACKGROUND AND INTRODUCTION

Essex Partnership University NHS Foundation Trust (EPUT) is a combined mental health and community services Trust. It is our ambition to provide high quality services to the population we serve. Our vision is therefore to work to improve people’s lives, and we will do this through living our values of ‘Compassionate, Empowering and Open’. As a new organisation we have four strategic objectives to support the delivery of our vision. A summary of the Trust’s vision, values and strategic objectives is shown in Figure 1. Figure 1:

Behaviours underpinning the values

Open Compassionate Empowering

Working to improve lives

Vision

Values

Strategic Objectives

Continuously improve patient

safety, experiences and outcomes

Attract, develop, enable and retain high performers

Achieve top 25%

performance

Co-design and co-produce

service improvement

plans

3

Each year our Board will review these to ensure they remain valid, connected to our vision, and the behaviours we expect all our staff to exhibit in everything they do. The Medicines Optimisation Strategy primarily supports the delivery of strategic objectives 1 and 3. Medicines management is the term that has historically been used when referring to managing people’s medicines. It has primarily been led by pharmacy teams and relates to the way that medicines are selected, procured, delivered, prescribed, administered and reviewed to optimise the contribution that medicines make to producing informed and desired outcomes to patient care. Medicines management focuses on improving systems and processes, and is central to the provision of quality healthcare. Medicines optimisation builds on the systems and processes of medicines management, but has a focus on getting the best outcomes for patients from their medicines. It is about ensuring that the right patients get the right choice of medicines, at the right time. By focusing on patients and their experiences, the goal is to help patients to:

improve their outcomes

take their medicines correctly

avoid taking unnecessary medicines

reduce wastage of medicines

improve medicines safety. Ultimately medicines optimisation can help encourage patients to take ownership of their treatment. Robust medicines management is an important enabler of medicines optimisation. Figure 1: The four principles of medicines optimisation

Medicines optimisation is based around four guiding principles (see Figure 1), which should inform the practice of front-line healthcare professionals with respect to medicines. These are consistent with existing national guidelines and good practice guidance around medicines use.

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Medicines optimisation can be described and measured in terms of effectiveness, safety and patient experience and are therefore directly linked to the NHS outcomes framework21 (see Figure 2). Figure 2: Medicines optimisation in the context of the NHS outcomes framework

Medicines Optimisation

Domain 1 Domain 2 Domain 3 Effectiveness

Preventing people from

dying prematurely

Enhancing quality of life

for people with long-

term conditions

Helping people to

recover from episodes of ill health or following

injury

Optimal patient outcomes are obtained from choosing medicines based on best evidence

Treatment of limited clinical value are not used and medicines no longer required are stopped

Patients’ beliefs and preferences about medicines are understood to enable a shared decision about treatment

Patients receive consistent messages about medicines because the healthcare team liaise effectively

Medicines wastage is reduced and the NHS achieves greater value for the money invested in medicines

Domain 4 Experience

Ensuring people have a positive experience of care

Patients feel confident to share openly their experiences of taking or not taking medicines and what they mean to them

Patients feel able to discuss and review their medicines with anyone involved in their care

Patients are more engaged, understand more about their medicines and are able to make choices

Domain 5 Safety

Treating and caring for people in a safe environment and protecting them from

avoidable harm

Optimal patient outcomes are obtained from choosing medicines based on best evidence

Treatment of limited clinical value are not used and medicines no longer required are stopped

Incidents of avoidable harm from medicines are reduced

Patient’s feel able to ask healthcare professionals when they have a query or difficulty with their medicines

Patients discuss potential side effects with a healthcare professional

Patient take unused medicines for safe disposal

In March 2015 the National Institute for Health and Care Excellence (NICE) published a guideline with best practice advice on the care of people who are using medicines and those who are receiving suboptimal benefit from medicines. NICE defined medicines optimisation as:

‘a person-centred approach to safe and effective medicines use, enabling people to obtain the best possible outcomes from their medicines.’

The guideline considered eight areas relating to the use of medicines and is based on evidence provided by over 140 research papers. It makes 48 recommendations (see Appendix 1), of which four were identified as key priorities for implementation:

Recommendation 22: Organisations should ensure that medicines reconciliation is carried out by a trained and competent health professional – ideally a pharmacist, pharmacy technician, nurse or doctor – with the necessary knowledge, skills and expertise including:

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Recommendation 4: Organisations should consider using multiple methods to identify medicines-related patient safety incidents – for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning. Recommendation 14: Health and social care practitioners should share relevant information about the person and their medicines when a person transfers from one care setting to another. Recommendation 16: Consider sending a person’s medicines discharge information to their nominated community pharmacy, when possible and in agreement with the person.

NHS England is due to publish a Mental Health Medicines Optimisation Strategy, and the Lord Carter review of Mental Health and Community Services is also due to be released in 2018. It is anticipated that these documents will be have an impact on EPUT’s Medicines Optimisation Strategy. Therefore this document sets out the Trust’s interim position, the finalised Strategy for the Trust will be developed and fully refreshed post the publication of these documents.

VISION

Patients are consulted on their beliefs and concerns about medicines and given well-informed data about their medicines. Wherever possible, they are empowered to be partners in medication treatment decisions through shared decision making. Patients receive safe, clinically-effective, and cost-effective medicines appropriate to their individual needs.

CONTEXT

Medicines are the most common intervention in healthcare and the NHS spends around £13.3 billion per year on them. More than a third of that expenditure takes place in hospitals. Despite the fact that the cost of medicines represents less than 10% of total NHS expenditure, spending on medicines is a focus of much attention due to it being a readily identifiable element of health service costs. Medicines play a crucial role in maintaining health, preventing illness, managing chronic conditions and curing disease. With the NHS facing a period of significant economic, demographic and technological challenge it is crucial that patients get the best outcome from their medicines. However, there is a growing body of evidence that suggests that medicines use is suboptimal, and that patients are not getting the most from their medicines.

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30-50% of medicines are not being taken as intended.

Just 16% of patients who are prescribed a new medicine take it as prescribed, experience no problems and receive as much information as they feel they need.5 Ten days after starting a new medicine, 30% of patient are already non-adherent; 55% of these don’t realise they are not taking their medicines correctly. Adverse drug reactions account for 6.5% of hospital admissions. Prescribing errors occur in 8.9% of medication orders in acute hospitals.

Over half a million medication incidents were reported to the NPSA between 2005 and 2010. 16% of them involved actual patient harm.

Medicines worth at least £150m are wasted in primary care each year.

The government White Paper Liberating the NHS established improvement in quality and healthcare outcomes as the primary purpose of all NHS-funded care. It emphasised the need to improve the outcomes of healthcare for all, to deliver care that is safer, more effective and that provides a better experience for patients. More recently the ‘Francis’ Report emphasised the need to put patients first at all times, protecting them from avoidable harm; and the ‘Berwick’ Review recommended four guiding principles for patient safety, including:

Place the quality and safety of patient care above all other aims for the NHS

Engage, empower, and hear patients and carers through the entire system, and at all times.

CURRENT TRUST POSITION

The Lead Director for Medicines Optimisation is the Trust’s Medical Director and the professional lead is the Chief Pharmacist. The Medical Director and Chief Pharmacist provide advice to the Trust Board of any statutory, professional or patient safety issues related to medicines optimisation and medicine use within the Trust. This may include service reviews and developments, national and local medication safety issues, clinical guidelines and procedures for medicines use. The Chief Pharmacist:

is professional lead for pharmaceutical and medicines optimisation services within the Trust and is accountable to the Medical Director for issues relating to medicines use

provides expert advice and opinion to the Medical Director and Trust Board on key issues relating to medicines optimisation and medicines use in general

acts as Controlled Drug Accountable Officer, and will inform the Trust Board of any relevant issues relating to the safe and secure management of controlled drugs. This includes membership of the Local Intelligence Network (LIN).

Within the Trust there are robust systems for the handling of medicines. This is underpinned by an overarching policy for the Safe and Secure Handling of Medicines

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(CLP13) supported by two comprehensive sets of procedures for medicines use in mental health and learning disability services (CLPG13-MH) and community health services (CLPG13-CHS). Adherence to procedures is monitored as part of the medicines management audit programme. Two Medicines Management Groups (MMGs) oversee all aspects of medicines management. They are responsible for the development, implementation, and monitoring of medicines-related documentation, policies, guidance and prescribing practice and ensure that procedures and systems are in place for the safe use of medicines. The two MMGs report to the Clinical Governance and Quality Sub-Committee, which is a sub-committee of the Quality Committee. The Quality Committee is a sub-committee of the Board of Directors. The Chief Pharmacist presents an annual report on the progress with medicines management to the board each year. This includes a summary of the activity of the two MMGs. The two MMGs regularly review medication incidents. The Clinical Governance and Quality Committee received reports on the number of medication incidents, and details are reported by exception as they are considered in detail by the MMGs. Adherence to national best practice guidelines such as those produced by NICE is monitored by the Clinical Effectiveness Group. The Chief Pharmacist is a member of both committees. Pharmacy services are provided in-house for Essex mental health and learning disability services, HMP Chelmsford, and South East Essex Community Health Services. In all other parts of the Trust pharmacy services are provided by local acute Trusts. Medicines management forms part of the core practice training programme designed to assist staff maintain safe working practices and ensure that patients receive a quality service. Medicines management training for qualified nursing staff is delivered by members of the pharmacy team and is available on a regular, usually monthly basis, training tailored to the needs of some of the smaller staff groups may be available less frequently. Part of the Trust’s assurance programme involves a medicines management audit programme. As well as regular ward level checks on the safe and secure handling of medicines and safe management of controlled drugs, this includes a programme of both clinically and process orientated audits. Examples include safe use of insulin and anticoagulants as well as transport and prescribing of medicines. The Trust Development Agency (TDA) developed a medicines optimisation and pharmaceutical services framework which allows Trusts to assess their performance in six domains:

Strategy, risk and governance

Safe use of medicines

Effective choice of medicines

Patient experience

Environment for medicines optimisation

Workforce for medicines optimisation Each domain consists of a series of criteria, within which four levels of achievement are described. The framework recognises that all organisations will have areas of strength and weakness in relation to medicines optimisation and pharmaceutical services and that it

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would be unusual for any trust to achieve ‘Level 4’ performance for all criteria. In conjunction with the NICE guidelines for medicines optimisation, the framework, has been used to inform the content of this document, concentrating on those criteria where the trust achieves the lower two levels of performance. Details can be found in Appendix 2. It should be noted that the level of medicines management input available in different services within the trust, and different geographic areas providing the same services, can be variable. This is largely due to investment decisions made by predecessor organisations. However it has not been possible, to date, to increase resources in those areas where there has traditionally been low investment.

STRATEGY, RISK AND GOVERNANCE

Effective decision, policies and procedures underpin good practice in medicines use, with pharmacy staff contributing to overall policy and service developments within the trust and engaged in key initiatives. Systems and processes governing the use of medicines within the trust are generally effective:

There is a named Lead Director with responsibility for medicines optimisation and pharmaceutical services

The Chief Pharmacist has Trustwide responsibility for medicines optimisation and pharmaceutical services and provides an annual report to the Board

There is a comprehensive, overarching medicines policy which is supported by an audit programme

Systems are in place for effective horizon scanning to identify new medicines or developments in the use of existing medicines. Within mental health services, where the trust is responsible for maintaining its own Formulary and Prescribing Guidelines, a new drug will typically be considered by the MMG close to the time of launch, based on a literature review undertaken on its behalf by the London Medicines Information Service. In community health services, the trust is contractually bound to prescribe following the commissioners’ formulary and the mechanism for the introduction of new drugs, with some geographic differences, is mainly via the local Area Prescribing Committee. However it is also essential that medicines optimisation and pharmaceutical services are considered when the trust is involved in developing proposals for service developments, business cases and tenders. The legal, regulatory and practical aspects of medicines use are often overlooked until late in the development process. Pharmaceutical expertise needs to be sought in relation to all such developments to ensure that the clinical risks and costs associated with medicines are considered. Area for development

All senior managers involved in the development of services, business cases or tenders to ensure that expert advice on medicines optimisation and pharmaceutical services is sought from the pharmacy team (TDA domain 1, criterion 4 and NICE recommendation 48)

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SAFE USE OF MEDICINES

Medicines Optimisation Principle 3 – Ensure medicines use is as safe as possible The safe use of medicines is the responsibility of all healthcare professionals, healthcare organisations and patients, and should be discussed with patients and/or their carers. Safety covers all aspects of medicines usage, including unwanted effects, safe processes and systems, and effective communication between professionals

Ensuring the appropriate use of medicines is of paramount importance to ensuring patient safety. All medicines prescribed for patients should be clinical checked by a pharmacist to identify medicines use which is inappropriate or potentially harmful due to interactions, incompatibilities or the risk of side effects. The knowledge and skills of a clinical pharmacist working as part of the multi-disciplinary team can make a significant contribution to minimising the potential for harm. Clinical pharmacy services should be available to all patients every day, with clinical pharmacists, and increasingly pharmacy technicians, using their expertise to ensure that patients achieve the best outcomes from medicines. Typical activities are shown in Table 1: Table 1: Clinical Pharmacy Activities

Regular review of prescriptions to check for accuracy, completeness, adherence to guidelines, and prescribing problems (interactions, therapeutic duplications, appropriateness of medicines, dosage etc)

Taking and reviewing medicines histories for new admissions (medicines reconciliation)

Undertaking full medication reviews and recommending changes to medicines where appropriate

Checking with patients and staff for adverse reactions

Being part of MDT meetings and ward rounds; contributing to the development of treatment plans at the point of prescribing

Talking to patients and carers about their medicines to support adherence to treatment

Liaising with primary and secondary care colleagues to ensure that care is not compromised by organisational boundaries Participating in discharge planning to ensure that treatment is continued after discharge

Advising and training medical and nursing colleagues on pharmaceutical care issues

Managing the supply of medicines to ensure that there are sufficient stocks for uninterrupted treatment

Ensuring appropriate transport and storage of medicines

Ensuring that appropriate monitoring occurs where medicines require it

Medicines reconciliation aims to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. It is basic practice, and paramount to patient safety, that an accurate drug history is recorded by the ‘clerking’ doctor at the times of admission. National best practice guidance19 is that this should be followed by pharmacy-led full medicines reconciliation soon after admission, using a number of different sources to compile as full and accurate a record of medicines as possible. More than 90% of patients admitted to inpatient mental health services in Essex benefit from a pharmacy-led full medicines reconciliation. However, this is not the case in other parts of the trust and over time, pharmacy-led reconciliation needs to be expanded to encompass all admissions to the Trust. Furthermore, with patients of increasing complexity

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being managed in the community, in both mental health and community health services, it would also be timely to explore the benefits and practicalities of implementing medicines reconciliation for high complexity community-based patients being managed by Trust staff (e.g. CRHT, IV antibiotic services). Areas for development

Pharmacy-led full medicines reconciliation to be available to all patient admissions (TDA domain 2, criterion 2 and NICE key priority recommendation 22).

Explore the benefits and practicalities of undertaking medicines reconciliation for community-based patients with highly complex needs (NICE recommendations 19 & 20).

Improve access to the Summary Care Record amongst staff who need to undertake medicines reconciliation (NICE key priority recommendation 22).

The National Reporting and Learning System (NRLS) receives more than 10,000 reports of patient safety incidents involving medication each month. Analysis of NRLS data nationally has allowed new risks to be identified and communicated to healthcare providers. The success of this system depends on the quality of reporting, and making sure that all incidents are reported. However, the quality of reports can be extremely variable, with essential information to allow understanding of medication error incidents often not included in reports. In March 2014, NHS England issued a stage 3 (directive) patient safety alert23 aimed to improve medication error incident reporting and learning. This included the need for all NHS trusts to identify a medication safety officer (MSO). The establishment of this role is integral to improving medication error incident reporting and learning. Key tasks include managing medication incident reporting locally, reviewing all medication incidents for data quality and investigating and sourcing additional information from reporters where it is missing, and improving medication incident reporting within their organisation. As an interim measure, this role has been taken on by the Chief Pharmacist, but it is clear that there needs to be dedicated resource if the desired improvement in reporting and learning from incidents is to be achieved. This will need to be explored further. Area for development

Identify dedicated resource in order to be able to undertake the MSO role in line with the NHS England Patient Safety directive (TDA domain 2, criterion 3 and NICE recommendations 1, 3, - 11).

Explore options for alternative methods to self-reporting to identify medicines related safety incidents (TDA domain 2, criterion 3 and NICE key priority recommendation 4).

EFFECTIVE CHOICE OF MEDICINES

Medicines Optimisation Principle 2 – Evidence based choice of medicines Ensure that the most appropriate choice of clinically and cost effective medicines (informed by the best available evidence base) are made that can best meet the needs of the patient.

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The geographic distribution of the Trust’s services means that medicines for inpatient wards and community clinics are supplied by the pharmacy departments of a number of different organisations, all of which use different pharmacy IT systems. This makes collecting and analysing data about medicines use challenging. As a result no system is in place to provide routine information on the quantities, types and costs of medicines used by individual wards and teams, monitor the introduction of new medicines or the implementation of NICE technology appraisals, because the existing pharmacy team does not have the capacity to routinely undertake such work which requires a degree of professional interpretation in order to be meaningful. Reviewing the medicines that individual patients are taking is particularly important in certain patient groups and circumstances. These include patient who may be at risk, are frail or have multiple illnesses; those taking medicines with potentially serious side effects, or which may be abused or misused. Medication review is a structured, critical examination of a person’s medicines with the objective of reaching agreement with the patient about treatment (where the patient is involved) and optimising the impact of medicines. It is an important intervention for ensuring that patient’s medicines are optimised, and in the case of level 3 (see Table 2) medication review provide an opportunity to discuss medicines with the patient. Table 2: Types of Medication Review

Level 1 Prescription review

Level 2 Concordance &

compliance review

Level 3 Clinical medication

review

Purpose Address technical issues relating to the prescription e.g. anomalies, changed items, cost effectiveness

Address issues relating to the patients medicines-taking

behaviour

Address issues relating to the patients use of

medicines in the context of their clinical condition

Patient present No May or may not be present Yes

Access to Medical Records necessary

No / Possibly Possibly / Yes Yes

Includes all prescribed medicines

Possibly but may be restricted to single items

Yes Yes

Includes all medicines No Yes Yes

Area for development

Explore the options for providing routine prescribing information to ward and clinics such as inclusion of a data analyst within the pharmacy team, or integration of data feeds into ClickView. (TDA domain 3, criteria 1, 2 and 5).

Ensure that a structured medication review is undertaken in high risk patients, for example those who have experienced multiple falls within the trust’s services, or who are receiving high risk medicines. (NICE recommendation 25).

Explore utilisation of clinical pharmacists to improve the physical healthcare monitoring of mental health patients by allowing ordering of laboratory tests.

Explore the option for subscribing to MI databank to support the answering and recording of medicines information queries.

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PATIENT EXPERIENCE

Medicines Optimisation Principle 1 – Aim to understand the patient’s experience To ensure the best possible outcomes from medicines, there is an ongoing, open dialogue with the patient and/or their carer about the patient’s choice and experience of using medicines to manage their condition; recognising that the patient’s experience may change over time even if the medicines do not.

The use of patient’s own medicines following admission has a number of advantages. Where patient’s own drugs (PODs) are assessed as suitable for use on the ward, it can achieve cost savings if the stay in hospital is short and changes do not need to be made to medicines during admission. Patients bringing their medicines into hospital with them can also reduce the risk that supplies of medicines in the home may be different from those of discharge, as well as reducing multiple dispensing and waste. Patients and carers need to be encouraged to bring medication with them on admission wherever possible, not only to facilitate the use of PODs, but also to support medicines reconciliation. Self-administration during an inpatient stay provides an opportunity to assess the patient’s ability to take the medicines accurately and is an important part of re-enablement. Facilities should be in place to support such activities where this is a relevant part of the patient’s care plan. Area for development

When inpatient units are built or re-furbished facilities for the safe storage of patient’s own medicines to support self-administration are considered (TDA domain 4, criteria 1 and 2)

Patients should routinely receive the medicines they need at the time they need them, and in a safe way. Omitted and delayed medicines were the most commonly reported category of medication incidents reported to the NRLS between 2005 and 2010, involving nearly 16% of all incidents involving medicines. For some medicines such as antibiotics, anticoagulants and insulin, a missed dose can have serious or even fatal consequences. In some conditions it may lead to slower recovery or loss of function. A retrospective audit undertaken in February 2014 demonstrated that over a seven day period 1.3% of inpatient doses were omitted. As part of the Trust’s Quality Strategy for 2017-20 the ambition has been stated that no dose of medication will be omitted unless for a valid clinical reason that has been recorded. Area for development

Investigate the opportunities for using the medication elements of the NHS Safety Thermometer to capture information on omitted doses (TDA domain 4, criteria 5 and NICE key recommendation 4)

Patients make decisions about medicines based on their understanding of their conditions and the possible treatments, their view of their own need for medicines and their concerns about those medicines. If patients are to be involved in informed decision making about

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medicines they need information in a format and with content that meet their individual needs. Within the Trust mental health patients are supported to take their medicines as intended through access to the ‘Choice and Medication’ website.27 This was launched in 2009 as a collaboration between the College of Mental Health Pharmacists (CMHP), Pharmaceutical Schizophrenia Initiative and National Institute for Mental Health in England (NIMHE) and operates and provides independent information written by highly qualified mental health professionals. The site provides information about mental health conditions, individual drugs and comparative information about groups of drugs (e.g. antidepressants, antipsychotics). It provides an ideal vehicle for shared decision making between patients and healthcare professionals and is used as part of the successful Medication Adherence Project (MAP) within the trust. Areas for development

Improve knowledge about the ‘Choice and Medication’ website with patients, carers and healthcare professionals (TDA domain 4, criterion 3 and NICE recommendation 39 - 42)

Explore the options for obtaining equivalent information to support patients with medicines for treating physical healthcare conditions (TDA domain 4, criterion 3)

Between 30% and 70% of patients experience either an error or an unintentional change to their medicines when their care is transferred between settings,15,19 and it is widely accepted that when patients move between care providers there can be significant problems due to miscommunication. National ‘best practice’ guidance15,22 recommends core content for discharge information relating to medicines. Area for development

Ensure that the information about medicines being provided at discharge complies with national ‘best practice’ guidance (TDA domain 4, criteria 6 and NICE key recommendation 14)

Explore the options for sending information about medicines on discharge to a patient’s nominated community pharmacy (NICE key recommendation 16).

ENVIRONMENT FOR MEDICINES OPTIMISATION

Electronic prescribing systems help improve the safety and efficiency of health by aiding the choice, prescribing, administration and supply of medicines. They reduce the risk of medication errors as a result of more legible prescriptions, a requirement for complete medication orders, and by providing alerts to contra-indications, allergies, and drug interactions. Nurses who administer medicines have clear and legible medication orders to work from without having to search for drug charts. Medication records can be accessed remotely by healthcare professionals. Such systems also provide a full audit trail of the prescribing and administration of medicines, allowing omitted doses to be identified and rectified in real time. Such technology supports reduced clinical risk, increased opportunity for oversight, decision support, reduce unintentional missed doses, improved communication with GPs, decreased discrepancies between primary and secondary care info on medicines use; communication with community pharmacy.

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Area for development

To implement electronic prescribing and medicines administration, linked to pharmacy to facilitate dispensing and supply of medicines, wherever possible (domain 5, criteria 2 and NICE recommendations 43 – 46).

Introduce a referral to community pharmacy scheme for patients being discharged from hospital who meet the criteria for the New Medicines Scheme (NICE recommendation 17).

WORKFORCE FOR MEDICINES OPTIMISATION

Medicines Optimisation Principle 1 – Make medicines optimisation part of routine practice Health professionals routinely discuss with each other and with patients and/or their carers how to get the best outcomes from medicines throughout the patient’s care

A well trained, skilled workforce is fundamental to the delivery of high quality, safe and effective care. Those staff involved in the handling of medicines need to understand how medicines optimisation supports the use of medicines by the patients they treat and support. Areas for development

Participate in and contribute to, the Trust’s workforce planning activities to ensure that the organisation has the necessary skills for the future in relation to all aspects of handling medicines (TDA domain 6, criteria 1).

Continue to develop the medicines management training programme for qualified and unqualified staff working in mental health and learning disabilities services and community health services (TDA domain 6, criteria 3 and 4).

Review the medicines management structures and arrangements for obtaining pharmacy services within community health services to ensure that maximum benefits are being obtained (TDA domain 6, criteria 1).

Update and review the Trust’s non-medical prescribing policy and procedural guidelines. Explore options for reducing the use of Patient Group Directions through the development of non-medical prescribers (TDA domain 6, criteria 1).

Develop a business plan for pharmacy services incorporating finance, service and workforce requirements (TDA domain 6, criteria 6).

Monitoring and Review Each service will be held responsible for working towards the priorities and targets set within the Medicines Optimisation Strategy. Progress will be monitored through the work

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of the relevant sub committees reporting into the Quality Committee who will oversee the delivery of this strategy and monitor progress.

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References

Horne R, Weinman J, Barber N, Elliott R, Morgan M, Cribb A, et al. Concordance, adherence and compliance in medicine taking. 2005.

Barber N. Patients’ problems with new medication for chronic conditions. Qual Saf Heal Care. 2004 Jun 1;13(3):172–5.

Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18820 patients. BMJ. 2004;329(7456):15–9.

Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. [Internet]. General Medical Council; 2009 [cited 2012 Sep 22]. Available from: http://www.gmc-uk.org/about/research/25056.asp

Cousins DH, Gerrett D, Warner B. A review of medication incidents reported to the National Reporting and Learning System in England and Wales over 6 years (2005 – 2010). Br J Clin Pharmacol. 2011;74(4):597–604.

York Health Economics Consortium/The School of Pharmacy University of London. Evaluation of the scale, causes and costs of waste medicines. 2010.

Department of Health. Equality and excellence: Liberating the NHS. 2010.

The Mid Staffordshire NHS Foundation Trust Public Inquiry. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 2013.

National Advisory Group on the Safety of Patients in England. A promise to learn – a commitment to act. Improving the Safety of Patients in England. 2013.

Audit Commission. A spoonful of sugar. Medicines management in NHS hospitals. 2001.

Steering Group on Improving the Use of Medicines. Improving the use of medicines for better outcomes and reduced waste: an action plan. 2012.

Royal Pharmaceutical Society of Great Britain. Keeping patients safe when they transfer between care providers – getting the medicines right. 2012.

National Institute for Health & Care Excellence. Patient Group Directions. 2013.

National Institute for Health & Care Excellence. Developing and updating local formularies. 2012.

National Institute for Health & Care Excellence. Medicines adherence. Involving patients in decisions about prescribed medicines and supporting adherence. 2009.

NICE / NPSA. Technical patient safety solutions for medicines reconcilation on admission of adults to hospitalcy, National Institute for Health & Clinical Excellence / National Patient Safety. 2007.

National Prescribing Centre. A single competency framework for all prescribers. 2012.

Department of Health. The NHS Outcomes Framework 2014-15. 2013.

National Institute for Health & Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. 2015.

NHS England / MHRA. Improving medication error incident reporting and learning (Patient Safety Alert NHS/PSA/D/2014/005). 2014.

General Medical Council. Good practice in prescribing and managing medicines and devices. 2013.

National Prescribing Centre. Room for Review. A guide to medication review: the agenda for patients, practitioners and managers. 2002.

Clyne W, Blenkinsopp A, Seal R. A guide to medication review. National Prescribing Centre. 2008.

Choice and Medication Website [Internet]. Available from: www.choiceandmedication.org/sept/

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Appendix 1: NICE Medicines Optimisation Guidelines – Recommendations

Systems for identifying, reporting and learning from medicines-related patient safety incidents Improving learning from medicines-related patient safety incidents is important to guide practice and minimise patient harm. Medicines-related patient safety incidents are unintended or unexpected incidents that are specifically related to medicines use, which could have or did lead to patient harm. These include potentially avoidable medicines-related hospital admissions and re-admissions, medication errors, near

misses and potentially avoidable adverse events. 1. Organisations should support a person-centred, ‘fair blame’ culture that encourages reporting and learning from

medicines-related patient safety incidents.

2. Health and social care practitioners should explain to patients, and their family members or carers where appropriate, how to identify and report medicines-related patient safety incidents.

3. Organisations should ensure that robust and transparent processes are in place to identify, report, prioritise, investigate and learn from medicines-related patient safety incidents, in line with national patient safety reporting systems – for example, the National Reporting and Learning System.

4. Organisations should consider using multiple methods to identify medicines-related patient safety incidents – for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning.

5. Organisations should ensure that national medicines safety guidance, such as patient safety alerts, are actioned within a specified or locally agreed timeframe.

6. Organisations should consider assessing the training and education needs of health and social care practitioners to help patients and practitioners to identify and report medicines-related patient safety incidents.

7. Health and social care practitioners should report all identified medicines-related patient safety incidents consistently and in a timely manner, in line with local and national patient safety reporting systems, to ensure that patient safety is not compromised.

8. Organisations and health professionals should consider applying the principles of the PINCER intervention to reduce the number of medicines-related patient safety incidents, taking account of existing systems and resource implications. These principles include:

using information technology support

using educational outreach with regular reinforcement of educational messages

actively involving a multidisciplinary team, including GPs, nurses and support staff

having dedicated pharmacist support

agreeing an action plan with clear objectives

providing regular feedback on progress

providing clear, concise, evidence-based information.

9. Consider using a screening tool – for example, the STOPP/START3 tool in older people – to identify potential medicines-related patient safety incidents in some groups. These groups may include:

adults, children and young people taking multiple medicines (polypharmacy)

adults, children and young people with chronic or long-term conditions

older people.

10. Organisations should consider exploring what barriers exist that may reduce reporting and learning from medicines-related patient safety incidents. Any barriers identified should be addressed – for example, using a documented action plan.

11. Health and social care organisations and practitioners should:

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ensure that action is taken to reduce further risk when medicines-related patient safety incidents are identified

apply and share learning in the organisation and across the local health economy, including feedback on trends or significant incidents to support continuing professional development. This may be through a medicines safety officer, controlled drugs accountable officer or other medicines safety lead.

Medicines-related communication systems when patients move from one care setting to another Relevant information about medicines should be shared with patients and their family members or carers where appropriate and between health and social care practitioners when a person moves from one care setting to another, to support high-quality care. This includes transfers within an organisation – for example, when a person moves from intensive care to a hospital ward – or from 1 organisation to another – for example, when a person is admitted to hospital, or discharged from hospital to their home or other location. 12. Organisations should ensure that robust and transparent processes are in place, so that when a person is

transferred from one care setting to another:

the current care provider shares4 complete and accurate information about the person’s medicines with the new care provider and

the new care provider receives and documents this information, and acts on it.

13. For all care settings, health and social care practitioners should proactively share complete and accurate information about medicines:

ideally within 24 hours of the person being transferred, to ensure that patient safety is not compromised and

in the most effective and secure way, such as by secure electronic communication, recognising that more than one approach may be needed.

14. Health and social care practitioners should share relevant information about the person and their medicines when a person transfers from one care setting to another. This should include, but is not limited to, all of the following:

contact details of the person and their GP

details of other relevant contacts identified by the person and their family members or carers where appropriate – for example, their nominated community pharmacy

known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see the NICE guideline on drug allergy)

details of the medicines the person is currently taking (including prescribed, over-the-counter and complementary medicines) – name, strength, form, dose, timing, frequency and duration, how the medicines are taken and what they are being taken for

changes to medicines, including medicines started or stopped, or dosage changes, and reason for the change

date and time of the last dose, such as for weekly or monthly medicines, including injections

what information has been given to the person, and their family members or carers where appropriate

any other information needed – for example, when the medicines should be reviewed, ongoing monitoring needs and any support the person needs to carry on taking the medicines. Additional information may be needed for specific groups of people, such as children.

15. Health and social care practitioners should discuss relevant information about medicines with the person, and their family members or carers where appropriate, at the time of transfer. They should give the person, and their family members or carers where appropriate, a complete and accurate list of their medicines in a format that is suitable for them. This should include all current medicines and any changes to medicines made during their stay.

16. Consider sending a person’s medicines discharge information to their nominated community pharmacy, when possible and in agreement with the person.

19

17. Organisations should consider arranging additional support for some groups of people when they have been discharged from hospital, such as pharmacist counselling, telephone follow-up, and GP or nurse follow-up home visits. These groups may include:



older people.

Medicines reconciliation Medicines reconciliation, as defined by the Institute for Healthcare Improvement, is the process of identifying an accurate list of a person’s current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated. The term ‘medicines’ also includes over-the-counter or complementary medicines and any discrepancies should be resolved. The medicines reconciliation process will vary depending on the care setting that the person has just moved into – for example, from primary care into hospital, or from hospital to a care home. Algorithms have been produced to show the different processes. 18. In an acute setting, accurately list all of the person’s medicines (including prescribed, over-the-counter and

complementary medicines) and carry out medicines reconciliation within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another – for example, if they are admitted to hospital.

19. Recognise that medicines reconciliation may need to be carried out on more than one occasion during a hospital stay – for example, when the person is admitted, transferred between wards or discharged.

20. In primary care, carry out medicines reconciliation for all people who have been discharged from hospital or another care setting. This should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within 1 week of the GP practice receiving the information.

21. In all care settings organisations should ensure that a designated health professional has overall organisational responsibility for the medicines reconciliation process. The process should be determined locally and include:

organisational responsibilities

responsibilities of health and social care practitioners involved in the process (including who they are accountable to)

individual training and competency needs.

22. Organisations should ensure that medicines reconciliation is carried out by a trained and competent health professional – ideally a pharmacist, pharmacy technician, nurse or doctor – with the necessary knowledge, skills and expertise including:

effective communication skills

technical knowledge of processes for managing medicines

therapeutic knowledge of medicines use.

23. Involve patients and their family members or carers, where appropriate, in the medicines reconciliation process.

24. When carrying out medicines reconciliation, record relevant information on an electronic or paper-based form. See section 6 medicines-related communication systems.

Medication review Medication review can have several different interpretations and there are also different types which vary in their quality and effectiveness. Medication reviews are carried out in people of all ages. In this guideline medication review is defined as ‘a structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication-related problems and reducing waste’.

25. Consider carrying out a structured medication review for some groups of people when a clear purpose for the review has been identified. These groups may include:



20

older people.

26. Organisations should determine locally the most appropriate health professional to carry out a structured medication review, based on their knowledge and skills, including all of the following:

technical knowledge of processes for managing medicines

therapeutic knowledge on medicines use

effective communication skills.

The medication review may be led, for example, by a pharmacist or by an appropriate health professional who is part of a multidisciplinary team.

27. During a structured medication review, take into account:

the person’s, and their family members or carers where appropriate, views and understanding about their medicines

the person’s, and their family members’ or carers’ where appropriate, concerns, questions or problems with the medicines

all prescribed, over-the-counter and complementary medicines that the person is taking or using, and what these are for

how safe the medicines are, how well they work for the person, how appropriate they are, and whether their use is in line with national guidance

whether the person has had or has any risk factors for developing adverse drug reactions (report adverse drug reactions in line with the yellow card scheme)

any monitoring that is needed.

Self-management plans Self-management plans can be patient-led or professional led and they aim to support people to be empowered and involved in managing their condition. Different types of self-management plan exist and they vary in their content depending on the needs of the individual person. Self-management plans can be used in different settings. In this guideline self-management plans are structured, documented plans that are developed to support a person’s self-management of their condition using medicines. People using self-management plans can be supported to use them by their family members or carers who can also be involved when appropriate during discussions – for example a child and their parent(s) using a self-management plan.

28. When discussing medicines with people who have chronic or long-term conditions, consider using an individualised,

documented self-management plan to support people who want to be involved in managing their medicines. Discuss at least all of the following:

erson needs.

Record the discussion in the person’s medical notes or care plan as appropriate.

29. When developing an individualised, documented self-management plan, provide it in an accessible format for the person and consider including:

the plan’s start and review dates

the condition(s) being managed

a description of medicines being taken under the plan (including the timing)

21

a list of the medicines that may be self-administered under the plan and their permitted frequency of use, including any strength or dose restrictions and how long a medicine may be taken for

known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see the NICE guideline on drug allergy)

arrangements for the person to report suspected or known adverse reactions to medicines

circumstances in which the person should refer to, or seek advice from, a health professional

the individual responsibilities of the health professional and the person

any other instructions the person needs to safely and effectively self-manage their medicines.

30. Review the self-management plan to ensure the person does not have problems using it.

Patient decision aids used in consultations involving medicines Many people wish to be active participants in their own healthcare, and to be involved in making decisions about their medicines. Patient decision aids can support health professionals to adopt a shared decision-making approach in a consultation, to ensure that patients and their family members or carers where appropriate are able to make well-informed choices that are consistent with the person’s values and preferences.

31. Offer all people the opportunity to be involved in making decisions about their medicines. Find out what level of

involvement in decision-making the person would like and avoid making assumptions about this.

32. Find out about a person’s values and preferences by discussing what is important to them about managing their condition(s) and their medicines. Recognise that the person’s values and preferences may be different from those of the health professional and avoid making assumptions about these.

33. Apply the principles of evidence-based medicine when discussing the available treatment options with a person in a consultation about medicines. Use the best available evidence when making decisions with or for individuals, together with clinical expertise and the person’s values and preferences.

34. In a consultation about medicines, offer the person, and their family members or carers where appropriate, the opportunity to use a patient decision aid (when one is available) to help them make a preference-sensitive decision that involves trade-offs between benefits and harms. Ensure the patient decision aid is appropriate in the context of the consultation as a whole.

35. Do not use a patient decision aid to replace discussions with a person in a consultation about medicines.

36. Recognise that it may be appropriate to have more than one consultation to ensure that a person can make an informed decision about their medicines. Give the person the opportunity to review their decision, because this may change over time – for example, a person’s baseline risk may change.

37. Ensure that patient decision aids used in consultations about medicines have followed a robust and transparent development process, in line with the IPDAS criteria.

38. Before using a patient decision aid with a person in a consultation about medicines, read and understand its content, paying particular attention to its limitations and the need to adjust discussions according to the person’s baseline risk.

39. Ensure that the necessary knowledge, skills and expertise have been obtained before using a patient decision aid. This includes:

relevant clinical knowledge

effective communication and consultation skills, especially when finding out patients’ values and preferences

effective numeracy skills, especially when explaining the benefits and harms in natural frequencies, and relative and absolute risk

explaining the trade-offs between particular benefits and harms.

40. Organisations should consider training and education needs for health professionals in developing the skills and expertise to use patient decision aids effectively in consultations about medicines with patients, and their family members or carers where appropriate.

22

41. Organisations should consider identifying and prioritising which patient decision aids are needed for their patient population through, for example, a local medicines decision-making group. They should agree a consistent, targeted approach in line with local pathways and review the use of these patient decision aids regularly.

42. Organisations and health professionals should ensure that patient decision aids prioritised for use locally are disseminated to all relevant health professionals and stakeholder groups, such as clinical networks.

Clinical decision support Clinical decision support software is a component of an integrated clinical IT system providing support to clinical services, such as in a GP practice or secondary care setting. These integrated clinical IT systems are used to support health professionals to manage a person’s condition. In this guideline the clinical decision support software relates to computerised clinical decision support, which may be active or interactive, at the point of prescribing medicines.

43. Organisations should consider computerised clinical decision support systems (taking account of existing systems

and resource implications) to support clinical decision-making and prescribing, but ensure that these do not replace clinical judgement.

44. Organisations should ensure that robust and transparent processes are in place for developing, using, reviewing and updating computerised clinical decision support systems.

45. Organisations should ensure that health professionals using computerised clinical decision support systems at the point of prescribing have the necessary knowledge and skills to use the system, including an understanding of its limitations.

46. When using a computerised clinical decision support system to support clinical decision-making and prescribing, ensure that it:

identifies important safety issues

includes a system for health professionals to acknowledge mandatory alerts. This should not be customisable for alerts relating to medicines-related ‘never events’

reflects the best available evidence and is up-to-date

contains useful clinical information that is relevant to the health professional to reduce ‘alert fatigue’ (when a prescriber’s responsiveness to a particular type of alert declines as they are repeatedly exposed to that alert over time).

Medicines-related models of organisational and cross-sector working The introduction of skill mixing of various health and social care practitioners to meet the needs of different groups of people has led to different types of models of care emerging across health and social care settings. Cross-organisational working further provides seamless care during the patient care pathway when using health and social care services. The type of model of care used will be determined locally based on the

resources and health and social care needs of the population in relation to medicines. 47. Organisations should consider a multidisciplinary team approach to improve outcomes for people who have long-

term conditions and take multiple medicines (polypharmacy).

48. Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

23

Appendix 2: Medicines Optimisation and Pharmaceutical Services Framework (Trust Development Authority)

Mental Health & Learning Disability Services

Domains

Domain 1 Strategy, risk

and governance

Domain 2 Safe use of medicines

Domain 3 Effective choice of medicines

Domain 4 Patient

experience

Domain 5 Environment for medicines optimisation

Domain 6 Workforce for

medicines optimisation

Do

ma

in C

rite

ria

1

A strategy to guide the development

of medicines optimisation is in place in the trust

Medicines are handled safely and

securely

There is an effective local

decision-making process for

medicines use

There is a policy and suitable

facilities for the use of patient’s own medicines

Medicines are stored, prepared and administered in areas that are “fit for purpose”

Workforce planning to

support delivery of medicines

optimisation

2

There is an executive level

medicines policy group overseeing medication policy and development

Medicines reconciliation takes

place > 80% of patients within 24 hrs

of admission and actions are routinely

followed up, documented and communicated

There are metrics for monitoring the cost and quantity of medicines used

Patients who are competent to do

so can self-administer their

medicines

There is a comprehensive

electronic prescribing and

medicines administration

system

Clinical pharmacy services support the organisation’s


strategy

3

The management of medicines is

underpinned by an overarching

medicines policy

Medication errors and harm from medicines are measured and

lessons learned are routinely embedded

in policies and practice

Audit of medicines use takes place

routinely

Patients are supported to take their medicines as

intended

Unwanted and returned

medicines are actively managed

Medicines are prepared and

administered by competent staff

4

There is oversight and control of

clinical risks and costs associated with medicines

The quality impact of cost reducing

schemes involving medicines or

pharmacy services are routinely

assessed and monitored

The principles of antimicrobial

stewardship are implemented

A duty of candour is applied to harm from medicines

All medicines are stored

appropriately

Training and development

includes medicines optimisation

5

A Chief Pharmacist plays a

leading role in medicines

optimisation

Policies and procedures for the

safe use of medicines are in

place

NICE guidance is implemented

effectively

Patients receive the medicines that

they need

Controlled drugs are managed

safely and effectively

Staff are able to raise concerns

about poor practice

6

The trust board and senior

management are actively involved in


Unlicensed, ‘off-label’ and

investigational medicines are

used safely

The trust has a published

formulary for medicines

Transfers of care occur according to

national ‘best practice’ guidance

and pharmaceutical

care plans

Areas where medicines are

stored, dispensed, prepared and

administered are monitored and

maintained

There is a pharmacy services

business plan linked to the trust’s

business plan

Level 4 Highest level

Level 3

Level 2

Level 1 Lowest level

24

Community Health Services

Domains

Domain 1 Strategy, risk

and governance

Domain 2 Safe use of medicines

Domain 3 Effective choice of medicines

Domain 4 Patient

experience

Domain 5 Environment for medicines optimisation

Domain 6 Workforce for


Do

ma

in C

rite

ria

1

A strategy to guide the development

of medicines optimisation is in place in the trust

Medicines are handled safely and

securely

There is an effective local

decision-making process for

medicines use

There is a policy and suitable

facilities for the use of patient’s own medicines

Medicines are stored, prepared and administered in areas that are “fit for purpose”

Workforce planning to

support delivery of medicines

optimisation

2

There is an executive level

medicines policy group overseeing medication policy and development

Medicines are reconciled routinely

There are metrics for monitoring the cost and quantity of medicines used

Patients who are competent to do

so can self-administer their

medicines

There is a comprehensive

electronic prescribing and

medicines administration

system

Clinical pharmacy services support the organisation’s


strategy

3

The management of medicines is

underpinned by an overarching

medicines policy

Medication errors and harm from medicines are measured and

lessons learned are routinely embedded

in policies and practice

Audit of medicines use takes place

routinely

Patients are supported to take their medicines as

intended

Unwanted and returned

medicines are actively managed

Medicines are prepared and

administered by competent staff

4

There is oversight and control of

clinical risks and costs associated with medicines

The quality impact of cost reducing

schemes involving medicines or

pharmacy services are routinely

assessed and monitored

The principles of antimicrobial

stewardship are implemented

A duty of candour is applied to harm from medicines

All medicines are stored

appropriately

Training and development

includes medicines optimisation

5

A Chief Pharmacist plays a

leading role in medicines

optimisation

Policies and procedures for the

safe use of medicines are in

place

NICE guidance is implemented

effectively

Patients receive the medicines that

they need

Controlled drugs are managed

safely and effectively

Staff are able to raise concerns

about poor practice

6

The trust board and senior

management are actively involved in


Unlicensed, ‘off-label’ and

investigational medicines are

used safely

The trust has a published

formulary for medicines

Transfers of care occur according to

national ‘best practice’ guidance

and pharmaceutical

care plans

Areas where medicines are

stored, dispensed, prepared and

administered are monitored and

maintained

There is a pharmacy services

business plan linked to the trust’s

business plan

Level 4 Highest level

Level 3

Level 2

Level 1 Lowest level

25

= MH & LD = CHS

Domain Criterion Level 1 Level 2 Level 3 Level 4

Domain 1

Strategy, risk and governance

1. A strategy to guide the development of medicines optimisation is in place in the trust

No evidence that the trust has a clear strategy for optimising patient outcomes from medicines (medicines optimisation) within its overall clinical strategy

There is a draft medicines optimisation strategy under discussion but not yet approved by the Board

Strategy that adheres to the Royal Pharmaceutical Society’s four principles for medicines optimisation in place and approved by the Board. Implementation plan in place

As level 3 plus key performance indicators developed and regular review of achievements undertaken

2. There is an executive level medicines policy group overseeing medication policy and development

The trust does not have a strategic oversight group for developing medicines policy, procedures and guidance and providing oversight of medicines safety

The trust has a strategic oversight for developing medicines policy and procedures and overseeing medication safety

The trust has an oversight group for developing medicines policy and procedures and it is responsible for making decisions about medicines that are implemented across the trust

The trust can provide evidence that implementation of policy, procedures and decision about medicines applies across the whole trust. The oversight group produces regular board reports.

3. The management of medicines is underpinned by an overarching medicines policy

No evidence that there is an overarching medicines policy that supports an integrated approach to medicines optimisation across the whole organisation

There is a comprehensive, overarching medicines policy that supports an integrated approach to medicines optimisation across the whole organisation

There is an overarching medicines policy in place and all clinical staff receive a copy or can access a copy as part of their induction

There is a comprehensive, overarching medicines policy in place and a regular audit programme exists to assure compliance

4. There is oversight and control of clinical risks and costs associated with medicines

The trust does not have robust business and financial planning, management, monitoring and reporting systems to manage clinical risks& costs associated with medicines

The trust has rudimentary business and financial planning, management, monitoring and reporting systems to manage clinical risks & costs associated with medicines

The trusts has robust business and financial planning, management, monitoring and reporting systems to manage clinical risks & costs associated with medicines

The trust has robust business sand financial planning, monitoring and reporting systems to manage clinical risks and costs associated with medicines, These are routinely shared and discussed with commissioners

5. A Chief Pharmacist plays a leading role in medicines optimisation

The trust does not have a chief pharmacist (or equivalent)

The trust has a chief pharmacist (or equivalent) responsible for operational pharmacy management and service delivery

The trust has a chief pharmacist who has Trustwide responsibility and is held accountable for medicines optimisation and pharmaceutical services

As level 3 and reports directly to an Executive Board member

6. The trust board and senior management are actively involved in medicines optimisation

There is no named lead Director for medicines optimisation and pharmaceutical services

There is a named lead Director for medicines optimisation and pharmaceutical services

There is a named lead Director for medicines optimisation and Board members are generally informed about medicines related issues

There is documentary evidence via Board minutes of active participation by the named lead Director and Board discussion of medicines optimisation issues that impact on the trusts business and its service users

Domain 2

Safe use of medicines

1. Medicines are handled safely and securely

No evidence of a system to routinely monitor and review the safe and secure handling of medicines to meet the clinical needs of patients and legal and regulatory requirements

Evidence the trust has an effective system to routinely monitor and review the safe and secure use and handling of medicines to meet the clinical needs of patients and legal and regulatory requirements

The trust has an effective system to monitor and review safe and secure handling of medicines and a named pharmacist is responsible for safe and secure handling of medicines. Regular compliance audits are undertaken

The Board received regular audit reports on the safe and secure handling of medicines and takes steps to address shortcomings. The Board is assured that it meets legal and regulatory requirements

2. Medicines are reconciled routinely

No evidence that there is a formal system for medicines reconciliation as recommended by national guidance

Evidence that there is a medicines reconciliation policy in place and medicines reconciliation takes place for some patients

Evidence that there is a medicines reconciliation policy in place and medicines reconciliation takes place for the majority of patients within a specified time after admission

Medicines reconciliation takes place for more than 80% of patients within 24 hours of admissions and actions are routinely followed up, documented and communicated

3. Medication errors and harm from medicines are measured and lessons learned are routinely embedded in policies and practice

Medication incidents are not routinely monitored and reported across the trust. There is not a documented mechanism to enable learning from medication incidents to be shared

There is an effective system for identifying, monitoring, analysing and reporting medication incidents across the trust. Evidence that learning from medication incidents in routinely shared across the trust

There is a robust system, which includes performance measures, for routinely monitoring, reporting and embedding learning from medication errors across the trust. Harm related to medicines is identified and reported to the Board

Action plans to reduce medication errors are devised, implemented and audited. Evidence that the Board is able to assure itself that the trust complies with national ‘best practice’ guidance for medication safety through regular reports on learning arising from incidents

26


4. The quality impact of cost reducing schemes involving medicines or pharmacy services are routinely assessed and monitored

No evidence that the impact on service quality of QIPP, CRES or other cost saving measures relating to medicines use or pharmacy services are formally assessed

Cost reduction schemes involving changes to medicines use or pharmacy services are devised and signed off by the Chief Pharmacist (or equivalent)

Cost reduction schemes involving changes to medicines use or pharmacy services are quality assess and signed off by the Chief Pharmacist and another senior trust manager

Cost reduction schemes involving changes to medicines use or pharmacy services are quality assessed and signed off by the Trust Medical Director or Director of Nursing. Quality impact is monitored regularly and reported through governance arrangements

5. Policies and procedures for the safe use of medicines are in place

No evidence that the trust has a set of comprehensive policies and standardised procedures to minimise the risk to patients from medicines

Evidence that the trust has a set of comprehensive policies and standardised procedures to minimise the risk to patent from medicines. This includes policies for patient group directions and non-medical prescribing

As level 2 and a clear description of the responsibilities of all staff involved in medicines procurement, supply, prescribing, and administration is available and included in staff appraisals. Process for regularly reviewing all patient group directions is in place

AS level 3 and evidence that compliance with medicines policies and procedures is monitored routinely and reported through the trusts integrated governance system. All patient group directions are up-to-date.

6. Unlicensed, ‘off-label’ and investigational medicines are used safely

No evidence of a policy for the safe use of unlicensed, ‘off-label’ or investigational medicinal products

Policy for the safe use of unlicensed, ‘off-label’ or investigational medicinal products in development

Policy for the safe use of unlicensed, ‘off-label’ or investigational medicinal products implemented for all patients and regularly audited

Policy for the safe use of unlicensed, ‘off-label’ or investigational medicinal products. Evidence that all patients consent to the use of such products and this is routinely recorded in their clinical notes

Domain 3

Effective choice of medicines

1. There is an effective local decision-making process for medicines use

No evidence that there is a clearly defined process for overseeing and decision on the medicines that are used within the trust

Evidence that there is a drugs and therapeutics committee or equivalent local decision-making body for overseeing effective use of medicines within the trust including new medicines

As 2 plus the DTC has a formal business plan approved through the integrated governance process. The introduction and use of new medicines is audited

DTC monitors and regularly reviews implementation of its decisions and takes action to address non-compliance. Evidence of active engagement with commissioners

2. There are metrics for monitoring the cost and quantity of medicines used

No evidence that there is regular review of the types of medicines, quantity and cost of medicines used across the trust

Evidence that the types of medicines, quantities and cost used by individual wards and teams are reviewed regularly

Evidence that information on the types of medicines, quantities and cost used by individual wards and teams are reviewed regular and sent to team managers

Evidence that senior managers receive and act on information about the types of medicines, quantity and cost used by their wards and teams

3. Audit of medicines use takes place routinely

Medicines audits either do not occur or occur on an ad hoc basis

The trust has an audit programme that includes some medicines audits

The trust has evidence that ti conducts a wide range of medicines-related audits that includes homecare services (where homecare services are provided to patients)

As level 3 plus evidence that audit results are used to continuously improve the quality of services provided and to provide assurance that medicines are used optimally

4. The principles of antimicrobial stewardship are implemented

No evidence of a policy to support the judicious use of antimicrobials and promote antimicrobial stewardship

Evidence of a specific policy to support the judicious use of antimicrobials. Antimicrobial stewardship audit undertaken

Trust antimicrobial policy contains specific recommendations on the implementation of national ‘best practice’ guidance (e.g. Start Smart then Focus) and a lead pharmacist for antimicrobials is in post. Evidence of active engagement across local health economy

As level 3 plus lead pharmacist has specific responsibility for monitoring and auditing antimicrobial usage and is a formal member of infection prevention and control committee (or equivalent). Evidence that audit results influence use of antimicrobials

5. NICE guidance is implemented effectively

No evidence of a formal process for implementing relevant NICE technology appraisal guidance

Evidence of a process for implementing relevant NICE technology appraisal guidance within 90 days of publication

Evidence of an effective mechanism for monitoring and reporting on the implementation of NICE technology appraisal guidance and taking action where poor compliance is identified

Reports on implementation of NICE technology appraisal guidance routinely published. Evidence of active engagement with commissioners

6. The trust has a published formulary for medicines

No evidence of a published formulary for medicines

Formulary in development or in place for some medicines

Comprehensive formulary developed and published in a publically accessible format. Evidence that commissioners have been actively engaged in development of the formulary

Formulary fully implemented, published and monitored. Evidence to demonstrate that non-compliance is actively monitored and justified to commissioners

27


Domain 4

Patient experience

1. There is a policy and suitable facilities for the use of patient’s own medicines

The trust does not have a policy for the use of a patient’s own medicines and there are no/limited facilities in patient areas for the safe storage and ready access to

A policy for use of patient’s own medicines is in development and there are facilities for the safe storage of patient’s own medicines in some clinical areas

A policy for use of patient’s own medicines is in place and there are facilities for the safe storage of patient’s own medicines in most clinical areas

A policy for use of patient’s own medicines is in place and audited regularly and there are facilities for the safe storage of patient’s own medicines in all clinical areas

2. Patients who are competent to do so can self-administer their medicines

The trust does not have a policy to enable patients to be assessed as competent to administer their own medicines

Self-administration policy and assessment scheme in development

Self-administration policy and assessment scheme in place and some patients assessed as competent to do so are able to administer their own medicines

Self-administration policy and assessment scheme in place and all patients assessed as competent to do so are able to administer their own medicines

3. Patients are supported to take their medicines as intended

No evidence that patients have access to and are helped to understand information about their medicines

Patients are provided with written information about their medicines

Patients are provided with written and verbal information about their medicines

Evidence that there is a mechanism to ensure that patients have understood the information that has been provided and know how to get help with their medicines should they need

4. A duty of candour is applied to harm from medicines

The trust does not have a mechanism for monitoring, reporting and informing patients (or their carers) when they have suffered harm as a result of a medicines-related issue e.g. adverse reaction, medication errors etc.

A policy to include a duty of candour with respect to medicines-related incidents is not development

Duty of candour policy in place and staff are trained to ensure effective implementation. Duty of candour requirement included in staff job descriptions

Evidence that patients are routinely informed when they have suffered harm as a result of a medicines-related issue. Chief Pharmacist routinely involved in investigations of all incidents leading to harm

5. Patients receive the medicines that they need

The trust does not routinely monitor omitted and delayed doses

Mechanism for monitoring omitted and delayed doses in development

Mechanism for monitoring omitted and delayed doses implemented and audited. Results are reported to service managers

Mechanism for monitoring omitted and delayed doses implemented and audited. Trust can provide evidence that it is actively taking steps to make improvements

6. Transfers of care occur according to national ‘best practice’ guidance and pharmaceutical care plans

No evidence of a mechanism for ensuring accurate information about the service user’s medicines are transferred to the healthcare professional(s) taking over the care of the patient

Evidence of a mechanism for ensuing accurate information about the service user’s medicines are transferred to the healthcare professional(s) taking over the care of the patient

Evidence of a mechanism for ensuing accurate information about the service user’s medicines are transferred to the healthcare professional(s) taking over the care of the patient complies with national ‘best practice’ guidance

As level 3 and implemented in all wards and departments and that this is regularly audited, including feedback from relevant stakeholders (e.g. GPs, care homes). Pharmaceutical care plans (or their equivalent) are prepared for appropriate patients

Domain 5

Environment for medicines optimisation

1. Medicines are stored, prepared and administered in areas that are “fit for purpose”

Medicines are stored, prepared and administered in areas not designated for the task

In some wards, clinics and team bases, medicines are stored, prepared and administered in designated ‘fit for purpose’ areas

In most wards, clinics and team bases, medicines are stored, prepared and administered in designated ‘fit for purpose’ areas

Medicines are stored, prepared and administered in specifically designated areas. These are regularly inspected to ensure compliance with legal, regulatory and ‘best practice’ guidance

2. There is a comprehensive electronic prescribing and medicines administration system

The trust does not have an electronic prescribing and administration system

The trust has implemented an electronic prescribing and medicines administration in some wards and departments, or for some patients

The trust has implemented an electronic prescribing and medicines administration in all wards and departments, or for all patients

The trust has implemented electronic prescribing and medicines administration system in all wards and departments for all patients that provides information for other care providers

3. Unwanted and returned medicines are actively managed

There is no evidence of a formal policy and standard operating procedure for managing waste and returned medicines

A formal policy and standard operating procedure for managing waste and returned medicines is in development

A formal policy and standard operating procedure for managing waste and returned medicines has been developed and implemented

As level 3 and compliance is routinely monitored. There is evidence that non-compliance is reported to senior managers and effective action plans developed and implemented

28


4. All medicines are stored appropriately

No evidence of standard operating procedures for monitoring medicines storage (including temperature-sensitive medicines and bulk fluids where used). Fridge temperatures are not actively monitored

A standard operating procedure (as level 1) is in development

There is a standardised operating procedure for monitoring medicines storage that complies with legal, regulatory and national ‘best practice’ guidance. Fridge temperatures are routinely monitored. Storage of bulk fluids has been risk assessed.

As level 3 and compliance with the procedure is regularly monitored. There is evidence that non-compliance is identified and action plans developed and implemented. Storage of bulk fluids meets national ‘best practice’ guidance

5. Controlled drugs are managed safely and effectively

Controlled drugs are not managed in line with the requirements of the Misuse of Drugs legislation and governance requirements

Controlled drugs are managed in line with the requirements of the Misuse of Drugs legislation and governance requirements in most clinical areas. Policy for safe management of controlled drugs in place

Controlled drugs are managed in line with the requirements of the Misuse of Drugs legislation and governance requirements in all clinical and non-clinical areas. Policy for safe management of CDs in place and routinely audited for non-compliance

As level 3 and the trust attends and actively contributes to the local controlled drugs intelligence network. CD accountable officer provides regular feedback through the trust’s integrated governance arrangements

6. Areas where medicines are stored, dispensed, prepared and administered are monitored and maintained

No evidence of monitoring and maintaining standards for pharmacy and ward environments where medicines are stored, prepared, dispensed and administered

Evidence of a policy to ensure that pharmacy and ward environments are ‘fit for purpose’ and comply with relevant legal, regulatory and ‘good practice’ guidance and standards

Evidence that policy is regularly updated and implementation audited

Evidence that action plans are in place to address any areas of non-compliance identified through audit within an agreed timescale. Evidence that the Board receives assurance of compliance with standards

Domain 6

Workforce for medicines optimisation

1. Workforce planning to support delivery of medicines optimisation

No evidence that integrated workforce planning to support delivery of medicines optimisation strategy takes place

Integrated workforce plan to deliver the strategy is in development

Integrated workforce plan completed and used to influence recruitment and skill mix for medicines optimisation. This includes strategy for developing non-medical prescribing

As level 3 plus the integrated workforce plan has been implemented and is linked to performance management and personal development planning for relevant staff

2. Clinical pharmacy services support the organisation’s medicines optimisation strategy

There is no formal clinical pharmacy service

Clinical pharmacy service available to a minority of patient or in an ad-hoc manner. Visits to clinical areas are unplanned or infrequent. No recording of pharmacy contributions

Clinical pharmacy service available to most patients according to need. Pharmacists visibly record when they have seen a prescription and assessed as clinically appropriate for the patient

Comprehensive clinical pharmacy service available for the majority of patients and activity and performance data routinely collected. Clinical pharmacist contributions monitored and audited

3. Medicines are prepared and administered by competent staff

No evidence that there is a formal mechanism for ensuring that staff who procure, store, distribute, prescribe, prepare, administer or handle medicines are appropriately qualified and competent to undertake their required roles

Evidence that staff who procure, store, distribute, prescribe, prepare, administer or handle are required to undertake mandatory training on induction and regularly thereafter

Evidence that staff are required to undertake mandatory training and their competence to undertake required roles with respect to medicines is assessed regularly

Evidence that training and competency assessments are included in appraisals and personal development plans of all staff who are involved in the use of medicines within the trust. Evidence of active engagement with local education and training commissioner

4. Training and development includes medicines optimisation

Medicines optimisation forms no specific part of the induction programme for medical, nursing and relevant allied healthcare professionals

Medicines optimisation forms a specific part of the induction programme for medical, nursing and relevant allied healthcare professionals. Pharmacy staff provide active input to the induction programme

In addition to level 2, some staff involved with the prescribing, dispensing and administration of medicines receive regular training and updates to keep them abreast with developments

In addition to level 3, medicines optimisation forms a part of the mandatory training programme for all relevant staff. Pharmacy staff provide additional input to education and training programmes

5. Staff are able to raise concerns about poor practice

There are no processes within the trust to enable staff to raise concerns about poor practice with medicines

There are processes within the trust to enable staff to raise concerns about poor practice with medicines

There processes within the trust to enable staff to raise concerns about poor practice with medicines and for these to be addressed by senior managers

There is documented evidence that senior managers of the trust have addressed any concerns raised about poor practice with medicines

6. There is a pharmacy services business plan linked to the trust’s business plan

The development of pharmacy services, including financial, service and workforce plans is ad-hoc or unplanned

A business plan for pharmacy services, incorporating financial, service and workforce plans, is in development

A business plan has been developed for pharmacy services, incorporating finance, service and workforce plans, which is linked to the organisation’s corporate plan that has been signed off by the Trust Board (or relevant sub-group)

As level 3 and performance against the business plan is monitored through KPIs agreed by the Board (or relevant sub-group)


Page 1 of 2

Agenda Item No: 8b

SUMMARY REPORT


25 April 2018

Report Title: Update On Potential Ligature Risk Assessment and Mitigation Processes

Executive/Non-Executive Lead:


Report Author(s): Faye Swanson Director of Compliance and Assurance


N/A

Level of Assurance: Level 1

X Level 2 Level 3


This report provides an update on the action that continues to be taken to strengthen the potential ligature risk assessment and mitigation processes within the trust.

Approval

Discussion

x

Information

x



1. Consider the content of this report 2. Request any further action or assurance as necessary


Action continues to be made to mitigate potential risk.

Significant investment (financial and management) continues to be made.

Good progress has been made in strengthening risk assessment processes.

Environmental improvements, prioritised based on risk, have been undertaken since publication of the CQC unannounced inspection (carried out in November 2017)

Ensuring that staff are aware of and understand potential risk has received increased attention.

There is commitment to continuing the work undertaken in the past year into 20188 and beyond.


SP 1: Continuously improve patient safety, experience and outcomes x





Page 2 of 2


1: Open x

2: Compassionate x

3: Empowering



YES

If yes, insert relevant risk: R1: If services fall short of the standards required to remain compliant with the Health and Social Care Act there is the potential for CQC enforcement action or in extreme cases closure of services. R3: If the Trust fails to provide high quality services from premises that are safe, then the risk related to ligatures is not minimised and this may impact on the safety of patients in inpatient services.


NO



x

Data quality issues



Service impact/health improvement gains x

Financial implications: (already allocated) Capital £


Governance implications x

Impact on patient safety/quality x





Report attached

Lead


1

Agenda Item 8b Board of Directors Meeting

25 April 2018

EPUT

UPDATE ON POTENTIAL LIGATURE RISK ASSESSMENT AND MITIGATION PROCESSES

PURPOSE OF REPORT

This report provides an update on the action that continues to be taken to strengthen the potential ligature risk assessment and mitigation processes within the trust.

BACKGROUND/ CONTEXT

The Board of Directors received reports in September 2017 and January 2018 that confirmed the context and action taken post merger to strengthen the ligature risk assessment and mitigation processes in the trust. In summary this was:

The CQC comprehensive inspection of former NEP services in August 2015 found that there were improvements required to minimise risk associated with potential ligature anchor points identified in in-patient services. A Warning Notice was subsequently issued by the CQC in November 2016 as a result of insufficient progress being made to address concerns raised.

On merger, the CEO of EPUT requested that a re- audit of all acute, secure and specialist mental health in-patient services was carried out across the whole new Trust.

Early re-audit experience identified that the ligature audit process that had been in place required strengthening and the opportunity was taken to review and strengthen it. By the end of September 2017, 8 wards had been subject to Executive led review, priority safety improvement works identified and funding released to undertake these.

In the January 2018 progress report, the Board of Directors were advised that progressing the safety improvement works at the pace anticipated had proved to be challenging but all major works agreed to the 8 wards had been completed.

The Board of Directors was advised that rather than progressing risk mitigation on a ward by ward basis, an approach based on risk stratification of all inpatient environments was now in place which had identified replacement of all non moulded toilets in forensic, adult acute, CAMHs, learning disability and functional older peoples in-patient environments and installation (in the same services, where there were none previously) of a minimum of 4 door top alarms to bedrooms (and ensuite depending on unit) where patients assessed as at risk would be cared for. Funding was confirmed to progress these improvement works.

In January 2018 the CQC published the findings of its unannounced inspection of the majority of the trust’s in-patient services in November 2017. The CQC acknowledged that progress had been made in mitigating potential ligature risk but identified that further work was still required.

The CQC did however confirm that at Byron Court (learning disability service) ligature risks were being managed effectively and that the ligature risk assessment carried out in September 2017 identified all ligature points. Within the trust’s forensic mental health service the CQC reported, as an area of good practice that staff identified ligature points and actions had been completed to reduce risk to patients.

2

PROGRESS UPDATE

Whilst the CQC findings were disappointing they were not unexpected given the scale of action identified as required and the point on the journey the trust was at in November 2017. The findings did however identify that the systems established could be effective, but needed to be more consistent across all wards and implemented at pace. Dialogue with the local CQC team through routine engagement meetings and resulting reflection on the trust’s approach, led to a re-focussing and deeper understanding of the wide range of actions required to mitigate potential risk. It is recognised that inpatient environments will rarely be entirely free of fixed ligature points because they were not designed to mitigate the potential risks being identified currently and/or there are not design solutions possible to eliminate risk entirely from all infrastructure, fixtures and fittings. There is also limited national guidance, standards or regulations against which comprehensive ligature risk assessments can be undertaken. The actions required cannot therefore just be focussed on the estate. Providers need to take a holistic approach to managing potential risk. Since February 2018 the following actions have been taken that encompass approach, environment and culture: Risk Assessment Processes

All ligature risk assessments carried out since April 2017 have been reviewed by the Risk Team with estates and local clinical leaders to ensure that they reflect current risks and mitigation plans are realistic.

The Ligature Risk Assessment tool in use has been subject to rigorous review and as a result it has been redesigned and strengthened. Photographs of potential risks are included in the assessments and heat maps (floor plans of wards identifying locations of potential fixed ligature points) are developed by ward teams as a result. Following testing, rollout of the revised tool has commenced.

All ligature risk assessments have been re-issued to every ward. They are now stored with the heat maps in a red wallet in the nursing station/ office, in a visible place.

All inpatient wards (and health based place of safety suites) have had ligature risk assessment completed since April 2017.

A process has been established to carry out risk assessment of potential ligature risk in community mental health clinics. Whilst these are public buildings; used by people living with mental ill health in their communities and those who have physical health conditions; staff recognising that there are potential fixed ligature points and considering these in the risk assessment of patients is part of the trust’s holistic approach to this risk.

Similarly, people experiencing mental health crisis attend acute general hospital accident and emergency (A&E) departments. Risk assessments have been carried out of all 5 local A&E departments.

Environment

The Estates Task and Finish Group met fortnightly since January 2018 (weekly since March 2018) to oversee the environmental improvement programme agreed. The appointment of a single contractor to carry out all required works has significantly impacted and improved the trust’s ability to address identified issues at pace, as has

3

the appointment of a dedicated Estates Project Lead to oversee the programme of works.

All obvious potential ligature risks identified by the CQC in the inspections carried out in November 2017 have been addressed. In some cases, actions taken are interim measures until longer term solutions can be implemented. For example, window handles have been removed and windows sealed shut. This is recognised as not ideal but the risk associated with leaving the handles in-situ has been assessed and removal agreed as the preferred option in the short term.

The replacement toilet programme and installation of door top alarms (where they were not in place previously) is well underway but may not be fully completed until late May 2018.

Line of sight audits have been undertaken in all inpatient environments and parabolic mirrors installed as requested by individual clinical teams to improve observation of patients in all areas of the ward.

There is a clear record of all works undertaken and any that remain on the current programme for completion for each ward. This has been shared with ward managers so that they are able to demonstrate progress made and have an understanding of future plans to share with staff or the CQC.

Awareness and Understanding

A ligature awareness on-line training package has been developed and launched in the past month to encourage greater understanding of the risk.

The re-issue of ligature risk assessments and development of heat maps has encouraged discussion within ward teams of the potential risks and development of the staff narrative about how they manage potential risks in the area that they work.

Staff have been encouraged to discuss potential ligature risk in local handovers and induction processes for new temporary and permanent staff.

CONCLUSION

There has been a significant investment (financial and management) on managing potential ligature risk over the past 12 months and it is hoped that the progress identified is welcomed. The action is on-going and this potential risk will remain high on the organisations agenda during 2018 and beyond.

RECOMMENDATIONS AND ACTION REQUIRED


1. Consider the content of this report 2. Request any further action or assurance as necessary

Report Prepared By Faye Swanson Director of Compliance and Assurance On Behalf Of Nigel Leonard Executive Director of Corporate Governance & Strategy

1

Agenda Item No: 8c

SUMMARY REPORT

BOARD OF DIRECTORS Part One 25 April 2018

Report Title: Duty of Candour Annual Review Executive/Non-Executive Lead: Natalie Hammond Executive Nurse Report Author(s): Sharan Smith, Head of Incident Management Report discussed previously at: Level of Assurance: Level 1 Level 2 Level 3 Purpose of the Report This report provides:

• An annual position on Duty of Candour compliance and an updated summary of associated work streams for the year 2017-18

Approval Discussion Information


1 Note the contents of the report 2 Approve the report for discussion at the Part 1 Board of Directors meeting 3 Request any further information or action


• The Duty of Candour actively encourages transparency and openness; the Trust has a legal and contractual obligation to ensure compliance with the standard.

• A number of areas of work are in place to support staff in encouraging an open and transparent culture. This includes an extended training programme, further work being undertaken around family involvement in investigations and further improvements to incident reporting and management to support transparency

• The Trust was compliant with Duty of Candour timeframes and requirements for all applicable incidents during 2017-18

Relationship to Trust Strategic Objectives SP 1: Continuously improve patient safety, experience and outcomes SP 2: Attract, develop, enable and retain high performers SP 3: Achieve top 25% performance SP 4: Co-design and co-produce service improvement plans Which of the Trust Values are Being Delivered 1: Open 2: Compassionate 3: Empowering Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? No If yes, insert relevant risk N/A Do you recommend a new entry to the BAF is made as a result of this report? No Corporate Impact Assessment or Board Statements for Trust: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, new Trust Annual Plan & Objectives

Data quality issues Involvement of Service Users/Healthwatch Communication and consultation with stakeholders required Service impact/health improvement gains

2



Governance implications Impact on patient safety/quality Impact on equality and diversity Equality Impact Assessment (EIA) Completed? NO If YES, EIA Score Acronyms/Terms Used in the Report SI

Serious Incident

NHS

National Health Service

FLO

Family Liaison Officer

MHS Mental Health Services Supporting Documents and/or Further Reading Lead

Natalie Hammond Executive Nurse

3

Agenda Item 8b Board of Directors

11 April 2018


DUTY OF CANDOUR

1.0 PURPOSE OF REPORT

To provide the Board of Directors with an annual position on Duty of Candour compliance and an updated summary of associated work streams for the year 2017-18

2.0 EXECUTIVE SUMMARY

As previously reported, the Duty of Candour is the requirement for all clinicians, managers and healthcare staff to inform patients/relatives of any actions which have resulted in harm. It actively encourages transparency and openness; the Trust has a legal and contractual obligation to ensure compliance with the standard. A number of areas of work have been taken forward to support staff in encouraging an open and transparent culture. Monitoring of this continues in regards to:-

• Mandatory training for staff via e-learning and within induction programme • Ad-hoc training to teams as required for further learning • Development of a FLO training package in partnership with the Police and CRUSE

bereavement; a programme of this training will be rolled out across the Trust upon finalisation

• Family Liaison Officer (FLO)/Duty of Candour lead is identified for all serious incidents and other applicable incidents. Monitoring and coordination is undertaken through the SI office to ensure compliance.

• Family Liaison Officers are included within all correspondence around investigations and informed of timeframes and scope in order to facilitate transparency and involvement of families in the investigation process.

• Terms of reference are shared with families at the start of serious incident investigations and the template of reports have been adapted to ensure family involvement is reported on and addressed through the investigation

• Weekly review of moderate harms and incidents for escalation to confirm if t h e y meet Duty of Candour criteria and to identify further investigations required.

• Commissioning of critical incident investigations and monitoring to complete within agreed timescales, with presentation of learning to the Learning Oversight Subcommittee

• Commissioning of case note reviews and monitoring via the Deceased Patients Review Group and presentation of learning to the Mortality Review Sub-Committee

• Monthly reporting via Performance Report of relevant incidents • Weekly progress and position statements sent to Directors and senior managers. • Agreement by all three community commissioners that unavoidable category 3 and 4

pressure ulcers acquired in care do not require us to automatically follow Duty of Candour

• Further updates have been made to Datix to ensure information captured supports decision making and maintains a contemporaneous record of Duty of Candour and FLO contact

4

The following table confirms that all applicable incidents have followed Duty of Candour requirements.

Area Measure 15/16 OT

16/17 OT

Q1 Jul-17

Aug-17

Sep-17

Q2 Oct-17

Nov-17

Dec-17

Q3 Jan-18

Feb-18

Mar-18

Q4 Outturn

North Essex MH

Total applicable cases

Where applicable was previously monitored through the SI Scrutiny panel.

25 6 7 1 14 6 6 5 17 10 10 8 28 84

Contact made within 10 days

25 6 7 1 14 6 6 5 17 10 10 8 28 84

South Essex MH


58 41 11 1 5 9 15 4 3 5 12 6 2 3 11 49


58 41 11 1 5 9 15 4 3 5 12 6 2 3 11 49

Specialist Services


4 2 0 0 0 1 1 1 0 0 1 1 1 0 2 4


4 2 0 0 0 1 1 1 0 0 1 1 1 0 2 4

South Essex CHS


58 41 0 0 0 1 1 0 0 0 0 0 0 1 1 2


58 41 0 0 0 1 1 0 0 0 0 0 0 1 1 2

West Essex CHS


58 41 2 0 0 0 0 1 0 1 2 0 0 0 0 4


58 41 2 0 0 0 0 1 0 1 2 0 0 0 0 4

Bedfordshire CHS


58 41 2 0 0 0 0 0 0 0 0 0 0 0 0 2


58 41 2 0 0 0 0 0 0 0 0 0 0 0 0 2

EPUT TOTAL


N/A N/A 40 7 12 12 31 12 9 11 32 17 13 12 42 145


N/A N/A 40 7 12 12 31 12 9 11 32 17 13 12 42 145

5

3.0 RECOMMENDATIONS

It is recommended that the Board of Directors: 1. Note the content of this report 2. Recommend any further actions as required

4.0 ACTION REQUIRED


1. Approve the Report

Report written by Sharan Smith Head of Incident Management


Agenda Item No: 8d

SUMMARY REPORT

BOARD OF DIRECTORS PART 1 25 April 2018

Report Title: Chair and Chief Executive: Division of Responsibilities

Executive/Non-Executive Lead: Professor Sheila Salmon, Chair Report Author(s): Cathy Lilley, Trust Secretary Report discussed previously at: n/a Level of Assurance: Level 1 Level 2 Level 3

Purpose of the Report This report outlines the division of responsibilities between the Trust’s Chair and Chief Executive.

Approval Discussion Information


1 Note the contents of the report 2 Ratify the document setting out the division of responsibilities between the Chair and

CEO 3 Request any further information or action.

Summary of Key Issues Code of Governance (revised July 2014) focuses on the leadership of a Trust and in particular that there should be a clear division of responsibilities at the head of the Trust between chairing the Board of Directors and the Council of Governors, and the executive responsibility for the running of the Trust’s affairs; no one individual should have unfettered powers of decision.

In accordance with best practice, both Sally and I believe it is essential that we are clear about our respective roles.

In line with Code provision A.2.1 “The division of responsibilities between the chairperson and chief executive should be clearly established, set out in writing and agreed by the Board of Directors”, the attached document sets out the differing and complementary leadership roles. It has been developed using good practice guidance from the Code as well as NHS Providers Foundations of Good Governance: a compendium of best practice and reflects the current practice within the Trust.

Relationship to Trust Strategic Objectives SP 1: Continuously improve patient safety, experience and outcomes SP 2: Attract, develop, enable and retain high performers SP 3: Achieve top 25% performance SP 4: Co-design and co-produce service improvement plans


Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? No If yes, insert relevant risk

Page 1 of 2


Do you recommend a new entry to the BAF is made as a result of this report? Corporate Impact Assessment or Board Statements for Trust: Assurance(s) against: Impact on CQC Regulation Standards, Commissioning Contracts, new Trust Annual Plan & Objectives

Data quality issues Involvement of Service Users/Healthwatch Communication and consultation with stakeholders required Service impact/health improvement gains Financial implications:


Non Recurrent £

Governance implications Impact on patient safety/quality Impact on equality and diversity Equality Impact Assessment (EIA) Completed? YES/NO If YES, EIA Score Acronyms/Terms Used in the Report NEDs Non-Executive Directors CEO Chief Executive Council Council of Governors Board Board of Directors Supporting Documents and/or Further Reading Lead

Professor Sheila Salmon Chair

Page 2 of 2

EPUT

RESPECTIVE ROLES: CHAIR AND CHIEF EXECUTIVE Board: Board of Directors Council: Council of Governors Chair Chief Executive • Reports to the Board and is accountable to

the Council for the performance of the Board

• Reports to the Chair and to the Board

• Other than the Chief Executive, no Executive reports to the Chair

• All members of the management structure report either directly or indirectly to the Chief Executive

• Ensures effective operation of the Board and Council

• Runs the Trust’s operation and day-to-day business

• Ensures that the Board as a whole plays a full part in the development and determination of the Trust’s strategy and overall objectives,

• Responsible for proposing and developing the Trust’s strategy and overall objectives

• The guardian of the Board’s decision making processes

• Implements the decisions of the Board and its Committees

• Leads the Board and the Council • Ensures the provision of information and support to the Board and Council

• Ensures the Board and Council of work effectively together

• Facilitates and supports effective joint working between the Board and Council

• Oversees the operation of the Board and sets its agenda

• Provides input into the Board’s agenda on behalf of the Executive Team

• Sets clear expectations concerning the Trust’s culture, values and behaviours, including setting the style and tone of discussions at Board meetings

• Communicates the expectations of the Board concerning culture, values and behaviours to all employees

• Ensures the Board’s and Council’s take full account of the important issues facing the Trust

• Ensures the Chair is aware of the important issues facing the Trust and proposes agenda items accordingly

• Ensures the Board and Council receive accurate, timely and clear information

• Ensures the provision of reports to the Board and Council contain accurate, timely and clear information

• Ensures compliance with the Board’s approved procedures

• Ensures the compliance of the Executive Team with the Board’s approved procedures

• Arranges informal meetings of the Directors to ensure that sufficient time is given to complex, contentious or sensitive issues

• Ensures that the Chair is alerted to forthcoming complex, contentious or sensitive issues affecting the Trust

• Proposes a Schedule of Matters Reserved to the Board; proposes terms of reference for each Board Standing Committee and proposes other Board policies and procedures

• Provides input as appropriate on changes to the Schedule of Matters Reserved to the Board and Committees’ terms of reference

• Facilitates the effective contribution and the provision of effective challenge by all members of the Board

• Supports the Chair in facilitating effective contributions by Executive Directors including effective challenge

• Facilitates constructive relationships between Executive and Non-Executive Directors

• Supports the Chair in sustaining constructive relations between Executive and Non-Executive Directors

• Ensures that constructive relations exist between elected and appointed Governors

• Supports the Chair in ensuring constructive relations between elected and appointed Governors

Division of Responsibilities: Chair & CEO April 2018 Page 1 of 2

EPUT Chair Chief Executive • Ensures constructive and productive

relations between the Board and the Council

• Supports the Chair in ensuring constructive and productive relations between the Board and the Council

• Ensures that Non-Executive Directors are able to lead in being accountable to the Council for the Board

• Ensures the presence and support of Executive Directors to the Non-Executive Directors in order to facilitate the accountability relationship

• Leads the Council in holding the Non-Executive Directors to account, ensuring the accountability process works effectively

• Supports the Chair in delivering an effective accountability process

• Chairs the Board’s Nominations Committee • If appointed, to serve on any Board Committee

• Initiates succession planning measures at Board level with the Nominations Committee to ensure appropriate Board composition and refreshment

• Provides information and advice on succession planning to the Chair and relevant Board Committees, particularly in respect of Executive Directors

• Proposes the membership and chairs of Board Committees

• Ensures effective communication on the part of the Trust with patients, service users, carers, members, clients, staff and other stakeholders

• Leads the communication programme with members and stakeholders

• Leads the provision of a properly constructed induction programme for new Directors

• Contributes to induction programmes for new Directors and ensures that appropriate management time is made available for the process

• Leads in updating the skills and knowledge and in meeting the development needs of individual Directors and of the Board as a whole

• Ensures that the development needs of the Executive Directors and other senior management staff are identified and met

• Ensures that members of the Council have the skills, knowledge and familiarity with the Trust to fulfil their role

• Ensures the provision of appropriate development, training and information for the Council

• Ensures that the performance of the Board and Council as a whole, their Committees, and individual members are both periodically assessed. This will include an externally led assessment at least once in every three years

• Provides input to the wider Board’s and Council’s evaluation process

• Sets Non-Executive Director objectives and reviews individual and collective performance at least annually, and provides outcome report(s) to the Council’s Remuneration Committee

• Sets Executive Directors objectives and reviews individual and collective performance at least annually, and provides outcome report(s) to the Board’s Remuneration Committee

• Promotes the highest standards of integrity, probity and corporate governance throughout the organisation and particularly at Board of Directors level

• Conducts the affairs of the Trust in compliance with the highest standards of integrity, probity and corporate governance

• Promotes continuing compliance across the Trust

• Ensures a good flow of information each way between the Board, Board Committees, the Council, senior management and Non-Executive Directors

• Provides effective information and communication systems

Division of Responsibilities: Chair & CEO April 2018 Page 2 of 2


Page 1 of 6

Agenda Item No: 8e

SUMMARY REPORT

BOARD OF DIRECTORS PART 1 MEETING

25 April 2018

Report Title: Board Governance Update

Executive/Non-Executive Lead: Nigel Leonard, Executive Director Corporate Governance & Strategy

Report Author(s): Cathy Lilley, Trust Secretary

Report discussed previously at: Level of Assurance: Level 1 Level 2 Level 3

Purpose of the Report The purpose of this report is to provide an update on a range of governance, legal and procedural issues for the Board’s attention.

Approval

Discussion Information


The Board of Directors is asked to: 1 Note and discuss the contents of the report 2 Request any further information or action.

Summary of Key Issues The report includes a number of updates to be brought to the Board’s attention covering:

EPUT Corporate Governance

Mental Health News

Sector News

Relationship to Trust Strategic Objectives SP 1: Continuously improve patient safety, experience and outcomes SP 2: Attract, develop, enable and retain high performers SP 3: Achieve top 25% performance SP 4: Co-design and co-produce service improvement plans


Relationship to the Board Assurance Framework (BAF) Are any existing risks in the BAF affected? No

If yes, insert relevant risk Do you recommend a new entry to the BAF is made as a result of this report?


Data quality issues Involvement of Service Users/Healthwatch Communication and consultation with stakeholders required



Page 2 of 6

Financial implications

Governance implications Impact on patient safety/quality

Impact on equality and diversity Equality Impact Assessment (EIA) Completed? NO If YES, EIA Score

Acronyms/Terms Used in the Report CQC Care Quality Commission ACS(s) Accountable Care System(s)

ICS Integrated Care System ACO(s) Accountable Care Organisation(s) NHSE NHS England DoH Department of Health

NHSI NHS Improvement FT Foundation Trust HEE Health Education England CEO Chie Executive Officer

DoLs Deprivations of Liberty CCGs Clinical Commissioning Groups STP Sustainability & Transformation Partnerships GDPR General Data Protection Regulation

AMHCP Approved Mental Health Care Professionals

Supporting Documents and/or Further Reading Main report

Lead

Nigel Leonard Executive Director Corporate Governance & Strategy


Page 3 of 6

Agenda Item 8e Board of Directors Meeting Part 1

25 April 2018

BOARD GOVERNANCE UPDATE

1 Purpose of Report

The purpose of this report is to provide an update on a range of governance and procedural issues that require the Board’s attention since the last report in March 2018. The full reports, briefings and publications referred to in this paper can be accessed using the hyperlinks.

2 Summary

Corporate Governance

2.1 Board of Directors Meeting Framework and Board Committees Effectiveness

Review As reported at the last Board meeting an initial analysis of the Board Committees Effectiveness review has been undertaken, and assurance was provided that there are no major concerns or issues raised, and there has been positive validation of the work of all committees from both members and non-members. Since that meeting an initial review of the Board of Directors meetings framework has also been undertaken. It is recommended that a report will be presented taking account of the findings and recommendations from both reviews and also taking account of the outcomes following the CQC inspection visit.

2.2 Legal & Policy Update This report is produced bi-weekly and discussed at the Executive Operational Sub-

Committee (EOSC). The Board will be notified of any emerging themes and key policies changes. Copies are available on request from the Trust Secretary.

Mental Health News

2.3 Strong Leadership Essential to Delivering Improvement in Mental Health

Hospital Care Report ink The CQC has published a report that explores how seven NHS mental health trusts have been able to make significant improvements in the quality of care and improve their CQC rating. Driving improvement: case studies from seven mental health trusts explores what Trusts that were rated as requires improvement have done to become good or outstanding. There were common themes that drove improvement across the featured trusts. Strong, visible and listening leadership is vital and good leaders engage and empower staff. Good leadership and good governance go hand in hand and the report found that most of the Trusts had made changes to their systems and processes to drive improvement. 2.4 Mental Health Act 1983: Implementing Changes to Police Powers Report Link DoH has published guidance on putting into practice changes to the provisions on police powers and places of safety, in the Mental Health Act 1983. The changes relate to police powers to act in respect of people experiencing a mental health crisis. The intention is to ensure their care and safety. 2.5

http://www.cqc.org.uk/news/stories/strong-leadership-essential-delivering-improvement-mental-health-hospital-care

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/656025/Guidance_on_Police_Powers.PDF


Page 4 of 6

2.6 2018/19 Planning Round: Letter from Ian Dalton, Chief Executive, NHSI Following the submission of the draft operational plan for 2018/19 on 8 March 2018, all NHS Trust and FT CEOs have been sent a letter from Ian Dalton setting out NHSI’s expectation that each Board will produce a plan built on effective capacity and demand planning as there were concerns that some plans were not sufficiently robust and/or were unrealistic. Assurance is provided that the Trust’s operational plan for 2018/19 will reflect these expectations. 2.7 Wide variation uncovered In how NHS and Local Authorities work together

when applying the Mental Health Act Report Link People might not be getting the specialist mental healthcare they need and when they need it most because of disparity in how approved mental health professional services are provided across the country. Approved mental health professionals (AMHPs) are typically social workers who work on behalf of local authorities to, amongst delivering other responsibilities, assess people to decide whether or not applications should be made to detain them under the Mental Health Act following medical recommendation. The CQC has published a briefing paper that sets out their key findings around what is working well and what the barriers are to these services running as well as they should be. 2.8 CQC publish briefing on Out of Area Placements for Mental Health

Rehabilitation Report Link This briefing highlights the high numbers of patients in residential-based mental health rehabilitation services who are being treated away from home. The briefing reveals that 63% of rehabilitation placements are out of area and argues that this could lead to people becoming isolated from their friends and families and cut off from the local services that will provide care following discharge. 2.9 Care for people with learning disabilities should be close to home wherever

possible, says NICE Report Link NICE is urging councils and health bodies to make sure that people with learning disabilities can access well-designed services and staff with the right skills so they do not need to move away for care or treatment. In a new guideline, NICE says children, young people and adults with learning disabilities who have behaviour that challenges should have the right support to live their lives in the community like everyone else. 2.10 CQC launces sexual harassment review of mental health wards The CQC has launched a review of "sexual assault and harassment" on NHS mental health wards, after a snapshot survey identified 900 incidents or risks reported by staff in a three -month window. The review was triggered after CQC inspectors found "sexual incidents" reported by staff at a Trust that was already being investigated for housing men and women on the same ward. When it broadened its search, it found that Trusts had reported almost 1,000 sexual safety issues. The CQC said that the cases it identified included verbal sexual harassment, or potential risks posed by men or women sharing a ward, as well as more serious cases of sexual assault. 2.11 CCGs warned over mental health funding pledge NHS England has written to all 207 CCGs to warn that they must deliver on a key NHS-wide funding pledge in order to meet the rising demand for mental health services. In the letter, Claire Murdoch, NHSE’s national mental health director, has ordered CCGs to ensure they boost spending on mental health by more than the size of their overall annual budget increase. She also states that all CCGs must meet the mental health investment standard (MHIS) during the new NHS financial year. Leaders of CCGs that do not comply face having to explain their failure to Murdoch or another senior NHSE official, and face sanctions.

http://www.cqc.org.uk/publications/themed-work/briefing-mental-health-act-approved-mental-health-professional-services

https://nhsconfed.us16.list-manage.com/track/click?u=feeeed3bba7c179fd3a7ef554&id=9a62867cb2&e=4f8c022647

https://www.nice.org.uk/guidance/NG93


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2.12 Deprivation of Liberty Standards (DoLS): Consultation Response Report Link DoH has published its response to the Law Commission’s consultation on how the law should regulate deprivations of liberty (DoLS) for people who lack capacity to consent to their care and treatment arrangements. It sets out the government’s provisional view of each individual proposal and mostly agrees with the DoLS model. Following the consultation, the Law Commission published a report on mental capacity and DoLS. The report set out its recommendations, together with a draft bill.

Sector News

2.13 NHS England and NHS Improvement: working closer together NHSE and NHSI have announced some key steps they are taking to bring the two organisations closer together. Acknowledging that commissioners and providers are serving the same people, both organisations recognise there needs to be a much stronger focus on collaboration and joint working nationally as well as in local health systems. Subject to their Boards’ approval, the intention is to establish new working arrangements from September 2018. These increased integration and alignment of national programmes, and the integration of regional teams. NHSE and NHSI will still have distinctive statutory responsibilities and accountabilities. The legislation also means that a formal merger between the organisations is not possible but the intention is to combine forces for those functions that would work better as one. 2.14 How regulation is evolving to align with local system collaboration The Changing Nature of Regulation in the NHS survey by NHS Providers explored the experiences of Trusts of moving to local system collaboration through STPs and ICSs, as well as the relationship between Trusts and the two regulators – NHSI and CQC. The findings of the survey make clear "that Trusts are already concerned about the level of regulatory burden they experience and there is a risk that the intentions for local systems to take on oversight roles simply adds an extra layer into the assurance system". Only one in five (20%) trusts said that they feel the national policy direction for the overall system architecture is clear, in relation to how they regulated. NHS Providers stated that “a clear and consistent direction of travel nationally is needed to develop a regulatory and oversight model that supports this new way of working and doesn’t duplicate existing oversight arrangements. The consequence of the changing NHS system architecture is that Trusts are juggling a growing number of roles and expectations, and the regulatory framework should recognise and respond to this." Read the full version on NHS Providers’ website. 2.15 Housing and health: Opportunities for STPs report A new report from the King’s Fund outlines the role of housing associations in STPs. It identifies three main offers for health: to offer appropriate housing options and support services for people leaving hospital; to provide housing on NHS estate land; and to support people with mental health problems with good-quality supported housing, enabling independent living in the community. 2.16 CQC: Changes to Regulatory Fees CQC has published its approach to regulatory fees for NHS providers for 2018/19. The new fee structure is based on developments in the Trust sector as a result of mergers and transactions. Under the new approach individual Trusts will pay a specific amount in proportion to the size of their annual turnover which aims to be more proportionate and allow the CQC to respond appropriately to small and large changes among providers. There is no new increase in the total amount of income CQC collects from Trusts in 2018/19 but individual Trusts will see a readjustment in the fee owed to CQC.

https://www.gov.uk/government/publications/deprivation-of-liberty-standards-dols-consultation-response/department-of-health-response-to-the-law-commissions-consultation-on-mental-capacity-and-deprivation-of-liberty

https://improvement.nhs.uk/news-alerts/nhs-england-and-nhs-improvement-working-closer-together/

https://improvement.nhs.uk/news-alerts/nhs-england-and-nhs-improvement-working-closer-together/

http://nhsproviders.cmail19.com/t/t-l-utmiry-pkiijtrtj-p/

http://nhsproviders.cmail19.com/t/t-l-utjygl-pkutjidht-q/


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The CQC plans to continue to engage with NHS providers and consult again in the autumn. 2.17 NHSI chair calls for ‘firmer’ fit and proper persons test In her interview with the HSJ chair of NHSI, Baroness Dido Harding calls for a much “firmer” fit and proper person test and pledges to stop “recycling” senior NHS managers who cross “a moral line”. Baroness Harding demanded tougher action to exclude those who do not deserve to work in the health service again.

3 Action Required


1 Note the contents of this report 2 Request further action/information as required.

Report prepared by Cathy Lilley, Trust Secretary On behalf of:

Nigel Leonard Executive Director Corporate Governance & Strategy 25 April 2018


Page 1 of 2

Agenda Item No: 9a

SUMMARY REPORT

BOARD OF DIRECTORS COMMITTEE / PART 1

25 April 2018

Report Title: USE OF CORPORATE SEAL

Executive/Non-Executive Lead: Sally Morris

Report Author(s): Sally Morris

Report discussed previously at: n/a



To update the Board of Directors when the Trust Corporate Seal has been used

Approval

Discussion

Information √


The Board of Directors are asked to note the contents of this report


The EPUT Corporate Seal has been used on the following occasions:-

3 April 2018 – Deed of Assignment, Queensborough House, Friars Walk, Dunstable Beds LU6 3JA between EPUT and East London FT

3 April 2018 – Deed of Assignment, Ground floor offices, Unit 1, 2 Railton Road, Wisley Business Park, Kempston between EPUT and East London FT

3 April 2018 – Deed of Assignment of undocumented interests in various properties between EPUT and East London FT

3 April 2018 – Deed of Assignment of undocumented interests in a property between EPUT and Cambridgeshire Community Services NHS Trust

16 April 2018 – Supplemental Lease part of first floor Chelmsford and Essex Centre

Relationship to Trust Strategic Objectives






1: Open

2: Compassionate

3: Empowering






Impact on CQC Regulation Standards, Commissioning Contracts, new Trust √


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Annual Plan & Objectives

Data quality issues






Governance implications √






Lead

SALLY MORRIS Chief Executive